ocPf73.L ANNEX V.4
ONCHOCERCIASIS CONTROL
IN THE
VOLTA RIVER BASIN AREA
Report prepared for the Governments of Dahomey, Chana, Ivory Coast, Mali, Niger Togo and Upper Volta
ANNEX V-4 ESTIMATED COST OF THE EPIDEMIOLOGICAL EVALUATION COMPONENT OF THE ONCHOCERCIASIS CONTROL PROGRATIIME IN THE VOLTA RIVER BASIN AREA
Geneva I 973 United Nations Development Prograrule Food and Agriculture Organization of the United Nations International Bank for Reconstruction and Development World Health Organization Annex V-4 page I
ESTIMATED COST OF THE EPIDEMIOLOCICAL EVALUATION COMPONMIT OF THE ONCHOCERCIASIS CONTROL PROCRAMME IN THE VOLTA RTVER BASIN AREA
I. GENERAL PROCEDURES l. The assessment of success or failure of the Onchocerciasis Control Programme requi.res methods by which changes in the vector population and in the disease can be evaluated quantitatively at suitable time intervals during and after completion of the campaign. The control programme has been conceived to achieve interruption of the transmission of the infection by a drastic reduction or even elimination of the vector in the present endemic areas. Intervention by mass chemotherapy can be considered only after extensive studies with appropriate drugs and methods of their administration have shown satisfactory results. The present evaluation I scheme^ is therefore designed to measure the impact made by vector control operations on the disease, taking into account that onchocerciasis In persons already infected will follow its natural course. However, if the transmission can be lnterrupted by successful control of Simulium, there will be no superlnfectlons and 1t can be expected that the natural course of the disease wilt be modrfred. Because the Iongevi ty of adult Onchocerca volvulus is consrderably shorter than the life expectancy of the human population in endemic areas, there wrll be a contlnuous reduction of infection intensity in the infected persons over the years, provided that no reintroduction of the vector occurs. Since r.nfection lntenslty rs closely associated with the frequency and severity of clinrcal manrfestatrons, it can be anticipated that the incidence of onchocercal lesrons will progressively decline. 2. The most sensitive method for assessing quantitative changes in endemlcity levels resulting from vector control is the measurement of the incidence of new infections in the susceptible, non-infected part of a population at risk, i.e. predominantly in children and young adults. The rate of change in incidence, or the force of infection, can only be measured against suitable baseline data that have been acquired over many years and reflect the dynamics of onchocerciasis under natural conditions which are subject to considerable annual variations. The lack of such data makes it necessary to use as baseline data age- and sex- specific prevalence ratios from carefull y selected villages and towns that are representative of the diverse epidemiological patterns in those parts of the seven countries concerned which are included in the programme area.
3. Changes in prevalence can be measured by a series of cross-sectional surveys conducted in the same communities. A conservative projection of the changes I Ettomological evaluation is described in Annes V-3 Annex V-4 page 2 expected ten years after the interruption of transmission is shorvn in the Figure V-4.I. Thrs projection is based on the assumption that in this originally hyperendemic area, persons already infected will stiIl have microfilariae in their skin snips ten years after interruption of transmission, despite a decrease in infection intensity due to the natural death of adult worms. In prospect, it wilt be easy to determine the percent of nerv infections in persons rvho had been found free of onchocerciasis at the time of the baseline study. Because of limitations in manpower, and of the logistics involved, 1t seems reasonable to re-survey a selected population sample at three-year intervals. Allowing for losses due to migration and death, it should stiII be possible to find a sufficiently large number of persons in each community who will participate throughout the evaluation period.
4. TWo approaches for studying the impact of the vector control programme on onchocerciasis in the human population are required. The first is the systematic study of age- and sex-specific rates of infection and clinical manifestations of onchocerciasis ln representatlve population samples, and the second is the Iongitudinal follow-up of the same individuals in a cohort. For these investigations use will be made of standardized study protocols and methods for diagnosing infection, rnfection lntensity and a variety of clini.cal manifestations. An example rs given in Appendix I to this Annex.
5. In prrnciple, the epidemiological evaluation of the Onchocerciasis Control ProBramme wiI,l be made at two levels of sophistication: (l) In all of the selected villages, a baseline study will first be conducted to determine the prevalence of infection and of severe clinical manifestations by age and sex. These surveys will include the taking of skin snips, external examinations for nodules and specified skin lesions, measurement of visual acuity by the illiterate 'E' test and a simple eye examination by the ophthalmologist. A11 villages rviIl be re-surveyed at three-yea!' intervals. (2) In about ten of the 1OO-13O selected villages, it is planned to conduct intensive epiclemiological and clinical studies, including elaborate eye examinations by slit lamp, funduscopy, taking of multiple standardized skin snips, urine examrnation for microfilaruria, and the application of a battery of diagnostic tests as required to determine the prevalence and severity of the most important co-endemic diseases such as malaria, schistosomiasis, trypanosomiasis, intestinal helminthiases, gross incapacitations, etc. These villages should be revisited at annual intervals.
6. To ensure high participation rates in all villages selected for evaluation, it will be necessary for the success of the longitudinal studies that treatment Annex V-4 page 3 be given by the medlcal team whlle working in a given village. Final arrangements for this essential research component must be made ln close cooperati.on with the national health authorities in each of the seven countries concerned. 2. SAMPLE DESTGN 7. The population in the programme area is estimated to be 10 million. Selection of villages to be lncluded in the evaluation study wilL be made accordinB to a stratification scheme based upon the observed or estimated prevalence of onchocerci.asis. At present, estimates of prevalence are available for communities and cantons representinB approximately 5.6 million persons or about half the population in the programme area. However, it is expected that more data will be obtained in the near future. 8. For the epidemiological evaluation of the Onchocerciasis Control Progranme, it is envisaged that surveys will be carried out by two teans working durlng the
"dry" season, i.e. approximately 15O working days per tean per year. If each tea.ur is capable of examining 50 persons per working dalr it will take about two years to examine the approximately 30 OOO persons in the population sarnples selected for longltudinal study. This would represent about O.5% of the population in the frame or O.3% of the total poputation in the progranrme area. Because of present deficiencies in baseline data from parts of the progrEunme area, it ls dtticipated that another 10 OOO individuals will be added to cover the entire area in the evaluation scheme. 9. In prevlous surveys, large differences in endemicity levels were found between villages located near to each other. The primary sa.mpling unit will therefore be the village. It is desirable that the sa.nrples should be spread out as much as possibte so that each country in the progratme area is represented. Furthernore, since the primary aim of the surveys ls to detemine the effect of the control programme in areas with high levels of endemicity, the villages will be selected so that approximately two-thirds of the population to be surveyed will be in villages where the endemicity levels are estinated to be medium and high. The four categbries of endemicity are (l) sporadic: O.1 - 9.9% prevalence; (2) low or hypoendemic: 10 - 39.9%; (3) medium or mesoendemic: 40 - 69.97o; and (4) high or hyperendemic: 'I@o ot Dore.l lO. The table V-4.f glves the estimated population in the progra.nrme area for each country and, depending on population size, the minimum number of clusters which will be selected and the number of persons to be surveyed assuning that each cluster has
l rhr" classification is slightly different from that proposed by the WHO Expert Committee on Onchocerciasis (Wld Hlth Org. techn. Rep. Ser. (1966) , No.335,24) and allows for a more flexible assessment. Annex V-4 page 4
3OO persons. Since the sampling unit is a village and the villages for which data are now available range in size from 45 to 20 OOO, selected communities with
populations of 3OO persons or less wtll be surveyed as a whole, while for larger villages, a cluster of houses will be selected instead. Accordingly, a cluster will be composed of.rn entire villaBe or of a part of one ancl will include not more than 3OO individuals. It should be noted that the sample wrll be overdrawn for countries represented by relatively small population samples. This is to ensure that there wilt be at least 3OO individuals in the encl.emrcity elasses "sporadic" and "Iow" rlnd about 6O0 individuals in the categories "r,tedium" and "high". 3. SELECTION OF VILLAGES Il. For six of the seven countries, viLlages have been randomly selected by end.)micity level (see Appendix 2). In this initial selection, tlreir number ts twice the minimum of clusters needed for the study. This procedure was used to ensure that the desired number of persons wiIl be obtainable, taking ilrto ,lccount that some viltages are smaller than 3OO individuals and also that lt may not be feasible to study some of the viltages selected. For communities where no populatio:r estimates were available average villaBe sizes for corresponding community classes were accumulated for each country. In Appendix 2 these figures are enclosed in parentheses. 12. For Togo, the presently available information on the prevalence of onchocerciasis by village was considered inadequate for sampling. Selection of villages will be made at a later date when sufficient baseline data wiII become availabte from epidemiological studies. For Dahomey, MaIi and Niger, the number of communities with estimated prevalence rates in the "medium" and "high" categories are very sma11. Villages in these areas will be randomly selected from any data that may become available in the future. 13. In Upper Volta, prevalence rates are known for many villages but only lnformation relating to cantons was available at the time this document was prepared' The data are being assembled. Meanwhile the number of villages in each canton was estimated on the basis of rts population size and also of the prevalence of onchocerciasis' A random selecti.on of villages was then made; the chosen communities are designated by numbers. For identification of these villages, a complete tist of all communities in each canton should be drawn up in alphabetical order and numbered' Those corresponding to the numbers selected wi.ll be included in the evaluation survey' L4. Since the total prevalence rates for entire cantons are averages comprising communities with different leveIs of endemicity, some villages with high endemicity wiIl probably remain unrecognized. To increase the probability of their being selected in the final sample, it is suggested that for these cantons only the villages with less than IOOO inhabitants be listed in alphabetical order and numbered. Annex V-4 page 5
4. SE,ECNION OF POPULATION CLUSTERS 15. For each endemicity class, there is a minlmum number of clusters to be surveyed. Each cluster should contar.n not more than 3OO indrviduals and enough clusters should be lncluded in order to obtaln the desired number of persons for each endemicity level. Ttre up-to-date census on a household basrs for each of the selected villages must first be obtained. 16. If the conununity has about 3OO individuals or less, then the entire village should be surveyed; if, on the other hand, the vitlage is much larger than 3OO persons, then a cluster of households will be selected in one of the two following ways: (f) If possible, a map should be prepared on whlch the location of each house or family compound is indicated. The houses should then be numbered serially in such a way that the last house is as close as possible to the first one. A random number should be drawn to designate the house with which the cluster should begin. From the census figures and the number of houses in the village, the average number of lnhabitants per house can be calculated and, on this basis, the number of houses required to obtain at least 3OO individuals determined. The cluster to be studied will therefore consist of all inhabitants in the selected houses. <2) If the village is much too large to map each house, then it should be divided into sub-areas according to natural or administrative borders. Each sub-area should be serially numbered and one of them randomly selected. The houses in the selected sub-area should then be mapped and the cluster of 3OO persons to be surveyed selected as described previously. If the selected sub-area has less than 3OO inhabitants, then houses from the closest sub-section should be selected to obtain the required cluster size. 17. For random selectlon and identification of the selected villages, two tables are given in Appendix 2 for each country in the programme area except Togo. The first table indicates for each of the four endemicity classes (a) the number of villages (for Upper Volta the number of estimated villages) for which prevalence information is available; (b) tne minimum number of clusters to be included in the survey, and (c) the number of persons to be surveyed. The required number of individuals should be obtained from the clusters (vittages) in such a manner that none of them will be composed of more than 3OO individualsr €.8. for 600 persons the minimum number of clusters is two, therefore two clusters of 3OO persons each may be studied or one cluster of 3OO ptus two clusters of 90 each (two villages wlth only 90 inhabitants each) and one cluster of r2o persons as may be needed.
18. Ttre second table ldentifies the villages randomly selected by endemicity class and indicates for each the last available populatlon census or an estimate of the population. This table is to be utilized as follows: Annex V-4 page 6
(1) Vilfages should be included in the survey in the order in which they are tisted. If it is not possible to study the population of a v1lLage, the next community on the list should be taken. (2) For each endemicity class, the first village listed should be visited (for Upper Volta, where villages may not be listed by name, see item (5) below), to obtain its latest census. If there are about 3OO persons or less in this viLlage, then the whole community should be included in the survey. If there are more than 3OO persons, a cluster of houses should be selected to obtain about 3OO individuals (see para. 15). (3) If the population of the village now included for survey does not correspond to the particular endemicity cIass, then the next village should be processed as listed under item (2). (4) As many villages as possible should be processed in order that the requ1red populatton size for the endemicity leve1 is obtained. (5) For Upper Volta, if a selected viltage is not listed by its name, all communities in the specified canton should be listed and numbered (see para. I3). The vitlage corresponding to the number on the list of selected vitlages should then be processed as in (1) and (2). If the number of villages in a canton has been overestimated and the selected village number exceeds the total of communities, disregard the number and try to process the next village on the list of selected communities. (6) Afl persons from the villages or cluster of houses in the larger communities which have been included in the survey should be registered and examined according to the study protocols.
5. REQU TRHI/IENTS 19. These investigations will be divided up between two teams, each comprising; an epidemiologist, an ophthalmologist, a laboratory assistant, a nurse, two drivers and local aids at the village level. The teams wiII be reinforced during the first survey cycle (baseline study) by statisticians and sociologists whose task will be to organize and conduct populatlon censuses in aII the villaBes to be monitored each year for a perrod of three months by consultants who will assist in the conduct of the intensive epidemlological and clinical studies. Technical and secretarial services will be provided to both teams by a technical officer and a clerk typist. Annex V-4 page ?
20. The main phases in the evaluation progranrme are as follows
Year Operations
r-3 First cycle of surveys (baseline study), to include: (a) the final identification of villages selected for evaluation (b) census taking in the 1OO-13O villages selected (c) collection and processing of baseline data from all of the 1OO-I3O villages selected Intensive studies in the 10 selected villages (3 months a year)
4- r9 Five cycles of surveys in the 1OO-I3O villages selected lntensive studies tn the 10 selected villages (3 months a year)
20 Flnal epidemioloBical evaluation
21. The team members and consultants will be working under the direct supervlsi.on of the Director of the Onchocerciasis Control Programme, with technical guidance and assistance provlded by WHO headquarters where data processing will be centralized.
22. Successful completion of the above progrEunme will depend on acceptance by the people to submit themselves to the exaninations and studies required. Medications will therefore need to be provided by the visiting tea.ns, under special arrangements made with the health authorities. 23. One of the major objectives of the Onchocerciasis Control Programre is the opening up of new land for settlement. At this time, it is impossible even to make projections of the scope and diversity of settlement progranunes in the seven countries included in the prograrme area. Nevertheless it can be foreseen that new communities of unknown sizes will be establlshed which cannot yet be consldered for sampling. Appropriate adjustments for their inclusion in the evaluation scheme will have to be made at a later date when the definite plans for development prograrnmes become available. 24. There is a serious dearth of epidemiologists and ophthalmologists, especially of those experienced ln parasitic diseases. De1ays for the recruitment of spectalists, even as short-term consultants, are often in the 6-9 month range. Annex V-4 paBe 8
Furthermore, it is reasonable to assume that for the full 20 year duration of the evaluation programme replacement of the field teams will be necessary at three year intervals at least. Such provisions have been made rn rhe training budget presented in Annex V-6. 25. The detailed requirements for the period f974-1993 are listed below. Internationally recruited staf r 2 epidemiologists for the whole period 2 ophthalmologists for the whole period 2 sociologists for the first three years 1 technical officer for the whole period 6 ^/^ consultant /V"u, for the whole period Locally recruited staff 2 statisticians for the first three years 4 drivers 2 census assistants 2 nurses 2 laboratory aides I clerk-stenographer Aides at village level Equipment 2 Landrover station-wagons (to be replaced on a three year basis) 2 light lorries (to be replaced on a five year basis) microscopes, ophthalmoscopes, etc. (at their maintenance value) Iaboratory supplies $ 3OOO/year drugs for treatment $ 1O OOO/Vear
field canping equipment (to be replaced on a six year basis) $ 10 OOO office supplies g ISOO/year Local operatin g costs Laboratory and office renting and maintenance g 68OO/year Maintenance and operating costs of vehicles $ t3 Soo/year (25 OOO xnfVear /vehicle ) Miscellaneous local expenses (postage, etc. ) $ 3OOO/year Internal technical meetings $ sooo/year Reporting costs Reporting, including data processing and analysis $ 11 OOOfVear
6. AI.ITICIPATED COST OF THE EVALUATION PROGRAMME 26. The anticipated annual cost and total cost of the programme are detailed in table V-4.2. The present tentative figures anount to $ t 92I. O4O for the Annex V-4 page 9 period L974-L979 (yearly average of $ 32O l?3) and $ 5 ?5I O2O for the period 1974-1993 (yearly average of $ 287 551). Should the epidemiological evaluation be subcontracted, managerial costs of about 2do would have to be added. Annex l'-{ page lO
TABLE V-4. I\{INIMUM I. NUMBER OF CLUSTERS AI{D PEOPLE TO BE INCLUDED IN THE EVALUATION STUDY
Es t ima ted Population to be population in area surveyed Country Mrnimum No. No. of No. of persons c lus ters
Dahomey 440 000 4.4 6 I 800
Ghana I 600 000 I6. O l6 4 800 Ivory Coast I OOO OOO 10. o T2 3 600 Mal i I 400 000 14. O L4 42@ Niger 60 000 o.6 6 r 800 Togo 500 000 5.o 6 I 800 Upper Volta 5 000 000 50. o 50 15 000
Total lo ooo ooo 100. o 110 33 000 Annex V-4 page II
TABLE V-4.2. ANTICIPATED AT.{NUAL COST AI,ID TOTAL COST OF TT{E EPIDHIIIOLOGICAL EVALUATION (Costs and currency at their July l9?2 values, US$)
r977 Total Categori€s 1974 1975 r976 and 1974- r993 onwards
Epidemiologists 66 000 60 000 60 000 60 000 I 200 000 Ophthalmologlsts 60 000 60 000 60 000 60 000 r 200 000 Soclologlsts 60 000 60 000 60 000 180 000 Technical offlcer 30 000 30 000 30 000 30 000 600 000 ConsuI tants 15 000 t5 000 l5 000 15 000 300 000 Statisticians 16 000 16 000 16 000 48 000 Drivers 4 000 4 000 4 000 4 000 80 000 Census assistants 4 000 4 000 4 000 40@ 80 000 NurseS 6 000 6 000 6 000 6 000 120 000 Laboratory aides 2 800 2 800 2 800 2 800 56 000 C lerk-s tenographer r 200 I 200 I 200 I 200 24 00,0
Village aides 10@ I OOO I OOO. 1 000 20 000 Vehic les 25 100 7 200 7 2o,0 7 2o,0 161 900 Technical equipment 2@O 2 000 2 000 2 000 40 000
Field equipment ro o@ r ?oo I ?OO r 700 42 300 Laboratory supplies 3 000 3 000 3 000 3 000 60 000 Drugs 10 000 ro ooo lo ooo 10 000 200 000 Office supplles I 500 I 500 I 500 r 500 30 000 Buildlng renting and maintenance 6 800 6 800 6 800 6 800 136 000 Vehicles' operating costs and maintenance 13 500 13 500 13 500 13 500 270 000 Miscellaneous local expense9 3 000 3 ()00 3 000 3 000 60 000 Internal meetlngs 5 000 5 000 5 000 5 000 roo ooo Reporting costs 1r ooo 1l ooo lt ooo l1 000 220 0@
Contlngencles 35 090 32 47C^ 32 470^ 24 870 522 820
Total 385 990 357 1?O 357 170 273 570 5 751 O20 \,rg_l:_! pagt.l2
I 00
.o@ lnfected 1972 C lnlect6s 1972
lnlected 1982 lntect6s 1982 a o 80 5
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CHILQNEN AITO TOUNG AOUTTS.IN A VITLAGE UITH INTERNUPTION OF TRANSTIISSION FIGURE:V 4.1 VARIAIIONS OE LA PREVALENCE OE L ONCHOCERCOSE EIII FOI{CTION DE t AGE CHEZ OES ETFAITTS ET OE JE'JNES AOUTTES OANS UT VILLAGE A FORIE EI{OEXICIIE OTTCHOCEROUIENNE AVANT ET OII ANS APNES I'IITTERRUPIIOil COTPTEIE DE tA IRANSTISSIOI{ Annar v-a p.3c 13 ClCf,(rECt.itTT SurlY ?cr I APPII{DIX I
2
S.r1.l ! ar Caril Flrat na FrthoC. - lluab. n.D Coutry nr.o ..rfl l{ r5 16 r r-i spen Pllce of rurvay l ::E Fattv. vl1l.aa Trlbc 436 n tlr(,aa..J
ilodule! none nona Y.! - llo haad ud neck ro schooI Olothrlcarb. - 6 !tha Yc. - i{o tml 2:t lamer Suruln 5 yra Y.t - xo l( ahar thorar 24 Soth I ud 2 Ya! - l(o abd..ad p6lv 2\ tltlSlo &rt[lo yrr - )3 rjo Y.r - lfo 1..o 26 t radar I +{ clvr I c€rv 2 ra Saol n 27 othcrt 3 +l unlnom Dt.thrlc.lb. - )6 irhr rao y.. No tnlm .pl6 2A othcr ltlarree 29
BloD3les: 3() 31 32 33 3{ ?t. rT'nrl. 35 36 3? 38 39
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?9 Hr. akln btooaY tr ao No. nf R. cornoa tr lllllllgllgr Y6t No Roaaakr:
I Tnra loaa rhlch haa baan davalopad toa uaa lo an onchoccrclaala 3urvey aponrord by thc Errtr3h Iadrctl icaaarch Councrl la alvan only ta an araaPla. l! ra nd ln lh. Proccaa of Darna r6vrad. Annex V-4 page 14
Ar)nendix I
l. Praktrca camera - Frame (flIm rdentlfrcatron)
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lrrrtt ( ) l.'r'irme ( f llm l(letltl I rcdtl(ln) :1 . Kowa camera f uncltr-, plx)tography Annex V-4 page 15 ixl CODING INSTRUCTIONS CoI s. t-4 Serial number 5 Card number 6-7 Month of survey 8-9 Year of survey lo Sex I = male 2 = female r t-12 Place of survey or village of survey (each village being allocated a number: Ol , 02, etc. ) 13 Area I = rain forest 2 = Savanna 3 = borderline, between savanna and rain forest r4-15 Tribe, each major tribe being allocated a number: 01, 02, etc. l6-r7 Age in years t8-I I Years spent at place of survey or within 2 miles of it 20 Occupation 2T Treatment O = never diethylcarbarnazine or suranin I = any arnount of diethylcarbamazine within the past 6 months 2 = 2 or more surarnin injections within the past 5 years 3=Iand2 4 = 2 or more surarnin injectlons more than 5 years ago 5=Iand4 6=2and4 7=3and4 8 = any arnount of dlethylcarba.mazine more than 6 months ago 9 = unknown 22-26 Number of nodules 9 = 9 or more nodules 27 Groin O= no visible swellings 1= visible inguinal swelling, excluding hernla, of any size and number - uni- or bilateral 2= visible femoral swelling, excluding hernia, of any size and number - uni- or bilateral e- land2 4= hydrocele of any deBree, uni- or bllateral 5- land4 6-- 2and4 '7= 3and4 9= not examined Annex V-4 page 16 Appendix I Col s. 28 Spleen O= normal or tnegative, spleen not palpable even on deep inspiration 1= spleen palpable only on deep or at least more than normal inspirati.on 2= spleen palpable on normal breathing but not proiected below a horizontal line tf2-way between the costal margin and the umbilicus, measured along a line dropped vertically from the left nipple a_ spleen with lowest palpable point proiected more than tf2-way between the costal margin and the umbiticus, but not beyond the line drawn horizontally through it 4= spleen with lowest palpable point below the umbilical level but not proiected more than Lf2-way towards a horizontal line through the symphysis pubis spleen with lowest palpable point below the lower limit of class 4 9= not examined 29 Other filariae Q = Do other filariae I = streptocerca present (diurnat blood mf absent) 2 = loa-loa present 3 =land2 4 = g?.!ql Present 5 =1and4 6 -2aod,4 7 =3and4 8 = streptocerca present (capillary blood not examined) 9 = Irot known or not examined 30- 3r Weight of shoulder biopsy in mg to one decimal point 32-34 Number of volvulus microfilariae seen in shoulder biospy 35- 36 Weight of buttock biospy in mg to one decimal point 37- 39 Number of volvulus microfilariae seen in buttock biospy 40 Skin pigment changes o= no shin depigmentation of either leg 1= unilateral shin depigmentation of any degree 2= bilateral shin depigTentation of less then-3 cmz on either side 2- bilateral shin depigmentation of from 3 c,n2 to half the shin Q= bilateral shin depigmentation of more than half the shin 5= shin depigmentation with depigrentation of any other area 6= macular dyspigmentation without depigmentation 'l= macular dyspigmentation combined with I, 2, or 3 8= macular dyspigmentation combined with 4, or 5 4l Skin atrophy O= absent 1= acute papular onchodermatitis of any extent 2= pachydermia of buttocks and thighs Iand2 4= 2 and elsewhere 5= slight presbydermia of buttocks and thighs 6= severe presbydermia of buttocks and thighs '7= 6 and elsewhere 8= skin reaction to diethylcarbamazine Annex V-4 page 17 Appendix I Col s. 42 Lymphoedema O = absent I - lymphoedema of the extremities, of any degree or extent 2 = p€au d'orange of the trunk, of any degree or extent 3=1and2 4 - lymphoedema of the scrotum or vulva 5-1and4 6=2and4 7=3and4 43 Groin O = Iro skin changes I = skin atrophy present 2 = skin folds less than I cm 3 = hanging groin more than I cm 4 = hernia, or hernia scar, unilateral or bilateral 5=land4 6=2and4 7=3and4 9 = not exarnlned 44 Leprosy O = absent I = tuberculoid 2 = lepromatous 3 = borderline 4 = ? leprosy, including cases without signs but with a hlstory of leprosy treatment 45-46 Visual acuity, right and left eye O= 6/6 1= 6/12 ,- 6/24 3= 6f6O or counting fingers at 6 m 4= counting fingers at 3 m 5= counting fingers at I m 6= hand movements 7- perception of light 8= no perceptlon of light o- unrecordable due to age or mental inability 47-48 Conjunctiva, right and left eye O- normal l= hyperaemia of any degree o- pinguecula (no corneal involvement) 3= any heaping up or irregularity of nasal or temporal limbal tissue with or without encroachment on to the cornea up to I mm pterygium 4= (corneal encroachment to be more than I mm) 5= land2 6- land3 7= land4 o- eye so shrunken that conjunctival condition of no importance Annex V-4 page 18 Appendix I CoI s. 49-50 Microfilariae in the anterior chamber, right and left eye O = absent I = I microfilaria present 2 = 2 to 5 microfilariae present 3=6to20mf 4=2lto5Omf 5=50+mf I = not visible due to corneal opacities 51-52 'Cornea', right and left eye O= normal (i.e. the other conditions in this column are absent) I= mild trachoma (vessels not encroaching more than 2 mm) severe trachoma (vessels encroaching more than 2 mm) 3= any dense corneal opacity of 3 or more mm diameter 4= corneal epithelial oedema 5= Lor2and3 6= lor2and4 '7= 3and4 8= Lor2and3and4 (t- cornea unrecognizable due to phthisis bulbi 53-54 Corneal opacities, right and left eye O = absent (conditions in cols. 51-52 may still be present) I = opacities within 2 mm of the limbus 2 = opacities outside the limbal zone, or limba1 + outside 3 = a clear cornea with five or less mf without reaction 4 = limbal opacities r five or less mf (mf without reaction may here be scattered, but those with reaction must be limbal) 5 = 2 and five or less mf in the cornea 6 = I clear cornea with six or more mf without reaction 7 = 8s for 4 above, but with six or more mf in the cornea I = 2 and six or more mf in the cornea I = not visible due to causes such as phthisis, corneal oedema, total leucoma, etc. 55-56 Type of corneal opacities, right and left eye O = absent (only when co1s. 53-54 equals O, 3, or 6) I = I white non homogeneous opacity at the level of Bowman's zone, the edges unclear, the diameter tf+ - lf+ mn 2 = an! round opacity of less than 2 mm diameter with a clear edge 3 = opacities not covered in I or 2, e.g. reactions round mf, small round stromal opaci ties 4=L ad2 5=1 and 3 6=2 and 3 7 =I and 2 and 3 9=8S cols.53-54 N.B.: corneal scars and nebulae are not coded, but are recorded separately Annex V-4 page 19 Appendix I Cols. 57-58 Sclerosing keratitis, right and left eye O= absent I= nasal encroachment o_ tenporal encroachment e- inferior encroactrnrent 4= land2 land3 6= 2and3 7= confluent, pupil free 8- part or whole of the pupil covered 9= as cols.53-54 59-60 Rrpil, right and left eye O= normal 1= pupll diameter more than 5 mn, poorly reacting ,- a small pupil bound down by posterior synechiae a- pear shaped deformation 4= slight deformation in any direction 5= posterior synechiae 6= 3and5 7= 4and5 9= as cols. 49-50 6L-62 Iris, right and left eye O= normal 1= disappearance of pupillary ruff of any degree ,- complete absence of crypts c- visibility of white iris stroma of any degree, excluding visibility at the bottom of crypts 4= land2 5= land3 6= 2and3 7= land2and3 o- as cols. 49-50 63-64 lritis, right and left eye O = absent I = scattered cells only 2 = acute iritis with injection, flare, and cells, with or without keratic precipltates (K.P. ) 3 = 4 quiet looking eye, but with flare and cells, no K.P. 4 = 4s 3, but with K.P. 5 = pigment on posterlor corneal surface 6 - irregular pigment on the anterior lens capsule, and/or old K.P. 7=4and5 8=5and6 9 = 4s cols. 49-50 65-66 Lens - Vitreous, right and left eye O= clear lens l= early cataract, fundus detalls mostly visible ;_ advanced cataract, fundus details largely obscured a- mature cataract, no fundus view 4= an mf between the lens and the vitreous (clear tens) an mf in the vitreous (clear lens) 6= as 4, but with early cataract Annex V-4 page 20 Append ixI CoI s. 65-66 Lens - Vitreous (contd. ) '7=4and5 8 = 6 and mf in the vitreous !) = as co1s. 49-50 6?-68 Optic disc, right and left eYe O= normal t= ? early optic atrophy 2= primary optic atrophy a- post-neuritic optic atrophy 4= features of 2 and 3 combined 5= pink disc 6= papi I 1i ti s 7= physiological cupping 8= pathological cupping (t- not visible due to opaque media 69-70 'Ridley' fundus, right and left eye O = absent 1 = irregular granularity of retinal pigment (stippling) 2=?L 3 = a clearly circumscribed area of retinal degeneration, with irregular pigment distribution and choroidal sclerosis 4 = ? early stages of 3 9 = as cols. 67-68 7t-72 Vessels, right and left fundus O - normal I = any obvious fibrous reaction around an artery 2 = any obvious fibrous reaction around a vein 3 = pathological narrowing of arteries 4=Land2 5=1and3 6=2and3 ?=land2and3 9 = 8s cols. 67-68 73-74 'Tigroid' fundus, right and left eye O= absent ]= mild peripheral, i .e. not seen when viewing the immediate disc surrounds, but present below ,- mild diffuse, i.e. seen when viewing the immediate disc surrounds 2_ marked periPheral 4= marked diffuse 5= gross central o- as cols. 67-68 75-76 Colloid bodies, right and left eye O = absent 1 = 4 group of discrete yellowish-white spots with clear margins, temporal to the macula 2 - similar spots scattered in the temporal fundus 3 = similar spots elsewhere in the fundus 4=Land2 5=1and3 6=2and3 Annex V-4 page 2l Appendix I Col s. 75-76 Colloid bodies, right and left eye (contd.) 7=land2and3 9 = 4s cols. 67-68 77-78 Choroiditis, right and left fundus O = absent I = lsolated pigment mass, the surroundinBs being normal 2 = orr€ patch of choroiditis 3 = more than one patch of choroiditis 4 = several irregularly placed pigment masses 5=2and4 6=3and4 9 = as cols. 67-68 79 Hour of skin biopsy O= skin biopsy taken between o7-o8 hrs. 1= skin biopsy taken between 08-09 hrs. 2= skin biopsy taken between 09-10 hrs. 3= skin biopsy taken between 10-11 hrs. 4= skin biopsy taken between I r-12 hrs. skin biopsy taken between 12-13 hrs. 6= skin biopsy taken between 13-r4 hrs. 7= skin biopsy taken between 14-15 hrs. 8= skin biopsy taken between r5-17 hrs. o- hour of biopsy unknown 80 Number of microfilariae seen in the R cornea O= none 1= Imf o_ 2-5 mf 3= 6-20 mf 4= 21-50 mf 5= 51-1OO mf 6= 101-5OO mf 7= 5OO + mf 9= as cols. 53-54 Annex \'-4 page 22 APPENDI\ 2 RANDOM SELECTION OF VILTAGES FOR EPIDEMTOI,OGICAL EVALI.IATION Based on data available in April 19?3t DAHOMEY Estimated population in Area 440 000 Persons to be surveyed: 1 800 I Minimum No. of I No. of persons No. of vrllages with to Endemrci ty clusters to be surveyed prevalence information be surveyed Sporadrc 5 I 300 Low 60 I 300 Med i um 6 2 600 lligh o 2 600 Villages selected bv Endemicity Endemicity Canton Vi I lage Population Sporadic Sonsoro Fedegui r 206 Kandr Thia 622 Low Kandi Kandi 6 388 Gogounou Gogounou 948 Medium Natitingou Kougnangou 6 041 Nat i t ingou Br rni 7 o34 Natitingou Perma 10 673 Natitingou Kotoponga 2 752 Further additrons will be made as more data become available. Annex V-4 page 23 Appendix 2 GHAt.IA Estimated Population in Area r 600 000 Persons to be surveyed: 4 800 Minimum No. of No. of villages with No. persons Endemicity clusters to of prevalence information to be surveyed be surveyed Sporadic 80 2 6@ low 156 3 900 Medium 69 5 I 500 High 31 6 I 800 Villages selected by Endemicity Endernicity District Vi 1 lage Population Sporadic Wa Tamina L L27 Wa Wogberi 153 Bui lsa Wiaga-Kpalinsa 200 Kassena Nankani Nyamia-Paga 837 [ow Tumu Sentia 305 Builsa Kazengsa 383 Tumu Nymetie (72(.j.) [,awra Suggo 493 Bui lsa Kadema-Senyansa 660 Tumu Timnie 229 Mediun Tumu Santisang 205 Lawra Gegenkpe 489 Bui lsa Bechamsi-Nanyens i 136 I-awra Tuopari 432 Bawku Kulumasa (s14) Bawku Danugu (514 ) Builsa Chiana-Asunia L 232 Bui lsa Kansarga-Luisa 599 Wa Yiziri 47L Wa Bielepong (514) High Fra-Fra Wubare 960 Tunu Sibele 450 Tunu Mangasan (500) Fra-Fra Dasang-Sekoti 175 Kassena-Nankani Kumbi lmiu 369 Kassena-Nankani Adognia 193 Tumu Pina 83 Tu.Eu Bas isan 2L5 Tunu Sawbellia 1 159 Builsa Chiana-Wurunia 449 Tumu Kwunchogaro (soo) Builsa Codembl isa 232 Annex V-4 page 24 Appendix 2 IVORY COAST Estimated Population in Area I OOO OOO Persons to be surveyed: 3 600 Minimun No. of No. of villages with No. of persons Endemicity clusters to to be surveyed prevalence information be surveyed Sporadic 141 2 600 Low 234 2 600 Medium 77 4 r 2o,0 High I7 4 I 200 Villages selected by EndemicitY Endemicity Canton Vi I lage Population Sporadic Dj imini Sarala (e82) M'Bengue Bougou 785 Dj imini Kagbonou (e82 ) Kiembara Namourgekaha 544 [,ow Komrorodougou Komrorodougou r 418 Nafana Niarana (676 ) Dj imini Tiepolo (676 ) Napie Lonakaha 227 Meditul Bouna Mazou (430) Tafire Kouroukouna 397 Pallaka Lanekaha 715 Dj imini Loniene (43O) Tombougou (430) Niarafolo Sepediokaha I r37 Mouhoulou Centre Tindikro (430) Mouhoulou Centre S ireba (430) Sinematiali Pediolokaha 462 High Bouna Niangdegeda (re7) Niarafo 1o Ferke-Sokoro 92 Bouna Rikoye (re?) Guiembe Tripoungo 256 Niarafolo Kissankaha 166 Bouna Vonkoro (1e7) Boron Bissidougou 88 Bouna Kiapere (1e7) Mouhoulou Centre Ouandegue (re?) Bouna Tibero (1e7) Boron Ouataradougou 256 Annex V-4 page 25 Appendi.x 2 MALI Estimated Population in Area r 400 000 Persons to be surveyed: 4 2o,0 Minimum No. of No. of villages with No. of persons Endemicity clusters to prevalence information to be surveyed be surveyed Sporadic 18 2 600 [,ow 87 2 600 Medium 35 5 I 500 High I 5 r 500 Villages selected by Endemicity Endemicity Arrondissement Vi 1 lage Population Sporadic Central Balazan Central Belefougou La Faya Dara Central Danka Low Fana Samogossoni 460 Beleko Kindjanoum 449 Fana Loutana 933 Mena Nionfalena 292 Medium Fana Nemougou t 743 Mena Ouadjana I49 Fana Bougoula r 300 La Faya La Faya (507) Mena Konossoro 74 Bougouni Kolasokouro (507) La Faya Kangare (so?) La Faya Goualafara (so7) Fana Diassague 401 Fana Faghor i bougou 509 Sikasso-Kadiolo Yatiale 295 Beleko Seylabougou lol Zantieboudougou Massima (507) Beleko Koloko 318 La Faya Goualala (so? ) High Beleko Sorogoro 287 Annex V-4 page 26 Appendrx 2 NIOER Estrmated Populati.on r-n Area: 60 000 Persons to be surveyed: I 800 Minimum No. of No. of vrllages with No. of persons Endeml.c i t y clusters to prevalence lnformation to be surveyed be surveyed Sporadrc 9 I 300 Low 22 I 300 Med i um I 2 600 l{igh o 2 600 Villages selected by Endemicity Endemici ty Area Vi I lage Population Sporadrc Foyer de Tamou Warkere 527 Foyer de Tamou Dolami 49L Low Foyer de Tamou Kare 262 Canton de Torodi Pobalauri (6e4 ) Medium Foyer de Tamou Tamou 704 Annex V-4 page 27 Appendix 2 UPPER VOLTA Estimated Population in Area 5 000 000 a Persons to be surveyed: 15 000 I Approximate Minimum No. of No. persons Endemici ty No. of villages with clusters to of to be surveyed prevalence information be surveyed Sporadic 2 352 8 2 400 Low I 067 8 2 400 Medium 283 t7 5 100 High 15 L7 5 1@ Villages selected by "average" Endemicity Population Endemici ty Cercle Canton Vi I lage Canton Vi 1 lage Sporadic Kombiss iri Doulougou No. 11 L9 822 Orodara Orodara No. 13 L5 677 Ouagadougou Bazoule No. 7 20 r77 Reo Didyz No. 13 42 0,68 Gaoua Lokosso No. 8 11 081 Kaya Boussouma No. 2 4L 4OL Koudougou Sabou No. ro 10 003 Kaya Kaya No. 42 4? 502 Barsalogho Piss i la No. 4 36 565 Bogande Coal la No. L4 35 113 Tougan Ressouly No. 27 42 000 Kaya Boussouna No. 26 41 401 Nouna Dokuy No. I LL ?4O Nouna Koloukan No. 5 3 956 Bobo-Dioulasso Karankasso No. I 4 088 Di6bougou Founzan No. I 7 508 Low Gaoua Boussera No. 8 4 942 Garangho Sanogho No.6 LT 249 Orodara Nanergue No. 13 16 566 Fada NrGourma Ponin-Yanga No.13 14 819 Manga Bere Siguinvousse 827 Orodara Taguara No. 3 20 295 Reo Reo No. 13 44 o'34 Kampti Midebdo No. 3 3 828 Kombiss iri Guirgho No. 3 10 155 Gaoua Iridiaka No. 3 4 7L8 Banfora Kareboroba No. I 21 015 Diapaga Gobnangou No.9 31 256 Gaoua Boussera No. 9 4 942 Kampti Boussoukoula No.3 2 946 Diapaga Gobnangou No. 22 31 256 Diapaga Gobnangou No. 14 31 256 Annex V-4 page 28 Appendix 2 Villages selected by "average" Endemicity (continued) Population a Endemicity Cercle Canton Vr I lage Canton Vi I lage a Medium Di6bougou Bapla No. 3 8 823 and Banfora Beregadougou No.7 Lt 972 High Di6bougou Koepere No.3 ll 919 Zabre Zabre Mande 333 Fada N'Gourma Pama No. 2 7 993 Caoua Batie-Nord No. 7 4 758 Banfora Beregadougou No. 13 LI 972 Di6bougou Di6bougou Sebeldougou <412) po po Pyiri 77 Zabre Zabre Ponga r o55 Banfora Beregadougou No. l6 LL 972 Gaoua Batie-Nord No. 5 4 758 Manga Binde Ipala 299 KaYa Kors imoro No.7 36 762 Zabre Zoaga Zame 730 Zabre Zabre Bass intore 72 Garangho Lenga No. 4 3 086 Banfora Baskomonos No.7 7 078 Po Guiaro Kolo 191 Kaya Korsimoro No. 5 36 ?62 Di6bougou Balpa No. 4 8 823 Kaya Korsimoro No. 20 36 762 Kaya Korsimoro No. 30 36 762 Kaya Korsimoro No. 24 36 762 Zabre Zoaga Dawega 1?O Kampt i Dankana No. 9 I 190 Banfora Baskomonos No. 8 7 o78 Di6bougou Koepere No. 7 I1 919 Kampt i Dankana No. 2 I 190 Kaya Korsimoro No. 18 36 762 Di6bougou Koepere No. I 11 919 Di6bougou Koepere No. lO 11 9r9 Zabre Youga Bourboko 934 Zabre Zabre Gonde Zabre 42r Banfora Beregadougou No. I LL 972 Di6bougou Koepere No. 5 11 919 Di6bougou Tiankoura No. I I 942 Kaya Kors imoro No. I 36 762 Banfora Beregadougou No.3 LT 972 Fada N'Gourma Pama No. 6 7 993 Banfora Baskomonos No. 15 7 078 a Di6bougou Tiankoura Balarkar (4L2) Zabre Zabre Gasgou r 776 Zabre Zourma Doumagou 82 Manga Manga Pyssi 565 Banfora [,oumana No. 12 20 620 Kaya Korsimoro No. 12 36 762 Banfora Loumana No. 16 20 620 Annex V-4 page 2v Appendix 2 Villages selected by "average" Endemicity (continued) Population Endemicity Cercle Canton Vi I lage l Canton Vi I lage Medium Zabre Youga Bougoure 275 and Gaoua Malba No. 12 I 369 High Manga Nobere Koakin 105 Di6bougou Zambo Pankuere (4r2) Gaoua Malba No. 10 8 369 Manga Binde Kai bo r 406 Banfora Diefoula No. 13 12 54r Garangho [-enga No. 5 3 086 Zabre Zabre Gnoungou It5 Banfora [,oumana No. 2O 20 62U^ Banfora Baskomonos No. 13 7 078 Banfora [,oumana No. I 20 620 Di6bougou Tiankoura Babiere <412) Po Po Coho 97 Po po Saoua 87 Po Po Ponkouyan I 219 Di6bougou Tiankoura No. I I 942 Zabre Zoaga Tabiss i 135 Kaya Korsinoro No.8 36 762 Banfora Diefoula No.7 L2 54L Banfora Beregadougou No. 19 LL 972 Banfora Beregadougou No. 18 LL 9?2 Po Po Mant iongo 66 Banfora Lournana No. 14 20 620 Banfora Beregadougou No.6 LL 972 Banfora Loumana No. 3 20 620 Di6bougou Bapla No. I 8 823 a