January 2004Volume 5, Number 1 THE CARTER CENTER

Eye of the Eagle

Gates Foundation Awards CarterCenter $10 Million to Fight RiverBlindness in the Americas

Niger Assesses Household LatrineUse, Maintenance, and Acceptance

continued on page 6

continued on page 2

In early 2002, the Niger nationalProgram for the Prevention ofBlindness, with the support of The

Carter Center and the InternationalTrachoma Initiative, launched a latrinepromotion project to control trachomain Niger. In the Zinder region, 1,282household latrines were built in thefirst year. (Another 1,295 latrines were constructed in January throughNovember 2003.) After a year of rural latrine promotion, the nationalTrachoma Control Program and TheCarter Center assessed the use, main-tenance, and acceptance of householdlatrines in the project area. The long-

help six countries halt transmission ofonchocerciasis throughout the region.The grant will provide supplementalfinancial and technical assistance tothe national programs in the sixendemic countries to increase the coverage and regularity of their semi-annual treatments. The Pan AmericanHealth Organization, which is theregional office for the Americas of theWorld Health Organization, will beresponsible for officially certifyingwhen transmission has been stoppedand the disease has been eliminated. In2001, the Carter Center’s InternationalTask Force for Disease Eradicationidentified river blindness as a target

range goal of this assessment is to explore ways to make householdlatrines affordable, acceptable, and sustainable.

In June 2003, an assessment teamvisited 50 villages and 200 householdsin the Zinder latrine project area. They held focus group discussions withvillage leaders and masons and inter-viewed heads of households to collectdata on latrine use, maintenance, andacceptability. The majority (73 percent)of persons interviewed were farmers,and there were an average of 10 residents in each household. For 78

What’s InsideColombia Hosts IACO 2003 . . . . . . . .2

Program Assists 50 Million Treatments .3

Dr. Katabarwa Joins Staff . . . . . . . . . . .4

Officials Visit Uganda . . . . . . . . . . . . . .5

Schools Celebrate Prevention Days . . .6

Lions and Hilton Visit Ethiopia . . . . . .7

Mali Launches Latrine Project . . . . . . .8

Sudan Holds Program Review . . . . . . .9

ITI Increases Donation . . . . . . . . . . . . .9

Organizations Collaborate in Research 10

Global Health News . . . . . . . . . . . . . .11

The Carter Center will escalatethe fight to eliminate riverblindness disease from the

Americas in this decade with a $10million challenge grant provided by theBill & Melinda Gates Foundation. Thegrant challenges the Center to raise $5million in matching funds to secure atotal of $15 million for the project.

“We have the science to end forever the suffering caused by river

blindness, which afflicts the poorest of the poor in this hemisphere,” saidformer U.S. President Jimmy Carter.“This generous grant not only willimprove life for our neighbors in LatinAmerica, but it will give hope to manymore people in Africa that their societysomeday may no longer be burdened by this disease.”

The Center, working through theOnchocerciasis Elimination Programfor the Americas, will use the grant to

River Blindness

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for eradication in the Americas, a decision endorsed by a conference of60 global experts in January 2002.

“We hope that this challenge grant will inspire other donors to support the Carter Center’s efforts toeliminate this debilitating, blinding disease in the Americas,” said Dr.Regina Rabinovich, director of theGates Foundation’s Infectious DiseasesProgram. “The elimination of riverblindness would mark a critical mile-stone in public health in the regionand pave the way for future progress in health and development.”

In Africa, where more than 18 million people are infected withriver blindness, the disease is not currently eradicable due to its heavyconcentration and challenges to dis-tributing the drug. “In the Americas,we can identify the entire populationwith the disease and treat a sufficientpercentage to eliminate transmission,”said Dr. Donald Hopkins, associateexecutive director for health programsat The Carter Center. “In Africa, the current goal is to control riverblindness as a public health problemwith annual doses of ivermectin.Nevertheless, it is expected that lessons learned in the Americas willcontribute to better control in Africa.”

Since 1996, The Carter Center has partnered with national ministriesof health, the Centers for DiseaseControl and Prevention, and LionsClubs International Foundation todeliver more than 50 million treat-ments of Mectizan® in Africa and Latin America.

The 13th InterAmericanConference on Onchocerciasismet Nov. 18-20 in Cartagena,

Colombia, reporting that the firstround of treatments in 2003 reached 92 percent of the eligible population inthe Americas, with all countriesexceeding their 85 percent coveragegoal for the first part of the two-times-per-year treatment strategy. This is thethird treatment round in a row that theAmericas have exceeded the coveragegoal of 85 percent. Provisional reportsthrough October indicated that218,634 persons have thus far beentreated in the second round, which is 67 percent coverage. A total of625,452 treatments were reported for the entire year through October.Percentages of ultimate treatment goal(2) achieved by each country throughOctober 2003, as reported in IACO

2003, are shown in Figure 1. For thefirst time, Venezuela has surpassed itstreatment coverage goal. Out of the eligible population of 96,306, a total of85,912 persons were treated in the firstround of 2003. (See Figure 2.) This is89 percent coverage, as opposed to 70percent for the same period in 2002.

A highlight of this year’s meetingwas a special meeting of ophthalmolo-gists to discuss ongoing research on theaspects of river blindness that impaireyesight. A report from this group isexpected in the coming months. Alsoof interest is the four-times-per-yeartreatment strategy slated to begin in

Colombia andparts of Mexico.Brazil is consider-ing a three-times-per-year strategy.

Mrs. CelsaSampson, representing Dr. EduardoAlvarez ofPAHO-Colombia,opened the meeting, andcomments weremade by healthrepresentatives of the Ministry

Gatescontinued from page 1

Figure 1

Colombia Hosts IACO 2003 Focusing Efforts to Achieve Eliminationof Onchocerciasis in the Americas

Waging Peace. Fighting Disease. Building Hope.

River Blindness

3www.cartercenter.org

of Health of Colombia, Merck, and OEPA. In addition to the country presentations on treatment coverage, treatmentfrequency, the impact of the programs thus far, and sus-tainability of the programs, Dr. Brian Duke of the RiverBlindness Foundation, Dr. Robert Klein of the CDC MedicalEntomology Research and Training Unit, Dr. Frank Richardsof the Centers for Disease Control and Prevention, and Dr.Carlos Gonzalez-Peralta of the Mectizan® Expert Committeemade presentations on specialized topics. The program wasalso pleased to have in attendance Dr. Libardo BastidasPassos, who is a former president of Lions Clubs InternationalFoundation and a physician.

As of October, a total of more than 8,214,287 people have received Mectizan for onchocerciasis inCarter Center-assisted programs in 2003, 82 percent

of the 2003 annual treatment objective. Of these treatments,49 percent have been in Nigeria. (See Table 1.) Uganda,Cameroon, Ethiopia, OEPA, and Sudan also have reportedtreatments in 2003. The program gave its 50 millionth treat-ment in July! Since its inception in 1996, the Global 2000River Blindness Program has assisted ministries of health toadminister 53,649,868 treatments in 11 countries in Africaand the Americas. Almost all of these treatments have beenassisted under the Lions-Carter Center SightFirst Initiative.

In response to this milestone, President Carter said,“Fighting blinding diseases has profound significance, not just for me as an interested observer, but for the child whowill never go blind and for his parents and grandparents, who now have hope their lives can improve. When peoplereceive Mectizan, it is often the only time they experiencesuch hope. The distribution of more than 50 million treatments is an incredible achievement.”

Continuing expansion of the Ethiopia River Blindness

Figure 2

Table 1

The Carter Center Assistsin More Than 50 MillionMectizan Treatments

continued on page 4

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4 Waging Peace. Fighting Disease. Building Hope.

The Carter Center’s RiverBlindness Program welcomesDr. Moses Katabarwa to the

Global 2000 team. Dr. Katabarwa is the new program epidemiologist, buthis history with Global 2000 dates backto 1996 when he became the countryrepresentative for the Carter Center’sUganda office. He previously workedwith onchocerciasis (for the River

Blindness Foundation), beginning in 1992.

Dr. Katabarwa has been a memberof the Lions Club since 1996. He has recently joined the chapter indowntown Atlanta. Because fightingblindness is one of the primary agendasof the Lions Club, the Atlanta Lionslook forward to hearing about his firsthand experiences with combatingriver blindness.

Dr. Moses Katabarwa Joins theGlobal 2000 Atlanta Office

Program has contributed substantiallyto this year’s treatment figures. Ethiopiasurpassed one million treatments forthe first time to reach 1,007,983 inJanuary-September 2003: almost twiceas many treatments as in 2002. In2003, the program began to treat inBench Maji zone (adjoining Kaffa andSheka zones) in the Southern Nations,Nationalities and Peoples region, and in North Gondar zone in the Amhararegion. The African Program forOnchocerciasis Control has approvedfurther expansion that will begin in2004 in Illubabor and Jimma zones,which also adjoin Kaffa and Shekazones but are administratively part of Oromiya region. Treatments are expected to double again in 2004.

“Lions have been ‘Knightsof the Blind’ for nearly

80 years. We are overjoyedthat in cooperation withThe Carter Center we’vebeen able to save the sight

of millions of people,” said Kay K. Fukushima,

chairperson of Lions ClubsInternational Foundation.

Health education and the distri-bution of Mectizan treatments havenot only prevented millions from contracting river blindness but alsohave saved multitudes of communitiesfrom near extinction. Villagers whoonce abandoned fertile land near rivers

to avoid being bitten have returned to their land and revived their localeconomy. Carter Center staff continueto hear stories from infected individualssuch as a Nigerian tailor whose eye-sight was beginning to be affected bythe parasite, but who reported that

Dr. Katabarwa, far right, visits with fellow Lions and President Carter in Uganda.

Center Assistscontinued from page 3

after taking Mectizan he could see well enough to thread a needle againwithout help.

We thank and congratulate ourpartners, especially Lions Clubs, otherdonors, and the ministries of health, for making this achievement possible.

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Addiss D, Rheingans R, Twum-DansoNAY, Richards F. “A Framework forDecision-Making for Mass Distribution ofMectizan® in Areas Endemic for Loa loa.”Filaria Journal. 2003; 2(Suppl 1): S9-18.

Ali MM, Baraka OZ, AbdelRahman SI,Sulaiman SM, Williams JF, HomeidaMM, Mackenzie CD. “Immune responsesdirected against microfilariae correlatewith severity of clinical onchodermatitisand treatment history.” Journal ofInfectious Disease. 2003; 187(4):714-7.

Ali MM, Mukhtar MM, Baraka OZ,Homeida MM, Kheir MM, MackenzieCD. “Immunocompetence may be impor-tant in the effectiveness of Mectizan(ivermectin) in the treatment of humanonchocerciasis.” Acta Tropica. 2002;84(1):49-53.

Eigege A, Richards FO Jr, Blaney DD,Miri ES, Gontor I, Ogah G, Umaru J,Jinadu MY, Mathai W, Amadiegwu S,

Hopkins DR. “Rapid assessment for lym-phatic filariasis in central Nigeria: a com-parison of the immunochromatographiccard test and hydrocele rates in an area ofhigh endemicity.” American Journal ofTropical Medicine and Hygiene. 2003;68(6):643-6.

Hoerauf A, Buttner DW, Adjei O,Pearlman E. “Onchocerciasis.” The BritishMedical Journal. 2003; 326(7382):207-10.

The Carter Center. “Summary: 2002Program Review for The CarterCenter/Lions SightFirst River BlindnessPrograms.” 2003 March.

World Health Organization.“Onchocerciasis (river blindness): Reportfrom the Twelfth InterAmericanConference on Onchocerciasis, Manaus,Brazil.” Weekly Epidemiological Record.2003; 78(41):361-4.

With Dr. Katabarwa’s assistance,Uganda reached many important milestones.

• He completed and produced an epidemiological map of the country,which shows the distribution ofonchocerciasis.

• During his tenure, the program therereached its ultimate treatment goalfor mass treatment with ivermectin.

• He has a passionate belief in thepower of community involvement,which led to the establishment of an effective, integrated, result-oriented research, monitoring, andevaluation mechanism for accessingand improving the performance ofthe community-directed strategy fordelivering ivermectin. As a result,more than 90 percent of Uganda’sRiver Blindness Program-assistedcommunities have been achievingcoverage of at least 90 percent annually. This strategy has nowbecome a national policy for allhealth programs requiring theinvolvement of communities, including malaria, HIV/AIDS, TB, lymphatic filariasis, and schistosomiasis.

Dr. Katabarwa has also been achampion for the involvement ofwomen in community-directed treatment with ivermectin (CDTI)activities and has published severalarticles on this topic. In September2002, he was appointed by the director-general of the World HealthOrganization to serve on the TechnicalConsultative Committee for theAfrican Program for Onchocerciasis.

The Carter Center looks forwardto Dr. Katabarwa’s contribution to theefforts at headquarters.

On Oct. 28, 2003, Lions ClubsInternational Foundation past President Jim Ervin

and Lion Dr. Tebebe Berhan, districtgovernor for District 411A (Ethiopia

and Kenya), paid a one-day visit toUganda to see what the local Lionshave done in improving the lives ofUgandans infected with onchocerciasis.

With local Lions and RiverBlindness Program staff, they traveledto Mbale district, where they visitedcommunities and viewed people withonchocerciasis signs and symptoms.The people of Mbale expressed gratitude to the Lions, the program,

Merck & Co.,and all otherpartners for making adifference intheir lives.

Lions Clubs International OfficialsVisit Uganda

River Blindness References

Past International President Ervinjoins Bufumo community membersand local leaders.

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6 Waging Peace. Fighting Disease. Building Hope.

latrine project has expanded beyond itsoriginal boundaries. Masons reportedhaving built 331 additional latrines in the intervention villages withoutproject contribution and 87 latrinesoutside of the project villages. Thirty-one villages had formed hygiene com-mittees to promote better hygiene and disease prevention. Forty-nine of the50 village leaders interviewed said thatthey would continue to build latrineswhen the project ends.

This first assessment of the ZinderLatrine Promotion Project provideshighly encouraging evidence that afterone year, household SanPlat latrinesare widely accepted, used, and main-tained in the intervention villages. This assessment provided additionalvaluable information for the nationalprogram to use in improving the “E” of the SAFE strategy.

percent of the latrine recipients inter-viewed, the Zinder project providedthem with their first household latrine.

Latrine use and maintenanceOver 90 percent of the adults in thestudy reported that they “always uselatrines.” Reported latrine use by children was lower, with 55 percentreporting that they “always uselatrines” and 18 percent reporting that they “use latrines often.” Thestudy suggests that latrines are usedmore often in the evening than in the afternoon or morning. Thirty-sixpercent of households reported thattheir neighbors used their latrine,though we do not know how often.Sixty-four percent of the adults interviewed reported having used alatrine during the last 24 hours, and 90 percent during the last 48 hours.

In 75 percent of the householdsvisited, women were in charge of cleaning the latrine, and latrines werereported to be cleaned an average ofthree times per week. Seventy-nine (39 percent) of the 200 latrinesinspected had been cleaned within 48 hours. Latrines were reportedlycleaned with water and soap (24 percent), water only (57 percent), and without water (13 percent).

On inspection, the assessmentteams found that latrine walls weremade mostly of dry grass (56 percent)or mud brick (36 percent). Only 15percent of the latrines had a door,which may have reduced privacy andlimited daytime use of the latrine.During the unscheduled household visits, the investigators found evidencethat 86 percent of the latrines hadbeen used recently, and 70 percent

were kept clean. Keeping latrine pitsclosed with cement covers provided bythe project is important to reducingboth flies and odors around latrines.Seventy-four percent of the latrinesinspected were closed at the time ofthe visit. Very few (6 percent) of thelatrines had exposed feces, and flieswere present in only 11 percent of the latrines.

AcceptabilityHousehold members reported that they appreciated latrines for proximityand easy access (59 percent), privacy(22 percent), environmental hygiene(7 percent), and disease prevention (5 percent). Few disadvantages to having a household latrine were reported, the most common being the odor (17 percent of respondents).

SustainabilityThe assessment found that the pilot

Niger Latrinescontinued from page 1

To promote awareness of tra-choma control, three primaryschools in Dera district—

Anbessamie, Arb Gebeya, and Hamusit—celebrated their first annualTrachoma Prevention Day in June and July 2003. Participants includedstudents, teachers, parents, and representatives of The Carter Center-Ethiopia, as well as local staff of thedistrict administration and health andeducation offices. Teachers and hygieneexperts read poems, and students in the schools’ trachoma clubs performeddramas and sang songs about trachoma

Ethiopia’s Dera District SchoolsCelebrate First TrachomaPrevention Days

control, hygiene, and health. Studentscompeted in trachoma question-and-answer contests. More than 200 participants attended each of theevents. Dera district is one of the fourdistricts in which the Amhara HealthBureau is working on trachoma controland prevention in collaboration withThe Carter Center.

Trachoma Prevention Day, part ofthe new trachoma prevention curricu-lum designed by the Amhara RegionalHealth Bureau and The Carter Centerto reach children in rural communities,is an important part of community

and sanitation clubs for grades 5-8.Over 7,000 students are involved inthe program at the three schools. Based on the final evaluation of the pilot

school programs,the curriculumwill be finalized,and the programwill expand to include other schoolsthroughoutDera and other highlytrachoma-endemic districts of theAmhara region.

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Lions pastInternationalPresident Jim

Ervin and Conrad N.Hilton FoundationVice President forPrograms DyanneHayes traveled toEthiopia Oct. 18-28,2003, to visit tra-choma control programs in theAmhara region. The team also included LionsMultiple District 411Chairman Dr. Tebebe Berhan, LionRamendra Shah, Dr. Joe Riverson ofWorld Vision International, and Mr.Teshome Gebre and Dr. Jim Zingeser of The Carter Center.

mobilization efforts in these highly trachoma-endemic communities. In2001, the newly launched AmharaTrachoma Control Program conducteda needs assessment that included interviews with schoolteachers. Thosestudies revealed that most school-teachers had minimal knowledge of the disease or its prevention. Teacherswere very interested and requestedhealth education materials and a structured guide to teaching trachomaprevention. Those requests led to discussions between The Carter Centerand the Amhara Regional Health andEducation bureaus. A working groupdeveloped a trachoma prevention curriculum and corresponding healtheducation materials to cover all com-ponents of the SAFE strategy with an emphasis on F&E. In addition, thelessons encourage students to identifyother problems related to hygiene intheir own communities and come upwith their own solutions.

The new curriculum was pilot tested in the three schools in Derabeginning in December 2002, where 71 teachers were trained in trachomacontrol and prevention. Trachoma istaught as part of the regular curriculumin grades 1-4 and through trachoma

The team first visited WorldVision’s trachoma control program inthe Borkena Valley. In Kemissie andAntsokia, the team was welcomed inlocal schools where trachoma healtheducation activities are going strong. Ahealth center where trichiasis surgerywas being done also was visited. Over78,000 persons in the Borkena Valleyat risk for blinding trachoma have nowbeen treated with Zithromax® donatedby Pfizer Inc. The World Vision program is funded by the HiltonFoundation and has received a grantfrom the International TrachomaInitiative.

The team visited the South GondarZone Trachoma Control Program, supported through the Lions-CarterCenter SightFirst Initiative, where theywere treated to demonstrations andpresentations in several public schools.At the Anbessamie Primary School,Trachoma and Sanitation Club

continued on page 8

Figure 3

Jim Ervin, Dyanne Hayes, Lions, and Carter Center representatives examine women after trichiasis surgery,Anbessamie Health Clinic, Ethiopia.

*This graph represents villages directly supported through the Carter Center’s Trachoma Control Program.

Lions Past International Presidentand Hilton Foundation VicePresident Visit Ethiopia

108180

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Trachoma

8 Waging Peace. Fighting Disease. Building Hope.

The success of latrine promotionprojects in Niger and Ethiopiahas clearly demonstrated

that thousands of household SanPlat(sanitary platform) latrines can be constructed in rural villages at low cost.Trachoma control programs have takena great interest in this technology forits potential to reduce the number oftrachoma-transmitting flies and bringother health benefits to participatingcommunities.

In April 2003, the Mali TrachomaControl Program began a pilot projectin two districts of the Ségou region topromote latrines and village-basedhealth education in trachoma-endemicvillages. The project is a collaborativeeffort of the National Program for thePrevention of Blindness, the regionalhealth bureau, the Baroueli and Bladistrict health bureaus, and The Carter Center. Dr. Modibo Traore andDr. Alassane Dicko, district medicaldirectors of Baroueli and Bla districts,respectively, launched the project andenlisted villages interested in trachomacontrol and improved hygiene. In thetwo districts, 63 rural villages with atotal population of 63,566 persons

Mali Launches Latrine PromotionProject in Ségou Region

were selected. Each village was asked to nominate two men to be trained as masons. Each village also selectedone man and one woman for healtheducation training.

A total of 104 villagers attendedthe two-day training for masons. Uponcompletion of their training, masonswere presented with enough cementand iron rebar to construct five demon-stration latrines in their home villages.Next, 102 health education volunteerswere trained in trachoma control attheir respective district health bureaus.Volunteers were encouraged to createvillage hygiene committees to promotegeneral hygiene and sanitation.

The long-term goal for the Malianproject is to promote a sustainablehygiene program in which latrine ownership and daily use is an integralpart of rural life. In August 2003, Mali’sMinistry of Health (including regionalsanitarians), UNICEF, and The CarterCenter held a meeting to discuss strate-gies for latrine sustainability in Mali.The Carter Center’s trachoma assis-tance to Mali is supported by theConrad N. Hilton Foundation.

members sang songs and performed dramas for the assembled students withimportant messages about preventingblindness. The headmaster of theAnbessamie School took his guests ona tour, including improved latrines andface-washing facilities. He presented his guests with copies of the school’strachoma and sanitation curriculum andworkbooks, which are being finalizedwith support from Lions and theCenter. Lion Tebebe announced that Ethiopian Lions Clubs would fund the translation of the curriculuminto Amharic.

Ato Zelalem Abera, coordinator of the South Gondar Zone TrachomaControl Program, took the team to rural villages where household latrineshave been built with support from theprogram. Health and hygiene promo-tion activities are ongoing in all 155villages in the program area, and morethan 3,000 household latrines havebeen built. Mr. Zelalem also led theteam on a tour of the Anbessamiehealth center, where corrective eyelidsurgery is done for trichiasis patients.More than 10,000 corrective eyelid surgeries have been performed as part ofthe program during the past three years,and 100,256 people were treated withZithromax in December 2003.

Past International President Ervin,Dyanne Hayes, and their colleagueswere honored at numerous events,including a banquet by the Lions Clubs of Addis Ababa. They also wereprivileged to meet with high officialsduring their visit, including H.E. YosefRetta, president of the Amhara region,who thanked the Lions, Carter Center,Hilton Foundation, and World Visionfor the work they are doing for the

Lionscontinued from page 7

people of the Amhara region. Hespecifically pointed out that the Lions-Carter Center program is working effectively to empower regional and zonal health programs and build local capacity.

On Oct. 27, H.E. Girma WoldeGiorgis, president of the FederalRepublic of Ethiopia, warmly receivedpast International President Ervin andthe Lions-Carter Center team at the

presidential palace in Addis Ababa.President Girma, a founding member of Ethiopia’s first Lions Club, expressedhis sincere appreciation for the goodwork being done with the support of Lions and The Carter Center to prevent blindness in Ethiopia. TheConrad N. Hilton Foundation andLions International are main supportersof the Trachoma Control Program insix African countries.

Trachoma

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First ProgramReview Meetingfor TrachomaControl Held inSouthern Sudan

On Nov. 11, 2003, theInternational TrachomaInitiative board of directors

approved Sudan’s request for 680,000additional treatment doses ofZithromax. This increased donationwill allow the Sudan TrachomaControl Program to expand treatmentin the areas already included in theprogram, as well as to begin treatmentin highly trachoma-endemic com-munities in West Darfur state.

The board’s approval coincidedwith the initiative’s fifth anniversarycelebration. In a press statement issued that day, Dr. Jacob Kumaresan,president of the initiative, said, “Weare winning the fight against blindnessfrom trachoma because we have anextraordinary strategy and effectivepartnerships in our program countries.Building on the momentum of ourachievements to date, we are broaden-ing the scope of the trachoma programsalready in place and will launch at least10 new country programs.”

The first program review meetingfor the Trachoma ControlProgram in the Operation

Lifeline Sudan/South operational area was held July 29-30, 2003, at the OLS/S compound in Lokichokio,Kenya. The 30 people who attendedthe review meeting represented alleight nongovernmental partners working to control blinding trachomain the areas of south Sudan supportedby the OLS/S consortium: Tearfund,MEDAIR, ZOA, Christian MissionAid, Adventist Development andRelief Agency, Sudan Medical Care,Christoffel Blindenmission, and TheCarter Center. In addition, representa-tives of the Sudan People’s LiberationMovement health secretariat and theWorld Health Organization were activeparticipants in the meeting.

The main objectives of the meeting were to review progress of theTrachoma Control Program in southernSudan, learn from the lessons of thepast year, and coordinate trachomacontrol activities for 2004. The partner organizations focused on howto implement a balanced SAFE strategyin southern Sudan in spite of the civil war. Challenges to the programincluded finding alternatives to tradi-tional latrines, which collapse readilyin the rainy season, and overcomingcultural resistance to using latrines.

International Trachoma InitiativeIncreases Zithromax to Sudan

By broadening their commitmentto the Sudan Trachoma ControlProgram, Pfizer, and ITI have shownthat they are dedicated to helping tofight trachoma in the most difficultareas of the world. With peace a realpossibility after decades of civil con-flict, health programs in Sudan arepoised to provide services to additionalisolated and underserved communitiesin both the north and south. In 2002,Sudan’s program treated a total of189,233 persons with Zithromax. In Operation Lifeline Sudan/South-supported areas of southern Sudan, The Carter Center has coordinated trachoma control activities in collab-oration with the SPLM health secretariat and six nongovernmentalpartners: Christoffel Blindenmission,the Adventist Development and Relief Agency, Christian Mission Aid,MEDAIR, ACROSS, and ZOA.

The Carter Center’s trachomaactivities in Sudan are supported under the Lions-Carter CenterSightFirst Initiative.

The lively discussion among participants throughout the meetingproduced recommendations for the program:

• Advocate for increased safe waterprovision in south Sudan

• Improve planning to achieve targetsin a timely manner

• Develop a supervision checklist forhealth education activities

• Develop line listings of target villages for monthly reporting ofSAFE activities

• Include more women in programactivities

• Identify culturally appropriate ways to empower target communities

• Scale up surgical activities with afocus on clearing the trichiasis backlog

• Do operational research for all compo-nents of SAFE, whenever possible.

Participants reported that the programreview was successful in meeting itsobjectives and that it helped create apositive team spirit and group identityfor the program in southern Sudan.

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10 Waging Peace. Fighting Disease. Building Hope.

feces produced significantly less M. sorbens. The peak density of flies on thefaces of children was observed in themorning between 9 a.m. and 11 a.m.,and Mr. Gashu’s observations suggest that temperature and relativehumidity may play an important role in governing the diurnal activity offlies. The initial data analysis suggests

Mr. Gashu Fentie is a biologistin the Amhara RegionalHealth Bureau with a strong

interest in vector-borne diseases.Illnesses transmitted by insects arehighly prevalent in the Amhara region,especially trachoma and malaria. Toincrease capacity in the region, Mr.Gashu entered the department of biology at Addis Ababa University tostudy entomology and chose to studyflies and trachoma transmission for hismaster of science degree.

In April 2002, Dr. Ellen Dotson,an entomologist at the U.S. Centers forDisease Control and Prevention, metMr. Gashu while visiting the SouthGondar Trachoma Control Program.Dr. Dotson had been asked to assist theregional health bureau and The CarterCenter to develop operational researchfor fly control. After meeting with Mr. Gashu and his thesis adviser, Dr.Teshome Gebre Michael, Dr. Dotsonagreed to be an external adviser on Mr. Gashu’s thesis.

Mr. Gashu’s entomological studiesbegan with direct observation of eye-seeking flies in the South Gondar village of Melefena, where 75 percentof the children observed had signs oftrachoma. The initial field observationswere done in December 2002 throughMarch 2003. About 95 percent of fliescaptured on the faces of children werefound to be Musca sorbens. Muscadomestica accounted for 2 percent ofthe eye-seeking flies captured. Themain breeding media for M. sorbenswere human and dog feces; herbivore

that improving sanitation by removinghuman and canine feces from the environment is an important step in trachoma vector control.

To continue his research and build laboratory skills in both fly andmosquito entomology, Mr. Gashuworked at the U.S. Centers for Disease Control and Prevention entomology laboratory in Atlanta, Ga., in November and December 2003. His study in the United States is sponsored by The Carter Centerthrough the Lions-Carter CenterSightFirst Initiative.

Addis Ababa University, CDC,and The Carter CenterCollaborate in Research

Bird M. Dawson CR. Schachter JS. MiaoY. Shama A. Osman A. Bassem A.Lietman TM. “Does the diagnosis of trachoma adequately identify ocularchlamydial infection in trachoma-endemic areas?” Journal of InfectiousDisease. 2003; 187(10):1669-73.

Frick KD, Basilion EV, Hanson CL,Colchero MA. “Estimating the burdenand economic impact of trachomatousvisual loss.” Ophthalmic Epidemiology.2003; 10(2):121-32.

Frick KD, Foster A. “The magnitude andcost of global blindness: an increasingproblem that can be alleviated.” AmericanJournal of Ophthalmology. 2003;135(4):471-6.

Gaynor BD, Holbrook KA, Whitcher JP,et al. “Community treatment withazithromycin for trachoma is not associated with antibiotic resistance inStreptococcus pneumoniae at 1 year.”British Journal of Ophthalmology. 2003;87(2):147-8.

Javaloy J, Ferrer C, Vidal MT, Alio JL. “Follicular conjunctivitis caused byChlamydia trachomatis in an infantSaharan population: molecular and clinical diagnosis.” British Journal ofOphthalmology. 2003; 87(2):142-6.

Kuper H. Solomon AW. Buchan J.Zondervan M. Foster A. Mabey D. “A critical review of the SAFE strategy for the prevention of blinding trachoma.”The Lancet. 2003; 3(6):372-81.

Mabey DC, Solomon AW, Foster A. “Trachoma.” 2003; The Lancet.362(9379):223-9.

Melese M. Alemayehu W. Gaynor B. YiE. Whitcher JP. Lietman TM. “Whatmore is there to learn about trachoma?”British Journal of Ophthalmology. 2003;87(5):521-2.

Munoz B, Solomon AW, Zingeser J, et al.“Antibiotic dosage in trachoma controlprograms: height as a surrogate for weightin children.” Investigative Ophthalmology& Visual Science. 2003; 44(4):1464-9.

Pizzarello L. “The Magnitude and Cost of Global Blindness: An IncreasingProblem That Can Be Alleviated.”Evidence-Based Eye Care. 2003; 4(3): 170-1.

Solomon AW, Holland MJ, Burton MJ, et al. “Strategies for control of trachoma: observational study with quantitative PCR.” The Lancet. 2003;362(9379):198-204.

Taylor HR, Dax EM. “New precision in measuring trachoma infection.” The Lancet. 2003; 362(9379):181-2.

Trachoma References

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11www.cartercenter.org

Mr. Andrew Terranella,M.P.H., M.D. candidate atEmory University, traveled to

the Global 2000 office in Jos, Nigeria,June 29 –Aug. 16, 2003, to assesspotential transmission of lymphaticfilariasis in two selected urban areas:Jos, Plateau state; and Lafia, Nasarawastate. With Dr. Abel Eigege, head ofthe Plateau and Nasarawa lymphaticfilariasis effort at Global 2000/Nigeria,and other Nigerian staff, Mr. Terranellavisited clinics and primary care centersin the two cities.

The team set up a surveillance system for clinical manifestations oflymphatic filariasis across six districtsin the city of Jos. A similar surveillancesystem was established in the city ofLafia. This surveillance system detected27 exclusively urban cases of hydrocele,

lymphedema, or elephantiasis and eight exclusively urban W. bancroftiinfections among 12,083 patients inthe two cities. They detected only onecase of adenolymphangitis (ADL). (See Figure 4.) At least two urban fociof infection exist in the NasarawaGwong and Tudun Wada districts of Jos.

Based on these findings, the program began treatment for lymphaticfilariasis in Jos for the first time inOctober 2003. The Lymphatic FilariasisElimination Program in Nigeria is alsoconducting treatment in 29 villages inPlateau and Nasarawa states and hastreated 2,298,859 people throughSeptember 2003. Cumulatively, TheCarter Center has assisted in morethan 5.2 million lymphatic filariasistreatments in Nigeria since the program commenced in 2000.

Lymphatic Filariasis in NigerianUrban Areas Pinpointed by Emory Student

Figure 4

At the 2001 Nigeria programreview, a decision was made to offer surgery to the

approximately 450 men with hydrocelewho were identified in the 1999-2000hydrocele survey. Dr. Gail Thomas, a surgeon and consultant to the Carter Center’s Lymphatic FilariasisElimination Program, visited Jos to evaluate the pilot hydrocele surgery project in central Nigeria, July 28 –Aug. 6, 2003.

Dr. Thomas examined80 patients following

their hydrocele surgery.

Approximately 170 surgeries have been performed since September2002. Dr. Thomas personally was able to examine 80 patients post-operatively following their hydrocelesurgery. Follow-up of patients 10months after surgery showed good outcome, with no recurrence of hydrocele, although the rate of postoperation wound infections among the 36 patients who were examined four weeks after surgery was unacceptably high.

The patients were extremely grateful and happy to share how thissurgery has changed their lives. Manyare now able to farm and participate in their family and community life,which was not possible a year ago.

ConsultantEvaluatesHydroceleSurgery Project

THECARTER CENTER

Global Health News

In November, Ms. Kelly Callahan,Carter Center resident technical adviser in Nairobi, Kenya, returned to the United States and Mr. MarkPelletier, former Carter Center/Khartoum, Sudan resident technicaladviser, has replaced her. Mr. RaymondStewart, who was the Center’s residenttechnical adviser in Ouagadougou,Burkina Faso, is now resident technicaladviser in Khartoum.

Dr. Jeremiah Ngondi, trachomaprogram control officer for The CarterCenter based in Nairobi, began an 11-month study of epidemiology inSeptember at Cambridge University

Milestones in England as a scholarship recipient.Ms. Alice Onsarigo joined The CarterCenter as the new program officer in Nairobi.

Similarly, Mr. Eric Dumakor, trachoma program control officer inGhana, has left to study at the LondonSchool of Hygiene and TropicalMedicine. Ms. Lydia Ajono has joinedThe Carter Center office in Accra asthe new program officer.

Mr. Ayman Elsheikh, data managerfor the Khartoum office, received one of the first Foege Fellowships, funded by the Bill and Melinda GatesFoundation, allowing him to study public health at Emory University inAtlanta, Ga., for two years.

For up-to-the-minute news from The Carter Center, visit our Web site: www. cartercenter.org.

One Copenhill453 Freedom ParkwayAtlanta, GA 30307

Ms. Peace Habomugisha has beenappointed acting country representa-tive of The Carter Center in Uganda.

The International TrachomaInitiative celebrated its fifth anniver-sary in New York on Nov. 11, 2003.The day’s events included speechesfrom U.N. Secretary-General KofiAnnan and a congratulatory videomessage from former U.S. PresidentJimmy Carter.

The ITI was created in 1998 by the Edna McConnell Clark Foundationand Pfizer Inc to assist trachoma-endemic countries in implementing the SAFE strategy and managingPfizer’s donation of Zithromax for treating active trachoma and pre-venting transmission of the disease.