Onchocerciasis Control Programme [OCP] - Burkina Faso

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Folder Title: Onchocerciasis Control Programme [OCP] - Participating Countries -Burkina Faso - Devolution - Correspondence

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Dates: 01/01/1988 - 12/31/1992

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30303447R2005-018 Other#: 7 2187428Onchoceriasis Con:rol Programme OCP - Participating Countries - Burkina Faso -

Devolution - Correspondence

DFCT.jA SSIFMIID Devolution -Urepntm

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BURKINA FASOMINISTRY OF HEALTHAND SOCIAL WELFARE

GENERAL SECRETARI-AT

EPIDEMIOLOGICAL SURVEILLANCEAND VACCINATION DIRECTORATE

ONCHOCERCIASIS AND HUMAN TRYPANOSOMIASISSURVEILLANCE AND CONTROL IN BURKINA FASO

SEPTEMBER 1988

SUMMARY

The Onchocerciasis Control Programme (OCP) started its operations in BurkinaFaso in 1974. The present epidemiological situation is such that the disease'sresidual surveillance and control activities can, in the context of Devolution, beintegrated with those of the other communicable disease covered by the Ministry ofHealth and Social Welfare, particularly trypanosomiasis.

Before the beginning of vector control, onchocerciasis was a real public healthproblem, with a blindness rate of 10% in the first line villages, and an obstacle tosocioeconomic development. Today, the transmission has been interrupted in the wholeof the country except the small focus of Pendie. A mass ivermectin treatment campaign-has been conducted there (1988) and will be undertaken annually.

The epidemiological situation of trypanosomiasis is not yet well known but thefirst entomological and immuno-parasitological surveys show the presence of vectortsetse flies, trypanosomiasis patients and a considerable movement of populationsaround the watercourses, all these being factors favourable to the revival of formerfoci.

The onchocerciasis surveillance strategy will include the detection of newcases, by means of a vast basic skin snip survey, and the preparation of a detailedepidemiological map followed eventually by an ivermectin treatment which will have tolast for at least 15 years. One hundred and twenty indicator villages will beselected and regularly evaluated every three years.

As regards the trypanosomiasis surveillance strategy, it will also consist of anactive screening of the target populations using immunological tests, andparasitological examinations if necessary. Follow-up surveys will also be conducted.Patients will be treated at appropriate centres and vector control carried out by thevillagers using traps and screens impregnated with insecticide.

All these surveillance activities will be undertaken by the mobile teams basedin the provinces and supervised by a National Coordinator responsible to theEpidemiological Surveillance and Vaccinations Directorate.

To carry out these activities successfully, personnel training, strengthening ofexisting facilities and the assumption of responsibility for the functioning of theproject are necessary. Its cost is estimated at 599 475 320 (five hundred andninety-nine million four hundred and seventy-five thousand three hundred and twenty)CFA francs (US $ 1 978 466).

1.- INTRODUCTION

Burkina Faso has benefitted from the operations of the Onchocerciasis ControlProgramme since 1974 in the greater part of its territory.- It is at presentexperiencing an intense resettlement activity in the valleys of its principalwatercourses.

A Devolution Committee was set up by decree number 01l/MSP/CAB/SG/L dated 31January 1985.

This Committee has already prepared a provisional Devolution plan which wassubmitted to the Joint Programme Committee (JPC) in December 1985 in Geneva.

The epidemiological situation of onchocerciasis is such that the authoritiesconsider that the few residual surveillance and control activities can be integratedinto the Communicable Diseases (trypanosomiasis, schistosomiasis, malaria, etc.)surveillance activities.

This document will make it possible to make preparations in detail for theDevolution process and its implementation in the field; its integration and supportto primary health care and the identification of needs and necessary resources.

Since the start of the Onchocerciasis Control Programme, spectacular resultshave in fact been recorded in the control of onchocerciasis. Today, the transmissionhas been interrupted, the incidence is nil and the intensity of infection has fallendramatically. Stabilization and regression of eye lesions are established facts inthat part of the Programme area that falls within Burkina Faso, i.e., more than 84%of the national territory.

The country is, however, faced with the other vector diseases which lead toserious repercussions on public health and socioeconomic development. Since 4 August1983, the country has undertaken more resolutely to control these diseaseseffectively. This control falls within the framework of a policy of globaldevelopment.

A special emphasis is laid on the harnessing of the agricultural potential ofthe onchocerciasis protected zones so as to attain food self-sufficiency. In thiscontext, the Government is very particularly concerned with the control oftrypanosomiasis in the light of the massive resettlement of these fertile valleysstill under the menace of this scourge. There are control programmes for otherendemic diseases, especially schistosomiasis and malaria.

Considering the insufficiency of the human and material resources, in 1985 theMinistry of Health and Social Welfare created a service for the surveillance andcontrol of vector communicable diseases called Entomology Service.

The functions of the Service are:- listing of vector diseases necessitating the setting up of a control

programme;- preparation of control strategies;- coordination of all field activities;- data evaluation.

A special malaria research and control programme is currently being prepared aspart of the bilateral cooperation between Burkina Faso and Italy.

The team of the Entomology Service is made up of two Public Health MedicalOfficers who have specialized in medical and veterinary entomology, a pharmacist whohas also specialized in medical and veterinary entomology, two specialist nurse ida simple entomologist. In collaboration with two provincial health directorat thas since 1986 been implementing a human trypanosomiasis surveillance and contr,programme.

Two years after the implementation of the said programme and considering therecent data on the disease, particularly in the Comoe Province, it has provednecessary to bring it up to date, with a view to its revitalization and extension,and extend the surveillance activities to cover onchocerciasis as part of Devolution.

Many similarities exist, in fact between onchocerciasis and trypanosomiasis,particularly as regards the populations at risk, the zones at risk of infestation,the transmission by blood-sucking vectors whose bio-ecology is related to water and,finally, the epidemiological surveillance methods.

2. EPIDEMIOLOGICAL SITUATION

2.1. Present situation of Onchocerciasis in Burkina Faso

Epidemiological situation before the start of control.

Before the start of vector control in 1975, onchocerciasis was a very seriousPublic Health problem in Burkina Faso. It has been estimated that some 580,000persons were infected with O.volvulusl. No reliable estimates were available for thetotal number of blind due to onchocerciasis in the country, but detailedophthalmological surveys demonstrated that onchocercal blindness rates in first linevillages could be as high as 10% of the village population and close to 50% of t'population above the age of 50 years.

The most affected zones were the river valleys of the Nakanbe (White Volta), theNazinon (Red Volta), the Sissili, the Bougouriba, the Koulpeolgo, the Comoe and theLeraba, which contained some of the worst foci of endemic onchocerciasis in theworld. The disease was also an important obstacle to socio-economic development andprevented the resettlement of the severely underpopulated valleys of such rivers asthe Nakanbe and the Nazinon.

Epidemiological impact of vector control.

The OCP started vector control in 1975 and the impact of control has been welldocumented by extensive epidemiological surveys. Baseline surveys were done in 116villages and follow-up surveys have been done at intervals of 3-4 years in 88 ofthose villages. The results have shown that vector control has been extremelysuccessful in Burkina Faso. Out of 6,354 examined children, who were born in thesevillages since the start of control, only four were found to be infected against anexpected number of 583 infected children had there been no control. All fourchildren come from one village, Pendie, where a localized relapse of transmission hadoccurred, but no infected children were found in any of the other 87 villages.

Following the interruption of transmission by vector control the parasitereservoir started to die out naturally. This resulted in a dramatic decline in theintensity of infection, as measured by the Community Microfilarial Load (CMFL) whichhad decreased by more than 95% after 12 years of vector control. This was a veryimportant achievement because the severity of onchocercal disease is directly relatedto the intensity of infection, and the control of onchocerciasis as a disease ofPublic Health importance could therefore already be claimed after 10-12 years ocontrol in Burkina Faso.

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Report of the Mission for Preparatory Assistance to the Governments of Dahomey,Ghana, Ivory Coast, Togo and Upper Volta. UNDP/FAO/IBRD/WHO, Geneva, 1973.

As was expected, the prevalence of microfilariae in the skin took a longer timebefore- it started to decrease, but it is now clearly showing the accelerated declinewhich had been predicted by epidemiological models. Examples of this important trendare shown in figure 1 for villages from different river basins which had a very highpre-control intensity of infection.

Relapse of transmission and ivermectin treatment along the Dienkoa river.

The only exception to the excellent results of control which has been detectedto date concerns the stretch of the Dienkoa river around the village of Pendie. Notonly were four children detected with new infections, but the decrease in the CMFLand prevalence was also unsatisfactory and indicated a considerable level ofsuperinfection in the adult population. Extensive skin snip surveys in thesurrounding area, with particular attention to children born since the start ofcontrol, indicated similar problems in neighbouring villages, but the problemappeared to be fairly localized.

A retrospective analysis of the available data suggests that transmission mayhave relapsed between 1980 and 1985, and the epidemiological trends for this focusare believed to be some ten years out of phase with the rest of the country. Aspecial strategy will therefore have to be developed for long term control for thisparticular focus once larviciding will be interrupted in the surrounding area. It isfor this reason that the Pendie focus was selected as a priority area for a communitytrial of the potential of ivermectin for transmission control in a situation withrecrudescence of O.volvulus infection.

The first round of ivermectin treatment was given in April 1988, and involvedthe treatment of 1390 persons from 10 villages in the focus. The treatment coveragewas between 65% and 72% of the census population with the exception of the village ofPendie itself, where the coverage was only 54%. For the purpose of the trial,larviciding was interrupted during 5 months in 1987 and during the same period in1988, in order to enable the collection of extensive pre- and post-treatmententomological data on the level of transmission. The results of the impact ofmass-treatment on transmission are expected to be available early 1989. Irrespectiveof the outcome, ivermectin treatment will be continued on an annual basis in thisfocus in order to protect the infected population from the development of onchocercaldisease.

Predicted epidemiological trends and interruption of larviciding.

Though the disease is under full control in the rest of the country, theparasite reservoir has not yet been eliminated. However, as has been shown in figure1, this reservoir is dying out fast and it is predicted that it may reachinsignificant levels after some 15 years of control. At that stage the risk ofrecrudescence of infection and disease may be negligible even if the vector would beallowed to repopulate the breeding sites. The OCP plans therefore to interruptlarviciding in large parts of Burkina Faso and in similar areas in neighbouringcountries. However, before larviciding will be interrupted, extensiveepidemiological data will have to demonstrate that such a decision would bejustified.

2.2.- Present situation of Trypanosomiasis in Burkina Faso

Entomological and immuno-parasitological surveys have been carried out in theSissili, Boulkiemde, Comoe, Mouhoun and Nahouri provinces (1986 and 1987).

More than 60 localities located near forest galleries and presenting activitieslikely to favour the revival of former trypanosomiasis foci or the creation of newones were the subject of a sampling of a tsetse fly population in the surroundings,while blood samples were taken from the most exposed populations on Wattman paper forIndirect Immunofluorescence.

As regards entomology

Riverine tsetse flies have been caught regularly in the forest galleriesthe principal watercourses and their tributaries. The vector control team hasundertaken prospection along the Leraba and the Comoe in the Banfora, LoumnanaSoubaka, Dakoro and Niangoloko districts.

Tsetse fly vectors of sleeping sickness have been caught in the forest galleriesalong the watercourses. The two species encountered are Glossina palprs (58%) andGlossina Tachinoides (42%). The mean of the densities per trap per day is 14 withextremes of 2 flies/trap/day at Guindougouba and 52 flies/trap/day at Koudougou.

The surveys on the Bougouriba showed a predominance of G.Tachinoides withdensities of 27 flies/trap/day. On the Mouhoun, the presence of tsetse flies hasbeen reported with an epidemiological context favourable to man-tsetse fly contact.Another serie of surveys is necessary in order to be more specific about the extentof vectors along this watercourse whose fertile valleys are the theatre of very heavyinternal migrations.

As regards imunology

Following passive detections, immuno-parasitological surveys were conductedamong some of the exposed populations.

Some 15 000 persons were examined and blood samples taken from them forimmunofluorescence. After treatment at Muraz Centre in Bobo-Dioulassos, 33 seraproved positive, i.e., 0.22%.

Card Agglutination Tests for Trypanosomiasis (CATT) were made but difficultappeared during the handling of the CATT and did not permit its utilization inscreening.

The parasitological confirmation was made in the laboratory of the specializedcentres of Ouagadougou, Bobo-Dioulasso, Koudougou and Banfora.

In 1987, 37 patients were detected in this way and treated.

There has been an assiduous surveillance of the zones at risk in the ComoeProvince in 1988. This surveillance has made it possible to identify a localtransmission focus at Diarabakoko and its surroundings where seven cases weredetected between April and July 1988.

The conclusions of the different mission reports support one another andgenerally describe the same epidemiological situation, viz:

- a rapid and considerable resettlement of the lowlands of the watercourses,with forest galleries really harbouring tsetse fly species that are vectors ofsleeping sickness.

- an intense permanent human activity on the banks of these watercourses,thereby favouring man-tsetse fly contacts (market gardening, fishing, watering,washing, etc.).

- a constant internal migration from the north and central-east towards the w-stand south-west coupled with a seasonal external migration of young rural dwellerbetween these zones and Cite d'Ivoire, particularly towards areas known to be acsleeping sickness foci.

- the few patients detected are from provinces very much affected by migration.

2.3.- Epidemiological prospects of the two affections

The many programmes for the development of the valleys protected fromonchocerciasis create a considerable internal migration movement. This migrationtakes place in a north-east to south-west direction. The valleys concerned withthese movements are the Bougouriba, Mouhoun,Comoe and Sissili valleys (see map No.1).

The return of abundant rains has been recreating ecological conditionsfavourable for the development of flies that are vectors of sleeping sickness. Tothese factors should be added the return to the country of many migrant workers amongwhom more and more trypanosomiasis patients are detected.

The persistence of the reservoir of the human virus, the migration of populationsbetween the savanna zone and the forest zone, where the problem of forestonchocerciasis still remains, and finally the imminent cessation of larviciding areall factors favourable to a probable recrudescence of onchocerciasis if asurveillance strategy is not put in place rapidly.

3.- Main lines of the surveillance and control of Onchocerciasis andTrypanosomiasis

3.1.- Present state of the health system and resources for epidemiologicalsurveillance

Burkina Faso is a Sahelian country without access to the sea situated in theheart of West Africa. Its total surface area is 272 122 square km. Its population is8,200,000 inhabitants, i.e., a density of 30 inhabitants per square km.

The economic activities, which are mainly agricultural, provide the populationwith a per capita income of US $ 150 (1986). Burkina Faso is among the leastdeveloped countries.

The following are the demographic indices:

- Birth rate 46 per 1000 (1986)- Death rate 22 per 1000 (1985)- Child mortality rate 167 per 1000 (1986)- Natural growth rate 2.6%- Life expectancy at birth: 45 years (1986)

The problem of potable water supply is still serious.

1984: 35% of the population have safe water within 15 minutes'walk, 50% in urbanareas have taps (24% at home and 26% from public taps). In the rural areas the rateof coverage as compared to the objective of 10 litres per day per inhabitant is 70%,the distribution varying very much, however, in the field.

Environmental sanitation is the source of many communicable diseases. Therate of coverage in terms of latrines is 38% for urban areas and 5% for rural areas(1984).

The present health system is characterized by an insufficient coverage due, onthe one hand, to the inequal distribution of the already limited resources and, onthe other hand, to the quality of the inadequate communication network.

The organization chart of the Ministry which was recently restructured is asfollows:

- General Secretariat of the Minister- National Pharmaceutical Supply Corporation (SONAPHARM)- Red Cross- Health Services Technical Inspectorate- Health Services Development Project (PDSS)

Eight central technical directorates:

- Professional Training Directorate- Epidemiological Surveillance and Vaccinations Directorate- Workers Health Directorate- Studies and Planning Directorate- Family Health Directorate- Health Education and Sanitation Directorate- Medical Supply and Traditional Medicine Directorate.- Administrative and Financial Affairs Directorate

In addition to these central directorates, there are 30 Provincial HealthDirectorates.

esourc.s for the public health services

Health services are provided to the population according to a pyramidal networkmade up of:

- 6,592 Primary Health Posts (PHPs) at the village level (1988)- 167 dispensaries- 29 maternity homes without dispensary- 415 Health and Social Welfare Centres (HSWCs) for areas having 15,000 to

20,000 inhabitants- 59 medical centres (MCs) for populations ranging between 150,000 and 200,000

inhabitants- 6 Regional Hospitals (RHs)- 2 National Hospitals.

There is a quantitative and qualitative insufficiency of manpower. The healthpersonnel situation (1986) is far from the standards generally accepted and advocatedby WHO for the country's two decades of independence.

Costs of public health services

Analysis of the health budget in relation to the national budget, from 1980 to1985, shows that after having fluctuated between 5% and 6% of the national budget, itis on a slight increase. Since 1983, the percentages have moved from 7.4% of thenational budget in 1983 to 7.3% in 1984 and 7.8% in 1985. However, it should benoted that more than 80% of this budget is devoted to personnel salary payment. Thisbudget does not include external bilateral, multilateral and non-governmentalassistance.

The health policy of the Burkina Government is defined as follows: theachievement of the health coverage of the population according to a popular healthsystem titled: health for the people by the people.

The main lines are:

- health for all;- implementation of a maternal and child assistance and protection programme;- policy of immunization against communicable diseases by increasing vaccination

campaigns;- sensitization of the masses for the acquisition of hygienic habits- To attain the objectives defined by the Burkinabe authorities with a view to

health for all by the year 2000, Burkina has adopted the WHO strategy based onPrimary Health Care (PHC) by laying emphasis on educational and preventive activitiesand calling on individuals, families and communities to contribute to the healthservices provided to them.

Up to 1986, epidemiological surveillance in Burkina Faso was included in otherdirectorates and did not exist on its own. It was at first attached to theDirectorate of Expanded Programme on Immunization (EPI) and then to theEpidemiological Surveillance and Vaccinations Directorate (ESVD).

Functioning of the epidemiological surveillance

The epidemiological surveillance follows the pyramidal path according to theorganization chart of the health services.

Each health post has a register for daily consultations in which the nurserecords all the diagnoses for the day. At the end of the day he enters the diseasesunder epidemiological surveillance on a special form.

This form, called Official Letter Telegram (OLT), is weekly and has to be sentat the end of every week to the medical centre or regional hospital on which thehealth post depends.

From the medical centre or regional hospital, this form is sent to theProvincial Health Directorate. The Provincial Health Director summarizes all thereports from all the health centres in his province and forwards them to theEpidemiological Surveillance Directorate in the form of monthly reports. The Studiesand Planning Directorate (SPD) enters these data in the computer.

The weekly OLTs of the HSWCs and MCs are forwarded to the Provincial HealthDirectorate which in turn, after processing them, sends them to the EpidemiologicalSurveillance and Vaccinations Directorate (ESVD).

However, because of dispatch difficulties, the OLTs are often very late inarriving.

When there is an epidemic in a locality, the responsible medical officer isinformed rapidly. Often it is the health worker who goes by whatever means possibleto inform his immediate superior.

The medical officer responsible for the zone concerned informs his ProvincialDirector who also informs the Epidemiological Surveillance and VaccinationsDirectorate. But before receiving directives which are often long in coming becauseof communication difficulties, he sets about containing the epidemic throughintensive treatments, isolation of patients and vaccination of the populations.

Surveillance resources

There is no special personnel for the epidemiological surveillance. All theworkers of the health centres participate in this surveillance and it can even besaid that the population itself participates since very often the health services arealerted by some of the people having seen anomalies as compared to what they are usedto seeing. The participation of traditional healers and the TerritorialAdministration services in the surveillance should not be forgotten.

Less than 10% of the health budget is devoted to Epidemiological Surveillance.The budget of the Five-Year Development Plan (1986-1990) estimated at 19 900 millionCFA francs has earmarked 1,600 million CFA francs for the control of the majorendemic diseases.

It should, however, be noted that the financing of this plan depends greatly onexternal aid mainly from France, Federal Republic of Germany, the Netherlands, theUnited States of America, Italy, Canada, WHO, UNDP, EEC, UNICEF, the World Bank andthe African Development Bank.

To protect the achievements of the Onchocerciasis Control Programme in thefertile valleys where onchocerciasis and trypanosomiasis are at their lowestprevalence but the epidemiological context is favourable to serious recrudescences,the Ministry of Health and Social Welfare intends to carry out a specialonchocerciasis and trypanosomiasis surveillance and control programme with theprospects of integration of other vector-transmitted diseases.

This is why the two years of field work have led us to review thetrypanosomiasis surveillance and control methods and strategy in a more realistic andmore effective framework which should be integrated with onchocerciasis surveillance.

Adjustments and modifications have to be made as regards:

- zones to be monitored- human resources- material resources- execution

The main objectives of this programme are:

(1) to prevent the appearance of human trypanosomiasis foci;(2) to maintain the cessation of onchocerciasis transmission and control

onchocerciasis infection.

To attain these objectives, in addition to the Boulkiemde and Comoe provinces,it has become urgent and necessary to extend the surveillance network to thefollowing provinces: Boulgou, Hbuet, Kenedougou, Mouhoun, Kossi, Bougouriba, Sourouand Poni. An effective surveillance of these provinces calls for the setting up andequipment of three additional basic teams at Bobo-Dioulasso, Dedougou and Tenkodogorespectively.

3.2.- Onchocerciasis surveillance strategy

The need for surveillance after the interruption of larviciding

Onchocerciasis is no longer a Public Health problem in Burkina Faso and the lastadult worms are rapidly dying out. It is predicted that the parasite reservoir willbe virtually eliminated in most of the country by 1990 and that the risk ofrecrudescence of onchocerciasis infection and disease will then be minimal. The OCPplans to stop larviciding in large parts of Burkina Faso in 1990 if the prevalence ofinfection continues to fall as predicted by epidemiological models.

The interruption of larviciding will result in the return of the vector in veryhigh densities and the possibility of localized relapses of transmission cancertainly not be ignored. It is thus imperative to establish a surveillance andintervention system which has as objective to detect and counteract any recrude, eof onchocerciasis infection and disease.

Epidemiological surveillance and ivermectin treatment

Recrudescence of onchocerciasis infection will initially be slow and associated

with low transmission levels. Entomological methods are not appropriate for thedetection of such low levels of transmission because they would involve thedissection of an impossibly large number of flies. Surveillance will therefore bebased on epidemiological methods only. The different surveillance and interventionactivities which constitute the devolution of onchocerciasis control in Burkina Fasoare listed below in sequential order.

Detection of new infections

Initially, the major activity will be epidemiological surveillance with asobjective to assess if there has been a localized relapse of transmission. Theindicator of such a relapse will be the presence of new infections as evidenced bypositive skin snips in persons who were previously skin snip negative. This type ofsurveillance will be based on skin snip surveys in the population of about 120indicator villages who will be followed up and examined at regular intervals of 3years. These indicator villages are first line villages which represent all riverbasins with potential breeding sites in the country. The final selection of theindicator villages will be made in close collaboration with the OCP.

Detailed epidemiological mapping of foci with new infections

Wherever new infections are detected, the extent and the seriousness of theproblem in the area concerned will need to be determined. Extensive skin snipsurveys may have to be undertaken in the other settlements around the indicatorvillage in order to obtain a detailed epidemiological map as an essential basis fordecision-making on possible interventions.

Decision on intervention

Following the detection of new infections and the epidemiological mapping of theproblem, it has to be decided if there exists a serious risk of recrudescence ofinfection and disease, and if the situation requires and warrants intervention. Thisdecision will be very difficult and no clear guidelines are yet available. However,ongoing studies in the OCP are expected to provide some essential information in thisrespect.

Intervention by mass ivermectin treatment

One thing is certain: if localized intervention is needed in an area where thereis a serious risk of recrudescence of onchocerciasis, then it will have to beintervention by mass ivermectin treatment because focal larviciding will not be arealistic alternative. Community trials have shown that ivermectin is sufficientlysafe for use in mass treatment provided adequate monitoring of possible adversereactions is assured. The drug will have to be distributed at least annually to thetarget population. The aim in recrudescence control by mass ivermectin treatment isinitially to prevent the recrudescence of the infection by bringing transmissionagain under control, and this implies mass-treatment for a minimum of 15 years.

Evaluation of intervention

It will be vital to evaluate if recrudescence has been brought under control orif the intervention strategy needs to be modified. This evaluation will also bebased on longitudinal skin snip surveys.

Technical guidelines

Skin snip surveys and ivermectin treatment

Only two types of field work will be undertaken, i.e. skin snip surveys and masstreatment with ivermectin. The techniques involved in skin snip surveys are wellknown and have been used and improved by the OCP for more than a decade. Thecommunity trials of ivermectin in the OCP have enabled the development and testing ofprocedures for mass distribution of ivermectin and monitoring of adverse reactionsfollowing treatment. Detailed technical -guidelines for these two field activitiescan be found in two manuals which the OCP recently developed for the purpose ofdevolution.

Data processing and analysis

The evaluation of the incidence of new infections requires a longitudinalanalysis of the skin snip data. It will be necessary to keep accurate individualrecords and to maintain a linked data base system. It has been decided to use therecord forms and the computerised data processing and analysis systems which havebeen developed by the OCP. This system will ensure rapid routine analysis of thedata and full compatibility with the data base system of the OCP. Implementation ofthe system, training in its operation and backup support will be provided by OCPstaff.

3.3.- Trypanosomiasis surveillance strategy

The Central Coordination Office, which hag the required competence (threeMedical-Officer or Pharmacist Entomologists with experience in trypanosomiasiscontrol) and the teaching aids (laboratory, demonstration materials) intends to nor retrain the personnel of the basic teams by receiving them in Ouagadougou bygroups of four for a month.

There will be short seminars for the personnel of the other health centres intheir provinces.

At the end of these seminars, a list of villages where there will be a closerepidemiological and entomological surveillance will be given to the nursesresponsible for these villages as well as posters and manuals to be used by theCommunity Health Workers so that as soon as they return they could start raising theawareness of the populations to the problem of trypanosomiasis.

The methodolosv adopted is the screening according to the two-phase strategy,treatment of patients and vector control.

The two-phase strategy consist of an initial phase devoted to the systematicscreening of the whole population of certain particularly sensitive zones.

It is then an active screening: the whole population is subjected to screeningimmunological tests, parasitological examinations being carried out on only thosesuspected. When this "combing" phase is finished then comes the:

Second phase: epidemiological surveillance which may take two forms depending onthe results obtained previously:

- either a simple surveillance, surveys being conducted when a new case screpnedpassively is reported.

- or a surveillance strengthened by regular visits to the villages which duringthe prospections presented a considerable number of new cases. The frequency ofthese visits will be adapted to constraints regarding the surveillance of the othercommunicable diseases.

The whole field work will be carried out by the basic-mobile teams havingequipment and credits necessary for their operation, and thereby in a position tocarry out the surveys to be entrusted to them under the best conditions. During thesystematic screening phase, the mobile teams will be utilized full-time for a more orless long period depending on the populations concerned.

Techniques to be applied

Immunological techniques

Card Agglutination Test For Trypanosomiasis (CATT) will be used only in thepermanent centres. Indirect immunofluorescence will be utilized for mass surveys.It enables a small team to examine many people within a short time.

Parasitological techniques:they consist of:

- evidence of parasites in lymph node fluid obtained from lymph glands.- search for trypanosomes in the blood by passage through the ion exchanger

columns.These techniques are practically up to date and used without difficulty in the

field; if necessary they have to be repeated several days.

Vector control techniques:Impregnated screens and traps will be used selectively at places where the

chance of man-vector contact is maximum. The period for the installation of thetraps or screens will preferably be the dry season when tsetse fly populationsnaturally decrease much and are confined to limited zones. The insecticide selectedfor the impregnations is deltamethrin.

The village health committee will be taught the insecticide impregnationtechnique and the installation of traps or screens at strategic places. The firstbatch of traps and screens will be provided free of charge. The maintenance andreplacement of the equipment for the following years will be their responsibilitywith the exception of the insecticide which will be provided regularly to them.

The sensitization of the pbpulations will be supported by the officialinformation organs (press, radio, television), billboards, posters and publicawareness days.

The role of the basic teams in the trypanosomiasis and onchocerciasis surveillancesystem

For trypanosomiasis, emphasis will mainly be laid on the generalization of thesystematic screening through blood samples on Wattman paper for indirectimmunofluorescence, both in mass campaigns and for all clinical suspects and allthose who come from foreign countries. This screening will be made in the Health andSocial Welfare Centres and in the peripheral dispensaries. The medical centres ofKoudougou Banfora, Bobo-Dioulasso, Dedougou, Ouagadougou and Tenkodogo, which areequipped with a laboratory and a hospitalization unit, will house the basic teamsand treat the detected patients. These hospitals will therefore be specializedregional centres (SRCs) for the control of human trypanosomiasis and will extendtheir specific trypanosomiasis control activities to the other provinces, in harmonywith the Provincial Directors of Health concerned. The duties of the basic teamswill be the following:

- In the SRCs, the basic team will lend support to the existing healthfacilities in the screening of suspects referred to the SRC, the collection andforwarding of preparations to the Muraz Centre for the follow-up of thesepreparations on ad hoc forms.

The team will also help the nurse responsible for the treatment and examinationof patients.

In agreement with the National Coordinator and the Provincial Director of ch(PDH), each team will have to establish an annual programme of survey missions to thezones selected for regular onchocerciasis and trypanosomiasis surveillance.

- A team may also be requested by a Provincial Director of Health, or oninstructions from the National Coordinator, to undertake certain surveys ifnecessary.

- The team leader will be answerable to the National Coordinator and theProvincial Director of Health of the Specialized Regional Centre for the quality andregularity of the technical reports to be sent to the coordination office everymonth.

The National Coordinator is responsible for the technical supervision of theteams and will maintain close contact with the Provincial Directors of Health so asto harmonize the work of the teams.

The supply of specific drugs, screening equipment and things necessary for thefunctioning of the project will be ensured by the Coordinator under the directresponsibility of the Provincial Director of Health on whom the specialized regionalcentre depends. The Provincial Directors of Health concerned will have to providejustification, every three months, for the expenses made, the utilization ofrenewable items and fuel.

For onchocerciasis, four (4) teams will be set up from those for trypanosomiasisand put under four appropriate Provincial Health Directorates (PHDs). Each tear '1undertake the screening and possibly Ivermectin treatment and be composed of a(team leader), a census clerk, a laboratory technician, a driver and if necessary alabourer.

The teams will lend support to the nurse in charge of the Health and SocialWelfare Centre (HSWC) and the village health worker (VHW) engaged in the passivesurveillance.

The surveillance and treatment reports will have to be prepared in accordancewith the directives contained in the manuals.

Technical supervision of the teams will be the responsibility of the NationalCoordinator while the administrative supervision will be under the ProvincialDirector of Health on whom the team depends.

4.- IDENTIFICATION OF RESOURCES AND EVALUATION OF THE COST OF THE PROGRAMME

4.1.- Personnel

To carry out the Onchocerciasis and Trypanosomiasis surveillance and controlprogramme successfully, the Ministry of Health and Social Welfare will have recourseto national abilities with a view to the strengthening of the EpidemiologicalSurveillance and Vaccinations Directorate and the Central Coordination Office and thetraining of the six basic teams.

4.2.- Material resources

The strengthening of the surveillance of the initial zone (Comoe and Boulk.and the extension of the activities to other provinces call for the procurement orvehicles, technical equipment, trek equipment and an increase in operating costs (seedetails in the chapter "Evaluation of costs of the Programme").

4.3.- The budget of the Programme.

(See -detailed cost in chap. V.)

4.3.1.- Investments

.Strenghtening and equipment of the centralcoordination office.................. 198,252,000

.Vhicles..................--.......... 32,500,000

.Technical equipment................... 18,815,364

.Vector control equipment-.............. 29,100,000

.Trek equipment..............-......... 3,475,200

. Training-public awareness............ 7,000,000Sub-total-.......................... 289,142,564

4.3.2. Recurrent expenditure

. Maintenace - Repair ................. 15,000,000. Fuel, Lubricants .................... 26,310,000

Drugs...............-- - - ........... 36,925,000Reagents and laboratory supplies.... 11,400,000

. Per diem..... ...---.. ......... 164,700,000Office supplies and others-........ 1,500,000

Sub- total- -....................... 255,835,000

TOTAL : Investments + Functioning 289,142,564+ 255,835,000

544,977,564 F CFA

10 % for contingencies............................ 54,497,756

Total :

Investment + functioning + contingencies ........ 599,475,320 F CFA

- i.e. Five hundred and ninety-nine million four hundred and seventy-fivethousand three hundred and twenty CFA francs (US $ 1,978,466)

5.-DESCRIPTIVE ESTIMATE OF COST OF PROGRAMME FOR FIVE (5) YEARS

5.1. Investments

--------------------------------- ---------------------------------------Designation Quantity Allocation Unit price Total (CFA) Observa.on

Duty free----------------------------------------------- ---------------------------------

5.1.1. Strengthening and Equipment of central Coordination Office

Construction E.S.V.D. OUAGA --- 160,000,000 1990

Equipment OUAGA --- 32,000,000 1990

Computer +SoftwareStabiliser 2 3,126,000 6,252,000

Sub-total 198,252,000

5.1.2. VMhicles

Toyota PICKUP 1 Coordination 4,000,000 4,000,000 1990

Toyota 3 Bobo-DioulassoLAND-CRUISER and accessories Dadougou

Tenkodogo 8,000,000 24,000,000

Moto-Cross 2 Entomo-team 1,000,000 2,000,000

Motor YAMAHA 100 LUX5 Banfora

Bobo-Dioulasso 1990D4dougouTenkodogoKoudougou 500,000 2,500,000 1990

Sub-total 32,500,000

Designation Quantity Allocation Unit price Total (CFA) Observation

-------------------------------------------------------------------------

5.1.3. Technical equipment for the six teams

Holth's punch 4 x 6 Ouaga 73,346 1,760,304

Slices 120 x 6 Koudougou 1,990 1,432,800 1989-90

Eppendorf pipette 2 x 6 Bobo 48,025 576,300

Lancets 2 x 6 Banfora 31,500 378,000

Microtiter plate 20 x 6 D6dougou 14,620 1,754,400

Curved scissors 2 x 6 Tenkodogo 1,200 14,400

Straight scissors 2 x 6 1,150 13,800

Kocker punch 2 x 6 620 7,440

Rectangular plates 4 x 6 6,200 148,800

Haricot plates 2 x 6 310 3,720

Mechanical scale 6 15,000 90,000

Tensiometer 6 16,500 99,000

M5 loupe 2 x 6 310,000 3,720,000

EDAK Trunk 6 19,400 116,400

Binocularmicroscope 2 x 3 Bobo 600,000 3,600,000

Centrifuge forcolumns 2 x 3 D~dougou 500,000 3,000,000

Tenkodogo

Stirring rod 2 x 3 150,000 900,000

Yamaha E.T. 500generator 3 200,000 600,000

Gas/electricfridge 3 200,000 600,000


5.1.4. Vector control

-------------------------------------------------------------------------------Designation Quantity Allocation Unit price Total (CFA) Observa- r

------------------------------------------------------------------------

Tsetse fly traps 1,500 Z,000 7,500,000

Screens 5,000 1,500 7,500,000

Accessories (bar-

rels,boots,gloves) 80,000

Seats 20,000

Insecticides(Deltamethrine) (4 impregnations per year x 5 years)

100 x 4 7,000 14,000,000


5.1.5. Trek equipment

Camp bed and sleeping equipment6 x 6 6 teams 50,000 1,800,000 1989-90

Folding tables 4 x 6 20,350 488,400

Chairs 8 x 6 7,250 348,000

Screw stool 2 x 6 29,900 358,800

Cooking equipment

6 80,000 480,000

Sub-total 3,475,200

5.1.6. Training, retraining and sensitization

Training of nurses 30 50,000 1,500,000

Seminars inthe provinces 10 x 2 200,000 4,000,000

Public awareness and preparationof manuals 1,500,000

Sub-total 7,000,000

RECAPITULATION OF INVESTMENTS

Strengthening and equipment of Coordination office 198,252,000

Vehicles 32,500,000

Technical equipment 18,815,364

Vector control equipment 29,100,000

Trek equipment 3,475,200

Training-retraining-awareness campaign 7,000,000

TOTAL 289,142,564

5.2. RECURRENT EXPENDITURE

-------------------------------------------------------------------------------Designation Quantity Allocation Unit price Total (CFA) Observation

-------------------------------------------------------------------------------

5.2.1. Maintenance and repair of generators and vehicles

6 x 5 years 6 teams 500,000 15,000,000

5.2.2. Fuel and lubricants

Fuel 3,500 1 x 6 x 5 years 232 24,360,000

Lubricants 100 1 x 6 x 5 years 650 1,950,000


5.2.3. Drugs

Ivermectin treatment5 years 300,000 15,000,000

Emergency kit

6 x 5 years 150,000 4,500,000

Treatment of trypanosomiasis patients5 years 3,485,000 17,425,000


5.2.4. Reagents and laboratory accessories

CATT and Immuno- 6 x 5 years 300,000 9,000,000fluorence

Filtration columns100 x 6 x 3 300 900,000

Petty lab. equipment6 x 5 50,000 1,500,000


5.2.5. Per-diem

Basic teams 6 x 6 x 120d x 5 years 7,000 151,200,000

Central Coordination Office3 x 90d x 5 years 10,000 13,500,000

Sub-total 164,700,000

5.2.6. Office supplies and others

6 x 5 years 50,000 1,500,000

RECAPITULATION OF RECURRENT EXPENDITURE

1. Maintenance and repair (vehicles and generators) 15,000,000

2. Fuel and lubricants 26,310,000

3. Drugs 36,925,000

4. Reagents and laboratory accessories 11,400,000

5. Per diem 164,700,000

6. Office supplies and others 1,500,000

TOTAL 255,835,000

TOTAL : Investments + functioning 289,142,564+ 255,835,000

544,977,564

10 % for contingencies 54,497,756

Grand totalInvestments + functioning + contingencies 599,475,320

i.e. Five hundred and ninety-nine million four hundred and seventy-fivethousand three hundred and twenty CFA francs (US S 1,978,466)

6.- PROVISIONAL TIMETABLE

The long-term objective of the programme is for the basic teams to beoperational at the maintenance phase for the monitoring of othercommunicable diseases including onchocerciasis whose surveillance is nowthe responsibility of Burkina Faso in the context of Devolution.

An adequate retraining of the personnel of the basic teams and themobile teams of the Expanded Programme on Immunization would be desirablefor the setting up of these multi-disciplinary teams for the surveillanceof communicable diseases (onchocerciasis, trypanosimiasis,schistosomiasis, dracunculosis, malaria, etc)

ACTIVITY YEAR

Trainint 89 90 91 92 93

- 6:Epidemiological-surveillance teams(with OCP/EPI Coordination

- Community healthworkers (by nationalteam, COORD and OCP/EPI)

- Laboratory assistants ---HSWC workers

Installation of equipment -

Field activities

- Selection of sitefor entomo. surveillance -

- Start of entomo.surveillance:

Trypano.Oncho. --------

- Start of epidemiologicalevaluation

Trypano.Oncho. --------

- Start of screening --

Evaluation:

Carte n* I r- - - 0 50 lookm

BURKINA FASO -- P l'OUDALAN

PHENOMENE MIGRATOIRE \.. 7Gorom-Gorom

P. do soU/M >bo 500 a 1000 migrants . -

D)Ibo DoriI000 a 2000 migrants ( Pdu ATr&W4 G

> 2000migrants -. ... do SENO

Bonforo Base dune iquipe de II Quahlg9o - do 11 du'----

surveillance BAN .jA

r...,,, ' Kongou"JIS NN A - NAE-\KflUTu/NGA TEGR/

- k aya GNAGNA

V-. de //RM6A)R&/o KOSS/ / u N. Zinlare - jousP do /aXSS

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0/ P.dINHei P O /a I -- 4 %- B R/ G H A N A ITO G 0

r I

P d /a CdOE Gaoua Migrations internes rurales des hommes par province d origine et province de destination.. P~du POL/N/ (INSD Recencement 1975)

C O T E D' I V OI R E

Carte n* 2 -- 50 100k~~0 50 lOOkm

[Ca r

p

nBURKINA FASO

ZONE PROTEGEE DE L'ONCHOCERCOSE Qoram Goroi

Zone d' *tud*

Zone d'intervention do I'AAVV 4DJIbo-----Limite d'Stat

G---Limits do province

9 Chef lieu do province eU

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oziniao~idugowASAO sou

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Tea dog-dengo

BoDioulasso

Oo d.,. bo.gou 0 Li 0 E N I N

G H A N A / T - G- Val I e de la Kompieng a

Vallie de la Bougaou ri b a

Val li~~e de 1 0' Valle' du Mouhoun V:4eduNkabV L i r a b d elll d ule d u ok n b

Le'rbo ee duPoniVallee du NazinonVallee de I a r A.Como e' V a llie d! 10 issili

S C 0 T E D'l 1 1R E

Carte n* 3

B U R K A FA S-

- -

BURKINAT FAO 50 100 kmTRYPANOSOMIASE.. ~

Taux d'Incidence Pour w00000habitants en 1970

15

0 de 16a 10 I

>1 ~< 10 Is3

32- 7 35

27 9 36

4 33

25

6\

Ij8 9

2 9 2 14

- 4r 4 E N I N

G H A N A TO G 0

I Soubss 0arg 19 Soudouou 28Bonfora 37 Dori

0,~~ ~ 4pnOuagadougou 12 Tenkodogo 21 Lio 30 oundi s 39 Goudrcy.13 Dio'bougou 22 Ri o 31 39oar G0okoc

6 Zorgho 32 Barsaogko 41 Mangoa15 Djibo 24 Didougou 33 Boulso 42 PoC E DI iRE Dogondi' 16 Ouoheqouyo 25No""o 34 Kaya 4 3 Tlisb'ilDialpago 17 Siguenego 26 Tama 35 Xongoussf 4 4 Zob'9 Fado N'Gourmo IS Titoo 2 7 Tougan 3 6Pts s ifa r

Carte no 4

BURKINA-FASO

EPIDEMIOLOGIE DES SCHISTOSOMIASES

+ Presence deSchistosomo hemotobium0 100kmDonnes chiffries our Schistosoma hommokobium

(Privalence globale pour la region)S.Bvuis glohwvus

aui~ngs jOUsSeoumef

Bu//nus guernel 8u/inus sp

0 8u/imus /runca/us

@ @ .o~.....S8Wings umbi/icotus

4 0 @@ @8

A 8u/inws forsko/i

d Ou/ings senega/en s/s a " *" e"O

X Presence de Shis/osoma monsoni

' Donnese chiffr's sur Smonsoni 0 carts17 @cajI" 7(Prevalence globole pour la region) o a I

8 8,ompho/ar/a peifferi4

Bt8ol,6h a/ria sp. M C

.0 a

BURKINA FASO

MINISTERE DE LA SANTEET DE L'ACTION SOCIALE

SECRETARIAT GENERAL

DIREG1TO DI LA SURVEILLANCEEPIDEKOLOGIQUE I DM VACCINATIONS

PROGRAMME DE SURVEILLANCE ET DE LUTTECONTRE L'ONCHOCERCOSE ET LA TRYPANOSOMIASE HUMAINE

AU BURKINA FASO

SEPTEMRS 1988

Le Programme de Lutte contre l'Onchoccrcosc (OCP) a d6buti ses uperations au

Burkina Faso depuis 1974 et la situation 6pidemiologique actuclile eat telle que lea

activites r6siduelles dc surveillance e de contrzle de cette affection dans le cadre

de la d6volution peuvent tre integr6es h cellos des autres maladies transmissibles

prises en charge par le Ministere do la Sant &i du 1'Action sociale,particulierement la trypanosomiase.

Avant de debut de Ia lutte antivectorielle, l'onchocercose constituait un r4elproblbme de sant6 publique avec un taux de c6cit gal & 10 % dans lee village depremilre ligne et aussi une entrave au d4veloppement socio-6conomique. Aujourd'huiIa transmission eat interrompue dans l'cnscmblc du pays dauf au niveau du petit foyer

de Pendi6 ; aussi un essai dc traitement & l'ivermectinc on campagne de masse y a t6

Instaur4 en 1988, traitement qui devra tre repria anuuellcmcnt.

La situation 6pid6miologique de la trypanosomiase n'sL pas encore bien cern6cmais lea prenibres enqu~tes entomologiques t immuno-parasitologiques montrent la

prsence de glossines vectrices, de malades et un important mouvement dc populationsaux abords des cours d'eau, facteurs favorables au reveil d'ancicnu foyers.

La strategie de surveillance de l'onchocercose comprendra la d6tection dc

nouveaux cas par une vaste enquete de base gr&ce & Ii biopsie cutan6c,

1'6tablissement d'une carte 6pid6miologIque d4taill~e, suivis Wventuellement d'un

traitement par 1'ivermewtine, traitement qui dcvra tre admiitr& pendant au moins15 ans. 120 villages indicateurs seront m~lectionne ct suivis r4gulibrement tous

lea 3 ans.

Quant & la stratsgie-de surveillance de Ia trypanosomiase, elle consistera A undepistage actif des populations-ciblcs utilisant les tests immunologiques, leaexamens parasitologiques en cas dc ncessit. Les enqu~tcs de suivi seront aussi

men6es. Les malades seront trait~s dans des centres appropri6s et la lutte

antivectorielle entieprise par les villageois & l'aidc dc piegeu et d'6crans

impregnis d'insecticides.

Lensemble de ces activitsa de surveillance sera assur6 par des 6quipes mobiles

basses au nivean des provinces et supervisaes par le Coordoanateur National relevant

de Ia Direction de la Surveillance Epid6miologique et des Vaccinations.

Pour mener & bien cen activit6s, la formation du personnel, le renforcement des

infrastructures existantes, la prise en charge du fonctionnement s'avbrentindispensables. Le coka du projct est esti6 & 599.475.320 (cinq cent quatre vingtdix-neuf millions quatre cent soixante-quinze mille trois cent vingt) francs CFA(US $ 1.978.466).

1. INTRODUCTION

Le Burkina Faso qui a b~ndficig des op6raitons du Programme de lutte contre I'Onchocercose depuis 1974 dans I'immense majorit6 de son territoire connaltactuellement une intense activit6 de repeuplement dans Ics vall6es de sea grandscours d'cau.

Un Comit6 de d6volution a 6t6 mis sur pied par arr~te num6ro 011/MSP/CAB/SG/L du31-01 -85.

Ce Comit6 a d6j& 6labor6 un plan provisuire de D6volution, qui a 6t4 soumis auComit6 Conjoint du Programme (CC11) en d4cembre 1985 i Genhve.

La situation 4pidemiologique de l'onchocercose est telle, que lee autorit~sestiment que lea quelques activit6s r4siduelles de surveillance et de contr6lepeuvent ftre int6gr4em aux activites de surveillance des maladies transmissibles(trypanosomiase, schistosomiase, paludisme, etc... ).

Le pr6sent document pcrmettra de preparer en d6tail le procresus de laDevolution et sa mise en oeuvre sur le terrain ; son integration et son appui auxsoins de santi primaires et l'identification des besoins et. des ressourcesnacessaires.

En effet depuis le d4but du Programme de Lutte contrc l'Onchocercose, desresultats spectaculaires ont 4t4 enregistres dans le domaine du contrale de Iamaladie onchocerquienne. Aujourd'hui la transmission eat interrompue, l'incidenceest nulle, l'intensite de l'infection eat en baisse spectaculaire. La stabilisationet la r6gression des 16sion* oculaires sont acquises (tans l'aire du Programme situdeau Burkina Faso, soit plus de 84 % du territoire national.

Le pays demeure cependant uonfront4 aux autres maladies A vecteurs, maladies quientralnent de graves r6percussions sur ]a sant4 publique et le d~veloppementeconomique et social. Depuis le 4 aoat 1983, le pays s'est engage davantage Acontr8ler efficacement ces maladies. Cette lutte s'inscrit dans le cadre d'unepolitique de d6vcloppement global.

Un accent particulier est mis sur la maltrise du potentiel agro-pastoral deszones liberes de l'onchocercose, ceci pour une aut.osuffisance alimentaire. Dans cecontexte, le GouvernemenL so pr4occupe tout particulierement du contr6le de latrypanosomiase au regard du repeuplement massif de ces vallbes fertiles, encore sousla menace de ce flau. D'attres end4mies font aussi l'objet de programme decontr6le, notamment la schistosomiase et le paludisme.

Compte tenu de l'insuffiSance des ressourccs humaines et mat4riellcs, leMinistere de la Sant6 et de I'Action sociale a cr66 en 1985 un service desurveillance et do Lutte contre les maladies transuisibles par vecteurs appe]6Service Entomologie.

Lee attributions du dit service sont les suivantes

- recensement des maladies & vecteuru n6cessitaht la mise sur pied d'unprogramme de contr8le,- 6laboration des stratgies de lutte,- coordination de toutes les activites sur le terrain,- 6valuation des donn~es.

Un programme p6cial de recherche et. de lutte contre le paludism etactuellement en cours d'1aboration dans le cadre de la Copdration beilat6raleBurkina-Italie.

L'6quipe du service entumologie est composic de 2 m6decins do sant6 publique

sp4cialis~s en entomologie medicale et vt6rinairet, d'un p)harmacien 6galementLsp6cialis6 en enLomologie madicale et vntArinaire, de 2 infirmiers sp~cialiaes etd'un entomologiste pur. Depuis 1986 elle assure, en collaboration avec deuxdirections provinciales do la sant6, la mise en oeuvre d'un programme de surveillance

et de lutte contre Ia trypanosomiase humaine.

Deux ans apres la mine en oeuvre du dit programme et compte tetu des donn6es

r4centes sur ]a maladic, notamment dans la Province do la Como6, il s'avbre

indispensable de le r~actuiliser en vue de sa redynamisation et de son extension, etd'6tendre lea activit6s de surveillance A l'onchocercose dans le cadre de laD6volution.

En effet de nombreuses similitudes existent entre l'onchocercose et latrypanosomiase : particulierement en ce qui concerne Ics populations A risque, leszones A risque d'infetation, la transmission par des vecteurs h4matophages dont labio-Acologie est liee & l'eau et enfin les methodes de surveillance lpidomiologique.

2. SITUATION EPIDEMIOLOGIQUE

2.1. Situation actuelle de l'onchocercose au Burkina Faso.

La situation 4pid4miologique avant le d4but du contr6le.

Avant le d4but de La lutte antivectorielle en 1975, l'onchocercose itait unproblime tr&s grave de sante publique an Burkina Faso. 11 a AtA estiuO que quelques580.000 personnes 6taient infect~es par Q. volvulus'. 11 n'y avait pasd'estimations fiables pour le nombre total d'aveuglet4 dus it l'onchocercose dans lepays, mais des enquates.ophtalmologiques dftaillees ont montr6 que lea taux de c~cit4unchocerquienne dans lem villagesi de premiere ligne pourraient atteindre 10% de Lapopulation villageoise et prbs de 50 % do la population agde de plus de 50 ans.

Les zones les plus touchees 4taient lea vall4es fluviales du Nakambe (Voltablanche), du Nazinon (Volta rouge), la Sissili, la Bougouriba, le Koulpeolgo, laComo4 et la Leraba qui contenaient. quelques-uns des foyers les plus graves dol'onchocercose endsmique dans le monde. Cotte maladie 6tait. Agalement un importantobstacle au d6veloppement socio-4conomique et empichait le repeuplement des vallle"trs sous-peupl6es des riviires telles que le Nakambe et le Nazinon.

L'impact 6piddmiologique de la lutte antivectorielle

L'OCP a tommec:4 ]a lutte antivectorielle en 1975 Ct l'impact ducun~trole a 6t4 bien rapport i travers des enquctes 6pidkmiologiques de grandeenvergure. Des eiiquetes de hame avaient t40 faites dans 116 villages et des enquitesde suivi ont 6t4 effectuses i des intervalles de 3-1 anfl dana 88 de ces villages.Les reaultats ont montr6 que la lutte antivectorielle a 4t4 un grand sucu.s% auBurkina Faso. Des G 354 enfants examines, n~s dans ces villages depuis le debut ducontro8le, seuls quatre avaient 6t6 trouv6s infect.6s contre un iombre de 583 attenduss'il n'y avait pas eu de lutte antivectorielle. Tous les quatre enfants viennentd'un seul village, Pendi4, ob il y a eu une recrudeence localise de latransmission, mais des enfantn infect~s n'ont pas 6t6 rencontr~s dans les 87 autresvillages.

1. Rapport de la Mission d'Assistance pr6paratoire aux Gouvernements de: Cated'lvoire, Dahomey, Ghana, Haute-Volta, Mali, Niger, Togo

PNUD, FAO, BIRD, OMS, Geneve, 1973.

Suite A l'interruption de la transmission par Ia lutLe antivectorielle, le

reservoir parasitaire a commenc6 A disparaltre naturellement Ccci a amen6 & un dcln

dramatique de l'intensitO de l'infection, mesurde par la charge microfilariene

communautaire (CMFC) qui avait chutM de plus de 95 % apr~s 12 anm de lutte

antivectorielle. C'6tait un acquis tres important puiuque la gravitQ de la maladie

onchocerquienne est W14e directement & l'inLenaiti de l'infection et, de ce fait, iA

maitrise de l'onchocercose en tant que maladie d'une importancc our la plan do Ia

Sante publique pourrait donc ddji tre affirmfe apres 10-12 ans de lutte au Burkina

Faso.Comme pr6vu, In prdvalene des microfilaires dans 1a peau a pris un temps plus

long avant de commencer A diminuer, mais elle montre clairement maintenant le diclin

acc&lr6 qui a t6 privu par les modeles 6pid~miologiques. Des exemples de cette

importante tendance sont montr6s cn figure 1 pour des villages de* diff4rents bassins

fluviaux qui avaient une Intensitk d'infection tres Olevie avant le commencement de

la lutte antivectorielle.

Recrudescence de la transmission et traitement par l'ivermectine.

La seule exception aux excellents resultats de la lutte antivectorielle qui

a 404 d6tect~e junqu'ici concerns le bief de la riviere Dienkoa autour du village de

Vendi6. Non seulement quatre enfants ont 6t d6tect s avec de nouvelles infections,

mais la baisse de Ia CMFC et de la pr4valence aussi n'4tait pan satisfaisant@ et a

indiqud un niveau considdrable de surinfection dans la-population adults. De vastes

enquates de biopsie cutan6e, avec une attention particuliere sur les enfants n4e

dcpuis le d6but du contr6le, ont indiqu6 des problimes identiques dane les villages

voisins, mais le probleme semblait assez localis.

Une analyse ritrospective des dunn4es disponibles semble indiquer que la

transmission pourrait avoir repris entre 1980 et 1986, eA l'on croit quc lea

tendances 4pid6miologiques de ce foyer sont quelque dix ans derrire le reste du

pays. Il faudra donc mettre au point une strat~gie speciale pour unc lutte A long

terme dans ce foyer. spcifique une fois le traitement larvicide interrompu aux

alentours. C'est pour cette raison que l foyer de Pendi6 a 406 choisi comae une

zone prioritaire pour un essai communautaire du potcntiel de l'iveruectine pour le

controle de la transmission dans une situation de recrudescence de 1linfection d'Q,

voiYvluX.

La premiere campagne du traitcment par l'ivermectine effectu~e en Avril 1988 a

concern6 1 390 personnes de dix villages dans Is foyer do Pendi. La couverture.du

traitement tait ontre 65 % et 72 % de la population reccnee i 1'exception du

village de Pendi6 lui-mume, o& Ia couverture n'a 06 que de 54 %. Pour les besoins

de V'essai, Is traitement larvicide a 6t0 interrompu pour cinq moiW en 1987 et durant

la mime p6riode en 1988 afin de permettre la collecte de tres grandes donnees

entomologiquos sur le niveau de transmission avant et apris le traitement. Les

rAsultats sur l'impact du traitement de masse sur iA transmission sont attendus debut

1989. Ind~pendamment des r~sultats, le traitement par 1'ivermectine so poursuivra

annuellement dans ce foyer afM de prot4ger la population infect~e de la maladie

onchocerquienne.

Pr4vision des tendances 6pid6miologiques et interruption du

traitement larvicide.

Bien que la maJadie soit completement sous contrcle dans le reste du pays, le

r6servoir n'a pas t6 hliminK. Cependant comme indiqu6 sur la figure 1, ce reservoir

disparait rapidement et iJ est pr~vu qu'il pourrait atteindre des niveaux

insignifiants apres quelque 15 ans de contr8le. A ce stade, le risque de

recrudescence de l'infection et de la maladie pourrait itre n6gligeable mime si le

vecteur arrive A repeupler les giLes larvaires. L'OCP a donc l'intention

d'interrompre le traitement larvicide dans presque tout le Burkina Faso et dans

d'autres zones idcntiques dans les pays voisins. Capendant, avant d'interrompre Is

traitement larvicide, de vaut.ei collectos de donn6c 6pid~ziologiques devrontd6montrer qu'une telle d4cision est justifi4e.

2.2. Situation actuelle do la trypanosomiase au Burkina Faso

Des missions d'enquetes entomologiques et immuno-parasitologiques ont 4t6

effectu4es dans lea provinces de la Sissili, du Boulkiemd4, dc la Comok, du Mouhoun,du Nahouri (1986 et 1987).

Plus de 60 localit6v situ~es A proximit4 de galerics forehLibres ct pr4sentantdes activites susceptibles do favoriser le raveil d'anciens foyers ou la creation de

nouveaux foyers de trypanosomiase ont fait I'objct d'un (ehantillonnage de

populations de glossines aux alentours, cependant quc des prslAvemel-ts de sang surpapier Wattman pour l'IFI' ont 4t4 roalisas sur les populations lea plus expos6es.

Sur le plan entomologique.

Les glosaines riveraines ont r~gulibremcnt 6t.6 uaptur4es dans lea galeries

forestitres le long des grands cours d'eau et leurs affluents. L'4quipe de lutte

antivecturielle a prospect6 le long de ]a L4raba et de la como6 daras lea d4partements

de Banfora, Loumana, Soubaka, Dakoro et Niangoloko.

Des glossines vectrices de la maladic du sommeil ont 4L capturdes dans lea

galeries forestieres tout au long des cours d'eau. Los deux especes rencontr6es sont

Ulossina balalis 58 % et -L~omnlaa Tachinoide2. 42 Z. La moyenne des densit6s parpiege et par jour eat de 14/P/j. avec des extremes de 2 mouches/piege et par jour A

Guindougouba et 52 mouches/piege/jour A Koudougou.

Les enquates sur In Boigouriba montrent une pr6dominance de g, j a~Si d avec

des D.A.P. de 27 mouchos/P/J. Sur le Mouhoun, la prdsence des glossines a 6t4signal6e avec un contexte 6pid4miologique favorable au contact homme-glossine. Une

autre s4rie d'enquetes .cst n6CePsaire pour pr6ciser l'i mportancc deR vecteurs le longde ce cours d'eau dont les valldes fortiles sont le th4tre de migrations internes

tres intenses.

Sur le plan imeunologlque.

Suite i des d6pistages passifs des enquates immuno-parasitulogiques ont 6t6menies au niveau de certaines populations expos6es.

Environ 15.000 personnes ont 6t6 examin4es chez lesquelles un pr6l6vement de

sang pour l'immunofluorescence a 4t4 fait. Apres traitement au Centre Muraz de

Bobo-Dioulasso, 33 s~rums se sont montr~s positifs soit 0,22 %.

Des examens d'agglutination, sur carte (CATT) 2 ont 6tk rhalis~s mais leadifficult4s apparues lore de la manipulation du CATT n'unL pas permis l'utilisationen d4pistage de masse.

LA confirmation parasitologie.a a 4t6 faite au laboratoire des centresspcialis~s de Ouagadougou, Bobo-Dioulasmo, Koudougou ou Banfora.

Fn 1987, 37 malades ont ainsi 6t6 dpist4s et trait6s.

(1) Immunofluorescence Indirecte.(2) Card Agglutination Test for Trypanosomiasis.

L'ann~e 1988 a connu une surveillgpee assidue des zones & risquc dans la

province de Ia Couo4. Cette surveillance a permis J'identification d'un foyer de

transmission locale h Diarabakoko et ses environs ob 7 cas ont W depistes entre

avril et juillet 1988.

Les conclusions des diff&rents rapports de mission me recoupont et dccrivent

gineralement la mame situation 6pidmiologique i savoir

- Un repeuplement rapide et important des bas-fonds des cours d'cau, avec des

forits galeries abritant effectivement des espces do glossines vectrices do la

maladie du sommeil.

- Une intense activiti humaine permanente aux abords do ces cours d'eau,

favorisant ainsi lea contacts hommes-glossines (maralchage, pache, abreuvage,

lessive, etc..).

- Une migration interne constante du nord et du centre-est vers l'ouest ot

sud-ouest couplee d'une migration externe saisonnire de jeunes ruraux entre ces

zones et la R6publique de COte d'Ivoire, notamment vors des rgions reconnues comme

foyers actifs de la maladic du sommeil.

- Les quelques malades d6pist~s sont originaires des provinces tris touchies parlea migrations.

2.3. Perspectives Spid4miologiques des deux affections

Les nombreux programmes de mise en valour des vall6cs ibOres do l'onchocorcose

crent un mouvement migratoire interne important. CeLte migration se fait elon

P'axe nord-est vers le sud-ouest. Les valUbes intbresses par ces mouvements sont

lea vallees de la Bougouriba, le Mouhoun, la Como6 et la Sissili (cf. carte No 1).

Le retour des pluies abondantes recr~e des conditions 6cologiqucs favorables au

dhveloppement des mouches vectrices de la maladie du sommeil. A cce facteurs, i1

faut ajouter le retour au pays de nombreux travailleurs migrants parmi lesquels V'on

depiste do plus en plus de trypanosomes.

La persistance du r6scrvoir de virus humain, les migrations de populations entre

la zone de savane et la zone de forit o le probleme-dc 'onchoccrcose dite de

"forit" demeure entierement pose et enfin l'arr&t imminent des 6pandages do

larvicidex sont autant de facteurs favorables h une probable recrudescence de

l'onchocercose si une strategie de surveillance n'est pas rapidement mise sur pied.

3. LES GRANDS AXES DE LA SURVEILLANCE ET DE LA LUTTE CONTRE L'ONCHOCERCOSE ET

LA TRYPANOSOMIASE.

3.1. Etat actuel du systeme de sant6 et moyens de Ia surveillance

4pid6miologique.

Le Burkina Vaso est un pays sahlicn situ6 au cocur de l'Afrique do l'Ouest sans

acces A la mer. Sa superficie est de 272.122 km2 et sa population est 8.200.000

habitants, soit une densit6 de 30 habitants au km2.

Les activit6s 6conomiques essentiellement agricoles et pastorales procurent & la

population un revenu par tate d'habitant de 150 dollars (1986). Le Burkina fait

partie des pays les moins avancas.

Les indices d~mographiques sont lea suivantsi:

Taux de natalit6 46 %.(1986)Taux de mortalit6 22 %.(1985)Taux de mortalit6 infantile 167 %.(1986)Taux d'acuroissement naturel 2,6 %

Esp4rance de vie & Ia naissance 45 ans (1986)

Le probleme d'approvisionnement en eau potable reste aigu.

En 1984 : 35 % de la popuJation disposent d'eau potable A 15 minutes de marche,

50 % b~n~ficient en zone urbaine d'une installation d'eau (24 % i domicile et 26% de

bornes fontaines). Dana les zones rurales le taux de couverture par rapport i

l'objectif de 101/jour et par habitant eat de 70% avec une rSpartition tres inigale

sur le terrain.

L'insalubritQ de 1'environnement est A la source de nombreuses maladies

transmissibles. Le taux de couverture en latrines est de 38 % en zone urbaine et do

5 % en milieu rural (1984).

Le systeme sanitaire actuel eat caractris par une couverture insuffisante due

d'une part A la rapartition inegale des ressources dejA limiL~es et d'autre part A la

qualit du r6seau de communication inad~quat.

H~cemment remaniK, l'organigramme du Miniatere eat comme suit

Le Cabinet du Ministre auquel sont rattachis- Le Secretariat g6n~ral du Ministre- La Socit nationale, d'Approvisionncment pharmaccutique (SONAPHARM)

- La croix Rouge- L'Inspection technique des Services de Sant6- Le Projet de DAveloppement des Services de SaMt4 (PDSS)

8 Directions techniques centrales- La Direction de Ia Formation professionnelle- La Direction de la Surveillance 6pidemiologique t des Vaccinations

- La Direction de Ia Sante des Travailleurs- La Direction des Etudes et de Ia Planification- La Direction dc Ia Sante de In Famille- La Direction de l'Education pour la Sant6 et I'Assainissement- La Direction de 1'Approvionnement saniLaire et de 2a Pharmacop~etraditionnelle.- La Direction des Affaires administratives et financieres

A ces Directions centrales x'ajoutent 30 Directions provinciales de ls Sant6.

Les moyens de services de Sant4 publique

Les prestations sanitaires sont fournics 4 In population suivant un r6seau typepyramide constitu6 de :

- 6592 Postes de Sant primaire (PSP) au Aiveau des villages (1988)- 167 Dispensaires- 29 maternit6s sans disperisaires- 415 Centres de Santt et de Promotion sociale (CSPS) pour les agglomrations de

15 A 20.000 habitaRi .- 59 Centres medicaux (CM) pour Jes populations variant entre 150 A 200.000

habitants.- 6 Centres hospitaliers ragionaux (CHR)- 2 H6pitaux nationaux.

On note une insuffisance quantitative et qualitatirdes ressources humaince.La situation du personnel de sant6 en 1986 est loin des normes gen4ralement admises

et pr~conis~es par l'OMS pour lea deux d~cennies des indapendances.

Lee coita des services de sant6 publique

L'analyse du budget de la santA par rapport anu budget de 1980 A 1985 montre

qu'apres avoir oscill4 entre 5 h 6 % du budget national, il manifeste une 16gzretendance A Ia hausse. Depuis 1983 Ice pourventages sont passis i 7,4 % du budgetnational en 1983 i 7,3 % en 1984 et i 7,8 % en 1985. Cependant il faut noter qucplus de 80 %de ce budget sont consacr~s aux paiements des salaires du personnel. Ce

budget toutefois n'inclut pas ]'assistance externc bilaterale, multilat6rale et nongouvernementale.

La politique sanitaire du Gouvernement burkinabe est dfinie comme suitobtenir Ia couverture wanitaire de la population selon un systeme de sant6 populaireainsi formul6 : A santQ par le peuple et pour le peuple.

Les grandes lignes sont :- une sant6 i In portee de touu- la mise en oeuvre d'une assistance et d'unc protection maternelle etinfantile,--une politique d'immunisation contre lee maladies transmissibles par lamultiplication des campagnes de vaccination,- une sensibilisation des masses pour Pacquisition de bonnes habitudeshyginiques,- pour atteindre les objectifs d4finis par lea autorit~s burkinab6 dansl'optique de Ia santQ pour tous en l'an 2000, le Burkina a adopti lastrat6gie de lOMS baase sur les soins de santG primaires (SSP), en- mettant l'accent sur Ics activitas 4ducatives et pr6veutives et enfaisant appel & IA participation des individus, des famillem et descommunauths i la prise en charge de leur propre sant6.

La surveillance ipid6miologique du Burkina Faso 6tait jusqu'en 1986 incluse dansd'autres directions ot n'existait pax & part entiere. Elle 6tait d'abord rattach~c iIa Direction du Programme Elargi de Vaccination (PFV) puis A Ia Direction de laSurveillance Epid~miologique et des Vaccinations (D.S.E.V.).

Le fonctionnement de La Surveillance Epid6miologique

La surveillance 6pidimiologique suit IA chemin pyramidal sclon l'organigrammedes services de sant&.

Chaque formation sanitaire possede un cahier ou un registre d consultationjournaliere ob l'infirmier enregistre Lous les diagnostica de la jc'urn~e. A la finde la journ~e il consigne sur une fiche conque A cet effet lea maladies soussurveillance kpid~miologique.

Cette fiche appel4e T146gramme Lettre Officielle (T.L.0) est hebdomadaire, doittre acheminke & Ia fin de chaque semaine au centre medica ou centre hospitalierrgional dont Ia formation manitaire d~pend.

Au centre medical ou hospitalo-regional, cette fiche eWt envoy6e i la Directionprovinciale de la Sante. Le Directeur provincial de Ia Santi fait Ia synthese detous les rapports de toutes les formations sanitaires de sa province pour lesacheminer i la Direction de la Surveillance Epid~miologique sous forme d rapportsiensuels. La Direction des Etudes et dc Ja Planification (DEP) consigne ces donn6esdans I'ordinateur.

Les T.L.O. hebdomadaires au niveau des CSPS et des CM sont athemin4s vera laDirection provinciale de Ia Sant& qui A son tour, apre traitement, lea achemine h laDSEV.

Mais compte tenu des difficults d'acheminement, les T.L.O. parviennent souventavec beaucoup de retard.

Lorsqu'il y a une 6pid~mie dans une localiti, le midccin responsable estrapidement saisi.

Le plus souvent c'est 1'agent de sante qui se diplace avec les moyens de bordpour informer son responsable hirarchique.

Le mAdecin responsable de Ia zone int.ress6e informe son Directeur provincialqui saisit la DSEV. Mais avant dc rcccvoir des directives qui souvent tardent ivenir du fait des difficultes de communications il W'attele A circonscrire l'4piddmiepar des traitements intensifs, isolement des malades et vaccination des populations.

Les moyens de la surveillance

I n'y a pas de personnel ap~cial pour Ia surveillance 6pid6miologique. Tousles agents de formatlons sanitaires participent i cette surveillance et on peut mmedire quo la population elle-mime participe dans iA mesure o6 bien souvent leaservices de sant6 sont aarms par des W)4ments do Ia population ayant constatN desanomalien par rapport & ce qu'ils ont l'habitude de voir. N'oublions pas laparticipation & cette surveillance des gu~risaeurs traditionnela. Participation desservices de I'Administration territoriale.

Moins de 10 % du budget dc la sant6 est consacr6 & A SurveillanceEpid~miologique. En effet le budget du Plan Quinquennal 1986 - 1990 estim6 A 19,9milliards pr~voit 1,6 milliards do francs pour la lutte contre les endimies majeures.

I faut cependant notor quo le financement de ce plan rcste largement tributairede l'aide ext6rieure, -principalement ]a France, la Rpublique federale d'Allemagne,lea Pays Bas, les Etats Unis d'Amerique, l'Italic, le Canada et 1'OMS, le PNUD, laCEE, 11UNICEF, la Banque mondiale et ]a HAU.

Pour sauvegarder lea acquis du Programme Oncho dans lea vall6es fertiles A6l'onchocercose et Ia trypanosomiase sont A leur plus basse pr~valence mais avoc uncountexte 4pidemiologique favorable A d" graves recrudescenses, le Ministrc de laSanti et de l'Action sociale entend mener un programme special de surveillance et delutte contre l'onchocercose ot la trypanomomiase avec des perspectives d'intdgrationA d'autres maladies transmissibles par vecteurs.

Cest pourquoi les deux annses de travail de terrain nous amenent A revoir lesmithodes et la strat.gie de surveillance et de lutte contre Ia trypanosomiase dans uncadre plus rWaliste et plus efficace qui devrait tre int6gr6 A la surveillance dol'onchocercose.

Des ajustements et des modifications doivent intervenir au niveau

- des zones i surveiller- des ressources humaines- des ressources matbrielles- de la misr en oeuvre.

Les objectifs principaux do cc programme tant do1) empicher I'apparition des foyers de trypanosomiasc humaine,2) pr~server l'arrit de la transmission de l'onchocercose et lutter contrel'onchocercose infection.

Pour atteindre ces objectifs, en plum des provinces du Houlkiemd et de Ia

Como, il devient urgent et indispensable d'6tendre le r6seau de surveillance aux

provinces suivantes : Boulgou, Houet, Kenedougou, Mouhoun, Kossi, Bougouriba, Sourou

et Poni. Une surveillance efficace de ces provinces nMcessite l'invtallation ct

l'6quipement de 3 4quipes de base suppl4mentaires respectivement h Bobo-Dioulasso et

A D6dougou et Tenkodogo.

3.2. Strat4gie de la surveillance et de La lutte contre l'onchocercose.

La n6cessit4 de la surveillance apres l'interruption du traiteuentlarvicide.

L'onchocercose n'est plus un probleme d santi publique au Burkina Faso ct les

derniers vers adultes disparaissent rapidement. 11 est prsvu que iA rservoir de

parasites sera pratiquement slimine dans Ia majeure partie du pays d'ici 1990 et quele risque de recrudescence de l'infection onchocerquiann et de la maladie sera alors

nimimal. L'OCP envisage d'arrkter le traitement larvicide dans de vastes parties du

Burkina Faso en 1990 si la prdvalepce de 1'infection cont.inue de baisser comme cela a

6t pr6vu par les modeles 4pid4miologiques.

L'Interruption du traitement larvicide aboutira au retour du vecteur en des

densitas tres 61evees et on ne peut certainement ne pas tenir compte de la

possibilit6 de recrudescences localis6es de transmission. I est donc imp~ratif de

mettre sur pied un systeme de surveillance et d'intervention ayant comme objectif de

d6tecter et remidier & toute recrudescence de l'infectin et de la maladie

onchocerquienne

Surveillance 6pid4uiologique et traitement par V'iversectine.

La recrudescence de 'infection onchocerquienne scra initialement lente et

associae A des bas niveaux de transmission. Les mithodes entomologiques ne mont pas

appropriees pour la detection de tels niveaux bas de transmission car elles

impliqueraient de fagon impossible la dissection d'un grand nombre de mouches. La

surveillance se basera donc sur des m~thodes 6pidsmiologiques uniqucmcnt. Les

diff&rentes activit6a de surveillance et d'intervention qui constituent la divolution

de Ia lutte contre l'onchocercose au Burkina Faso sont 6numnr4es ci-apres en ordre

s4quentiel.

- Ditection de nouvelles infections.

Initialemsnt, l'activit6 principale sera Ia surveillance ipid6miologique avecl'objectif d'6valuer s'il y a eu une recrudescence localiske de transmission.

L'indicateur d'une telle recrudescence sera Ia pr6sence de nouvelles infections mises

en 6vidence par des biopsies cutan6es positives, chez des personnes qui auparavant

avaient des biopsies cutan6cm iAgatives.

Ce type de surveillance sera basc sur des enquitcs de biopsies cutan6es dans lapopulation de quelque 120 villages indicateurs qui sera suivie et examine A desintervalies reguliers de trois ans. Ces villages indicateurs sont des villages depresiere ligne qui repr~sentenL Lous les bassins fluviaux dU pays avec des gttes

larvaires en puissance. La s4lection definitive des villages indicateurs se fera en

6troite collaboration avec 1'OCP.

- Cartographic dpid4ziologique dktailise des foyers ayant denouvelles infections

Partout oi de nouvelles infections sont d6tect.eb, l'ampleur et la gravit6 du

probleme dans la zone concernde devront &tre dAtermin6es, De vastes epquites de

biopsies cutanees pourrhient tre Wicessaires dans les autrcs villages autour du

village indicateur afin d'obtenir une carte Apid4miologique dtaill6e comme une base

essentielle pour la prise de decision sur des 6ventuelles interventions

- Dcision d'intervention.

Suite i la detection de nouvelles infections et A la cartographie

6pid6miologique du problime, on doit d6cider s'il existe un Wrieux risquc derecrusdescence d'infection et de la maladie, et si Ia situation demande t justifieune intervention. Cette dAcision sera tris difficile A prendre et des lignefdirectrices claires ne sont pas encore disponibles. Toutefois, il est attendu quedes Atudes en cours A 1'OCP donnent des informations essentielles i cet 6gard.

- Intervention par e traiteaent de sasse avec l'ivermectine

Une chose est certaine : si une-intervention localisde est n6cessaire dans unezone of il y a un s3rieux risque de recrudescence de l'onchocercosc., elle devra alorstre une intervention de traitement de masse par 1'ivermectine car le traitementlarvicide limit6 ne sera pas une alternative realistc. Les esmais communautaires ont

montri que I'ivermectine est suffisamment sans danger pour le traitement de massepourvu qu'une surveillance adequate des r~actions secondaires soit assurbe. Lom~dicament devra itre distribui au moins annuellement A la population cible. Le butde la lutte contre )a recrudescence par le traitement de masse avec 1'ivermectine estinitialement d'empacher la recrudescence de l'infection en maltrisant Iatransmission et ceci signifie le traitement de masse pour un minimum de 15 ans.

- Evaluation de 1'intervention

Il sera vital d'Avaluer si la recrudescence a 4t6 matris6e ou s'il fautmodifier la strat~gie d'intcrvention. Cette ivaluation sera basic aussi sur desenquktes longitudinales de biopsies cutanies.

Lignes directirces techniques

- Enquites do biopsies cutanses et traitement par l'ivernectine

Soulc deux sortes de travail cur le terrain seront entrepriaes A savoir des'enquetes de biopsies cutanees et le Lraitement de mause par l'ivermectine. Lestechniquem impliqu6es dans les enquates de biopsies utanes sont bien connues et ont6t utilisies et am4lior~es par 3'OCP durant plus d'une d~cennie. .Les essaiscommunautaires do l'ivermectine dans 1'OCP ont permis la mise au point et 1'essai deproc~dures pour la distribution de masse d I'ivermectinc et la surveillance desrAactions secondaires apres le traitement. Les lignes directrices techniquesdMtaill~es pour ccs deux activitAs de terrain se trouvent dans deux manuels que l'OCP

a pr6pares rcemment pour les besoins de ]a d6volution.

- Traitement des donnies et analyse

L'Avaluation de l'incidence de nouvelles infections exige une analyselongitudinale des donn6es des biopsies cutanes. I1 sera Aicessaire de tenir desdossiers individuels corrects et de maintenir un systeme de base de donnies 1i6es.TI a 6t d4cidi d'utiliser les fiches individuelles et lea uystimes de traitement etd'analyse mis au point par l'OCP. he systeme assurera une analyse rapide de routinedes donnkes et une compatibilitA entiere avec le systeme de base de dann6es de 1'OCP.La mise en oeuvre du systeme, la formation et le souLien necesbaire scront fournispar le personnel d'OCP.

3.3. Strat~gie de surveillance de la trypanosomiase

La coordination centrale qui a lem compstences requises (3 entomologistes,m6decin ou pharmacien exp6riment6s dans la lutte conLra la trypanosomiase) et lemateriel didactique (laboratoire, matdriel de ddmonstration) se propose d'assurer laformation-recyclage du personnel des 6quipes de base en lee recevant A Ouagadougoupar groupe de 4 pendant un mois.

Le personnel des autres formations aura dos o4minaires de courte dur~e au niveaude leurs provinces.

A l'issue des seminaires, une liste de villages qui feront l'objet d'unesurveillance 4pid~miologique et entomologique plus .roite sera rexise aux infirmiersresponsables de ces villages de m~me que des affiches et des manucls i P'usage desAgents de Sant6 communautaires afin qu'ils entament des leur retour, lasensibilisation des populat.ions au probleme de la trypanosomiase.

La mthodologie adoutig est le d~pistage selon la straLtgie en 2 temps, letraitement des malades et la luLte anti-vectorielle.

La strategie en 2 temps consiste dans :

Un premier temps A faire le contr6le syst~matique de toutc la population decertaines zones particulierement sensibles.

I s'agit alors d'un d~pistage actif : 'enmemble de Ia population est soumiseaux tests immunologiques de d~pistage, des examens parasitologiques tant mis enoeuvre sur les seuls suspects. Cette phase de "raLissage" Vtant achevee, on passealors au :

Deuxieme temps : est la surveillance 4piddmiologique, qui peut prendrc deuxaspects suivant les rsultats obtenus predcdemment

- soit une simple surveillance ; dem enquetes 6tant faites lorsqu'un nouveau casd6pist4 passivement est signal.6

- soit une surveillance renforcke avec passage rgulier dans lea villages ayantpresent6 au cours des prospections un nombre important de nouveaux cas. La fr6quencede ces passages sera adapt~e aux contraintes de surveillance des autres maladiestransmissibles.

L'ensemble du travail sur lA terrain est realis& par les 4quipes mobiles desbases disposant du materiel et des credits necessaires A leur fonctionnement, aptesainsi A assurer dans lee meilleures conditions les enqutes qui leur seront confides.Au cours de la phase de contr6le systmatique, les 6quipes mobiles scront utilisies Aplein temps pendant une~p6riode plus ou moins longue en fonction des populationsconcernees.

Lea techniques & mettre en oeuvre

Techniques iamunologiques

Le CATT (Card Agglutination Test. for Trypanosomiasis) ne sera utilis6 que dansles postes fixes. L'IFI (Immunofluorescence Indirecte) sera utilis6 pour lesenquites de masse. La technique de l'JFI permet A une 6quipe au faible effectif depratiquer l'examen h un grand nombre de personnes en pe" de temps.

Techniques parasitologiquesi

Elles consistent on.:- la mise en 6vidence du parasite dans le suc ganglionaire par ponction des

addnopathies :- la recherche du trypanosome dans le sang par passage sur colonnes

6changeuses d'ionR.

Ces techniques sont pratiquement au point et utilisables Kano difficult6s sur le

terrain ; elles doivent etre, en cas de besoin, r6phties pendant plusieurs jours.

Techniques anti-vectorielles

L'utilisation des 6crans et piiges impregnes sera faitLe de manirc odloctive, au

niveau des endroits ob le risque de contact homme-vecteur est maximum. La periode de

pose des pieges ou 4crans sera de pr6f6rence la saison s6che quand lea populations dc

glossines sont naturellement tres reduites et confindex A des zones restreintes.L'insecticide retenu pour les imprignationa est l djtbmethrjina.

Le Comit6 villageois de sant6 sera initi6 a la technique d'imprkgnation dc

l'insecticide et & la pose des pJges ou 6crans dans les endroits stratigiques. Le

premier lot de piLges et 4crans sera fourni gratuitement. La maintenance et le

remplacement du materiel pour les anndes qui suivent beront & sa charge, exceptionfaite de l'insecticide qui lui sera r~gulierement fourni.

La sensibilisation des populations aura pour support lee organes officiels

d'information (presse, radio, ttltvision) et. aussi des panneaux, affiches, journ6es

de sensibilisation.

Le r8le des 6quipes de base dana le systeme de surveillance de la trypanosomiame et

de l'onchocereose.

Pour la trypanosomiase, P'accent sera essentiellement mis mur la g6niralisation

du contr6le syst6matique par lea pr6livements de sang sur papier Wattmatt oour l'IFI

tant en campagne de masse que pour tous lea suspects cliniquem et tous ceux qui

reviennent do l'6tranger. Ce controle se fera tant au niveau des CSPS qu'au niveau

des dispensaires p6riph~riques. Les centre4 m4dicaux de Koudougou, Baiffora,Bobo-Dioulasso, Dedougou, Ouagadougou et Tenkodogo qui sont 6quip6% d'un laboratoire

et d'une salle d'hospitalisation abriteront lea 6quipes de base et assureront lea

traitements des malades dtpist6s. Ces hopitaux seront donc des centres r6gionaux

sp4cialises (CRS) pour ]a lutte contre ln trypanosomiase humaine et itendront Icurs

activites specifiques de contrale de la trypanosomiase aux autres provinces, en

harmonie avec lea directeurs provinciaux de la sant6 concerns. Jes tiches des

equipes de base seront lea Muivantes :

- Au niveau des CRS, l'6quipe de base appurtLera son appui aux si.ructuressanitaires existantes pour le dtpistage des suspects orient6s vera le CRS, pour lacollecte et lI'acheminement des confettis vers le Centro Muraz et pour le suivi dc ccs

confettis sur des fiches ad hoc.

- L'6quipe apportera aussi son concourA A l'infirmier charg6 des traitements et

du contrale des malades.

Chaque 6quipe devra 4tablir de commun accord avec le coordonnateur national ctle Directeur provincial de la Santh (DPS), un calendrier annuel de missions

d'enquite% dans des zones retenues pour la surveillance r6guliere de l'onchocercose

et de La trypanosomiase.

- Une 6quipe peut aussi tre sollicitee par un DPS uu sur instruction du

coordonnateur national pour certainces enqutes en cas de besoin.

- Le chef d'6quipe sera responsable devaut le coordonnateur national et leDirecteur provincial de la Sant du CRS pour la qualiLQ et la r6giiaritQ des rapportstechniques qui devront itre envoy6s h la coordination touu les mois.

La supervisjon technique des 6quipcs de base relive du coordonnateur nationalqui gardera des contacts truits avec les DPS concern6s afin dharmoniser le travail

des 6quipes.

L'appruvisionnement en m6dicaments specifiques, cu maLeriel de d6piatage et du

uicessaire de fonctionnement sera assur6 par lo coordonnateur sous la responsabiliti

directe du DPS d'o0 relive le contre regional spicialisk, Les DPS concern~s devrontfournir tous les 3 mois lea justifications des d4penses effectuaes, de l'utilisationdu mat4riel renouvellable ainsi que du carburant.

Pour l'onchucercose, quatre (4) 6quipes seront constituieg A partir de celles dela trypanouomiase et basies au niveau de quatre (4) Directions Provinciales de laSant (DPS) appropridcs : chaque Quipe se chargera du d~pistagc actif et6ventuellement du traitement par 1'ivermectine et sera compuke d'un infirmier chef

d'6quipe, d'un reconscur, d'un technicien de laboratoire, d'un chauffeur et en cas de

besoin d'un manoeuvre.

- Les 6quipes apporteront leur moutien i l'infirmier chef du centre de sant6 ct

de Promotion sociale (CSPS) et i l'agent de santQ de village (ASV) commis i lasurveillance passive.

- Les compte-rendus (rapports) de surveillance et de traitevent seront 6laborisconform~ment aux directives contenues dans les manucls.

- La supervision technique des 6quipes sera assurie par le Coordonnateurnational et celle administrative par le Directeur Provincial de la sant6 dont reliveI'6quipe.

4.- IDENTIFICATION DES RESSOURCES ET EVALUATION DU COUT DU PROGRAMME

4.1.- Le Personnel

Pour mener & bien le programme de surveillance et de lutte contrel'Onchocercose et la Trypanosominse, le ministire de la sant6 et la 1'Action Socialeaura recours aux comp4tences nationales pour le renforcement de Ia Direction de LaSurveillance Epid6miologique et des Vaccinations ainsi que la Coordination centraleet la formation des six 6quipes de base.

4.2.- Les ressources mat6rielles

Le renforcement d la surveillance de la zone initiale (COMWE etBOULKIEMDE) et l'cxtension des activites i d'autres provinces nAcessitentI'acquisition de vWhicules, de mat~riel technique, du matiriel de tourn~e et uneaugmentation des depenses de fonctionnement. (Voir d~Lail dans le chapitre"6valuation des cokts du programme").

4.3.- Le budget du Programme.

(Voir devis detaill6 au chap. V.)

4,3.1.- Les investissements

RenfroremenL et 6quipement de la coordination centrale. ..................................... 198,252,000

.Vhicul s................ .......... 32,500,000

.Materiel technique..................... 18,815,364

.Matsriel do lutte anti-vectorielle 29,100,000

.Matdriel de tourn~c.................... 3,475,200

. Formation - %ensibilisation........... 7,000,000Sous-total.......................... 289,142,564

4.3.2.- Les charges ricurrentes

. Entretion.............................. 15,000,000

. Carburant Lubrifiant................... 26,310,000

.M4dicaments........ ................... 36,925,000SRfiactifs et accessoircs do labo........ 11,400,000Per diem........................... ... 164,700,000Fournitures dc bureaux et divers....... 1,500,000

Sous total. ............. 255,835,000

Total 1nvestissements + fonctionnement289,142,564

+ 255,835,000

544,977,564 F CFA

10 % d'impr6vus ......... ............... 54,497,756

Total global:

Investissement + fonctionnementL + impr6vu .... 599,475,320 F CFA

- Soit cinq cent quatre vingt dix neuf millions quatre cent soixante quinsemille trois cent vingt francs. (US $ 1,978,466),

5.- DEVIS DESCRIPTIF DU COUT DU PROGRAMME POUR CINQ (5) ANS

5.1.- Les investissements

----------------------------------------------------------------------------Designation Quantit4 Affect.ation Prix Unit Total (CPA) Observation

Hors taxe

---------------------------------------------------------- ----------------

* 5.1.1. renforcement et dquipoaent de la coordination centrale

Construction D.S.E.V OUAGA --- 160,000,000 1990

Equipement OUAGA --- 32,000,000 1990

Ordinateurs +logiciels +Stabilisateurs 2 3,126,000 6,252,000

Sous total 198,252,000

5.1.2. Les v6hicules

Toyota PICKUP .1 Coordination 4,000,000 4,000,000 1990

Toyota 3 Bobo-DioulagmoLAND-CRUISER et accessoires DWdougou

Tenkodogo 8,000,000 24,000,000

Moto-Cross 2 Equipe entomo. 1,000,000 2,000,000 1990

Moto YAMAHA 100 LUX5 Banfora

Bobo-Dioulaoso 1990WtdougonTenkodogoKoudougou 500,000 2,500,000 1990

----------------------------------

Soos-total 32,500,000

- -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - --^

Deiignation Quatiti1.t- Affectation Prix Unit Total (CFA) Observation

Hors tmxe--------------------------------------------------------------------------------

4.1.3. Mat6rie) technique pour lea 6 hquipes.

Pince de Holth 4 x 6 Ouaga 73,346 1,760,304

Lame cercl4e 120 x 6 Koudougou 1,990 1,432,800 1989-90

PipetteEppendorf. 2 x 6 Bobo '18,025 576,'300

Lancettes 2 x 6 Banfova 31,500 378,000

PlateauMicrotitier. 20 x 6 Dvdougou 14,620 1,754,400

Ciseaux courbes 2 x 6 Tenkodogo 1,200 14,400

Ciseaux droits 2 x 6 1,150 13,800

Pince de kocher 2 x 6 620 7,140

Plateau 6maill6rectangle, 4 x 6 6,200 148,800

Plateau 6mai116haricot. 2 x 6 310 3,720

Balancehdcanique. 6 15,000 90,000

Tensiomitre 6 16,500 99,000

Loupe MS 2 x 6 310,000 3,720,000

Cantine EDAK 6 19,400 116,400

Microscopebinoculaire. 2 x 3 Pour los

6quill.m deBobo 600,000 3,600,000

Centrifugeumepour colonne. 2 x 3 D4dougou 500,000 3,000,000

Terikodogo

Agitateur 2 x 3 150,000 900,000

Groupe 6lectro-gone YAMAHA(E.T.500). 3 200,000 600,000

Frigo mixtegaz/secteur. 3 200,000 600,000

Solul-total 18,815,364

4.1.4. Lutte antivectorielle

-----------------------~)------------------------------------------------------

Designation Quantit4 Affectation Prix Unit Total (CFA) OLservatiun

liegesa 1500 5,000 7,500,000glusaines 1'0

EcranK 5,000 1,500 7,500,000

Actessoires(fcts, bottes, gants) 80,000

Sceaux 20,000

Insecticides(Deltamethrine) (4 impr6gnations par an x 5 ans) 7,000 14,000,000

100 x 4

SouB-total 29,100,000

4.1.5. Mat6riel de tournie.

Iits de camp et n6cessaire de couchage,6 x 6 6 Aquipes 50,000 11800,000 1989-90

Tables pliantes 4 x 6 20,350 488,400

Chaises 8 x 0 7,250 348,000

Tabouret A via 2 x 6 29,900 358,800

Caisse de popotte 680,000 180,000------------------------------

Sous-total 3,475,200

5.1.6.- Foration, recyclage et sensibilisation

formation niveau infirmier 50,000 1,500,000

Seminaire dans les provices 200,000 4,000,00010 x 220,0 4,000

sensibilisation et confectionde manuel de vulgarisationi 1,600,000


RECAPITULATIF DES INVESTISSEMENTS

Renforcement et equipement de la coordination 198,252,000

V0hicuies 32,500,000

Materiel technique 18,815,364

Matkriel de lut.te antivectoriellc 29,100,000

Matsriel de tournpe 3,475,200

Furmation - recyclage - sensibilisation 7,000,000

TOTAL 289,142,564

5.2. LES CHARGES RECURRENTES

---------------------------------------------------------------------------Designation Quantit4 Affectation Prix Unit Total (CFA) Observation

---------------------------------------- ----------------------------------

5.2.1. Entretien et rsparation den groupes ct v4hicules

6 x 5 ans 6 !quipes 500,000 15,000,000

5.2.2. Carburant et lubrifiant

Carburant 3,500 1 x 6 x 5 an 232 24,360,000

Lubrifiainnt 100 1 x 6 x 5 ans 650 1,950,000


5.2.3. MWdicaments

Traitement Ivermectine5 ani 300,000 15,000,000

Trousse d'urgence6 x 5 ans 150,000 4,500,000

Traitement Trypanosomes5 ans 3,485,000 17,425,000

sous-total 36,925,000

5.2.4. RWactions et acceasoires de labo

Designation Quantit6 Affectation Prix Unit Total (CFA) Observation

-------------------------- ----------------------------------

CATT et IF! 6 x 5 ans 300,000 9,000,000

Colonnes do filtration100 x 6 x 5 300 900,000

Petit mat6riel de labo6 x 5 50,000 1,500,000

Sois-total 11.00,000

5.2.5. Per-dies

Equipes de base 6 x 6 x 120j x 5 ans 7,000 151,200,000

Coordination centrale3 x 90j x 5 ans 10,000 13,500,000


5.2.6. Fournitures de bureau - divers

6 x 5 ails 50,000 1,500,000

RECAPITULATIF DES CHARGES RECURRENTES

1. Entretien et reparation (vihicules et. grupes) 15,000,000

2. Carburant et lubrifiant 26,310,000

3. M4dicaments 36,925,000

4. riactifs et accessoires de laboratoire 11,400,000

5. Per diem 164,700,000

6. Fourniturem de bureau et divers 1,500,000

TOTAL 255,835,000

Total Investissements + fonctionnement : 289,142,5644 255,835,000

544,977,564-10 % d'imprevus 54,197,756

TOTAL GLOBAL :investissement + fonctionncmeinL + imprdvu.. 599,475,320

-Soit cinq cent quatre vingt dix neuf millions quatre cent soixante quinoeille trois cent vingt franca. (US $ 1,978,466)

6.- CALENDRIER PREVISIONNEL

L'objectif A long terme du programme est quc, k]n phame de maintenance, ICSkquipes de base puissent 41re oprationnelles pour la surveillance d'autres maladiestransmissibles, parmi lesquelles 1'Onchocercose dont la surveillatice revicntd6sormais au Durkina Faso dans le chdre de la D~volution.

Un recyclage adiquat du personnel des (quipem de base ainsi que des 6quipesmobiles du PEV pourra, Ftre indiqu# pour la mise sur pied de ces 6quipes polyvalentegde contr8 le des maladies transmissibl t oncho, trypapnio (Schistosomiasc,dracunculose, paludisme, etc...)

ANNFF

ACTIVITES 89 90 91 92 93

Formation

- 6 6quipes surveil-lance 6pid6miologiquc(avec OCP/EPI Coordina-tion) ------------------

- agents de santdcommunautaires (par1'4quipe nationalcCOORD. ET OCP/EPI ------ --

- laboratina et agents ------------------CSs

Mise en place du mat4riel -------------

Activit6es ur le terrain

- choix de ates poursurveillance entomol.: ------------------

- commencement de ]asurveillance entomol.:

Trypano. ------ ------------------------------------Oncho. --------------- --------------

- commencement dcl'6valuation 6pidemio.:

Trypano. ----------------------------------------------Oncho. -----------------------------------

- commencement dud6pistage: ---------

Evaluation: ----------------------------

CLUB DU SAHEL

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Les regimes fonciers et I'installation des populations dansles zones liberees de l'onchocercose

Burkina Faso

Que se posse til dans les zones libkres de lonchocercose? LeBurkina Faso offre un exemple e.ceptionnel de la succession d'uneapproche dirigiste fAp-daMu' dans les ann6es 1980, puis d'uneapproche participatiue de developpement concerte : la gestion desterrairs.

Une analyse minutieuse, 6 partir detudes de cas sur le terrain,permet d'identifler les 6cueils ou les auantages des politiques depeuplement, ainsi que leur impact sur les ressources naturelles.

La demarche "gestion des terroirs" a dtpassO le stadeeHperimental et if est possible aujourd'hui de la pr6senter commeune grille de traUall incontournable pour accompagner ledeueloppement durable des zones debarrassbes de l'onchocercose.

1 I1 g a 15 ans, creation des zones RIJU'

Les droits fonciers traditionnels Atalent entre les mains deschefs de families autochtones, sous le contrfle des chefs de terres.Les politiques d'installation de populations menbes parl'administration ont eu un impact tres fortement negatif sur lagestion des ressources naturelles et sur le climat social dons leszones dites "RUU".

Les zones amenagees 6taient peu ou pas peuplees, etl'administration les a consider comme libres de droits fanciers, Enrealit6, les autochtones, en retrait, conseruent leurs rites et leursdroits d'appropriation foncIre. Prenons par eHemple la region deBagr6, o6 les medecins ont recens6, dans les ann6es 60 auH abordsde la riuiere Nakambe (em-Uolta Blanche), une centaine de uillagesabandonn6s (ROLLAND et BARY 1969), Une etude fonciere prtalable6 l'amtnagement du Barrage de Bagr6 montre, 25 ans plus tard, queles prftres traditionnels (de la terre, de [a chasse et de la p@che)nont jamals cess i de perpetuer leurs rites. uls ne rtsidenteffectliuement plus sur les abords de la riuiere, redevenus uneforft, mais leur emprise fonciere est connue de tous (Faure 1990).

Pour temoigner de l'impact de l'installation des colons sur'occupation foncibre et la gestion des ressources naturelles,

prenons deuH etudes de cas, I'une vers la frontiere du Ghana et dela C te d'luolre et lautre sur le Plateau Mossi ,

I nUU :AutorIto pour I'Amenagement des ueiIes des Uoltas.

A. FAURE-Foncier et instafiation. de populations-Club du Sahel/04-94

1.1. UPIU/U PU-EST (Prouince de la Bougouribe, Djipologo)L'UU installe des migrants uenant du Plateau mossi et des

Dagara, du meme groupe ethnique que les autochtones, mais venusd'autres departements. Le territoire decoup6 par I'RUU dons ta forstest nomm6 UI; If couvre en falt deuH terroirs, ceuH de Djipologho etde Kankanpelle, L'installation des nouveaut arrivants declenche unepnlitijiu d'nrriipatinn dp l'espace par les autochtones; iS font frontface aun colons; le chef de KankanpeIlI installe 100 families Dagarede snn plein gr6 et Its dtruisent les reserjues foncl'res, En 15 ansoIn furft rtgresse et les WIaphonts disparaissent. Les colons perdentles portions de terres preuues pour l'eftension future de leurschamps et le plan d'amenagement devient caduque,

Le regime foncier anterleur 6 I'Ml) protegealt les r(servesforestires, puisque nul n'osait sinstaller sans demanderl'autorisation des chefs coutumiers. Les colons reclament a I'RLIIdes titres fonciers ofin d'opposer des droits officiels aumautochtones.

1.2- UPI/zone pastorale do Gadoghin (Prouince du Ganzourgou)Sur le Plateau Mossi, Ia zone pastorale de Gadeghin est conque

selon des idees theoriques, sans tenir compte des r~alit6s duterrain. Cans cette region de forte densiti humaine et bouine,l'association entre lagriculture et le'leuage est indispensable(transferts de fertilit6 : contrat de fumure auec acces au pults etaum r~sidus de recolte). La mise en oeuure de l'amenagement estfaite me/u m///fitri et les agriculteurs autochtones sont chasshshors de la zone. En outre, lestimation de la charge en bWtall estth6orique; Ia zone 6tant redulte (6 000ha), le nombre maoimal deboeufs est estim6 6 2 500. C'est oublier que le troupeau est uneentIte fractionnoble et mobile, et son flu" incontrolable. En 1990 oncompte plus de 6 000 totes 6 certalnes saisons.

L'administration Ignore les droits fonciers des autochtones(dont certains sont agropasteurs) ou les nie.

Quels sont les resultats observes 10 ans plus tard? Lesressources naturelles sont systematiquement detruites et le terroirpiII6. Les arbres sont mutils : uente du bois et charbon pourOuagadougou, 6branchage pour nourrir les animauH en fin de saisonseche. Personne ne se sent responsable et l'entretien des sols estnul. Cette destruction Ovidente sassocie 6 une concurrence entrefactions d'6leueurs pour contrbter le magasin d'intrants (contenantdes sous-prodults agro-industriels, du set et des produitspharmaceutiques) et pour diriger le Groupement d'leveurs,interlocuteur des decIdeurs enterieurs, capables de fournir credit etaide alimentaire,

A. FAURE-Foncier et installation de populations-Cub du Sabel/04-94

3

URPllzone pAstorale de 6adeghinregIon de forte densit6 de population et d'animauH

1980 HUU 1990 ONRTdes erreurs de conception et l'approche "gestion desd'eH6cution terroirs"- agriculteurs autochtones - rtflemion en cours surchassis munu m///teri l'association necessaire- zone pastorale espace rfduit agriculture/levage(6 000ba) - des concertations entre les- conception rigide des agro-pasteurs autochtonesfronti ere s de ]a zone resident des villages alentours(notamment pour lacces au et les 6leueurs Install6s parpuits) lA'M- nombre mamlmal de breufs - des amenagements anti-estlm6 4 2 500; en felt > 6 000 6rosifs Et foresterip pnuren 1990 recuperer des terres- non prise en compte des d6gradeestransferts de fertilite avec les - les 6leueurs clotfrent leursterroirs voisins (contrats de parcs de nult avec des holesfumure, rfsidus dle rtmolte) ulues pour uiter d'abottre les- ignorance des droits ba/anller

fonciers des autochtonesR1sultat :destrujction des les resultats ne sont pasrgesurces-noturelles encore concluants, mais le- pillage du terroir (arbres dialogue est amorc6 entremutilts : uente de bois et autochtones et 6leueurscharbon pour Ouagadougou,ebranchage pour nourrir lesanimaum en fin de salsonseche);- personne ne se sentresponsable : aucun entretiendes sols.

Pour conclure sur to situation fonclere des zones am6nag(espar AlRI dons les ann6es 1980, on constate la consommation desressources naturelles en reaction A l'installation des colons; lescolons reclament des titres fonciers pour repondre auH strat6gled'occupation des autochtones.

2. Les annees 90 : nouveau" migrants et nouuellespolitiques

Quinze ons apr~s la creation des RUU, des mauuaises recoltesot les d6clarations de politiques nationales (A1organisation Agraire

A. FAURE-Foncier et installation de populations-Club dsu Sabel/04-94

et Fonclere de 1984) transforment 6 nouveau loccupation delespace dans les zones de peuplement2. Le Programme National deGestion des Terrairs est espbriment6 et presente une alternativeaUH politiques anterieures pour integrer ces nouuelles migrationsspontaniles.

2.1. Pe nouwelles vogues de migrants "spontanes"DIH ans apres linstallation officlelle des populations RUU par

l'administration, les forets du sud et de l'ouest du Burkina fontl'objet de defrichements effrenbs. Les causes sont uarles : l'effetde Ia declaration rtvolutionnaire "1a terre appartient 6 I'Etat".3Interpret6e per les migrants comme "les chefs nont plus le contrbledu fancier". Les s~cheresses successiues transforment les parcoursdes boeufs transhumants, qui descendent dons les forts du sud.f'autres profitent de l'annonce d'un amenagement hydro-agricolepar l'Etat (Bagr6, la Kompienga) pour se deplacer et Ils esperentb~neficier des terres amenagees par Is suite.

L'accueil des nouveauH uenus par les populations autochtonesuarie. Certains responsables coutumiers qui ant perdu leur maitrisedu foncier sont incapables de rbagir. Par elemple a' Diarkadougoudons la Bougouriba, 50 familIes autochtones Puguli ignorent lesmigrant. 150 families Mossi sont pourtant arriuees en 2 ans, depuis1991, et suluent un /eader religieum, cheikh appartenant A Iaconfrrie tidjune de Ramatoulage. Ils cultirent le coton, carplusieurs chefs d'eHploitation ant fait auparavant un skjour dunedizaine d'annte 6 Solenzo; ils organisent une solidarit6 socialebasbe sur la hierarchie religieuse (prise en charge des plus demuniset des malades); leur economie agricole est deuelopp6e car lecheikh attire la main-d'oeuure de quelques centaines d'616uescoraniques; mais ii n'y a pas dinfrastructures sociales ou sanitaires(forages, ecoles, dispensaires); aucuns contacts auec lesautochtones. La fordt est progressluement d~truite pour Mtretransformee en champs.

Hilleurs, le pouvoir des chefs coutumiers est tel que nul noses'Installer sans demander leur auls. A Dissanga par eHemple dans leKenedougou, les autochtones contralent les meilleures terres debes-fond, oO Us cultivent les bananes et le riz, ils interdisent au"'btrangers" de planter des arbres, leurs rites et relations sacreesaum ressources naturelles sont uluaces (oupres des mares, desbosquets). Ils b6nkficient des prestations en main-d'oeuure

; les Zones de peuplement incluent ici les zones lIberies de l'onchocercose le longdes riujbres et les outres forets du sud et de I'uest du purkine, peu peuples oucours des cinquante ennAes prickdentes.3 La nRF (RdorganisatIon Rgralre et Fonciere de 1984 dclere dons son article I"le terre appertient 6 l'Eta".

A. FAURE-Foncier et installation de populations.-Club du Sahel/04-94

offertes per les nouweaut venus : les chelkhs enuolent leurs Wa/betrauaillier sur leurs champs.

La foret est progressiuement detruite pour ouurir denouweaum champs au detriment des r~serues fonclres et des zonespostorales traditionnelles. Portout les conflits entre agriculteurs et6leueurs augmentent et ils reclament des modes de r~solutionappropri6s.

La question foncIre est cruciale, loccupation de lespace 'esttransform6e au cours des dernidres annles. I reste des espaceslibres dons le sud-ouest (Bougouriba, Poni, Comot, K~nfdougou),mais ailleurs, [a concentration du betail est inqui6tante, paretemple sur les abords du Barrage de Bagre : 18 000he depfturages ont W perdus par submersion. Faut-il recrber des zonespastorales, 6 quelle 6chelle, dons quel cadre Institutionnel?Comment proteger les ressources naturelles? Comment accuelilirces populations d'agriculteurs afin d'arriver 6 un deueloppementporticipatif, concerte et durable?

2.2. La reponse du gouuernement : une gestion d6centralisee etdemocratique basde sur un cadre institutionnel officiel

Les decideurs burkinab6 ont rapidement pris conscience del'ampleur du phenomene migratoire dcIench6 uers les espaceslibres dds le debut de Ia Reuolution. ils ont propose1'enperimentation de lapproche "gestion des terroirs" dons desulliages-tests, puis ont enterine son adoption dans laReorganisation Agraire et Foncire de 1991.

2.2.1. La RMorganisation Rgraire et Fonciere de 1991 preuoit lacreation de Commissions Iillageoises de Gestion des Terroirs (CIGT)dans son article 1074. I est egalement possible d'obtenir des titresfonciers, tent reclames par les colons de I'lUS,

4 Art. 107 :"Dens les pillages, les attributions des commissions prkuues 6 'article106 sont enerc6es par des Commissions PiIageoIses de Gestion des terroirv,organisses en sous-commissions spclalIls6es."5 Certains titres sont priceires et rftocahles : permis d'occuper(lol de 1960;1991 : art. go, permis de recherche et permis d'etfploitetion de substancesmingrales (ert.97 et 99); d'autres au contraire peuoent deuenir de uerltables1itres do proprIt6, lils offrent un droll de Joulssonce permanent -usus/fructus/jus/ebusus : arrbtt de mise & disposition (art, 95), permis urbaind'habiter, pervais d'euplelter(ert, 96 roits de superficles consolId6s aprOsrballsetion de mise en valeur conforme oun temtes en vigueur.Les Titres dejoulssance sont deflurks per l'dministration des domalnes, 6 titre onereum (taeset redeuanceso. Montant des taees de joulissance sur les terres du DFN sur desterrains rureum : en principe 4 090 F/he.

A. FAURE-Foncier et installation de populations-Club du Sahel/04-94

6

2.2.2. En 1990, IMPU change de nom pour deuenir l0'NAT6 et adopteune nouvelle politique: les bureaum d'eH6cution changent Iademarche en s'appugant sur les autochtones, auperavant esclus;l'opproche devient porticipatiue et consensuelle : elle s'appuie surdes negoclations entre groupes sociaun; on abandonne lesmatricules pour adopter les noms des villages locauH (par enemplele U1 deuient DJipologho). Dans les anciennes zones les autochtonessont intgres 6 l'amenagement (par enemple au U4 Rapadama). Pourles zones nouuellement amenag6es, I'ONHT pratique " 'installationspontan6e assistbe" (par exemple, Bouni dens la Bougouribaabandonne 50% de son territoire pour les .nouueaum uenus de Po-Es t).

2,3. Le Programme National de Gestion des TerroirsLa dhmarche "gestion des terroirs" adoptee par les projets est

la suivante : dtablir un diagnostic concerte auec les populations, fairelinuentaire des ressources et des besoins, proposer une hierarchiedons les actions a entreprendre, e'aluer les financementsnbcessaires, rediger un Plan de D0ueloppement Uilageois no unContrat Ulllageols, nommer une Commission Uillageolse de Gestion desTerroirs, composer un R1glement de gestion des ressources.

Tous les projets accompagnent ces differentes phases par desrealisations concretes : l'organisation d'une Banque de Cfr6ales, desaides en transport (camion et carburant) pour In restauration des sols,un moulin pour les femmes, ou une infrastructure sociale (eau, 6cole,dispensaire.. ),

L'interuention d'un programme de gestion de terroir prodult undouble effet : Is structuration de I'espace et I'arganisation desprnducteurs, motiubs par les enjeuH GT qui rclament ensuite lareconnaissance de leurs droits 6 gerer les ressources naturelles.

Le concept de "zonage" qui consiste 6 attribuer des vocations6 des parties du terroir, par activites, obtient un rhel succes dansles zones cotonnieres. Par eHemple a Kimi et Sebedougou, Ind6finition des terroirs, suivie par le "zonage", a permis de protegerles recoltes de coton et de dbplacer les champs situ6s sur les zonesnon agricoles. La protection des reserues foncieres et pastoralesest assur6e par les Peul, appuges par les services forestiers et leprefet, pour infliger des amendes au contreuenants (Faure 1992).

La question des transhumants est prise en compte par lescadres des programmes de "gestion des terroirs": par eHemple donsla Bougouriba, les cadres d~cident d'integrer differentes 6chelles deconnaissance et d'interuention. Ils ont remonte les parcourssalsonniers pour s'entretenir avec leurs collegues vettrinaires et

F ONfIT: Office National d'lfmenagement des Terroirs.

A. FAURE-Fon.ier et injstalaItion de populations-Club d u Sahe/04-94

7

Identifier les pistes suluies. Cette strategie permet d'informer les6leueurs qui uont traverser temporairement une zone amenagee,

Conclusion ; comment traiter la question fanciire dans leszones d'installation?

L'eHperience du Burkina Faso montre qu'il est possible dertsoudre les questions foncieres et Ia problematique de gestion desressources naurelles par un programme 6quiualent 6 celul de la"gestion des terroirs"

Quelques grandes lignes peuuent tre d~finies et certainsprincipes consellIes

- Faut-lI des titres fonciers? Ce nest pas necessaire, laquestion fonciere est surtout sociale et se regle & I'amiable7

- Scurit6 fonciere - gestion dhcentrallsee des ressourceslocales. L'6chelle de decentraisation est 6 considrer

- Une uolont6 politique nationale declaree est ntcessaire- La qualitO de l'encedrement est une condition (utilisationdes longues uernaculaires, haut niueau de qualification,

ulsion globale de la demorche, esperience en milieu rural)- L'approche participatiue menee aupres de tons lesgroupes socIoun- Le facteur temps dolt ftre menag6

Toutes ces remarques saccordent auec les rbflexions meneespar les pays du CILSS et le Club du Sahel pour preparer laConference de PraYa sur le fancier, la decentratisation et [a gestiondes ressources naturelles (CLUB DU SRHEL/OCDE-CILSS 1994).

Pour le Burkina, il reste 6 conquerir un cadre institutionnelofficiel de gestion dfcentraliske i l'echelle la plus locale desressources (reconnaissance des reglements des Comiths de GestionIillageois non seulement par l'administration, mais aussi par lesservices specialises - forestiers, veterinaires). I faut aussig6neralIser l'approche "gestion des terroirs" sur le territoirenational, par une meilleure connaissance de la demarche par lesfonctionnaires, cadres et agents du dueloppement.

7 Rclamts par Jes migrants RU depuis plus de 10 ans. Le Jol emiste au Durkina(nRr rkuls6e en 199 I), les Titres de jouissance suifsent. Les cultiateurs ne lesdemanderont pas k cause des coats de ]a procedure administratiue. Le sfcurItOfoncidre est 114e0 aum besains d'nuestissements : une question soclale et descontreintes 6conomIques (pas de reconnaissance des terres rurales cornmegarentle nypothecolre per les Bonques pour obtenir des prets.

A. FAURE-Foncier et installation. de pOpuaLinRs-Cub du Sabel/04-94

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BIBLIOGRRPHIE

CLUB DU SRHEL/CDE-CILSS, Sgnthses rEigonales sur le foncIej Ad6centrallsptlon et la gestion des ressources noturelies au Sahel, 2vol. Januier 1994, multig.FRURE R., Etude soCio-ethnologaque de j trame foncihre du borrog-de-Ingr6, Ouagadougou, CFD/ONRT, mal 1991, 36p., multig.FDURE R., Ejrcptlid proche 'gestlon dgterroirr par lesPA- ' " "u- BurkinajFaso. Dnze etudes de cosOuagadougou-Paris, PNT/rcti; auril 1992, 1 30p., multig.HERAIQIET J.P., 1978, "La mise en ualeur des Uallees des liolta : unaccident historique", ahiers ORSTOM, serie Sciences Humaines, HI(1 pp. 81-97,H. UEDRRDGO, R. FRURE, R.-R. COMPRORt ET M. DUEDROOGO, IJIjIsauisses do cas" sur le foncler et a d6 fragisI- B iEasv, Ouagadougou/Paris, CILSS/PNGT/Club du Sahel, Januier 1993,0P., multig,

ROLLRND R. et BALRV 6., 1969, L'gondhcieose OD_ 1U or1uswOuagadougou, Orgenisation Mondiale de le sant6, Programme deLutte contre l'Onchocercose dans la 11g9on du Bassin de la Dolta,85p. + cartes, multig

A. FAURE-Foncier et installation de populations-Club du Sabel/04-94

BURKINA FASOCARTE DE SITUATION DES PROJETS A. V.V. - **OUDALAM *

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S 1 U Zorgh 9 U.D Bkn 17 UP KorpigSCOMO E DOE +2 11 Kombissiri 1la Projet Lunf iira-

3 tv Mango. * Pilate BagrL rj.d dvlpe-n- t. og o sud 12 il 'i Sndr4 rura! intesre

. 1 Bugouribn 13 " NouhAno

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BURKINA FASO

MINISTRY OF HEALTH AND SOCIAL WELFARE

General Secretariat

Transmissible Disease Control Directorate

DEVOLUTION PLAN UPDATEOF THE ONCHOCERCIASIS CONTROL PROGRAM IN BURKINA FASO

Onchocerciasis and Human Trypanosomiasis Control and Eradication of Dracunculiasis.

APRIL 1992

DEVOLUTION PLAN UPDATEOF THE ONCHOCERCIASIS CONTROL PROGRAM IN BURKINA FASO

Onchocerciasis and Human Trypanosomiasis Control and Eradication of Dracunculiasis

CONTENTS

Acronyms and Abbreviations Page

Summary 1

1. Introduction 3

2. Epidemiological Situation 4

3. Epidemiological Prospects of the Three Affectsions 90

4. Present State ff the Health System and Resourcesfor Epidemiological Surveillance 10

5. The Objectives of the Devolution Program 14

6. Strategies and Action 15

7. Program Evaluation 20

8. Program Administration and Management 22

9. Accompanying Measures 22

10. Identification of Resources and Evaluation of Program Cost 23

11. Descriptive Estimate of Program Cost for 5 years (in CFA francs) 25

Recapitulation of budget by funding period 31

Timetable 32

Appendices (6)

Maps (4)

Figures (5)

ACRONYMS AND ABBREVIATIONS

ASC Agent de Sant6 Communautaire (Community Health Worker)ASV Agent de Sant6 Villageois (Village Health Worker)AV Accoucheuse villageoise (Village Midwife)AVV Am6nagement des Valle6s des Volta (Volta Valley Development)

CAP Connaissance Attitude Pratique (Attitude/Awareness Survey)CATT Card Agglutination Test for TrypanosomiasisCCP Comit6 Conjoint du Programme (Joint Program Committee)CHN Centre Hospitalier National (National Hospital Center)CHR Centre Hospitalier R6gional (Regional Hospital Center)CM Centre M6dical (Medical Center)CMFC Charge Microfilarienne Communautaire (Community Microfilarial Load)CNDO Comit6 National de D6volution du Programme Onchocercose (National

Committee of the Onchocerciasis Program)CRS Centre R6gional Specialis6 (Specialized Regional Center)CSPS Centre de Sant6 et de Promotion Sociale (Health and Social Welfare Center)CRESA Centre R6gional d'Education pour la Sant6 et l'Assainissement (Regional

Education Center for Health and Hygiene)

DAP Densit6 Apparente par Piege (Apparent Density per Trap)DCMT Direction du Controle des Maladies Transmissibles (Transmissible Disease

Control Directorate)DEP Direction des Etudes et de la Planification (Studies and Planning Directorate)DPS/ASF Direction Provinciale de la Sant6 et de l'Action Sociale et de la Famille

(Provincial Directorate of Health and Social Welfare)

IEC Information Education CommunicationIFI Immuno Fluorescence IndirecteINSD Institut National des Statistiques et de la D6mographie (National Institute of

Statistics and Demography)

MEDIFA Laboratoire des M6dicaments du Faso (Faso Medical Laboratory)

OCP Onchocerciasis Control ProgramOMS Organisation Mondiale de la Sant6 (WHO)ONAP Office National d'Approvisionnement Pharmaceutique (Office of National

Pharmaceutical Supplies)ONAT Office National de l'Am6nagement des Territoires (National Office of

Regional Planning)OST Office de Sant6 des Travailleurs (Occupational Health Office)

PDSS Projet de Developpement des Services de Sant6 (Health ServicesDevelopment Project)

PSP Poste de Sant6 Primaire (Primary Health Post)

SONAPHARM Soci6t6 Nationale d'Approvisionnement Pharmaceutique (NationalPharmaceutical Supply Corporation)

SP/CNLES Secr6tariat Permanent de la Commission Nationale de Lutte contre lesEffets de Secheresse (Permanent Secretariat for the National DroughtCommission)

TLO T616gramme Lettre Officielle (Official Letter Telegram)

SUMMARY

The Onchocerciasis Control Program (OCP) started operations in Burkina Faso in 1975.The present epidemiological situation is such that the disease's residual surveillance andcontrol activities can, in the context of devolution, be integrated with those of the othercommunicable diseases covered by the Ministry of Health and Social Welfare, particularlyhuman trypanosomiasis and dracunculiasis (Guinea worm).

When vector control started onchocerciasis was a real public health problem with ablindness rate of 10% in the first line villages and an obstacle to socioeconomicdevelopment. Today, the transmission has been interrupted in the whole of the country andonchocerciasis has ceased to be a public health problem, allowing land to be cultivated thathad previously lain fallow. However, human migration into the protected zones and thereturn of flies after larviciding has stopped are factors that call for vigilance in order toavoid a recrudescence of this endemic disease.

The epidemiologic situation of trypanosomiasis is not yet well known but the firstentomological and immuno-parasitological surveys show the presence of vector tsetse flies,trypanosomiasis patients and a considerable movement of populations around the watercourses, all these being factors conducive to the revival of former foci.

The findings of a national survey of dracunculiasis conducted in December 1991 showed thatit is very much a public health problem, affecting in varying degrees every province in thecountry.

The onchocerciasis recrudescence prevention strategy will consist of the following fouraction programs:

e Instruction in health education for the target populations (IEC: Information EducationCommunication)

- Longitudinal epidemiological surveillance of the indicator villages- Mectizan treatment of the onchocerciasis-infected migrants- Mectizan treatment of populations exposed to disease recrudescence.

Trypanosomiasis surveillance strategy will consist of an active screening of the populationsat risk using immunological tests and parasitological examinations if necessary. Follow-upsurveys will also be conducted. Patients will be treated at appropriate centers and vectorcontrol carried out by the villagers using traps and screens impregnated with insecticide.The strategy for eradicating dracunculiasis will consist of combining several types of actionbased on epidemiological surveillance, the supply of drinking water and health education.

Each phase of every strategy adopted for onchocerciasis, human trypanosomiasis anddracunculiasis will be supported by a personnel training and retraining program at everylevel.

1

All these epidemiological surveillance activities will be undertaken by the health centers aswell as by mobile teams based in Ouagadougou and in certain provinces. The NationalDevolution Committee, a multi-sector technical body, is responsible for implementing theProgram. Within this committee, the National Coordinator for the Devolution Program,responsible to the Transmissible Disease Control Directorate (DCMT), will supervise thePlan's activities in liaison with the Provincial Health Directors.

To carry out these activities successfully, personnel training, health education, strengtheningand equipping central coordination and assuming responsibility for the project are necessary.

For the years 1992-1996 the project cost is estimated at 1,610,884,256 (one billion sixhundred and ten million eight hundred and eighty four thousand two hundred and fifty six)CFA francs i.e., U.S. $5,712,355 (U.S. $1 = 282 FCFA).

2

1. INTRODUCION

The Onchocerciasis Control Program in Burkina Faso has now entered its devolution phasewhich is the process of integrating its activities with those routinely conducted in the field.Devolution is intended to provide support for primary health care for the control,monitoring and eradication of vector diseases such as onchocerciasis, trypanosomiasis anddracunculiasis in zones where they exist or where there is a likelihood of a recrudescence.The surveillance and control of transmissible vector diseases in the provinces at risk willrelease the human energy needed to cultivate the many fertile valleys in these regions. Thedevolution process therefore is an integral part of an overall development policy. In orderto achieve these objectives, the basic health structures in certain provinces must bereinforced which consists firstly of renovating and rehabilitating existing healthinfrastructures and equipping them so that they can effectively be a center of support andresources as well as a model in the national health system. At a time when theonchocerciasis protected zones are undergoing intense resettlement and development thegovernment of Burkina Faso intends to give priority to a policy of educating and sensitizingthe population in order to safeguard the achievements of the Oncho Program and thenational heritage of the river basins. This strengthening of infrastructure also includes thetraining and retraining of field personnel.

A national devolution plan was elaborated and approved by the ninth Program JointCommittee (PJC) in December 1988 in Dakar, S6n6gal.

The present report, which is a revised version of the 1988 document, details theimplementation of the devolution process, taking into account the eradication ofdracunculiasis as well as onchocerciasis and sleeping sickness.

Since the start of the Onchocerciasis Control Program in 1975 spectacular results have beenrecorded in the control of onchocerciasis. Today, the transmission has been interrupted,the incidence is nil and the intensity of infection has fallen dramatically. Stabilization andregression of eye lesions are established facts in that part of the Program that falls withinBurkina Faso i.e. more that 84% of the national territory.

The country is, however, faced with the other vector diseases which lead to seriousrepercussions on public health and socioeconomic development.

As an example, a survey conducted by the Muraz Center in (OCCGE) in 1984 in thecountry's western regions showed that dracunculiasis accounts for annual losses of aroundone billion CFA francs.

A special emphasis is laid on the harnessing of the agricultural potential of theonchocerciasis protected zones so as to attain food self-sufficiency. In this context thegovernment is particularly concerned with the control of human trypanosomiasis and theeradication of dracunculiasis in light of the massive resettlement of these fertile valleys stillunder the menace of this scourge. There are control programs for other endemic diseases,especially schistosomiasis and malaria.

3

2. EPIDEMIOLOGICAL SITUATION

2.1. Onchocerciasis

2.1.1. Epidemiological Situation Before The Start Of The Control

Before the start of vector control in 1975, onchocerciasis was a very serious public healthproblem in Burkina Faso.

It has been estimated that some 580,000 persons were infected with O.volvulus '. Noreliable estimates were available for the total number of blind due to onchocerciasis in thecountry, but detailed ophthalmological surveys demonstrated that onchocercal blindnessrates in the first line villages could be as high as 10% of the village population and closeto 50% of the population above the age of 50.

The most affected zones were the river valleys of the Nakambe (White Volta), the Nazinon(Red Volta), the Sissili, the Bougouriba, the Koulpeolgo, the Comod and the Leraba. whichcontained some of the worst foci of endemic onchocerciasis in the world. The disease wasalso an important obstacle to socioeconomic development and prevented the resettlementof the valleys such as the Nakambe and the Nazinon.

2.1.2. Epidemiological Impact of Vector Control

The OCP started vector control in 1975 and the impact of control has been welldocumented by extensive epidemiological surveys. Baseline surveys were done in 116villages and follow-up surveys have been done at intervals of 3-4 years in 88 of thosevillages. The results have shown that vector control has been extremely successful inBurkina Faso. Out of 6,354 children examined, who were born in these villages since thestart of control, only four were found to be infected against an expected number of 584, hadthere been no vector control. All four children come from one village, Pendi6, where alocalized relapse of transmission had occurred. The particular case of Pendi6 will be dealtwith later on.

Following the interruption of transmission by vector control the parasite reservoir startedto die out naturally. This resulted in a dramatic decline in the intensity of infection, asmeasured by the Community Microfilarial Load (CMFL) which had decreased by more than96% after 12 years of vector control. This was a very important achievement because theseverity of onchocerciasis disease is directly related to the intensity of infection, and the

1Report of the Mission for Preparatory Assistance to theGovernments of Cote d'Ivoire, Dahomey, Ghana, Upper Volta, Mali,Niger and Togo. UNDP/FAO/IBRD/WHO, Geneva, 1973.

4

control of onchocerciasis as a disease of public health importance could therefore beclaimed after 10-12 years of control in Burkina Faso.

As was expected, the prevalence of microfilariae in the skin took a longer time before itstarted to decrease, but it is now clearly showing the accelerated decline which had beenpredicted by epidemiological models. Examples of this important trend are shown in figure1 for villages from different river basins which had a very high pre-control intensity ofinfection.

2.1.3. The Case of the Village of Pendi6 (Dienkoa Basin)

The only exception to the excellent results of vector control concerns the stretch of theDienkoa river round the village of Pendi6. Not only were four children detected with newinfections in 1985, but the decrease in the CMFL as well as prevalence was unsatisfactoryand indicated a considerable level of superinfection in the adult population. Extensive skinsnip surveys, with particular attention to children born since the start of control, indicatedsimilar problems in neighboring villages, but the problem appeared to be fairly localized.

A retrospective analysis of the available date suggests that residual transmission continuedand even intensified between 1980 and 1985 and the epidemiological trends for this focusare believed to be some ten years out of phase with the rest of the country. A specialstrategy for long term control in this particular focus has been developed ever sincelarviciding was interrupted in the surrounding area. It is for this reason that the Pendi6focus has been selected as a priority area for a community trial of the potential of Mectizanfor disease control in a situation with recrudescing transmission.

The first round of ivermectin treatment in April 1988 involved 1,390 persons from sixvillages in the Pendi6 focus. The treatment coverage was between 65% and 72% of thecensus population with the exception of the village of Pendi6 itself where the coverage wasonly 54%. For the purpose of the trial, larviciding was interrupted during five months in1987 and during the same period in 1988 in order to enable the collection of extensive pre-and post-treatment entomological data on the level of transmission. Irrespective of findings,Mectizan treatment has been continued on an annual basis in this focus so as to protect theinfected population from onchocercal disease. It is reassuring to note that today the CMFLin the Dienkoa basin (Pendi6), as in other river basins of Burkina Faso, is below 0.50, rulingout the risk of blindness from onchocerciasis.

2.1.4. Predicted Epidemiological Trends and Interruption of Larviciding.

Though the disease is under full control in the rest of the country, the parasite reservoir hasnot been eliminated. However, as has been shown in Figure 1, this reservoir is dying outfast and it is predicted that it may reach insignificant levels after some 15 years of control.

5

At that stage the risk of recrudescence of infection and disease may be negligible even ifthe vector manages to repopulate the breeding sites. The OCP has therefore interruptedlarviciding in large parts of Burkina Faso and in similar areas in neighboring countries.

Post control entomological surveys conducted over a dozen sites in Burkina Faso clearlyindicate that despite a return to pre-treatment levels of the incidence of T,;e*sCfly bites, <transmission is, if not nil, at least negligible. For example, from July 1990 to July 1991,19,301 par females were dissected at Nab6r6 on the Bougouriba. Only eight females wereinfectious, i.e., a rate of 0.41 infectious females for 1,000 par females versus 100-200infectious females for 1,000 before the start of the Program. The mathematical modeldeveloped by the OCP shows that with such a rate of infection the recrudescence of thedisease is quite improbable.

2.2. Human Trypanosomiasis

Entomological and immuno-parasitological surveys were carried out in the provinces ofSissili, Boulkiemd6, Como6, Mouhoun, and Nahouri in 1986 and 1987 and in Bougouribaand K6n6dougou in 1989.

More than 60 localities situated near forest galleries and presenting activities likely to favorthe revival of former trypanosomiasis foci or the creation of new ones were the subject ofa sampling of the tsetse fly population. Blood samples were taken from the most exposedpopulations on Wattman paper for Indirect Immunofluorescence.

2.2.1 As Regards Entomology

Riverine tsetse flies have been caught regularly in the forest galleries along the principalwatercourses and their tributaries. The vector control team has prospected along theLeraba and the Como6 in the Banfora, Loumana, Soubaka, Dakoro and Niangolokodistricts.

Tsetse fly vectors of sleeping sickness have been caught in the forest galleries all along thewatercourses. The two species encountered are Glossina palpalis 58%, and GlossinaTachinoides 42%. The mean of the densities per trap per day is 14 with extremes of 2flies/trap/day (DAP) at Guindougouba and 52 flies/trap/day at Konandougou.

The surveys on the Bougouriba show a predominance of G.Tachinoides with apparentdensities of 27 flies/trap/PD. On the Mouhoun, the presence of tsetse flies has beenreported with an epidemiological context favorable to man-tsetse fly contact. Another seriesof surveys is needed in order to be more specific about the extent of vectors along thiswatercourse whose fertile valleys are the theater of very heavy internal migrations.

6

2.2.2. As Regards Immunology

Following passive detections, immuno-parasitological surveys were conducted among someof the exposed populations. Some 46,000 persons were examined and blood samples takenfrom them for immunofluorescence. After treatment at the Muraz Center in Bobo-Dioulasso, 111 serums proved positive, i.e., 0.24%.

Card Agglutination Tests for Trypanosomiasis (CATT) were made, but difficulties appearedduring the handling of the CATT which made them unfit for use in mass screening.

2.2.3. Parasitological Confirmation

This was made in the laboratory of the specialized centers at Ougadougou, Bobo-Dioulassou, Koudougou and Banfora. The zones at risk in the Como6 region underwentrigorous surveillance in 1988. This surveillance made it possible to identify a localtransmission focus at Diarabakoko and its surroundings where seven cases were detectedbetween April and July 1988. Over the last five years, 200 cases of trypanosomiasis havebeen detected throughout the country.

The findings of the different mission reports support one another and generally describe thesame epidemiological situation, viz:

* A rapid, large-scale resettlement of the lowlands of the watercourses where theforest galleries actually harbor tsetse fly species that are vectors of sleepingsickness.

- An intense, permanent human activity on the banks of these watercourses therebyfavoring man-tsetse fly contacts (market gardening, fishing, watering, washing, etc.)

* A constant internal migration from the north and central-east toward the west andsouth-west, coupled with a seasonal external migration of young rural workersbetween these zones and neighboring countries, particularly towards areas knownto be active sleeping sickness foci.

- The few patients detected are from provinces highly affected by migration (98% ofcases detected originated from contamination outside the country).

7

2.3. Dracunculiasis

2.3.1. Passive Reporting Data

Like the other endemic diseases, dracunculiasis is under-reported by the health authorities.Some of the many reasons for this are listed below:

- Since no modern, effective treatment exists, patients do not come into the healthcenters for treatment.

- The health centers are either geographically or financially out of reach for thepatient.

- Since the disease is not usually fatal, patients are not motivated to come to ahealth center for treatment.

Passive reporting for dracunculiasis in Burkina Faso, therefore, gives an average of 1,000to 2,000 cases per annum, which is a far cry from the actual situation.

2.3.2. National Survey Data

So as to determine the actual extent of dracunculiasis in Burkina Faso a national survey wasconducted in December 1990. Every province is affected to one degree or another (seeMap No. 4).

Out of 8,086 villages visited, 2,621 were affected, i.e., an incidence of 32.5%. Among thevillages affected, 21% reported only one case.

42,187 cases were reported for the entire country, i.e., a rate of 54.5 per 10,000 (seeAppendix V). Seventy percent of villages affected had more than 10 cases whichdemonstrates the extent of the scourge in the country.

Although retrospective, the national survey was able to locate the peak season for thedisease between June and August, which conforms to surveys conducted by the MurazCenter.

The analysis of the situation as regards sources of drinking water in relation to cases ofGuinea worm revealed that 84% of the villages affected had at least one source of drinkingwater. The reasons for this apparently paradoxical situation include the following:

e Number of water points inadequate for the size of the village, causing long waitinglines for the women who end up having recourse to surface water;

* Water point remote from the village;

8

* Water points located in sacred areas;- Surface waters used on cultivated land;e Refusal to drink water from certain wells because of its taste;- Ignorance of link between dracunculiasis and water.

Such a situation recommends placing particular emphasis on population awareness duringwell installation programs.

The link between dracunculiasis and a source of drinking water is given in the table below.

Situation of Villages Affected in Relationship to the Water Source

VILLAGES PERCENTAGE

Villages affected w/o drinking water 295 3.7%Villages unaffected w/o drinking water 1,186 14.7%Villages unaffected with drinking water 4,261 52.8%Villages affected with drinking water 2,326 28.8%

Total 8,086 100%

Source: Transmissible Disease Control Directorate - Ministry of Health and Social Welfare

3. EPIDEMIOLOGICAL PROSPECIS OF THE THREE AFFECTIONS

The many programs for the development of the valleys protected from onchocerciasis createa considerable internal migration movement. This migration takes place in a north-east tosouth-west direction. The valleys concerned with these movements are the Bougouriba,Mouhoun, Como6 and Sissili valleys (See Map No. 1).

The return of abundant rains has been recreating ecological conditions favorable for thedevelopment of flies that are vectors of sleeping sickness. To these factors should be addedthe return to the country of many migrant workers, among whom more and moretrypanosomiasis and onchocerciasis patients are detected.

The persistence of the reservoir of the human virus, the migration of populations betweenthe savanna and forest zones, where the problem of 'forest' onchocerciasis still remains, andabove all, the return of flies due to cessation of larviciding are all factors favorable to arecrudescence of onchocerciasis if a prevention strategy is not put in place rapidly.

Regarding dracunculiasis, government action has helped contain the affection fromspreading. Dracunculiasis, however, still remains a public health problem and an obstacleto socio-economic development, and demands a greater mobilization of resources for itseradication which today seems feasible.

9

4. PRESENT STATE OF THE HEALTH SYSTEM AND RESOURCES FOREPIDEMIOLOGICAL SURVEILLANCE

4.1. General Introduction

Burkina Faso is a Sahelian country without access to the sea situated in the heart of WestAfrica. Its total surface area is 272,528 square km., with a population of 8,881,000inhabitants (INSD - National Institute of Statistics and Demographics - 1989 figures), i.e.,a density of 32 inhabitants per square km. The economic activities, which are mainlyagricultural and herding, provide the population with a per capita income of US$ 210(1986). Burkina Faso is one of the least developed countries.

The following are the demographic indices:

e Birth rate: 46 per 1,000 (1986)- Death rate: 22 per 1,000 (1985)* Child mortality rate 134 per 1,000 (1986)- Natural growth rate: 2.6%* Life expectancy at birth: 48 years (1986)

The problem of potable water supply is still serious.

In 1984, 35% of the population had safe water within 15 minutes walking distance, 50% inurban areas had access to a water point (24% at home and 26% from public taps). In ruralareas, the rate of coverage as compared to the objective of 10 litres per day per inhabitantwas 70%, with distribution varying considerably in the field.

Environmental sanitation is the source of many communicable diseases. The rate ofcoverage in terms of latrines is 38% for urban areas and 5% for rural areas (1984).

The present health system is characterized by an insufficient coverage due on the one handto unequal distribution of the already limited resources, and on the other hand to the natureof an inadequate communications network.

4.2. Organization Chart of the Ministry of Health and Social Welfare

The Ministry's organization chart was recently restructured as follows:

- The Office of the Minister- General Secretariat of the Minister

10

The General Secretariat comprises the following twelve government directorates:

* Disease Prevention Through Vaccination Directorate- Studies and Planning Directoratee Family Health Directorate- Health Education and Sanitation Directorate" Pharmaceutical Services Directorate- Administrative and Financial Affairs Directorate- Professional Training Directorate* Transmissible Disease Control Directorate- Social Reinsertion Directorate- Child Care Directorate- Family Health Directorate- Government Inspection of Socio-Sanitary Services

Also reporting to the General Secretariat are the following:

e The National and Regional Hospital Centers (CHN and CHR)e The National Pharmaceutical Supply Corporation (SONAPHARM)- The Red Cross" The Health Services Development Project (PDSS)* The Occupational Health Office (OST)- The Faso Medical Laboratory (MEDIFA)" The Permanent Secretariat for The National Drought Commission (SP/CNLES)- The Schools and Institutions for Professional Training and Retraining

4.3. Resources For The Public Health Services

Health services are provided to the population on the lines of a pyramidal network asfollows:

- 6,592 Primary Health Posts (PSP) at village level (1988)- 148 Dispensaries- 16 Maternity Clinics Without Dispensary* 463 Health and Social Welfare Centers (CSPS) for population centers of 15,000

to 20,000 inhabitants* 63 Medical Centers (CM) for population centers of 150,000 - 200,000

inhabitants- 9 Regional Hospital Centers (CHR)* 2 National Hospital Centers

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Human Resources

Manpower is inadequate in terms of quality and quantity. The health personnel situationis far from the standards generally accepted and advocated by the WHO for the country'stwo decades of independence.

4.4 Cost of Public Health Services

Analysis of the health budget as a percentage of the national budget from 1985 to 1990shows that after having fluctuated between 5% and 6%, it is on an upward trend.Percentages have moved from 7.4% of the national budget in 1983 to 7% in 1990.However, it should be noted that more than 80% of this budget is allocated to staff salaries.This budget does not include external bilateral, multilateral and non-governmentalassistance.

4.4.1. Equipment Resources

Health structures are under supplied with equipment, logistics and expendables. Thisinadequacy in numbers is combined with the difficulty of maintaining equipment andlogistics in working order.

Many of the apparatus (X-ray and laboratory apparatus) and vehicles can not be used, veryoften due to minor breakdowns, thus considerably cutting back on service performance.

4.4.2. Financial Resources

The public health system works on an operating budget taken up mainly by salaries (75%-84%) and medical students' and trainee nurses' bursaries.

The Ministry of Health and Social Welfare only began to enjoy the benefits of theinvestment budget since the start of the first Five Year Popular Development Plan. Inrelation to the Ministry's budget, the investment budget increased on average from 1.10%for 1985-86 to 4% between 1987 and 1990.

A big effort has been made over the last three years in the field of drugs and technicalequipment. The budget allocated to these items rose on average from 3.7% of the 1985-87Ministry of Health and Social Welfare's budget to 6.7% between 1988 and 1990.

Income from hospital charges has not changed (12% of the Ministry's budget).

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4.5. The Health Policy of the Burkina Government

Government policy is aimed at achieving a health coverage for the population along thelines of a welfare system: health for the people by the people.

The main lines are as follows:

e Health for all- Implementation of maternity and child health caree Policy of immunization against communicable diseases by increasing vaccination

campaigns* Mass education in hygiene- To achieve the government objectives of health for all by the year 2000 Burkina

Faso has adopted the WHO strategy based on primary health care (SSP), layingemphasis on educational and preventive activities and calling on individuals,families and communities to take over responsibility for their health care.

4.6. Epidemiological Surveillance Operations

Epidemiological surveillance in Burkina Faso is carried out by the Transmissible DiseaseControl Directorate (DCMT). It follows the pyramidal pattern along the lines of the healthservices organization chart.

Each health post has a register for daily consultations in which the nurse records all thediagnoses for the day. At the end of the day he enters the diseases under epidemiologicalsurveillance on a special form.

This weekly form, called Official Letter Telegram (TLO), has to been sent at the end ofeach week to the medical center or regional hospital on which the health post depends.

From the medical center or regional hospital, this form is sent to the Provincial HealthDirectorate which summarizes all the reports from all the health centers in its provinces andforwards them to the Transmissible Disease Control Directorate. The Studies and PlanningDirectorate (DEP) computer processes the data.

However, because of dispatch difficulties the Official Letter Telegrams are often very latein arriving. When there is an epidemic in a locality the medical officer in charge is quicklyinformed. Often it is the health worker who goes by whatever means possible to inform hisimmediate superior.

The medical officer in charge of the zone in question informs his Provincial Director whothen contacts the Transmissible Disease Control Directorate. But before receiving

13

directives, which are often long in coming because of communication difficulties, he setsabout containing the epidemic through intensive treatments, isolation of patients andvaccination of the population.

4.7. Surveillance Resources

In the context of an integrated health system, all the workers of the health centers areinvolved in epidemiological surveillance together with effective participation by thecommunity. In fact, very often the health services are alerted by people having seenanomalies compared to what they are accustomed to seeing. Territorial AdministrationServices also make a valid contribution.

Less than 10% of the health budget is devoted to epidemiological surveillance. The budgetof the Five-Year Development Plan (1986 - 1990) estimated at 19,900 million CFA francshas earmarked 1,600 million CFA for the control of the major endemic diseases.

To protect the achievements of the Onchocerciasis Control Program in the fertile valleyswhere onchocerciasis and trypanosomiasis are at their lowest prevalence, but theepidemiological context is conducive to serious recrudescence, the Ministry of Health andSocial Welfare intends to carry out a special onchocerciasis and trypanosomiasis surveillanceand control program with the prospects of integrating with other vector-transmitted diseases.

This is why the three years of field work have led us to review the trypanosomiasissurveillance and control methods and strategy in a more realistic and effective frameworkwhich should be integrated with onchocerciasis surveillance.

5. THE OBJECIVES OF THE DEVOLUTION PROGRAM

The main objectives of the program are as follows:

- Keep the onchocerciasis transmission level at zero and counteract anyrecrudescence of the disease

" Prevent human trypanosomiasis foci from emerging in onchocerciasis protectedzones

- Eradicate dracunculiasis by 1996

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In order to achieve these general objectives the Ministry of Health and Social Welfare hasidentified intermediate objectives for the successful outcome of devolution viz.

e Provide training for personnel involved in the program

- Set up a program for educating, informing and communicating with the population

- Identify the zones where onchocerciasis is likely to recrudesce and humantrypanosomiasis foci likely to reappear

- Supply all the villages affected by dracunculiasis with drinking water

- Provide filter screens to every household in the villages affected by dracunculiasis

e Treat every case of dracunculiasis detected throughout the entire program

- Set up an epidemiological surveillance system integrated with the National HealthInformation System.

6. STRATEGIES AND ACTION

6.1. Onchocerciasis

As reported previously, onchocerciasis is no longer a public health problem in Burkina Fasoand the last adult worms are dying out rapidly. The parasite reservoir is virtually eliminatedin most of the country and the risk of recrudescence is minimal.

The OCP has therefore stopped larviciding of every watercourse in Burkina Faso except fora small stretch of the Mouhoun in the region of Poni, the basins of the Dienkoa and thelower Sissili where epidemiological results are not yet fully satisfactory, showing aprevalence of approximately between 7% and 8%.

The interruption of larviciding has already resulted in the return of the vector in very highdensities, and although the files are virtually no longer carriers of the pathogenic agent, thepossibility of localized relapses of transmission can not entirely be ruled out due mainly tothe question of human migration mentioned previously.

So as to prevent, therefore, any recrudescence of onchocerciasis, Burkina Faso has adopteda four part strategy:

, - Information, education and communication* Epidemiological surveillance* Mectizan treatment of onchocerciasis-infected migrants* Mectizan treatment of populations exposed to a recrudescence of the disease

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6.1.1. Information, Education and Communication (IEC)

IEC and mobilization of the target population will play a front line role in the change ofbehavior needed to promote health care and safeguard OCP achievements.

It could certainly be an integral part of a package for controlling other endemic diseasesand better still, part of the three phase health development scenario for strengtheningprimary health care activities at community level and insuring support from the higherechelons of the hierarchy.

The future creation of regional education centers for health and hygiene (CRESA) will giveadded clout to the system.

The specific objectives of the health education programs can be defined as follows:

* Educate the population to recognize flies and then inform the closest health andadministrative authorities.

* Direct the migrants suspected of onchocerciasis infection to the health centers

- Join in the attitude/awareness surveys (CAP) and Mectizan treatment or vectorcontrol campaigns.

Action to be undertaken in this context can be summarized as follows:

e Elaborate and distribute an information and health education leaflet ononchocerciasis in the zones concerned

" Organize training seminars and assess the knowledge of the target individuals

- Periodical assessment of IEC activities

* Schedule training workshops for Provincial Health and Social Welfare Directorates,health and social welfare centers and villages

" Broadcast radio programs through the regional stations to backup information inthe zones concerned

- Produce educational films for population awareness

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6.1.2. Epidemiological Surveillance

As already indicated earlier, the likelihood of a recrudescence of onchocerciasis is very low,even minimal. Even if recrudescence should occur, infection will initially be slow andassociated with low transmission levels. Current entomological methods are not appropriatefor the detection of such low levels of transmission because they would involve thedissection of a very large number of flies.

Surveillance will therefore be based on epidemiological methods only and will have as itsobjective to detect any relapse of transmission and assess the impact of control resourcesavailable.

The indicator of such a relapse will be the presence of new infections in individualspreviously uninfected. This type of surveillance will be based on skin snip surveys at regularintervals in the indicator villages. At present, this is three year interval. These indicatorvillages, whose numbers will vary depending on the epidemiological situation, are first linevillages which represent all river basins in the country with potential breeding sites. Theseindicator villages will be selected in close collaboration with the OCP.

Epidemiological surveys will be conducted by centralized and regional and mobile teams.

Skin snip surveys are carried out using common techniques that have been used by the OCPfor over ten years. Owing to the risk of contamination by the AIDS virus, however, the newWHO recommended technology will be used in the field. Once the immunologicaltechniques have been developed they may very well replace the skin snips.

In places where new infections have been detected, the extent and the seriousness of theproblem in the zone in question will have to be assessed. Extensive skin snip surveys mayhave to be undertaken in the other settlements around the indicator village in order toobtain an epidemiological map of the river basins involved.

System implementation, training and back-up will be supplied by OCP personnel.

6.13. Mectizan Treatment of Infected Immigrants

All immigrants found to be skin snip positive or highly suspect of onchocerciasis infectionduring the epidemiological surveillance or the special surveys on migration will be treatedwith Mectizan.

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6.1.4. Mectizan Treatment of Exposed Populations

If an active epidemiological survey proves there is a recrudescence in any one zone, thelatter will be subjected to massive Mectizan treatment. At the present time, it isrecommended carrying out treatment once a year over a relatively long period (around 15years) in liaison with the mobile teams.

6.2 Human Trypanosomiasis

Control strategy for human trypanosomiasis is based on patient screening and treatment aswell as vector control.

6.2.1. Patient Screening and Treatment

The initial phase will be devoted to the systematic screening of the whole population incertain particularly sensitive zones. The entire population is subjected to screeningimmunological tests while parasitological examinations are conducted on only suspect cases.Once this 'combing' phase by the mobile teams has been completed, the second phase willconsist of an epidemiological survey which may take two forms depending on the resultsobtained previously:

- Either intensified surveillance by regular visits to the villages which featured aconsiderable number of new cases during propsection

- Or a passive surveillance in villages where no case has been detected. New surveyswill be conducted when a new case has been brought to light by this passivesurveillance. Patients will be treated in specialized health centers.

6.2.2. Vector Control

Vector control will be based essentially on the trap technique. Insecticide-impregnatedtraps will be used selectively at places where the risk of man-vector contact is maximum.The period for the installation of the traps will preferably be the dry season when tsetse flypopulations decrease naturally at a high rate and are confined to limited zones.

The village health committee will be taught the insecticide impregnation technique and howto install traps in strategic locations. The first batch of traps will be provided free. Overthe following years the village will contribute to the cost of maintaining and replacingequipment, except for the insecticide which will continue to be free.

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6.3. Dracunculiasis

6.3.1. Community Health Education and Mobilization

Dracunculiasis is a disease mainly linked to ignorance and its eradication will be based onan overall strategy that includes the educational approach, a prior requirement to any healthprevention and promotion activity. Every communication channel adapted to the ruralenvironment (local radio, talks, etc.) will be used by all the agents involved in the programwith full participation by the community.

6.3.2. Filtration of Drinking Water

Filtration is aimed at eliminating the infected cyclops from the suspect drinking water.Simple technique of the filter screen will be used which can be easily applied by the villagecommunity.

6.3.3. Treatment of Cases

Since no really effective drug exists against larvae and adult worms, treatment consists ofdressing wounds which relieves the patient, prevents super infection and avoidscontaminating the drinking water.

6.3.4. Drinking Water Supply

Providing a supply drinking water is one of the main strategies in a dracunculiasiseradication program. Unfortunately, it requires considerable investments which are nottaken into consideration in the present document.

Burkina Faso has undertaken major efforts in village well drilling but installations are stillinadequate.

As part of the program for eliminating Guinea worm, the affected villages without wellsshould be the first to benefit from the village hydraulic program of the second Five-YearPlan (1991 - 1995). This naturally calls for close collaboration between the healthauthorities and those in charge of supplying drinking water to the rural areas. Such a policywill have to be substantiated by an official text.

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6.3.5. Epidemiological Surveillance

Epidemiological surveillance is an essential part of the plan for eliminating dracunculiasis.

In the initial phase of the program, surveillance activities will be aimed at identifyinginfected villages and the number of cases. The survey of drinking water sources will be acomplementary action.

At a later stage, this surveillance will be used for assessing the effectiveness of intervention.The newly-infected villages will be detected in time as will be the villages where the endemicdisease persists despite the control methods in place.

At the end of the program, the epidemiological surveillance will be used to effectivelyconfirm elimination.

7. PROGRAM EVALUATION

The evaluation will be used to check the achievement of the fixed operational objectives andthe program effectiveness. An internal evaluation will have to be made by the program'snational supervisors. The external evaluation will have to be conducted at the end of thesecond year and at the end of the program. Both will consist of an operational and anepidemiological evaluation.

7.1. Operational Evaluation

Training

* Percentage of health personnel trained- Percentage of community health workers trained- Percentage of surveyors trained* Percentage of supervisors trained- Percentage of other agents trained

Health Education

- Percentage of Medical Centers (CM) and Health and Social Welfare Centers(CSPS) equipped with visual aids (posters, educational materials and leaflets)

- Number of posters distributed- Number of programs broadcast on radio and TV- Number of health education sessions in the villages

20

Treatment of Cases

- Percentage of villages fitted out with medical kits* Number of cases of dracunculiasis treated in Primary Health Posts (PSP) and

health centers- Number of cases of dracunculiasis treatede Number of cases of onchocerciasis treated

Water Filtration (Dracunculiasis)

- Number of filter screens made" Number of screen distributed- Percentage of households with at least one screen

7.2. Surveillance/Epidemiological Evaluation

" Percentage of health centers with correct case reporting- Percentage of health centers which communicated the reports in time- Percentage of reports received

Supervision

- Number of supervisory missions undertaken versus number estimated (central,intermediate and peripheral)

Passive Reporting of Cases

e Number of villages affected per district and per province- Number of cases identified per village, district and province

Active Search for Cases

* Number of villages that underwent epidemiological surveillance surveys* Prevalence after survey (onchocerciasis and trypanosomiasis)- Incidence after survey- Number of immigrants infected (onchocerciasis and trypanosomiasis)

7.3 Impact on Target Population

At the end of the program, a CAP survey will be required to determine effectiveness.

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8. PROGRAM ADMINISTRATION AND MANAGEMENT

8.1. Role of The National Devolution Committee and Central Coordination

The National Devolution Committee is the technical body in charge of programimplementation (see Appendix VI for composition and attributions).

As a member of this committee, Central Coordination reporting to the TransmissibleDisease Control Directorate will be allocated the adequate personnel and equipment toserve as technical and administrative support to the mobile teams and the Provincial HealthDirectorates.

Technical supervision of the mobile teams is the responsibility of the National Coordinatorwho will keep close links with the Provincial Directors of Health and Social Welfare(DPSASF).

The Directors concerned will have to provide regular justification for their expensesincurred, the utilization of expendables and fuel.

Data processing and analysis will be carried out by the Transmissible Disease ControlDirectorate (DCMT) with technical back-up from the Studies and Planning Directorate(DEP) and the OCP.

8.2. Peripheral and Provincial Levels

The program will be implemented by the Provincial Health Directorates in liaison withCentral Coordination using the support of peripheral facilities.

8.3. Logistics and Financial Management

An experienced manager will handle the program's finances. His main duties will be themanagement of logistics and keeping the accounts up to date.

9. ACCOMPANYING MEASURES

The intermediate objectives identified as being required for the implementation ofdevolution involve the following accompanying measures:

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9.1. Developing and Equipping Central Coordination

It is proving necessary to build up and equip the Transmissible Disease Control Directorateowing to the current dispersion of services reporting to the central operations that play amajor role in the surveillance of transmissible diseases. Such measures would allow for afunctional infrastructure adequately equipped to take account of changing needs in qualityand quantity of epidemiological surveillance and control of transmissible diseases.

9.2. Health Personnel Training and Retraining

Since devolution is a process integrating the routine activities of the health centers, training,supervision and retraining of agents in the field have become vital for implementingscheduled operations. The following categories of agents are subject to such training andretraining:

- The Provincial Health Directors (DPS) and the primary health care supervisors inthe provinces.

- The health workers from the peripheral health facilities

* The community health workers (ASV + AV: village health workers and mid-wives)

- The National Coordinator and the other agents in the Program

10. IDENTIFICATION OF RESOURCES AND EVALUATION OF PROGRAMCOST

10.1. State Participation

In order to successfully carry out the Devolution Plan of the Onchocerciasis ControlProgram, Burkina Faso will call upon the Ministries and national authorities concerned tobuild up the Transmissible Disease Control Directorate operations, as well as CentralCoordination, set-up mobile health teams, insure personnel training and retraining andinstruct and inform the population in the field of health education.

The State, which has already covered over 75% of the Program's area in health and socialwelfare infrastructures (dispensaries, maternity homes, wells, dams, schools and lines ofcommunication) will continue to fund the payroll of the agents involved in theimplementation of the Devolution Program (see Appendix II and III).

23

The State, therefore, has already contributed over 6,144,400,000 CFA francs, i.e., US$21,788,652 in investments for health and capital infrastructures and at least 500,000,000 CFAfrancs (US$ 1,773,050) per annum for personnel salaries.

10.2. Program's Complementary Budget (See detailed cost estimate in Chapter 11 andAppendices)

10.2.1. Investments

- Building and equippingcentral coordination operations 198,252,000

e Vehicles 91,000,000e Medical technical equipment 12,557,682- Computer equipment 4,862,500- Vector control equipment 6,850,000* Trek equipment 2,769,400- Training/seminar/retraining 229,428,000- IEC materials 127,917,000

Sub-total = 673,636,582. F CFA

10.2.2. Recurrent Expenditure

* Vehicles and generator maintenance 20,000,000- Fuel/lubricants 107,405,000- Drugs 97,000,000- Filter screens 390,000,000* Reagents and lab supplies 7,600,000- Per diem/surveys (surveillance) 221,650,000- Office supplies 15,000,000* Computer servicing 1,883,900

Sub-total = 860,538,900. F CFA

Total investments andrecurrent expenditure 1,534,175,482. F CFA5% for contingencies 76,708,774. F CFA

General total: Investments and recurrentexpenditure and contingencies 1,610,884,256. F CFA

i.e., One billion six hundred and ten million eighty hundred and eight four thousandtwo hundred and fifty six CFA francs.

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11. DESCRIPTIVE ESTIMATE OF PROGRAM COST FOR FIVE (5) YEARS(IN CFA FRANCS)

11.1. Investments

11.1.1. Building and equipping DCMT in Ougadougou 198,252,000

11.1.2. Vehicles

Ouantity Unit Price Total

4 x 4 Vehicle 7 9,000,000 63,000,000

SG4 Truck 1 10,000,000 10,000,000

Mopeds 30 600,000 18,000,000

Sub-total= 91,000,000

11.1.3. Computer Equipment

386 SX-MHzPersonal Computer 1 1,134,250 1,134,250

Color Monitor 1 266,760 266,760

EPSON Printer 1 287,400 287,400

Portable 386 SX-MHzComputer 2 1,050,000 2,100,000

Portable Printer 1 375,000 375,000

Sheet Feeder 1 88,400 88,400

600 VA Stabilizer/SurgeProtector 1 610,750 610,750

Sub-total= 4,862,560

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11.1.4. Medical Technical Equipment for 3 Teams


Holth's Punch 4x3 73,346 880,152

Slices 120x3 Koudougou 1,990 716,400

Eppendorf Pipette 2x3 Bobo = 3 48,025 288,150

Lancet 2x3 Banfora 31,500 189,000

Microtiter Plate 20x3 14,620 877,200

Curved Scissors 2x3 1,200 7,200

Straight Scissors 2x3 1,150 6,900

Kocher Punch 2x3 620 3,720

RectangularEnamel Plates 4x3 6,200 74,400

Haricot Enamel Plates 2x3 310 1,860

Mechanical Scale 3 15,000 45,000

Tensiometer 3 16,000 49,500

M5 Loupe 2x3 310,000 1,860,000

EDAK Trunk 3 19,400 58,200

Microscope 3 600,000 1,800,000

Centrifuge

(microhematocrit) 2x3 teams 500,000 3,000,000

YAMAHA E.T. 500Generator 3 teams 300,000 900,000

Gas/electric fridge 3 teams 300,000 900,000

Sub-total= 12,557,682

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11.1.5. Trek Equipment


Camp bed and

Sleeping Equipment 6x5 50,000 1,500,000

Folding tables 4x5 20,000 400,000

Chairs 8x5 7,250 290,000

Screw stools 2x3 29,900 179,400

Cooking equipment 5 80,000 400,000


11.1.6. Vector Control

Tsetse fly traps 300 5,000 1,500,000

Accessories (drums, boots, gloves) 80,000

Buckets 20,000

Insecticides (4 impregnations per year x 5)

(Deltamethrine) 150x5 7,000 5,250,000


11.1.7. Training and Seminars

Seminars/retraining costs(see Appendix 1 for details) 229,428,000

11.1.8. IEC Materials (see Appendix IV for details) 127,917,000

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11.2. Recurrent Expenditures

11.2.1. Vehicle Maintenance and Repair

8 x 5 years 20,000,000

11.2.2. Fuel and Lubricants

Coordination andMobile Teams 3,500 1 x F272 x 8 x 5 years 38,080,000

Support for DPSASFin Devolution Plan 1,500 1 x F272 x 30 x 5 years 61,200,000

Lubricants 2,500 1 x 5 x F650 8,125,000

Sub-total= 107,405,000

11.2.3 Drugs

Emergency Kit(Standard) 4 x 5 years 150,000 3,000,000

Treatment of TrypanosomiasisPatients - 5 Years (100 patients/year) x 30,000 15,000,000

Treatment ofDracunculiasis Cases 79,000 x F1000 79,000,000

Sub-total= 97,000,000

11.2.4. Laboratory Reagents and Supplies

CATT andImmunofluorescence 4 x 5 years x 300,000 6,000,000

Filtration Columns 100 x 4 x 5 x 300 600,000

Small Lab Equipment 4 x 5 x 50,000 1,000,000

Sub-total = 7,600,000

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11.2.5. Epidemiological Surveillance Budget

Mobile Teams 3 x 60 days x 6 x 2,500 x 5 years 13,500,000

DESA Team (CRESA Agent and Communication Agents)3 persons x 36 days x 10 x 5 years x 2,500 13,500,000

Central Coordination (Supervision) 4 x 60 days x 5 yearsManagerial Staff 2 x 90 x 5 x F5,000 4,500,000Nurses 2 x 90 x 5 x F2,500 2,225,000Drivers 2 x 90 x 5 x F1,500 1,350,000

SurveysPer Diem

Surveyors 600 x F2,000 x 5 days x 2 12,000,000Supervisors 300 x F,2500 x 4 days x 2 6,000,000Village Health Workers 8,000 x F500 x 1 day x 2 8,000,000Central and Provincial Coordination 1,320,000

Transportation

Fuel for Surveyorsand Supervisors 1,000 x 10 1 x 2 7,000,000Fuel for Coordination Operations 680,000

Supplies

Survey supplies and equipmentNotebooks 3,000 x F300 x 5 4,500,000Pens 15,000 x F50 x 5 3,750,000Miscellaneous 50,000 x F30 x 2 3,000,000

Expenses for case survey and water source surveillance agents4,000 x F1,000 x 7 months x 5 years 140,000,000

Sub-total = 221,650,000

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11.2.6. Office Supplies for 5 Years

Central Coordination 5 x 1,500,000 7,500,000CNDO Permanent Secretariat 5 x 1,000,000 5,000,000Mobile Teams 5 x 100,000 x 5 2,500,000

Sub-total = 15,000,000

11.2.7 Computer MaintenanceF376,780 x 5 years 1,883,900

11.2.8. Drinking Water Filtration

1st Year 1,000,000 screens x F150 150,000,0002nd Year 400,000 screens x F150 60,000,0003rd Year 400,000 screens x F150 60,000,0004th Year 400,000 screens x F150 60,000,0005th Year 400,000 screens x F150 60,000,000

Subtotal = 390,000,000

30

RECAPITULATION OF BUDGET BY FUNDING PERIOD (CFAF)

ACTIVITIES APR 92-JUL 93 AUG 93-DEC 96 TOTALPHASE I PHASE II

-Training 68.082.500 161.345.500 229.428.000

-EpidemiologicalSurveillance 78.827.000 142.823.000 221.650.000

-I.E.C. 68.630.000 59.287.000 127.917.000

*Patient Treatment 32.200.000 64.800.000 97.000.000

-Filter Screens 12.150.000 377.850.000 390.000.000

-DCMTConstruction 10.000.000 188.252.000 198.252.000

-Medical TechnicalEquipment 6.976.788 5.580.894 12.557.682

'Trek Equipment 2.769.400 - 2.769.400

-Vehicles 91.000.000 - 91.000.000

-Vector ControlEquipment - 6.850.000 6.850.000

-VehicleMaintenance 7.000.000 13.000.000 20.000.000

" Fuel/Lubricants 30.000.000 77.405.000 107.405.000

'Lab Reagents 3.000.000 4.600.000 7.600.000

'Office Supplies 5.000.000 10.000.000 15.000.000

'ComputerHardware/Maintenance 5.362.500 1.383.900 6.746.400

'Contingencies 2.000.000 74.708.774 76.708.774

TOTAL 422.998.188 1.187.886.068 1.610.884.256(US $ 1.499.994) (US $ 4.212.361) (US $ 5.712.355)

1 US $ 282 FCFA

31

TIMETABLE

ACTIVITIES YEAR

1992 1993 1994 1995 1996

-DCMT Construction

e Training/Retraining

e Epidemiological Surveillance

- I.E.C.

-Patient Treatment

- Filter Screens

- Purchase Medical Technical Equipment

-Purchase Trek Equipment

-Purchase Vehicles

-Purchase Vector Control Equipment

-Purchase Lab Reagents

-Purchase Office Supplies

-Purchase Computer Hardware

-Annual Evaluation

-Program Evaluation

32

APPENDIX I: TRAINING

DESIGNATION QUANTITY UNIT DURATION ALLOCATIONCOST

1/ Training formembers of 3epidemiologicalsurveillance teams-Per diem:

members 18 3.000 4 days 216.000facilitators 2 5.500 4 days 44.000

-Transportation 18 20Fx500K m - 180.000

Sub-total................... ................... .................. ................... 440.000

2/ Instructor Training-Per diem

Instructors 70 3.000 4 d x 2 1.680.000Facilitators 5 5.500 4 d x 2 220.000Support Staff 2 2.000 4 d x 2 32.000Project Officer 1 4.500 4 d x 2 36.000Drivers 30 2.000 4 d x 2 480.000

-Transportation(flat rate) - 930.000 x 2 1.860.000

-Office Supplies(flat rate) - 200.000 x 2 400.000

Sub-total................... ................... .................. ................... 4.228.000

3/ Health PersonnelTraining/Retraining*Per diem

Health Workers 680 2.500 4 d x 3 20.400.000Facilitators 60 5.500 4 d x 3 3.960.000Project Officers 30 4.500 4 d x 3 1.620.000Support Staff 60 2.000 4 d x 3 1.440.000

-Transportation(flat rate) 680 2.000 x 3 2.720.000-Supplies (flat rate) 450.000

Sub-total................... ................... .................. ................... 30.590.000

APPENDIX I (Continued)

DESIGNATION QUANTITY UNIT COST DURATION ALLOCATION

4/ ASC Training" Per diem

ASC 8 000 1.500 3 d x 3 108.000.000Facilitators 680 5.500 3 d x 3 33.660.000

" Supplies 8.000.000

- Transportation 225.000(flat rate)

Sub-total............... ....................... ....................... ....................... 149,885,000

5/ Training of otheragents- Per diem

Personnel 1 500 2.500 3 d x 3 33.000.000Facilitators 60 5.500 3 d x 3 2.970.000Project Officers 30 4.500 3 d x 3 1.215.000

* Transportation(flat rate) 1 500 1.000 1.500.000

- Supplies - 300.000 x 2 600.000

Sub-total .................... ....................... ....................... 39.285.000

6/ Field Trips andbackgroundexchange 5 1.000.000 5.000.000

229.428.000

MINISTRY OF HELTHAND 5OCTAL WELFARE. BURKINA FASO APPENDIX -

GENERAL SECRETARIAT DEVELOPMENT OF HEALTHINFRASTRUCTURES IN THE ONCHO

- ZONE (1986-1990) JULY 1999.-TRANSMISSIBLE DISEASE C)NTROL-IRECTOR ATE

PROVINCES DISPENSARY 4ATERNITY OTAL INFRA BUILD-UP CosrRucrJ5-1986 1990 : 86 90 86 90 86 90____ ___ ___ ___ ____ _ _ ___ ___86 90 S986 .iS90 CH C cs c.M C.,,. :

BAZEGA - - 1 1 12 23 5 2 - 26 29 - 8 - 3 -- ~ :i 6*i 8 :3 - - 17 :21 - - 5 - 4 -BOUIOU E

17 21 3 -42Boui.ou1 3 3 24 34 1 4 1 1 30 43 1 - - :10 3BOULXIEMDE - 1 1 2 20 *2423 (C

* 0UX~IE - 1 0:4 2 3 1 .1 24 :31 1(NC) - 1 4 :1:COMIDE 2 2 19 27 4 2 - - 25 2 1 1 2 . 7 -GANMOURGOU - - 1 1 6 127-12 14 22 - - - 3 .0I.RNA-.*112 1 7 9 - 18 :22 1- - 6- - 3GO4

MA -2 1 7 1 19 . 3 - . - 122 1- 6 4 -,.~uT1 1 31 25 .11 3 .4 45 45 1 14 1 1 -KENEDOUGOU - 2 2 16 18 - - - 18

Kos - . .82 -- 2 3- 3 3 10 .15 - - - . 13 18 -- -- - - 5

MOtEOUN - 1 3 3 24 26 1 1 -28 31 1 NC) 2NAROURI -1 1 4 5 2 1 7 7NAENGA -10

- - .1 3 -

2'OUMITENGA - - 3 3 13 1 2 27 31 2 4PASSORE- - 1 2 5 8 6 22 3 5

UI1 2 3 10 -9 (10 13 - - 22 26:SANQUIE 1 2 1 9:10 3: 1 2 2 1 15 .1 2 :-SISSILI - - 2 12 22 30 - : - : o .6SoURoU - 3 4 20 25 - - 1 4 .29 - - 3 1 2:TAPOA : - - 2 2 6 -12 - - 1 - 6 14 6-' - ' 3 * 1 *2 'Z:TA W~oA - - 1 j 2 : 2- 14 r - : - .: - - :6 :ZOtDO315 .7 7 7 1 14 :15 r- - .1 1

TAL 2 7 i: 451 2/,7 :363 108 : 96' 14 : 9 411 : 5 4 : 4 : 44 : 5 :74 :26~I.2 C). !

APPENDIX III

BI TRKINA FASOSTRY OF HEALTHSOCIAL WELFARE

GENERAL SECRETARIAT

TRANSMISSIBLE DISEASE CONTROL DIRECTORATE

COST OF HEALTH INFRASTRUCTURE BUILD-UP DURINGTHE FIRST FIVE-YEAR PLAN-1986-1990 (JULY 1990)

DESIGNATION BUILD-UP & EQUIPMENT NEW BUILDINGS AND FACILITIES

UNIT COST QUANTITY TOTAL UNIT COST QUANTITY TOTAL

CHR 467.000.000 4 1,868.000.000 1.167.000.000 2 2.334.000.000

CM 35.000.000 4 140.000.000 60.000.000 5 300.000.000

CSPS 6.600.000 44 290.400.000 13.500.000 74 999.000.000

DISPENSARY - - 8.000.000 26 208.000.000

MATERNITY - 5.000.000 1 5.000.000

Sub-total: 2.298.400.000 Sub-total: 3.846.000.000

General Total: 2.298.400.000 + 3.846.000.000 = 6.144.400.000 FCFA

N.B.: CHR = Centre Hospitalier R6gional

CM = Centre Medical

CSPS = Centre de Soins et de Promotion Sociale

APPENDIX IV: IEC

DESIGNATION QUANTITY UNIT COST DURATION ALLOCATION

I.E.C.

- CAP Survey 1.800.000

Production ofMaterials

e Visual Aids

- EducationalMaterials 680 d 18.000 12,240.000

- Posters/Leaflets 160.000 150 24.000.000

* Audio Material

- National RadioPrograms 2.916.000

- Local Radio'grams 6 2.916.000 17.496.000

t Kecording 108 x 7 12.500 9.450.000Costs

* AV Material44.550.000

- 3/4 VHS Video

- VHS 2.000.000Documentary

10.000.000- 16mm Film

Communication 11 3.000 21 d x 5 3.465.000Expenses

TO TA L IEC........ ............................. ........................... ........................... 127.917.000

APPENDIX V

AATIONAL SURVEY ON DRACUNCULIASISIN BURKINA FASO - NOVEMBER -DECEMBPR 1990

ENDEMISM RATE BYPROVINCE

PROVINCES ?opulation N.- of cases EndemismPRO VI N CtEi _ o f G .w o r m r a t eBAZEGA 163 978 677 41.3BOUJGURIBA 311 769 138 44BOULGOU -228 94 451 19.7BOULKIENDE 443 872 339 7.6COMOE 441 036 1 519 34.4GANZOURGOU 215 912 807 37.4GNAGNA 213 050 2 786 130.8GOURMA 3 2 97 1 222 59.1HOUET 3137505 15.3KADIOGO 409 580 118 2.9XENEDOUGOU 61 987 1 .2KOSSI 158 900 6 .4KOURIE 326 134 228 7.0OUUNG

211 858 466 22.0NHOUR 277 474 348 12.5N ER 117 783 41 3 .5

NABEITENGA 192 797 3 432 178.0OUBRA

320 174 3 266 102.0OASSLAE 136 753 662 48.4PAOR 233 277 986 42.3

PANGIE 261 793 1 556 59.4SANUITENGA

213 785 30 1.4SNMON 425 204 12 436 292.5SOISILI 159 174 1 046 65.7SOUSLI 306 363 662 21.6

SOURO 202 484 805 39.8APOR 287 551 1 429 49.7APONA 186 393 8 .4YAENOG 562 269 6 176 109.8

ZOUNDWEOGO 145 027 41 2.8

BURKINA 7 753 159 42 187 54.4

APPENDIX VI

THE NATIONAL DEVOLUTION COMMTITEE OF THE ONCHOCERCIASIS CONTROLPROGRAM (CNDO)

I. COMPOSITION

The National Devolution Committee is a multisectoral, technical body comprising experts from fourministerial departments. Its composition is as follows:

1/ Ministry of Health and Social Welfare

- Transmissible Disease Control Directorate (DCMT) - 6 members- Health Education and Sanitation Directorate - (DESA) - 3 members- Professional Training Directorate (DFP) - 2 members- Health Services Development Project Directorate (PDSS) - 1 member- The Office of the Health Minister - 1 member (press attach6)

2/ Ministry of Agriculture and Animal Husbandry - 3 members3/ Ministry of Information and Culture - 3 members4/ Minister of Water Resources - 2 members

The Permanent Secretariat

Sitting on this committee is a group of four (4) people comprising the permanent secretariat (SP)in charge of daily management of the Program:

1. The Director of Transmissible Disease Control2. The National Devolution Coordinator3. The Director of the Office of Regional Planning (ONAT)4. The Program Administrator

II. ATTRIBUTIONS

The main attributions of the committee are the following:

- Set up national epidemiological surveillance and treatment teams* Monitor Devolution Plan implementation* Coordinate activities at national level- Ensure liaison between government, OCP, funding agents and WHO/AFRO- Ensure liaison between committees in other countries* Draw up an annual report on the country's devolution activities

MAP NO.1

MIGRATORY MOVEMENTS

500 to 1 000 migrants

1 000 to 2 000 migrants

more than 2 000 migrants

BANFORA Surveillance team base

Rural internal migration of males by province of origin and

province of destination

INSD Figures 1975

Carte n* I - - 0 50 lookm

BURKINA FASO , -' -_'_ALAN_

PHENOMENE MIGRATOIRE .. Gorom-GoramP_ du SOUM

--- 500 Z 1000 migrants ..-e D)Ibo o

1 000 (' 2000 migrants do W~rm .

> 2oo0migrnts rants P. do SENO

Base dune quipe de o-p dv P.d'-surveillance BAd" NAl

eKongous S NMA- -NAAIEA'*-/NEA TEN6 .N *A

--J- K eNA NA-

/ ~ %o Xd NO/WTU . Iouno G

%:'o-\re - .o--P d* o IOvjSt bo uu l

69 0d* D iapMAx Ku * 0 . Fad TNa Nbu

. \ d1 5AG p Pv ,o TAPOA

P. do HOuiE /.P 'o -E N INS-P f o- P du BOULGCJ.\

* -a I T E 0- oir*'- du NAN =/ M '--'- .. --

-G H A N A TOGOr nora

P do /0 ** ?E Migrations interne rurales des hoimes par province d origine et province de destination.

J I (INSD Recencement 1975)

C O T E D' I V O R E

Map No.2

ONCHOCERCIASIS FREE ZONE

Study zone

AAVV intervention zone

State border

Boundary of province

Main town of province

Car 2500 50 100km

BURKINA FASO --

ZONE PROTEGEE DE L'ONCHOCERCOSE Ga Gor..o.

Zone detude

Zone d'Interventlon de 1'AAVV 00seol- -.LImIte d'ito t

Limite de provinceChef lieu de province .%

7bygen :yValle du Souroul,0Yk

Novae

seusee----

DidougowAA oV011e' du Mouhoun " i, 0** *ors

Kom s , Fede N'Gow rme1coopiso Diapat

Tankodego

ro dara e,,, .ie 8E N I N

I J Vaii4e de laKomnpieng aG H A N A /T G d

VGeo el Buouub

e''' Vall4 du Mouhoun;Vol lie del Ioled oob

Le~aboValle'e du Pon iVC,11ee de lo ,. - ALComo e L')V 011e de Io Sissiji

C 0 T E D' ;O I R E

Map No.3

TRYPANOSOMIASIS

Incidence rate per 100 000 inhabitants in 1970

Carte n t -

BUt 4A FASO - - .50. 1OOTRYPANOSOMIASE

Taux d'Jncidenc. pour sooooohabitants en 1970

1110

> 10637

32

3.3

10-S \ .

41

424

G H A' N A TO G 0

I oou s e G o r o g go 1 9 s o r a u w t o bo l e o f l -2 ombiosirt I I Koupleo 20 Moudougou 29 Bobo.-DWpuuso 36 Oudga,

4 Sopome' 00 3pnd9 Oour cyI Dlobougou 23 RS 1 %r SI Orodoro 40 Yoko5 Znlai, 4 Goouo 23 linacto - .. -.a Zorgho 4-dougeo 3 orsaIgho 41 Mange55 OJlbo-., 24 Didvgeu 33 Souls. 4 PoC7T E D 1Dogon4 S Ouqoyo 25 Noun. 34 Kayo 4 3iM- E ad N'oIa o 1 Tioueg 29 516 36 Kogouss 4 4 Xe,.

Fod o N bGour m oa 1 S T Itoo r oug n O es a

Map No. 4

INCIDENCE OF DRACUNCULIASIS BY PROVINCE IN BURKINA FASO (1990)

INCIDENCE DE LA DRACUNCULOSE

PAR PROVINCE AU BURKINA FASO. 1

(1990 )26 0Carte NO 4

2 09

13 27

15 22 142

12 25 30

10 16

o 1.LE BA 1 11-L E KADIOGO 21.1E PONI 10200/10.0002.LE BAZEGA 12-LE KENE.DOUGOU 22-LE SANGUI E

6 ~3.L A BOUGOUR113A 1:)-L A KOSSI 23-LE SANMATENGA ;r-100 < 20-+

21 4-LE BOULGOU 1 .'.L KOURITENGA 24.-LE $ENO?50-105-LE 12ULMKEMDE 15-LE MOU HOUN 25-LA 51551tL1I6.L1A COMOE 1i , LE NAHOURI 26-LE SOUM m j>30 <50 -

0 70 Km 7.LE GANZOURGOU 17'-LE NAMIENTENGA 27. LE 5OUROU Z>g10 < 301-8ALA GNAGNA lib-L ' OUEMITENGA 29-LA TAPOA

5 9-LE GOURMA 13-L'IOU1DAL AN 79.LE YATENGA<1/1.0reatsaio : Paca YMEGO10.L E HOUE T 20 -LE PASSORE 30 -LE ZOUNDWFOGO Uites d L

Fig. 1

Epidemiological trends in Burkina Faso

- imulation for holo-endemicity; CMFL=65

90

80

70U)

60

E0 50

UC 440

a 30

20

10

0-0 2 4 6 8 10 12 14 16 18 20

Years of control* White Volta + Sissili Predicted

A Koulpeolgo X Lerabo V Bougouribo

* .2

Predicted epidex. ological trendsVector control from 1975 to 1990

1t0

too90-

0 80.

o 70

'C.q. 60

O% 50

co40,

U 3020 -.--.

10 -

0 --1970 1980 - 1990 '2000 2010

-- Prevale'nce of faf........ oCalendar Year

-Prevalence of blindness

----- Annual Transmission Potential

Fig.

Recridescence after premature xuterruption-of controlVector cdntrol from 1975 to 1988

1e0 N

100

80 -

g 70 - -* 70

so

50 -

10

0 -- 1990---- 2010...

1970 1990 2010 2030 2050

Prevalence of afs -......... 04F Calenda~r Year

Prevalence of blindness----- Annual Transmission Potential

F

Recrudescence Control using Iveirmectini2 _ - 25 years of annual treatment. starting In the year 2012

vector control110 -

100Annual mass treatmenttoo -

90 - -

0 80 -

0 70

L 60 \

a) 50 -

40-

L 30 -

20--10 -

0 - .. - ....

1970 1990 2010 2030 2050

Calendar Year-Prevalence of a -C n Y

- Prevalence of blindness----- Annual Transmission Potential

Fig. '

Recrudescence Control "sing Ivermectin

120 Annual Treatment storting in the year 1995

Vector contr I110

100 -

90>

80-

70 Annual mass treatment0 g0

4 -70

al 600

50

U 40

30

20

10 -

0 - -

- 1970 1990 2010 2030Prevalence of mfs Calendar Year.......-- CMFLC

Prevalence of blindness----- Annual Tronsmission Potential

The World Bank 1818 H Street, N.W. (202) 477-1234

INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT Washington, D.C. 20433 Cable Address: INTBAFRAD

INTERNATIONAL DEVELOPMENT ASSOCIATION U.S.A. Cable Address: INDEVAS

Le 10 mars 1992

S.E. Fr~ddric Assomption KORSAGAMinistre des Finances et du PlanMinistere des Finances et du PlanOuagadougou, BURKINA FASO

Monsieur le Ministre,

Je vous remercie pour votre lettre du 10 fWvrier 1992 au Reprdsentant de la Banque Mondiale au

Burkina Faso, concernant le ddmarrage du financement de la ddvolution du Programme de lutte contre

l'Onchocercose.

Je suis heureux de vous informer que nous avons pris les dispositions nicessaires afin de rendre

effectif un prdlkvement de USS 400.000 pour financer le ddmarrage du Plan de Ddvolution au Burkina

Faso pour la pdriode allant du ler Mars au 31 Juillet 1992. Les retraits de cette somme peuvent

commencer dts I present sous les catdgories 2,4, et 5 de I'Accord du Crddit. La date de clOture du Crdit

N*1607-BUR est maintenant fix6e au 31 juillet 1992. Le financement d'un montant additionnel de US$

600.000 pour la ptriode allant d'aoat 1992 4 juillet 1993, ndcessitera un accord entre la Banque et le

Gouvernement sur une extension de la durde du credit et un report de la date de clOture au 31 juillet

1993.

J'espere que'vous trouverez ces dispositions I votre convenance en attendant qu'une extension

du Credit N*1607-BUR soit ddcidde.

Je vous prie d'agrder, Monsieur le Ministre, l'expression de ma tres haute considdratjon.

I e r r e dieChef

o3) 3 2. Division des Ressources Humaines

2. - Ddpartement du SahelR6gion Afrique

cc: Son Excellence Hamado OuimingaMinistre de la Santd, de l'Action Sociale, et de la Famille

M. le Directeur du Projet Sante I (PDSS)

RCA 244423 - W"A 04140

THE WORLD BANKBURKINA RESIDENT MISSION

B.P. 622 - OUAGADOUGOUFax (226) 30.86.49 - Phone (226) 30.62.37/38 - 30.72.57 - Telex 5265 BF

FACSIMILE TRANSMITTAL FORM

Date: December 24, 1992Dept/Div N*s: AF5BU

Number ofpages: (including this page)

MSG :

FROM : Cdlestin Bado

TO : COMPANY/ORGANISATION : AF5PH- - J 9031CITY AND COUNTRYFOR ATTENTION : B. Vitagliano

- FOR IMMEDIATE DELIVERY -

TELEFAX N 0473-8216

SUBJECT :

Pribre trouver ci-joint lettre No 2212 du 23 nov. 1992 du Ministre de la Santd relative I unerequete pour financement compldmentaire du Programme de Ddvolution "dlargie"

Salutations. Bado.

AF5PH

i a,, received /Z)

Vssigned to

u ate ack'd

Sent to AFISC._ ___

Transmission authorized by: C. Bado

MINISTERE DE LA SANTE, BURKINA FASODE L'ACTION SOCIALE LA PATRIE OU LA MORT, NOUS VAINCRONS I

ET DE LA FAMILLE

Ouagadougoufe ~ 2 3 NOV. 1992

No 9 2 __2212 .... . /SAN-ASFISGIDCMT a ait

cit 469

Objet: Requite pour Financementcomplimentaire du Programme et -am lede Divolution"ilargie".

A

VIL. 139/92 Monsieur le ReprisentantRisident de la BanqueMondiale au Burkina FasoSIC du Ministre des Financeset du Plan

Ouagadougou

Monsieur le Reprisentant,

Selon les termes de votre lettre citie en rifirence, la Banque Mondialemarquait son accord pour le financement du Programme de Divolution "glargie".Pour ce faire, une enveloppe de Un million Cinq Cent Mille (1 500 000) US$ ripartiede la maniere suivante, itait rlservie -au Programme

- Quatre Cent Mille (400 000) US$ pour la piriode allant d'Avril 4 Juillet 1992.

- Un million Cent Mille (1 100 000) US$ d'Aoat 1992 d Juillet 1993.

La premiere tranche, soit Quatre Cent Mille (400 -000) US$ itant en coursd'exicution, je viens par la prisente solliciter la mise 4 la disposition du Programmede Divolution "ilargie", la deuxieme tranche, soit Un Million Cent Mille (1 100 000)US$ conformiment d la requite ci-jointe.

Confiant que comme par le passt, l'appui de votre institution ne nous fera pasdifaut, je vous prie d'agrier Monsieur le Reprisentant, 1'expression de messentiments distinguis.

Minist~r : cc rnencesI

Ar' vo 7

2 3 NOV. 1992-

[T1STB 7T F NANCESU L

PROGRAMME DE DEVOLUTION ELARGIEREQUETTE POUR L'ANNEE 1993

INTRODUCTION

Apres la r6vision du Programme National de D6volution Oncho enAvril 1992 lequel programme int6gre desormais la lutte contre laTrypanosomiase humaine et l'radication du Ver de Guin~e, un pland'action 1992 a 6t6 6labor6.

Ce plan 1992 correspondait A la premibre ann6e de mise en oeuvre dece programme de dsvolution 61argie.Ainsi des activit~s de formation, d'information- 6ducation-communication (l.E.C.), de surveillance 6pid6miologique etd'approvisionnement en eau potable ont 6t6 men6es sur le terrain.

Cependant des activit~s non moins importantes telles que lasupervision centrale et le traitement des cas de Ver de Guin~e n'ont pasencore d~marr6.

I s'agira donc pour l'annee 1993 de rendre effectives toutes lesactivit6s pr~vues dans le programme et de renforcer celles qui sont d6jeen cours.

I. DESCRIPTION DES ACTIVITES

L'objectif pour l'ann~e 1993 6tant de consolider le programme ded6volution 6largie, les activit~s suivantes sont envisag~es

- Information - Education et Communication.- Surveillance Epid6miologique.- Traitement des cas.- Approvisionnement en eau potable.- Equipement des structures.- Supervision des activit6s.

1.1. Information - Education et Communication (I.E.C.)

L'I.E.C. et la mobilisation des populations cibles devront jouer unrole d6terminant dans le changement de comportement de ces populationset du msme coup entrainer une meilleure adhesion aux strat6gies de luttepreconis~es.

... /

D'une maniere g~n6rale tout le personnel de Sant6 form6 A cet efis.et les agents de Sante Communautaire assureront en permanence lasensibilisation des populations sous forme de causeries-debats.

Sur le plan national des 6missions radio portant sur I'Onchocercose,la Trypanosomiase et le Ver de Guin6e seront diffus6es par la stationnationale et les stations locales deux fois par mois avec notammentrenforcement des 6mission en saison des pluies.

I est aussi prevu de mettre A la disposition de chaque DirectionProvinciale de Sant6 3 cassettes VHS pour le "repiquage" de films desensibilisation.

Enfin pour l'annse 1993 nous comptons demarrer la r6alisation d'undocumentaire en VHS. Ce documentaire doit fixer les principales activit6sdu programme de D~volution 6largie.

1.2. Surveillance Epiddmiologique

La surveillance 6pid6miologique devra nous permettre de sui%I'6volution de ces 3 endemies. C'est ainsi qu'en plus du systhme nation:de surveillance passive par les formations sanitaires, une strat~gie desurveillance active sera mende sur le terrain. D'une manibre g6n6rale lesequipes provinciales et centrales sont form6es pour effectuer lesdvaluations 6pid6miologiques sur IOnchocercose et la Trypanosomiasemais dans la pratique, ces missions se d6roulent & des p6riodesdiff6rentes.

1.2.1 Onchocercose

Conform6ment au plan d'action g~n6ral la surveillance del'Onchocercose en 1993 sera bas6e sur des enqubtes 6pid6miologiquesdans 20 villages de premieres lignes. Dans ces villages des 6valuations6pidemiologiques seront r6alis6es sur toute la population et consisteront& des d~pistages parasitologiques de cas.

La methodologie des enquetes sera bas6e sur la biopsie cutan~eexsangue ou SNIP tout en prenant des pr6cautions afin d'eviter le risquede contamination par le virus du SIDA

Ces enquetes necessiteront le d6placement de deux 6quipes de 9personnes issues des 6quipes locales et centrales. et dureront 30 jours.La pdriode la plus favorable A ces enqudtes se situe entre F6vrier et Avril.

./3

1.2.2 .Trypanosomiase

La surveillance active de la Trypanosomiase humaine serapoursuivie dans la province de la Como6 ob0 une transmission locale a dt6fortement suspect6e. Ainsi, des enquetes 6pid~miologiques seront faitesdans une trentaine de villages A risque notamment dans des villages oides cas ont d6j& 6t6 d6pist~s. 40 jours seront n~cessaires A la rdalisationd'une telle mission. Les enquCtes seront effectu6es par 2 equipes de 6personnes chacune (6quipe provinciale et equipe centrale).

La m~thodologie de l'enqudte sera basse sur l'examen de toute lapopulation : palpation de ganglions cervicaux, C.A.T.T chez les suspects etr~alisation de confettis pour l'l.F.I. pour l'ensemble de la population. Laconfirmation parasitologique est faite sur les suspects immunologiques.

Des contacts seront pris avec I'OMS G6nbve pour l'obtention d'unem6thodologie nouvelle permettant un screening rapide sur le terrain..

1.2.3. Ver de Guinde

La surveillance du Ver de Guin6e consitera A recenser les cas dansun registre d~pos4 au village. Cette activit6 sera r~alis~e par l'agent deSant6 Communautaire ou tout autre 616ment form6 sous la supervision desinfirmiers.

Pour l'annee 1993, il est pr6vu 1 000 r~gistres de surveillance6piddmiologique qui viendront en appui aux 4 000 r6gistres confectionnesen 1992.

1.3. Traitement des cas

1.3.1. Onchocercose

Le traitement au MECTIZAN * dans le cadre de la pr6vention del'Onchocercose revetira deux aspects : le traitement de masse despopulations ' risque et le traitement des cas confirm6s.

- Traitement de masse.

Selon la situation 6pid6miologique et entomologique deux zones ont6t6 retenues pour le traitement de masse au MECTIZAN*. I s'agit dubassin de la Dienkoa (Pendi6) et du bassin de la Sissili.

./4Un total de plus de 34 villages seront concern~s et toute

population sauf contre indication est soumise au traitement.

Vingt jours seront n6cessaires A la r~alisation de cette mission detraitement et la p~riode la plus favorable p6ur le faire doit se situerentre Mars - Avril. Les agents impliqu6s dans cette campagne de masse aunombre de 24 sont issus des directions provinciales de Sant6 desprovinces concern6es et de la coordination centrale.

- Traitement des cas confirm6s

Pour 'ann6e 1993, un lot de comprimes de MECTIZAN * sera mis Ala disposition de toutes les formations sanitaires suceptibles deconfirmer des cas d'Onchocercose.

1.3.2. Trypanosomiase

Le traitement de la Trypanosomiase humaine se poursuivra dans lesCentres sp6cialis~s de Ouagadougou, Koudougou et Banfora. N4anmoins destraitements de malades pourront 6tre entrepris dans les chefs lieux deProvinces ou des cas seront d6pist6s. Dans ces cas le produit (ARSOBALD.F.M.O.) leur sera envoy6 du niveau central accompagn6 d'une fictechnique de traitement.

1.3.3. Ver de Guinde

Cette activit6 consiste A effectuer des pansements chez des sujetsatteints de Ver de Guin6e afin de les soulager, eviter les surinfections etemp8cher ces malades de contaminer dventuellement les eaux de boissons.

De ce fait des produits de pansement seront mis A la disposition desvillages end6miques.

1.4 Approvisionnement en eau potable

Outre la politique d'hydraulique villageoise qui va se poursuivre surle plan national, le programme d'iradication du Ver de Guin'e mettral'accent sur la filtration de l'eau de boisson, au moyen de tamis-filtre. Is'agira pour 1993 de confectionner, 400 000 tamis-filtres. Ces tamisconfectionn6s A Ouagadougou seront mis 4 la disposition des DirecticProvinciales de la Santi qui en feront la repartition dans les villag.enddmiques.

1.5. Supervision - Evaluation des activites

La supervision est un volet important du programme. Unesupervision provinciale d'au moins 5 jours par *mois est indispensable ' lacoordination centrale pour se rendre compte du d6roulement des activit6ssur le terrain et d'apporter si besoin est un appui technique aux DirectionsProvinciales de la Sant6.

A la pdriphdrie les Directeurs Provinciaux de Sante et lesResponsables des formations Sanitaires devront superviser les activit6sjusque dans les villages.

1.6. Equipement

Afin de bien mener toutes ces actions sur le terrain un 6quipementaddquat est ndcessaire. Cet dquipement consistera en I'achat de

- 4 Whicule 4 X 4 pour la surveillance 6pid6miologique et lasupervision (dquipe s mobiles)

- 1 Camion pour la distribution des tamis et autres logistiques.

- 30 Mobylettes pour la supervision provinciale.

- Carburant et lubrifiant pour la coordination la surveillance, lasupervision centrale et provinciale.

- Fournitures et materiel de bureau

- Construction de la Direction dur Controle des MaladiesTransmissibles. (6tudes)

II. COUT DU PROGRAMME DE DEVOLUTION ELARGIEJUILLET 92 - AOUT 93

2.1 Information Education -Communication (I.E.C.)

2.1.1. Emissions Radio

- 1 station nationale

/6

6 (stations rdgionales ) 1 200 000-F x 7 = 8 400 000 F

Frais de r6gie

2.1.2. Confection de toiles iducatives647 x 14 000 F 9 058 000 F

2.1.3. Confection d'affiches50 000 x 50 F 2 500 000 F

2.1.4. Confection de livrets Mducatifs10 000 x 300 F 3*000 000 F

2.1.5. Achat de vidiocassettes VHS3 VHS x 30 x 8 000 F 720 000 F

2.1.6. Rialisation de documentaire en VH 2 000 000 F

Sous total 2-1 ...................................... 25 678 000 F

2.2. Surveillance epidemiologique

2.2.1. OnchocercoseNombre de personnes : 18durde : jours 30

Perdiem : 18 personnes x 30 jours x 2 500 F = 1 350 000 F

Carburant pour 4 v6hicules4 x 4 (10 000 km A 20/100 km)30001x 272 F = , 816 000 F

Accessoires de tournde et de laboiatoire50 000 F x 2 6quipes = 100 000 F

2.2.2 Trypanosomiase

Nombre de personnes : 12Durde de la mission 30

Perdiem 12 personnes x 40 jours x 2 500 F= 1 200 000 F

Carburant pour 2 v6hicules4 x 4 (10 000 km ' 20 1/100 km)

2 000 1 x 272= 544 000 F

. Accessoires de tournde et de laboratoire50 000 F x 2 6quipes = 100 000 F

- 2.2.3. Ver de Guinie

. Confection de r6gistre de notification1 000 x 300 = 300 000 F

. Prise en charge des ASC pendant 7 mois7 x 1 000 F x 4 000 AS= 28 000 OOOF

. Enqu~te exhaustive sur 1'ensemble du paysFormation de 450 agents

.Perdiem : 450 x 2 500 F x I jours= 1 125 000 F

. Transport 450 x 3 000 F = 1 350 000 F

. Collecte des donnees 450 x 5 jours X 2.500 F = 5 625 000 F

. Fourniture de bureau = 300 000 F

. Traitement des donndes = 1 500 000 F

Sous total 2.2......... 42 310 000 F

2.3. Traitement

2.3.1. Onchocercose

-Traitement de pendii et bassin de la Sissili

. 12 agents de Santg

. 4 Chauffeurs

. Durde = 20 jours

- Perdiem = 12 x 20 jours x 2 500 F = 600 000 F4 x 20 jours x 1 500 F 120 000 F

./8

- Carburant = 3 000 1 x 272 F = 816 000 F

- Accessoires de tournde : 50 000 F X 4 = 200 000 F

2.3.2. Ver de Guinie produits de pensement

3 000 villages x 10 000 F 30 000 000 F

Sous total 2-3....................... 31.736.0 00 F

2.4. Filtration de l'eau de boisson

. Confection de tamis-filtres400 000 tamis x 125 F = 50 000 000 F

. Carburant pour d6poser les tamis3000 1 x 272 F = 816 000 F

. Perdiem des agents charg6s de la livraison2 x 2 500 x 30 = 150 000 F

Sous total. 2-4...................... 50 966 000 F

2.5. Supervision - Coordination

5 jours de mission par mois soit 60 jours. Perdiem 2 500 F x 60 jours x 2 = 300 000 F

1 500 F x 60 jours x 2= 180 000 F

. Carburant pour la coordination - supervision(50 000 km A 20 1/100 km)

10 000 1 x 272 F= 2 720 000 F

. Carburant pour les DPS ASF (1 500 l/DPS ASF).1 500 1 x 30 x 272= 12 240 000 F

Sous total 2-5 = 15 440 000 F

./9

2.6. Equipement

3.6.1. Logistiques

S4 v6hicules 4 x 4 : 4 x 9 000 000 F= 36 000 000 F

. Camion : 1 x 10 000 F= 10000000 F

. 30 Mobylettes : 30 x 500 000 F = 15 000 000 F

. Entretien 6 x 500 000 F = 3 000 000 F

2.6.2. Matireil et fourniture de bureau = 2 500 000 F

2.6.3. Cotzstruction DCMT (Etude) = 10 000 000 F

Sous Total. 2-6............................. 76 500 000 F

TOTAL Gdnesral............................. 242 630 000 F CFA

1 010 959 US$

1 US$ =240 F CFA

CHRONOGRAMME DES ACTIVITES

OBJECTIFS ACTIVITES RESPONSABLES J F M A M J J A S 0 N D

INFIRMIER,EDUQUER production supports Coordination

(toiles, livrets, affiches) et DMP

Causeries debats Agent Santd ASC

Emission radio Agent information

Evaluation Oncho Equipes mobiles

Surveiller les " Trypano -3 endemies " Ver de Guinee Inf. plus ASC

Enquiete sur le V.G.

Traiter les Traiter les cas de V.G. A.S.C.malades et population les trypanosomiases Infirmier

cibles L'Onchocercose Equipes mobilesSuperviser les Supervision Centrale Coordination

Activites et provinciale DPSASF

Filtrer I'eau de boisson Confection de tamis Coordination

Equiper les struct. Achat de materiel Coordination

PDSS

THE WORLD BANK/IFC/M.I.G.A.Headquarters: Washington, D.C. 20433 U.S.A.

Tel. No. (202) 477-1234 // Fax Tel. No. (202) 477-6391 // Telex No. RCA 248423-FACSIMILE COVER SHEET AND MESSAGE

DATE: November 24, 1992 NO. OF PAGES: 3 MESSAGE NUMBER: \(including this sheet)

TOName: Mr. Albert Osei, Resident Representative Fax Tel. No. (226) 30.86.49

Organization: The World Bank City: OuagadougouCountry: BURKINA FASO

FROMName: Bruce Benton Fax Tel. No. (202) 473-8216

Dept./Div. AF5PH Dept/Div No. 230/50Room No. J-9047 Tel. No. (202) 473-5031

SUBJECT: BURKINA FASO - PDSS1 et PDSNLettre du 24 novembre 1992

MESSAGE:

Merci de bien vouloir transmettre courrier ci-joint h S.E. Monsieur Christophe Dabird,Ministre de la Santd, de l'Action Sociale et de la Famille.

L'original vous parviendra par le prochain pouch.

Meilleures salutations.

T 'ssion authorized by: Bruce Benton. AF5PH

If you experience any problem in receiving this transmission, inform the sender at the telephone or fax number listed above.1884 (2-90)

MINISTERE DE LA SANTE, BURKINA FASODE L'ACTION SOCtALE LA PATRIE OU LA MORT, NOUS VAINCRONS I

ET DE LA FAMILLE

Ouagadougou, le 2 E 92

1995 -No.S!2_.SAN-ASF/SG/DCMT. - e la Sante

Obtet Demande de financement du____Plan de D6volution Onchocer- e La -7afttZ~

cose.

A

RMf.- Monsieur le Repr6sentant Residen

de la Banque Mondiale au Burkina

Faso - OUAGADOUGOU -

Monsieur le Representant,

Par lettre en date du 10 Mars 1992 (copie ci-jointe)

votre institution a accord6 au Programme de D4volution Onchocer-

cose un financement de 1.000.000 US S liberable en deux tranches

l'une de 400.000 US $ pour la periode du ler Mars au 31 Juillet

1992, l'autre de 600.000 US $ pour celle du ler Aolat 1992 au 31

Juillet 1993, cette derniere necessitant un accord entre la Banqu

Mondiale et le Gouvernement sur une extention de la duree du cr6-

dit N*1607-BUR jusqu'au 31 Juillet 1993.

Par ailleurs, par lettre 139/92 en date du 24 Mars 1991

vous avez accept6 le principe d'un financenient compi6mentaire de

500.000 US $ au titre du cr6dit 1607-BUR pour prendre en comptele volet dracunculose du Plan de Devolution Onchocercose.

L'enveloppe r'serv6e a la D4volution serait ainsi

portae a 1.500.000 US $ pour la p6riode dusler Mars 1992 au

31 Juillet 1993.AFSPH /.F

lecive on ......... Lo . f .

~ecit'd...... .... ............. .. . o".~ ~ -~ Assigned t

- . Date ack'd.-.............. . ................ .Sent to AFISC

- 2

Toutes les conditions 6tant a present r6unies, je

vous saurais gr& des dispositions qu'il vous plaira de prendre

pour rendre effectif cet engagement financier et permettre le

d~blocage de la 26me tranche du financement qui s6'1everait

ainsi a 1.100.000 US S (600.000 + 500.000).

Je vous prie d'agreer, Monsieur le Repr6sentant,

l'expression de ma parfaite consideration.

MINISTERE DE LA SANTEDE L'ACTION SOCIALE ET BURKINAFASODE LA FAMILLE ---------

------------- La Patrie ou la Mort,SECRETARIAT GENERAL Nous vaincrons!

DIRECTION DE LA MEDECINEPREVENTIVE

BILAN PARTIEL DESACTIVITES DE DEVOLUTION

ELARGIE A LA LUTTECONTRE LA

TRYPANOSOMIASE HUMAINEET LE VER DE GUINEE

Ouagadougou, le 2 Decembre 92Le Coordonnateur National dede la Devolution

1

Dans le cadre de la mise en oeuvre du programme de d6volution61argie les activit6s suivantes ont 6t6 r6alis6es

1*) FORMATION DU PERSONNEL

La formation des formateurs provinciaux charg6s de former lesagents de sant6 dans leurs provinces respectives a 6t6 faite en f6vrier1992 en ce qui concerne la Dracunculose et en avril 1992 pourl'Onchocercose et la Trypanosomiase humaine.

Ces formateurs 6taient constituds par les Directeurs Provinciauxcharg6s de la Sant et les responsables de soins de Sant6 Primaires.

Quant A la formation des infirmiers des C.S.P.S et C.M., desagents de Sant6 Communautaire et d'autres intervenants elle estpratiquement achevde dans toutes les provinces concern6es (Tab. 1).

C'est une formation int6gr6e prenant en compte l'Onchocercose,la Trypanosomiase humaine et le Ver de Guin6e qui a 6t6 donn6e h cesdiff6rents niveaux. Les modules de formation sont axdes surl'6pid6milogie et les strat6gies de lutte adopt6es dans notre plan ded6volution.

20) INFORMATION EDUCATION ETCOMMUNICATION (I.E.C)

Apres la s6rie de formations dans les provinces les infirmiers et lesagents de Sant6 Communautaires ont entrepris l'6ducation pour la Sant6dans les villages end6miques. Les supports utilis6s sont les toiles6ducatives et les livrets. Les s6ances de sensibilisation se d6roulent sousforme de causeries-d6bats.

2

Sur le plan national des journdes de sensibilisation ont 6t6organis6es les 16 et 17 juillet Ouagadougou autour des trois grandesend6mies. Ces journ6es de sensibilisation organis6es conjointement parles ministeres de la Sant6, de l'Eau, de l'Agriculture et de l'Informationavaient pour tout d'attirer l'attention des autorit6s et du public, sur lan6cessit6 de lutter contre ces fl6aux et de pr6senter les moyens de luttesappropri6s.

Des m6ssages de sensibilisation en langues nationales seront bient6tdiffus6s par la radio nationale et les stations locales.

Une chanson de sensibilisation en mor6 portant sur le Ver deGuin6e a 6t6 r6alis6e par Monsieur COMPAORE Issouf, vedette de lachanson Burkinab6. Les cassettes de cette chanson ont 6t6 distribu6esaux stations locales et nationales pour large diffusion.

30) SURVEILLANCE EPIDEMIOLOGIQUE

La surveillance de l'Onchocercose, elle a permis de d6pister 17 casdans 16 villages de premiere ligne. La pr6valence globale est de 0,26 %(carte n' 1 et Tab. 2).

Au niveau des formations sanitaires 61 cas d'Onchocercose ont 6t6d6pist6s.

Aucune prospection sur la Trypanosomiase humaine n'a 6t6 faiteen 1992 dans la mesure oii le traitement des confettis par le CentreMuraz n'est plus possible.

N6anmoins 16 malades ont 6t6 d6pist6s passivement et trait6s dont3 A Ouagadougou 8 h Koudougou et 2 Banfora et 3 A Bobo-Dioulasso.

3

Dans le cadre de la surveillance de la Drancunculose 2920 r6gistresont 6t6 mis A la disposition des provinces pour les villages enddmiques.Pour l'instant le recensement des cas de Ver de Guin6e par les agentsde Sant6 Communautaire est en cours. Les r6sultats partiels qui sontdisponibles font 6tat de 39.5 cas recenc6s dans 425 villages.

40) TRAITEMENT

Pour l'ann6e 1992 le traitement au MECTIZAN* a grande 6chellepar les 6quipes a concern6 deux zones = Pendi6 et bassin de la Sissili.Au total 5028 personnes ont 6t6 trait6es. Cette population trait6e estr6partie entre 34 villages et hameaux d'habitation. 6934 comprim6s deMECTIZAN* ont 6t6 distribu6s. Carte n' 2 Tab. 3 et 4).

Quant au traitement par les centres fixes il a 6t6 r6alis6 dans leszones A.V.V. de LINOGUEN (Oubritenga), de TIEBELE et ZIOU(Nahouri). C'est ainsi que 14.859 personnes ont 6t6 trait6es avec un totalde 22.966 comprim6s de MECTIZAN* (Tab. 5 et 6).

Compte tenu de la portion de financement mise h notre dispositionle volet traitement des cas de Ver de Guin6e n'a pas 6t6 retenu pour1992. Il le sera en 1993.

50) APPROVISIONNEMENT EN EAU POTABLE

5.1. Filtration de l'eau de boisson

Les tamis-filtres ont 6t6 confectionn6s et plac6s dans les villagesend6miques. A ce jour plus de 100.000 tamis ont 6t6 distribu6s.(Tab. 7).

4

5.2. Forages

Des requ~tes pour l'installation de forages dans les villagesend6miques ont 6t6 adress6es au Pr6sident CARTER DE GLOBAL2000 lors de son passage dans notre pays et A la R6publique du Japon.Un sous-comit6 approvisionnement en eau a 6t6 cr66e.

60) SUPERVISION

Du carburant a 6t6 mis A la disposition des Directions Provincialesde la Sant6 pour assurer la supervision des activit6s pr6vues dans lecadre de la d6volution 61argie.

La coordination s'est rendue dans quelques provinces afind'apporter un appui technique aux directions provinciales de la Sant6.

70) DIFFICULTES RENCONTREES

La principale difficult6 rencontr6e dans l'ex6cution de ceprogramme de d6volution 61argie est d'ordre financier. En effet pourcette premiere ann6e une tranche de 400 000 DOLLARS a 6t6 mise Anotre disposition ce qui n'a pas permis d'ex6cuter tous les volets duprogramme. En outre la mise en place tardive de fonds ne nous a paspermis de d6marrer les activit6s A temps notamment en ce qui concernele Ver de Guin6e. Enfin nous sommes toujours confront6s A une certainelourdeur quant au d6blocage des fonds pour mener les activit6s aumoment propice.

Le manque de personnel au d6but du programme n'a pas permisaux responsables du programme de mieux suivre sur le terrain led6roulement de la mise en oeuvre du programme dans les provinces.

1 ~LISTE PAR PROVINCE WE MTS FORUES PAR CATEGORIE

NO PROVINCE IMDCINS INFIftIElS ASC AUTRESECT

1 B0uOmU 2 52 0 152 BOULKIEMDE 1 73 242 353 SISSILI 2 31 594 04 SANGUIE 1 24 216 25 SOUROU 1 31 245 216 MOUHOUN 2 66 534 07 KOSSI 5 28 746 908 HOUET 3 57 . 159 COMOE 1 44 . 0

10 PONI 6 71 133 011 BOUGOURIBA 4 26 250 2012 PASSORE 3 23 364 013 YATENGA 4 96 - 014 SOUN 1 16 128 015 SENO 2 25 - 2816 OUDALAN 4 46 44 5417 SANHATENGA 2 28 -351 018 NAMENTENGA 3 56 318 8219 GNAGNA 2 .44 563 520 KOURITENGA 0 16 367 021 GANZOURGOU 1 47 170 3022 BAZEGA 1 29 633 023 NAHOURI 2 20 381 5024 ZOUNIMEOGO 1 39 165 025 GOURMA 4 43 397 2226 BAM 0 34 773 60

AL 61 1097 8101 529

I tli~

OCP/ DEVOLUTION BURKINA FASOJornvier 1992 UKN FASJorte no I SITUATION GEOGRAPHIQUE DES VILLAGES SENTINELLES POURLA SURVEILLANCE EPIDEMIOLOGIQUE DANS LE CADRE DE LA DEVOLUTION

Dori .

chiouya

r' N. -- '0 50 1O0kM

(F

Ku yoFog

Sono

Kou LertI(OLrf0 Loi-

Tons i -

DeououOUAGADOUGOU -Dedougou

0) 0

0 4

0Foda N Gourm 361 Dbouog

23

To l 2 8 229 287 360 99 27onzi G 8 365 Arly/

57 0 155 0 284 366 362

eoboolouiosso 177 207 L 95 0 2422 . 363 220

Bonfo a 40

51 4 In 509 odl5155 51 149 Nndoa

00 Doug00

To pi m or

Tab. 2EVALUATION EPIDEMIOLOGIQUE - BURKINA FASO(EQUIPE NATIONAL) - MAI 1992

POPULATION POPULATION POSITIF % ABSENTS %VILLAGES BASSIN RECENSEE EXAMINEE %

LERY 042 MOUHOUN 466 411 88,19 0 55 11,80

DIOSSO 042 BOUGOURIBA 370 234 63,24 0 136 36,75DAN 041 BOUGOURIBA 499 199 39,87 0 300 60,12KIMPEO 004 BOUGOURIBA 110 72 65,45 3 4,16 38 34,54TONIOR-BAMENE 009 POUIENE 226 193 73,66 3 1,55 69 26,33

BAMBASSOU

NANDOLI MOUHOUN 329 242 73,55 2 0,82 87 35;95SAKORA 287 CMDE 620 215 34,47 2 0,93 405 65,32FOLONZO 019 COYAE 597 482 80,73 2 0,41 115 19,26NADERA 5151 LERABA 487 121 24,84 2 1,65 366 75,15KOMBOUGOU 358 OTI/PENDJARI 370 257 69,45 1 0,27 113 30,54NATIABONI 219 KOULPEOLGO 586 390 66,55 0 196 33,34LOABA 284 NAKAMBE 217 90 41,47 0 127 58,52ZANSE NAKAMBE 314 250 79,61 0 64 20,38KERMA NAKAMBE 129 106 82,17 0 23 17,82DINDERGOU 234 NAZINON 423 190 34,86 0 355 65,13

LIBOURE 218 545 190 34,86 0TOTAL 6324 3638 57,52 1 0,26 2686 42,47

N.B. : Le village de Nabissirabogo a refus6 de participer A 1'enqudte.

NOTIFICATION DES CAS EN 1992DE VERS DE GUINEE TRYPANO ONCHO

Milliers

53,905__ ___ _ _

4-

3f

2

0- 0,015 0,061

DRACUNCULOSE TRYPANOSOMIASE ONCHOCERCOSE

MASF\DMP

O C P/ DEVOLUTIONJonvier 1992 BURKINA FASOcarte noLL SITUATION GEOGRARHIQUE DES VILLAGES SENTINELLES POURLA SURVEILLANCE' EPIDEMIOLOGIQUE DANS LE CADRE DE LA DEVOLUTION

Dor,

- l ouyo

F N3ur

N 4 o 4 ~oltFod

s-N Gourmo 0 3 1 Diooc 35

0 32 358

- Do Tn -' 0-8 -219 . . 360199 017Zi 13

/ 2 *6 Arly

ON2344 0 2200

\Sobo Dioulo~s 0 '.177 207 eo.4195 0 422 6

2 8

29 207 0

1 85To o pimo

4C +

66 CAMPAGNE DE TRAITEMENT AU MECTIZAN DE LATab. 3 ZONE DE PENDIE DU 21 AU 25 AVRIL 1992

NBRE DE VILLAGES POP. RECENCEE POP. EXAMINEE POP. TRAITEE EXCLUS TRAITEE MECTIZAN

Pendi6 Badala 1026 777 (75,73 %) 596 (52,08 %) 179 (17,44 %) 249 (24,26 %) 939

Pendi6 H. Sud 99 63 (63, % 52 (52,52 %) 11(11,11 %) 32 (36,36 %) 81

Bomoeni 155 76 (49,03 %) 62 (40 %) 14 (9,03 %) 79 (51 %) 95

Pendie H. Nord 115 83 (72,17 % 72 (62,60 % 11(9,56 %) 32 (27,82 %) 113

Gu6ma 30 25 (83,33 %) 25 (83,33 % 0 5 (16,66 % 48

Bafoulague 218 184 (84,40 %) 144 (66,05, %) 42 (19,26 %) 34 (15,59 %) 235

B. Hameau 226 156 (69,02 %) 118 (52,21 %) 36 (15,92 %) 70 (30,97 %) 188

Fon 308 221 (75,75 %) 167 (54,22 %) 52 (16,88 %) 87 (28,24 %) 255

Soubayandougou 795 498 (62,64 %) 385 (48,42 %) 113 (14,21 %) 297 (37,35 % 625

Kountseni Samogo 131 83 (63,35 %) 65 (49,61 %) 19 (14,50 %) 46 (31,11 %) 104

Sourgoulogo 279 166 (59,60 %) 130 (46,60 %) 34 (12,18 %) 114 (40,86 %) 206

Dienkoa Chutte 195 114 (58,46 %) 98 (50,25 %) 16 (8,20%) 81 (41,53 %) 146

Simblni Village 81 46 (56,79%) 34 (41,97 %) 12 (14,81 %) 35 (43,20 %) 53

Simbleni 1 51 43 (84,31 %) 33 (64,70 %) 10 (19,60 % 8 (15,68 %) 57

Simbleni II 94 72 (76,51 %) 50 (53,19 %) 22 (23,40 %) 22 (23,40 %) 79

Ponworo 148 110 (74,32%) 87 (58,78 %) 23 (15,54 %) 38 (25,67 %) 128

Kountseni Centre 1381 1085 (78,56 %) 811 (58,72 %) 274 (19,84 %) 296 (21,43 %) 1228

1332 3801 (71,28 %) 2929 (54,93 %) 868 (16,27 %) 1529 (28,67 %) 1579

Tab. 4 PREMIERE CAMPAGNE DE TRAITEMENT AU MECTIZAN*

DU BASSIN DE LA SISSILI 02-09 JUIN 1992

VILLAGES POPULATION POPULATION POPULATION NBRE COMP. POPULATION POPULATION

RECENSEE PRESENTE % TRAITEE % MECTIZAN* EXCLUE % ABSENTE %

NATIEDOUGOU 121 103 85,12 72 59,50 74,5 31 25,61 18 14,87

SIA + KOUNA 159 144 90,56 109 68,55 118,5 35 22,00 15 9,43

NAZINGA-RANCH 125 110 88,00 90 72,00 117,5 20 16,00 15 12,00

BOALA 565 456 80,70 317 56,10 360 139 24,60 106 18,76

KOMBILI 272 188 69,12 147 54,05 159 41 15,08 84 30,89

BOASSAN 145 135 93,10 92 63,44 101,5 43 29,65 10 6,89

SARO 125 122 97,60 88 70,40 96 34 27,20 3 2,40

OUALEM 118 108 91,52 78 66,10 89,5 30 25,42 10 8,47

NESSARE 167 152 91,01 107 67,07 113 45 26,94 15 8,98

KOUNTIERO 311 253 81,35 173 55,62 183 80 25,72 58 18,64

NISSIBI 58 57 98,27 42 72,41 44 15 25,86 1 1,72

BORI 223 183 82,06 137 61,43 172,5 46 20,62 40 17,83

PRA 44 43 97,72 35 79,54 39,5 8 18,18 1 2,27

OKOUNA 185 170 91,61 120 64,86 124 50 27,02 15 8,10

TASSYIN 248 187 187 75,40 210 54 21,77 7 2,82

KOUNOU 191 191 125 65,44 145,5 46 24,08 20 10,47

PYIN 251 251 180 71,71 206,5 46 9,16 23 18,32

TOTAUX 3308 2862 86,52 2099 63,45 2354,5 763 23,06 441 13,33

* La Population de Kouna (8 personnes) a t traitbe avec celle de SIA.

DIRECTION PROVINCIALE DE LA SANTEDE L'ACTION SOCIALE ET DELA FAMILLE DE L'OUBRITENGATab. 5

RAPPORT DE DISTRIBUTION DE MASSE D'IVERMECTINEDANS LA PROVINCE DE L'OUBRITENGA

POPULATION TOTALE 5 i 15 ans 16 A 50 ans Nbre CP

Village n* 1 1201 477 724 1925

Village n* 2 907 268 638 1388

Village n* 3 484 193 291 775

Village n*4 208 83 125 333

Village n* 5 1377 562 815 2192

Village n* 6 314 117 197 511

Village n* 7 523 231 292 815

Village n* 8 650 223 427 1077

Totaux 5663 2154 3509 9016

DIRECTION PROVINCIALE DE LA SANTEDE L'ACTION SOCIALE ET DELA FAMILLE DU NAHOURITab. 6

RAPPORT DE DISTRIBUTION DE MASSE__ _ _D'IVERMECTINE DANS LA PROVINCE DU NAHOURI __ _

DEPARTEMENT FORMATION VILLAGES QUANTITE DE POPULATION

SANITAIRE COMPRIMES CONCERNEE

Donne 1100

Zanc6 708

Youka 1679

C.S.P.S. Mouma 1769Z 10 U DE Gou 878 7832

Z I 0 U Yelbissi 1900 Personnes

Narguina 700

Id6nia 600Koubout6 1850

Mouma Peulh 538

C.S.P.S. V 1 557TIEBELE des V 2 716 1364

A.V.V. V 3 330

V 4 625

TOTAL GENERAL 14 villages 13 950 cp. 9 196 personnes

NOMBRE DE TAMIS RECUS PAR PROVINCE EN 1992

PROVINCE NOMBRE DE TAMIS

BOULGOU 1300BOULKIEMDE 6800SISSILI 3000SANGUIE 500SOUROU 3700MOUHOUN 4000KOSSI 5500HOUET 1500COME

4000PONI 6500BOUGOURIBA 5000

PASSORE 4100YATENGA

6000SOUN

4000SENO 1950OUDALAN 1000SANMATENGA 5000NAMENTENGA 11900GNAGNA 7000KOURITENGA 2000GANZOURGOU 5000BAZEGA 2600NAHOURI 100ZOUNDWEOGO 0GOURMA 3000

"BA4 19270

* OUBRITENGA 26220

TOTAL 140940

* BAM POUR 1989/92 = 19270 TAMIS RECUS* WUBRITENGA 1989/92 = 26220 TAMIS RES

' S * NOMBRE DE TAMIS PLACES PAR PROVINCE EN 1992

PROVINCE NOMBRE DE TAMIS

BOULGOU 0BOULKIEMDE 4423SISSILI 3000SANGUIE 500SOUROU 3200MOUHOUN 2000KOSSI 5500HOUET 0COME 0PONI 5200BOUGOURIBA 955PASSORE 2437YATENGA 5979SOUN 3000SENO 1P9?OUDALAN 3J50SANMATENGA 5000NAMENTENGA 9550GNAGNA 6463KOURITENGA 2000GANZOURGOU 2896BAZEGA 1622NAHOURI 80ZOUNDWEOGO 0GOURMA 3000BAM 700

* OUBRITENGA 26120

TOTAL 8998 99 7

1- 1989/92 14816 TAMIS PLAGESRI 0A 190/92 : 26120 TAMIS PLACES

Onchocerciasis Control Programme [OCP] - Burkina Faso

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