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 I Twenty-third Session t Ouagadousou, 23 - 27 Septembet 2002 t- EAC23.4 Original : English

RBPORT ON A MISSION TO MALI, TOGO, SENEGAL, GUINEA AND COTE D'IVOIRE

(May 19 to June 3,2002)

Professor A. Abiose & Dr M. S. Traor6

I I i 1

EXECUTIVE SUMMARY AND RECOMMENDATIONS

Two members of the Expert Advisory Committee, Professor Adenike Abiose and Dr Mamadou S. Traore, accompanied by Dr Asimawe Pana carried out high level advocacy visits to four OCP countries, Mali, Togo, Senegal and Guinea from 20-31 May, 2002. Professor Abiose accompanied by Dr Siamevi carried out a similar visit to Cote d'Ivoire on 3 June, 2002. We had audience with the ministers of health of Togo, Cote d'Ivoire and Senegal, the general secretary of health of Mali and Guinea Conakry and the secretary of state for planning in Guinea Conakry. We had also audience with the representatives of the World Health Organisation in Togo and Guinea Conakry.

The objective of the mission was to raise awareness on the impending closure of OCP and to advocate for support for post-OCP activities in each country at the highest level. In all the countries, high government officials expressed their appreciation and gratitude to OCP for the achievements and expressed their full confidence in the national onchocerciasis control programme staff. The mission was assured of the commitment of governments to maintain the gains of OCP by effectively integrating onchocerciasis surveillance and CDTI activities into the health care system; and in the case of Togo, carryring out any residual larviciding activities. We were also assured of the willingness of governments to support the establishment of the MDSC.

The mission also carried out a site visit to the special intervention zone of Kara Keran Mo and held discussions with the national coordinator for Togo, OCP staff in Kara and the community in the affected area. There was evidence of integration of onchocerciasis control into other health care activities, the regional director of health being the national coordinator, and the medical officer in charge of CDTI in his district. The community was committed to ivermectin distribution for as long as was necessary. There were however problems with CDTI activities needing attention in the area: the scattered communities with low geographic coverage, demand for motivation by CDDs, and isolated areas of low therapeutic coverage. There was inadequate logistic support for epidemiological surveillance. National teams had been trained for entomological surveillance but had not become fully operational.

The difficult terrain and difficult to access breeding sites were recognized as factors contributing to poor entomological results in the past. Recent modification in vector control activities has significantly improved the results. Though carrying out their duties effectively, the staff in Kara were very anxious of their future post-oCP. The mission recommends as follows:

Political

Onchocerciasis in the context of maintenance of the gains of OCP should be addressed at the level of head of states and given a high profile like Roll Back Malaria and HIV/AIDS. Nuisance control should be viewed as a development issue and where necessary, addressed across borders.

I Surveillance Activities

There is a need for OCP to give additional support to countries in terms of equipment, material and logistic support prior to its closure, and in the case of Togo and Guinea Conakry, even after, to ensure continuation of effective surveillance for onchocerciasis. The plan for decentralization and integration of activities at the peripheral level, which is being prepared by Guinea Conakry should be finalised as soon as possible and the process commenced preferably before the closure of OCp. 2

CDTI

Motivation of CDDs is still a problem across the countries, and solutions should be defined on a country- by- country basis. A geographic coverage of 100% is a must. Alternative options should be clearly defined where this has not been achieved in 2002. OCP should facilitate as a matter of urgency the meeting between the national coordinators of Benin and Togo to discuss the solution to their cross-border issues and possible harmonisation of time of ivermectin distribution for maximal effect on transmission in the special interventionzone of Kara Keran Mo. Countries should find ways of utilising CDDs in other health interventions appropriate to their training and skills, in the spirit of integration.

Staff Matters

There is a need to take an early decision on the strategy to be adopted in the Kara Keran Mo area post OCP. This would facilitate decisions on future deployment and emloyment of staff.

Acknowledgement

We would like to acknowledge the impeccable preparation for and coordination of this trip by OCP Director and his staff. We particularly appreciate the support and attention to detail of the OCP staff (Dr Pana and Dr Siamevi) who accompanied us. We appreciate the background information provided and arrangements made by all the national coordinators. Finally we would like to express our deep appreciation to all the Ministers of Health and high level officials as well as WHO representatives who made time to see us and share their experiences with us.

1 I J

Abbreviations used

EAC Expert Advisory Committee CDD Community Directed Distributor CDTI Community Directed Treatment with Ivermectin JCP Joint Co-ordination Committee of the Programme MDSC Multidisease Surveillance Centre MOH Minister of Health SIZ Special Interventio n Zone OCP Onchocerciasis Control Progiamme WR Representative of the World Health Organisation wHo World Health Organisation 4

Fronr May 19 to 3l 2002, Professor Abiose and Dr Traor6 on behalf of the Expert Advisory Committee, (EAC) paid visits to high authorities of five OCP countries. The itinerary is attached as Annexe 1. The objective of the mission was to have a discussion with the Ministers of Health on the closure of thc Programme and advocate for necessary arrangements to be made by national governments to maintain the achievements of the Programme. The EAC members were accompanied by Dr Pana, as nrandated by the OCP Director.

Background documents summarising onchocerciasis control activities in each country prepared by the OCP staff were provided. These documents included vector control activities, the epidemiological situation, the control strategies used, the most significant results and the conditions to sustain the achievements. More detailed reports were also provided by some of the National Coordinators on the current situation analysis and the perspectives beyond 2002.

Meeting with Government Officials l. In Mali, the Minister of Health rvas not available. The team met with the Permanent Secretary Dr Abdrahamane Tounkara.

After an introduction by both the national Co-ordinator Dr M.O.Traor6 and Dr Pana on behalf of the Director of OCP, the EAC members gave an overview of the onchocerciasis control activities in West Africa. We have stressed the public health and socio-economic importance of the disease that motivated the international community in the 1970s to join their effort for a co-ordinated action against onchocerciasis. This sustained effort for nearly 30 years covering such a large geographical area is unique in the history of disease control. The Programme is coming to an end, onchocerciasis in no longer a public health problem and the fertile lands previously depopulated are now flourishing. However, there is a need for the governments to maintain these efforts. In Mali, the achievement has been impressive. A national team is operational and numerous health personnel have been trained in various disciplines: parasitology, entomology, epidemiology and public health. These personnel have demonstrated their ability to conduct the activities in the most effective integrated and decentralised way. The epidemiological situation is satisfactory as the prevalence is below 5Yo in most areas and CMFL are almost nil. The therapeutic coverage with ivermectin is above 78o/o,but the geographical coverage is not optimal (78% in 2001). There is an urgent need to find ways to improve this figure.

The current operational problems include, the instability of community distributors, the imperfect handling of data from the periphery to central level for decision making, the insufficient participation of the communities in the epidemiological surveillance, (especially skin snip) and the lack of equipment and logistics at regional level for a complete decentralisation of the activities. AII these will need strong support from the highest authorities in term of financing and most importantly in term of the direct involvement of high level officials in community mobilization and information, education and communication, as has been the case during the last few years for HIV/AIDS and malaria. \

We also emphasised the need for the authorities to support the Multidisease Surveillance Centre that is been established following their request.

The Permanent Secretary followed our advocacy with great interest and promised to take the issues forward on behalf of the MOH. He is convinced that the maintenance of onchocerciasis on the health agenda needs to be taken at an even higher political level and should involve the Heads of State.

He is also convinced that the epidemiological surveillance must be fully integrated into the health services and decentralised. Nuisance control is currently being carried out in the development project 5 areas of Selingu6 and Baguin6da. He thinks it is necessary to establish mechanisms for countries to share their experiences in dealing with nuisance problems. He stresses that he sees simulium bites as a development issue not just nuisance as the population may run away from the villages if nothing is done. He requested the EAC to assist in this process.

The permanent secretary raised a few concerns that were thoroughly discussed. These include human resource development and career development. The MOH had requested the National Coordinator to produce an inventory of health personnel who benefited from OCP training grants during the last 25 years and their current posts. This work is in progress and should give an up to date situation analysis of health personnel that could be involved in onchocerciasis control activities in the post OCP phase.

2. In Togo, we met the Minister of Health, Prof. Agba C. Kondi, with the Representative of the World Health Organisation in Togo, Dr Deo Gratias Barakanfitiye in attendance.

The meeting was short and sharp. Having met Prof. Abiose on several occasions,'including the last JCP, the honourable Minister stressed that there is not any need for advocacy before the Togolese authorities. The government is well aware of OCP achievements, and the necessity for all countries to make every effort to maintain these achievements. He is confident that competent national, regional and district teams are in place. They have been able to conduct activities in a very effective way so that the epidemiological situation is satisfactory in all basins except the Kara, K6ran M6 areas (SIZ). The therapeutic coverage of CDTI in most places outside the SIZ is above 80%, while the geographic coverage (82%) needs to be improved. The Minister of Health is convinced that the activities will have to be pursued in an integrated and decentralised way. E.g. a vehicle given for onchocerciasis control activities will also be used for lymphatic filariasis control. The government will support these efforts but he hopes very much that specific actions and financial provisions will be recommended by the EAC for the SIZ by the end of the Programme.

The EAC members stressed that there is no doubt about the commitment of the Togolese government, but there is still a need at this stage for every partner to play effectively its part for onchocerciasis to remain of little public health importance.

The EAC members had met with the WR, Dr Barakamfitiye, the day before and had the opportunity to discuss the perspectives for onchocerciasis control activities after 2002. He is convinced that the MOH is committed and has been directly and personally supporting community based health interventions. However, one should not underestimate the financial constraints and the economic difficulties most Participating Countries are going through.

He had two main concerns: one is the under-utilisation of health services, only about 20%o of the population are using health services. This is reflected in the poor success of community based health interventions. It is a constant struggle to convince the community that it is in their interest to participate in CDTI, malaria prevention and vaccination campaign. The other is the non-utilisation of data for decision making. Health personnel at peripheral level do not understand or value the data they are collecting and its relevance for decision making. There is a need to redefine what type of data should be collected at peripheral level and for what purpose. According to the WR, the World Health Organisation (WHO) is willing to assist countries to establish effective epidemiological surveillance systems.

3. In Senegal, we met the Minister of Health, Dr Awa Seck, in presence of the adviser in communication of the WR, Mr Khalifa Mbengue, who gave us copies of the November 2001 issue of the Bulletin of the WHO Representation in Senegal. This issue includes a report written by the Co- ordinator of the National Onchocerciasis Control Programme, Dr Diawara, on the conditions for the maintenance of onchocerciasis conhol in Senegal. 6

After an introduction by both Mr Mbengue and Dr Pana, the MOH rvelcomed EAC members. On behalf of the government, she expressed her gratitude to OCP for what has been achieved during the last 15 y.u., in Senegal and for the continuous support. She knows that onchocerciasis has been brought to significantly low level of endemicity; but she is convinced that it is not yet time to forget the risk of recrudescence. Many years ago, Senegal has given priority to the integration of disease control into the activities of health services. The Regional Director of Heath is also the co-ordinator of the onchocerciasis control programme, and considers onchocerciasis as one of the major diseases he has the responsibility to control. The MOH said she would welcome expert advice on the best way to maintain OCP achievements.

The EAC members expressed their gratitude to the Minister for her understanding and good will. We explained that we have so far confined ourselves to our scientific role and have hardly had any contact with government officials in the past. But we felt that before the end of the Programme, we seriously should play some advocacy role to ensure that national authorities are taking OCP closure and thai they are making necessary alrangements for the maintenance phase'

We expressed our appreciation for the results obtained by the Senegalese team. In 2001, they had is to achieved IOO% geographic coverage and a therapeutic coverage of around 80%. The challenge maintain these results in order to prevent any recrudescence. To meet the challenge, we need not only financial support but also the government's direct involvement in community information, education and mobilisation. The good integration and decentralisation of activities in Senegal is an asset, rve should capitalise on this process.

The EAC members requested also the Senegalese government support of the MDSC that is being established in Ouagadougou for the epidemiological surveillance of major diseases including onchocerciasis. A dalabase will be available to countries in the MDSC and the sharing of experience and information exchange will be a useful tool for disease surveillance and control. As she rightly stated, without such concerted actions, we will hardly achieve anything.

The MOH was pleased about our appreciation for her team and invited EAC members to visit the field; one EAC member who had given us a satisfactory picture of what is happening in field did this last year. The minister of health also had recently visited the area and was impressed by the work CDds are doing. She is however concerned about the overspecialisation of the field workers in general. She would want to see the CDDs trained to do other health interventions, not just ivermectir distribution. What she feels is her most important concern is the development of effective data management, and integrated information system. She hopes very much that EAC would assist in this members confirmed that this is in line with the establishment of the MDSC. ^Concerningpro..fr. The EAC the specialisation of workers, the EAC is giving a lot of weight to the training of staff and their I1t.g.uiion in the global health system. E.g. there are many "simulium captureurs" (fly capturers) who are also drivers and the entomologists trained by the OCP countries are expected to be involved in all vector borne disease control, not just onchocerciasis.

4. In Guinea, the innovation was the anangements made for us to meet high officials of three departments: health, finance and planning. Because of the cancellation of our flight from Dakar, by the time we reached Guinea with a 24-hour delay, the minister of health was not available. We met with the General Secretary Dr Momo Camara and an impressive array of staff including the first Adviser to the minister ol health, Dr Mohamed Sylla, the National Director of Health, Dr Maki Barry, the coordinator of the national onchocerciasis control programme Dr Nouhou Diallo and his team. 7

After introductory statements by Dr Diallo and Dr Pana on behalf of the OCP Director, the EAC members expressed their apologies for their late arrival because of the flight cancellation. We expressed our appreciation of the special arrangement made by the Guinean authorities to meet not only officials of the ministry of health,,but also officials of the ministries of finance and planning. This indeed is a proof of a good understanding of the need for involvement of the key sectors of the government in planning for the post OCP phase. We expressed our pleasure about the achievements made in Guinea, competent staff are in place and they have achieved a high therapeutic and geographic coverage during the last two years. The integration and decentralisation of CDTI and the epidemiological surveillance in the health care system is well underway. There is however a need to maintain these achievements. There are also difficult areas in the Mafou and Tinkisso basins where even more vigorous efforts will need to be made, as transmission is not yet entirely under control. We sought government support in this process, in the areas of financing and social mobilisation to raise the awareness of the communities about the risk of recrudescence, if they do not fully adhere to CDTI and epidemiological surveillance. We also sought the support of the Guinean authorities for the MDSC that is being established in Ouagadougou. The General Secretary expressed the gratitude of the government to OCP for the achievements and assured the EAC members of their support to maintain the gain. He had however a few concerns: one is the fear of ivermectin resistance rvith the large scale use of the drug; the second is the cost of DEC patch test when it becomes available; and the decision to be made for ground larviciding in the SIZ. The EAC members gave an update on these issues and assured the General Secretary that these are priority research areas for OCP and WHO/TDR, and that would not be a responsibility for any single country. The cost of the commercial DEC patch test at US 0.10 each would be affordable.

The EAC members met with the Secretary of State, Minister of planning Dr El Hadj Omar Kouyat6, together with the National Director of planning Mr Ibrahim Sorry Sangar6 and the national director of programmes, Mr Mamadou Bah.

The Minister of planning was brought up in an onchocerciasis endemic area and had seen his very dear relatives dying blind. He showed great understanding of the social and economic impact of the disease and had followed the success of OCP with keen interest. He had however a few concem on the closure of the Programme. The first is the timing: OCP activities started in Guinea 10 years after the beginning of the Programme in the other countries, he would therefore expect OCP closure in the other areas before Guinea. The second is the economic difficulties the country is going through because of insecurity, the war in neighbouring countries and refugee problems. He would therefore like to advocate for closure of OCP to be delayed by one year to enable them to make necessary provision to adequately fund the onchocerciasis control activities. The EAC members expressed their deep appreciation to the minister for his understanding. We gave an overview of the development of the Programme from 19'74, the main control methods used since, the impact of the discovery of ivermectin on control and its large scale use from 1988; the rationale behind the timing of OCP closure initially planned for 2000 and then 2002. This closure had been agreed upon by all OCP countries a few years back, and an agreement signed to maintain the gains of OCP. A delay in the

{ closure would therefore not be negotiable with the donors. However, there are difficult areas like Kara Keran M6 in Togo and Mafou and Tinkisso in Guinea where the epidemiological situation is not entirely satisfactory; and where EAC will recommend necessary actions to be supported after OCP closure. The minister expressed his gratitude to OCP and assured the mission of the support of the Guinean government to maintain the achievements.

We raised the same issues with the WHO Representative in Guinea, Dr Kadidiatou Mbaye, in the presence of the Head of Epidemiology division, Dr Jean Bandusha. She is confident that the integration and decentralisation of disease control process is underway in Guinea, and will include onchocerciasis. Her most important concern is the epidemiological surveillance, especially along the borders with Siena Leone. She would want to see the surveillance system strengthened and assured 8 the mission of her support. We drew her attention to the establishment of the MDSC an{tstre informed us about the mechanism they have to send samples to Dakar for the PoliomiTelitis Eradication Programme. They will explore the way similar mechanisms could be used for similium flies that are going to be collected for entomological surveillance and sent to the MDSC in Ouagadougou.

5. In Cdte d'Ivoire, we met with the Minister of Public Health, Professor Abouo N'dori Raymond in the presence of the Principal Secretary, Professor Gnalioule Oupoh Bruno, the inspector general of health, Professor Loukou Guillaume and the director of finance, Mr. Ve Zo.The Executive Director, Dr Brika Gbayoro Pierre was also in attendance.

After an introduction by Dr Brika and Dr Siamevi, we expressed our appreciation to the minister for graciously rescheduling the time of our meeting. We explained the scientific and advisory role of EAC in OCP activities over the years and the need for the advocacy visit to countries prior to the closure of OCP. We explained the strategies employed in Cote d'Ivoire, the current epidemiological and entomological situation, as well as CDTI activities. The integration of control activities in the country, whereby the national coordinator for onchocerciasis control was also the Executive Director in charge of other diseases like malaria, HIV/AIDS and schistosomiasis rvas acknowledged, as was the role of industry in controlling fly nuisance. Cote d'Ivoire, rvith the assistance of one of her partners had also taken the initiative to design, field test and customize IEC material to make sure they were culturally acceptable and easily understood in the country. Attention was drawn to the low geographic and therapeutic coverage for ivermectin distribution in Cote d'Ivoire in 2001, with 33% geographic and 55.8% therapeutic coverage. Although the political situation in the country at the time and delay in receipt of the ivermectin contributed to the low coverage, a definite effort to rectify the situation is imperative.

We then reminded the minister of the country responsibility to continue epidemiological and entomological surveillance to detect recrudescence, reinforcement of CDTI activities and its decentralisation and integration into health activities at the peripheral level, and continuation of a national budgetary line for onchocerciasis control. The development of the AFRO Multi-disease Surveillance Centre on OCP premises and its post-OCP support to countries was brought to the attention of the minister. The minister expressed his appreciation of the visit, and immediately directed the national coordinator to ensure maximal coverage rates for CDTI in 2002. He promised the commitment of his government to the required post-OCP activities.

Vision 2020 Advocacy

In all the countries visited, the officials were reminded that onchocerciasis is only one of many blinding diseases, and were encouraged to support the "Global Initiative for the Elimination of Avoidable Blindness, VISION 2020: The Right to Sight". The minister of health of Togo and the WR indicated their commitment, while the minister of health for Senegal and the health secretary for Guinea Conakry stated that their countries were already participating in the Vision 2020 component of the Health for Peace Initiative. The Minister of public health for Cote d'Ivoire, having declared open the Vision 2020 Advocacy forum for West Africa just before the EAC team met with him in his office, promised his commitment and further stated that a national plan for Vision 2020 would be developed and resources mobilized for its implementation.

Field visit in the Kara K6ran MO areas

During our advocacy mission in Togo, the EAC members felt it important to visit the Special InterventionZone of Kara K6ran M6. The trip was well organised by the OCP in a way to enable us to go to the field and come back to Lom6 to catch our plane to Dakar in time. 9

The schedule was very tight. (Annexe 2)

Two-hour flight by plane from Lom6 to Sarakawa

Two-hour flight by helicopter over the breeding sites on the Kara and K6ran rivers and adjacent .communities.

Two-hour meeting with the villagers, community distributors and district health staff Two hour meeting with the national team of the onchocerciasis control programme Two hour discussion with the OCP staff in Kara

1. Flying over the Kara K6ran

A two-hour flight by helicopter was organised by the OCP staff based in Kara. The programme included flying over seven breeding sites on the Kara River and landing in Titira for fuel; then flying over nine breeding sites on the K6ran River and landing in Landa-Pozanda village for a meeting with the villagers.

We were impressed by the landscape. The breeding sites, which were between hills, had an overhang of trees and are hardly accessible even by helicopter. The villages and hamlets are scattered around the rivers and on the hills and most were isolated hamlets; they have poor road access and did not seem to be heavily populated. Water flow on most parts of the Kara River was slow running at the time of the visit. The picture was similar on the K6ran River, but water flow was faster.

2. Meeting with the OCP staff

All OCP staff present in Kara attended the meeting. After introductory statements by Dr Akpoboua, we expressed our deep appreciation to the staff for the hard work they are doing under very difficult conditions. It is indeed a great pleasure for us to be in Kara at last after having heard so much about it for many years. OCP is coming to an end. The results indicate that despite the combination of larviciding and CDTI, the epidemiological situation is not satisfactory; the region may need special attention, possibly the extension of activities beyond 2002; but a decision will be based only on scientific evidence. OCP closure is perceived in Kara as 'cold shower' and the staff is worried about the future. We assured them that all possible care is been taken to reduce the social impact by the training and reallocation of staff. If an extension is granted some staff, probably, not all, will continue to be employed.

Dr Akpoboua stressed that the staff will have to face two main challenges in 2002:

show evidence that the current vector control activities is having a significant impact on 1 transmission. show evidence that the entomologists trained are fully operational.

The EAC members asked the team how confident they are in meeting these challenges.They believe they have during the last year improved their skills and technologies for a fairly exhaustive identification of breeding sites; a more precise dosage of insecticide and its correct application at even less accessible breeding sites; a greater involvement of ground larviciding staff in CDTI sensitisation and a better assessment of the effectiveness of insecticide application. All in all, they have now in place rigorous quality control mechanisms that make them confident that vector control activities could make a difference. The entomological results so far are as good as or even better than 10 those of 2OOl, except on the MO River. However, even with low fly densities, there is evidence of infection indicating ongoing transmission.

3. Meeting with the national Onchocerciasis control team

Dr Dare and his team welcomed the EAC members in the meeting room of the Regional Administration of Health. Dr Yakwa, the district medical officer for Kara, laboratory technicians, were present. He introduced his colleagues and gave an entomologists and CDTI supervisors all ' overview of the organisation of onchocerciasis control activities. The activities are well integrated and decentralised under the responsibility of the district medical officer at district level. Although the therapeutic coverage is78o/o, there are pockets of very poor results. Beside OCP, other organisations like Sight Savers and GTZ have given financial support to the programme during the last two years (training of 400 personnel in 2001). However, there are difficulties.

* The villages in the Kara K6ran M6 areas are dispersed. Some were been identified only recently by helicopter. This dispersion leads to two main problems: the unsatisfactory geographic coverage and the increasing demand of motivation by the community distributors because of the supplementary effort they would make to go treating on a house to house basis at remote areas. Thi- demand for CDD motivation is now a national problem for which solutions like cost recovery an involvement in paying activities like National Immunisation Day are being considered.

* The lack of equipment, logistic, supplies and IEC material for the regional team to perform epidemiological surveillance, for the entomologists to be fully operational, for the staff to do proper IEC. In 2OOl, the team has adopted a commando type intervention to increase the coverage of the treatment with ivermectin. During the discussion the EAC members suggested that the team consult with the other OCP country teams to share experiences in setting appropriate IEC programmes. The meeting and collaboration of the national co-ordinators of Benin and Togo recommended by EAC is now urgent and should also involve peripheral / district health workers in the two countries.

4. Meeting with the Community of Landa Pozanda village

The Canton Chief, the Village Chiel eight Community Distributors and two supervisors, the District Medical Officer and the Regional Director of Health, attended the meeting.

The Canton Chief welcomed the team on behalf of the Canton and expressed his gratitude to OCP f< their assistance during more than 20 years. He said he is now 47 years old and had seen many adults going blind or leaving the village when he was 15. His generation was lucky to have witnessed the achievements of OCP, which enabled them to retain their sight and remain in the community. He is committed to take all necessary actions with the community to maintain the achievements.

The EAC members thoroughly discussed with the CDDs, the philosophy of CDTI, the organisation of ivermectin distribution, and the problems they encounter during their work and possible solutions. I One of the main problems raised by several CDDs is the lack of community support. The communities have selected the CDDs and have imposed on them to conduct house to house ivermectin distribution, they argue that the immunisation programme is doing door to door treatment. There is therefore a need for continuous IEC to make the community understand that CDTI is in the interest of the community not the CDD alone. Because of all these problems the CDDs would want some incentives that could motivate them to do their work. These may include providing them with bicycles, T shirts, hats or boots; or get them involved in other health programme as a recognition of their status as health personnel. ll

The EAC members were very pleased to have been able to undertake this visit in the Kara K6ran MO areas. We are impressed by the dedication of all the staff working in the field: the national, regional and district health staff, the OCP staff and community distributors.

This indeed is a difficult area that definitely needs special interventions combining very effective larviciding, adequate CDTI, cross-border collaboration and appropriate IEC.

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Annex 1: Programme of the Mission

May 19 and 20 arrivals of Dr Traor6, Dr Pana and Prof. Abiose in Bamako May 2l meeting with the Permanent Secretary of the MOH of Mali May 7l departure from Bamako to Lom6 via Abidjan May 22 meeting with the Representative of the WHO in Lom6 May 23 meeting with the Minister of Health of Togo ly'ray 24 departure from Lom6 to Kara by plane May 24 Kara K6ran M6 sites tour visit by helicopter May 24 n-reeting with Village Chief, District Medical Officers, Nurses and Community Distributors of Landa Ponzada village. May 24 meeting with the National team of the Onchocerciasis Control Programme May 24 meeting with the OCP staff in Kara May 25 Departure to Lom6 by road May 26 departure from Lom6 to Dakar May 27 meeting with the Minister of Health of Senegal May 29 departure from Dakar to Conakry May 30 meeting with the Minister of Health of Guinea May 31 departure Dr Traor6 to Brussels May 31 departure Prof. Abiose and Dr Pana to Dakar June I departure Prof. Abiose and Dr Pana to Ouagadougou June I debriefing meeting with OCP Director, Dr Boatin June 2 departure Prof. Abiose and Dr Siamevi to Abidjan June 3 meeting with the Minister of Health of Cdte d'Ivoire.

I l3

Annex 2

Programme of the mission to Kara by Professor A. Abiose, Dr Traor6 S. Mamadou (EAC members) and Dr A. Pana on 24 and 2510512002

Fridav 24 .05.2002

10h Arrival of the delegation by Cessna from Lom6 Reception at Sarakawa . Presentation of the programme for revision

10h30-12h30 Flying over Kara - K6ran by helicopter as follows :

l) Sarakawa Sikan, Kajol Aho-Lao Kpessie, Tougel Naboulgou, Koumongou, Titira (hameaux) _ Titiia depot 2) Titira-Sola, Hound6-Koutantagou /Tapounde Kawa-Bassar - Landa-Pozanda - pozanda village

3) Landa-Pozansa vilrage - wHo (participants : prof. Abiose, Dr Traor6 S. Mamadou and M. O. Sina) Stop over at Landa-pozanda for CDTI evaluation.

12h30-lsh Lunch break

15h Meeting with the National coordination team at the Regional Administration of Health 16h30-18h Meeting with the Personnel of the OCp Kara base

l9h Dir-rner oftered by the coordination and officials of the ocp Kara base to the delegation

saturday 25.05.2002 Departure of the delegation to Lom6 by road.

, by helicopter Annex 3: Kara K6ran Mo area map showing itinerary of'trip

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