par Dissak Delon, Fanny 
Président du jury De Spiegelaere, Myriam
Promoteur Godin, Isabelle
Co-Promoteur Kamgno, Joseph
Publication Non publié, 2019-11-27
Président du jury De Spiegelaere, Myriam
Promoteur Godin, Isabelle
Co-Promoteur Kamgno, Joseph
Publication Non publié, 2019-11-27
Thèse de doctorat
| Résumé : | Onchocerciasis, also known as river blindness, is a vector-borne parasitic disease caused by a very thin worm called Onchocerca volvulus and transmitted by the bites of black flies belonging to the Simulium species. The burden of the disease is heavier in Africa, especially among the poorest population of the continent. In fact, onchocerciasis is responsible for debilitating eyes and skin lesions, having negative psychosocial and economic impact at local (communities) and even national levels in the countries affected. Since 1995, onchocerciasis control activities focus on the Community Directed Treatment with Ivermectin (CDTI), a strategy adopted in African countries by the former African Program for Onchocerciasis Control (APOC) consisting of yearly mass administration of ivermectin. APOC closed at the end of 2015 after beginning the transition to onchocerciasis elimination. By that time, APOC’s achievements were more than 119 million people that were treated with ivermectin; many countries that had greatly decreased the morbidity associated with onchocerciasis; and more than 800,000 people in Uganda and 120,000 people in Sudan that no longer required ivermectin.Those brilliant results are less remarkable in Cameroon, where after more than 20 years of mass treatment with ivermectin, onchocerciasis prevalence is persistently high in many CDTI zones, remaining above the expected prevalence as predicted in the elimination process. This situation could be detrimental to the country, whose partners’ mandates are not unlimited. Indeed, despite the predictions, there is still some uncertainty around the actual date of cessation of ivermectin mass drug administration (MDA), which might not encourage the efforts of the donors who support the country in the fight against onchocerciasis. The persistence of onchocerciasis as a major public health concern has been recognized by the Cameroon’s ministry of public health as one of the weaknesses of the national disease control department. In reply to this situation, they decided to scale up the CDTI strategy, by setting the country’s target for therapeutic coverage to 80% (beyond the APOC’s target of 65%); reinforcing community stakeholders for better appropriation; and enhancing supervision, surveillance and operational research, among others. However, it should be noted that the specific reasons that explain the persistence of onchocerciasis in Cameroon are yet to be elucidated. If we summarize the above strategies, we notice that the main strategy of the ministry of public health consists in reinforcing the usual strategies, without documenting the exact weaknesses of those strategies. Why were they not optimal before? What can be done to reach these new goals? Based on those major questions, we wanted to enrich local evidence about the difficulties encountered by the country concerning onchocerciasis control and propose some recommendation that would help health policy makers in the process of control and even elimination of onchocerciasis.Our main objective was to understand the failed segments of the CDTI in the Littoral, Centre and West regions of Cameroon, where onchocerciasis prevalence remains remarkable. Our results allowed us to enrich evidence with 2 major lessons:Firstly, the health system functions as a loop, with the stakeholders mutually interacting and influencing each with another. Our findings showed that the barriers to CDTI were linked and mutually influenced: the frustration of operational level health staff favoured the remissness of community workers, which led to populations’ dissatisfaction about the ivermectin distribution campaigns. This dissatisfaction caused and was also enriched by poor community participation; low adherence to ivermectin (leading to poor therapeutic coverages); and at broader extend, populations’ mistrust towards the health system.The second key lesson from our work goes beyond the restricted circle of onchocerciasis control and can be adapted to Community Directed Interventions (CDI) in general. Indeed, the findings of our 3 main surveys, showing the low community ownership and the implementation gap in the framework of onchocerciasis control might bring into question the feasibility of the CDI approach that is being scaled up in the country since 2016. Besides these “pessimistic” results, we also identified some indicators of CDI feasibility in rural and semi-urban settlements, which included community eagerness for health information and their massive personal and financial adhesion to interventions that they perceived as important. |
