COM MUNIW DIRECTED TREATM ENT WITH IVERMECTIN

ONCHOCERCIASIS CONTROL ^{PROG RAM ME}

rN wEsT

AFRTCA (OCP)

COM MUNIW ^{DIRECTED TREATM ENT} WITH IVERMECTIN

FOR HEALTH PROFESSIONALS

Field work and training manual

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WORLD HEALTH ORGANISATION

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Control of

Oncl-rocerclasls...

...41

.

Approaches to ivermectin distribution in the community ...44

.

First contact with the comrnunity

.

How the CDTI programme works

.

The information system for the CDTI prograrrune

.

Iverrnectin:generalinfonnation

.

Side-effects of ivermectin

'

CHECKLISTS:

.

Calculating the amount of ivermectin to order

.

Examples of repoft forms Teaching materials

.

_HANDOUTS:

.

Onchocerciasis and its management

Student assessment

.

Assessrnent plan

t

Assessment form

..69 7t

PRBFACE

This modulc is intended for thc following categories of worker:

r

_{Nurscs in charge} of primary level clinics/ health centres.

r

District level supervisors of these nurses.

'

Officers from NGOs who are running community based ivermectin distribution programmes.

Trainers for this module should:

r

Have considerable

field

experience

of

community based ivermectin distribution.

!

_{Have had prcvious} experience as trainers.

This module is also suitable for in-service training. In such a case only the relevant sessions are used.

The training of village level distributors, and general information about onchocerciasis, are the subjects of other modules.

This rnanual has been prepared by Prof D Prozesky in collaboration with staff of

the Planning, Evaluation and Transfer Unit of OCP

-

especially Dr B Boatin, Dr K Siamevi, Dr W Soumbey Alley, Dr N Dembdle.Printing coordinated by Mr A Daribi

© Copyright Onchocerciasis Control Programme in West Africa (WHO/OCP) All rights reserved.

INTRODUCTION TO THE MODULE

Thc elirnination of onchoccrciasis as a disease of public health impofiance is achievcd by two major strategies:

r

Interruption of transmission by thc blackfly - this is achieved through larviciding.

.

_{Yearly treatmcnt} of villagers in affected areas with ivermectin.

Larviciding

will

have achieved its aims by the year 2002. when OCP ceases operations. However ivermectin distribution

will

^have to continue in many areas

for

some

time

after that. Ivermectin distribution

is

also the only practical lneans available

at

present

of

controlling recrudescence

of

the disease, if this should occur.

At first ivemectin

was distributed

in the

villages

by

teams

of

health workers working directly

for

OCP. These teams visited each affected village yearly, and themselves gave out the treatment. They have now been discontinued, since it was decided that countries needed to start organising this progranlne themselves, in preparation for the year 2002.

This approach has now been replaced by the so-called CDTI (Cornmunity Directcd Trcatment with lvermectin) approach. ln this approach:

,

_{Villagcrs choose} whether to takc ivcrmcctin regularly, and

if

they ^do, plan thernselves how they want to do it.

.

_{Villagers selectcd}

_{by thcir}

villages are trained as distributors. They administcr thc ivennectin in their villagc ycarly, or twice yearly.

These villagers are trained and supervised

by

nurses working

in

^the

frontlinc

prirnary health centres,

who also order and

supply ^the ivermectin that is needed.

.

_The nurses themselves are supervised and supported in this activity by their district and regional managers, and also by the person in charge

of

the national onchocerciasis programme. Each level orders and supplies the ivermectin that is needed.

At the end of the module district manogers ^need to be able to perform the following additional ^tasks :

.

_Makc and implcment

a

plan

to

monitor and support the ivetmectin distribution

a.tiriti.,

^{of health centres in} their district yearly, ^through including the CDTI programme in the 'minimum ^package of activities' for that level.

.

_Motivatc health centre ^nurses to continue with thc CDTI programlne.

.

Calculate the amount of ivermectin needed for the sub-districts in his/

her district for ^{the year, and order} it from the regional headquarters.

.

_{Write a} yearly report about the CDTI ^programme for his/ her catchment area, using the standard forms provided.

At the end of the module all trainees ^have to be able to:

.

Discuss briefly how onchocerciasis is caused; its symptoms ^and signs;

its treatment ^and Prevention.

.

_Describe in detail how a CDTI ^programme is supposed to operate'

I

Discuss the differcnce ^between community based and community directed ivermectin distribution, ^and their relative advantages and disadvantages.

,

_List the three criteria whereby successful ivermectin distribution programmes are judged.

r

Discuss the following ^aspects of the drug ivermectin: formulation;

dosagc schedule; indications ^and contra-indications; side-effects ^and their rnanagcment; duration of ^treatment'

PRACTICAL ARRANGEMENTS

Being a motivator and organiser for village level ivermectin distribution is a skill ^- or more precisely, a group of skills. Trainees leam skills by:

'

^Seeing them demonstrated by someone who is an expeft.

r

Performing them themselves under supervision.

r

_Getting feedback on their performance, so they can improve.

Some

of

the skills are office based (planning, reporting, ordering) while others are village based (training, educating). The ovcrall module timetable

will

thereforc look like this:

.

Preparatory classroom work.

.

Field trip to a village.

'

Further classroom work and assessment.

A

detailed tirnetable

is

given

in

the next section. The content must be considered rrore or less fixed, but the timing should be altered to

fit

in with the local situation.

It is

assumed that a team

of

at least

two

(preferably three) experienced trainers from Head Office and/or the regional office

will

be conducting the training.

An imporlant skill the trainees leam here is that of training. Each has to get a turn to train distributors in the village, which lncans that the trainee group cannot be too big. About four is probably the maximum in a village - so

if

larger numbers of trainees are taken, more than one village

will

have to be used simultancously.

The course is 3 % days long and looks like this:

r

_{Two days in class}

'

^{One full day in the field}

.

_{Half a day in class.}

It is likely that thc

classroom

training will be

done

at the

district headquarters, so therc should be

a

suitable village nearby.

This

should

Two visits

arc needed

to

stafi

up

the programme

in a

village: one to introduce the CDTI proramme, and another to train the distributors:

.

_{Ideally trainees should practise both of thcse in thc ficld. However} the

timc

interval between

the two

visits may

bc

quite long, since ^the villagers need timc to make their decisions.

t

_{How to undertake} the first visit

will

thereforc be leamed in a role ^play.

The second visit

will

be practiscd in the ficld, in a village.

Before this training takcs placc the trainers

will

therefore have to do the first visit to ^a suitable village, to motivate them to become part of the CDTI programme; to ask thern

if

they want to participate; to ask them to decide how to run it, and to sclect distributors; to ask them to prepare for a second visit whcn training

will

take place . Note that:

'

^{Thc datc for} the training of the distributors is set to coincidc with the training course for thc nurscs and their managers.

.

_{Therc should be another visit a few days} before thc retum visit, to ^make surc that cverything is still in order.

'

Villagers should be clear that they have to providc a notebook, a ^pen and a stick 2 metres long.

The choice of village for the training is imporlant. CDTI should not be in operation there yet; but

if

it is, new distributors must be trained.

In

casc the

first

village doesn't work out (e.g. because

of

an unexpected cvent

likc a

funeral)

it is

as

well to

rnake anangements

with a

^second

village, just in case.

Arrangements

for

transpoft and mcals for the field

trip

have to be ^made well in advance.

We assume that nurses learn certain skills during their basic training, ^and practise them continually.

It

is therefore not ^necessary to include them in this course. Examplcs:

r

Treating colnlnon ailmcnts.

'

Communicating health messages effectively.

There are plenty of materials to be prepared before the course starts:

.

_Trainers are advised to go through the plan for each session, where the materials needed are clearly stated, and make sure they have everything ready that is needed.

r

_{They need}

_{to get}

_copies

_of

_handouts, checklists, and

the

training manual 'Community directed treatment

with

ivermectin

- CDTI

(for village distributors)' ready for each trainee as well.

r

_{At the} beginning of the course each trainee gets a copy of the manual to work with and to keep.

The

nurses

who ate coming on the

course

also

need

to

^prepare.

Specifically,

they

need

to find out the

names

and, if

^{possible, the}

populations of all the villages in their catchment area.

This is more than a training exercise -

it

is also an exercise in planning and administration:

.

_The different levels of the health service plan how to cooperate in ^the new programme.The health centre nurses make lists of the villages they have to deal with.

.

_{Each level} plans how it

will

support the next.

'

^{Specific plans are made} for ordering and distributing ivermectin.

.

_{Issues like transport} are addressed,

DETAILED COURSE TIMETABLE

DAY

1

Morning: Classroom Session

Session

I Introduction to the course

Time

08h00-08h50

Content r

Course objectives, practical arrangements.

Method

^I

a

lntroductions - trainers and trainees.

Trainer introduces the objectives of the course

o Time for

trainees

to ask

questions, discuss, clarifu.

Trainer hands out course timetable, goes through

it

with trainees.

Trainer

discusses

practical

arrangements with trainees: accommodation, transport etc.

Materials

^Handout of course timetable.

Session

2 Onchocerciasis

Time

09h00-09h50

Content r

Onchocerciasis: how it is caused and spread.

.

Onchocerciasis: symptoms and signs.

r

The treatment of onchocerciasis.

!

_The control ofonchocerciasis.

Method r

^{This sessions is best done as} a discussion, since the

trainees may know a lot already

about onchocerciasis. The trainer introduces each

of

^the

topics above; ^asks what students know; adds what they don't know.

r _{At the}

_end

_he

_asks:

_{'So what is the part}

that ivermectin plays

in

onchocerciasis? And why

is it

so important?'

Materials

^Handout: 'Onchocerciasis and its management'.

Session

3 Approaches to ivermectin distribution

Time

10h00-10h50

Content ' j'":1ffi:ir;ru,",m:H,,Hil,ffi;*

o

Community directed: 'owned'by villagers.

.

The advantages/ disadvantages ofeach approach.

.

Choosingthe'communitydirected'approach.

Method r Short input from

trainer,

OR

gives handout to trainees to read.

.

Then discussion about the differences between the three approaches - especially between (2) and (3).

.

Discussion about the advantages/ diadvantages

of

each.

.

_{Trainer asks:}

_{why we}

_{are using}

_the

_'community

directed' approach? Trainees debate and

one of

them summarises at the end.

Materials

Handout: 'Approaches to ivermectin distribution in the community'.

I

l '1

i

Session

4 Organisation of the CDTI programme

Time

l lh00-12h00

Content '

Starting up the progralnme in the villages in an area.

.

Continuing with ^{the programme year} by year.P

Method Trainer gives out handout: 'How the

CDTI programme

works'. Trainees read it

^through

together in groups of two or three.

Trainer leads

discussion

on each point,

until everyone is quite clear.

Materials

Handout: 'How ^the CDTI ^programme works'.

Afternoon: Classroom Session

Session

5 Ivermectin and it side-effects

Time

15h00-16h30

Content '

Appearance, cost, source, storage.

r

_{How it works.}

.

Indications/contra-indications.

.

_{Frequency and route} of administration, dosage.

r

Community views and misconceptions.

r

Side-effects and their treatment.

r

_{Reporting severe reactions} to ivermectin.

Method r

Trainer gives

out

handouts: 'Ivermectin: ^general information' and'S ide-effects of ivermectin'.

. _{Trainer and}

_trainees

_{work through}

_{each point}

together, discussing it until everyone is clear.

r

Trainer gives each trainee

2

copies

of the

fonn 'Rcport

of

serious side-effects due

to

ivermectin' - one to keep as an example, one to use now

in

the exercisc.

. Each trainee

prepares

such a report,

using information read out by the trainer. Afterwards they and the trainer check each other's efforts and give feedback.

.

Short discussion on how the completed form must be sent to the district office, then to Head Office.

Materials .

_Handouts: 'Ivermectin: general information' and 'Side-effects of ivermectin'.

.

_{Enough copies} of the form: 'Report on serious side- effects due to ivermectin'.

r

Information about a case with serious side-effects due to ivermectin, to read out for the exercise above.

Scssion 6

Making a list of villages Time

^{I 6h40- I 7h30}

Content If

an area is designated

for

ivermectin distribution by the National Office, all the villages and hamlets in it must be covered.

The health

centres

who will run the

CDTI programme have to divide up the villages between them, so that no village is left out.

Method

Trainers (who are also Head

Officc

staff) present the information about which areas and villages are

to be covered.

The nurses come

with

prepared information about

the population

of the

villages

in their

catchment area.

Using their local

knowledge,

the

health centre nurses and district managers allocate specific areas

and villages

to

each health centre.

A

rough

list

^is

made for ^each health centre.

Each

list is

presented

to the

group. Discussion follows under these headings: are

we

leaving out any villages/ hamlets? is there any duplication?

At

the end, each nurse makes a neat,

final

list.

A

copy is given to thc district managers.

Materials A

Head Office information about villages that have

to

be covered mass distribution by teams).

Paper and pens.

the area and the

(from the era

of

Session

7 _{Making the} first order of ivermectin

Time

17h40-18h15

Content

Calculating what is needed systernatically.

Method Trainer

explains: nurses

have to havc

enough

ivermectin with them before they can

stafi implernenting CDTI.

Trainers present available information about ^the population of the villages concerned.

Trainees use this knowledge, and their own knowledge

ofthcir area, to allocate a population to each village on their list. They work out the total population

of

the villages of their health centre catchment area.

Thcy

work out

the number

of

ivermectin tablets they necd: population x 3.

They fill in the

routine national order

form if

applicable,

or

makc their own 'Yearly sub-district ivermectin order'for ivermectin. They make a copy, and hand the original to the district managers.

NOTE:

This ivermectin should be handed to the nurses at the end ofthe course, before they leave.

I

_The trainer points out that a different system is used

for

the yearly orders

-

this is going to bc learnt in Session 15.

Materials r _A

Head Office information about the population

of villages in the area (from the cra of

^lnass

distribution by teams).

r

Paper and pens.

'

^{Copies of} the 'Yearly sub-district ivermectin order' forms.

DAY ²

Morning: Classroom Session

Session 8

The first visit to a village

Time

07h00-09hs0

Content .

The importance

of

doing the

first visit well:

good and bad approaches.

.

Thc information the village needs to have.

.

Exactly what we

will

ask the villagers to do.

Method

Trainer asks trainees

to

recap what they learnt in Session

2

about

the 3

approaches

to

ivermectin distribution.

Trainces

get

handouts:

'First

contact

with

^the

community'and'How the CDTI ^programme works'.

o All

read the

first

one quietly

-

followed

by

a disussion of its main points.

o

Second handout:

all work

through the section on'The first visit' together.

Short discussion about different kinds

of

authority in villages in the area, and how to approach each.

Group discussion about what

to tell tl,e

villagers about CDTI ^at the first visit - trainer summarises on blackboard.

Group discussion about what to ask villagers to do for CDTI - trainer summarises on blackboard.

Each trainee prepares a little memo they can use to guide themselves during such a meeting.

Role play: one trainee plays a nurse arriving at a

village, trainers and other trainees play chief and

villagers (the

trainee uses

the

memo

s/he

has

prepared). After the play the trainee gets feedback from the others, using the material in'The first visit'

as a checklist.

If

there is time repeat the play to give other trainees a chance.

r

_{Trainer asks}

_a

_trainee

_to

_summarise

_the

lessons learnt.

Materials

Handouts: 'How ^the CDTI prograrnme works'; 'Firsl contact with the community'.

Blackboard and chalk.

session

9 _{Key messages for the village} distributors

Time

10h00-1Ohs0

Content .

Distributors need

to know

more than

the

other villagers.

t _{The facts they need} to know deal

with:

onchocerciasis in general; ivermectin.

Method

Trainees

use their village distributor

training manuals.

Each trainee

reads

through the

two

handouts: 'Ivermectin - the medicine

for onchocerciasis'

and

'Onchocerciasis

and

^its

management'.

Discussion about what they have read

-

whether they think more or fewer key messages are needed;

which are the most important.

Materials ^The manual 'Community directed

treatment _with ivermectin - for village distributors'.

Session

10 Skills village distributors need to learn

Time

^{r rh00-12h00}

Content

^I

! I

The distributor's record system - thc notebook.

The hand-ear test for detennining children's age.

Preparing a measuring rod.

Method

^Trainees

use their village distributor

training manuals.

Tliey look at the

checklist:

'How

to complete the notebook properly.'

A

demonstration notcbook is passed around for ^thern to see.

.

They discuss any problems they have.

o

Each trainee prepares

a

page

for

'Recording ivermectin distributed

to

a family.' The trainer reads out a few examples from a family, which

the

trainees

fill in on the

pages

they

have prepared. They check each other.

o

The trainer summarises: the important thing ^is to have a simple, reliable system.

A ^quick

demonstration

of the

hand-ear test for children - the arm must go over the head.

Trainees

are

shown

a rod

villagers

can

use to measure height. Using the tape rleasure and knife, each makes their own. The traincr points out that they

will

^{use the one} they make now as an example when they conduct training themselves back home.

Materials The

manual 'Community directed treatment with ivennectin - for village distributors'.

A demonstration notebook with an example of ^each

of thc two kinds of

^pages

villagers need

to complete, prepared by hand.

A notebook page for each trainee.

A demonstration measuring rod.

Enough straight sticks to make a rod for each traince.

A measuring tape and a knife.

I t I

!

Afternoon: Classroom Session

Session

11 Stocking and dispensing ivermectin

Time

15h00-15h50

Content r

^{Keeping record} of ivermectin

.

_{Making and keeping a} stock book.

Method '

^Short input from trainer: ivermectin can't just follow

the

same system as

the

other drugs, since

it

is

specially donated and is dispensed by villagers.

.

Discussion: ask trainees how they plan

to

do and record receiving, stocking, issuing. Show examples of receipt, register for comments.

.

Finally group makes definite decision on how they

are going to keep the

records.

They

prepare examples

of the

necessary forms

for

themselves there and then.

r

_{Trainer stresses} importance

of

keeping copies

of

everything.

Materials t

Paper and pens.

r

Examples of receipt and stock sheet.

Session 12

Preparing to train the distributors

Time

^{I 6h00- r 8h00}

Content

^{How to use the} village distributor training manual.

Method

Trainecs

work in ^pairs, under

supcrvision

of

trainers:

o First they familiarise

themselvcs

with

^the

training manual'Community directed ^treatment witl, ivermectin - for village distributors'.

.

Tl-ris is discussed with the trainers to clarify ^any problems.

o

Thcn

(if

there is time) each trainec 'teaches' the other somc of the sessions.

Finally the trainer makes practical arrangements for thc next day:

o

When to leave, who is going to which village, what they have to take with them.

.

Who is going to teach which session (there are 8 sessions to be taught).

That evening each trainee ^prepares thoroughly for the sessions sihe

will

teach - also the materials s/he

will

use.

Materials ^The manual 'Community directed

treatment with ivermectin - for village distributors'.

Session

12a In the evening

Trainees prepare their teaching sessions for the next day.

Trainers assess the skills ^trainees leamt during Day 2, using the skills assessm ent form.

DAY 3

AII day: Practical in the village

Session 13

Training village distributors

Time

^{The whole day}

will

be needed - ^get there early!.

Content

^I

I

Training the village distributors.

Assessing the village distributors.

Method

^Upon

arrival the

team goes

to

greet

the

village chief, and to meet the chosen distributors. They find

out what

method

of

treatment

the village

has

decided to use.

A

suitable place for the training is agreed upon. The trainees take the initiative; the trainers observe.

Each trainee

in

turn teaches the sessions s/he has

prepared.

The trainers and the other

trainees observe.

At the

end

of

each session feedback is

given to the'traincr'.

During Session 5 'Doing the census and treatment' they use the method of arranging treatment that the village has decided upon.

Before leaving arrangements are made

with

the

distributor

to

complete the

job,

_and

to visit

^the

health centre with his notebook to report when he is through.

Materials r

Each trainee has

his/ her copy of the

manual 'Community directed treatment with ivermectin - for village distributors'..

' ^Enough

^ivermectin

measuring rod, handouts village.

tablets,

demonstration and checklists to leave in

Session

13a In the evening

r

Trainees learn for their test the next day

r

Trainers prepare test questions for the written test.

.

_{Trainers assess} the skills trainees leamt during Day 3, using the skills assessment form.

DAY 4

Morning: Classroom session

This is a parallel session. The class splits into two groups.

A.

^{Session plan}

_for

^{health centre} staff (who will actually train the village distribators)

Session

14 Yearly reporting

Time

07h00-08h00

Content '

Completing yearly reporl forms required ⁽² kinds).

r

Completing the yearly order form for ivermectin.

Method Short input from trainer

about

the

information

system for CDTI, using the handout

'The information system for the CDTI programme'.

Trainer gives each trainee two copies of each form.

One must be kept (since trainees

will

copy them each year when making thcir reporls) and one

will

be used now in the exercises in class.

Trainer shows an example

of

a completed 'Yearly village repoft form'.

Each trainee prepares such a form, using the data from a village distributor's notebook.

Trainer shows an example

of

a completed 'Yearly sub-district report form'.

Each trainee prepares such a

fonn,

using thc data from the form they prepared above, as well as about 5 other'Yearly village report forms'supplied by the trainer.

r

_Trainees (and trainer) check each other's forms and give feedback.

Materials r

Enough examples of ^each blank form.

.

Enough examples of each form correctly completed.

r

_Photocopy

_{of one}

_complete

_village

distributor's notebook for each traincc.

'

^'Yearly village report fonns' from

5

othcr villages for each trainee.

'

^Handout: 'The information system

for the

CDTI programmc'.

B.

^{Session plan}

_for

^health district managers (who only need to supervise the training oJ'the village distributors)

Session 14

Yearly reporting

Time

07h00-08h00

Content '

Completing the yearly report form required.

'

Completing the yearly order form for ivcrmectin.

Method Shorl input from trainer

about

the

inforrnation

system for CDTI, using the handout

'The information system for ^the CDTI programme'.

Trainer gives each trainee two copics of thir repoft form. One must be kept (since trainees

will

copy them each year whcn making their reporls) and one

will

be used now in the exercises in class.

Trainer shows an cxample

of

a completed 'Yearly district report form'.

Each trainec prcpares such a form, using the data

frorn

about

5 'Yearly

sub-district

report

forms' supplied by the trainer.

'

^Trainees (and trainer) check each other's fonns and give feedback.

'

Since there

will

be some time left, trainees may now

join

the other half of the ^class to see what has tc ^bc done at sub-district level.

Materials r

Enough examples of ^each blank form.

r

Enough examples of each form correctly completed.

. _'Yearly

sub-district

report forms' from 5

^sub-

districts for ^each trainee.

r

_Handout: 'The information system

for the

CDTI programme'.

Session

15 _Making a yearly order for ivermectin

Time

08h10-08h50

Content '

Calculating the amount of ivermectin nceded for the coming ^year.

'

Completing the yearly ordcr form for ivermectin.

Method '

Trainer gives each trainec two copies of the 'Yearly sub-district ivetmectin order'form (or _{the form} that

is

being routinely used

for

ordering drugs

in

the country). One must be kept (since trainees

will

copy

it

each year when rnaking their ordcr) and one

will

bc used now in the exercise in class.

'

Trainer gives out handout: 'Calculating the amount

of

ivermectin to order', goes through it with ^the trainees.

,

Each trainec prepares such

an

order, using the

:t'"##t,T3il"t'.",10-o'r,.,", reporr rorm,

they prepared in Session 14.

Information given by the trainer: about a village that didn't participate properly, and about the prcsent amount

of

ivermectin

in the

^health

centre dispensary.

r

Trainees and trainer check each other's orders and givc feedback.

r _A

short discussion about how district ^rnanagers

will

rnakc their order (simply adding togcther the ^sub- district orders).

Materials '

^{Examples of the blank order form.}

' ^Thc

^completed

^'Yearly

sub-district report forms' from the previous session.

'

Information about

a

village that didn't cooperate, and present stock levels, to givc to trainees during the exercisc.

This is a parallel session. The class splits into two groups.

A.

^{Session plan}

_for

healtlt centre staff (who will octually train the village distributors)

Scssion 16

Monitoring and supporting

Time

09h00h-09hs0

Content

^I

t

Monitoring the CDTI programme.

Motivating village distributors to continue with the programme.

Method

Discussion with trainees about problems that could arise

with CDTI

at village level; how one would become aware

of

them; what one could do about them.

Practical monitoring: trainees work out together:

o

How they can

fit

in monitoring CDTI with their other village visits.

o

What exactly they must monitor for CDTI.

o If they

have

a

special checklist

for

village visits, how they can add CDTI to it.

Discussion

with

trainees about rnotivating villages and distributors who are doing well, and those who are not.

Materials

^None.

B.

^{Session plan}

_for

health district managers (who only need to supervise the training of the village distributors)

Session

16 Monitoring and supporting

Time

09h00h-09h50

Content

^!

I

Monitoring the CDTI programme.

Motivating health centre nurses to continue with the programme.

Method

Discussion with trainees about problems that could arise

with CDTI at

health centre level;

how

one

would become aware

of

them; what one could do about them.

Practical monitoring: trainees

work out

how they can

fit in

monitoring CDTI

with

their supervisory visits to the health centres.

r

_In particular they discuss how to add CDTI to the supervisory checklists they use.

r

Discussion

with

trainees about motivating health centre nurses who are doing well, and those who are not.

Materials

^None.

Session

17 _{Written test}

Time

10h00-10h50

Content

Questions covering

all the

knowledge and decisions trainees have to ^learn - dealing with 'must knows'rather than'nice to knows'.

Method

^I

!

Written test.

While the trainees are writing the trainers meet to finally assess all the trainees' practical skills, using

the

skills assessment sheet, and

work out a

total

mark. They

decide

who

passes

and fails

^the

practical.

One trainer goes to take Session 17, the others stay behind to mark the papers and to prepare the sheet

with the final results.

Materials

^!

I

Prepared questions.

Skills assessment forms.

Session

18 Funding, materials and transport

Time

^{I lh00-l lh50}

Content

^Practical affangements for the resources the programmc

will

nccd.

MethOd ^NOTE:

^{One trainer takes this session while the others mark}

the tests.

r

_{This is the time for} everyone present to plan exactly

how to

proceed.

This will

take

the form of

a :

"' in;:';J',r ffi fl

^"

:il'

"fJ.',: 1""

un

ⁱ n,. grat

e

rhe

visits

to

the villages

for

CDTI,

with

the other visits that they already do (e.g. EPI).

Transport

to

get

to

the villages: where

it will

come from, who

will

pay for fuel.

Subsistence

(if

any) when the nurse is out in the field.

The

timetable

for

ivermectin ordering and supply.

Any other

practical arrangements needed to implernent CDTI in that area.

.

_{The trainer's} task is to make sure all these areas are covered, and that there is a clear way forward in all of them.

If

possible, each nurse gets the ivermectin s/hc needs now.

'

^Finally each nurse makes

a

timetable

for

his/ her two visits to the villages on his/ her list. The district manager gets a copy.

Materials r

_Enough ivermectin for all learners attending.

.

Paper and pens.

Session

19 Closing ceremony

Time

t2h00-12h20

Method

The results are put up on a notice board before the ceremony.

The usual: thank yous, handing out ofattendance certificates and enjoying a snack.

ONCHOCERCIASTS AND ITS MANAGEMENT

Onclroccrciasis is a disease caused by the macrofilaria Onchocerca volvulus, which invades the subcutaneous tissues of thc body.

The

life

cycle

of

Onchocercil volvulus

Within a year the femalc worm starts producing n-rilIions of microfilariae, which migrate to the skin of the inf'ected person.

The adult worms live for about l5 vears.

When the blackfly bites a hunran again, the larvae are introdnccd into thc skin of

this individual. Thc larvac grorv into adultl-rood in the subcutancous tissues of

the new victim.

After going througl.r a few larval stages and a pupal stage, the adult flies emerge flom the water 7-10 days after the eggs werc laid.

The female blackfly Simulium needs blood meals before she can lay her eggs. When she bites an infectcd person _she ir-rgests some of thc microfilariae together with thc blood.

The eggs hatch and the larvae livc in the water, attached to objects like leaves, sticks and stones. They need oxygen rich water to thrive, which is why ^the fly lays her cggs ncxt to f'ast

flowing water.

The microfilariae ^go through three larval stages in the blackfly. The last one migratcs to the head and mouthpiece of the fly.

The

life

cycle of

the blackfly Simulium

After taking a blood rneal thc femalc backfly lays her eggs at the edge of fast flowing streams and rivers.

A f-emalc blackfly taking a bloocl mcal

Blackfly eggs attachecl to a stick

'

^{The adult female}

^fly

^{lays a} large number of eggs every 4 to 5 days

of

her short lifc. Bctwcen every egg laying she has to take a blood meal.

She

will

therefore bite several humans, at an interval of a week or so.

This makcs her an ideal vector for the parasite.

'

^The blackflies clearly prefer living close to rivers, and that is where most cases of onchocerciasis are found (hence the old name 'river blindness'). However a single fly can migrate a hundrcd kilometres or more, especially if assisted by strong winds.

Symptoms and signs

of

onchocerciasis

Almost all the symptoms and signs are caused by the microfilariae, and not by the adult worm.

'

^The most common symptom

is

itching, which

is

caused

by

body's reaction to microfilariae dying

in

the skin.

It is

severe and continues day and nieht. This leads to the followins clinical signs:

o

An onchocercal dermatitis - small papules.

.

'Lizard skin' - areas of roughening.

o

'Leopard skin' - areas of depigmentation (especially on the lower limbs).

As the

number

of

microfilariae

in the body

increases, increasing numbers find thcir way to the eyes. Every part of the eye is eventually affected by inflammation, tissue damage and scarring. This leads to a

gradual loss

of

vision, and eventually to irreversible blindness - often by as early as the age of thirty-five.

The adult worms may cause painless nodales under the skin. These are especially noticeable over bony parts like the skull and pelvis.

The constant itch (leading to lack of sleep), the slow loss of vision, ^and the effect of the high parasite load together have a profound effect on the quality of lrfe of the sufferers. They become weak, debilitated and depressed. In small children the heavy parasite load can interfere with growth and development, leading to a clinical syndrome refered to as

'onchocercal cretinism'.

Symptoms and signs

of

onchocerciasis

Itching f)nchoccrcal dcrmatitis 'Lizard _skin

'Leopard skin Nodulc on tlrc face Loss of ^vision

As a result of the disease many fertile river basins were abandoned by

their

populations,

with

profound economic conscquences

for

^the

countries concemed.

Diagnosis

of

onchocerciasis

The diagnosis is made by taking two small skin biopsies (over the left and

right

iliac

crests respectively) and examining them microscopically. The living microfilariae are easily observed emerging from the biopsies.

Taking skin biopsies

Treatment

of onchocerciasis

Until

about

l0

years ago there was no effective called diethyl-carbamazine (DEC) was tried, but effects.

The only drug we now have available well tolerated compound:

r

_{It is} highly effective as a microfilaricide. For this reason it immediately relieves the itching, and also causes early eye lesions to be reversed. It achieves these effects by being administered once a year.

r _It

_does not however

kill

the adult parasite, although it appears to lower the fertility of the female worrn.

More

detailed information about ivermectin and

its

use

is

given

in

^a

separate handout.

treatment known.

A

^drug

it

had many serious side-

CONTROL OF ONCHOCERCIASIS

In ordcr to control the diseasc wc have to brcak its cycle

of

trausrnission (man

-+

blackfly

-+

man). Two ways have been worked out of achicving this:

l.

Larviciding

Tlrc goal here is to eliminatc the vector Simulium by killing its laryae:

.

_Each

_river

_whcre

_it

_{brceds has}

_to

be idcntified. and an insccticide adrninistcred to each breeding site in those rivers once a weck.

.

_{This has mostly been done by} helicopter, but also on the ground and with boats.

r

_{The process has to be} continued for at lcast l 5 ycars, until all thc adult wonrs have died out and thcrc are no microfilariae left in skins of the population.

[-arvicicling by hclicoptcr

Ground larviciding

Larviciding by boat

2.

Commanity directed treatment with ivermectin (CDTI)

Ivermectin

is

administered

to

the whole population

of

the affected areas once a year (sometimes twice):

Such infrequent administration is sufficient since all microfilariae are

killed, and the fertility of the

female

worm is

dminished

for

^a

susbstantial period.

As a result transmission

of

the parasite is cut down

by

75% (but not halted completely).

The

administration

is

achieved done

by

enlisting

the help of

^the

villagers themselves.

Even those who feel well must be treated, since although their parasite load may be low they can still be sources of infection for others.

Larviciding is the most reliable and elfective woy of eliminating the disease. CDTI helps the larviciding to take effect rnore quickly, but is

not

sufficient

in itself to

achieve

control

where there

is a

high prevalence of the disease. In situations where the parasite load is low CDTI

will

probably be sufficient to control the disease, but it

will

have to continue yearly for many years.

Since 1974 the Onchocerciasis Control Programme (OCP) has been using these stratcgies to control the disease in West Africa - first only larviciding, then later CDTI as well. We now have a situation where the disease is no longer a public health threat.

In

addition, many thousands

of

^hectares

of

fertile land in river basins have been resettled.

APPROACHES TO IVERMECTIN DISTRIBUTION IN THE COMMUNITY

Since it became known that mass treatment of villages with ivermectin was essential for controlling onchocerciasis, three approaches have been used.

1. Treatment

of villages

by

mobile teams

of

health

workers

This was the strategy first used by the Onchocerciasis Control Programrne (OCP). Teams

of

health workers were employed by the programme ^and given transport. They visited

all

the villages

in

the area assigned to them every year, and gavc the treatment to the villagers.

Advantages

.

The great advantage is that one can be sure that the work is being done.

.

Because some tearn members were health workers (nurses for example) thcy could also treat other illnesses when they were in a villagc.

This madc villagers vcry happy about the visits.

Disadvantages

.

_{It is} very costly and countries cannot afford it.

.

Because they do not come from the area, the teams sometimes miss isolated villages.

.

Ifsomeone is absent, or pregnant, or sick during the team's visit, they miss the treatment.

.

As soon as the teams stop operating the ivermectin stops being distributed.

2. Community

based

treatment

In this

approach health workers

no

longer

go

around and

givc

out the ivermectin themselves.

In

stead,

local

health workers

from the

health centres go to the villages and ask the villagers to hclp with distributing the ivennectin every year. They tell them exactly how to go about it, and train someone

to do it

that way. The programme

still

'belongs'

to

the health workers - they are responsible for it, and the villagers just help them to do it.

Advantages

.

The great advantage is that it is much cheaper - the country can afford it in the long term.

.

_People who were absent, pregnant or sick can be given the treatment later, by the distributor in the village - and still in the same year.

Disadvantages

t

_{It takes a while to get it} going. In the rneantime, the disease is not standing still.

.

Sometimes the villagers do not cooperate well and abandon the programme. After all, they are being asked to help the nurses to do theirjob, and get no reward for that.

r

_{It places} a new burden on health workers who may already be overcommitted - they have to do the visits for motivation, training and follow-up.

3.

Community directed treatment

This approach is sirnilar to the second one, but with one important difference. In stead of being told how to go about the treatment, villagers are approached and asked if they want to have this programme in their village, on their own terms.

If

they do, they themselves have to decide how they want to tackle it. The health worker

will

only provide the necessary technical information and training. The programme therefore 'belongs'to the village.

Advontages

.

_This system has all the advantages

ofthe second one.

r

_In addition, research has shown that compliance is much better with this approach than with the second one.

This is not surprising - the villagers have accepted responsibility for the programme in their village, and have ownership of it.

Disadvantages

These are the same as for the second approach, but to a lesser degree:

.

_The villagers are much less likely to abandon the programme.

t

_It takes less ofthe health workers' tirne because it is more sustainable.

It should be clear why the third approach, the community directed one, is the one now being used in CDTI prograrnmes throughout Africa.