THREE CAMEROONIAN CDTI PROJECTS

@'fiffi"fi'llmn"

ASSESSMENT OF GEOGRAPHIC COVERAGE

OF

THREE CAMEROONIAN CDTI PROJECTS

qgj

Technical report

Drafted by

Joseph Kamgno and Hugues Clotaire Nana Djeunga

With the participation

of

tarc

Kouam, Elvis Kah Fang, Gilbert Bamboye Fondze and Paul Blaise Mabou

February,2A12

OUTLINE _{OF THE} TECHNICAL REPORT

OUTLINE

INTRODUCTION

METHODOLOGY

Preparation of survey Conduct of the survey Data management

RESULTS, INTERPRETATIONS AND DISCUSSION

CONCLUSION AND PERSPECTIVES

ACKNOWLEDGEMENTS

REFERENCES

APPENDICES

INTRODUCTION

The

elimination

of

onchocerciasis

is

actually

on top of the

agenda

of the

African Programme for Onchocerciasis Control (APOC) and stakeholders. This unprecedented decision

was

mainly motivated

by

previous studies reporting

the

feasibility

of

the eradication of onchocerciasis using available tools ^(Dadzie et al., 2003; Diawara et al.,

2009). APOC

was

launched

in

¹⁹⁹⁵

and

since

then, its

strategy

was

based on community directed treatment with ivermectin (CDTI).

ln

disease endemic ^countries,

CDTI

^projects

were

delimitated based

on rapid

epidemiological assessments for onchocerciasis (REA) and rapid epidemiological mappings of onchocerciasis ^(REMO) (Taylor et al., 1992; Ngoumou et al., 1994). To date, all these ^projects are supported by APOC and NGDOs involved in the control of onchocerciasis in Africa. However, before engaging

in the

elimination

of river

blindness,

it is

^important

to ^evaluate

^the

achievements

of the

CDTI strategy after more than

20

years

of

treatment. Since a

couple

of

years, surveys aiming

at

evaluating

the

impact

of

CDTI

on the

levels of endemicity

of

onchocerciasis are organised by APOC. Besides these impact ^studies, the African Programme for Onchocerciasis Control ^is also assessing actual levels of the geographic coverage of CDTI projects in disease endemic countries, in order to insure that all the onchocerciasis endemic communities are actually treated

with

ivermectin and that some untreated villages or communities would ^not constitute a reservoir for the transmission of the disease.

ln this scope, the main objective of the present survey was to map communities eligible to ivermectin treatments in the North West CDTI project of Cameroon as well as some unmapped communities in the West and Littora! 2 ^projects, and to check whether these communities effectively benefitted from regular mass ivermectin distributions.

To achieve this objective, we proposed to:

r'

Record geographic coordinates

of

health facilities present

in the

North West CDTI ^project zone and in some unmapped communities of West and Littoral 2 CDTI projects.

{

Record geographic coordinates

of

communities eligible

to

CDTI

in the

North

West project area and in some unmapped communities of West and Littoral ² CDTI projects.

r'

Collect informations relative

to

CDTI such as the starting and

the

last year of treatment with ivermectin, the number of community directed distributors (CDD), the challenges of CDTI for the health facilities and the communities as welt as the type and state

of

health facilities present in the West CDTI ^project area and in some unmapped communities of West and Littora!2 CDTI projects.

METHODOLOGY

-

Preparation of the survey

Enumerators were almost

all

recruited among those who previously

took

part in the same type of survey in others Cameroonian CDTI projects (Centre 1, Centre 2, Centre

3,

Littoral

1,

Littoral

2,

South, East and West). Most

of

them were recruited at the Department of Geography of the Faculty of Arts, Letters and Human Sciences of the University of Yaound6 l. Besides this specificity, all the enumerators were at least at the third year of their course of study and team leaders were at teast PhD students. Then, their training offers more guarantee to their ability to well manipulate GPS and to master

the

challenges

of the

survey. Three experienced supervisors were recruited: Marc Kouam, PhD in Parasitology; Kah Elvis who is preparing a PhD in Geography and who was team leader during the previous surveys; and Hugues Clotaire Nana Djeunga who is preparing a PhD in Parasitology on the epidemiology of onchocerciasis in Cameroon.

The general coordination

of the

survey

was

assumed

by

Doctor Joseph ^Kamgno, epidemiologist physician

and

Executive Director

of

Filariasis

and other

Tropical Diseases Research Centre (CRFiIMT).

The training of enumerators took place at the CRFiIMT located at Yaound6 and was divided into two main ^phases: theoretical and practical.

During the theoretical phase of the training, the objectives, the goat and the challenges of the survey were well explained to the enumerators. Data coltection forms were atso reviewed in details. Enumerators had the opportunity to discuss with supervisors and the coordinator about the implementation of the survey.

-

The practical phase of the training consisted in one hand to fill the different forms and in the other hand to record the geographic coordinates using a Global Positioning System (GPS).

ln

fact,

team

leaders recorded,

as a

preliminary, geographic coordinates of some points of the city. Enumerators were then randomly sent at these points in order to ^record the geographic coordinates by themselves and their records were compared

to thme of team

leaders.

The

training enumerators succeed

to

^{record properly}

selected by the training staff.

-

^Conduct

ofthe

survey

Following the guidelines provided by the APOC management (these guidelines were printed and distributed to each enumerator, team leader or supervisor), the supervisor or the team leader if necessary had a briefing with the chief of the district or the health office chief. During this briefing, the objectives and the ^goal of the survey were clearly stated and relevant informations dealing with the implementation

of

the CDTI in the distric{ were collected

as well as

informations

on

others heath facilities

not

directly implicated

in the CDTI.

Using

the

district

map

provided

by the chief of

^district,

enumerators were deployed on the field regarding the accessibility and the number of health

areas and

communities.

For an

efficient coverage

of CDTI

^project areas, enumerators as well as team leaders used motor bikes. Helmets were then ^provided to these individuals and accident insurances were contracted for their security.

ln each health facility, the objectives and the goal of the survey were also explained to the person

in

charge

of the

health centre and

the

data collection form GC01 was administered

to the

latter.

The

geographic coordinates

of the

health centre were recorded using a Garmin etrex high sensitivity type GPS provided by APOC, and useful informations

on the

communities (number, accessibility, relative distances, relevant informations on CDTI) to be visited in that health area were provided by the chief of the centre. Then, geographic coordinates and the features

of

others health facilities not implicated in the CDT! were recorded on the data collection form GC03.

was

considered successful

since all

^the

the

geographic coordinates

of the

^points

ln each community, enumerators explained the rationale of the survey to the chief of the village and/or one or more leaders of the community or the village. lnformations on the CDTI gathered at

the

health centre were verified near to the latter and discrepancies

were

discussed

before the filling of ^the data

collection

form GC02.

Geographic coordinates of the village or the community were recorded at the chief palace which was considered as the centre of the village. For small communities (generally made up of

just few

houses

and

sometimes without

a

chief),

the

coordinates

were

recorded approximately at the geographic centre of the community.

During the period of the survey, data collection forms were assembled every evening by

team

leaders

and

supervisors. Discrepancies

were

discussed

and

corrected and missing values were as far as possible completed forthwith or the next day. Difficulties encountered by enumerators were discussed and solutions ^proposed to overcome such situation. The programme of the following day was also addressed. At the end of the survey, a brief report was drafted by each team leader and/or supervisor.

-

^Data management

The data entry process was performed by four enumerators who took part to the field

suryey, under

the

supervision

of

Hugues Nana Djeunga

who is

involved

in

these surveys since the beginning of the project in 2009.

All

relevant data dealing with the implementation of surveyed CDTI projects were recorded into a purpose-buitt Microsoft Access database. All variables or parameters of the different data collection forms were taken into account. Data were recorded on separate datasheets for the forms GCO1, GC02 and GC03. Data were sorted and filtered in the Microsoft Access database. When necessary, these data were exported from

a

Microsoft Access

to

Excel database for further analysis. Descriptive statistics (frequencies, cross tabulations

...) were

also performed using

the

software PASW Statistics version 18 (SPSS, lnc., Chicago, lL, U.S.A.). Missing values were then completed and aberrant data corrected.

RESULTS, INTERPRETATIONS AND DISCUSSION

From the 15th

July

2011

to

15th

August2}ll

and

from

15th November 2011

to

30th November 2011 (catch-up surveys), 494 health facilities were visited among which 209 were implicated in CDTI activities in the 18 health districts surveyed in the North West CDTI project. ln these 209 health areas, ¹³⁴⁴ communities were surveyed. ln addition, during

the

catch-up surveys,

72 and 95 not

previously mapped communities were surveyed respectively in the Nkondjock health district (the only district of the Littoral 2 CDTI project which was up

to

now not yet visited due

to

bad roads) and in

9

^partially

covered districts (Bafang, Bandja, Bangangte, Bangourain, Foumban, Foumbot, Kekem, Kouoptamo, Malantouen) of the West CDTI project.

Many communities and sometimes health areas or health district were found on the field but not in APOC lists which were far

to

be exhaustive. For example, Nwa

is a

new health district

which was

previously

a

^health

area of the Ndu

health district; 67 communities were visited in this new health district. This discrepancy is due to the fact that the lists ^provided by the management of APOC were quite old (2006) and do not

take into account the recent

changes

in the

Cameroon

health system.

When considering the list ^provided by APOC, almost all health facilities and communities were

visitd

in the North West CDTI project (tables 1) and all the unmapped health facilities and communities of the West and Littoral 2 ^projects were surveyed.

Regarding

the last year of the

Mectizan distribution,

the ^year

2011

was the

most frequent in the North West with an occurrence percentage of 86.5% (table 2; figure 1).

ln the Littoral

2

project, among the

72

unmapped communities, 52 (72.2o/o) received their last treatment in 2010 and 20 ^(27.8%o\ in 2011. The same ^pattern was found in the West CDTI project where 43195 communities received their last dose of ivermectin in 2011,47195 in 2010 and very few before these dates [01 (Fofon in Kouffen health ^{area I} Foumban health district) in 2009 and

4

(Matta health area

I

Malantouen health district) in 20061. lt is important to notice that in the West and Littoral Regions, assessments of

the

impact

of

repeated treatments

with

ivermectin

on the

levels

of

endemicity of

onchocerciasis were conducted

in

2011; then, the distribution

of

ivermectin

in

these communities were ongoing during our surveys or took place later.

Table

1: Distribution of

^Health

facilities and communities visited in the

North West CDTI proiect of Cameroon

Table 2: Number of communities per last year of Mectizan distribution

Ako 5 6 120.0 45 48 106.7

Bafut 4 13 325.0 18 77 427.8

Bali 6 6 100.0 40 41 102.5

Bamenda ₁₀ 17 170.0 88 93 fis.7

Batibo 13 14 107.7 83 97 116.9

Benakuma 4 5 125.0 18 18 100.0

Fundong 11 12 109.1 61 68 111.5

Kumbo Est ^'19 19 100.0 98 108 110.2

Kumbo Ouest 16 20 125.0 106 129 121.7

Mbengwi 14 15 107.1 79 84 106.3

Ndop 14 15 107.1 97 't07 110.3

Ndu ₁₄ 8 57.1 36 71 197.2

Njil<wa 6 o 100.0 27 27 100.0

Nkambe 10 14 't40.0 _{106 93 87.7}

Nwa I 6 I I 67 I

Santa

I

9 100.0 46 50 108.7

Tubah ₅ 10 200.0 36 58 161.1

Wum ^'t0 14 140.0 79 108 136.7

ot

o

:

ETo l!

2009 ²⁰¹⁰

Last year of CDTI in the conrrrrnities

Figure

1: Distribution of

communities according

to the last

year

of

CDTI

in

the North-West project

Table 3 and figure 2 show that most of the communities of the North West CDTI ^project are regularly treated.

The

number

of

^year

of

treatment

is

quite variable

with

most communities treated during at least 8 years. ln the West CDTI ^project, the most frequent year for the last treatment was 16 years (34.7Yo\ whereas in the Littoral 2 project, it was between 11 ^(26.40/o) and 12 years (47.2Yo). ln all these projects, it was reported that the inappropriate

period of

ivermectin distribution (Mectizan distributions sometimes undertaken during the farming period) and sometimes the lack of tablets (coupled with difficult access

to

communities due

to

bad

or no

roads) render difficult

the

^optimal

geographic and/or therapeutic coverage of the North West CDTI project.

One should note that the lack of tablets reported in some communities might be due to the fac{ that some individuals coming from communities where drugs were not or not yet distributed sometimes moved in neighbouring communities where CDTI are ongoing to received Mectizan.

Table 3: Number of communities per number of years of Mectizan distribution

02345678910 12,r3 16

17

Nunber _{of lrears} of CDTI in the conmunities

Figure 2: Distribution of communities according to the number of years of CDTI

s

.9o oc o

C'o lr.

17 11 0.8

16 12 0.9

13 b _0.4

12 4 .3

10 21 1.6

I

⁹³ 6.9

8 901 67.0

7 130 9.7

6 42 3.1

5 79 5.9

4 ^'1s 1.0

3 10 0.7

2 17 1.3

0 5 0.4

CONCLUSION AND PERSPECTIVES

During the surveys, the situation of community directed treatment with ivermectin was successfully assessed in 209 health facilities and 1344 communities eligible to CDTI. In addition, all the up to now unmapped communities of West and Littoral 2 CDTI ^projects were successfully surveyed and the map

of

these projects completed. Even

if

some communities are not regularly

or

not

at

all treated due

to

accessibility, inappropriate period of drug distribution

or

no enough tablets available, the communities eligible ^to CDTI in North West, West and Littoral 2 CDTI projects are in general regularly treated.

To ^provide enough information to the African Programme for Onchocerciasis Control in its onchocerciasis elimination challenge, we are ^planning to survey also non CDTI areas

of

Cameroon since recent studies and surveys show relatively high prevalence ^of onchocerciasis nodules

and

evidence

of

ongoing transmission

in non CDTI

^areas

(Katabarwa et al., 2010).

ACKNOWLEDGEMENTS

The

present surveys

were

funded

by the

African Programme

for

Onchocerciasis Control. We are thankful to all the chiefs of Districts, Community Directed Distributors and leaders of villages or communities surveyed for their contribution to the survey.

REFERENCES

Dadzie

Y.,

Neira M.

and Hopkins

D. (2003). Final report

of

the conference on the eradicability of onchocerciasis. Filaria Journal2 (21, 141p.

Diawara L., Traore M. O., Badji A., Bissan Y., Doumbia K., Goita S. F., Konate L., Mounkoro K.,

Sarr

M. D., Seck

A.

F., Toe L., Touree

S.,

Remme

J.

H. F. (2009).

Feasibility

of

onchocerciasis elimination with ivermectin treatment

in

endemic foci in

Africa:

first

evidence

from

studies

in

Mali

and

Senegal.

PLoS

Neglected Tropical Diseases 3: e497.

Katabarwa

M. N.,

Eyamba

A., Chouaibou M., Enyong P., Kuete T., Yaya

S.,

Yougouda

A.,

Baldiagar

J.,

Madi

K., ondobo Andze G. and Richards F.

^(2010).

Does onchocerciasis transmission take ^place in hypoendemic areas? a study from the North Region of Cameroon. Tropical Medicine and lnternational Health 15 (5): 645-652.

Ngoumou P., Walsh

J.

F.

&

Mac6

J.

M. ^(1994).

A

rapid mapping technique for the prevalence

and

distribution

of

onchocerciasis:

a

Cameroon case

study.

Annals

of

Tropical Medicine and Parasitology 88: 463-474.

Taylor

H.

R., Duke

B. O. L. &

Munoz

B.

(1992). The selection

of

communities for treatment

of

onchocerciasis with ivermectin. Tropical Medicine and Parasitology 43:

267-270.

APPENDIGES:

LIST OF THE PERSONNEL WHO PARTICIPATED IN DATA COLLECTION

g6h6rale Dr ^Isaac BAYORO

Mr Hugues NANA DJELINGA

Dr Gilbert BAMBOYE FONDZE

Dr Donatus NYUYFOMO TUKOV

MrElvis MBIAYAMBA

Superviseur

.",f$E'$r'iteut

Superviseur Sirodrviseur . ",1.:,i:e'ii;''.

Superviseur ..;i9,,Fn{-$,1!9}+e

Chef d'6quipe

.1; ],$.1,iq$*4:!3t{pe Chef d'6quipe .--,. ..9!.+Ptubl"

EnquCteur Fnqu6teur Enqudteur

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Enqu6teur .l E_riqucteur

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Enqu0teur .,,.',€{SLqgF.}lr ^.

Enqu€teur

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EnquOteur

*-+;):41-ili. . ?- ?. -.; -_. ii€i,1:+i-&f-4",$'lf'

DT DJATCHE WOLINDJE

Mr MABOU Paul Blaise

Mlle Mirabelle Flaure MAFO

Mr Marcel DOUMTSOP ^Enqu€teur

Mr Louis St6phane NLATE NTEN Mr Alirou. IvIOLILI OI\( NJISA\,I Mr Patrick NDJANA MESSINA

.W:S*lsrrd+Fl{N,_e.ffiN"fiw"gf ^UNG;

MrNarcisseNZUNE TOCHE

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FSgF+MSst

^l

Mr Achille DAMNO DJAWE

Enqu€teur ,EPq1$Js"ur,

EnquOteur

EnquOteur

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