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WORLD HEALTH

ORGANIZATION

ORGANISATION MONDIALE DE I-A SANTE

Onchocerciasis Control Programme in West Africa

Programme de lutte contre l'Onchocercose en Afrique de l'Ouest

REPORT OF THE MEETING ON THE STRENGTHENING OF EPIDEMIOI-OGICAL SURVEILI-ANCE FOR INTEG RATED ENDEMIC DISEASE CONTROL

IN

WEST AFRICA BUILDING ON OCP E)GERIENCE

Ouagadougou, 24 - 26 March, 1994.

1.

INTRODUCTION

A

meeting on "the strengthening of epidemiological surveillance for integrated endemic disease control in West Africa building on OCP experience" was held from 24 to 26 March 1994 at the headquarters of the Onchocerciasis Control Programme in West Africa (OCP).

The objective of the meeting was:

to identify the problems and constraints related to the integration of endemic disease control programmes in the context of the multidisease surveillance and

control approach;

-

to find solutions to such problems and overcome the constraints;

-

to study how the OCP managerial and operational experience and facilities could support multidisease surveillance and control programmes.

The

meeting was opened

by Dr

Ebrahim

M.

Samba,

ocp

^{Director, who}

welcomed all the participants and expressed his satisfaction at seeing that all the national officials responsible for preventive medicine, endemic diseases

orlpidemiolory

in the eleven OCP articipating Countries were present (see list of pticipants attached hereto as Annex 8).

He

then indicated

that the first

objective

of

OCP had been attained, i.e., onchocerciasis was no longer a public health problem or an obstacle to socioeconomic development. However, the second objective, i.e., helping the Participating Countries to maintain this achievement, was yet to be attained.

He therefore said that OCP would ensure the training

of

nationals and donor support

in

order

to

avoid getting back

to

square one after the external funding had ceased.

Dr M.

sidatt,

wHo

Representative, ouagadougou, and

Dr K. Mott,

chief, SCH/WHO-

CTD/TDR,

respectively, thanked thc participants and underscored the importance of the meeting from which concrete resuits

*erl

e*pected by all.

7

a

2.

^{ADOPTION OF} THE AGENDA

The

agenda proposed

by the

^chairman,

Dr F.K.

Wurapa, ^WHO/AFRO, Brazzaville, was adopted without any amendment.

3.

STRATEGIES

AND

NATIONAL PROGRAMMES

The eleven national officers in charge of preventive medicine, endemic ^diseases or epidemiolory reported on the present state of the strategies for the surveillance and control of endemic diseases in their respective countries.

Generally ^speaking, the different presentations highlighted:

- The

importance

of

epidemiological surveillance

to the

detection ^of

recrudescence and the taking of adequate measures.

- The

^generally

weak

capabilities

of the

Participating Countries ^for epidemiological surveillance.

The surveillance was passive and/or active depending

on

the diseases. ^The surveillance tools were generally:

periodic reports (monthly, quarterly, ^etc.) telegrams, official letters

reports on special surveys

telephone messages.

-

^The constraints related

to

epidemiological surveillance could, among ^other things, be summarized as follows:

vastness of some of the countries

communication and transport difficulties low health coverage

insufficient logistic, material and human resources

lack of staff motivation

weak national health information systems

the number and type of diseases selected in the devolution ^plans varied from one country to another but, generally, ^the following diseases could be selected:

dracunculosis, trypanosomiasis, malaria, schistosomiasis, leprosy, tuberculosis (see list of diseases selected in the devolution ^plans in Annex 7).

-

^The resurgence

of

some diseases which, hitherto, were not a public health problem; in ttris field, ^yaws, tuberculosis and tr)rpanosomiasis could be selected.

-

Although some diseases constituted a public health problem in s.ome countries, they were not yet the subject

of

a written and structured control ^programme.

They are schistosomiasis, yaws and lymphatic filariasis.

-

The reception of the surveillance reports varied from one country to another and depended on the time the transmission took. The coverage rate ranged from 79 to ^90Vo.

{

4.

-3- -

The lack of supervisory tools.

-

Integration difficulties at the operational (district) ^level.

-

The present needs, which emerged from the constraints, were mainly:

.

^staff training in terms of number and quality

.

financial resources available

.

staff motivation.

IDENTIFICATION OF ^{COMMON ELEMENTS} IN THE

^VARIOUS

PROGRAMMES

Four working groups were set up

to

identify common elements

in

the various programmes as regards:

-

health education (Group 1)

-

epidemiological surveillance (Group 2)

-

prevention and patient care (Group 3)

-

monitoring and evaluation (Group 4)

During the presentation of the ^results of the first session of the working groups,

the

different rapporteurs mentioned

the

difficulties encountered

in

^{starting the}

deliberations. However, the results available were presented.

After

some changes, guidelines were given to the participants with a view to a better organization of the rest of the deliberations.

Besides, Professor Molyneux ^proposed an outline which the working groups could use for the analysis of the different problems.

A

copy of this outline is attached to this document as an Annex 6.

After this presentation of the first results of their deliberations in the plenary, the working groups continued with their analysis of the themes entrusted to them.

The results of the working groups are attached hereto as annexes (2 to

5).

^It

should be noted that the time-limits did not allow the working groups to finish their subjects; nor the plenary session to discuss in depth the deliberations presented by these groups.

PROBLEMS IN IMPLEMENTING MULTIDISEASE SURVEILI-ANCE AND CONTROL PROGRAMMES

During one of the plenary sessions on 25 March 1994, the participants ^examined this subject at the ^same time as that concerning the improvement of integration. The following were the main points which emerged from the discussions:

-

Normally, the problems of integration should be posed and solved even before

the preparation

of the

devolution plans;

but

many reasons

did not

make it possible to go through this stage.

5

-4-

-

The integration of multidisease surveillance and control activities would pose

more diverse problems but this did not in any way detract from the relevance of the principle of an integration and should not lead to inaction. On the contrary, everything possible must be tried so as to carry out the integration of the activities successfully whenever possible and desirable.

- The

need

for the

States which had

not

done so yet,

to

prepare

a

clear integration policy which defined the role of the different actors.

-

The integration must not lead to a complete disruption of what existed already The existing facilities must absolutely be taken into account.

-

The need for a real decentralization of health care and of the implementation of the different programmes.

-

The problem of staff, in terms of number and quality, and their motivation was encountered in many cases.

-

The attitude of the donor partners was a deciding factor in the success of the implementation of the different programmes in an integrated framework.

USE

OF

OCP OPERATIONAL

AND MANAGERIAL

EXPERIENCE TO

IMPROVE INTEGRATION IN THE CONTEXT OF

MULTIDISEASE SURVEILT-ANCE AND CONTROL PROGRAMMES

This theme was dealt with by Professor Molyneux. After recalling the objectives assigned to OCP, he developed the factors which had contributed to the success of this Programme, viz., among other things:

-

existence of clearly defined objectives;

6

-

choosing of a realistic time-frame for the implementation of the programme;

-

use of appropriate technologies;

-

vincibility of the problem targeted;

-

signing of contracts with third parties for the implementation of specific tasks;

-

^{priority given} to operational research;

-

long-term commitment of all the partners involved in the implementation of the Programme;

-

permanent flow of transparent information, between all the actors, on the Programme' life through an excellent communication network;

-

establishment of an excellent transport system;

-

establishment of a significant data bank on the ^Programme.

-5-

Immediately after this presentation, Dr Ebrahim M. Samba, OCP Director, took the floor and developed the following theme:

7 USE OF OCP INFRASTRUCTURE AND PROCEDURES

IN

SUPPORT OF MULTIDISEASE SURVEILI-ANCE

AND

CONTROL PROGRAMMES AT THE REGIONAL LEVEL

The following points could be recalled from this important presentation:

-

Data collection and transmission: data collection and transmission in the whole Programme area had been possible, without any delay, because

of a

significant and effective radio communication system. Besides, this communication network ^had allowed a permanent flow of information without which enormous difficulties would ^{have been} experienced

in the field in the

implementation

of the

Programme. The speakers proposed that this communication system should be maintained and become the property of the Participating Countries after OCP had come to an end.

-

Satellite network: this network had played an invaluable role in vector control through the on-line transmission of hydrological data to the teams responsible for the treatment of the watercourses. It was proposed that this system be maintained even after OCP had come to an end.

-

l-aboratory network: because

of

the varied utilization possibilities

of

these laboratories, they could continue to render great services to the countries after ^{the end} of OCP.

-

Computer system: this system, which was

at

present unavoidable

in

^the

processing of epidemiological surveillance data, could render ^many other services to the countries.

-

Documentation system:

the

considerable

data bank

established

by

^the

Programme was a valuable tool which universities and researchers in other institutions in the Participating Countries could use.

-

^{Transport system:} the nature

of

OCP's activities had led

it ^to

^{establish an}

effective transpoft system which could be useful to the countries after OCP.

-

Staff: ninety-eight per cent

of

the OCP staff were

from

the Participating Countries. These workers could continue to render great services to the countries, even

after OCP.

8.

CLOSURE AND CONCLUSIONS

The closure of the meeting took place on Saturday,26 March 1994. ^{When the} meeting resumed, the draft recommendations proposed by the group of rapporteurs were read. They were adopted after some amendments. The recommendations are attached hereto Annex 1. The closure ceremony was presided over by Professor G.L. ^Monekosso, WHO Regional Director

for Africa.

After a brief address, he declared the meeting closed.

6-

The meeting, which was a great success, was the first

of

its kind, initiated and organized by OCP, that brought together representatives of 11 African countries in the subregion

to

discuss problems related

to

the integration

of

activities concerning the control and surveillance of the main endemic diseases rife in West

Africa. It

made it

possible:

to exchange fruitful experiences between the Participating Countries on many aspects-of the control

of

some endemic diseases which were public health problems in our subregion;

- to ^identify the major

problems related

to ^the

integration

of

activities concerning the control and surveillance of the main endemic diseases rife in our subregion;

-

to sketch lines of reflection, through the relevant recommendations (Annex 1),

on the possibilities of resolution of these problems;

-

to identify some shortcomings in the epidemiological surveillance systems in the Participating Countries;

to remind the countries of the lessons to be drawn from OCP'S success.

-7

^-

ANNEX 1 - RECOMMENDATIONS

1.

Considering the complexity of multi-disease surveillance, the participants could

not

completely examine

the

issue

within

the

time-limit.

However,

in

view

of

the importance

of the

^{theme to}

,the

^success

of

devolution,

it

was important

for

^the

Participating Countries

to

agiee

on a joint

_document.

To that

end,

the

^meeting

recommended that

all

the participants should meet again

in

another meeting

to

be convened by OCP with a view to submitting concrete proposals to the Joint Progralnme Committee.

2.

Considering the need for integrating the activities concerned with the surveillance and control of the different endemic diseases;

Considering the complexity of this issue, in the light of the different experiences,

for the countries that had not yet embarked on this process, the meeting ^encouraged

them to

^prepare guidelines

for the

integration, getting

all the

actors involved (Participating Countries and donors) ^payrng particular attention to:

-

definition of specific objectives to be attained;

-

definition of strategies to be implemented;

-

description of the exact role of each actor;

-

determination of necessary resources to be mobilized.

3.

Considering the incessant changes both in socio-economic situation ^and

in

the control strategies adopted, and in, a view of a need for constant adaptation to current realities, the meeting recommended that the countries should lay emphasis on the following elements already contained in their devolution ^plans:

-

definition of clear and specific objectives;

-

^use of appropriate technologies;

-

giving high priority to manpower training;

-

establishment of a reliable data bank.

4.

^The meeting, having clearly shown the many difficulties related to the integration of surveillance and follow-up activities, even

if it

concerned only two endemic diseases,

Recommended that:

-

the lists of endemic diseases contained in the plans already presented to the donors should remain unchanged;

-

countries whose plans were under preparation should make sure, to address the real issues of integration of the activities related to the control of ^{the endemic}

diseases that would be selected.

-8-

Annex 1 (cont'd)

5.

Considering the invaluable role played by the OCP facilities in the Participating countries

in

the success of Onchocerciasis control and considering that these facilities should be transferred to the countries at the appropriate time, the meeting recommended that:

-

OCP should take the necessary steps so that these facilities should be made available to the countries and in satisfactory working order.

-

the countries and OCP should take counsel together in order to identify the possibilities of using and maintaining these facilities for the strengthening of national health services.

6.

^{In view} of the statutory responsibility of WHO with regard to health development

in

the countries, the meeting recommended that WHO,

at

the country, regional and

global levels, should increase

its

collaboration

with

the countries

in

their efforts to implement the activities in OCP devolution and in improved multi-disease surveillance and control.

-9-

ANNEX 2

.

_{HEALTH EDUCATION}

Composition of the Group ¹ Chairman

Rapporteur Members

Prof. KassanJ<ogno

Dr

Diallo

Dr Foundohou, Dr Gaye, Dr Nimag4 Mr Senghor, Dr Heinmiiller The working group on health education met on 24 March 1994 to examine the level of information, education and communication (IEC) within the framework of the integrated control of major endemic diseases in West Africa.

The methodologl used was as follows:

1. Review of IEC experiences in the different countries.

2. Identification

of

IEC-related common elements

within the

framework of integrated control.

3. Conceivable solutions.

4. Implementation strategies.

1. IEC experiences in the countries

The following points are worth mentioning:

1. In all

the countries, there

is a

national

IEC

department responsible

for

the planning and implementation of activities.

2.

^These activities belong to different endemic diseases' control programmes and

therefore maintain different contents.

Their implementation is subject to the financial and material capability

of

the programmes concerned.

The implementers of IEC activities are, in most of the countries, the same for the same target groups.

Each programme determines its IEC requirements, often without collaboration with the departments in charge at the different levels, and uses workers of its choice.

The activities are carried out from time to time, with a lack of complete long- term follow-up, whence the lack of real impact on the behaviours of the target populations.

While the IEC activities are integrated at the base, for most of the programmes, the diversity of the epidemiological components for different diseases complicates the production of appropriate messages for target groups common to the different programmes.

3

4

5.

6.

7 r

_10_

Annex 2 (cont'd)

8.

Inadequate determination of IEC requirements.

9. I-ack of

coordination

due to the

reluctance

of

officials

in

^charge

of

^the

prograrnmes.

10.

Difficulties in having access to the media.

2. Identification of common elements

in

the different health education programmes

In

the

light of

the discussions,

it

appeared that

at

least four elements can be considered as common points of the IEC sections in all the programmes, ^viz.:

- training - target ^groups

- nature of the desired change in behaviour

- transmission channels used for passing on the ^message.

Other criteria could be added.

It

also emerged from the discussions that, for each of the points selected, some diseases combined

with

onchocerciasis control

in the

context

of

devolution can be grouped together by taking into ^account:

-

their transmission mechanisms;

-

the specificity of the target groups ^(age, profession, etc.);

- the

orientation

of the

behavioural change desired (etrvironment, ^healthy individual or sick individual);

- the

expected performance

of the

channels

of

information

in the

rural environment ^where the greatest number of target groups is found.

The following table summarizes the results of these discussions.

1.

^TRAINING

1.1

-

dracunculosis

-

schistosomiasis

1.2. -

onchocerciasis

-

malaria

-

trypanosomiasis

1.3. -

yellow fever (existing vaccination).

2.

^{TARGET GROUP}

2.1. -

schistosomiasis (adolescents, occupational groups)

-

malaria

-

yellow fever (children, adolescents and others)

-

dracunculosis

-

11 - Annex 2 (cont'd)

2.2. leprosy

2.3 -

trypanosomiasis

3.

^{NATURE OF} BEHAVIOURAL CHANGE DESIRED

3.1. environment malaria

schistosomiasis

3.2. -

^healthy individual . dracunculosis . malaria

. schistosomiasis . yellow fever

3.3. -

^{sick individual malaria}

dracunculosis schistosomiasis trypanosomiasis

4.

TRANSMISSION CHANNETS USED

4.1. -

film by CENEBUS Projection followed by conversation/discussions . malaria

. onchocerciasis . schistosomiasis

.

trypanosomiasis

61rn=projection . dracunculosis

. leprosy

(desirable if technical and logistic resources exist already at the district or regional level and according to cost-effectiveness).

4.2 COMMUNITY MULTIPLIER GROUPS

for

diseases which call

for

a change in behaviour in households.

. schistosomiasis ₎

. dracunculosis ) in particular .

malaria

₎

4.3.

DRAWINGS, ''PICTURE BOXES''

4.4.

^POSTERS

4.5 AWARENESS-RAISING CAMPAIGNS, e.g. by storytellers, griots, sketches, etc.

4.6.

effect)

GATTIERINGS (Should the occasion arise because they

will

have very little

-12-

Annex 2 (cont'd)

3. Conceivable solutions with a view to an improvement of the integration First solution

The best solution would be

the

allocation

of a

single budget

for

devolution (including all the devolution diseases) and to achieve that the different partners have to sit down and have discussions together.

Second solution

-

^palliative

To group together all the IEC packages of the different programmes in a single IEC unit which will do the work mainly at the peripheral level; this requires that the IEC departments already existing should be really decentralized and supported in terms of means and human resources (at the district level).

_13_

ANNEX 3

.

EPIDEMIOI-OGICAL SURVEILLANCE Introduction to the presentation (Synthesis)

Group 2 analysed the question of epidemiological surveillance for the integrated control

of

the diseases

in

thd devolution plans

of

the Participating Countries. This analysis was aimed

at identiffing

common elements,

as

regards epidemiologlcal surveillance, in the different control programmes which could serve as a basis for a real integration of devolution activities.

Firstly, the group defined the essential activities carried out in any epidemiological surveillance;

five

categories

of

activities

were

selected:

Data

collection

-

Data transmission - Data analysis - Mobilization of necessary resources - Decision-making for possible actions to be taken, for example in case of recnrdescence.

Secondly, the group analysed the activities taken individually

at

the different implementation levels, disease

by

disease,

limiting itself, for lack of time,

to onchocerciasis and trypanosomiasis.

Thirdly, and finally, the group made a synthesis of all the information gathered on the different activities analysed

for

onchocerciasis and trypanosomiasis; the same process can be used for the other endemic diseases. This synthesis gives quite a specific indication

of

the corrmon elements between onchocerciasis and trypanosomiasis as regards epidemiological surveillance, which allows a better assessment of the possibilities of integration of these two diseases.

-14-

Annex

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ANNEX 4 - PREVENTION AND PATIENT CARE COMPONENT Identification of common

elements

in the various

programmes

(a) Patient

care

COMMON ELEMENTS

CARE: EXISTENCE

OF

EFFECTIVE DRUGS

for the

treatment

of

the different diseases selected: then envisage an early treatment of cases with essential generic drugs. INTEGRATION OF CARE in the peripheral health facilities.

REHABILIATION:

proper to the leprosy programme

Comments: The modalities for the treatment of patients cannot constitute the only elements for integration. The identification of the common elements should be related also to:

the health team. Can the same team treat these different endemic diseases?

the health structure. Can these different endemic diseases be treated in the same health facility?

the laboratory: can the same laboratory undertake the biological diagnosis of the different endemic diseases?

DISEASE TNDTV.

TREAT.

MASS.

TREAT

HOSPITAL OTHER

DRUGS.

SURGERY PHYSICAL RET{AB.

ONCHO YES Possible Possible

TRYPANO. YES NO Yes necEssary No

SCHISTO. YES YES Possible Possible

LEPROSY YES NO Possible Possible YES

GUTNEA WORM YES NO Possible Possible

MAI.-ARIA YES NO Possible necessary No

-20-

Annex 4 (cont'd)

( b) Prevention

DISEASE VECTOR CONTROL VACCINATION PROPHYI.-AXIS

ONCHOCERCIASIS YES (BI-ACKFLY

coNTROL)

NO TRYPANOSOMIASIS YES (TSETSE FLY

coNTROL)

NO IMPROVEMENT

OF

LIVING

CONDITIONS

SCHTSTOSOMIASIS YES (MOLLUSC

coNTROL)

NO BATH IN CLEAN

WATER

LEPROSY NO NO

GUINEA ^WORM YES (Abate) NO POTABLE

WATER

MAI.ARIA

YES (ANOPHELES

coNTROL)

NO USE OF

MOSQUITO NET

COMMON ELEMENTS

VACCINATION: ^vaccines not available for all the programmes selected. Then ^{early diagnosis and} treatment of cases.

VECTOR CONTROL ^: oncho, trypano (similar), malaria, ^guinea worm (sometimes).

PROPHYLAXIS: Improvement of living and environmental conditions.

WATER SUPPLY: ir.dispensable (guinea worm, schisto), but also for the other diseases.

Conclusion: The prevention of these different ^{endemic diseases,} through vector control, sanitation ^and potable water supply can be integrated and undertaken by a team

of

entomolory and sanitation technicians.

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