LIST OF CONTENTS
Page
SUMMARY I
1.0 INTRODUCTION I
2.0 MATERIALS AND METHODS
2.1 Study Area 4
2.2 REMO Implementation 6
3.0 RESULTS AND DISCUSSION 8
4.0 REFERENCES l3
5.0 ACKNOWLEDGMENT t6
6.0 APPENDIX t7
6.I Mission Schedule t7
6 2 REMO Data 20 SUMMARY ln recognition of the obvious public health problem of onchocerciasis in Liberia, and the need to generate a comprehensive epidemiological data necessary for the successful implementation of this disease control through Community Directed lvermectin Distribution (CDTI) strategy, WHO African Program for Onchocerciasis Control (APOC) as a partner in the program in Africa sponsored this nation-wide Rapid Epidemiological Mapping of Onchocerciasis (REMO) in the country. With a good quantitative understanding of onchocerciasis and its vector species; and a sound knowledge of the geography of Liberia, a total of 12O villages were selected for this study. Of this, 21 (17 .5o/o) of the villages were inaccessible at the time of this exercise. Using community nodule rate as indicator of disease endemicity, randomly chosen residents farmers, aged >.20 years, especially males were clinically examined. A total of 99 accessible selected villages were examined. The present results showed that human onchocerciasis is endemic in Liberia, especially along fertile banks of the major rivers and their tributaries. These results are integrated into the Geographical lnformation System (GlS) and are presented to ensure adequate coverage of endemic areaslzones that require CDTI priority in the ongoing APOC partnership control strategy in the region.
1. INTRODUCTION
Onchocerciasis (River blindness) is a chronic parasitic disease caused by filarial nematode, Onchocerca volvulus; and it is transmitted by black flies (simulium species). Onchocerciasis is known to be endemic in many areas of 26 tropical African countries (including Liberia), six South American countries and Yemen.
Since 1947 (Stoll,1947), human onchocerciasis has been recognized as a disease of significant public health importance and an impediment to socioeconomic development in endemic areas (Nwoke, 1990; Molyneux & Davies, 1997). This
I debilitating disease causes different types of characteristic ocular lesions, especially in endemic villages in the savanna belt of West Africa. These lesions, often lead to irreversible blindness in untreated patients, hence the name river blindness because these blindness cases are seen more in village settlements along the rivers (the breeding sites of vectors and high transmission foci of the disease). ln addition, onchocerciasis infection causes very severe and worrisome onchocercal skin diseases (OSD), disfiguring and embarrassing hanging groin and genital elephantiasis as well as other systemic complications. These non-ocular manifestations have recently been found to cause more burden than blindness in most endemic areas in Africa, especially in the rainforest belt.
The history of human onchocerciasis in Liberia dates back to 1926 when the Harvard Expedition gave the first evidence of the disease occurrence in the country (Strong, 1936). This was strengthened by the work of Burch et al (1955) on "Onchocerciasis in Liberia". This among other works stimulated the studies of Miller & Gunders (1958); Miller &Franz (1958); Gunders & Neuman (1963); Reber & Hoeppli (1964) and Gratama (1966). All these earlier workers contributed tremendously to our initial knowledge of the disease prevalence and clinical complications in endemic communities. The studies of Frentzel-Beyme (1973, 1975) brought to focus a more global picture of onchocerciasis distribution and the associated severe ocular lesions in the country, especially among endemic communities of Bong and Montserrado Counties. These clinical results were confirmed by the entomological evaluation studies of Garms (1973, 1987). Other studies in Liberia include ocular onchocerciaisis and palpable and impalpable experiments in the hyperendemic rainforest areas (Albiez et al, 1981' Albeiz, 1983a, Schulz-Key & Albeiz, 1977) as well as the studies of Barbiers & Trips (1984) in the Harbel Firestone Rubber Plantation, Margibi County.
2 These studies among other publications and reports point to the fact that onchocerciasis is prevalent in Liberia. However a lot more epidemiological information is needed on the disease distribution and intensity in many counties and districts because results available indicate that many zones are yet unidentified and unstudied. This situation has therefore left the country with limited epidemiological baseline data. Such limited information on the disease intensity and pattern, no doubt has continued to affect the effective planning and implementation of any control measure in the country.
Fortunately, WHO/APOC is committed through partnership with MOH and various national and international Non-governmental Development Organizations (NGDs) to control onchocerciasis in all endemic Africa countries outside Onchocerciasis Control Program (OCP). The strategy of this partnership is to put in place within the first five years of any project a sustainable control program; through Community Directed Distribution of lvermectin (CDTI). That is, community ownership of the program. To achieve this mission WHO/APOC requires comprehensive epidemiological data generated using a uniform standard or protocol in any endemic area. ln Liberia this sort of baseline data is limited if not absent, and this has made it difficult for WHO/APOC to initiate any CDT! project in the country. ln recognition of this obvious gap and the need to determine where CDTI strategy should be implemented in liberia, and at the same time ensure adequate coverage of all the endemic zones, WHO/APOC sponsored this nation-wide Rapid Epidemiological Mapping of Onchocerciasis (REMO), December 26, 1998 to February 9, 1999.
J 2. MATERIALS AND METHODS
2.1 STUDY AREA
13 counties of the The nation-wide REMO exercise was carried out in all the states (since 1847)' Republic of Liberia. one of the oldest independent African (Hasselimann, '1979). The Liberia is rocated between ratitudes 4' 2' N and B' 30' N by Guinea in the north' study area is bordered on the northwest by sierra Leone, the country on the south and cote d'lvoire on the east. The Atlantic ocean borders in 1998, Liberia and southwest. with an estimated population of 2.72 million (42,OOO sq' Miles)' occupies a land area of 1 1 1 ,366 square kilometers
in places by long The Liberian terrain is varied; the low sandy coast is backed promontories' Away from the narrow lagoons, and is interrupted at intervals by rock lnland, the western part coast, the land becomes rolling plain with many small hills. culminating is densely forested, mountainous terrain tending north-east-south-west, in mt Vuutivi, 1,300 meters (4,528ft)'
rivers, is a low The central hinterland, roughly between the st. Paul and cesstos meters (600 - 2000 ft)' inland plateau, with heights ranging between 190 and 610
poorly drained swamps' Characterized by small hills encirculed by many sinuous, vivid excarpments, the most the plateau is set off from the coastal plain in places by the Capital City' notable being at Reputa, 105 km (65 miles) northeast of Monrovia' with forest' The eastern section of the country is rugged and covered
wet and dry seasons' The climate of Liberia is warm all year round with a marked dry season is between The rainy season is between May and November; and the 5,210 mm (205 inches) December and April. The highest annual rainfall of about
4 LIBERIA G u inea Sie r;a Leone -;t-n,*-.),^"v--. _i
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? Lonta Zorzor h Zot , Z' 'Jene C6te a a Ecllc Y.1ll,, O 0 Gbanga dWoiie a t Sanoyre f ,rrnc o I
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Atlantic fe Ocean Julrtoa Ttrtuko +
l EotdatS + llatn augott Rerrwrys + AttOorts Metn rcacts o Aamondt Rtvats @ Iton ^APIfAL Saurrlo J- Sc.pgrts @ C) AFRICAE00KS U0 @ irang.nara (100 inches) o@urs at Robertsport and this decreases south-eastwards to 2540mm at cape Palmas and to 1780mm (70 inches on the central plateau. Maximum dry season rainfall occurs in June through september. sometimes there is short (August break) at the peak of rain (July - August)' Leone, The major river systems in Liberia are the Mano on the border with sierra All Lofa, st. Paul, st. John, cesstos and cavalla at the border with cote d'lvoire' which these river systems are oriented north-east-south-west except the Cavalla, rapids at the flows north-south. The rivers have numerals tributaries and are cut by points where the littoral plain joins the interior relief-creating numerous breeding The sites for the vector of human onchocerciasis (Garms and Vajlme, 1975). vegetation of Liberia is essentially tropical rain forest, with some trees attaining gives the inland heights of 60 meters (197 ft). The seasonal rhythm of the rains at the cavalla forest a semi-deciduous regime. The evergreen forests of the basin on the Guinean river and the stands in the Gola forest thin out inland, giving way, along border, to somewhat guinea savannas with forests on steep slopes and streams. similar parkland savanna exists on the sandy soils along the coast' and Belle There are about seven large nationalforest reserves in Liberia viz: Kpelle forest in Lofa County; Grebo forest in Grand Gedeh County; Sapo forest that is located in stretches from sinoe into Grand Gedeh county; Gola forest reserved lt is Grand Cape [Vlount while Krali national forest reserve is in Sinoe County. human important to point out here that these forest reserves have little or no setflements and are therefore more or less uninhabited areas in Liberia. 2.2 REMO IMPLEMENTATION The implementation of this study was commenced with high level advocacy and a mobilization, and theoretical and field practicum for the six-man NOTF team, geographer and county health coordinators. (see appendix for the scheudle). The 6 team was exposed to all the important aspects of the disease and the vectors as well as REMO protocol (Ngoumou & walsh, 1993; WHO, 1992,1995). To ensure that the REMO procedure/technique has been learned correctly by the of team, the field practicum was carried out in known onchocerciasis endemic area Firestone Plantation, Harbel in Margibi County. At the end of the training, REMO sample villages were selected and the exercise adequately planned. For the purpose of this exercise, the country was divided into three REMO Zones; ( l) East (Maryland, Grand Kru, Sinoe and Grand Gedeh counties) ( ll) Central (Margibi, Grand Bassa, River Cess, Bong and Nimba Counties) (lll) West (Montserrado, Bomi, Grand Cape Mount and Lofa Counties) Each zonal REMO team was made up of a team leader, an assistant and a country health officer. The village guide is appointed each day of the exercise. For obvious reasons each team was led by a senior member of the NOTF from the REMO zone. The WHO Temporary Adviser participated in the exercise and also played both supervisory and facilitatory roles. with the time-table of the exercise well made, counties were informed in advance, each team went ahead for the field implementation. There were radio facilities and as a results the teams were in constant communications with each other and the base in Monrovia. For consistency and as part of the protocol, the REMO results were validated by the WHO Temporary Adviser. Notwithstanding, the inherent difficulties associated with extensive and intensive field study as well as the immediate political history of Liberia, we had good cooperation of the villagers and the REMO exercise was a great success. 7 3. RESULTS AND DISCUSSIONS A total of 120 sample villages from 13 counties in Liberia were selected for clinical examination for onchocercial nodules during Rapid Epidemiological Mapping of Onchocerciasis (REMO) in the country, December 26, 1998 to February 9, 1999. Of this number, 21 (17.5o/o) of the selected villages were not accessible at the time of the study. This is not unexpected if one takes into consideration the immediate past history of the country. Most of the access roads and bridges to these villages were damaged as a result of the civil war. With the ongoing reconstruction it is believed that these areas are going to be accessible in due course. However, this does not significantly affect the REMO results (Table 1). REMO exercise was suc@ssfully completed in 99 (82.5o/o) of the selected villages. The present result showed that human onchocerciasis is widespread and virtually present in all the 13 counties in the country; though at different levels of endemicity. Similar observations or impressions were expressed by previous workers such as Burch, (1955), Gratama (1966) and Frentzel-Beyme (1975). The results showed clearly that the distribution and intensity of onchocerciasis in Liberia did not coincide with or follow any administrative/political boundaries of the country. Rather, the major rivers and tributaries (consisting the breading sites of vectors) largely govern the distribution and levels of endemicity of the disease. The results further revealed that villages along the Mano and Lofa Rivers and their tributaries; from northern Grand Cape Mounty County to Lofa County are meso to hyperendemic for onchocerciasis - having community nodule of >- 2Oo/o. This confirms the intense breeding of S. yahense and and S. Sanctipauli observed by Garms & Vajime (1975) and up to 60 - lOOo/o community microfilarial rates in adult population in the region (Frentzel - Beymen, 1975). 8 o ! { !o P J P lrr F 9"' l.) i o m o S", 1\, i I c 7 -{ t- tr TD 4. o o 9. o z o o _o o o =0, f - =o m t- =o =3 o o o o !, o J E GI= E z = CL= e. =CL o CL= { =il o !, q o *o o o t! o x =o. - 0) o o o -q, o c o !, o o CL m o CL @ o s o 0) o! N (.) I @ (., N (, N N o) (., o) ! { o Or (,, (o { c N .J -crr s -o) L@ -o .s -(,r .5 P -(., Ol 1@ (D (D @ o) "9Or N o b, J- tD "} @ (rlN (.) io(rl I N Ot (., { { CD (, N (, N G' N { o) o o (,(., { N 5 { o o o) (o z a u, Barbiero & Trips (1984) also recorded hyperendemic onchocerciasis in this typical rainforest zone of Liberia. Ecological and cytotaxonomic studies of Garms & Vajime (1975)and Garms (1983) identified S sanctipauli and S. yahense to be breeding in these water courses. ln addition, Garms et al (991) reported that there are temporary focus of savanna species of S. damnosum complex: S. damnosum s.str. and S. sirbanum, breeding and biting at the Bong iron ore mine area; especially during the dry season. They believed that this is a clear demonstration of savanna flies seasonally invading the area, aided by the northeasterly harmattan winds. This calls for caution during the proposed CDTI control program in Liberia. This is because these invading savanna flies are often associated with severe blinding onchocerciasis. lt means that for a comprehensive sub-regional control, the proposed CDTI program should also extend to the source of invasion, most likely Guinea (if it had not started CDTI before now). The advantage of this is obvious. ln course of this study we recorded high rate of nodulectomy cases among sample population at Firestone Rubber Plantation, Montserrado and Bong Counties among others. This observation confirms the reports of Schulz-Key & Albiez (1977); and Albiez (1981; 1983a, 1983b) of mass nodulectomy in this area by scientistfrom Liberia Research Unit and lnstitute of Tropical Medicine Harburg during experiental and chemotherapeutic studies. And since our present exercise uses community 10 onchocercal nodule rate as criterior for determining the disease endemicity in this atea, such nodulectomy must have reduced the positive nodules in communities up to the extent that the highest nodule rate in hyperendemic typical rainforest with to 90% microfilarial rate was 34% along St. Paul River. Fortunately, this does not affect the epidemiological pattern of the disease, especially when our results confirmed that all these areas are CDTI priority zones' The presence of breeding sites of S. yahense and S. damnosum s.str' along the St. John Rivers and numerous tributaries (Garms & Vajime, 1975) is believed to have created serious transmission foci that resulted to the high level of onchocerciasis observed among villages on the northern part of Grand Bassa and eastern Bong countries. This is supported by the high microfilarial rate or about 63% recorded by Frentzel-Beyme (1975) within these same zone, especially among employees of the Liberian Agricultural Company (LAC) ln course of this study, it was observed that the fly biting was so serious and the disease troublesome and known in northern Grand Bassa that Dana Center for Preventive Ophthalmology, John Hopkins University (led by Prof. H. R. Tayloy) in collaboration with Division of Geographical Medicine, University of Alabama at Birmingham (led by late Dr. Bruce M. Green) conducted ivermectin trails in this zone between 1984 and 1990. Again, WHO/Liberia, Christian Health Association of Liberia (CHAL) - an NDGO and Catholic Health Secretariat were involved in mass ivermectin delivery sometimes ago mosly in this zone to ameliorate the problems of these endemic villages. parts Onchocerciasis was observed to be endemic in communities in the northern of Sinoe, Grand Kru and Maryland Counties as well as communities of Grand Gedeh County living close to Cavalla River. Previous studies have also reported similar result even though Frentzel-Beyme (1975) noted that "exceptions were found in what sizeable pockets of high transmission actively seems to exit in Eastern Liberia"). ln his own contribution, Gratama (1966) after analysis of over 1l 600 patients of the Firestone Plantations Hospital at Cavalla, Maryland (Eastern Liberia), he concluded "that in the northern part of Maryland endemic transmission was possible". This was confirmed by the identification of S. yahense, and S. sactipauli in these river systems. Even though most of these earlier works did not sample most of the river courses nor examined many communities from different bioclimatic areas due to obvious technical and logistic reasons, it is important to state here that these results are good indicators and informative historic documents - drawing our attention to the public health problem of the disease in Liberia. On the whole onchocerciasis intensity and endemicity in Liberia decreases as one moves southwards towards the coast, the Atlantic. Few cases of onchcercal nodules were observed in these coastal or near coastal communities and they are believed to be imported cases. This is because the sluggish, swampy, salty and polluted water in this zone are not suitable for the breeding of the vector flies and therefore no transmission occur here. This may be part of the problem arising form the great movement of people (in and out of fertile and productive endemic area) in the country, especially in the last decade. This brings to mind the issue of hundreds of workers from hyperendemic zones of Bong Mines, Yekepa, Firestone Rubber Plantation, Liberian Agricultural Company (LAC), timber companies as well as other areas who were displaced by the civil war and are now scattered all over the country. The epidemiological and public health consequences of this phenomenon are very obvious. These infected people if not treated in their new locations are bound to constitute source of infection and transmission to hitherto non-endemic area. !t is therefore adviced that while the CDTI strategy is implemented in meso - and hyperendemic zones, effort should be made by MOH and supporting NGDOs to establish clinic-based distribution in other zones of the country. t2 4. REFERENCES syustematic nodulectomy and Albiez, EJ (1981). combined treatment by diethylcarbamazin citrate (DEC)' 1980/81: 5 - 6 ocular onchocerciaisis in a Albiez, EJ; Ganley, JP & Buttner, DW (1981). hyperendemicvillageintherainforestofLiberia. Tropenmed' Parasitol ' 32' 25 -28' adult onchocerca volvulus during Albiez, EJ (1983a). studies on nodules and and Upper a nodulectomy trail in hyperendemic villages in Liberia VoltaZ,Palpableandimpalpableonchocercomata.Tropenmed. Parasitol . 34: 54 - 60. Albiez, EJ (1983b).LongtermtreatmentofonchocerciasisformtheLiberia after complete rainforest with low dose of diethylcarbamazin citrate nodulectomy. Tropenmed. Parasitol ' 34"267 -270' of onchocerciasis on selected Barbiero, vK & Trips, M (1984). The prevalence Liberia' division of the Firestone Rubber Plantation, Harbel, AM. J. Trop. Med' Hay' 33(3): 403-409 (1955). onchocerciasis in Liberia Burch, TA; Quallo, DM & Greenville, HJ AM. J. TroP. Med' HgY' 50:366 - 378' 13 Frentzel - Beyme, RA (1973). Prevalence of onchocerciasis and blindness in the population of the Bong Range, Liberia. Tropenmed. Parasitol. 24"339-357 Frentzel - Beyme, RA (1975). The geographical distribution of Onchocerca volvulus infection in Liberia. Tropenmed. Parasitol. 26:70 - 87 Garms, R (1973). Quantitative studies on the transmission of Onchocerca volvulus by Simulium domnosum in the Bong Range, Liberia. Z Trooenmed Parasitol. 24.358 - 372 Garms, R (1987). lnfection rates and parasitics loads of Onchocer volvulus by species of the Simulium domnosum complex occurring in Liberia. Angewandte Zool. 70'.101 - 117 Germs, R; Cheke, RA & Sachs, R (1991(. A temporary focus of savanna species of the Simulium domnosum complex in the forest zone of Liberia. Troo. Med. Parasitol. 42: 181 - 187 Gratama, S (1955). Onchocerciasis in the southeastern territories of Liberia with studies inthe pathogenesis of hydrocoele and elephantiasis. Acta Leidensia. 35: 1 - 135. Gunder, AE & Neumann, E (1963). A controlled study of the ocularfindings in Liberian subjects with microfilariae of Onchocerca vulvulus at the outer canthus of the eye. Am. J. Trop. Med. Hgy . 2'. 761 - 766 t4 Hasseliman, KH (1979). Liberia: Geographical Mosaics of the Land and the people. Ministry of lnformation, cultural Affairs and Tourism, Monrovia, Third Press lnternational, New York. Miller, MJ & Franz, KN (1958). Some clinical aspects of onchocerciasis in Liberia Am. J. TroP. Med. HgY. 7: 558 - 560 Miller, MJ & Gunders, AE (1958). Studies on onchocerciasis in Liberia Proce. 6th lnt. Congr. Trop. Med. Malaria. 2'.299 - 304 Molyneux, DH and Davies, JB (1997). Onchocerciasis control: Moving towards the millennium. Parasitol. Today. 13 (1 1): 418 - 423 Ngoumou, P & Walsh, JF (1993). A manual for Rapid Epidemiological Mapping of Onchocerciasis (REMO) TDR/TDE/ONC HO/93' 4 Nwoke, BEB (1990). The Socioeconomic aspect of human onchocerciasis in Africa. The present appraisal. J. Hyg. Epidemiol. Microbiol. lmmunol. 3a(1): 37 - 44. Reber, EW & Hoeppli, R (1964). The relationship between microscopic skin alterations, histological changes and microfilariae in one hundred Liberians with onchocercal dermatitis. Z. Tronmed. Parasitol. 15: 152 - 163 Schulz-Key, H & Albiez, EJ (1977). Worm burden of Onchocerca volvulus in a hyperendemic village of rainforest in West Africa. Tropenmed. Parasitol. 28'. 431 - 438 15 Stoll, NR (1947). This wormy World. J. Parasitol. 33: 1 - 8 Strong, RP (1930). The African Republic of Liberia and the Belgian Congo. Cambridge Harvard University Press. 1 (1930): 24O - 257 . WHO (1992).Methods for community diagnosis of onchocerciasis to guide ivermectin-based control in Africa. TDR/TDE/ONCHO/92.2. WHO Geneva WHO (1995). Supplementary guide-line for Rapid Epidemiological Mapping of onchocerciasis (REMO). TDR/TDE/ONCHO/95.1 WHO Geneva 5. ACKNOWLEDGMENT I am grateful to WHO/APOC for given me the opportunity to serve and contribute in this exercise. lwish to express my indebtedness to WR Lagos and WR Monrovia for their active support and encouragement. My thanks are due to all the members of NOTF of Liberia for their commitment, and technical support. I want to specially thank Dr. Kamara, the WR Monrovia and all WHO staff for their care and hospitality. Dr. Bolay gave me a lot of encouragement and support in this exercise. This work is dedicated to the "People at the end of the road" who produce the bulk of our food and industrial raw materials in Africa. Dr. B. E. B. Nwoke Professor of Medical/Public Health Parasitology & Entomology 16 MISSION SCHEDULE WIIO/APOC RAPID EPIDEMIOLOGICAL MAPPING OF ONCHOCERCTASTS (REMO) rN LTBERTA PERIOD OF MISSION December 23,1998 - February 10, 1999 ADVISER (CONSULTANT) Professor Medical Parasitology & Entomology School of Biological Sciences Imo State University Oweri, Nigeria ALLOTMENT NUMBER: ou/rcP/GTD I s04 I AP I 98 I 040 I 00 STICKER NUMBER: oul98l017l04 DECEMBER 23, 1998 Travel (Owerri - Lagos) DECEMBER 24 Collected Flight ticket and other travel documents from WR Lagos. (This was the only working day left for me to collect these documents as the next day, December 25, DECEMBER 25 Christmas and public holiday. I had to stay in Lagos to enable me travel the next day. DECEMBER 26 Travel (Lagos - Abidjan) DECEMBER 27 Travel Abidjan - Monrovia) December 28 - 29 Meeting with WHO, NOTF, MOH' collect available maps, documents and materials for the exercise !7 DECEMBER 30, 1998 - Theoretical training of NOFTF on Onchocerciasis, vector JANUARY 2,1999 species and REMO JANUARY 3 - 4,1999 Planning and arrangements for the field work JANUARY 5 Travel for the field exercise JANUARY 6 - 24 Consultant complete field training, REMO exercise and initiates validation JANUARY 25 Consultant returns to Monrovia JANUARY 27 REMO teams expected back to Monrovia JANUARY 27 - 3I Coalition and appraisal of the REMO results, selection of villages for validation/update *61finalize arrangement for data entry FEBRUARY I - 2 Preliminary Sr-rmmary sent to APOC and REMO validation/up date (t he C onsultant operating from Monrovia) FEBRUARY 3 - 7 Completion of data entry, and mission report and the submission of final report and the submission of final mission report to APOC and others. FEBRUARY 8 Travel (Monrovia - Abidjan) FEBRUARY 9 Travel (Abidjan - Lagos) FEBRUARY 10 Travel (I-agos - Owerri) 1B SUMMARY OF MISSION IN LIBERIA LOCATION NUMBER OF NIGHTS 1. Lagos 4 2 Abidjan 2 3. Monrovia Z5 4. Oncho-Endemicvillages 20 Total 49 Nights DR B. E. B NWOKE WHO Temporary Adviser/Consultant 19 I N) o o F a a a rr rr ? rr a rr a a (t F i+ t+ o- o o g) o- o r+ o r+ :-+ !.+ o o) 0l DD FO E FU D, A)' 0r' p' ID, FU ID' F! o Fg 0) ID o o 5 o) o) o) F_ F ? z o- ? ? z ? -l F It! z - E { FiE z o\ oo \o @ \o oo @ o\ o\ @ A \o 5 @ @ @ zz o @ @ O F o a1 o z A s A A s A s s EF o o\ @ O u) o\ o\ 3i! ol+ o 7<3 tt, \o s \o o\ o\ A A U=F NJ N) tr 1..) NJ tJ NJ N) 90 !.., s N) I 90 tJ F o io !\, s s bo b\ b\ : { LD s (n a xlt F \] N) N) t) N) s { N) s o\ \o 5 @ <,- 2tn o- z4 Z>.i tt \o e> N) A A N) o\ N) N) FF t-J tJ f.) 5 1..) li :J E' FT ? o\ 1..) ! !.., o\ ! t) I \o ij Lp \o : s r< o o |no o o o z z o Fl Fl zH f, F FU E t! 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