I

Dr Lawrence Osei

EPI Consultant

Summarv

Between 18th June and Lst July 1993, at the instance of the Programme Director and the Chiefs of EPI and Devolution, I undertook a trip to to collect data needed for effective take off of devolution in Ghana. Even though not all the required data were available, certain important contacts were made which hopefully would propel people into action. Promises were made by certain key personnel to provide the remaining data within the shortest possible time. I

2

UPDATE OF IVERMECTIN DISTRIBUTION IN GHANA

1.0. Introduction

Onchocerciasis which used to be a big public health problem in some 11 West African countries is no longer a major health threat in the sub-region. This is due to successful control by the Onchocerciasis Control Programme (OCP). To maintain this success, it has been found necessary to involve the participating countries more actively than has hitherto been done. To this end, it has been found necessary to gather certain vital statistics regarding onchocerciasis control in the various countries. Such data, among other things would help proper planning of activities aimed at maintaining the low prevalence rates achieved through the OCP.

At the instance therefore of the Programme Director and the Chiefs of EPI and Devolution, OCP, I undertook a mission to Ghana to gather data relating to onchocerciasis control in the country.

2.0, Terms of reference

To obtain a map of Ghana showing:

l. AII fixed (health) centres and posts where ivermectin is or is intended to be given.

ii. Zones where ivermectin is distributed by Non-Governmental Organisations (NGOs) and in each case indicating which NGO is involved.

iii. To investigate the outcome of AFRO-MEMORANDUM on "Support for workshops in epidemiology for District Health Teams in OCP participating countries sent to Ghana.

iv. To investigate factors militating against effective public Health Training in Ghana.

v To collect data on nodule examination undertaken at the onchocerciasis chemotherapy research centre, .

vl. To bring back an up-dated Devolution document of Ghana.

3.0. Data collection methodolory.

Between June 18th and July 1st 1993, I undertook a mission to Ghana to gather data relating to the above terms of reference. In all,32 people from 8 of the 10 Regions of the I

J

country were interviewed. The regions covered were :

1. . 2. Norther Region 3. Brong Ahafo Region 4. Greater Region 5. 6. 7. 8. .

In addition a meeting was arranged by the National onchocerciasis Control Secretariat (NOS) at which I met and was briefed by representatives of various NGOs currently engaged in ivermectin distribution in the country. Present also at the meeting *"r. ,"prrsJntatives of NGOs who, even though have not started ivermectin distribution, intend to do so in the near future.

See Appendix 1 for the list of people interviewed from various parts of the country.

Attempts were made to interview the following people without success.

1. Hon. Colonel (rtd) Obimpeh, Minister of Health, Ghana.

2. Dr Ken Aryeetey, National Co-ordinator of onchocerciasis control - out of the country.

3. Dr Kofi Ahmed, head of epidemiology division, Ministry of Health, Ghana.

4.0. Outcome of the mission.

4.1. Map of Ghana showing fixed health centres and posts where ivermectin is or is intended to be given.

After consultation with Dr Adamafio, director incharge of public health services and Mr J.K. Fosu, Chief Executive, NOS, a map of Ghana showing fixed health centres and posts where ivermectin is supposedly given or intended to be given was given to me (appendix 2). Unfortunately this map was received at the last minute and it was not poriiUt" to cross check from a random sample of these centres, which of them do actually iee onchocerciasis cases. The national Co-ordinator could be made to undertake this exercise at a latter date.

My tour in the country had however already taken me to certain hospitals where enquiries had been made regarding onchocerciasis treatment. Impressive among the lot was Catholic Hospital where about 2000 cases of onchocerciasis are treated every year. These cases come from the surrounding villages along three important river basins and their tributaries. These rivers are Pra, Okye and Brupia. 4

St. Martin De pores Hospital in Ekwei, a border town between Ghana and C6te d'Ivoire, also sees a number of cases from along Amanzule and Ankobra river basins.

An ophthalmologist at Takoradi Hospital sees a number of patients with onchocercal eye problems referred from Effia Hospital, Sekondi or from nearby Health ientres. These patients are usually from villages along the tributaries of river Prah. Other hospitals which see cases are Hospital (from along the tributaries of river Ankobra) Kibi Hospital (tributaries of river Ayensu and river Densu) and (river Volta).

Aodm Hospital does not see cases at all.

An issue of concern, however, is the non availabiity of Health Centres or Posts in the Kulpawn and Sissili river basin areas (see map, appendix 2) for passive ivermectin distiibution. Since these are problem areas attempts should be made to cover them effectively.

In the meantime, an NGO must be made interested to cover the area. However a nore permanent solution to adequately cover the area with ivermectine distribultion should be sought.

4.2. Zones where ivermectin is distributed by NGOs

Sight Savers and Lions club of Ghana are currently involved in ivermectin distribution, either alone or in conjunction with NOS. (See appendix 3 for areas they cover).

Other NGOs wishing to get involved with ivermectin distribution in the near future are Assemblies of God, Adventist Development and Relief AgencylGhana (ADRA) and Friends of Oncho International.

4.2.1.. Sight Savers

Sight Savers, under the directorship of Dr Richard T. I-e Mesurier is engaged in community self treatment in the western region. About 70 community based distributors were trained in January t992 to undertake the ivermectin distribution. The training was 3-4 days long and was undertaken by Dr Pacqud of Sight Savers, Mali. Each community distributor is in charge of about 2-4 villages, and his activities are overseen by a District Supervisor. A district Supervisor has a number of community distributors under his care. A Regional Co-ordinator, who supervises the activities of the district co-ordinators has been appointed and paid a per diem by Sight Savers to enable him perform effectively. The Regional Co-ordinator is currently in the person of Mr Wesley Kudom, a Principal Technical Officer of the Medical Field Unit. According to Mr. Kudom, community registers are being compiled. The supervisors of the community distributors in conjunction with the latter will assemble information covering their respective villages for submission to the Regional Co-ordinator, who in turn will send a regional report to the NOS in Accra. 5

One big problem faced by Sight Savers in the discharge of their duties is the poor road network ofthe Region. This poses a problem to the Supervisors in reaching the target villages under their supervision. As a result, returns coming in from the field are not very encouraging.

4.2.2. Volunteer

One volunteer was visited. He is in the person of Mr Raymond Nyalegbedzi, a school teacher in charge of two villages, Bonsaso I and Bonsaso 2 on the river Bonsa. The villagers were very happy about the work being done by this volunteer.

4.2.3. District Co-ordinator

Mr A.K. Acquah, a technical officer of the MFU and district co-ordinator was also visited. His problem has been regular supply of ivermectin for his village volunteers. The matter has bLen referred to NOS, which has promised to ensure regular ivermectin supply.

4.2.4. Other activities by Sight Savers

Sight Savers have trained some co-ordinators in the Central region as well. They are prepared to train people for other NGOs who want such help for effective ivermectin distribution.

4.3.0. Lions club

The president of the lions club, Dr. Victoria Tonugble said they have volunteers who need training to distribute ivermectin in the Eastern Region. Sight Savers has agreed to organise a training session for them. The distribution is to start in the Suhum-Kraboa- Coaltar area very soon. The club hopes to undertake control of yaws as well in the region. This intention has been communicated to the minister of Health .(see appendix. 4).

4.4.0. ADRA

ADRA has agreed to undertake ivermectin distribution in the Central Region in conjuction with the Ministry of Health. The representative of ADRA indicated, however, that their earlier proposal to their heaquarters in the USA requesting funds to distribute ivermectin in Ghana was returned to them for review which has been done and are now awaiting response.

Meanwhile, ADRA is thinking of alternative avenues and points of intervention in the programme in the Central Region. This is contained in a letter addressed to the writer (see appendix 5). 6

4.5.0. Friends of Oncho International (FOI)

The representative of FOI indicated that the organization is still in its formative stages. He regretted, however, that even though a letter has been written to the Ministry of Health about their intention to distribute ivermectin, they are yet to receive the reply which will facilitate mobilization of funds from the United States for the purpose. The Chief Executive of NOS assured him that he would contact Dr. Adamafio for the reply to be effected as early as possible.

The FOI representative indicated further that the organization was trying to attract medical doctors into their membership. He was happy to say that one doctor from the police hospital has joined them already. They were preparted to work closely with other NGOS in the distribution of ivermectin.

5.0 AFRO memorandum on "Support for workshops in epidemiolory for District Health Teams in OCP participating countries

After talking to some key people from the WHO office and the Ministry of Health in Accra, it came to light that even though modules for the workshops were received by the WR and were forwarded to the Ministry, no action has been taken. Attempts to see the officer who supposedly has the modules now failed!

6.0. Public Health training in Ghana

An MPH programme for some 10 candidates during the 1992/93 academic year could not take off because the Minitry of Health could not accomodate the candidates.

The Director General of health in Ghana thinks, however, that it was not the responsibility of the Ministry to provide accomodation. To this end, he would want the medical school to cost the training programme (including accommodation). The Ministry then only takes up the financial responsibility when sponsoring candidates.

When the Vice Dean of the Medical School was contacted, he indicated that the School of Public Health (SPH) which is coming up soon will automatically take up the function of the old programme. The SPH is under the University of Ghana and therefore the latter will now accommodate candidates under its post graduate residenry system.

The West African Fellowship Programme is however under the ministry of health and therefore it is their responsibility to provide accommodation. The Medical School only offers tuition as far as that programme is concerned. 7

6.1,. OCP sponsored candidates

Dr. J.D.Otoo, director of manpower training indicated that the 2 candidates being sponsored by OCP for courses in Kenya are still around because there has not been any communication from AFRO, Brazaville.

7.0. Results of nodule examination from Onhocedrciasis Chemotherapy Centre Hohoe.

The Director of the Centre provided preliminary data which is attached as appendix 6.

8.0. Devolution Document for Ghana

All attempts to get a revised devolution document for Ghana failed. However, the director in charge of public health, Dr. Adamafio and the chief executive of NOS, Mr. Fosu have promised to make this document available in the shortest possible time.

9.0. Conclusion

Even though all the data required from Ghana were not available, the mission to Ghana was worth while. With the various contacts made, I hope the michinery has been put into the required gear for foward movement, and I hope the promises made will be honoured.

10.0. Acknowledgement

I am very grateful to Dr. Ebrahim M. Samba, Director of OCP, Dr. Boalrye Boatin, Chief of EPI and Dr. A. S6k6t6li, Chief of Devolution for making it possible for me to be associated with data collection for effective onchocerciasis control in Ghana. I am grateful also to the numerous people in Ghana who granted me audience whilst in the country. Appendix I

List of people interviewed from various parts of the country.

1 Mr. James Tutu Osei, Sub Sector Chief, Onchocerciasis Control Programme, .

2. Dr. Kwame Adogboba, Regional Director of Health Services for Upper East Region, Bolgatanga.

3. Dr. A.K. Diallo, Sector Chief of OCP, Tamale.

4. Messrs. Ziblim, and Ampah, Technicians Attached to VCU, Tamale.

5. Mr. Adams, Technician Attached to VCU, Tamale.

6. Dr. O.A. Debrah, Ophthalmologist, Presbyterian Eye Clinic, Bawku.

7. Dr. David Effyshaw, Ophtalmologist, Presbiterian Eye Clinic, Bawku.

8. Mr. Samuel Aruk, Eye Nurse Attached to the Presbyterian Eye Clinic, Bawku.

9. Mr. Boama, General Manager, Presbyterian Eye Clinic, Bawku.

10. Mr. J.K. Fosu, Executive Director, National Onchocerciasis Secretariat (NOS), Accra.

11. Mr. Kwabena Abankwa, NOS, Accra.

12. Dr. Adamafio, Director, Public Health Services Ministry of Health, Ghana, Accra.

73 Dr. Moses Adibo, Director General of Health Services in Ghana, Accra.

L4. Dr.J.D. Otoo, Director of Mampower Training in Ghana, Accra.

15. Prof. S.K. Owusu, Vice Dean, University of Ghana Medical School, Accra.

16. Dr. B.C. Dando, WR, WHO Office Accra.

17. Dr. Fenella Avokey, WHO office, Accra.

18. Dr. Richard Le Mesurier, Sight Savers, Royal Commonwealth Sosiety of the blind, Accra. 19. Dr. Vinolia Tonugble, current president, Lions Club, Accra.

20. Mr. George Wood, Christian eye clinic, .

21. Dr. Isaac Sagoe, Ophthalmologist, Takoradi Hospital, Takoradi.

22. Mr. Wesley Kodom, Principal Technical Officer, Medical Field Unit, and working closely with Sight Savers, Tarkwa.

23. Dr. Afenyadu, Medical Officer in charge, Hospital, Axim.

24. Mr. Tamakloe, Technical Officer, Medical Field Unit, Axim.

25. Dr. Irene Arkhurst, Medical Officer, St. Martin Depores Hospital, Ekwei.

26. Mr. Nicholas Amgborme, I-aboratory Techncian, St. Martin Depores Hospital, Ekwei.

27. Dr. Edward Osei-Kuffour, District Medical Officer of Health, Tarkwa.

28. Mr. Agnes Ayivi, District Public Health Nurse, Tarkwa.

29. Mr. Raymond Nyalegbedzi,Teacher and village volunteer in ivermectin distribution,, Bonsaso, Western Region.

30. Dr. Anthony Van Haastert, acting DMOH, and in charge of Assin Fosu Catholic Hospital.

31. Mr. A.K. Acquah, Technical Officer, MFU Assin Fosu

32. Dr. K. Awadzi, Director, Onchocerciasis Chemotherapy Research Centre, Hohoe. APPENDIX 2

FIXEO HEALTH CENTRES AND POSTS WHERE IVERMEGTTN !S OR IS TNTENDED TO BE GIVEN. 3. l. "iA- o. ll. *-+ e*-* + Wl -+-+-+_ ^ +' '@ Po9 + ku Gwollu N o n don oru{Voll rl90 Tumu { + :A

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S, Horplf d, C HGollh c.nrres +- +tnlernorionot boundortes Reglonol boundorles Roodr - APPENDIX 3

AREAS OF IVERMECTIN DISTRIBUTION BY NGOS

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WESTERN REGTONE STGHT SAVERS COAST Holf AsstN rosu I r,ros SECONDI sUHUM KRABoA qoau,An[ LroNS cLUB Axim Nlwonto i. Tor EAST AKIM NOS/ LIONS CLrrS tTFr+i- 4 ,1,..lr APpendir 4 t' /0t 'a/' LIONS ljIlJB$ II{TIIIIATIIIilTI trJrl (0r0!l1rla lrrr0tltl GHANA SIGHTFIRST PROGRAMME We Drstncl 403^ Srctt'tltrhs't 75Years1992- P,O.Box 6870 ACCRA NORTH -,tgtz 'l'clcr: r755 VIMARI' Far: t2+t'Jti

'29Ih...Yar-s.hr.. r c 93 Your Rel ou, Rer..Ir9ll93/gS

The Hon. Mlnteter of Health l.tlnletry of Health Accra Thro I Dr. Otoo Ghalruau Natlonal Preventlon of Bllndnees Conmlttee Accra

Your Excellency,

LroNs CoNQUERT.NG BLTNpNESS

Followlng our earller Istter dated 28th May, L992, we the Llone of Ghana, heve uadc aoue funpact on the Natlonal Eye Care Programme. L au rendlng you the lngredlente of our acttvltles ae well as the chronology of Slghtflrat.

COMMI.TTEE UE},TBERS

1) Llon Dr. Vinolla Tonugble Golden SFR, Chalrnan 2) Llon Alfred Arnoah Golden Assl8tant SFR 3) Llon Neleon Agbeal Prenler Llone Eye Instltute, Chalrnan 4) Llon E. A. Folson Ebony Treagurer s) Lion Naua Eal Parry Golden Secretary 6) Llon Ekow San I remler CSF, Chalruan 7) Llon N. K. Bulley Preuler JSS, Chalrroan 8) Llou Kay Anoah Ibouy Publlclty e) Leo Kwabeoa Akuffo Sankofa OCP Assletant

1. NATIONAL PREVENTION OF BLINDNESS COMMITTEE

Llone V. Tonugble, N. Agbeel and E. Sam are nembers of the above-naned Comlttee. Thla Comlttee Deets regularly and eee to the luplementatlon of the Natloual Eye Care Program.e.

Llon Ekow San le a ueuber of the Sub-Couulttee that 1e planulng the 1993 Bllndneee Awarenesg week scheduled for May, 1993.

2. LIONS EYE INSTITUTE

Thle rr1ll be located ln Korle Bu Teachlng Hospltal. We are currently worklng on acquleltlon of the elte plan.

2l ,.,..

Isl SIGHTFIRST Reprosentatrve LION DR VItJOLIA TONUGgLE, 229802 (ALL HOURST SIGHTFIRST Secrctary LION hOPE 8EO .\(O :26239 Vrdeonrart, Workrrrg Hc,r,rr r'' 2 Fund-ralslng letters wlth lncentlves for blg donors are belng dlstrl- buEed to conpanles and organleattons, lnc1udlng USAID and Departnent of Ophthalnology, Stanford Unlverslty' USA.

Sod-cuttlng w111 be done aa soon aa aoue donatlons, caeh or kind, have beeu recelved.

I{e plan to lnvlte the Zonal Presldent baeed ln Bourklna Faso for the eod-cuttlug.

Requeat for aseletance from Llona Internatlonal, Oak Brooke, w111 be eent after the sod-cuttlng.

3. AKROPONG JSS

Conetructlon of the Workshop for the bllnd etudents of Akropong School for the Bllnd le etllI golug on suoothly and we hope to couplete it thle year.

Thle yearta Journey for Slght, Ltonet eponsored walk, comea on ln May and funde raleed w111 be ueed for the bulIdlng.

4. ERCI.ASIS CONTROL PROGRAMI'IE ocP

Lloue have adopted Eastern Reglon for OCP. I'le are co-ordlnatlng ulth the Technlcal Teau ln the Mlnlstry of Health and the varlous OCP organs to help eradlcate rlver bllndneee ln the Reglon.

Survey of the prevalence of dlsease w111 start eoou and we hope to comtrence dletrlbuEtng Lveruectln ln the near future.

{ Exaolnatlon of the Reglonts medlcal recorde shohred an outbreak of yaws ln eone dletrlcte.

tlons are plannlng to acqulre the needed Penlcllln etc. for Yaws eradl- catlon. The ocP Technlcar rean w111, therefore, be used for a conblned Oncho and Yawe control proJect. Requeet letter to MedLco France ls belng paeeed through Ehe Dl8trlct Governor for eupply of Benzathlne Penlcl1ln etc. for the Yawe eradlcatlon.

5 Accra Llone Clube have reeolved to open a Ghana Slght Flrst Account at Bank for Houslng and Constructlon. Thle account w111 recelve all cash dotrattone for Slght Flrst proJecte and money frou thle account w111 be dlebureed eolely for Eye Care actl.vltlee.

6 Indlvldual Club Slght Flrst Actlvltlea are belug planned ln addltlon to the above proJecte.

January, 1993 - Accra Golden Ll.ons launched Eye Testlng project in the Accra perl-urban schools. Eye care health educatlon was glven by an Eye Speclallst to teachers and puplle from 16 schools. Eye examlnatlon revealed aone treatable case6 such as cataract, ln a 9-year old pupil. Each echool Headteacher wae glven SNELLENTS EYE CHART wlth the Caupalgn Slght Flrst Logo.

Phaee two lnvolves dlst,rlbutlon of Eye charts to prlvate crlnlce for cash donatlons to enable ue prlnt more charts for other Ist cycle echools.

3l ..... /

3

7 a Gleucona Screenlag Programe - A regueet letter fron Ghaua Aseoclatlon of Glaucoua hae beeo recelved aud lre uny aponsor a technlcal tean ln May for a screeuing exerclse 1n Battor, Volta Reglou.

Thauk you.

Yours falthfully,

,1,^" LION DR. VINOLIA TONUGBLE SIGHTFIRST RXPRESENTATIVE

accS Dr. Otoo Chalruan Natlonal Preventlon of Bllndneee Conmlttee Accra I The Dlrector OCP - Accra

The Deaa Ghana Medlcal School Kor1e Bu - Accra The Dlrector EpldluJ.ology Dlvlelou Mlnlatry of Bealth Accra The Adnluletrator Korle Bu Teachlng Hoepltal Accra Appendir 5

ADRA June 25, L993 ADVENTIST DEVELOPMENT AND RELIEF Dr. Osei AGENCY OCP Consultant GHANA P. O. Box 549 P.O.Box 1435 Ouagadougou Accra, Ghana Burkina Faso Te|:?120779 Telex: 2119 GH Dear Dr. Osei,

sHoRT t{oTB ON THB TNTENTIONS OF ADRAIGHANA TO HELP rN _cJJLSr_S__rflTlg IVERHECTIN IN THE CENTRAL REGIO]I-OT GHANA ADRA had worked closely with the Ministry of Health in Ghana to come up with a document to present to the River Blindness Foundation of Texas, U.S.A. by November, 1991. since then ADRA has had no favorabre response as to the funding of the project, which amounts to about g450,OOO.OO over a 3 L/2 - year period. After attending the meeting of the consortium of NGo,s in oNcHo-cERcrAsrs contror in Ghana, convened by the National oncho secretariat, ADRA is now thinking of alternative avenues and points of intervention in the programme in Central Region as follows: 1. Reducing the cost of Ivermectin distribution to manageable IeveIs so that locaI funds can be solicited for the project. 2 Coming up with a planned and systematic socio- economic support to rehabilitate survivors in the areas declared to be oncho free.

These are intentions and we hope to work on them and put finishing touches to them before the next meet,ing of NGO's in the Oncho control scheduled for September. Yours sincerely,

.t-'(-. T. Agboka Director Appendir 6 3l--=: . .. ". . oNCHOCERCIASIS CHEMoTHERAPTRESEARCHCENTRE (ocRc) Tcl:O91'8367 HoePltal' P.O. Bor L44, Hohoe , Ghana. Hohoc lt2332l)669840 Telex:c/o GAI{EIVS 24OOGH Far:c I o Dr B. Boacin Chief EPI 5"Efro."tciasis control Programme P O Box 549 Ouagadougou Burkina-Faso 290693

Dear Dr BoaEin,

ManyapologiesforEhelo,,gdelayin'sendingyoutheresulE,soft'heoi froil ctre Camlia and Asubende. examinaEion ""a"i"" finished monEhs ago and.Ehe data held on 2 0f our The task was t,o wild lucEuat,ions in E'he volEage comput,ers. urrt"ii""aE,e1y, "*i"i -f tso be senE overseas for auppty, boEh ;;;;r;;; uiote-aoin ana had repairs. Ehe first' rule in The hard disc had to be re-formaEEed and since of Jio uact< up dat'a was ignored) ' all was lost ' Ehe use "o*Jlf"i" resulEs could not be To compound Ehe difficult,ies, Ehe original ;;";;;i-Eirr t.""ttrv when thev were re-entered' which I was able Eo x am sendlng you t,he result's from the Gambia C'o-ifre deparguie of Dr Osei' The embryogrammes from check prior 'irr!"c"ntbI;-wirt Ehe nexg oCP vehicle Aeubende .na f ollow wieh ' will be made we will examine all and any nodules you send' slides ivailable t,o anyone else to verify t'he result's ' can you Did t,he ocp ever EesE a disposabre skin snip punch? rf so, EEff *. Ehe i"",-rtt,= and also leE me have a few Eo try ouE'?? Many thanks

SincereJY,

K AWADZI

c/o WIIO Roprcrcntrtlve, P. O. Bor M-142, Accra. Tcl: O21-226276 Tclcx: 7OZ WHO GH ,.

ASSESSUEN'T OT WOR![ VIABXLIIY OE' NODULES FROM THE G.AMBIAIV BASIN 25th Febnrary, 1993

gUIII{ARY

No. of Pat,ienEs 39

No. of Nodules 49 No. of complet,ely calcified nodules 7 (14r)

FEMAIJE WORMS

foEal Number 93 Yo. dead 66 (7Lr) No. alive 27 (2et) tlo calclfled of dead 30 (4sr) [o. of llve females showing signs of ageing plgrmenEs, inclusions . eE,c 22 (81r) Vo. of product,ive live females L1 (41r)

vt&LE WORMS

IoEaI Number 32 [o. dead 4 (12r) Vo. allve 2B (88r) [o. of live males showing signs pigrment,s, inclusions of ageing etcl 20 (7t*) /

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