& & woRLD MARCH EPIDEMIOLOGICAL

RAPID

EPIDEMIOLOGICAL _MAPPING

OF ONCHOCERCTASTS (REMO) rN SOUTHERN SI.TDAN,

MARCH t-28,2003

MISSION REPORT FOR

woRLD

HEALTH ORGANZATTON (WHO) AFRICAN PROGRAMME FOR ONCHOCERCIASIS

CONTROL (APOC)

OUAGADOUGOU,

BIIRKINA

FASO

BY Dr.

Mounkaila Noma

Chief of Epidemiology

&

Vector Elimination WHO/APOC Ouagadougou, Burkina Faso

Prof. B.E.B. Nwoke; Dr. I.N.S Dozie

&

^{C. M.IJ.}

Ajero

WHO/APOC REMO Temporary Advisers

Imo State University Nigeria PMB 2000 OweriArligeria

March 27.2003

LIST

OF CONTENT

1.0

^Summary

2.0

Introduction

3.0

^{Materials and Methods}

3.1

^{Study Area}

3.2

REMO Training

3.3

REMO Field ^Exercise

4.0

Results and discussion

5.0

^References

6.0

Acknowledgements

7

.0

^Appendix

7

.l

^{Mission Schedule}

7

.2

^{List of} Nationals Trained

7.3

^{REMO Data}

]a

1.0 ^SUMMARY

Rapid Epidemiological Mapping

of

onchoc-erciasis (REMO)

*u,

.orrducted in Southe* ^{S.rdan, March}

1'

28,2003 with the

rrpport of African

^Programme

for

Onchocerciasis Control

(APOC)

During

this

^{study, a total}

of

300 villages (both

fr9*

REA and REMO ZOOr; were selected.

out

^{of this,}

^ll8(39.3%)

of them were either inaccessible and/ or insecure ^at the time

of the study. REMO

exercise

was

successfully conducted or validated

in

182(60.7%)

of the

villages ^selected. The result showed

that orrhotttciasis was

^absent

in

⁶⁽³

_'3%) ^of

^the

examined villages while

in

176(96.7%) of the villages, varying degrees of the

iir.ur.

intensity were ^observed. Out of the ¹⁷⁶ vilLges positive for onchocercal nodule, 33(18'S%) ^had nodule rates

of 1- 9%;

^{4a(25 .0%) had}

10-

19% nodule rates while 82(46.6%) and 17(9.7%)

had

20- ^{39% and}

40-

100% nodule

rates

respectively.

The

integration

of the

^data

^into

^Atlas

Geographical Information system (Atlas GIS) ^helped to define the

tommunity

^{Directed Treatment}

with

Ivermectin(CDTl) priority zones, where REMO ^needs to be refined Or carried out as well as non-CDTI ^zones.

2.0 INTRODUCTION

From

the grim

background

of the

seriousness

of the

^public health implications

of hu*an

onchocerciasis

and its

socio- economic impact in endemic ^areas,

it

became clear that

it

is no longer ^{a disease} that can be taken for granted' This ^encouraged

wrro

^{(as executing agency)}

in

¹⁹⁷

⁴ with

^donor agencies and eleven ⁽¹

1)

endemic -countries

in West Africa to

^establish

Onchocerciasis Control ^Programme

(OCP).

^{OCP, the largest}

single and most successful tropical ^disease control ^programme

wal

^{solely based}

^on

aerial spraying

of

breeding sites (rivers)

with

biodegradable larvicideJ

to kill

the aquatic larvae of the flies which transmit the disease. ^{The success story} of OCP has

been reported severally

(Duke,

1990;

WHO,

1994; APOC'

2000). ^To

^sustain

^this

^{success, and}

to

confiol ^{the disease in} other ^endemic country ^outside

the OCP

^{atea, global efforts} continued

in

search

oi

complementary strategy for the disease control.

Recent years have ^seen considerable progress in the control

of

human onchocerciasis and the dramatic ^change of emphasis in

strategy. The

opportunity ^presented

by the

^{discovery and}

registrations

of

ivermectin (Mectrzan) as

a

safe and effective

mlcrofilaricide for

large-scale

(mass) oral ^{treatment of}

onchocerciasis

was a remarkable breakthrough.

^This

development revolutionised ^{the disease} control strategy' ^Infact, repeated, annual single-dose treatment

with

^{Mectizan reduces}

th;

development

of ^{clinical illness, visual}

impairment, disfiguring

iLin

conditions and significantly ^decreases vector

infeciivity, thus

reducing fiansmission (APOC,

2000). ^on

October

Zt,

tggg, Merk

&

^{Co. Inc. at a press} conference took ^an unprecedented decision and announced

that it would

supply Mectizan free

for

the treatment

of

onchocerciasis

to

^{any one} who ^needed

it, for

as long as necessary.

This

commitment,

provided

^agencies, otganisations

like OCP and

^endemic

countries

not only *itf,

^incentive

^but

^also

^with

^formidable

challenge. This ^{open a new} chapter and opportunity; ^and WHO

African

^Programme

for

Onchocerciasis Control (APOC) ^was launched ,n1ggS to take up this challenge to control the ^disease

in

¹⁹ endemic African countries ^outside the OCP ^area.

A

massive consortium comprised of governments

of

^{19 partner} nations, donor countries,

WI{O,

Merk &' ^Co' Inc', TDR/WHO'

world

Bank, NGDOs, UNDP ^and

FAO all

came together to

help

established

and

support

a ^novel

prografiIme-APOC-to

ou"rr.,

the distribution

of

Mectizan ^and

to

ensure

it

^reached

those populations most at

risk.

^{And the} objective of APOC "is

to

estaUiish,

within a

^period

of

12'15 years, effective, ^seJf-

sustainability and Community Directed ^Treatment

^with

Ivermectin (CDTD

throughout

the

endemic areas

in

^the

geographical scope of the

piogtam*e."

^{By this, APOC's g!!l_is}

to treat 50 million

^peopie

^pet

^year

by

2010 through ^CDTI

stratery (APOC, ^200b).

-

Furthermore,

in

selected and isolated foci,

IpOC

^{aims to eradicate the vector,} wherever possible, by using environmentally ^{safe methods} (WHO, 1996)'

From its inception, the philosophy ^of APOC ^{has been} to provide

Mectizan

^treatment

6 ^{the people at the}

^highest

^{risk of}

developing the most ^severe complications (WHO, 1995

a).

^In

this conc.!t,

th.

general agreement is that ivermectin ^{should be} distributed first tJcommunities that ^are atrisk of developing the severe and disabling ocular ^and dermal complications (Taylor et

al, ^1992;

WHO, tggz).

^{And the level}

^of

communrty's

risk

^is directly ^ielated io the intensity ^of the disease in the community (Remme

et

a1,1989). This ^according to

wHo

^{(1992, 1995 a)}

and ^Ngoumou &walsh ⁽¹⁹⁹³⁾ is usually

^determined

epidemi[logically

using Rapid

Epidemiological ^Mapping _{_}

of

onchocerciasis

(ngrr,rol In view of the

foregoing, ^APOC requires comprehensive epidemiological ^data on onchocerciasis using the WHO ,e.ommended REMO from all APOC ^countries for effective GDTI strategy. The REMO ^{data help} to delineate the areas lzones that need CDTI

priority

and at the ^same time

ensure adequate coverage of ^the high risk areas.

In Southern Sudan, the first clinical observation of

onchocerciasis was made

by

^Ensor

in ^1908.

^{Ensor described}

what was then known as "craw craw"

in

soldiers stationed in

Meridi in

Bahr ^El-Ghazal

Region.

^{About three decades after}

Ensor,s

observation,

Bryan ^{(1935) reported} a

^definite

association

of

onchocerca

volvulus

^infection

with

blindness and

onchorrr.ul skit

diseases. Infact, Bryant ^{called oncho-} blindness,

"Jur

blindness" ^because the disease was prevalent between the Jur ^and the Balanda near the Jur river tributaries.

Since these initial ^{studies, other} works identified onchocerciasis

and its

^vectors

in the different parts of

^{Southern Sudan,}

including

Kirk (|g37),Lewis

^{(1957), Haseeb} et al (1962), Satti (1985),

iVittiu*r

et al (1985), ^{Kaneene at} al (1985), and Baker

it

^Abdeinur

^(1986).

^{'These results though}

^not

coordinated showed that onchocerciasis and its vector species ^are prevalent and widespread in Southern ^Sudan.

However, there are alot of more ^{areas where} the prevalence and distribution of onchocerciasis ^is yet unknown. Furthermore, ^the available dataare not comprehensive ^enough to give the ^needed spatial distribution

of

the disease. The ^absence

of

^complete

epiOemiological information on the ^disease

in

Southern ^Sudan

till

^{now tras} timited APOC's ^complete implementation of

cDTI in

all the high-risk communities.

It

is against this background

and in

,onsidetation

of the

current cease-fire

that

^APOC

sponsored this study with the following objectives:

tul ^To

^{train the 3outhern} Sector onchocerciasis Task Force (SSOTF) members on REMO procedures and techniques

(b) io

^assist

^the

Task Force ^conduct

REM9

exercise in selected

villages and also

^appraise

and validate

^the

existing ^REAIREMO results-that will

^generate

,o-pr.hensive

epidemiological data

that will

^enable

APOC delineate ^areas that need CDTI priority ^{and at the}

same time ^{ensure adequate coverage}

of all

^{the high risk}

communitie s/villages.

6

3.0

MATERIALS

AND METHODS 3.1 STUDY

AREA

The study ^area of this mission is ^Southern Sudan' Southern Sudan

is

^bordered

^{on the}

^west

^by

^Central

^Africa

^Republic

(CAR), on the ^East by Ethiopia ^{and on the} southern boundaries by oemocratic Republic of congo (DRC), Uganda and ^Kenya.

ti ^is

administratively

divided into

three ^{regions; Equatorial} Region on the South, Bahr El-Ghazal Region on the north west urrd tfrc Upper

Nile

on the north

east.

^{Each region is divided} into counties (Fig 1,2).

The major topographical ^feature of Southern Sudan is the White Nile

*t

^lch constitutes the main drainage system. It transverses the three regions from the ^southern border with Uganda, DRC and

cAR.

^{In the Upper Nile} region, the main tributaries ^{of the} White Nile ^{are; Baro, Pibot,} Bahr El-Jebel rivers; in the Bahr El Gazal,the main rivers ^are the Jur,

Kiir,

Pongo, and Chel while the main tributaries of ^the

white Nile

in Equatoria Region ^are

wau,

Kideopo, sue, Ibba, and

Yei rivers.

^{These rivers arise}

from the watei

^shade

or

headwaters

of

the White

Nile,

and

therefore

^are

fast flowing with a lot of rapids'

^These

characteristics ^create favourable breeding ^sites for the Simulium vectors.

The climate

of

Southern ^Sudan is tropical with average annual temperature of about ^29C (about85F). The rainy season months are April-September with ^annual rainfall of ^more than 1000 mm

(a0 inches). In

^{Southern Sudan, the} vegetation varies from

typical .uioforrrt in the

^southern

^part to

Guinea/derived Savannah in the northern area. ^There is a vast swampy and or

flood plain in the

Jonglei area

of the upper Nile-

^Human

settlement, though seriously ^affected by many years of

civil

^war

is

basically

rural

Farming and livestock production are ^the

main

occupations

of the rural

conrmunities. Exposure to infection

in

Southern Sudan is by ^way of village proximity ^to

breeding sites and occupational activities. In

^endemic

.LI I

=0 6a

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communities, both old ^{and young} are exposed to infection ^such that the disease prevalence gradually increases

with

advancing

age.

3.2 REMO

TRAINING

One

of

the major objectives

of this

^{mission was capacity} building

- to

enabie the Southern Sector Onchocerciasis Task Force (SSOfp) of Sudan have ^a pool of well trained manpower that

will

^train the Regional ^and County control ^{teams as} well ^as

possess the capacrtylo continue successful REMO exercise in

u.tut

^{that are} inaccessible or insecure at the time of the ^present exercise. To achieve this, a26-man SSOTF team ^(see appendix

7

.2)

^{was trained for four days (March} 1A44,2003) in ^Rumbek

on all ^aspects of the WHO recommended

^Rapid

Epidemiological Mapping of Onchocerciasis

^(REMO) documents (Ngormou ^and

walsh,

^1993;

^WHO,

¹⁹⁹⁵

b).

^In

addition, the team was ^exposed to the biology and ecology

of

the disease vectors, epidemiology, clinico-pathological ^aspects

and the

socio-economic

impacts of the

^disease

on

^the

population. The

team

was

^{also taught}

the

current ^disease

iontrot

^{strategy adopted by}

^WHO/APOC. At

the ^end

of

^the

theoretical training at Rumbek, all the team members were taken to a known endemic community, Wulu ⁱⁿ the Lakes County for

a

one day intensive practical (March 15,2003) on community mobilisation, use

of REMO

forms,

clinical

examination and identification

of

onchocercal

nodule.

The training ^{was very}

successful.

3.3 REMO

FEILD

EXERCISE

At

the end

of

the practicum,

six

groups were formed

(with

^a member

of

^{SSOTF as}

_Soup

^leader)

to

^carry out

field

^REMO

exercise in the accessible and secure selected (REMO _)villages based

on the lJN

^security

advise. For

^{obvious logistic and}

security reasons, the team to upper

Nile

region (Boma) ^had !o fly ^for

ihi, .*..tise

^{with a UN} designated plane. Where ^possible

urd ,.rure,

^{the APOC team} facilitated and supervised the field exercise. ^Having established the time-table, ^and

UN

security clearance for theirillages to be examined, ^adequate logistic ^and material supports including communication ^system (radio and

mobile ^phone), all ^{the groups went ahead with}

^the

implement

tiott of the field REMO

^exercise

(March

^15-262, ZObf). At ^{the end of the field exercise,} the collated ^results were

impressive and consistent with previously

^described

epidemiological patterns of the ^disease. There is no doubt ^there fore

that tfrit nbnno

^exercise

in

Southern Sudan

is a

huge success, notwithstanding the inherent difficulties associated with extensive community bised-studies

in

an area under

civil

^war

conditions.

4.0

^{RESULTS AND DISCUSSION}

With the

support

of

^WHO/APOC,

^Rapid

Epidemiological Mapping of Onchocerciasis (REMO) was conducted in Southem Sudan,

Idarch l-28, 2003. It is

^important

to

note here that REMO as an operational procedure is ^used to determine through

a

rapid and simple method

the

approximate distribution ^and

,.r..ity ^of

onchocerciasis in

the

^{area andl} or validate existing information and results of previous mapping exercise' ^{This is} carried out in order to provlde ^a rational basis for planning ^and implementation of cost-effective and sustainable onchocerciasis control.

Against this background, on arrival ^at Nairobi the APOC ^team triO to study and appraise the historical epidemiological ^{data on} onchocerciasis from ^{1908 and the} REMO exercise conducted by Health

net

International

GINI)

^{and other NGOs}

in

^Southern

Sudan, lggS-2002.

It

^{was observed} that the previous REMO

exercise was ^relevant but the

^sampled

^villages

^lacked

geographical co-ordinates (latitudes and longitudes) and ^lvere

iot- siictly

^selected

in

accordance

with wHo/

^REMO

procedure.

9

However, the ^{results were} consistent with

^known

epidemiological and entomological data

in

^{Southern Sudan'}

Ufft.n the

^selection

of the REMO

villages

for ^the

^present

exercise was completed,

their

geogfaphical co-ordinates ^were

directly

calculated using topographical maps as

the

use

of

Geographical Positioning

system

^(GPS)

was prohibite{ l"

Soutlern ^{Sudan at the}

time of

the exercise. Before the field exercise, consistent results

of the

^previous

^REMO

^exercise which colresponded

to

^{villages selected}

in

the ^present _1tud.V were adoptedand validated where possible. Infact, the endemic onchocerciasis

village

^used

for the

^practical

^was

^primarily

selected to help validite the previous REMO exercise.

A total of

300 REMO ^villages (both from

REA

and REMO 2003)were ^selected in this exercise. ^{Out of} this _, ¹ 13(39'3%)

of

them were either insecure anil ^or inaccessible ^at the time of the present

study.

^{REMO exercise was} successfully conducted or validated

in

182(60.7%) of the ^selected villages. By the present

result,

onchocerciasis

is

^absent

in

^6(3.3%)

^{of the}

^villages

examined

while in

176(96.770) villages, varying ^degrees

of

disease intensity were observed. Of the ^{176 vtllages} positiv.

It

oncho cercal nodule, 33(18.8olo)

had nodule

^rate

of ^l'9%;

44(25.0%)

villages had

^10-19%

^nodule

prevalence while

gzi+o.ayi

_{and {t1s.7%)} of the villages ^had 20-39s% and 40- IOO% nodule ^rate resPectivelY.

The distribution and intensity of Onchocerciasis in the ^exercise

was

integrated

into Atlas

Geographical Information ^System (Atlas

CfSl $ig

^{3) and}

^it

^{was observed}

^to

^be consistent with known epidemiological information of the ^disease

in

Southern Sudan. Furthermore, the same software was ^used to define the CDTI priority ^{areas, no} CDTI areas and where REMO should ^be performed

ot

^refined

^(Fig. 4).

^{From- here}

^{it is}

^{clear that}

bnchocerciasis is endemiCin ^{Southern Sudan} but more REMO data are urgently needed

to

actually define the boundaries

of

CDTI priority ^zones.

10

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5.0 REFERENCES

APOC(2000). Empowering Partnerships and communities ^: APOC and the fight to ^get rid of Aftica ^{of River} Blindness--- ^WHO African ^Programme for

Onchocerciasis Control (APOC), Ouagadougou/Burkina Faso.

Baker, RHA &Abdeinur, oM(1986). Onchocerciasis in Sudan. The distribution of the ^{disease and} its vectors.

Trop. Med. Parasitot. 37:341-355

Bryant,

-

J(1935). Endemic retino-choroiditis in Anglo-Egyptian Sudan, and its possible relation to Onchocerca volvulus.

Trans. Rov. ^Soc. Trop. ^Med. Hvg' 28: 523-532

Duke, BOL(1990). Human Onchocerciasis: An overview of the Disease. Acta Leidensia.

59OeD'

^9-24

Ensor, H (1908). The advent of craw-craw in the Anglo-

Eryptian Sudan. J. Roy. Army ^Medical corp. ^10:140-143 Haseeb,

MA;

satti, MH

&

Sherifl ^M(1962). Onchocerciasis in

Sudan. ^BulL WHO 27: 609'615

Kaneene, JB et al (1985). An epidemiological ^study

of

Onchocerciasis in Bahr ^EL-Gazal province. Sudan Med' J' 2l(suPPl .): 65-71

Kirk, R (1947). Observations ^on onchocerciasis in the Bahr El- Gazalprovince of Sudan. Ann Trop. Med. Parasitol

4l

_'357 - 364

Lewis, DJ(1957). Simuliidae and their ^relation

^to

Onchocerciasis in Sudan. ^BulL

wHo.

16.671-67 4

tl

Ngoumou, P& Walsh, JF(1993). A Manual for Rapid

Epidemiological Mapping ^of onchocerciasis (REMO)

TDR/TDE/ON CIJiO ^{t 93} -4 WHO ^Geneva

Remme, HJ et al (1989). Ocular onchocerciasis ^and intensity

of

infection inthe cofirmunity.1. West African ^savannah.

Tron. Med. Parasitol. 40:340-347 _'

Satti, MH(1985). A historical account of Onchocerciasis in

Sudan Med.J 21:5-8

Taylor, HR; Duke,

BoL &

Munoz,BC (1992). The selection

of

-

communities for treatment of Onchocerciasis with ivermectin. ^{Trop. Med.} Parapitol' 43"267-270

wHo(1992).Methodsforcommunitydiagnosisof

Onchocerciasis to ^gUide ivermectin-based control in Africa. TDR/TDE/0NCH0/92'2, ^Geneva

wHo

^{(lgg4). Twenty years} (1974-1994) of onchocerciasis control ^Programme in west ^Africa.

wHo

^Geneva.

WHO (1995a). Onchocerciasis ^and its control: ^Report of a

wrro

^{Expert committee on} onchocerciasis control.

WHO Tech ^ReP. Ser. No 852

wHO

(1995b). The importance of onchocercal Skin ^disease:

Report of a multy county study. TDR Applied ^Field Research RePort, No

I

^Geneva'

WHO

(1996). African ^Programme

for

Onchocerciasis Control (ApOC). programme document for ^phase 1. APOC Ouagadougou.

williams

^{et al (1985).} Cunent distribution of onchocerciasis in

Sudan. ^{Sudan Med.} J. 2l:9'17 ^.

t2

6.0

AKNOWLEDGEMENT

we

^{are grateful} to APOC for the opportunity given to ^us to serve in thiJ exercise and to WHO Lagos, Southern ^{Sudan and} Kenya

for their

^efforts

to facilitate our mission. We

^are

indebted

to the

^{chairman and members}

of

^SSOTF

^for

^their

support ^and goodwill through ^out the study. The ^{success of} this exercise was made compaiatively ^easier by the ^{expertise and} professionalism ^as well ^as commitment exhibited by HealthNet international

(HNI) in

generating the REA results even in the mist of

civil war.

The contributions of ^the field teams, village heads and drivers ^are highly appreciated. To all that contributed to the ^{success of} this study, we ^say thank you'

t3

7.0

APPENDX

7.1. MISSION SCHEDULE

AGENDA

Activities

r

Arrival of APOC ^Team Feb.28'n 2oa3

.

Meeting with SSOTF,WHO/Southern Sudaru WHO/I(enYa

.

Collection of maps, rePorts and materials

o

Planning of REMO ^exercise (training

& field exercise)

.

Travel clearance Mar.1-8'n ^2OO3

r

Departure for Lokichoggio

.

Arrival in Lokichoggio

.

Security briefing by OLS

.

Orientation of APOC ^and HNI team members ^(BY WHO)

.

Departure for Rumbek

o

Arrival ^{in Rumbek} Mar. 8-9" 2003

. nui"i"g ^on

^{REMO methods and}

techniques

r

Selection of REMO villages/ (sampling of villages)

ion for field ^exercise Mar. 10-14'" 22003

.

Practicals

o

Field REMO ^exercise Mar.15-21*2003

for Nairobi

o

Dataentry, analYsis

o

Mission report

.

Planning comPletion

of

^{REMO in}

Southern ^Sudan

o

Debriefing SSOTF, WH0/Southern Sudan

r

f)enarhrre of APOC team l/rer.23-29'" ^2OO3

7.2

LIST

OT SSOTF

TRAINED

1.

^{Dr. Samson Paul} Baba/SSOTF Coordinator

2.

^{Dr. Samuel Patti}

3.

^{Dr. Pius Subek}

4.

^{Dr. Angok Gordon}

5.

^{Dr. Margarret Itto}

6.

^{Mrs Esther Poni}

7

.

^{Mrs. Agum Isaac}

8.

Mrs. Merry ^LucY

9.

^{Mrs. Irene Mueller}

10. Mr. ^{David Bido} 11. Mr. Mathew ^Guaso

12. Mr. Evans Ariko 13. Mr. Remijo Amule

14. Mr. Michael Luggalla 15. Mr. Emmanuel Ezama

16. Mr. Nek Martin 17. Mr. Daniel Dut

18. Mr. Cornelius Ndungu 19. Mr. Mario ^Deng

20. Mr. PhilliP ^Makuach 21. Mr. Martin Mande

22.Mr.

John Samuel Marko 23.Mr. ^{WisleY B. Court} 24. Mr. Jonathan Sebit 25. Fasil Chane

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