*-'
WHORLD HEALTH
ORGANIZATION ORGANISATION MONDIALE
DE I-A SANTE
ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFRIQTJE
DE L'OUEST
TRAINING MODULE FOR PERIPHERAL HEALTH WORKERS
ocP/EPL/DOC/94.21
INTRODUCTION
TheonchocerciasisControlProgramm"(:."].:."WestAfricahasbeenoperational
in the
savannaur"u. of
seven west-et i.ur, co.rr,tri.. (
Benin'
Burkina Faso' coted,Ivoire,Ghana, Mali, Niger uro
rogoj ;;."
1975. As from 1985 the operational area was widened to include:(a)
the western extension areas' comprising of Guinea, Guinea Bissau, western Mali, Senegal and Sierra leone and(b)
the Southern extension, made up of the southern parts of Benin, Ghana, Togo and COte d'Ivoire'ob
e41v9--q tbe Pro raElqgThe objective of the programme has Deen uu
""
r"*.
O"u"lop*"nt throughout theffiHJ:ij***r:ii;y"f tx};,:?,ffiTl:x':i::"i;illln'"",.main'lain
this achievement '
y of the Programme
rh is obj e ctive h as b e e n pur sue d thr ou:l
^tT.::1.fl"iil:?',HJf'": :liil'"i:l ,.,",ril;'*::ffi'::"H,'"T;:T;:: :J;i;";;."ftio,,
ot the Programme *rowever' since 1987/88, drug tfeatment--i'e r".,*"ai1 t'^"u"*
addedto the
control effortsprimar,y
to, *oruiaity
contror;the'fkst
objectiveof
the drug treatment beingto
treatinitiarly those at highest risk
of orr*
orrrrdness, with subsequent treatmentof all
thoseinfected with the Parasite'
white
the vector control activities have been carried out largely byocp
staff' thecontrol through chemotherapy has
u"".,
,rna"rtaken by national teams withocP
supportthrough ,u.g.
,.ui"-iir,riurti"n
of ivermectin. I-arge scale treatment has been confined to carefulry defined areas that satisfv set down criteria''n"'" "]:
n:::l;;J.t:T'il"t:it[1:
donotmeetthecriteriaforlargescaletreatment,butmayanddohavert who may ue treated through
ott,",
*".t,anisms, as for "*u,np'",through passive means.
The impact of these control measures have been measured,
among others, through
epidemiorogicar "uuluutio.rs carried out by nationar teams together
with
ocP
staff'*' "!-
2
With the reduction of the disease to levels at which
it
is no longer of public health and socioeconomic importancein
the respective countries larvicidingwill
ceaseor
hasceased. The countries are thus ushered into the phase of devolution which is the taking over by these countries from
the
OCP those activities whichwill
help maintain and strengthen OCP achievements.In
this respect and in the contextof
this manual the twomain
activities to be performed are epidemiological surveillance and treatment through ivermectin distribution.The aim of the
epidemiological surveillanceis to keep a watch on
theepidemiological situation through periodic active case detection, be in a position to promptly detect and confirm any possible recrudescence of infection and take the appropriate control action through ivermectin distribution.
The overall goal of this manual is
two-fold: i)
to train and equip the peripheral health staff to be able to diagnose and treat onchocerciasis cases by passive means andii)
to train staff at the district level to be able to undertake active epidemiological surveillance and large scale ivermectin distribution.A. GENERAL
a.
Peripheral health workers.
There are three levels of operation in the structure of the peripheral services:lrvel A -
Community level workers who are usually volunteers. They include community clinic attendant and traditonal birth attendant.lrvel
BIrvel
CBasic health institutional level with nurses and technicians.
District hospital from where the District Health Management Team operates.
It
is the seat of administration of district health delivery with personnel of higher qualification.b.
Objective of the trainingThe objectives of training are:
ffifi'u-
3
1.
to equip the level B and C peripheral health worker with the know-how and the ability to diagnose, take appropriate action when he is confronted with apatient
or
suspected caseof
onchocerciasis andto
manage onchocerciasis data.2.
to make it possible for trained level B and C health workers to undertake the training of levelA
health workers.3. to
equipthe level C
health workersto be able to
undertake active epidemiological surveillance and large scale ivermectin treatment.c.
Specific objectivesAt the end of the training programme the peripheral health workers, given the necessary tools, should be able to:
1.
Give an account of:-
The causative agent of the disease-
The vector that transmits the disease-
The mode of transmission of the disease-
Clinical manifestations of the disease (signs and symptoms)-
Complication(s) of the disease.-
Distribution of the disease in his country, and in the OCP area.-
Public health importance of the disease (ditto).-
Importance of migrants in the transmission of onchocerciasis.2.
Make presumptive diagnosis through-
relevant history taking;-
proper interpretation of early symptoms of disease;-
proper inspection and palpation of the body for identification of onchocercal lesions and possible nodule.3.
Make definitive diagnosis-
through filling in an appropriate Iaboratory form.-
sending suspected patient to an appropriate laboratory for skin snipping-
reading and interpreting correctly laboratory results when obtained.4.
Take an appropriate action by giving correct treatmentfilling in an appropriate form after treatment.
referring appropriately
6.
Train level A workers by:showing them simple clinical diagnosis on conhocerciasis;
encibling them to refer a presumptive and suspected case to a higher level.
This will be achieved through proper recording of data
proper filling in of records proper retrieval of records simple data analysis
management of new cases
correct interpretation of analysed data
timely transmission of analysed information to a higher level request for feedback on information.
8.
Health talks to infected individuals about the mode of transmission, symptoms and treatment of the disease.
Health education of the general public about early symptoms of the disease and the need to report such symptoms to the health auihorities.
use of visual aids to make the public understand the disease better.
(Annex 1)
organise an active epidemiological surveillance in selected villages Obtain and record characteristics of villages examined.
Undertake a census of the villages concerned.
Undertake parasitological examinations using the skin snip technique and microscopy analyse.
To organise and analyse data obtained from the above.
throush:
9.
1.0.
1.1.
t.2.
(Annex 2)
TRAINING
Parasite. vector. life cycle. clinical presentation Causative agent of disease
-
Agent : Onchocerca volvulus.-
Habitat - Sub-cutaneous tissues of man-
Adult worms are coiled togetherin
sub-cutaneous nodules which may be visible.-
Female worms produce millions of microfilaria, which spread throughout the skin and other organs including the eyes.The vector
- A
fly of the germs Simulium commonly called blackfly.-
Only a few of these species transmit the disease in min.-
These vector speciesof the
disease belongto the
Simulium damnosum complex.-
There are forest as well as savanna species.-
They are found mainly along watercourses because they breed in fast flowing waters.-
These flies are tiny, but can fly long distances, up to about 80 km in 24 hrs.They can fly even longer distances when they are aided by winds.
1.3. Breeding of fl,v (life cycle) (fig.1)
-
Eggs are laid by female adult fly on rock surfaces and debris just submerged in the turbulent areas of the flow, where oxygen concentration is high.-
Eggs require high concentration of orygen to develop.-
The eggs hatch into larvae, thento
pupae and eventually wingedflies. It
takes about 10
-
14 days for eggs to develop into winged flies.1..4. Transmission (tig.Z)
-
Duringft1 blood meal, (necessary for the development of its eggs), the adult female blackfly picks up microfilariae which are
in
the skin, together with blood.Life cycle of the blact flJr Fig-1
Real size about 2
nl
(rale) d
AOUTT
I
(Ferale)
\
Real
4m
gutE
?u ta
(in cocosrl
Ilevelops
into
adultnale or
fenaleRm-l st'^
7to8u
t1
lott
tAiYAL RWC
Source: -
OCp UATB.fAL- WManual
\
FIG.
2.
LIFE CYCLE OF ONCHOCERCA VOLVULUSOnchocerco volwlus
A
Mrcrof ilerirc\
Adulr in iubcutanGou5
/
Subcuttnrout trsrus
I I I I
I
through fly bira wound
tlltuc
HOMO
fi
SAPIENSI --
lntecrrvc rr.ec
I
\
Micro{rtrria in rkin
Mrgratlr to hcrd rnd proborcrr
#
SIMULIUM
/=
lngcatcd
/
Penetrat6 rtomach
/
acrc mutclel
ru
hd stage Larva @< (sauiage lorml Thor/
Iffya
t
The
Disease//
{it'
Fig-3
Arlult wornr.
Microfilariae
introduced by
flymatu
re in
su b-cu
taneous
tissu e s.Females
rneasure about50cnr.
Malcs about4cm.
Wormso[ botl:
sexes are found coiled togetherin nodules.
Nodules
tftl
It:_f
+g;r
People strffr:rinr; frorn onchor;orr:iasrs rrsually have nodulr:s rrr dil ir)roltt l)arts of tlrr: lrorly
I t.'
'-J'" I
_ +r; 7._. -
Ii,t!i
,1,
l
ii '/; llffi
9
The adult male fly feeds on plant juices and does not transmit the disease.
most of the
microfilariae ingestedare
imprisonedin the
peritrophic membrane and digested in the stomach of thefly.
Some manage to escape, pass through diffeient stages, penetrate and enter the muscles of the chest ofil"
ny urrJg"t
to the head where they develop into infective larvae; these different changes lasting 8to
10 days.The infective larvae enter the biting parts of fly and when next the fly feeds on man, the infective microfilariae are injected into the skin.
The infective larvae grow into maturity
in
the sub-cutaneous tissues where they couple, often forming nodules.These nodules contain male or female adult worms.
After about ayear, the female worm starts producing microfilariae into the skin, and the transmission cycle continues.
The adult female worm lives about L4-15 years before
it
dies.The life span of the microfilariae in the skin is at most two years.
1.5. Clinical manifestations of diseases L.5.1. Early signs and symptoms.
-
The symptoms associated with onchocerciasis are due to the presence of thesemicrofilariae in the skin and eyes.
-
Reddish rash associated with intense skin irritation, visible on a light skin.- Mild
and intermittent skin irritation-
Disturbance of sleep due to intense skin irritation'-
Scratch marks may be seen on skin.-
These different lesions are mainly found on the lowerpart of
the trunk, buttocks, thighs and legs.- In ,o-"'.urJr,
a fibrous tissue reaction occurs around the adult worms and produces nodules which can be seen and palpated, especially around the parts bt tt e body where the bone is superficial (head, chest and iliac crest).(Fig.3).L.5.2. I-ate signs and symPtoms.
- Wrinkled, dePigmented skin.
-
Iropard
skin - Visual disturbances - Blindness.10
The eye lesions result from invasion of different parts of the eye by microfilariae.
Note: It
is important to diagnose and treat before late signs appear.1.6. Comolications of the disease.
- The most serious complications are those associated with the eye. They include : Keratitis, which is inflammation of the cornea. These inflammations leave opacities on the cornea and affect sight.
Iridocyclitis which is inflammation of the iris, some small muscles in the eye, and which may lead to increased eye ball pressure.
Retinitis which is inflammation of the retina, a very sensitive part of the eye.
Inflammation of the optic nerve, the nerve that innervates the eye.
Blindness, which is a very late complication.
Other complications include unsightly leopard skin and nodules.
Constitutional disturbances from lack of sleep as a result of continued scratching of the skin.
1.7. Distribution
.
The disease has focal distribution in Africa, I-atin America and the Arabian Peninsula.. In
Werst\Africa,
the disease was presentin
its severe formin
the eleven countries covered by OCP, i.e., Benin, Burkina Faso, Cdte d'Ivoire, Ghana, Guinea, Guinea-Bissau, Mali, Niger, Senegal, Sierra Leone and Togo..
Infection is usually foundin
populations living about 10 km either side of rivers in these areas. One of the largest endemic areas in West African was along the Volta river basin.1.8. Public Health and socioeconomic Importance of the disease.
Prevalence of disease tends to be very high in endemic areas.
Very high microfilarial loads cause serious complications (blindness).
Fertile lands are abandoned by villagers because of nuisance of flies and fear of blindness.
11
'
I-owered production and productivity..
The btind become a burden on other members of the family andf or village and the nation..
I-owered outputof
school childrenin
endemic areasfrom
excessive skin scratching and lack of sleep.2.O. Makins oresumotive diasnosis.
2.1.
Proper history taking.-
Has patient got skin irritation or any other symptom suggestive of onchocercal infection?-
How long has he had these symptoms?-
Is itching severe enough to disturb sleep?-
Has patient ever reportedat a
health institutionwith
similar symptoms before?If
so which institution and what was he told was the problem?-
Has patient been diagnosed before as an oncho patient?-
Where does patient reside at present and for how long?-
Has patient stayed somewhere else other than where he is staying now?-
What is the occupation of the patient?-
Is patient taking drugs,if
so what drugs.-
Has patient changed the soap he uses for bath?2.2.
Interpretation of symptoms.-
Note that notall
skin irritations are due to onchocercal infection, thus the importance of taking a detailed history.- If
all other causes of skin irritation and or reddish rash are excluded, proceed to inspection and palpation of the body.-
L,ookout for
possiblenodules.
Differentiate nodulesfrom
other skin conditions like lipoma (soft, not tender), ganglion (turgid and found usually at small joints), inflammatory swellings (painful or tender to touch, may feel hot to touch) or haematoma (bleeding into the skin).12
3.0. Making definitive diagnosis.
-
Presence of microfilaria in snipped skin constitutes definitive diagnosis.For non-laboratory technician
- Fill in
correctly appropriateform to
requestskin
snipor
sendto
oneauthorised to make request.
-
Read and interpret correctly laboratory report.4.0. To take appropriate action.
4.1. - If
laboratory report is positive for O.volvulus, must be able to treat or refer appropriately for treatment.If
to treat, then.4.L.1.
-
Must be able to apply exclusion criteria for ivermectin treatment:a) children under 5 years.
b) weight less than 15 kg.
c)pregnant woman
d) lactating mother in the first week of lactation.
e) severely
ill
patient.4.1.2. Be able to read scale and determine what dosage should be given to an individual based on weight.
'
15 - 25 kg bodyweight
- Vz tablet'26
- 44 kg bodyweight -
1 tablet'45 - 6a kg body
weight -
1tlz tablets' 65
+
kg bodyweight
- 2 tablets.4.1.2.1. To repeat treatment yearly.
4.1.3. Proper address must be taken
to
be ableto
trace those patients excluded from treatment for subsequent treatment later on.4.L.4.
Fill
in correctly, the communicable diseases reporting form and send to appropriate place(s).4.L.5. Refer or inform appropriate quarters for necessary follow-up and or action.
13
5.0.
Manage data obtained through passive detection of cases5.1. -
Peripheral workers in general and record keeping officers in particular should be made to understand proper filing and retrieval of medical records.-
Medical assistants and nurses to know and understand record keeping in the consulting room for easy reference.-
Understand simple data analysis (old and new cases)Distribution of cases by month and by year.
Distribution of cases by age Distribution of cases by sex.
Distribution of cases by place of residence or locality.
- To
understand trendsin
distribution and therefore recognize any unusual signals of change early enough for action.- To
understandand write
monthlyand
annual reportsand
distribute appropriately.-
Proper recording of tablets of ivermectin used.Duties to be carried out by chief health post nurses in zone not on a large-scale treatment.
-
Identify among the patients all suspected cases of onchocerciasis.-
To treat with ivermectin all those not presenting a contraindication.- To
undertakea
migration studyon all
suspectedor
confirmed cases of onchocerciasis. (Annex 3).-
Record all these resultsin
a summary table.t4 Finalization
Country
1.
I-arge-scale treatment zone (monthly).If
the health workers of the district concerned took part in the large-scale treatment.District...
.Health sector Period..Villages Census
population
No. treated
Vo
No. of tablets
Observations
V1
v2
V3
2.
Zone not on a large-scale treatmentPeriod.
Villages No. of
CASCS
No.
treated
No. of tablets
Observations
15
DEVOLUTION OF THE ONCHOCERCI,ASIS CONTROL PROGRAMME IN WEST WEST AFRICA PASSIVE SURVEILI.A,NCE AND TREATMENT FORM FOR FIXED CENTRES
Peripho1.ury5 October, 1993.
Date Serial No.
Family Name &
First Name
Sex Age From Clinic Labo Weight in Kg
Ivermectin dosage
Reason
for non- treatment
Observations
CI D
CI G