Rapid assessment of loiasis and onchocerciasis in Equatoria region of Southern Sudan: 4th to 24th 2005

AFRIGAII PRoGRAHUE FOR ONGHOGERGIASIS GONTROL (APOG) PROGRATTIE AFRICAIH DE LUTTE GONTRE L'ONGHOGERCOSE RAPID ASSESSTENT OF LOIASIS A]ID ONGHOGERGIASIS Iil EoUAToRIAREGIoIIoFSoUTHERNSUDA]tl 4th to 24n apfil 2(N5 lullssloll REPORT by Mr Honorat G.M. ZOURE Biostatistics and mapping officer, APOC 01 BP 549 Ouagadougou 01, Burikina Faso Tel: +226 50 34 29 53/59i60 E-mail: zoureh@.oncho.oms.bf Mr Hilary Adie WHO/APOC TemPorary Advisor Coordinator, Cross River State CDTI project Ministry of Health Calabar, Nigeria Tet. +234 803706371',l E-mail : enternilr2002ng@vahoo. conri Dr. DaddiJima WHO/APOC TemPorary Advisor N ational Coordinator, Onchocerciasis Control, MOH, Addis Ababa, Ethiopia, Tel- +251 1 150993, mobile: + 2519 4A5722 E-mail: daadhij@Yahoo. com Dr Innocent Takougang WHO/APOC TemPorary Advisor Department of Public Health Faculty of Medicine and Biomedical Sciences P.O. Box: 1364 Yaound6, Cameroon Tel: +237 9652808 E-mail: itakouga ng@vahoo'com April 2005 Table of contents ACRONYMS. BACKGROUND COUNTRY INT'ORMATION......... IVERMECTIN DISTRIBUTION CDTI pRoJECTS ru SorrnmnN SuoaN....... RATIONALE FOR RAPLOA AND REA IN EQUATORIA REGION... OBJECTIVE OF TIM MISSION Spscmic oBJECTTvES METHODOLOGY....... REMO/ RAPLOA FIELD DGRCISE.............. Phase I: Field Preparations. (4-6 April 2005, Nairobi, Kenya)' Phase II. Searity Clearance. (7 April 2005, Lokichoggio, Kenya)""" " Phose III. Training on RAPLOA and REMO. Phase IV. Field exercise Phase V. Report wrifing (18-26 April 2005, Nairobi, KEI'|YQ' RESULTS AND DISCUSSIONS TRAtr{hrG ON RAPLOA AXO REA ....... .. STAruS REPORT ONTHE RAPLOA FIELD DGRCISE... SraruS REPORT ON THE REMO FIELD E)(ERCISE . ....'' . ..... DIFFICTJLTIES ENCOUNTERED ............... RECOMMENDATIONS .......... ACKNOWLEDGEMENTS .......... II 1 I I 2 4 4 5 5 5 5 5 6 6 6 6 6 7 1 8 8 9ANNEX.... 26SAMPLE PHOTOS ACRONYMS AAH ARC APOC CAR CBM CDD CDTI DRC GIS HNI IMC tRc MEC MHYH MRDA NGDO NPA OV RAPLOA RD REA REMO SAE SIDF SSOTF SU HA TCC TDR Aktion Afrika Hilfe American Refugee Committee African Programme for Onchocerciasis Control Central African RePublic Christoffel-Blindenmission (German NGO) Community-Direded Distributor Comm u nity-Di rected Treatment with lvermecti n Democratic RePublic of Congo Geographical lnformation SYs{em HealthNet lnternational lnternational Medical CorPs lntemational Rescue Committee MectizanrM Expert Committee Many Hands of Your Heart Mundri Relief and Development Association Non-Governmental Development Organization (see NGO) Norvegian PeoPle Aid Onchocerca volvulus Rapid Assessment Procedure ol Loa loa Restricted definition Rapid Epidemiological Assessment Rapid Epidemiological Mapping of Onchocerciasis Serious Adverse Event Sudan lnland Development Foundation Southern Sector Onchocerciasis Task Force Sudan Health Association Technical consultative committee (APOC scientiflc advisory group) Special programme for Research and Training in Tropical Diseases (part of CRD' a department of CDS, WHO) United Nations Children's Fund World Health Organization UNICEF WHO 11 1Background country information The Southern Sudan is divided into three administrative levels: regions, counties and payams. The "Region" is the largest administrative zone. There are three administrative regions in Southem Sudan: Bahr elGhazal, Equatoria, and Upper Nile. The "County" is the district within the administrative zone. County boundaries change from time to time and new, smaller counties are carved out of larger ones. The "Payam" is a sub-district of the county, can usually be located on published maps, and have a civiladministrator. Equatoria region lies in the most southem part of Sudan. lt is bordered by five countries, namely Ethiopia, Kenya, Uganda, DRC and CAR in the East, Southeast, South, Southwest and West r.espectively. lh tne North it is limited by the southern regions of Bahr El Ghazal and Upper Nile- Geographically, the region is divided into Western, Central and Eastem Equatoria, and it has 13 adrninistrative counties (Annex 1 ). Most of the region has 8 months of rainfall in a year. The vegetation ranges from equatorial rain forest in the west and southwest to woodland and open savannah towards the north. The people practice subsistence agriculture and animal husbandry. Some of the tribes are semi- nomadic. The region is well known for diseases such as sleeping sickness, onchocerciasis, draconculiasis, malaria, hydatic disease, leishmaniasis and burulli ulcer. lvermecti n d istri butio n The distribution of ivermectin has been going on in Equatoria region since 1996. However, it was not really based on Community-Directed Treatment with lvermectin (CDTI) strategy and the treatment coverage was generally low (Table 1). Several NGDOs are involved in ivermectin distribution. The lntemational Medical Corps (lMC), Aktion Afrika Hilfe (AAH), Mundri Relief and Development Association (MRDA), Samaritan' Purse, Sudan lnland Development Foundation (SIDF), OXFAM-GB, Many Hands of Your Heart (MHYH) operate in Western Equatoria. ln Eastem Equatoria the distribution is made with the iollaboiatibn of ZOA Refugee Care, Sudan Health Association (SUHA), American Refugee Committee (ARC), D. REJAF and Norvegian People Aid (NPA). Table 1: Treatment figures in Western and Eastern Equatoria Year COMMUNITIES POPULATION Total Treated o/o Total Treated o/o Eastem Equatoria 2002 438 74 17 285,000 61,816 22 2003 18,392 Westem Equatoria 2002 401 240 60 658,000 291,093 43 2003 63,304 CDTI projects in Southern Sudan The first Rapid Epidemiological Mapping of Onchocerciasis (REMO) exercise was conducted in Southem Sudan in March 2OO3 (Annex 2). As a result, five (5) CDTI projects were recommended for approval by the 17th session of the Technical Consultative Committee (TCC) of APOC in September 2003, namely, East Bahr-el-Ghazal, West Bahr-el-Ghazal, Upper Nile, East Equatoria and West Equatoria. The NGDO partner for the Eastem and Western Equatoria 2cD-Tl projects is christoffel-Blindenmission (cBM)r Field activities are conducted in westem Equatoria with the rrpp"rt oilntemational Medical'Corps (lMc) and of AKion Afrika Hilfe (AAH) for Eastern Equatoria CDTI project. Each cDTl poect has a project coordinator at project level, county supervisors at the project supervisory centers level, and payam supervisors' The western Equatoria cDTl project @vers the 5 counties of Ezo, Maridi, Mundri, Tambura and Yarnbio. lt has a total population at risk of 1,081,035 for 2005' The first lefter of agreement between APOC and the southem sudan onchocerciasis Task Force (SSSTF) for the implementation of CDTI for west Equatoria covers.the. period May 2004 - nprif ZbOS. fn" first instatlment was received in September 2OO4 and CDTI activities were launched in the same month. The project coordination office is located in Yambio. The county health department of Yambio a*ocated a room toi tne project, but the space is not enough to a-c-commodate all the office equipment. Therefore tne pioject has been forced to keep the office machines (computer' pint!r, photocopieO i" tn" WoriO Health Organization's (WHO) otfire temporarily' The project coordination office is composed of the following staff members: - Mr David Jacob Bido, project coordinator - Mrs Mary Francis, financialclerk - Mr JosePh NdukaYo, secretary - Mr Jackson BabuYa, driver - Mr Milton Alfred, assistant driver - Mr Santo Noti, securitY guard The Eastern Equatoria cDTl project covers 7 counties, namely: Budi, -J-uba Kajo Keji' Magwi Terekeka, Torit ano iei. it nas'a total population at risk of 888,380 for 2005' The retter of agreement for the first year of imprementation of cDTr is not yet signed. The project coordination office will be established in Yei' Rationale for R^APLOA and REA in Equatoria region southern Sudan falls within the Loa loa belt. some of this information was derived as far back as the 20rh century as drawn by Angro-Egypti;n ;ndominium maps. The endemicity of Loa loa is supported by the remote sensing r"t'ot Loa loa (Figure 1) and the probability contour map tr,gure2),bothoevetopeobytheLiverpoolschoolofTropicalMedicine' Recent studies (Richer, 2OO2\ indicated the existen e or Loa roa in Equatoria region (Mundri, Maridi, Yambio, Yei, Kajo-Keji, Mvolo and lbba counties)' ln April 2002 with the support of HealthNet lnternational (HNl) and The carter center' blood survey for Loa roa'wai-Eimeo out in ir*uuru, Ezo, yamb'ro and Maridi counties of west Equatoria. pretiminarylr*"y resurts.indicated the presence of roiasis in the region' However, daia on the degree of endemicity of loiasis is fragmentory. Mass distribution of ivermectin for the contror of onchocerciasis has been going on since.1996 in Tambura, Ezo and yamoio counties w;;i iquatoria;. Five (5) cases of sAE were reported over the last six-years. f n iitt Equatoria CVlii.luntYl, 'two deaths probably related to SAE were described (Richer, 2OO2). ' Field mission report 3There is a known relationship between the prevalence of history of eye worm at the community level and the risk of severe adverse events (sAEs) following mass treatment of onchocerciasis with ivermectin fl'DR, 2001). Since Southem Sudan is in the process of starting CDTI, it became imperative that Rapid Assessme nt ol Loa iia (nnpuon) be conducted in order to determine the level of endemicity of Loa loaand the strategy to be used for Mectizan distribution, especially in communities starting new CDTI projects. Based on the recommendations of MEC and TCC for the treatment of onchocerciasis with Mectizan@ in areas co-endemic for onchocerciasis and loiasis, and on the predictive maps of risk for SAEs occunence (Figures 1 and 2), the Southem Sudan Onchocerciasis Task Force t$sorrl with the $;& iioi.r Apoc Manigement decided to conduct RAPLOA exercise with the aim of determinind tn" level of Loa loa endemicity in the CDTI priority areas so as to take precautions during mass distribution of ivermectin' The REMO exercise in 2003 was not able to cover some of the areas that vvere inaccessible at the time of the rr*"y; therefore it was imperative to conduct REA in areas that needed refinement and which became accessible. Fiqure 1: SPOT Vegetation model map (Thomson et al., 20012) superposed with Southern Sudan counties Iiur.r"._t llr', .i '; j, !l ,:, "; I li* t:t ;i.: ; ' :1'. * It: fi *€n - ,r.i^ , Thomson M, Obsomer V, Connor SJ ef a/. (2001) Determining the spatial overlap between the distribution of Loa loa and onchocerciasis in APOC countries using GIS and Remote Sensing Technologies: Final n"portto Apoc 15t1ot2oo1. Liverpool schoolof Tropical Medicine, Liverpool,2001 -, i ;{E n*n i ' +..?r ".1 r lq 4' .r '' -'*l{.&-. . s,..; hAFAETA FUC. 4 Fiqure 2: Probability Contour Map3 superposed with Southem Sudan counties Fr ':'t) lkjlr;{ ol lH,lli t'tl'l 0riq-1 f!+ . I qi ur-J ! lrl-1ilf.rF.lI trr rll, Lr! ,l -i nr-tt{r;. il l r, 1.! : Lr!1.f'1 lr - ir i1,: tli f-,11 1 Objective of the mission 1. To buird the capacity of ssorF in the rapid assessment of roiasis and onchocerciasis 2.ToassessthelevelofLoa/oaendemicityinEasternandWestemEquatoriaCDTIproject areas. 3. To refine/complete REMO for the Equatoria region' Specific obiectives -TotrainpartnersofSSOTF(central,countyandpayamlevels)inrapidassessmentofloiasis and onchocerciasis. _ To conduct Rapid Assessment of Loa /oa (RAPLOA) in the CDTI priority areas of the East and West Equatoria CDTI Projects' _ To conduct Rapid Epidemiorogicar Assessment of onchocerciasis (REA) in the accessible areas of Equatoria region wnere REMO results need to be refined or are yet to be completed loa prevalence using the recalibrated 2002 3 Development of an Operational ContourlVlap for Loail;ifiil;nial Risk l\ilodet (Draft), Thomson et al" .,1.,. - .*-+ .i;:rifi+., 5Methodology REMO| RAPLOA field exercise REMO/RAPLOA field exercise was planned in six phases as follows: Phase l: Field Preparations. (46 April 2005. Nairobi. Kenva). The first three days were spent in Nairobi discussing and arranging all the administrative processes needed for the field activities- On the first day, the Head of Southern Sudan WHO Coordination office, Dr Abdullahi Ahmed' received and welcomed the team, and assigned Mrs Agnes Wanyoike to work with the team to address administrative issues. The team identified logistics and gathered the necessary information on the East and West Equatoria CDTI project areas. On the second and third days, the team together with the SSOTF identified and marked on the rnap the villages to be surveyed for RAPLOA and REA, and started duplicating th'e surveylo-t- The selection of study villages gave priority to the villages that were targeted for the REMO exercise in 2003 "r ti.r"y w6re lumciLnfly iepresentative and took into account topographical data. Additional villages *ere selected in ireas were REMO needed to be refined. For RAPLOA, 66 villages were sei-ected in Western Equatoria and 81 in Eastem Equatoria. REA was to be conducted in 31 of the villages. Out of these villages, 14 were in Western Equatoria while 17 were in Eastern Equatoria. fhe team took the opportunig of the stay in Nairobi to meet with the national onchocerciasis control coordinator oi k"ny", br David Sing. During the discussions, Dr Sang emphasized on the need for implementing onchocerciasis surveillance in Western highlands of Kenya (on the border with Uganda) whe-re onchocerciasis cases are reported by different investigators after vector control has been completed in the 50s. il.s to On Thursd ay 7r|' April, the team left Nairobi for Lockichoggio where the.security briefing for Southem Sudan was provided. lt stemmed out from the briefing that West Equatoria CDTI prgect area was under phase ll of the United Nations security system. Similarly, in the East Lquatoria CDTI project area, some counties were inaccessible for security reasons (Torit, Magwi, Juba). Phase lll. n ino on RAPLOA REMO Two training sessions were organized, the first in Yambio (9-11 April 2005) and the second in Yei (16-18 April2005). The training' in yam'bio targeted the participants of Western Equatoria. The participants of Eastem Equatoria were trained in Yei. The main components of the training were the objectives, procedures and techniques of the Rapid Assessment procedure for Loiasis (RAPLOA). The following support documents were used: - TDR/|DE/RP/RAPLtO1.1WHO(2001) Rapid Assessment Procedure for Loiasis - TDR/|DE/RP/RAPLOA/02.1 WHO(2002) Guidelines for Rapid Assessment of Loa loa - TDR/TDE/ONCHO/93.4 WHO(1993) A manual for Rapid Epidemiological Mapping of Onchocerciasis The following topics were covered during the training (Annex 3): - public health importance of onchocerciasis, - overview on APOC, - severe adverse events and their impact on sustainability of CDTI, - satellite imaging based on vegetation index, 6- RAPLOA procedure and REMO prccedure. T1,e last day of the training was devoted to field exercise. This field exercise gave the opportunity to 6re APOC teari to identify points that were not well captured during the training, and to give further explanation and guidance' Phase lV. Field exercise Following the training in yambio, participants from West Equatoria were organized in eighteen ira) t".,it according to their payam ot 6rigin and deadlines for reporting the results were given to each team takinj-into ac"ouni the number of villages and the difficulty of the tenain (Annex 4a). These teams "6rr"n."d the field survey on the 13th of April. The RApLOA/REA field exercises in East Equatoria were planned from 18-30 April 2005' They were planned to eno on tne goth of April 2oos:sD,fteen (16) teams were made for the execution of field activities (Annex 4b). Phase v. Report writina (18-26 Aoril 2005. Nairobi. KENYA). Report writing was started on 18rh April. Briefing yvith the Head of Southem Sudan WHO Coordination oniceloor pr""" on 25rh April. Dr RhmLo stressed the need that APoC involves the WHO office in tecnnicat'support to the projects in the implementation of .CDTI, in particular if sorne of the project areas'were to be'found co-endemic for onchocerciasis and loiasis. He thought that this-could be done if APOC strengthened the wHo office by appointing temporary advisors for 6 to 11 months. He does not know whether wHO is member of the SSOTF since he has never been invited to a SSOTF meeting' The members of the ApOC mission left for their respective countries on 25th and 26th April 2005. Results and discussions Training on RAPLOA and REA A total of 110 participants were trained. These were county and g?yam.onchocercerciasis supervisors, and Cor;;liy-Directed Distributors (CDDs). Fifty eight (58) participants were from west Equatoria and 52 from East Equatoria (Annexes 5a and 5b). Status report on the RAPLOAfield exercise out of the 147 villages selected for RApLOA exercise in west Equatoria and East Equatoria, we have availed data f-* f S villages (annex 6). The nece-ssary arrangements have been made for further results to be sent to Apoc Management by sSorF. lf required, the temporary advisors remain available to assist in the compilation and analysis process' seventeen (17) of the villages that were selected for the REMO and RAPLOA exercises in Juba and Torit couniies were inaccessible at the time of our visit. Loa loa was known in most areas of Westem Equatoria. Several local names were used to deSignate the eye WOrr, "rOrO", "kiri miro", all meaning eye worm' ln EaStern EquatOria' the worm was less known in the studied communities' The percentage of eye worm (RD) was higher in western Equatoria than in the Eastern Equatoria. ln West Equatoria, the percentage of people repollng history of eye worm (RD) was greater than 40% in Akorogbodi, Gangura and Nambazia in Yambio county' ln East Equatoria, there was no village with RD greater than 40%. Eye worm was poorly known in most of the villages. The preliminary results agree with the Probability contour Map (Figure 3)' 7Further discussion of the results will be made when all the data are received. We could not cornplete the field data cottection process due to road infrastructure difficulties and time constraints related to the logistics. Fiqure 3: Superposition of preliminary RAPLOA results with the Probability Contour Map f:. l]h !i rliii ;i i I l :ii 1 I t:1 1f ::'u"'iil.niqi '- E - .',-{ .- J .:ri :i-r. ; 4 ,.'d-, ..tl I l "i , l.! ,:i .. I r. : Sfatus report on the REMO field exercise Out of the 31 villages selected for REA exercise in West Equatoria and East Equatoria, we n3y9 availed data for 2lannex 7). The prevalence was 46.70/o in Garia I and 35.0% in Riftenze The remaining results are expeited to be forwarded to APOC Management by the SSOTF. The Kapoeta County was reported by the SSOTF to be hypo-endemic for onchocerciasis and also the area targeted for REMO refinement was uninhabited. D ifficu lties encou ntered Due to difficulties of terrain (bad roads, lack of means of transportation), geographic and social accessibility of villages, long distance between villages and isolated homestead distribution within viilages, it wai not polsible for reduced team of surveyors to carry out the exercise. ln consultation with the sSotF, the team resorted to training a large number of persons each of whom conducted the exercise in their own payam. The implication of this was that the direct supervision was difficult. This explains why all the expected results were not available at the time this report was compiled. . ..: :'.:;.,x:, c.:i . .:$. ],iF:,Eri JUBt Ii'FtI l,lr 8Recommendations The preliminary results indicate that the prevalence ot Lo3 /oa varies widely in Equatoria region, and the complete return of the RApLoA survey results from SSorF will be highly important for fran"t identiiication of high-risk villages and implementation of CDTI' The implementation of CDTI in high risk villages of Mundri, Yambio and other identified counties(as rernaining RApLoA survey results b6come available) should be done following the rccommendations o{urcncCTorttre treatment of onchocercrasis with Meclizan@ rn areas co- endemic for Onchocerciasis and Loiasis' During the implementation of CDTI, adequate means of transportation should be provided at the county (motorbike;t ;J payam ioixes) tevels to facilitate the distribution and supervision processes. Acknowledgemenb our gratitude to Dr Azodoga sek6t6li, Director of APOC for giving us the opportunity to participate in its activities. Wl wish to thank Dr Abdullahi Ahmed, the Head of Southern Sudan wHO Coordination office for their *rm reception and assistance throughout the mission' we are indebted to Dr samson p. Baba, the coordinator of the Southern sudan onchocerciasis iasf Force, for facilitating our field exercise in Southern Sudan. We wish to thank the following partners of the SSOTF for the logistic assistance: AAH, ARC, tMC and uNlcEF. We thank all the wHo staff in Nairobi, Lockichoggio and Yambio offices. we are indebted to t#-;;iy administrative and medical authorities of Equatoria region for facilitating RAPLOA and REMO exercises' our thanks to Dr Mickey Richer, Dr Jayaprakash Valliakoleri, Dr Ricard ^Lino Laku, Mrs Agnes Wanyoike, Mr Sinnshaw Tiruneh, Mr Fasil Chane, Mr Mike Salla, Mr Ceaser Longa and all otheis who assisted us in our mission' we crave the indulgence of everybody omitted erroneously to overlook the omission, may God help you all. 9ANNEX Annex 1: map of southem sudan showing the regions and counties L*ger,ld E:r] Essiurrue+rintIss t::. Iii{ia:'l + Annex 2: REMO results of Southem Sudan following 2003 exercise REMO maP Suilen Southeru sectol Le$end ..'.:'r lto cort Refine ffio"n,,n.corr Excluded HHI Rrtuo eenoirxr Stiltes Re$i0ns '. no(lul€s o0 o 1-e o 10-19 0) 2t- 39(} 4a-1oo I---] 0 E[G Ht{.4 100 200 ,,i..HilAF:':aru 1i't3 i I i ! : LATJdfl AET'EI TIVAU l0 AGIex 3: Agenda of the training sessions in Eastern and westem Equatoria Dr Baba8:00 - 8.15The Southern Sudan Onchocerciasis Task Force Dr Jima8:15 - 8:40of onchocerciasisPublic health im MrZour68:40 - 9:00APOC DTT9:00 - 9:30of CDTIon sustainand theirSevere DrT9:30 - 10:00lntroductionin the reventio n of SAEs Mr Adie10:00 - 10:15of Loa loain the of SAEs : The bi 015 - 1A.45Ccffee break. Dr Takou10:45 - 11.15indexbased onSatellite Clinical RAPLOAns i- tr it r-'l; -i 2 {la - 1:i.oa Dr Takou13:00 - 13:15uestionnaireClinical The Dr Tr13:15 - 13.30uestionnaireThe individualClinical NS DrT of RAPLOAlm Dr Takou13:30 - 13:45 Selection of communitiesa Dr T;13.45 - 14:OOthe communitiesa Dr14:00 - 14'.15 with chiefs and leadersa Dr14:00 - 15:00e RAPLOA forms Dr Takou15:15 - 16:00teamsofa Dr T,16:00 - 17:00 Role SaturdaY selected communitiesField exercise inSun 11'.15 - ..: : r,l 4CD ] tt, _.o :rL -o}i'L o oE E G'oo :=Lo $N :=L o_ oN :L o- N :=Lo N c\t :=L o_ @ :L o- @ :=L o_ o) _- Lo t-r :L o- $ :=L o- o C\t L o- __ Lo $ !- o N :=g o- NN o o(, o o .9 ,=tr EE o C' o olr =0, = q, E' tE -g E G,oF E(E oF r'iol sHldt>lLIfl * r >l olo .CI E .eml r(E-cl t > 6lgr t -c.l z. GlcDl* iPl, sl El =l €l >t -ot =gslEl 9:o.-r EIE !lYl0a oal o ofE(E m ooN oEo o)z *-l(Ei -lrlcl _ol <t NI olYI o -o -o c(E Eo m o =o =j -o E(U co o .v. 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Y (a (D'Y o .o-. Y '= o,o = o -ooLo = '6 o)c E o o- oL o oo L o o) .E Eo oE oc(5 (U .E o ofo lrJ E o .t, G' IU ,E an E oo o C o .U, o o- E oo iir .fl xlolcl cl <t co --'6'6 LLLL(Dq) LL cL o- (f' (f) C\l (\l ::LLoo c{ C\lCIN(()o{ -'6 Eo :Lo @ c\l :Lo C\l c\l :: =:LLLLoocLo- lolr)l(rro ot c{ (\l (\l Lo @ ::: =LLLLo-o-oo 1., ro lr, (,GIN(\IOI :::=:=LLLLLo-cLo-oo I-Fl-r\F ---FF o o(, o o .g c a E E o o os -oE LL(!o >Y -(\i C,,cca._ g d.D,F-Eiz o--o - E E-9 E EE 3_36'5S -C\i(fi+d (s Lq) o-oY - -Y,'-(U;i .9;o-z -oi =o(! J Bo o p E-E EPSg - o,i c.i + '= cot - (Ul =-v(EV (! H &Ee : L e.-E o 6'6'o>oY - oi <tj .+ 6 co -v, E(E !9=o E 5 E a=L L >\C, -gi58?= -oic.i+d o oll E o = C(U E E8 c$, 'o4 =(uo)c5O <J - c.,i .9E(E(EE =.E6aU)= o$ Eg - c.i (D C' ,J o .v)J o)co -cEOe(s= >j EEOE3oEl -cluo -cri (l)E EoJ (l) C(! E Elrl - 5 or(5a>J= -c (9Bs s5 - c.i Ega=aE o<co '<= (uccoE o-c>F - cli (U oc =gEorE9 =(DEA -rri o 0)oc '6 ot(U o E(E oF oL = -o ocoo p (g o =o = o(EF .Coq) ooa E o)oo I o o)oo _, '=(! o m o(u Eooo -(! (E o)aJ 6(E L .9 '6) =o =(E E(o CD ) =ooJ EoL o,C oI .o)d P.e i -g Eo o .o5<Nt- :OII E GoF o -ooLo N o) (E C '(E J (9 '6 (E c ,6 J t (D =o(E J lf, o) fooJ (o o) o)L oF N (l) -(D @ '6 o o)o 6 o) o) (D o '6 L o)x o) E o)iI $ oJ(L t o (g o TUt L ots oq)(,,(s I ct o EL E I l5 Anr]ex.5a: List of participants in Westem Equatoria Neh Joseph Abasi Kotobi DD Eboul Eluzai Fresser B. Yothoma John Filbert Su sor Mathew Guaso M i cou Gordon Gaba f Filbert Vic'tor medical fficer Anthony Aboro I Fzo uJarnes Elineo Khar5do Sevenlo Yenqere payam Fra ncis Andrew Su CDDElinama John Levi Gershom Jonathan Ezikia Maridi mSu Ernmanue! Phelemon f Su sor Ezo CDD Ezo D Titi Bakata Grace N. Abasi Emilia Diko Grace Jiraldo mbio Peter G. Jacob Yambio payam SuPervisor Martin Musura medical Officer MamLexon H. Abdalla Silvano Angotua Barnaba Mambe Charles Suliman Kozi John Kasara aridi mSu Mario Berewete Ti mSu or Peter Danahiningo M Su or Fresser Juma Maridi cou r Elia Tabani mSu Yam CDDBoniface Timon Lexon Frezeir B u Su Michael Baya Kazimillio Benet Mundri Ezo cou sor Sabino Philipo mbura CDD Sirnon Peter Tam m CDD Sirnon Ukes Tambura CDD Felix A. Unsbofi Tambura CDD TamburaSirnon Kesito Jacob Usumo Su sor ect Yambio CDD Yambio m Joseph Nalukayo lsaiah Awumbu Martin Samuel John Nakio John Peter Ezo Tito M. Amos lbba r Arkanqelo Basonqodo Naandi u John Ziqba Ezo Peter Thow Yambio CDD EIisa Angelo Jackson Abisai Yambio county Supervisor Titus Enosa Yambio Fasil Chane CBM, Rumbek Mike Salla coordinator Eva Cabatingan rMc e coordinator Samson P. Baba SSOTFF Coordinator David Bido a CDTI Data man SSOTF Rum coordinator Yambio Ceasar Longa Bendect Ariwa idi SU sor Maridi countv SuPervisor Nagero Kozi payam Supervisor Nzara T6 A!@5h: List of participants in Eastem Equatoria Moro Lasu CFIW Emrnanuel zama ama S Malish Gulumbi Su Alfred Bara CDD m Loice Atai Valentino Sebit Yei cr-lw Yei ei Ku CDD S Mowusi TicFaelLusalla Luka Luate Tabu m=EpM5ml Mori Thomas e Lasu r Wilson UP!! Di Pi OV member Pa OV member Buro member Gulum o sor u C cou ulo CDD mSu or dent Lafon Student Lafon Lafon cou Lafon cou Kimba C PO Su n/Finance officer o sor Yei r linical cou I n mSu i cou medical officer Pacidi mSu umule Jarnes Ruman Lidu U ced le Lona Araba Phi Peris Alex Mogga Abure Cons William De Leu Yasmin Simon Arike Rose Ru n Omo ae Mahlon Yousif Modi S rack Pudo Patric Cons Ginsa Dua hn Lori Cosmas Batali Paul Adawa Emma Selwa Yu u Andrua -Rictrard Wan -lacobnassan Joseph Hissen Nvaouqo Ubwoyee Otogo payam Su Otooo pavam Su Kneyi payam SuPervist c,o (g a o)oo o (,, c EOE X >o 0) o 5^L- G)IJ sE ag -grtsE !EE ta *9oe L (l)orl -OcEO 4to4- A)L tuolF(, z oJ ooooooFq I- c{ ooo C)oo o,q F.-6l oooooo(\tq F c! oooooo o,ol F c{ ooooootr) a F* c{ oooooo c.) oq t-c! oooooo@q Fc\ oo o,o(\It-r- oq t- c\l oooooo(o oj c{ ooooooro\ @ c{ oooooo(t, o,N oooooo c! o, c\l oooooo$tc! o,N o(f) (f)(v) @o@\ o,N ooooootq o,C\ oooooo o)\ o, c! oooo C)o@\ o,N o F(o @O)6l Ot c! ooooooN ,q o,N o o,@ @@ (f, o o; C\l oooooo@ro o, c{ ooooooo e? o) c{ tuolF F 5 oooooooo ,ri oooooo o, d oooooo c{o to oooooo(o rri oooooo@q(, oooooo rOq ro ooooooo(r) trj oo[oF c\l C\Ir- oq t ooooooo rf) + C)ooooo rr)q ro oooooo o,\!t oooooo q lo oooooo (f,\t oF(o(o r o)(oq(, ooooooF c\l ro oooooo d oooooo q $ o@NF-No@q $ oooooo c\tq $ o$t$ o, q s oooooot-\$ oooooo$ o) + r.u o 5J = .E (E E p(,)(u !o =o,(u L(u m ob(u i5 oN IU oLoa C, Ec(E oz L o -o E(u z .E (E E(E d) -o E(E(D CE -o -o o .v. =L(E = o 3o B aNoY _(U p -o oEo o,z o 6 LE(tr(D ,6 (D N CI, 3 f o)c o L(o .v.(E o)L = oEc =E(u o,z :o o(ot (L oN trJ o N lU oN tu oN ul oN TU oN IU oN I,IJ oN tu (Eo -o (Uo -o (u -o -o (u -o -o (E -o -o oNoY q) No !< o) -o E(u = o) -o E(E = E L$ = E L o = E L(u = € L(u E L(! 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Lo (g o tu o(l) = (E L a o) = (5l L o (E =o UJ U'(l) = o Lo (g =o ul aq) = (E o C,)ou oq) = .slLo (E)o ul atq) = (t, L o o3(, u altq) = (I, L o oaou o o) = o L o o)q IU ao = (E g o (U Jo ul ]D o) = (EI Lo (E)o UI o o) E (! L o (E q ul a(l) = (! L o o =o ul aq) = (g q o (5 o uJ oq) = $ L o o =U ul o o) = o Lo (E C'tl U' o) = o L o oaq IU oq) = o L o (E o o) = Ct Lo o =q lU a o) B =l*,l* (oolloc!tol o(f)o,C\t@C\tf-c{ {*1*l: o)({)@c,F(f)@cf, t-$(otrJ)t$t @ \t II l ll o .v =L(g +l*l* co o a o)o -o o o -o '-o tt,ooooE (l) E ooooo(g o -oo art o)() o(E E -9 -o oo o,oo(E E o)EtsoEP>b oo5^L= (DLI sE Ag Fq C\l(o (aq F C\I (o\ (o tr)\ (f, l() o, o,t tq t-(f, -grtsE EEEFa (o c., C! 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