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WORLD HEALTH ORGANIZATION ORGANISATION MONDIALE DE LA SANTE ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA PROGRAMME DE LUTTE CONTRE L'ONCHOCERCOSE EN AFRIQUE DE L'OUEST EXPERT ADVISORY COMMITTEE Ad hoc Session Ouaeadougou. ll - 15 March 2002 I EAC.AD.9 Original : French August-September 2001 SOCIO.DEMOG HIC STUDY IN THE OTI BASIN ITS TRIBUTARIES (K6ran, Kara; r + 2 CHAPTER I _ BACKGROUND 1. Background to onchocerciasi s control in the Kara reqton. OCP started its activities in Togo in 1977, by treating the Oti basin and its tributaries (Kara, Keran, Mo). This area is called the "initial zote". The activities were mainly vector control (insecticide spraying). In 1986, another zone was demarcated and named the "southern extension zone". This is found in the southern part of the country, in two groups of basins: the Mono basin (with its tributaries: Anie, Amou, Amoutchou, Ogou, Chra), and the YotolZio and Haho basin, to which the great rivers of Gban-Houo, Wawa and Asukawkaw are added. In 1988, ivermectin distribution started in some areas of the Kara region. This second/new method of treatment was conducted by an OCP team, including some national health workers (health assistants, nurses) and doctors. In 1989, the National team was put in place to assist members of OCP. This collaboration was to enable mass treatment in the villages to be carried out. But this phase ended in 1996, after the training of nurses involved in implementing CDTI in the region of Kara. These nurses, in tum, were to train community treatment agents, selected by the communities themselves. After this, the CDTI implementation process was to be extended to the entire national territory, with a rapid training of health workers of the four other regions of the country in 1997. Observation: It might be necessary to recall here, in passing, that the training for CDTI implementation in Togo dates back to 1996197, and that since then no other training nor re- training was given to the agents in charge of implementing this strategy. To make matters worse, a lot of new health workers are recruited and posted to health facilities, beginning 1998. Most of these workers, out of necessity, are involved in Oncho control, without any prior training. Could CDTI implementation be effective in such conditions? 2. The entomo-epidemioloeical situation in the Oti basin (and its tributaries) 2.1. The epidemiological situation in the Oti basin (and its tributaries) Prior to the inception of the Onchocerciasis Control Programme in West Africa in 1974, this disease was a critical public health problem in Togo. The disease was hyper-endemic in the affected areas, especially in the Oti basin and its tributaries: Kara-Keran-Mo, where prevalence rates were between 70 and 80%o, and blindness rates reached between I and 3oh. Dw to the collaborative efforts of vector control, which have gradually been made in these basins since 1977 by the Programme, and the use of ivermectin since 1988, onchocercal disease is no more a public health problem in Togo. The epidemiological surveys undertaken in the endemic follow-up villages showed that prevalence rates of between 70 and 80oZ recorded at the beginning of the programme, have dropped and are considerably low. The rates could currently be around l|Yo on the basins (in Togo), except in the Kara-Keran area, where they are still 60%t. It is worth noting I Data from the National Team report J that onchocerciasis in the Kara-Keran region is blinding, and it is transmitted by the savanna species. 2.2. The entomological situation in the Oti basin (and its tributaries) Prospecting surveys showed that since the Kompienga dam was filled with water in 1988/89, the Oti has become a perennial river. Certainly black flies might be crossing from the Oti to its tributaries (Keran, Kara, Mo), and despite the intensification of larviciding, there was, in this endemic zone, an increase in black fly numbers (captured and infecting) in 1997. According to two recent reports2, the entomological situation of the zone is as follows: - the measures taken in 1977, namely, the intensification of prospecting and ground larviciding, the extension of larviciding to lower Keran and lower Kara, the experimental treatment of the Oti, the enhancement of distribution of ivermectin to populations; - in 1999, Annual Transmission Potential figures (O. volvulus) were higher than 100 at only one point of Tchitchira (Keran), and the ATP, which was equal to-l54 in 1988 fell to 135 in 1999; in Tapounte, on the upper Keran, the ATP was 91 in 19983. All the other points on Keran Kara, Mo had corrected O.volvulus ATPs that are lower than 100 in 1999. The analysis of results show that the rates of reduction in gross ATP figures in 1999, as compared to pre- control data, or before the South-East Extensions, were between 78 and 94o/o on the Keran, 93 and 99o/o on the Kara, and99o/o and 100% on the Mo. The persistence of transmission on the upper Keran in Tchitchira needs to be given special attention. Considering the data on the entomo-epidemiological situation, it appears that the elimination of onchocerciasis in the endemic areas (Kara-Keran-Mo) is below expectation, hence the entomo- epidemiological problem in this endemic zone. 3. Issue of the entomo-epidemioloeical situation in the Oti basin (and its tributaries) After several years of combined control of onchocerciasis (in this zone), i.e. vector control, with the intensification of prospecting, extensive larviciding, and the experimental treatment of the Oti at particular periods of the year; distribution of ivermectin to populations of the zone; the conclusion that could be drawn, to date, is that the entomo-epidemiological profile of the disease is still not satisfactory in this endemic zone. This situation is of concern and raises some questions: why this situation? What could be the underlying causes? In other words, to what could causes of this partial failure be attributed? ' & 3 - Meetrng report on entomological research (Ouagadougou24-25 March 2000) - Meeting report on strategies and operational research (Ouagadougou2T-29 March 2000) 4 Let us start with the assumption that vector control (with all measures intact) is successful, and that it is well conducted and efficacious. Or, that it is a failure, insufficient or badly carried out? We leave the task to the specialists to find responses to this. If, therefore, the problem and the hypothesis of vector control are not taken into consideration, one may ask if the causes are not social and demographic-related? As a matter of fact, the mode of population settlement, the migration pattern, the organization of treatment, the degree of involvement of actors in the CDTI strategy etc... could not be said to be favourable or unfavourable factors. What about other potential factors such as the disturbing ancestral practices, the levels of patronage and appreciation of ivermectin by the beneficiary population, their level of ignorance etc.. If all this is verifiable, then there is reason to question the coherence of the onchocerciasis control programme in this endemic zone. 4. Objectives and expected outcomes of the study For a better appreciation of the objectives pursued in this study, as well as the expected results, we deem it necessary to recall its goal and content, as contained in the terms of reference. 4.1. Goal and content of study To better clariff the situation that obtains in the Oti basin, (and its tributaries: Kara, Keran, Mo), and to improve same before the end of the Programme, a socio-demographic study is necessary in order to f,rnd the linkage between, on the one hand: - the mode of settlement of populations, the spatial distribution and accessibility of agglomerations in the zone; - potential migration inflow, periods of great population movements, their causes and influence on the efficacy of Oncho control actions; - treatment organization: those in charge, their incentives (motivation), and their numbers in each agglomeration, the mode of distribution, (door to door, meeting places) etc.., period of distribution, the number of annual treatment conducted by distributors; - any other factor that could explain the present situation in the zone, or which could influence it (attitudes and behaviour of populations, health personnel incentives, and their involvement in control activities... And on the other hand: the entomo-epidemiological situation, as obtain to date in the zone. 4.2. Objectives of the study and expected results On the basis of the goals and content of the study (which in some respects, is a kind of guiding evaluation) it will try and take stock of the situation. The study must throw light on the modes of population settlement and their projection on the sites: space distribution and territorial partitioning. From here, it should be possible to arrive at how this 5 form of agglomeration leads to social logics, as for example: the ethnic factor in land issues, identity competitions (rivalry, quarrels), the setting of boundaries and modalities of inter-clan linkages, and other forms of articulation and disarticulation of the social fabric, and of the social experience that go through the length and breadth of the sites. At this point of the demonstration, it would be helpful to also show whether there are constraints or not, and the scope of action of community distributors, who are called (or obliged) to work in these surrounding environments. ln other words, the study must allow for the appreciation of the link befween the dispersed nature of habitats and the geographical inaccessibility or land-locked nature of some sites, by explaining the relationship between the organization of CDTI and these different variables. [n a word, there is need to bring to the fore the existence of potential difficulties that this form of agglomeration, and the natural character of sites may create and show how this may compromise the CDTI strategy.
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