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Onchocerclasis Control Programme in Wcst Africa pnograrure de Lutte contle l'Onchocercose en Afrique de l'Ouest CONJOINT DU PROGRAIVIME JOINT PROGRAI\{ME COMMITTEE COIVIIIE .CCP du Pr6sident Office of the Chairztan JPC Burcau ii JOINT PROGRAUT{E COHUITTEE JPC11.8(c) Eleventh session ORIGINAL: ENGLISH t Cona 3-6 December 1990 Septenber 1990 Provisonal agenda item 9 DEVOLTTTON PLAI{ - CONTROL OF ONCHOCERCTASTS, YAWS, LEPROSY AT{D GUIIIEA I|OR}I IN GHANA I t, REPUBLIC OF GHANA j MINISTRY OF HEALTH DEVOLUTION PLAN CONTROL OF ONCHOCERCIASIS, YA}VS, LEPROSY AND GUINEA }VORM Prepared by NATIONAL ONCHOCERCIASIS COMMITTEE NATIONAL ONCHOCERCIASIS SECRETARIAT MINTSTRY OF FINANCE & ECONOMIC PLANNInNG ACCRA JUNE I99O 3 SUMMARY The Onchocerciasis Control Programme (OCP) began its control operations in Ghana in 1974, in what is now called the Original Programme area in northern Ghana, covering the present-day Upper East, Upper West and Northern Regions. In 1988 the control activities were further extended southward to cover the southern Extension area. In the Devolution exercise about to take off, however, only the original Programme area is involved. Prior to OCP control operations, the epidemiological data showed that the original Programme area was highly endemic for the savanna blinding type of onchocerciasis. About a third of the population was afflicted by the disease, with a blinding rate reaching up to l09ir in certain communities. The area cqntained some of the worse affected localities, such as villages in the Sissili/Kutpawn area and along the Btack Volta, where prevalence rates reachecl 70% or more. Nakong, on the Sissili River, for instance, had a prevalence rate of 1000/u in adults. The disease created serious obstacles to the socio-economic advancement of much ol' the highly endemic area. Following intervention efforts by the OCP, significant control of onchocerciasis in the Programme area has been achieved. However, a number of 'black spot" areas have remained problematic. Those include the Sissili/Kulpawn area and the Bui area on the Black Volta where residual transmission still occurs, due to a combination of factors such as the high CMFL and high ATP in the past, occurrence of insecticide resistance and reinvasion by the flies. In the Devolution Plan of Ghana, the chief aims are to sustain the gain so far achieved, to prevent recrudescence of the disease and to overcome the problems posed by the "black spot" areas. The devolution activities will be closely integrated into the PHC programme, full1, involving community participation. Apart from surveillance and control of onchocerciasis, the Devolution Plan envisages the inclusion of the control of three other diseases of public health importance endemic in the proS,ramme area. These are leprosy, yaws (to be eradicated by 1995) and Guinea worm (to be eradicated by t993). Their inclusion in the Devolution programme is fully justified by the fact that, like onchocerciasis, they present distinct skin manifestations which lend themselves to easy differential disgnosis. They also constitute problems for the socio-econom ic development. In the Devolution Plan, three Potyvalent Teams, a Monitoring Team and an Evaluation Team are to be set up in order to ensure the effective execution of the plan. The PTs rvill provide technical resources and backings to all stages of the devolution activities, including the large-scale survey to be carried out once every three years. The Monitoring Team will assess and ensure the smooth implementation of all aspects of the institutional arrangements to be put in place. Finally, the Evaluation Team will carry out, in the third and fifth year of the programme, epidemiological and parasitological surveys to evaluate the progress and the achievement of the Devolution Plan. High priorities in the Devolution Plan are also accorded to the training of health personnel of all levels to cope with the integrated control programme and the strengthening of health facilities within the programme area. For the successful implementation of the Devolution Plan, the estimated cost for the l'irst five years amounts to 936,000,000 cedis or US $ 2.t40.000. 2 OF CONTENTS TABLE Pages EXECUTIVE SUMMARY 3 1. INTRODUCTION 4 2. EPIDEMIOLOGICAL SITUATION 5 2.1. Epidemiological situation of onchocerciasis 5 2.2. Epidemiological situation of other diseases: yaws, leprosy, Guinea worm 7 3. GENERAL SITUATION IN THE COUNTRY 8 3.1. General presentation 8 3.2. Demographic and Socio-Economic Indices 9 3.3. Organization Chart of Ministry of Health and Health Policl' 10 3.4. Personnel and facilities 13 3.5. Cost and Financing of Public Health Services r3 3.6. Function and Resources for Epidemiological Surveillance 14 4. SURVEILLANCE AND TREATMENT 14 4.1. Objectives for onchocerciasis, yaws, leprosy and Guinea worm 15 4.2. Activities for onchocerciasis, yaws, leprosy and Guinea worm 15 5. ORGANIZATION OF SURVEILLANCE AND TREATMENT 16 5.1. Human resources L7 5.2. Material resources 20 5.3. Cost of programme for five years 2t 5.4. Ghana Government contribution to Devolution Plan implementation 22 6. PROVISIONAL TIMETABLE 23 ANNEXES l. Phases of the implementation of the Programme in the original Programme area 25 2. Northern Ghana within the Volta Basin 26 3. Pre-control prevalence of onchocerciasis 27 4. Prevalence of onchocerciasis in 1989 28 5. List of diMstricts in the Devolution area 29 6. Estimated cost of the Devolution-Plan 30 7. Material allocations 38 5 2. EPIDEMIOLOGICAL SITUATION 2.1. Epidemiologicel Situetion of Onchocerciasis 2.1.1. Situatiort before the beginning of Vector Contol The objective of the Onchocerciasis Control Programme (OCP) is to eliminate onchocerciasis as a disease of public health and socio-economic importance throughout the Programme area and to ensure that there is no recrudescence of the disease thereafter (Anon, 1985). In pursuance of this the OCP is pre-occupied mainly with the savanna or blinding form of onchocerciasis which, in the Programme area, is endemic mainly in the savanna regions. The forest or non-blinding form of the disease is not covered by the Programme (Anon, 1986). Prior to the launching of the OCP in 1974 it was estimated that onchocerciasis affected berween 1.0 and 1.5 million inhabitants, with blind people numbering about 120,000 in the Votta River basin area. This area covered an estimated 764,000 sq. km in the seven originalll' selected endemic countries in West Africa (Anon, 1973). In Ghana the area involved covered all of Northern Ghana circumscribed by the Black Volta to the West and south-west, the Oti river to the east and with the Volta lake as the southern border. This covered an estimated 98,000 sq. km. with a population of 1.6 million (1970-71 Census) (See Annex 2). Duke-Elder (in Crisp, 1956) stated that about 30,000 of them were blind, i.e., about 25%of all blind persons in the original OCP area. In some villages, a tenth of the people were blind and in others, where the struggle had been won by the fly, the people had abandoned their homes carrying wirh them rhe menace of the disease to areas further south. Thus there were high population densities in the area between the valleys of the White and Red Voltas, the Sissili and the Kulpawn rivers, while the valleys themselves were sparsely populated or even uninhabited (Crisp, 1956). Relatively densely populated areas were encountered in the Bawku district in the extrenre north-east and around Tamale in the centre, and in the Wa and Lawra districts in the north-west. Generally, the northern portion of Ghana has low population density while the southern portion is rather densely populated. Annex 3, shows the prevalence of onchocerciasis in the Programme area. This area, particularly in the Upper Regions of Ghana, was among the worst onchocerciasis endemic areas in the Volta basin. The area drained by the Red and White Voltas, the Sissili and the Kulpawn rivers, and along the Black Volta supported prevalence rates of over 70%. And as stated above, the whole population was affected in some localities. Since the southern extension of the Programme. the high prevalence endemic areas of Asukawkaw in the Volta Region and Pru in the Brong-Ahafo Region have now also been covered. Crisp (1956) reported the following infection rates in the different age-groups in the Red Volta area: 30% (under l0 years); 9l% (10-20 years); 100% (31-40 years); 100% (41-50 years): 100% (50-60 years). In the village of Nakong on the Sissili river 100% prevalence rate u'as a recorded. He also recorded 60J% at Widenaba, ?l% at Sapeliga. 77.E% at Zongoiri and 89(),r ar Tilli. It has been noted in the endemic areas in Ghana that blindness rates of over 590 were in villages of 200 inhabitants or fewer whereas they were exceptional in villages with 500 or nlore. Furthernrore there was no population growth in the communities where the blindness ratc' equalled or exceeded 5% (Rnon, l9E5). 2. 1.2. Tlrc prcscttt sinrutiotr 4 I. INTRODUCTION Ghana is situated in the middle of the coastline of West Africa. It extends some 850 knt between latitude 4o4'N and latitude llol2'N and stretches some 480 km between longitude tol2'E and 3ol5'W. It is bordered on the east by Togo, on the west by COte d'lvoire, on the north by Burkina Faso and on the south by the Atlantic Ocean, the Gulf of Guinea. Ghana lies squarely within the endemic onchocerciasis belt of West Africa. There is blinding onchocerciasis in the Volta basin which includes all of the Northern and Upper Regions and portions of the Brong Ahafo and Volta Regions. Forest onchocerciasis is also endemic in many parts of the forested southern areas of the country.