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RAPID EPIDEMIOLOGICAL MAPPING OF

ONCHOCERCTASTS (REMO) rN

MISSION REPORT (UAY L6 - JUNE 1-5, 1997'

FOR

WORLD HEALTH ORGANTZATION AFRTCAN

PROGRAUME FOR ONCHOCERCIASIS CONTROL (APOC)

BY

DR. B.E.B. NI{OKE (OVlrCP/cTDl 5O4lAPle7 I O40'

STATUS: WHO Temporary Adviser (U197 lOt4329l

Professor of Medical/Public Health Parasitology & Entomology School of Biological Sciences Imo State University

PMB 2000 Owerri, Nigeria i. ' ., Phoner (234)83-23 05 85 (Home)

a Fax: (2341A3-23 18 83 ( it, ') t" rfw

JUNE 15, 1997 ,, /.l'^

Fr;r lrr iol nr.;1i :.rr" I .,,

;'1 !r

'y[' ruf II ) SUMMARY

Under the sponsorship of the African Programme .for Onchocerciasii Control (APOC), Rapid Epidemiological Mapping of onchocerciasis was conducted in Malawi Uelireen 1,6th May and June l-6th L997. During the course of the exercise-, 4O5 villages were primarily selected to be examined for the prevalence of onchocercal nodules of due to which 48 ( 1f-. 85Ul were not sampled - inaccessibility. Pending the final Atlas GIS analysis of the data, the results showed that: L. O onchocerciasis is apparentty absent from all the 5 Northern Districts of Uafawi: ChitiPa, Karonga, Mzimba, Rurnphi, and NkhatabaY. 2.O In the central Region, onchocerciasis is absent in 7 districts of Kasungu, Nkhotakota, salima, Mchinji, Dowa, Ntchisi and Lilongwe out of the 9 Districts. has endemic communities on the western border with Mozambique as welI as with the southern border with the Mwanza/Neno area. There is also onchocerciasis at the east-central- part of . 3. O The Southern Region is the onchocerciasis zone in Malawi. Onchocerciasis is endemic in Thyolo, south and Eastern Mulanje, Phalombe, Mwanza, Chiradzulu, and western and southern BIantyre. The Mwanza and Thyolo onchocerciasis foci spread into meso endemic foci in northern . 3

LIST OF CONTENTS

Title page ""'l

Summary 2

List of contents " " 3

]-.0 INTRODUCTION ...... 4

2.O MATERIALS AND METHODS ....6

2.L StudY Area ""'6

2.2 Training of National Teams... " " "9

2.3 Planning and Implementation ' ' 10

3. O RESULTS AND DISCUSSION . . ].]-

4.0 REFERENCES...... ].3

5.0 ACKNOWLEDGEMENTS ...15

6.0 ANNEXES ..].6

6.1 Trip Schedule ""'L6

6.2 Population of Mal-awi(1"989).... " "t7

6.3 Map of Matawi showing the Present onchocerciasis areas as determined by REMO..l-8 6.4 Summary of REMO results in Malawi May/June L997 19 4

1.0 INTRODUCTION Human onchocerciasis was first formally reported in Malawi by Gopsil (L939). Later Harvey (L967 ) made another report-. These early studies described cases only i" . The first systematic atternpt to present a nation-wide prevalence- 1t'd geographical ai=t.iUrtion of onchocerciisis in Malawi was carried out by Ben-sira and his colleagues in L972. In this study a totaL of 3482? people from alt over the country were randomly chosen ind skin snipped and most of these came from Th-yo]o district. This \^ras followed up subsequently othei epidemiological studies which include the work by -(1-976), (L986), of Rampen ' 'L991)eudaen (L979), Chirambo et AI gurnham (1-988 , . AI1 these studies showed that endemic onchocerciasis is far from being restricted to the Thyolo District as was previously thought. nntomoroqical studies have also confirmed this, ds vector r-ri"= have been found breeding and biting in other areas outside Thyolo (Berner & carr, 1954; Lewis, L96L; Davies, t985; TambaIa, 1-988; Roberts, r-ee0). Before the last two decades or so, simulium neavei complex was the predominant vector of human or"iro"".ciasis in MaIawi, especially on the Thyolo Highlands, the main onchocerciasis foci in the country ao" MeiIIon , 1-930; Lewis ,Lg6L) - with the rapid population growth and movement of people in the l-960s i"'a L97os i; the country (Coleman, L974), and resultant widespread deforestation as welI as other environmental modifications Simulium damnosum complex displaced the less aggressive S.nearrei complex as the main disease vector. Burnham (1991-) noted that the prevalence of Simulium has increased steadily since the 1950s when Berner & Carr (1954) observed that S.damnosum was hardly noticeable. This increase of S.damnosum was to the extent that in Lg85-87, over 99.92 of the l-00,000 Simulium flies caught biting man in the country were S.damnosum s.7. (Roberts, 1990). From the already known bionomics of s.damnosum.s.7., especially the ffignt range and vectorial capacity as welt as Lfre continued movement of inhabitants in the country, the extent to which onchocerciasis is endemic has rernained undefined. This has created Some fundamental questions and difficulty to health planners i-nvolved in onchocerciasis control to operationally define endemic Districts/areas. The definition of people at risk of infection in Malawi is especially important now that wHo executed African Programme for Onchocerciasis Control (APOC) is determined to control 5 this debilitating disease in Africa to such a level that it will no longei be a public health problem or obstacle to socioecoromi" development in the continent. The APOC main strategy for tnis control effort is Community Oirectea Oistrif-uifion (CDD) of ivermectin to endemic areas. For obvious operational reasons, and successful i*pi"*""iation of the cDD strategy, there is, therefore, need for a nation-wide baseline- epidemiological information gathering based on uiriformTstindard procedure to define areas where cDD should be applied, where it is possible and where the disease is not endemic. This information is not readily avaitable or comprehensive in most endemic African countries including Malawi. In Malawi and elsewhere r^lhere onchocerciasis is endemic, and where mass ivermectin distribution has been adopted, the hitherto acceptable conventional diagnostic procedure f or identifying _communi-ti-es e1igibIe f or treatment is the skin lnip method to determine community Microfilarial Rate tcMRl.- The advantage of this method is that it is a specific diagnostic procedure very useful in small scale survey, in irospitals and laboratories, and very reliable. when efficiency of intervention programmes needs to be assessed. However, skin snip method has a lot of technical and Iogistic Iimitations: it is invasive and time consumi-ng, ?equires expensive equipment/materials and cornmunities show poor cooperation. This method is also likely to increale the risk of infection of HIV, infective hepatitis etc (wHo, L9g2). In Malawi in particular, tne skin snip method is complicated by the ieculiar length and the tough topography of the _Great ifift Valley -system as weII as the scattered settlement pattern. arl these make national-wide coverage aifficuft if not impossible by this method' AII these shortcomings taken into consideration, TDR/WHO has developed and adopted an alternative epidemiological assessment method for rapid mapping of human onchocerciasis in endemic countries in Africa. This current method is Rapid Epidemiological Mapping of onchocerciasis (REMO). REMO exercise is based on the prevalence of palpable onchocercal nodules lonchocercomata) in the community. T-ni= has a very good ierationship with community Microfilariar Rate (Taylor et AI, Lggz; wHo , :-gg7). REMO has been used severally in the field in the last 2-3 years and has proven to be simple and non-invasive, rapid and cheap, appllcable and pratticable over wide range of ecological conditions. rt i= also reliable and sensitive regardless of the severity and duration of infection. ft is non-technical acceptable and tolerable in terms of sociocultural and relilious considerations as weII as absence of risk of 6

complications or infections (Nwoke, 1993;L9941 Nwoke et aI l-9931 Ngoumou & Walsh l-993). With the APOC interest to support endemic African countries including Malawi to control human onchocerciasis, and the absence of a comprehensive national-wide epidemiological data on the disease as werr as the urgent need to determine endemic areas where community Directed Distribution of ivermectin should be implemented and at the same time ensure adequate coverage, the objectives of my mission as WHO Temporary Adviser were:

1 To assist the NOTF of Malawi with the training of REMO survey teams and

2 The planning and i-mplementation of REMO surveys throughout Malawi.

2.0 MATERIALS AND METHODS

2.I STT]DY AREA The study area for this mission was Marawi, a randrocked southeast African country of dramatic highrands and extensive lakes. The Repubric of Marawi with a current estimated population of 1,2 miltion occupies a narrow, curvinq strip of rand along the East African Great Rift Valley stretching about 837km from north to south, it has a width varying from 8km to t-60km. rt is bordered by Tanzania to the north, Mozambique to the east and south, and south west, and Zambia to the west. Its total area of l-18,484 sq.km includes some 24,ZOg sq.km. of inland water areas of Lake Malombe, Chilwa, Cniuta and Lake Ma1awi (Green, l_983). While Malawi's landscape is highly varied, there are four basic physicat regions: viz. the East African or Great Rift Valley, the centrar prains, the highrands and the isolated prateau or mountaineous areas. The Great Rift Valley by far the dominant feature of the country i9 a gigantic trough like depressj-on runnin| throughout the country from north to south and containing Lake Marawi and valrey. The Lakers littorar situated along the western and southern shores and ranging from 8km to 24km in width, covers about 8z of the total rand area and is spotted with swamps and Lagoons. The shire River valrey stretches some 4o0km from the southern end of the Lake Marawi at Mangochi to Nsanje at the Mozambique border and contains Lake Malombe at its northern end. The central region prains rise to an artitude of between 760 and tillo 7 metres (2500 4500ft) and lies beyond the littoral to the west. The plains cover about three quarters of the total land area. The highland areas are mainly isolated tracts that rise to as much as 24OO metres (8000 ft) above sea 1evel. They comprise the Nyika, Viphya and Dowa highlands, and Dedza kirk Mountain range in the north and west and the Shire Highlands in the South. The high plateau areas are mostly isolated massifs of Mulanje at 3OOO metres (1O,OOOft) and Zomba at 2,LOO metres (7000 ft) and represent the fourth physical region. The major drainage system is that of Lake Ma1awi. ft is fed by various rivers including North and South Rukuru, Dwangwa, Lilongwe and Bua Rivers. The Shire River, the Lakers only outlet flows through adjacent Lake Malombe and receives several tributaries before joining the River in Mozambique. A second drainage system is that of Lake Chilwa, the rivers of which flow from the Lake Chilwa- Phalombe plains and the adjacent highlands. There are two main seasons in Malawi: the dry season (May October) and wet season (November April). Altitude has an important effect upon temperature. Nsanje, ln the Shire River plain, has a mean JuIy temperature of degrees Celsius (69 degrees F) and an October mean of 29 degrees C (84 degrees F) while Dedza, which Iies at an altitude of more than L5OO metre (5000ft), has a July mean of L4 degrees C (degrees) and an October mean of 2L degrees C (59 degrees F). On the Nyika plateau, and on the upper levels of the , frosts are not uncommon in Juty. AnnuaI rainfall is highest over most parts of the northern highlands and on the Sapitwa peak of Mulanje Mountain, where it is about 2,3O0 mm (90 inches) . AnnuaI rainfall is lowest in the lower Shire VaIley, where it ranges from 650 to gOOmm (25-35 inches). It is important to note here that in the recent past as a result of global climatic/environmental changes, Malawi has experienced low and erratic annual rainfalI. During the L99L-94 period the country had a severe drought disaster that sar,,r the drying up of three quarters of its river systems. An international appeal for assistance was also launched. In the current L996/97 rainfall cycIe, some parts of aTe experiencing drought. The effect of these on the epidemiology of water-associated diseases like human onchocerciasis is not yet understood. The natural- vegetation pattern refrects diversities in altitude, soils, and climate. Savanna (grassy parkland) occurs in the dry lowland areas. Open woodland with 8

bark cloth trees or regumious trees unsuitabre for timber, is widespread on the fertite plateaus and escarpments. woodrands, with species of acacia tree cover isolated, fertire prateau sites and river margins. Muranje and Zomba massif and other highrands are covered by grassrand and evergreen forests. swamp vegetation is, however, being greatly artered by human settrement. Much of the original woodland has been cleared and at the same time, forests of softwoods are being pranted in the highrand areas. There are a rot of toresl reserves in the country estimated at 6400 sq. km. These forest reserves together with several nationar park create favourabre environment for the diversity of game animars . antelopes, buffalo, elephants, Ieopards, 1ions, rhinocercoses, and zebra. HippopotamuseJ live in Lake MaIawi. A rurar virlage in Malawi is usuatry smalr predominantry rnade up of farmers, curtivating maize, toba-co, peanutsl cassava, rice, tea, sugar cane, coffee etc. The virlages are limited by the amount of water and arable rand availabre in the vicinity. on the prateaus, which support the burk of the population, the most common village sites are at the margins of rivers or streams characterized by woodrand, grassrand and fertire arluvial soils. rn the highland areas, scattered vilrages are located near perenniar mountain streams and pockets of thin but arabre rand. However, improvement in road network and the sinking of bore-hores in semi- arid areas as we]1 as irrigation projects have perrnitted the establishments of new settrement in previously un-inhabited areas. Health facilities in Marawi include central Hospitars, Generar Hospitars, mentar hospital, leprosaria and District Hospitars as welr as numerous comm-unity clinics and hearth centres. The current emphasis ok hearth services in Malawi is primary Health cire (pHC). There are 25 administrative Districts in the country. Each district has a functionar hospital and the pHc iystem is strongry supported at this lever. with adequate logistic support (Four-wheel vehicles, motorcycres and bicycres) by Government and international aono? agencies and effective communication network, the District hospitar staff have adequate coverage of the communi-ties in the District. To strengthen this, pHc in Matawi has for sometime now, estabrished a health cadre carred the Health surveirrance Assistants (HSA) attached to the vilrages/communities. supported by ; bicycle, the HSA lives in the village and has a catchment population of 2900 villagers to mobilize, assist and rLptrt to the District office of any disease epidemics or hearth rerated.emergencies. This has continued to herp in the timely intervention and success of the pHc system and 9

strategy in this country. ),) TRAINING OF ST]RVEY TEAMS For this study three different groups were trained: the Nationar and District teams as wert as the Health surveil-rance Assistants (HSA). The detailed REMO training was given to the Nationat team who in turn trained and red the District teams and HSAs to the serected communities for the REMO exercise. At each revel of the training there were theoreticar and practical aspects. Members of the Nationar team red by the Nocp National coordinator are experienced and ha-ve been working at different levers of onchocerciasis contror in the country. This fact notwithstanding, there was need for this tra.in.ing since REMO is a n"r hi.gnostic toot and it is signif icant that globar standard-s in proceaure be maintained for obvious epidemiorogical reasons. The team was, therefore, exposed to ; 3 _ day detailed theoreticar training which covered arr the essentiar aspects of wHo-REMo documents (Ngoumour & walsh , 1,gg3, wHo, 1-995). rn addition, other aipects covered incruded thg b.iorogy and contror of the di=ea=e and vector in Ma rawi , cr inicopathologicar- manifestations, socioeconomic impact of the disease in endemic areas, and the need and the current strategy for contror with emphasis on the community Directed oistribution of Mectizai. rn course of the training, team members were given opportunities f ' or personar contributions and discutsior',=.' rt a rewarding training. ,u= At the end of the training, the National team traverred to. Muranje/ for the fierd practi-um. This was designed to ensure that the REMO tecinique had been correctry learned. rn doing this the telrn was first of arr given the opportunity to inaepenalntry mobilize and train the oistfict neaftn personner This is because this lever of staff are very importani in the successfuL imprementation of the REMO. At the end of this, r was satisfied with the rever of performance of the team. For the fina] practicum, the Nationar team was divided llt" three groups: one red by the Nationar coordinator, the other led by the Deputy coordinator whilst another group was led by a senior fierd officer involved in rEF distribution of Mectizan in Thyolo oi=tri"t. in"=. groups were no\^/ assisted by the District mernbers and atl were taken to High -ni=x . lro and *" secondary rine virlages in the oistrict. This hras done to systematicarly and effectivery demonstrate to each team member nodure palpation and how to differentiate 10

onchocercar nodures from the common lymph nodes, ripoma, sebaceous cysts, gangrion and other-rumps in'the'skin which are not of onchocercal origin. of less- r; addition, but significant to REMO, !h"y- were arso taught how to identify Leopard skin and acute/chronic onchodermatitis. Every member of the team was allowed to independentry examine the same villagers, using the community REMO forms to take a1r the records. These results were pulred together, validated and discussed after each virrage exercise' - to make sure that variations are reduced before the teams were arl-owed to embark on independent survey. At the end, percentage agreement of the practical my vLridation of their REMo exercise in the 3 endemic communities was satisfactory (98u r.oo?). rhis ri"ra -p.-a"ticar training was very significant in irr" success of this exercise and therefore lasted for three days (May 2L- 23) - rt was so designed that at the end members of it alr', the of th? three groups were adequately informed and prepared to lead successfurry an i-naepenaent District and HSA REMO team to serecttd io -pr"a""" standard and acceptable results. "o*rnr.,itie=

District and HSA members were mobilized and trained by the National teams, with most of the trainings done in the field in course of the REMO exercise.

2.3 PLANNING AND IMPLEMENTATION During the pranning and imprementation stage, efforts were made to-. put together and review aIr avairabre reports, studies and surveys on onchocerciasis and vectors in the country. Attempts to divide th;--ountry into different ecologicar zone were not feasibre as the Great Rift Varrey which dominates the features determines the bioecorogicar and . zone runs throughout- the country. so the administrative division irito trrr"" fegions (North, centrar and south) ,"." adopted and each District in each Region constituted a sub unit. However, the main focus was the river systems in the Regions. By .this arrangement a group of the national team was assigned a negion for trris exercise. Each member was assigned a catchment District in th; negion. This \^/as a,n.uj9I strategy to enable us complete this exercise within the time ii.me. fn each Region, areas which onchocerciasis are likely to be free without significant human population such as parks, ^1akes, highlands, mountains, national games and forest reserves were identified .rra kept aside. fn the planning and implementation, attention was given to areas which appear t; be suitable 11

for onchocerciasis but with few or no avairabl_e data and areas bordering arready known foci. Arso attention was given to areas where onchocerciasis has been suspected such as s.ongwe the River system in chitipa and Kar6nga , thg Nyika highrands of Rumphi, chitifa and uortirern Mzimba Districts as well aJ i; Dedza. REMO in the suspected areas. mainly in the Northern Region was personarry carried out by me working jointry ,itn the National coordinator. The southern ana-centrit priority areas were handred by the Deputy National cooldinator and finally varidated by me according to wHo (r-995). To successfurry implement this programme, a time-tabIe for the survey and rerated a-ctiviti"s in each Region/District was drawn-indicating the order in which each activity witr be undertaken. Long before the commencement of the exercise. The National coordinator had written retters to arr the districts informing irr"* of the exercise and the need for their effective sipport 3ld p.urticipation . with the time-table in prace, ^ arr Districts were finarly informed in advance of the dates of the REMO and the serected communities in the oisiiict and the need for the virlage mobirizaton by HSAs and need for Logistic support. This approach was very successful because arl- the Districts in ttre country have a functionar telephone line /system which enables us to plan well ahead of time.

fn addition the availability of strong vehicles and motorcycles at the Districts and the bicycles with the HSAs in these villages facilitated our exercise. In any case of lack of petrol/gasoline in the District vehicles or motorcycles, the team had to take up this responsibility to facilitate them. After-putting every plan in pIace, arr the materiars, and arrowances for the teams were colrected and every team moved into the fierd to implement the REMO exercise. The teams were in constant communication and in case of anv_ difficurty that cannot be handred, the fnternati-onar Eye Foundation at Brantyre was informed fo5.lecessary action. As the exercisi continued, the validation was also made. Notwithstanding the inherent difficulties associated with such extensive fierd survey, this arrangement achieved great success.

3.0 RESULTS AND DTSCUSSION summary Th" of the REMO exercise in Marawi (May r_6 June 76, L997) is shown on Tabre l_. A total of 4o5 villages were serected for the REMO exercise but 357 (88. t-52) were examined whire the remaining 48 eszl were not sampled mainly due to inaccessibliiy i1r-. t2

The resurts showed that of the 25 Districts in Marawi, only 9 of them have endemic onchocerciasis foci. onchocerciasis was found to be apparently absent in arr th? five (s) northern DistrictJ- of cnitipa, xaionga, Mzimba, Rumphi and Nkhata Bay. r had to personarly conduct the REMO exercise in 7 of the High nisi vj_rrages on the songwe River in chitipa and xaronga Districts because of its boundary with tanzania. r arso had to participate in REMO of 6 High Risk communities on the Nyika Highrands of Rumphi and Northern Mzimba. A1r these efforts showed that onchocerciasis is apparently absent the whore of Northern Malawi. rt rnay be we-lr that g.damnosum suspected to be breeding i., this region (Roberts, L990) is the ketaketa torir which have been observed by v^a ji.me (1,997 ) to be non man uiting in other areas of the country; or that the flies ,;1, be biting, but no parasite in-the population to transmit. rn the central Region, of the nine (9) Districts, onry two Districts: Ntcheu and Dedza are endemic. The other Districts: Kasungu, Nkhotakota, Salima, Mchinji, Dowa, Ntchisi and Lirongwe are apparentry riee from onchocerciasis. Most of the ri',rer systems in the centrar region are sruggish and most of these communities are on the priin, which someti_mes become flooded. Arr these areas are unfavourabre to the breeding of the vector fries. The presence of onchocerciasis in Ntcheu and Dedza is no€ unexpected because these foci are within the same Kirk Range mountains on the Mozambican border from in the Southern Region of the country. rn the southern District, these are onchocerciasis foci 3I" in Thyolo, Mulan j e, Northern Chikwawa, Irlrurru, and chj-radzuru as werr as southern Zomba. This shows that apart f rom the eastern side of trrulin j e mountain, onchocerciasi-s is a major problem along the Thyolo chikwawa escarpment from uuolra to Nkura. on the west of the shire River the di.sease is enaemic from northern chikwawa to Mwanza arong the Kirk Range mountains. However, a furr picture oi this srroura be cLearer when the resurti are f inarly put=i"av ir., the Altas GfS. rt may be important to point out here that there is urgent need to know what is the onchocerciasis situation i_n- Mozambique in view of the disease endemicity in -trre Muranje/Thyolo eastern border and the Mwania/Ntcheu western border. The significance of this in our current control strategy need not be over-emphasj_ze. r wish to observe that the pHc system especialry the District arrangement and the pre="n"" of the Health surveirlance Assisstants is a qood frame-work for the 13

CDD strategy in onchocerciasis control. 4.0 REFERENCES

Ben-Sira, Ii Ticho, V. & yassur, y (Lg72). onchocerciasis in Malawi: prevarence and oistribulion. 66 2 296-299

Berner, L & Carr, AF (1954). Entomological Report. The Shire Valley Report, Sir Williim Halcrow and Partners, Vor.. 2. London. Government of . Budden, F H (L979). Brindness in Malawi. Lilongwe Marawi. office of the programme coordinator. worrd Health Organization.

Burnham, GM (r-988). onc_hocerciasis in the Thyro of Soutnern l,lata ligllandsLondon. of

Burnham, GM (r-991). onchocerciasis in Marawi. 1. Prevalence, rntensity, and geographical distrlbution of onchocerca volvurus inrection in the Thyoro Highland B5:4 93-496 chirambo, MC et A1 (r-986) . Bl-indness and visuar impairment in southern Marawi Bu1r. wrd. Hrth. org. 642 567-572

Coleman, G (L974). The African population of Malawi, and analysis of censuses 1901-1966. Soc. Malawi Journal . 27:27-4L

Davies, JB(1985) . Observations on Simulium damnosum s.I in ThyoIo Highlands of Malawi. WHO Unpublished report WHO/ONCH o/85.163. WHO Geneva De Meil-1on, B(1930). on Ethiopian simuriidae. Burr. EntomoI. Res . 21,: t_85-200 Gopsil, ML(1939). onchocerciasis in Nyasaland. Trans. Rov. Soc. Trop. Med. Hyg. 32r55L-552 Green, JW(1983) (Ed. ) The Nationar Atlas of Malawi. Department of Survey, Government offi Harvey, R{ (1,967). The early diagnosis and treatment of onchocerciasis. Central Afr. Med. J. 13: 242_245 l,9wi9{.JD (196r-). The simurium neavei Simuliidae) in Nyasalana@. comprex (Diptera: 30:303-31-0 t4

Ngoumou P & lVaIsh, JF(1ee3). A manual- f or Rapid Epidemiological Mapping of onchocerciasis. TpR/TpE/ONCHO / 93 . 4 . WHO Geneva Nwoke, BEB ( l_993 ) . Rapid epideniological assessment of onchocerciasis endemicity in lligeiia. Nigeria J. biotech. l-1- z 2L3-2L6 Nwoke,BEB et AI (L993). Human onchocerciasis in the rainforest zone of southeastern Nigeria. 1. Rapid assessment for community diagnosis in the Imo River Basin. Niqer ia J. Par sito I. 15:7-LB Nwoke, BEB (L994). Rapid epidemiological Mapping of onchocerciasis (REMO) in Southeastern -zone of Nigeria. . ppl22. Rampen,F. (L97 6) .The geographical distribution of onchocerciasis in Malawi. East Afr. Med. J. 53 :25L-254

Roberts, M.J(1990) . Vectors of onchocerciasis in the Thyolo Highlands and other onchocerciasis foci in Malawi. Acta Leidensia. 59 (1 & 2)z 45-47 Tambala, pAJ(r-989). chromosome analysis of simulium damnosum S. I. (piptera: Simutii gg. Dissertation. Liverpoor s@car Medicine. Taylor, TT et aII (L992). The selection of communities for treatment of onchocerciasis with ivermectin. Trop. Med. Parasitol . 43 (4) z 267 -27 o

Vajime, CG(L987). Report on a short term mission to Marawi. cytotaxonomy of the simuriurn damnosum complex in the Thyolo Highlands of Uafawi :+ ppf-Z.rG; Nigeria (JuIy 1.e87 )

WHO, (7992). Methods for community diagnosis of onchocerciasis to guide ivermectin bised Control in Africa. TDR/TDE/ONCHO/92.2. WHO Geneva.

!H9r (199s). Supplementary guide-Iine for Rapid Epidemiotogicar Mapping of onchocercia-sis (REMo) TDR/TDF/ONCHO/95. 1. WHO Geneva. 15

5.0 ACKNOWLEDGEMENT r am grateful to wHo-African programme for onchocerciasis control (Apoc) for the opporluniiy given to me to serve in this capacity, Lilongwe and L; wR r,afos- and offices for ar-r tnlir &'rorts to facililate my mission. r am indebted to the Nocp Malawi Nationar -coordinator, Mr Tambara and arL the members of the National REMO. team; Sitima,. Katambo, Nkhoma, Makina, Mpeni and Mizati for ttrlir suppJrt and goodrirr throughout the survey and to ubewe and oanlwe who maintained courage ind cheerfulness i; dE;i"; us through all the tough terrain to reach the ,peopie at the end of the road'i. r wish to speciar_ry acknowledge with thanks !h" support,-witte, encouragement and hospitality given to me by or tnternitionar Eye Foundation country Director,. Blantyre and her correigues in the course of this mission. The success of ttiis exercise wa: made. comparativery easier by and the numerous support commitment of arr the oistritt Health officiars and Health surveil]ance Assistants. To arl that helped in this exercise f say thank you. t6

6.0 ANNEXES

6.I TRIP SCHEDULE

May 1l_ Owerri - Lagos (Road) May L2-L3 Lagos May 14 Lagos - Addis Ababa (Air) May l_5 Addis Ababa Lilongwe (Air) May l-5 Lilongwe Blantyre (Air)

May l_6-t-9 Blantyre NOCP He May 20 Blantyre - Thyolo - Mulanje May 2t-23 Mulanje (FieId Practicum, REMO, & Validation) May 24 Mulanje Blantyre May 25-June 7 Blantyre Northern Central & Districts June 8 Dedza - Ntcheu - Blantyre June 9 Blantyre - Mwanza June L0 Mwanza - Thyolo June l_0 ThyoIo Blantyre June 10-16 Blantyre June L7 Blantyre Lilongwe (Air) June t_8 Lilongwe Addis Ababa (Air) June 19 Addis Ababa Lagos (Air) June 27 Lagos Owerri L7

6.2 POPULATTON OF MALAWT (1989)

1 chitipa LOt r 879 2 Karonga 155, 458 3 Nkhata Bay L42, L24 4 Rumphi 101r 738 5 Mzirnba 449 ,059 6. Kasungu 332 ,595 7. Nkhotakota L7 L, 427 8. Ntchisi L27 ,623 9. Dowa 337 rLO6 10. SaIima 2OO, LO6 11. Lilongwe 1r 045 ,672 L2. Mchinj i 267 r942 13. Dedza 434 r277 L4. Ntcheu 389r 390 15. Mangochi 539r805 15. Machinga 552 , t48 L7. Zomba 455r080 18. Chiradzulu 2L7 ,4L9 19. Blantyre 626, L6g 20. Mwanza L32 r78L 2L. Thyolo 453 r 986 22. Mulanje 67tr3OL 23. Chikwawa 348 r284 24. Nsanj e 223, L77

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