the world health organization year 2013 progress report
TRANSCRIPT
AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL
The World Health Organization Year 2013 Progress Report 1st September 2012 – 31st August 2013
JAF19.5
www.who.int/apocPROv isiOna l agen da i T em 5
© Copyright african Programme for Onchocerciasis Control (WHO/aPOC), 2013. all rights reserved.
Publications of the WHO/APOC enjoy copyright protection in accordance with the Universal copyright Convention. Any use of information in the WHO/APOC Progress Report should be accompanied by acknowledgement of WHO/APOC as the source.
For rights of reproduction or translation in part or in total, application should be made to: Office of the APOC Director, WHO/APOC, BP 549 Ouagadougou, Burkina Faso [email protected]
WHO/APOC welcomes such applications.
The WHO African Programme for Onchocerciasis Control
Progress Report 20131st September 2012 – 31st August 2013
AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL
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List of tables, figures and annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8
PaRT 1: THe YeaR in RevieW
1. Progress in Community-directed Treatment with ivermectin (CdTi) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
1.1. DiseaseMapping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.1.1. Mapping of onchocerciasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.1.2. Mapping of loiasis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 111.1.3. Mapping of other Neglected Tropical Diseases (NTDs) . . . . . . . . . . . . . . . . . 11
1.2.GeographicandtherapeuticCoverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 121.2.1. Status of geographical coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.2.2. Status of therapeutic coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141.2.3. Classification of the districts in relation with the
therapeutic coverage thresholds in 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151.2.4. Trend in geographic and therapeutic coverage in
APOC countries, 2009-2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
1.3.Monitoring,EvaluationofCDTIProjects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 191.3.1. Monitoring the implementation of CDTI projects. . . . . . . . . . . . . . . . . . . . . . . . . 191.3.2. Community Self-Monitoring (CSM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
1.4ManagementofMectizantabletssuppliedbytheMectizan®DonationProgram(MDP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221.4.1. Supply of Mectizan tablets including joint applications . . . . . . . . . . . . . 22
1.5.DevelopmentandImplementationofaCommunity-directedIntervention(CDI)CurriculumandTrainingModule . . . . . . . . . . . . . . . . . . . . 221.5.1 Achievements in 2012 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231.5.2 Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25
2. elimination of Onchocerciasis in africa . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
2.1.StatusofOnchocerciasisinendemiccountriesinAfrica . . . . . . . . . . . . . . . 262.1.1. Epidemiological Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 262.1.2.Entomological Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
2.2.Delineationofivermectintreatmentboundariesandtransmissionzones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 282.2.1.Delineation of ivermectin treatment boundaries. . . . . . . . . . . . . . . . . . . . . . . . . . 282.2.2 . Delineation of transmission zones. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Table of content
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3. Partnership and collaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
3.1.CDTIprojectandNGDOsupportforonchocerciasiscontrol . . . . . . . . 33
3.2.CollaborationwithotherProgrammesandInstitutions . . . . . . . . . . . . . . 33
3.3.Co-ImplementationofCDTIwithotherhealthinterventions . . . . . 343.3.1. APOC support to NTDs activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 353.3.2. Expanded co-implementation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
4. government contributions to CdTi activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.1.Governmentfinancialcontributionstoonchocerciasiseliminationactivities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
5. Programme management and finance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
5.1.ProgrammemanagementandstatutoryMeetings . . . . . . . . . . . . . . . . . . . . . . . 425.1.1. The Joint Action Forum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425.1.2. Technical consultative Committee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 425.1.3. Committee of Sponsoring Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43
5.2.TechnicalSupporttoCountries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
5.3.Programmeexpendituresandincome . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445.3.1. Direct Financial Support to Countries and Management
of the APOC Trust Fund. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445.3.2.Programme Budget Allocation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 445.3.3.Financial Reporting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
PaRT 2: WaY FORWaRd
6. elimination of Onchocerciasis and co-implementation of PC/nTd interventions within peripheral Health systems strengthening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 496.1.ParadigmChangeforElimination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
6.2.Cross-BorderCollaborationtoAchieveElimination . . . . . . . . . . . . . . . . . . . . . . . 496.2.1.Cross border meetings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
6.3.TransitionTaskForceoftheCSA . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
7. support to peripheral health systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
7.1.Peripheralhealthsystemsstrengthening . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557.1.1. Technical Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 557.1.2. Master and Bachelor Degrees in Public health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 567.1.3. Gender Mainstreaming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
annex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
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list of tables, figures and annex
Tables Table1: Summary of ivermectin treatment in APOC participating countries in 2012, as reported
by NOTFs Table2: Number of the districts in relation with the coverage thresholds reached in 2012, as
reported by NOTFs Table3: Number of communities and districts implementing Community Self-Monitoring and Stakeholders meetings in 2012 Table4: CDTI projects selected for the multi-country study on CSM Table5: Number of ivermectin tablets shipped by MDP to countries in 2012 Table6: Results of epidemiological evaluations from 1 September 2012 to 31 August 2013 Table7: Summary of the mapping of ivermectin treatment boundaries in three countries, 2013 Table8: Number of treatments in 2012 for NTDs in APOC-supported regions in United Republic of Tanzania Table9: Countries / Projects direct Financing Table10: Breakdown by major activities of APOC 2012-13 budget Table11: Financial reporting and monitoring as of 18 July 2013 Table12: Number of Health Professionals trained/retrained in 2012
Figures Figure1: Map of the estimated prevalence of palpable nodules in the 20 APOC countries Figure2: Evolution in geographic coverage of treated districts by country, 2011 and 2012, as reported by NOTFs Figure3: Evolution in therapeutic coverage of treated districts by country, 2011 and 2012, as reported by NOTFs Figure4: Pre-control status of Onchocerciasis in Burundi (based on REMO data) and microfilaria prevalence in 20 ivermectin naïve communities surveyed for delineation of ivermectin treatment boundaries in 2013 Figure5: Preliminary delineation of transmission zones at the border of Cameroon, Chad and Central African Republic Figure6: Number of health interventions delivered using the CDI network Figure7: CTP-NTD co-endemicity map of the DRC in 2012 (map built by National Onchocerciasis Control Program/DRC Figure8: Map showing onchocerciasis endemic transmission areas across the border of Uganda and DRC Figure9: Map showing onchocerciasis endemic transmission areas across the border of Cameroon, CAR and Chad and results of epidemiological evaluationsFigure10: Number of CDDs trained/retrained in CDTI strategy in 2012
annex TableA1: Cytotaxonomy identification of S. damnosums. l. larvae collected from rivers in Cameroon, CAR, Chad and Nigeria
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AfDB African Development Bank
AFRO WHO Regional Office for Africa
APOC African Programme for Onchocerciasis Control
CAR Central African Republic
CDD Community-Directed Distributor
CDI Community-Directed Intervention
CDTI Community-Directed Treatment with Ivermectin
CFSP Training Centre in Public Health, Togo
CSA Committee of Sponsoring Agencies
DFC Direct Financial Cooperation
DfID Department for International Development
DNA Deoxyribonucleic acid
DRC Democratic Republic of Congo
FACE Direct Funding Authorizations and Certifications of Expenditure
FMPO Faculty of Medicine, Pharmacy, and Odontology
GIS Geographic Information System
GSM Global Management System
GTMP Global Trachoma Mapping Project
HKI Helen Keller International
HMM Home Management of Malaria
IPDSR Institute of Population Development and Health Reproduction
IPM Independent Participatory Monitoring
IRC International Rescue Committee
IRSP Regional Institute of Public Health Ouida
ISED Institute of Health and Development
JAF Joint Action Forum (APOC governing body)
LA Letter of Agreement
LLIN Long Lasting Impregnated Nets
MDSC Multi-Disease Surveillance Centre
MF Microfalariae
MITOSATH Mission To Save The Helpless
NGDO Non-Governmental Development Organisation
NGO Non-Governmental Organisation
NOCP National Onchocerciasis Control Programme
NOTF National Onchocerciasis Task Force
NTD Neglected Tropical Disease
OCP Onchocerciasis Control Programme in West Africa
PC-NTDs Preventive Chemotherapy Neglected Tropical Diseases
PEC Primary Eye Care
PRONANUT National nutrition programme
RAPLOA Rapid Assessment Procedure for Loa loa
REMO Rapid Epidemiological Mapping of Onchocerciasis
RPRG/AFRO Regional Programme Review Group of AFRO
SCH Schistosomiasis
SCI Schistosomiasis Control Initiative
STH Soil-Transmitted Helminthiases
TCC Technical Consultative Committee (APOC scientific advisory group)
TDR WHO-based Special Programme for Research and Training in Tropical Diseases
TRC Technical Review Committee
TTF Transitional Task ForceUCAD Cheikh Anta Diop University of
Dakar, Senegal
UFAR United Front Against River-blindness
UK United Kingdom
UMST University of Medical Sciences and Technology
UNICEF United Nations Children’s Fund
USAID United State Agency for International Development
VHT Village Health Team
WAHO West African Health Organisation
WHO World Health Organisation
abbreviations
executive summary
In 2012, one thousand three hundred and thirteen (1313) districts in 115 projects in 24 onchocerciasis-endemic countries reported Community-Directed Treatment with Ivermectin (CDTI) activities while 1295 (98.6%) reported treatment data. Treatments are yet to be reported for or did not take place in the remaining districts due to security challenges, non-receipt of data, or socio-political unrests. 1116 districts (85%) in 10 coun-tries achieved 100% geographic coverage of the endemic communities. Overall, 181,709 communities (95.3%) distributed ivermectin and 99,316,949 persons (76.4%) were treated in 24 countries. 52.3% of the districts in 14 countries that reported treatment reached the threshold of 80% therapeutic coverage needed to achieve onchocerciasis elimination. Three countries (Angola, South Sudan and Central African Republic) are however below the 65% therapeutic coverage required for control. To ensure that these treatments are carried out in 2012, Mectizan® Donation Program (MDP) shipped a total of 581,737,000
ivermectin tablets to 26 countries.
Results of the epidemiological evaluations conducted between 2012 and 2013 indicated that the assessed foci located in Burundi, Central African Republic (CAR), Ethiopia, Equatorial Guinea, Malawi, and United Republic of United Republic of Tanzania may have already reached the breakpoint for onchocerciasis elimination. Moreover, results of entomological evaluations conducted in 4 countries (Benin, Ghana, Mali and Uganda) in 2012 indicated that infectivity rates were above the threshold of 0.5x10-3 in Uganda, zero in Benin, Ghana as well as in 2 of 3 sites in Mali. However, the minimum number of 6000 flies per site required for proper statistical interpretation of the entomological situation at these foci was not obtained for most points.
The delineation of ivermectin treatment boundaries was implemented in 3 countries (Burundi, Cameroon and Chad). Except for Cameroon there will be no need to expand ivermectin treatment boundaries. Outcomes of the transmission zone delineation conducted in Cameroon, Nigeria, Chad and Central African Republic indicated that there is one transmission zone that covers Northern Cameroon and Chad which descends a bit into Central African Republic but does not include parts of North-East Nigeria.
Countries and their partners have used the Community-Directed Interventions (CDI) network established through APOC to implement other health interventions. Over
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46 million persons were reached in 2012, with soil-transmitted helminthiases (STH) and lymphatic filariasis (LF) interventions recording the highest treatments (40.7% and 38% respectively). In United Republic of Tanzania, APOC supported the treatment of 10,041,551 persons (44.4%) of the 16 million treatments provided for four preventive chemotherapy neglected tropical diseases (PC-NTDs) in 2012. NTDs co-implementation has been extended from 36 districts in 5 regions in 2009 to 971 districts in 14 regions in 2013.
To strengthen CDTI performance APOC supported the improvement of training modules on CDTI and the training of 81,520 health professionals (all categories combined) from 22 countries in various areas. A total of 668,094 Community-Directed Distributors (CDDs) also in 22 countries were trained (23% newly trained and 77% retrained) on CDI strategy in 2012. Overall, the proportion of female CDDs involved in CDTI activities has increased from 25.0% in 2010 to 29.0% in 2011 and to 30.8% in 2012.
A total of 126 CDTI project/programmes and six National Onchocerciasis Task Force (NOTF) secretariats supporting projects have received direct financial support. As at July 2013, the total funds contributed to countries during the 2012-13 biennium amounts to USD 37,87 million, out of which USD 20,2 million were disbursed in 2012 and USD 12,67 million disbursed in 2013.
During the period under review APOC Management, the Committee of Sponsoring Agencies (CSA) members, the Transition Task Force (TTF) put in place by the CSA and Stakeholders devoted a significant part of their efforts to develop a concept note and strategic plan 2016-2025 for a new regional entity that will lead the elimination of onchocerciasis and lymphatic filariasis as well as provide support to countries for the elimination/control of other NTDs. Both documents are submitted to JAF19 for consid-eration and approval.
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1.1. disease mapping
1.1.1. Mapping of onchocerciasis
With the shift from control to elimina-tion, countries are reviewing critically the onchocerciasis distribution map to ensure that all potential zones of transmission of the infection have come under treat-ment with ivermectin. Ethiopia’s National Onchocerciasis Task Force (NOTF), in October 2012, received technical and finan-cial support from APOC to conduct surveys and refine REMO results in 36 districts in 10 zones (Assosa, Awi, Dawuro, East Wellega, Horo Gudru Wellega, Kamashi, Metekel, West Shewa, West Wellega and Gambella). The survey followed an in-depth review of Rapid Epidemiologic Mapping of Oncho-cerciasis (REMO) data coupled with local knowledge on the status of onchocerciasis in the country. A total of 3,445 persons were examined in 86 villages. Based on the results, Community-Directed Treat-ment with Ivermectin (CDTI) has been extended in existing CDTI projects areas. They have also allowed for the identifi-cation and initiation (after approval by APOC) of two new CDTI projects in Assossa and Kamachi zones. Meanwhile, a thor-ough review and analysis of all REMO data available have been done and the pre-control endemicity map of onchocerciasis in the APOC-participating countries has been updated (Figure 1). Based on this map it is estimated that 35.8 million persons
would have been infected by 2011 in these countries if there had been no CDTI. Two papers have been finalized and submitted to a peer-review journal.
1.1.2. Mapping of loiasis
Additional data (using parasitological examination) on the level of Loaloa infec-tion was collected in Chad and Cameroon, utilizing the opportunity of onchocerciasis epidemiological surveys in previously hypo-endemic areas (see section 2.2.1). Parasite identification and counting are on-going in the two countries for a better delineation of the risk areas for severe adverse events (SAEs).
1.1.3. Mapping of other Neglected Tropical Diseases (NTDs)
APOC Management provided technical assistance to Nigeria in the identification of NTDs mapping gaps. It also contrib-uted with other partners to the review of the status of the mapping of Preven-tive Chemotherapy Neglected Tropical Diseases (PC-NTDs) in the African Region during a consultative meeting held in Addis Ababa in June 2013. As a follow-up to this meeting a joint Center for Neglected Tropical Diseases (CNTD) of Liverpool and APOC mission visited Gabon and assisted the Ministry of Health in planning a coor-dinated mapping of lymphatic filariasis and onchocerciasis. This coordinated mapping is yet to be implemented.
Part 1: tHE YEar IN rEVIEW
1. Progress in Community-directed Treatment with ivermectin (CdTi)
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Figure1: Map of the estimated prevalence of palpable nodules in the 20 APOC countries
1.2. geographic and Therapeutic Coverage In 2012, 115 projects in 24 onchocerciasis-endemic countries in Africa implemented CDTI and reported data. A total of 1,313 districts reported CDTI activities while 1295 (98.6%) reported treatment data (Table 1). Ivermectin distribution did not take place in Equatorial Guinea as it was postponed to January 2013 to allow for conduct of epidemiological evaluation surveys in November-December 2012. In Côte d’Ivoire, ivermectin distribution did not take place in 10 districts due to inad-equate financial releases by the Govern-ment and partners. Senegal could not share any CDTI data due to the retention of health information by health personnel between June 2010 and February 2013. The national programme is trying to retrieve
what is available. Three (3) CDTI projects in Angola (Bengo, Huila and Moxico) and one in Nigeria (Adamawa) are yet to report 2012 treatment data. In Central African Republic (CAR) some reporting forms were stolen during socio-political unrests in the endemic districts. However, the national office with support from health staff and Community-Directed Distributors (CDDs) who remained in their villages has succeeded in rebuilding partially the database and this is what has been used to report on the country activities.
Ivermectin distribution has been suspended in nine districts in Uganda (Mbale, Bududa, Manafwa, Sironko, Mitooma, Bushenyi, Kabarole, Kyen-jojo, Maracha), in two districts in Mali (Bougouni, Yanfolila) and in one district in Sudan (Abu Hamed) where available
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Country
No.ofcommunities No.ofpersonsNo.of
districts
Total Treated
Geo-graphic
coverage(%)
Total Treated
Thera-peutic
coverage(%)
Thatreported
Thattreated
Angola 2,539 1,280 50.4% 1,212,200 430,329 35.5% 26 17
Benin 4,731 4,655 98.4% 3,304,364 2,768,062 83.8% 50 50
Burkina Faso
391 391 100% 219,298 186,040 84.8% 6 6
Burundi 369 369 100% 1,498,298 1,204,433 80.4% 10 10
Cameroon 10,199 10,180 99.8% 6,851,789 5,500,491 80.3% 111 111
CAR 6,042 3,460 57.3% 1,678,522 985,325 58.7% 10 8
Chad 3,250 3,250 100% 2,086,183 1,718,974 82.4% 20 20
Congo 770 770 100% 848,286 689,138 81.2% 27 27
Côte d'Ivoire
2,386 2,386 100% 1,537,096 1,219,178 79.3% 36 36
DRC 40,474 39,100 96.6% 30,379,763 23,126,855 76.1% 242 238
Eq. Guinea
Ethiopia 32,786 32,673 99.7% 8,016,831 6,446,552 80.4% 98 98
Ghana 5,024 5,020 99.9% 4,351,572 3,466,716 79.7% 73 73
Guinea 6,663 6,663 100% 2,694,390 2,236,136 83% 20 20
Guinea Bissau
889 717 80.7% 168,128 107,835 64.1% 17 17
Liberia 5,269 5,012 95.1% 2,938,398 2,388,812 81.3% 15 15
Malawi 2,186 2,186 100% 2,123,209 1,758,924 82.8% 8 8
Mali 3,983 3,983 100% 4,844,513 3,956,909 81.7% 15 15
Nigeria 33,618 33,366 99.3% 37,356,314 29,032,404 77.7% 400 400
Senegal
Sierra Leone
8,451 8,451 100% 3,293,838 2,642,036 80.2% 12 12
South Sudan
6,728 4,047 60.2% 5,707,037 2,473,693 43.3% 44 41
Sudan 172 172 100% 169,368 146,468 86.5% 2 2
United Republic of Tanzania
6,257 6,116 97.7% 2,364,865 1,872,181 79.2% 17 17
Togo 2,884 2,832 98.2% 3,108,940 2,599,544 83.6% 28 28
Uganda 4,640 4,630 99.8% 3,281,974 2,359,914 71.9% 26 26
Total 190,701 181,709 95.3% 130,035,176 99,316,949 76.4% 1,313 1,295
Table1: Summary of ivermectin treatment in APOC participating countries in 2012, as reported by National Onchocercisis Task Forces (NOTFs)
evidence suggest that onchocerciasis transmission has been interrupted.
In Sudan the decision to suspend treat-ments was taken by the Federal Ministry of Health (Higazi TB et al., 2013)1, while in Uganda the suspension was recom-
1 Higazi TB, Zarroug IM, Mohamed HA, Elmubark WA, Deran TC, Aziz N, Katabarwa M, Hassan HK, Unnasch TR, Mackenzie CD, Richards F, Hashim K. (2013). Interruption of Onchocerca volvulus transmission in the Abu Hamed focus, Sudan. Am J Trop Med Hyg. 2013 Jul;89(1):51-7. doi: 10.4269/ajtmh.13-0112. Epub 2013 May 20.
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mended by the Uganda Onchocerciasis Elimination Expert Advisory Committee.
In Mali, ivermectin distribution is stopped in the districts of Bougouni and Yanfolila, co-endemic onchocerci-asis-lymphatic filariasis, where mass treatment for lymphatic filariasis is suspended since 2011, following the reach of the threshold of less than 1% LF prevalence recommended by WHO for elimination.
In order to evaluate also the reach of the threshold for elimination of onchocerci-asis in the two above-mentioned districts under ivermectin treatment since 1989, Phase 1b epidemiologic evaluations carried out in 2013, showed zero prevalence and microfilarial loads in the 20 villages evalu-ated in the basin Baoulé-East and its tribu-taries common to the 2 districts. This trend towards elimination of onchocerciasis is still to be confirmed by entomological evaluation that is going on.
CDTI was extended to new areas iden-tified as endemic for onchocerciasis in Democratic Republic of Congo (Ituri South) and Ethiopia (Illubabor, Jimma and North Gondar zones). This is consequent to the refinement of the pre-control prevalence maps for these countries.
Due to frequent changes in the delinea-tion of district boundaries APOC Manage-ment, in collaboration with country programmes, is updating its database of the endemic districts including the esti-mated population at risk based on current endemicity level of the disease. This may result in an increase in the number of endemic districts.
In the current report, treatment coverage refers to the coverage (geographic/ther-apeutic) achieved for the districts that implemented and reported CDTI activities and where interruption of transmission of onchocerciasis infection is yet to be achieved.
1.2.1. Status of geographic coverage
Under the supervision of health personnel at frontline health facility level, 181,709 communities distributed ivermectin, repre-senting an overall geographic coverage of 95.2%, with a median value of 99.8% and a minimum of 50.4% (Angola). Ten countries reported 100% geographic coverage of the communities in the target districts. In four countries (Angola, CAR, Guinea Bissau and South Sudan) geographic coverage was less than 95%. These countries had been previously classified as post-conflict coun-tries in the APOCstrategicplan2008-2015. All the countries previously classified as stable achieved at least 96% geographic coverage.
1.2.2. Status of therapeutic coverage
Overall, 99,319,949 persons out of a total population of 130,035,176 were treated in 24 countries giving 76.4% therapeutic coverage with a median value of 80.3% and a minimum value of 35.5% (Angola). A total of 14 countries reached the threshold of 80% recommended for the elimination goal. Angola, South Sudan and CAR (with partial data) are however below the 65% therapeutic coverage required for control.
1.2.3. Classification of the districts in relation with the therapeutic coverage thresholds in 2012
A total of 1116 districts representing 85% of the 1313 districts that reported CDTI data have achieved 100% geographic coverage of the endemic communities (Table 2). In 10 countries, all the districts achieved full geographic coverage. 52.3% of the districts that reported reached the threshold of 80% therapeutic coverage needed to achieve onchocerciasis elimination.
Sixteen (66.7%) of the 24 reporting coun-tries (Angola, Benin, Cameroon, CAR, Côte d’Ivoire, DRC, Ethiopia, Ghana, Guinea Bissau, Mali, Nigeria, Sierra Leone, South
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Sudan, United Republic of Tanzania, Togo and Uganda) have less than 75% of districts with adequate treatment coverage (>=80%). These countries especially, need to develop innovative approaches to improve treatment compliance and ensure full geographic coverage.
Country
Levelofgeographiccoverage Leveloftherapeuticcoverage
<100% 100%%with100%
<80%>
=80%
%ofdistrictswithcove-
rage>=80%
No.ofdistrictsthat
reported
Angola 19 7 26.9% 23 3 11.5% 26
Benin 12 38 76% 16 35 70% 50
Burkina Faso 0 6 100% 0 6 100% 6
Burundi 0 10 100% 1 9 90% 10
Cameroon 9 102 91.9% 37 74 66.7% 111
CAR 10 0 0% 8 2 20% 10
Chad 0 20 100% 2 18 90% 20
Congo 0 27 100% 7 20 74.1% 27
Cote d'Ivoire 0 36 100% 18 18 50% 36
DRC 26 216 89.3% 135 107 44.2% 242
Eq. Guinea
Ethiopia 9 89 90.8% 42 56 57.1% 98
Ghana 3 70 95.9% 25 48 65.8% 73
Guinea 0 20 100% 2 18 90% 20
Guinea Bissau 13 4 23.5% 17 0 0% 17
Liberia 14 1 6.7% 3 12 80% 15
Malawi 0 8 100% 0 8 100% 8
Mali 0 15 100% 8 7 46.7% 15
Nigeria 20 380 95% 207 193 48.3% 400
Senegal
Sierra Leone 0 12 100% 7 5 41.7% 12
South Sudan 44 0 0% 44 0 0% 44
Sudan 0 2 100% 0 2 100% 2
United Republic of Tanzania
3 14 82.4% 8 9 52.9% 17
Togo 14 14 50% 1 27 96.4% 28
Uganda 1 25 96.2% 16 10 38.5% 26
Grandtotal 197 1,116 85% 627 687 52.3% 1,313
Table2: Number of the districts in relation to the coverage thresholds reached in 2012, as reported by NOTFs
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1.2.4. Trend in geographic and therapeutic coverage in APOC countries, 2009-2012
Figures 2 and 3 show by country the geographic and therapeutic coverage achieved in CDTI districts for 2011 and 2012.
Countries which had high geographic coverage (greater than 97%) in 2011 maintained or improved on it in 2012. Significant decreases were observed in CAR (90.4% to 57.3%), Guinea Bissau (88.4% to 78.4%) and South Sudan (82.1% to 60.2%). The decrease in CAR is explained by the incompleteness of the reports while in Guinea Bissau it was caused by the late start of CDTI activities (November 2012). For South Sudan, the reasons for the decrease are mainly due to inadequate accountability of resources entrusted to
project staff, security challenges in project areas which disrupted CDTI activities, as well as inaccessibility of communities for six months of rains (May – October) which coincided with the period APOC’s funds were disbursed.
Significant improvement in treatment coverage was observed for Angola, United Republic of Tanzania, Côte d’Ivoire, Ghana, Guinea and Sudan. The same countries with decreases in geographical coverage also presented significant decreases in therapeutic coverage.
Given the vital need for a full geographical coverage if the goal of elimination is to be achieved, APOC Management will inten-sify efforts in strengthening the capacity of national programmes to manage and analyze the data reported by communities.
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0 25 50 75 100
Sudan
Sierra Leone
Malawi
Congo
Chad
Burundi
Burkina Faso
Uganda
Guinea
Cameroon
Ethiopia
Nigeria
Ghana
Mali
Togo
DRC
Benin
Liberia
Côte d’Ivoire
CAR
Guinea Bissau
Tanzania
South Sudan
Angola
Figure2: Evolution in geographic coverage of treated districts by country, 2011 and 2012, as reported by NOTFs
2011 2012
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0 10 20 30 40 50 60 70 80 90 100
Benin
Burkina Faso
Malawi
Togo
Liberia
CAR
Mali
Sudan
Congo
Chad
Guinea
Cameroon
Sierra Leone
Burundi
Nigeria
Ethiopia
Ghana
DRC
Guinea Bissau
Côte d’Ivoire
Uganda
Tanzania
South Sudan
Angola
Figure3: Evolution in therapeutic coverage of treated districts by country, 2011 and 2012, as reported by NOTFs
2011 2012
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1.3. monitoring, evaluation of CdTi Projects
1.3.1. Monitoring the implementation of CDTI projects
The independent participatory monitoring (IPM) exercises are usually conducted in the 2nd year of a CDTI project. These help to verify that the CDTI processes are imple-mented correctly, that all CDTI partners are fulfilling their roles, and that projects are making satisfactory progress towards sustainability.
This independent participatory moni-toring exercise was carried out in Uganda Phase V CDTI project, which is in its 3rd year of implementation, 17 – 29 June 2013 in all the three districts of the project (Kitgum, Lamwo and Pader). This project is located in an area emerging from several years of conflict. A total of 30 communities were visited by a 7-man team to assess the status of implementation and extent of compliance with the CDTI approach.
Findings: • Community ownership of the process is
very weak in all village.
• Few communities did not understand their responsibilities within the scheme or were unwilling to take on any respon-sibilities while trying to settle down after a protracted conflict.
• Dichotomy between CDDs and the newly introduced Village Health Workers: The former are not paid while the latter are recognized by government and paid some stipends that range from 2,000 to 5,000 shillings for rendered service. This has led to a massive attri-tion of CDDs who were not given any such stipend.
• The peripheral personnel were not trained on the CDTI approach and were as ignorant of the CDTI strategy as the community members.
• The project had ignored the fact that the
population has just come out of conflict and in the refugee camps hand-outs were given to refugees. It is therefore difficult to ask people under such circumstances to support their CDDs.
• The District health offices have not been very helpful with respect to timely release of funds or contributing to the support of the project.
• The Non-Governmental Development Organizations (NGDOs) involved had been having uncoordinated relation-ships governed by rivalry and discordant practices, which have created difficulties in the communities and in the counties.
• Funds tracking is a major challenge.
ReCOmmendaTiOns: The monitors made the following recommendations:
nOTF
• Develop and implement a stakeholders re-engagement strategy to ensure joint planning and harmonized practices.
• Resolve and define roles of Village Health Workers (VHW) and those of CDDs to stop current attrition.
• Re-introduce the CDTI project in the three districts with emphasis on health education, mobilization, and training.
• Mobilize resources for renewed activi-ties, taking note of post-conflict factors.
districts
• Increase human resources available for the project.
• Make community participation a key element of health care in post-conflict areas.
• Train all health personnel on CDTI.
• Ensure census is carried out before Iver-mectin ordering.
• Mobilize resources for CDTI.
• Collaborate with NOTF for a stake-holders’ round-table planning of the next phase.
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• aPOC
• Use Phase V to study factors influencing CDTI in post-conflict areas.
• Respond to special concerns of CDTI in post-conflict environment.
• Support health education, training, supervision as well as filling of human resource needs and capacity gaps.
Given the above findings and recommen-dations APOC Management intends to:
• have a dialogue with all stakeholders as a first step to redirecting the Phase V CDTI project;
• stop direct funding of Phase V CDTI through the Districts. Funds will rather be channelled through the WHO office in Uganda. A technical officer based in Kitgum will assist the three districts using an imprest account directly managed from WHO/Kampala. This
will enable activity-based funding and ensure that funds released are used for the purpose for which they were approved;
• review the project work with NOTF to ensure a coordinated approach within the broad health policy which approves payment to community directed health team members.
1.3.2. Community self-monitoring (CSM)
Implementation of the CDTI strategy has shown that communities are not only able to distribute some drugs and commodi-ties they are also able to track their project performance and to find solutions to issues that constrain implementation. During the period being reviewed out of 190,644 communities, 37,334 (19.6%) in 10 coun-tries were reported to have implemented community self-monitoring (Table 3).
Table3:Number of communities and districts implementing Community Self-Monitoring and Stakeholders meetings in 2012
CountryNo.ofcom-
munitiesthatreported
Community-selfmonitoring
StakeholdersMeeting No.of
districtsthatreportedNo. % No. %
Angola 10,615 74 0.7% 31 0.3% 26
Burkina Faso 391 0 0% 0 0% 6
Burundi 369 27 7.3% 81 22% 10
CAR 3,250 1,913 58.9% 0 0% 20
Cameroon 9,725 1,631 16.8% 1,631 16.8% 105
Congo 770 0 0% 770 100% 27
DRC 64,149 12,849 20% 10,317 16.1% 368
Ethiopia 32,786 5,288 16.1% 18,061 55.1% 98
Liberia 5,269 0 0% 0 0% 15
Malawi 2,186 841 38.5% 2,186 100% 8
Nigeria 32,469 10,391 32% 9,925 30.6% 383
Sierra Leone 8,451 0 0% 8,451 100% 12
South Sudan 6,728 0 0% 0 0% 44
United Republic of Tanzania
6,257 4,248 67.9% 4,510 72.1% 17
Togo 2,884 0 0% 0 0% 28
Uganda 4,345 72 1.7% 72 1.7% 26
Grandtotal 190,644 37,334 19.6% 56,035 29.4% 1,193
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This low level of CSM implementation, despite APOC’s efforts to improve it, is a source of concern to the Programme. Consequently, the Technical Consultative Committee of APOC (TCC) at its 33rd session appointed a sub-committee to examine the issue of Community Self-Monitoring (CSM) in order to determine scientifically its impact on CDTI and particularly its effect on therapeutic coverage and project sustainability. TCC proposed that a desk review be conducted at APOC HQs on two countries (Malawi and Chad) and that a multi-country study with clear terms of reference be conducted.
a) «desk Review» on Csm
The desk review at APOC/HQ revealed both qualitative and quantitative shortcom-ings. The qualitative issues included lack of information in the annual technical reports on how communities have effectively used CSM to improve CDTI performance and implementation of the concept in ways that deviate from its original purpose. The key quantitative shortcoming noted was that of the 525 annual technical reports reviewed for the 2006-2010 period only 131 (24.9%) reported the outcomes of the CSM conducted in treated communities.
b) multi-country study on Csm
From 8 to 12 July 2013, a workshop to develop the protocol for the multi-country study on CSM was held in Ouaga-dougou. The workshop had the following objectives:
• Prepare a detailed multi-country study protocol on CSM according to interna-tionally accepted scientific standards.
• Develop tools for the study and a training guide for data collection.
• Determine the geographic area of the study and select the projects that will be involved.
• Prepare the budget for the study.
The workshop developed and finalized the protocol and budget for the study and these have been approved by TCC. The study is expected to start in 2014 in 13 selected CDTI projects in 8 countries (Table 4).
Table4:CDTI projects selected for the multi-country study on CSM
African Sub-Region Language group Country CDTI Projects
West Africa
EnglishNigeria
1. Cross River (Southeast)
2. Kwara (Northwest)
3. Ogun (Southwest)
4. Taraba (Northeast)
Liberia 1. Northwest
FrenchCôte d’Ivoire 1. Côte d’Ivoire
Burkina Faso 1. Burkina Faso
Central AfricaFrench
Democratic Republic of
Congo (DRC)
1. Tshopo (West)
2. Bas-Congo (North)
Cameroon 1. Western
English Cameroon 1. Southwest I
East and Southern Africa English
United Republic of
Tanzania1. Kilosa
Ethiopia 1. Jimma
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Table5:Number of ivermectin tablets shipped by MDP to countries in 2012
Country Mectizan tablets Observations
Benin 6,467,500
Joint application for Onchocerciasis and Lymphatic filariasis (412,021,000tablets)
Burkina Faso 36,789,000
Cameroon 32,072,500
Côte d'Ivoire 15,003,500
Ethiopia 968,500
Ghana 40,172,500
Guinea Bissau 935,000
Liberia 6,472,500
Malawi 30,818,500
Mali 36,214,000
Nigeria 108,893,000
Senegal 3,480,500
Sierra Leone 14,424,500
United Republic of Tanzania 45,047,500
Uganda 34,262,000
Burundi 3,317,500
Onchocerciasis (110,861,500tablets)
CAR 5,098,000
Chad 4,900,500
Congo 1,753,000
DRC 65,479,000
Equatorial Guinea 184,000
Guinea 10,440,500
South Sudan 9,923,500
Togo 9,765,500
Mozambique 34,925,500 Lymphatic filariasis (58,854,500tablets)Niger 23,929,000
TOTAL 581,737,000
1.5. development and implementation of a Community-directed intervention (Cdi) Curriculum and Training module
During this reporting period APOC continued to provide technical and finan-cial support to 15 faculties of medicine as well as nursing and public health schools to integrate the teaching of CDI strategy in their training curricula. This is consequent to the participatory process initiated in 2009 involving the African Programme for Onchocerciasis Control (APOC), and
1.4 management of mectizan tablets supplied by the mectizan® donation Program (mdP)1.4.1. Supply of Mectizan tablets including joint applications
In 2012, 581,737,000 ivermectin tablets were shipped by MDP to 26 countries, 71% of the drugs supplied were under a joint application for Onchocerciasis and Lymphatic filariasis (15 countries), 19% was for Onchocerciasis alone (9 coun-tries) and the remaining 10% was for LF only (2 countries). The details of the dona-tion of ivermectin are shown in Table 5.
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some universities in Central, East, and West Africa for the pre-testing of the incorporation of the Community Directed Intervention (CDI) strategy into the curri-cula of medical, nursing and public health schools.
During the reporting period, APOC received seven proposals to pre-test the integra-tion of the CDTI strategy into the school’s curriculum from four countries (Benin, Burundi, Sudan, and Togo), three of which were approved by APOC Management.
Training institutions in Sudan, Nigeria, Cameroon, Burundi and DRC received as appropriate shipments of APOC’s Trainers Handbook (English version) and the 2nd edition of the CDI Curriculum (French and English versions). These training materials are expected to be distributed to relevant staff of these institutions for the teaching of the CDI module. The process of trans-lating the Trainers Handbook in French is ongoing for training institutions in fran-cophone countries.
APOC provided four universities/facul-ties (UCAD, UNN Enugu Campus, Nnamdi Azikiwe and UMST) with the second instalment of funds for piloting of the inclusion of the CDI Strategy in their curri-cula after receiving their technical and financial reports on the usage of the first instalments.
1.5.1. Achievements in 2012
senegal
Cheikh anta diop University of dakar (UCad), dakar
The Cheikh Anta Diop University of Dakar (UCAD) was selected as the pilot site in Senegal for the inclusion of the CDI strategy in the curricula. The institute of Health and Development which has a rich experience in Community Health was chosen as the host department. After providing the necessary preliminary infor-mation on CDI to the faculty teachers, a
multidisciplinary committee was set up to plan the process of introducing the strategy into the curricula of the univer-sity. The faculties involved in this pilot project were: Faculty of Medicine, Phar-macy, and Odontology (FMPO); Institute of Health and Development (ISED); and the Institute of Population Development and Health Reproduction (IPDSR).
The training on CDI topics in FMPO started in May, 2011 and is on-going in the current 2012-2013 academic year. It targets the 6thyear medical students.
At the Institute of Health and Develop-ment (ISED) the training on CDI was intro-duced as part of the module on Commu-nity Health for the 18th cohort for the Certificate on Specialized Studies in Public Health. A total of nine students in their 4th and final year of studies for diploma in Specialized Studies from Benin, Congo, Mali, and Senegal have benefited from this training.
The training of CDI has not started at Masters in Public Health level due the LMD (Licence [bachelor], Master, Doctorate) reforms and the process of harmonizing the public health DES curricula.
nigeRia
University of nigeria, nsukka (Unn)
In the University of Nigeria, Nsukka, the CDI Strategy has been fully integrated into the curricula of Nursing Sciences Department (Faculty of Health Sciences) and Community Medicine Department (Faculty of Medical Sciences). In Nursing Sciences, the strategy is introduced at the 3rd level and then carried through the 4th and 5th (Final) levels. In Community Medi-cine it is integrated into the Primary Health Care course in the 5th (Penultimate) level. Elements of the strategy are introduced during the didactic lectures and demon-strated in the rural community during the Primary Health Care rural posting.
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Elements of CDI are being reflected in examination questions in both faculties. The next and final step will be the presen-tation of the proposal to the University Senate Curriculum Committee and then to the Senate for approval. It is envisaged that both the Committee and the Senate will give approval.
TOgO
Training Centre in Public Health (CFsP), lomé
Following the meeting on the evalua-tion of the inclusion of the CDI strategy in curricula of faculties and schools of public health held in Ouagadougou in 2012, the Training Centre in Public Health (CFSP), Lome, included a 2-credit (50 hours) module on Community Directed Inter-ventions (CDI) and a 1-credit (25 hours) module on NTDs in the new curriculum for the award of a Bachelor’s Degree in Public Health.
sUdan
University of medical sciences and Technology (UmsT), Khartoum
After piloting the CDI strategy in 2012 at the post graduate level (MSc in Public and Tropical Health & MSc Commu-nity Nursing) and at the undergraduate level (Faculties of Medicine & Nursing Sciences), the strategy is now incorporated in the curricula of the aforementioned programmes/faculties since the start of the 2012/2013 academic year.
For the MSc in Public and Tropical Health, which is an 18-month (3 semesters) programme, the CDI has been included as a three-week module delivered during the second semester and at the beginning of the third semester. Two student batches (batches 10 and 11) of the MSc Public Health have taken the CDI module. The teaching methodology is interactive and participa-tory. Two students in batch 10 chose CDI-related project topics for their thesis. One
was on ‘Documenting and Analyzing the Use Of Community Directed Interventions (CDI) in HIV Prevention In Sudan among Policy Makers and Health Care Providers’, while the other was on ‘Local Knowledge and Practices about Sickle Cell Disease and Intervention preparedness using CDI among the Messiria people, Western Sudan’. Both students have finished their thesis and secured very good grades.
Moreover, as part of their assignments the students of batch 11 have produced a film on the role of healthcare workers on the acceptance of the CDI strategy by the community. The MSc Public & Tropical Health also conducted a TOT workshop on CDI in May 2013 for staff of the Faculty of Nursing Sciences at UMST, since most of them are new to the strategy.
Benin
Regional institute of Public Health (iRsP), Ouidah
The CDI strategy has been fully incorpo-rated into the curriculum of the Regional Institute of Public Health (IRSP), Ouidah, which runs three Masters Programmes in Public Health (with options on epidemi-ology, nutrition and health). An existing 1-credit (25 hours) Community Initiative module was revised and upgraded to a 2-credit (50 hours) module on Commu-nity Directed Interventions as part of the curriculum leading to the award of a Masters in Public Health. Thirty (30) students have taken this module in the 2012/2013 academic year.
KenYa
Kenyatta University, nairobi
Kenyatta University carried out 3 sensiti-zation meetings in the School of Medicine. Participants included staff from Schools of Nursing, Dentistry and Public Health. Thereafter a working group was formed and this has designed the first draft of the new course on CDI. The new course is a revision of an existing course on Commu-
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nity-based Education and service which now incorporates components of CDI. This draft of this new course will be presented to the school for adoption and subse-quently to the college academic board. It is anticipated that the final approval by the Senate will come through latest by early 2014.
Others
Following the Abuja and Nairobi meetings on inclusion of CDI into health institu-tions curricula some Nursing and Health Sciences faculties/schools in Burundi, Cameroon, DRC, and Kenya organized workshops/meetings to sensitize the Deans, Chancellors and academic board members on CDI and to advocate for its incorporation into the training curricula. The academic boards of these institutions gave approval to pre-test the CDI curric-ulum and appropriate proposals were developed and submitted to APOC for
consideration. Implementation of activi-ties for the approved proposals is on-going and reports are awaited.
1.5.2. Challenges
Major challenges in scaling up the inclu-sion of CDI strategy in the curricula of training institutions are mainly two-fold:
• High turnover of some deans and rele-vant academic staff, which has resulted in delays in scheduling meetings and in submitting the necessary technical and financial reports;
• Limited budget, which has constrained APOC from extending support to more training institutions.
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2. elimination of Onchocerciasis in africa
2.1. status of Onchocerciasis in endemic countries in africa
2.1.1. Epidemiological EvaluationEpidemiological evaluations for the elim-ination of onchocerciasis transmission in APOC countries, which was started in 2009, continued during the reporting period (Table 6). Phase 1a and Phase 1b
studies were conducted in the following 10 countries: Democratic Republic of Congo, Central African Republic, Ethiopia, Burundi, Cameroon, Republic of Congo, Equatorial Guinea, Malawi, Nigeria, and United Republic of Tanzania In Phase 1a evaluations 10-15 villages are sampled to assess the level of onchocerciasis infection in human populations. In Phase 1b studies more villages are sampled.
Table6:Results of epidemiological evaluations from 1 September 2012 to 31 August 2013
Country Projects PhaseNo.of
villages
No.ofpersons
examined
No.MFcarriers
Crudeprevalence
ofMF(%)
Burundi Cibitoke-Bubanza 1a 10 3,424 0 0%
Cameroon
Adamawa II 1a 9 2,816 53 1.9%
South West I 1a 8 2,159 257 11.9%
South West II 1a 9 2,055 283 13.8%
CAR Ouaham and Ouham Pende 1a 19 4,898 0 0%
Congo Congo (Pool ) 1a 28 4,004 568 14.2%
DRCBas-Congo 1a 17 4,162 2065 49.6%
Uélés 1a 10 1,752 595 34%
Ethiopia North Gondar 1b 10 1,927 0 0%
Eq. Guinea Bioko 1b 25 2,388 3 0.1%
MalawiMalawi Extension 1b 11 2,082 29 1.4%
Thyolo/Mwanza 1b 12 2,105 13 0.6%
Malawi
Adamawa 1a 19 2,913 0 0%
Cross river 1b 22 3,832 275 7.2%
Ebonyi 1b 7 1,465 45 3.1%
Ekiti 1a 10 1,939 36 1.9%
Kaduna 1b 17 2,600 0 0%
Taraba* 1a 15 1,897 103 5.4%
United Republic of Tanzania
Tanga 1b 20 3,596 1 0%
Tukuyu 1b 16 3,068 0 0%
* Evaluation conducted by the Non-Governmental Organisation Mission to Save the Helpless (MITOSATH) with technical support provided by APOC
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Summary of results of the epidemio-logical evaluations conducted between September 2012 and August 2013
The results of the epidemiological evalu-ations conducted between 2012 and 2013 are presented in Table 6. Based on these results the evaluated projects located in Burundi, Central African Republic, Ethi-opia, Equatorial Guinea, Malawi, and United Republic of Tanzania may have already reached the breakpoint for oncho-cerciasis elimination. Phase 1b studies will be conducted in a larger number of villages to confirm the observed trends. Cross-border considerations, disease prev-alence levels in neighbouring projects as well as outcomes of entomological studies will however influence decisions on when to suspend ivermectin treatments in these projects.
2.1.2. Entomological EvaluationEntomological evaluation is a key activity in determining the level of onchocerciasis transmission in the sites being moni-tored. In 2012, with the collaboration of NOTFs and selected communities a total of 113,111 flies were collected in nine (09) surveillance points. These were sent to the laboratory for the identification of O.volvulus Deoxyribonucleic acid (DNA) to determine the level of transmission in the sites being monitored. The studies are in two directions: the studies on the elimina-tion of onchocerciasis in APOC countries and the surveillance of onchocerciasis in the ex-OCP countries.
In 2012, the management of APOC laid emphasis on capacity building in countries (development of high quality surveillance/evaluation teams and strengthening of health systems) to assess the levels of O.volvulus transmission.
2.1.2.1. entomological evaluation in aPOC countries
Uganda9,594 flies were collected in 2012 in four surveillance points (Amua Moyo, Isango, Kathembo, and Kisanga) and examined. The infectivity rates observed were above the threshold of 0.5x10-3. The entomolog-ical situation of onchocerciasis transmis-sion is therefore not satisfactory. Given the average of about 2,400 flies collected per site it is important that catches continue to reach the minimum number of 6,000 flies required per site for the effective interpre-tation of the entomological situation in the affected projects.
2.1.2.2. entomological evaluation in West african endemic countriesFor the period being reported, 10,517 flies were collected in the ex-OCP countries and analyzed at the molecular biology laboratory in Ouagadougou to determine the infectivity rates. Samples from Niger and Côte d’Ivoire are still being analyzed. Blackflies collected from Benin, Mali, and Ghana have been analyzed and the results are presented below.
BeninSurveillance activities were conducted in the river basins of Zou (at Kouffolekpa village) and Kouffo (at Zoundji village). Ten thousand one hundred and sixty-five (10,165) flies were collected (4,003 and 6,162 flies respectively) and on analysis no Onchocercavolvulus DNA was detected. Infectivity rates were zero. These satis-factory results need to be followed by the application of the rotation of the surveillance points to cover many more basins. Strengthening close supervision of catchers would also contribute to getting higher numbers of flies.
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maliOn the Niger River basin 5,653 flies were collected at Tienfala near Bamako and on the Faya River basin 3,836 flies were captured at Faya Pont. The surveillance point (Kankela) on the Kankelaba River yielded 16,270 flies. All these were analyzed and the infectivity rate was observed to be zero at both Tienfala and Kankela, but was 0.28 x 10-3 at Pont Faya. The results are good and the pattern has been consis-tent for the last ten years. Nevertheless, an effort needs to be made to apply the rotation of the surveillance points to cover many river basins.
gHanaIn Ghana, a total of 68,229 flies were collected in 2012 from 13 surveillance points. All the pools screened were nega-tive to O.volvulus probe. However, of these 13 active surveillance points, only three yielded more than 6000 flies per site. The other sites yielded less than 5000 flies each. In order to get the required minimum of 6,000 flies per site supervi-sors need to confirm the productivity of the selected breeding sites, ensure catches are made during the period of maximum production, and closely supervise catchers.
2.1.2.3. Blackfly trappingTo address ethical concerns on the use of human baits for fly-catching and to ensure the collection of adequate numbers of blackflies for control and surveillance a research has been initiated to develop a trap targeting onchocerciasis vectors that will prove to be as efficient as human landing collections. The human bait has been the standard method for collecting onchocerciasis vectors in Africa and Latin America. The research is being under-taken by a consortium of institutions in America, Mexico and Africa (APOC inclu-sive) through a grant from Bill & Melinda Gate Foundation. It is coordinated by Prof. Unnasch from the University of South Florida at Tampa. APOC is contributing (technical and logistic support) to the testing of different types of traps, phero-
mones and attractants that have effects on collection of Simuliumochraceums.l. and Simuliumdamnosums.l.
Comprehensive evaluations of trap plat-forms were simultaneously conducted for their ability to collect S. ochraceum and S. damnosum, primary vectors of onchocer-ciasis in Latin America and Africa respec-tively. The Esperanza trap, coated with BG lure and Co2 collects up to 250% of what the human bait can collect in a day. On the other hand, other studies have demon-strated that human olfactory attractants, when used in conjunction with CO2, are extremely effective for collection of both S.ochraceum, a major vector of O.volvulus in Latin America, and S.damnosum, the major vector of O.volvulus in Africa. The Esperanza window trap, when baited with appropriate lures and carbon dioxide can be used to collect substantial numbers of the onchocerciasis vectors S.ochraceums.l. and S.damnosumin spite of the differ-ences in the ecology of the two species. The entire field tests were carried out in collab-oration with in-country NOTFs’ teams. In the coming months, experiments aimed at making a specific lure to S.damnosum will be conducted. Specific compounds have been identified and selected. The trials may provide insight on very specific lure to the African vectors.
2.2 delineation of ivermectin treatment boundaries and transmission zones2.2.1. Delineation of ivermectin treatment boundariesThe move towards onchocerciasis elimi-nation (JAF 14, Kampala, Uganda, 2008) brought a new mapping challenge i.e. to determine areas where ivermectin treat-ment needs to be expanded. To address this challenge APOC decided to use skin biopsy for the delineation of ivermectin treatment boundaries to confirm that an additional 25,428,281 persons will be needing ivermectin treatments.
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Delineation of ivermectin treatment boundaries was planned for 10 coun-tries namely Burundi, Cameroon, Central African Republic, Chad, Equatorial Guinea (mainland), Ethiopia, Democratic Republic of Congo, Gabon, Nigeria and Mozam-bique. Surveys have been implemented in Burundi (Figure 4), Cameroon (Littoral and South provinces), Chad and in the mainland of Equatorial Guinea (Table 7). Planning is going on for the comple-tion of surveys in the remaining coun-tries early 2014. The available data reveal that expansion of ivermectin treatment boundaries to the remaining ivermectin naïve area district of Edea is restricted
because of the co-endemicity of loiasis and onchocerciasis. Consequently, an alternative treatment approach is needed. Elsewhere (Burundi, Chad and Equatorial Guinea), available epidemiological data (to be confirmed by entomological studies) do not warrant expansion of ivermectin treatment boundaries.
2.2.2. Delineation of transmission zonesDuring the year under review various activities towards the delineation of trans-mission zones continued. These activities were conducted in Cameroon, Nigeria, Chad and Central African Republic.
Figure4: pre-control status of Onchocerciasis in Burundi (based on REMO data) and microfilaria prevalence in 20 ivermectin naïve communities surveyed for delineation of ivermectin treatment boundaries in 2013
Table7:Summary of the mapping of ivermectin treatment boundaries in four countries, 2013
Country VillageNBof
personsexamined
Mf*positive
Crudeprevalence
in%
Standardizedprevalence
in%
CMFL**in%
Burundi 20 4,212 2 0-0.28% 0-0.3% 0-0.00783%
Cameroon 22 3,305 99 0-18.1% 0-10.8% 0-0.31%
Chad 23 6,181 2 0-0.5% 0% 0%
Mainland of Equatorial Guinea
40 2,042 6 0-5.8% 0-7.0% 0-0.05%
* Number of Onchocerciasis microfilariae carriers** Community MicroFilarial Load
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As sampling was done in Cameroon during the rainy season in 2012, complementary sampling was conducted during the dry season in North West, North and South West Regions by the trained personnel from Cameroon. Overall, more than 200 sites were visited and larvae of Simuliumdamnosums.l. were obtained, processed, identified and the data analyzed for inclu-sion in the current progress report.
Samples in Nigeria were obtained only from Cross River State. A total of 10 sites were visited in late 2012 and sampling has just started again at the beginning of this year’s rainy season.
The trained personnel from Chad and Central African Republic were assisted by the APOC secretariat staff to undertake initial sampling in their respective coun-tries. More than 30 sites (24 in CAR and 7 in Chad) were visited in Chad and CAR, and the larvae of S.damnosum collected were processed, identified, and the data analyzed for inclusion in the current report.
Cytotaxonomic identification of the samples showed the presence of only S.damnosums.s./S. sirbanum from the North and Extreme North regions of Cameroon and from Chad (Table A1 in the annex). None of these savannah species was identified from the South West and North West of Cameroon in the dry season. The samples from the Cross River State in Nigeria were majorly S.squamosum (forest species). Simuliumdamnosums.s. and S.sirbanum (savannah species) were found in only one site. However these were different from those identified in northern Cameroon, Chad and CAR.
The results indicated that in CAR although S.damnosums.s. and S.sirbanum were found in sympatric at all the sites, the former was the majority at one site with the latter (S.sirbanum) being the predomi-nant species at two sites.
A comparative analysis of the chro-mosomal inversions of the individuals collected both in the dry season and the rainy season indicates zonal delineations of interest to APOC. These can be summa-rized as follows and shown on Figure 5.
• The savannah species S.damnosums.s./S.sirbanum from North Cameroon; Chad and part of CAR where samples were collected are similar to one another but they differ from the same species (S.damnosums.s./S.sirbanum) from Taraba, Adamawa and Benue States.
• There is a transmission zone that covers Northern Cameroon/Chad and CAR. How far this transmission zone goes in Chad and CAR is not known. Also the southern limit of this transmission in Cameroon has not been determined since the Adamawa Region of Cameroon has not yet been sampled. It does not however go into North West or South West Cameroon.
• Populations of S. squamosum and S.mengense are the most widely distrib-uted species in South West and North West regions of Cameroon.
• S.mengense occur only in Cameroon where two forms with limited inter-breeding were found. There was no S. mengense in the Nigeria or CAR samples examined to date although S.squamosum were found in the two countries.
• Populations of S.squamosum found in CAR were chromosomally different from those identified from South West and North West Regions of Cameroon. However, identifications from the Adamawa region will need to be done to delineate the transmission between these adjacent areas. This is planned for 2014.
As earlier stated, it is now clear that there is one transmission zone that covers Northern Cameroon and Chad. It descends a bit into Central African Republic but does
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not include parts of North-East Nigeria that share borders with Cameroon. Further data is however needed to determine the southern limits in Cameroon since no sampling has been done in the Adamawa Region of Cameroon. It is also not known if the savannah species identified from the CAR samples will still be found breeding at those sites in the rainy season. Unfor-tunately the security situation precludes any sampling in CAR for now.
Based on these observations, the preva-lence of infection as reported during the epidemiological evaluations for all the areas concerned (North Cameroon, Chad and border areas of CAR) will need to be below the threshold for treatment before treatment can be stopped. There is the risk of reinvasion if treatment is stopped prematurely in an area when the others still harbour significant infections in the population. There should be a cross-border effort between the countries. In 2014 the
Cameroon NOCP need to plan for sampling in the Adamawa region. Furthermore, once the security situation improves in CAR sampling will need to be undertaken by the country teams.
The limited distribution of S.mengense to rivers in only South West and North West regions of Cameroon indicates that S.mengense could be a locally important vector involved in local transmission. There will be the need to determine the vectorial importance of this species in localities where it has been found and also relate this to the epidemiological situ-ation. Furthermore, there is the need to determine how far west in Cameroon it is distributed.
Transmission assessment should be done for S.mengense and should it be found to be an important vector species, then plans could be made for a possible local eradication as is being done for S.neavei in Uganda.
Figure5: Preliminary delineation of transmission zones at the border of Cameroon, Chad and Central African Republic
Boundary of transmission zone with dotted lines indicating where the limits are not known because samples have not yet been collected.
?:Indicate areas not yet sampled.
Possible movement of vectors across the zone.
1:Transmission zone covering Cameroon; Chad and CAR with savannah species S. damnosums.s. and S. sirbanum.
2:Transmission zone of South West and North West S. squamosum and S.mengense.
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The personnel trained from Cameroon, Nigeria, Central African Republic and Chad are now capable of sampling members of the S.damnosum complex, separating them from other simuliids breeding at the same sites, storing them for further processing, preparing the chro-mosome slides and undertaking the cytotaxonomic determinations. Further-more, laboratory equipment and reagents to undertake the cytotaxonomic activities in the countries have now been received at APOC headquarters and are being distrib-uted to the countries.
It is therefore envisaged that soon all procedures will be done in the countries by the trained technical staff. This will assist in expanding the geographical scope of sampling to assist in speeding up the finalization of transmission zones’ delin-eation maps as well as contribute to the assessment of the level of transmission in APOC countries. Moreover, two additional cytotaxonomy experts have been invited to assist in the identification of samples that were collected from Ethiopia, Congo (Brazzaville) and Sudan.
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3. Partnership and collaboration
In implementing CDTI activities, APOC partners with Member States Govern-ments as well as Non-Governmental Development Organizations (NGDOs). Government counterpart contributions, as well as NGDOs funding, are used in co-financing CDTI activities.
The African Development Bank (AfDB) and the World Bank have been tasked by the 17th JAF session to develop guidelines and tools to assess government counter-part funding. The process is still ongoing and the outcome will be presented to the 19th JAF.
APOC contributions are disbursed to Government implementing depart-ments using the Direct Financial Coop-eration Mechanism, with streamlined reporting procedures for both technical and financial implementation.
3.1. CdTi Project and ngdO support for Onchocerciasis controlAs per 25 August 2013 , the NGDO Group comprising of 14 full members and 3 associate members continue to partner with APOC by providing support to most endemic countries where CDTI activities are being implemented.
During the 41st session of its annual meeting, the NGDO Group unanimously agreed to rename its constituency as the “NGDO Coordination Group for Onchocer-ciasis Elimination” in order to align to the new objective of APOC of shifting from control to elimination of onchocerciasis.
In the effort to improve coordination with other programmes, members of the Group
strongly support the new initiative by the Regional Programme Review Group of AFRO (RPRG/AFRO) and the Technical Consultative Committee of APOC (TCC) to coordinate implementation of activities in lymphatic filariasis (LF) and onchocerciasis co-endemic areas. The Group agreed to expand its support to other LF elimination activities where feasible.
Despite funding challenges, members of the Group renewed their commitment to support countries with poor performance in relation to CDTI activities, particularly Angola, Central African Republic (CAR), the Democratic Republic of Congo (DRC) and South Sudan. To this end, Sightsavers has initiated or intensified in-country part-nership with other NGOs such as World Vision Angola and United Front Against Riverblindness (UFAR).
Following the successful second cross-border meeting between DRC and Uganda which took place from 18 to 20 July 2013 in Kinshasa, other stakeholders including members of the NGDO Group working in these countries were requested to actively increase their support to APOC usual contributions to the implementation of these joint activities.
3.2. Collaboration with other programmes and institutions
As part of its collaborative policy, APOC has jointly worked with other programmes and institutions during the reporting period. This collaboration has taken place through joint meetings and workshops initiated either by APOC or by other
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programmes and institutions. APOC repre-sentatives also attended several meetings and workshops organized by its partners to keep abreast of their prospects and priori-ties. These meetings included:
• Loiasis Scientific Working Group Meeting (UK, Liverpool, March 24-25, 2013);
• Regional Consultative Meeting on Neglected Tropical Diseases (NTDs) (Republic of Congo, Brazzaville, March 20-22, 2013);
• Fourteenth Ordinary Meeting of the Assembly of Health Ministers of ECOWAS (Cape Verde, Praia,April 4-5, 2013);
• Sub-Optimal Response Meeting (Ghana, Accra, April 22-24, 2013)
• Forty-ninth meeting of Mectizan Expert Committee/Albendazole Committee (Ghana, Accra, April 25-26, 2013);
• Protocol Development Workshop on Status of LF in Areas with Ivermectin Treatment for Oncho (USA, Atlanta, May 9-10, 2013);
• CDC Onchocerciasis Advisory Board Meeting (USA, Atlanta, May 7, 2013);
• National NTD Symposium with the motto of “End the neglect, integrate, scale-up and sustain” (Ethiopia, Addis Ababa, June 12-14, 2013);
• Consultative Meeting on Mapping of Neglected Tropical Diseases in the African Region (Ethiopia, Addis Ababa, June 17, 2013);
• Pharo Nineteenth meeting (France, Marseille, September 16-17, 2013);
• Forty-second session of the NGDO Coordination group for Onchocer-ciasis elimination (UK, Brighton, September 16, 2013).
3.3. Co-implementation of CdTi with other health interventionsCo-implementation of NTDs amenable to preventive chemotherapy has increasingly become an area of interest to many donors supporting the African continent.
The CDI network established through the African Programme for Onchocerciasis Control (APOC) partnership has been used over the past decade by countries to imple-ment other health interventions often alongside Community-directed treatment with ivermectin (CDTI) or by just using the trained community-distributors.
The main interventions implemented during this period have been lymphatic filariasis control activities through simultaneous distribution of ivermectin and albendazole, malaria control (by providing insecticide-treated bednets and interventions associated with the home management of malaria), and, malnutri-tion and vitamin A deficiency alleviation (by providing vitamin A supplementa-tion). Other interventions are schisto-somiasis control (by providing praziqu-antel), cholera and soil-transmitted helminthiases control (by providing interventions to improve hygiene and sanitation), poliomyelitis and measles eradication (by providing immuniza-tions), trachoma control (by providing azithromycin), primary eye care – cata-racts (by detecting and referring cases) and HIV/AIDS control (by sensitization). Out of 1313 CDTI Districts, 777 (59.2%) reported co-implementation activities. A total of 47,584 348 treatments/commod-ities were delivered using the CDTI network of community distributors.
Figure 6 shows number of people reached with the above mentioned health inter-ventions during the reporting period in 10 countries.
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STH (Burundi, Cameroon, DRC,Liberia, Nigeria, Tanzania, Uganda)
LF (Cameroon, DRC, Liberia, Mali, Niger, Nigeria, Sierra Leone, Tanzania)
SCHISTO (Burundi, Mali, Nigeria,Tanzania, Uganda)
TRACHOMA (Cameroon, Mali, Nigeria,Tanzania, Uganda)
Vit A (Cameroon, DRC, Nigeria,Tanzania)
PEC (Cameroon, Nigeria,Tanzania)
Malaria HMM (Nigeria,Tanzania)
EPI (DRC, Nigeria)
Malaria LLINs (Cameroon, Tanzania)0 5 10 15 20
18’733’128
17’525’460
4’373’564
2’617’470
2’225’271
947’508
655’012
259’890
247’045
Number of interventions delivered (in Milion)
3.3.1. APOC support to NTDs activitiesDuring the reporting period September 2012 to August 2013 APOC continued to provide support for various NTDs collab-orative activities.
nigeRia APOC participated at a roundtable discus-sion organized by The World Bank, MITO-SATH, END Fund and the Federal Ministry of Health Nigeria in Abuja 6th December 2012. The aim of the meeting was to share information about NTDs and mobilize support for its control/elimination as well as to sensitize non-governmental authorities to get more involved in the funding of Neglected Tropical Diseases interventions in Nigeria and Sub-Saharan Africa. Awareness was raised in private funders in Nigeria on the importance of controlling and eliminating NTDs. The achievements of APOC were presented with the expectation that these will moti-vate greater private support in Nigeria for the Nigerian NTD program and APOC. Participants at these roundtable discus-sions came from the private sector and
were mainly friends to General Danjuma who has already donated USD 1 milion to the APOC Trust Fund.
APOC also participated at several meet-ings held at Sheraton Hotel, Abuja, 4th – 8th February 2013 and provided technical support for (i) Domestication of National NTD Master Plan by States (ii) Develop-ment of plans for mapping of NTDs in Nigeria; (iii) Breakfast Meeting of Stake-holders on Control & Elimination of NTDs, and (iv) the NTD Steering Committee meeting. Participants at the domestica-tion workshop included representatives from the Zonal and National NTD Offices of the Federal Ministry of Health; NTD Program Officers from the respective 36 States and FCT as well as representatives of various national and international Non-Governmental Development Organiza-tions (NGDOs). In attendance as facilita-tors / consultants were representatives of World Health Organization / African Programme for Onchocerciasis Control (WHO/APOC) and the WHO / African Regional Office (WHO/AFRO). Technical Consultants from the academia / members
Figure6:Number of health interventions delivered using the CDI network
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of the National NTD Steering Committee were also in attendance. The major aim of this meeting was to develop state NTD plans using the national NTD Multi-year Master Plan as a guide. At the end of the meeting the states were at several stages of finalization of their plans.
The aim of the mapping meeting was to identify the mapping gaps for all the PC-NTDs, develop mapping plans and finalize the mapping budget. APOC provided technical support in the following domains:
• Providing oncho, Loaloa mapping, and CDTI treatment data to the oncho-LF-Loaloa group.
• Providing expertise for evidence-based decision making by the group (Diegel and Thompsom loaloa predictive maps; loaloa mapping methodology, et.c).
• Development of prevalence maps for all the five PC-NTDs disease by State for use by the states.
• Preparation with the country of a presentation on update and issues on Drugs Supply Chain Management & Usage.
• Facilitation of the plenary session on update and issues on PCT Drugs Supply Chain Management & Usage.
eTHiOPia
national nTd symposium, 12-14 June 2013, Hilton addis ababa with the motto of “End the neglect, integrate, scale-up and sustain”
The objectives of the symposium were to officially launch the National Integrated Master plan for the prevention and control of Neglected Tropical Diseases; review the current achievements, identify chal-lenges and opportunities for governments and relevant stakeholders in addressing NTDs; and to enhance integrated manage-ment of NTDs and co-implementation. More than 400 participants representing federal government offices, regional
health bureaus, and partners attended the meeting. Partners represented at the meeting included WHO, USAID, DFID, World Bank, Bill & Melinda GATES Foun-dation, international NGOs and research institutes as well as the academia.
During the symposium the National NTD master plan was launched by His Excellency Dr Kesetebrhan Admasu, Minister of Health of Ethiopia. A forum was established that will be a platform for knowledge sharing and documentation of best practices in NTDs. The forum will also facilitate translating evidence to action promote achievements in NTD control/elimination, and strengthen the partner-ship among government, civil societies, the academia and development partners in the control and elimination of NTDs. At the end of the meeting the participants adopted the ‘the Addis Ababa Declaration for the Control and Elimination of NTDs in Ethiopia’ which contains eight major points of commitment.
Partners Consultative meeting on elimination of Onchocerciasis and launching of new CdTi Projects of assossa and Kemashi Zones, 15-16 June, 2013, ethiopia Hotel, addis ababa
With the shift in paradigm from oncho-cerciasis control to elimination of infec-tion and interruption of transmission of onchocerciasis in endemic countries in Africa additional efforts are required. Such efforts are mainly in the intensification of activities such as: i) identification of all endemic communities, ii) establish-ment of sustainable onchocerciasis control programmes in all endemic areas where they are needed, iii) ensuring regular and high treatment coverage with ivermectin, iv) implementing good and regular super-vision and monitoring of the elimina-tion activities; and v) strengthening the integration of CDTI activities into health systems.
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In this context, the Federal Ministry of Health of Ethiopia convened a consultative meeting to address in detail the existing challenge of achieving onchocerciasis elimination by 2020. The forum facilitated the dialogue between the governments, partners including donors, and NGDOs already working or interested in working on onchocerciasis and other PC-NTDs in Ethiopia.
The specific objectives of the consultative meeting were:• Update partners on the current epide-
miological status of onchocerciasis in the nine existing CDTI projects and two new project areas (Assossa and Kemshi);
• Review and agree on work plans and timelines of onchocerciasis elimination in Ethiopia;
• Propose and agree on key activities that will contribute to the elimination of infection and interruption of trans-mission of onchocerciasis in endemic areas in Ethiopia;
• Define key implementation strategies including semi-annual treatment;
• Agree on implementing partners in the field, their concrete technical and finan-cial commitments;
• Agree on the organizational arrange-ments of CDTI projects, and
• Launch officially the two new projects.
The meeting was attended by more than 60 participants from Federal Ministry of Health, Regional health bureaus, Zonal health departments, NGDOs (The Carter Center, Light for the World, RTI), WHO (WCO, AFRO and APOC), USAID, MDP, and Merck & Co. Inc.
Consultative meeting on PC-nTd mapping in the african Region: 17 June 2013, Hilton Hotel, addis ababa
A small group of experts from WHO/AFRO, WHO/APOC, MDP, CNTD, RTI, SCI and Sight-savers met to assess the status of PC-NTDs mapping and to identify the gaps. The forum was used to discuss the Regional Framework for Coordinated Mapping, Update on PC-NTDs Mapping in the African region: Achievements and Current Plan for Mapping of: Lymphatic Filariasis, Trachoma, Schistosomiasis, STH and Onchocerciasis; Consolidation of PC-NTDs Mapping Status, Gaps and Needs in the WHO African Region; Review of Country PC-NTDs Mapping Plans and Budgets; and, Partners’ Commitment and Support for PC-NTDs Mapping in the African Region.
Participants at the meeting agreed on ‘Next Steps on Selection of Start-up Countries for Mapping Surveys, Timeline, and Funding Mechanisms for PC-NTDs Mapping in the
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African Region and Follow-up Mechanism between AFRO and Partners’. Such next steps outlined included regular telecon-ferences on mapping issues per country.
sOUTH sUdan
a stakeholders meeting was held in Juba, 17-18 July 2013
Organised by the Ministry of Health of The Republic of South Sudan and co-financed by the African Programme for Onchocer-ciasis Control. The main objective of this meeting was “TocontributeinthecreationofaforumfordialogueontheeliminationofonchocerciasisandotherPC-NTDsinSouthSudaninordertomobilizenecessaryresources”.
A total of 56 participants were at the meeting representing stakeholders such as NGDOs, WHO and South Sudan authorities. The major focus was to build consensus around the road map document proposed by APOC for a reorganization of onchocerciasis control/elimination in South Sudan.
Technical presentations at the meeting included overview of onchocerciasis in South Sudan, the shift from control to elimination to shrink the onchocerciasis map and the draft road map document.
Outcomes of the meeting:
• Partners adopted the road map docu-ment with all the recommended inputs;
• The Ministry of Health and partners made statements of commitment to the implementation of the roadmap.
Next steps: Revise the roadmap budget based on additional inputs and partners’ commitment for financial and technical support for the implementation of the identified activities.
3.3.2. Expanded co-implementation:
a) United Republic of Tanzania
United Republic of Tanzania has continued co-implementing NTD control and elimina-tion activities, expanding implementation from 36 districts in 5 regions in 2009 to 972 districts in 14 regions by 2013 (>50% geographical coverage). Integrated NTD programme was initiated in 2009 when APOC/USAID shifted from supporting CDTI in onchocerciasis endemic communities to supporting distribution of multiple drugs in all communities in the 6 regions, including those in non-oncho endemic areas. More partners later joined in supporting NTDs programmes co-implementation in United Republic of Tanzania. Currently, IMA/RTI/USAID is supporting such integrated inter-ventions in 9 regions while Liverpool/CNTD and SCI are assisting in 2 urban cities of Mwanza and Dar-Es-Salaam.
An annual joint planning with all NTD part-ners and stakeholders successfully took place in March 2013 where objectives set in the new NTD Master Plan were used to guide activity planning, resources alloca-tion and resource gap identification.
To ensure that all PC-NTDs are mapped in United Republic of Tanzania the Ministry of Health and Social Welfare (MOHSW) is collaborating with partners to complete trachoma mapping in the entire country by 2013. Trachoma is the only PC-NTD that is yet to be fully mapped in the country. In addition trachoma impact assessments have been planned in a number of districts that include 7 onchocerciasis endemic districts supported with APOC Trust funds for the distribution of Zithromax.
The annual mass drug administration for five targeted PC-NTDs was held between September and December 2012. A total of 36 million treatments were provided in United
2 Ruvuma, Morogoro, Tanga, Iringa, Njombe and Mbeya are oncho endemic regions currently supported through APOC Trust funds.
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Republic of Tanzania achieving a thera-peutic coverage of 79% for albendazole and ivermectin drugs, and 73% for Zithromax distribution. Of the 22,593,473 persons targeted to receive Ivermectin and alben-dazole drugs in 2012 10,041,551 persons (44.4%) were from the six APOC-supported regions where over 16 million treatments were provided for four PC-NTDs drugs (see Table 8).
The Technical Consultative Committee had recommended that the expanded co-imple-mentation in United Republic of Tanzania be documented since the country has been a pioneer in the development and imple-mentation of an integrated NTD policy. This documentation will ensure that others learn from their experiences. In October 2012 two experts identified by APOC visited United Republic of Tanzania to document the development and imple-mentation of the co-implementation of Neglected Tropical Disease (NTD) control activities with Community Directed Treatment with Ivermectin (CDTI) in the Ruvuma and Morogoro regions. Their report (based on the outcomes of inter-views with people involved at all levels of the program as well as observations made) highlighted some of the interesting devel-opments and key lessons learnt. Moreover, in October 2012 two teams of external evaluators were mandated by APOC management to evaluate the sustain-ability of the co-implementation in the same regions where information for the documentation of the co-implementation
was collected. Overall, the results showed that in both regions CDTI activities were implemented in an integrated manner with other NTDs e.g. there were inte-grated plans of activities for all the NTDs, and IEC materials as well as the Commu-nity treatment register were developed/revised to reflect all the NTDs. Meanwhile, the outcomes of the evaluation are being analyzed for publication in a peer-review journal.
b) democratic Republic of Congo
In 2012, preventive chemotherapy neglected tropical diseases control in the DRC was focused on the distribution of Mectizan for onchocerciasis control, and mapping of lymphatic filariasis (LF), schis-tosomiasis (SCH) and Soil-Transmitted Helminthiases (STH). CNTD/Liverpool funded the surveys while WHO/APOC provided technical expertise and facilita-tion for the duty payment exemption of the commodities utilized.
The integrated mapping of LF, SCH, and STH was conducted in 30 health zones in the province of Bas Congo. This brings to four the number of provinces mapped. Figure 7 presents the co-endemicity map of PC-NTDs in DRC as of 2012. The overall results of the endemicity per disease in the four provinces (Katanga, Kasai Occi-dental, Kasai Oriental, and Bas Congo) are as follows:
• lymphatic filariasis: 65 health zones are endemic.
Regions Ivermectin Albendazole Praziquantel Zithromax Total
Tanga 1,353,795 1,353,795 335,793 126,136 3,169,515
Morogoro 1,618,124 1,618,069 343,041 -- 3,579,234
Mbeya 2,158,368 2,158,368 458,154 -- 4,774,890
Iringa 654,858 654,858 134,754 -- 1,444,470
Njombe 453,715 453,715 47,762 -- 955,192
Ruvuma 923,682 923,682 223,590 174,886 2,245,840
Totaltreatments 7,162,542 7,162,487 1,543,094 301,018 16,169,141
Table8: Number of treatments in 2012 for NTDs in APOC-supported regions in United Republic of Tanzania
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• schistosomiasis: 122 health zones are endemic out of which 10 has high preva-lence rates (6 in Katanga, 3 in Bas Congo, and 1 in Kasaï Oriental).
• sTH: 192 health zones are endemic , of which 13 with prevalence >70%.
Currently, the mapping of LF, Schistosomi-asis, and STH has been completed in these provinces of Katanga, Kasai Occidental, Kasai Oriental, and Bas Congo which have a total 193 health zones (health districts) with a total population of more than 30 million people (source EPI 2012).
Following the development of the multi-year (2011-2015) NTD master plan, aligned with the National Health Development Plan (NHDP), a partners meeting was organized by the Ministry of Health in January 2013 for resource mobilization. APOC, the CNTD-Liverpool and GTMP NGDOs expressed their commitments at the meeting to cover the budget for the complete mapping of LF, SCH, STH and trachoma. The major focus will be the health areas of the provinces in the
southern part of the country, including the province of Katanga, the two Kasai (East and West), the province of Bandundu and that of Maniema.
The five CDTI projects selected and funded by APOC to carry out co-implementation of NTD control activities in the prov-inces of Bas Congo, Kasai Oriental, and Katanga conducted advocacy, training, and Mectizan mass distribution activities in the CDTI areas within the reporting period. The network of Community-directed Distributors of Mectizan was used for the distribution of Mebendazole and Vitamin A in the communities.
Mectizan orders for 2012 were submitted directly by the CDTI projects to MDP through WHO. Mebendazole and Vitamin A orders were however placed by the National Nutrition Programme (PRONANUT) through UNICEF. On the other hand Albendazole orders were submitted by the National NTD Coordi-nation for STH through WHO/AFRO, but the drugs are yet to be delivered.
Figure7: PC-NTDs co-endemicity map of the DRC in 2012 (map prepared by NOCP of DRC)
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4. government contributions to CdTi activities
4.1 government financial contributions to Onchocerciasis elimination activities The Programme document stipulates that “the executing parties of CDTI projects will be able to apply for up to 75% funding from the Programme. The NGDOs and the host governments (working together as the NOTF) will be responsible for 25% of CDTI project costs (in cash or kind) that will not be available from APOC. It is expected that the percentage of APOC funding will decrease over time as projects mature. Contributions from NGDOs toward 25% project cost contributions shall not include overhead costs of these organizations outside the country whose CDTI they are assisting. For focal vector eradication proj-ects, the executing parties will be able to apply for 100% funding”.
During the tenth session of the Joint Action Forum (JAF) in December 2004 in DRC the Forum stressed that participating coun-tries needed to allocate more resources to health, and particularly, to onchocerciasis control activities. In this regard, it was agreed that countries should specify the nature of government contributions (cash or kind, salaries, capital equipment, infra-structure and recurrent cost) and indicate, over a minimum of 3 years, the trend of government contributions (whether they were increasing or decreasing). Since then, efforts were made to report regularly at JAF taking into account the decision by JAF10. However, at the 17th session of the JAF in December 2011, it was noted that understanding governments’ financial contributions remains a complex issue
which requires expertise. Therefore, JAF instructed APOC Management to engage experts to assess countries’ financial contributions.
Based on this decision, the Committee of Sponsoring Agencies (CSA) requested the World Bank and the African Develop-ment Bank to assist APOC Management in developing the terms of reference and in recruiting two consultants who will prepare tools and guidelines for collecting, assessing and managing government expenditures on onchocerciasis in APOC member countries. Advanced drafts of the tools and guidelines have been developed and are being pre-tested in two countries (Cameroon and Ethiopia). On finalization they will be presented to JAF19 for adop-tion. Once adopted, they will help in insti-tutionalizing the resource tracking and estimation system at country level. It is expected that the evidence collected will assist in resource mobilization at country level and contribute therefore to the elimi-nation effort by partners.
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5. Programme management and finance
5.1. Programme management and statutory meetings5.1.1. The Joint Action Forum
The eighteenth session of the Joint Action Forum (JAF) of APOC was hosted by the Republic of Burundi, 11-13 December 2012 in Bujumbura, Burundi. 17 representa-tives of APOC and OCP countries attended and presented updates on activities in their countries. Also in attendance were 17 representatives of the donor commu-nity, 19 representatives of NGDOs as well as representatives of research Institu-tions and the statutory bodies of APOC. As requested by JAF17, the Management presented the ConceptNote, theStrategicPlanofActionandbudget2016-2025 foreliminationofonchocerciasisinAfrica, and the revised PlanofActionandbudgetsforthetransitionalperiod2013,2014and2015. While the transitional budget to inten-sify APOC activities in 2013 in the frame-work of the elimination of onchocerciasis infection in Africa and the PlanofActionandBudget2014-2015 were approved by JAF18, the ConceptNote and the StrategicPlanofActionandbudget2016-2025foreliminationofonchocerciasis inAfrica were endorsed in principle with inputs provided for the revision of the two docu-ments and their resubmission to JAF19 for consideration.
5.1.2. Technical Consultative Committee
The 35th and 36th sessions of the Technical Consultative Committee (TCC) of APOC took place respectively in September 2012 and March 2013 in Ouagadougou, Burkina
Faso. TCC35 reviewed the Concept Note on the role of APOC’s new strategic direc-tion for the elimination of onchocerciasis, co-implementation of other health inter-ventions and strengthening of health systems as well as the draft Strategic Plan of Action and Budget for the post 2015 period. The committee discussed other strategic issues like the progress on new diagnostics of PATH in elimination of O.volvulus infection and received updates on epidemiological assessments in four countries (United Republic of Tanzania, Uganda, Chad and Benin), black fly trap-ping and other studies related to onchocer-ciasis, capacity building in entomological assessments, the delineation of transmis-sion zones, ivermectin response markers as well as LF and onchocerciasis control/elimination Programmes’ collaboration. The 35th session also reviewed five opera-tional research proposals and 62 technical reports of projects under implementa-tion in the countries, and received reports from the Technical Review Committees (TRCs) of Cameroon, Nigeria and Uganda on technical reports reviewed by the TRCs of those countries.
The 36th session discussed strategic issues such as the revision of ivermectin treat-ment boundaries for the purpose of elimi-nation, evaluation of epidemiological trends towards elimination, confirma-tion that the breakpoint has been reached and treatment can be stopped, criteria and areas for six-monthly or alterna-tive treatment, identification of possible areas for alternative treatment strate-gies in APOC countries, and the contribu-tion of its members in the preparation of new project proposals for Ethiopia. It
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received updates on entomological studies conducted in tree countries (Cameroon, Nigeria and Uganda), delineation of transmission zones, black fly trapping and other studies related to onchocer-ciasis, the predictive S.damnosum habitat modelling in Burkina Faso and Northern Uganda, the new diagnostics of PATH, moxidectin development, ivermectin response markers, and, investigations on the presence of nodding syndrome in North East DRC. TCC36 also made inputs on the score card for monitoring the prog-ress for NTDs control/elimination. Addi-tionally, the committee reviewed eight operation research proposals, two new project proposals, 28 technical reports, and received reports from the TRCs of Nigeria and Cameroon on reports reviewed by TRCs of those countries for projects older than seven years. Summaries of the above activities of TCC are provided in the respec-tive reports of TCC.
5.1.3. Committee of Sponsoring Agencies
The management and operations of the African Programme for Onchocerciasis Control are periodically monitored by the Committee of Sponsoring Agencies (CSA) between two sessions of the Joint Action Forum (JAF). Four meetings of the CSA were held during the reporting period. The APOC Trust Fund does not pay for the participation of CSA members in the meetings. Nevertheless, to allow the contribution of country representatives in discussions on the Concept Note for a transformed APOC, an expanded CSA session was organized in July 2013 for which the CSA members decided to fund their participation from the APOC Trust Fund. In addition to this special subject, the highlights of the CSA meetings included:
1. development of guidelines and tools for assessing government’s financial contributions to onchocerciasis and other NTDs elimination in the frame-
work of the paradigm shift from control to elimination;
2. follow up and update on the compre-hensive 10-year plan and costing for the period 2016-2025 including the contri-butions/roles of APOC in NTDs control/elimination;
3. review of the plan of action and budgets for the bridging period 2013-2015;
4. discussions on the revision of the criteria and guidelines for certification of elimination of onchocerciasis, and reinforcement of the collaboration with OEPA on onchocerciasis elimination;
5. preparations for JAF19;
6. creation of a Transitional Task Force (TTF) to provide technical advice to APOC and AFRO on aspects of the elimination target during the transi-tion period 2013-2015;
7. review of TCC membership within the evolving new context.
In addition, CSA sessions discussed various issues brought to their attention by the partners such as AfDB, the NGDO Group for onchocerciasis elimination, the World Bank, the Legal department of WHO (relating to APOC, including the signing of the revised Memorandum of Under-standing of APOC by member countries), WHO/HQ and WHO/AFRO (on issues related to NTDs). CSA also discussed ways of promoting APOC activities and achieve-ments as well as the reinforcement of the collaboration between APOC and NTD/AFRO.
The guidance from the CSA including the creation of the TTF played an important role in the swift implementation of the decisions of the 18th session of the JAF, facil-itated the collaboration between the two onchocerciasis elimination programmes in the world, and is improving technical, administrative and financial discussions among partners for the achievement of elimination targets.
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5.2. Technical support to countriesAPOC continued its special support to some countries, mainly post-conflict countries, through the technical advisors appointed in Angola, Burundi, Chad, CAR, DRC, South Sudan, and Guinea Bissau. In 2013, APOC assisted South Sudan in developing a road map for the re-organisation of CDTI to control/eliminate onchocerciasis and other PC-NTDs. This reference document is available to all partners willing to provide support for integrated NTDs control/elimi-nation activities in the country.
Within the context of elimination, APOC is improving support to countries for the conduct of activities that will hasten the achievement of this goal. The key areas of support provided to countries included, among others:
• Training of trainers in CDTI strategy (Angola, South Sudan).
• Planning of integrated NTDs control activities (Burundi, Ghana).
• Data management and analysis (Cameroon, DRC, Liberia, Niger, United Republic of Tanzania).
• Disease mapping (Ethiopia, Cameroon, Chad, Burundi, Nigeria).
• Epidemiological evaluation (Burundi, Cameroon, Congo, Nigeria, United Republic of Tanzania, Ethiopia, DRC, Equatorial Guinea).
• Development of CDTI project proposals (Ethiopia).
• Development of road map for re-launching of CDTI in South Sudan.
• Country project review meetings (DRC, Ghana).
• National meetings on NTDs control (Nigeria, Ethiopia).
APOC will pursue its goal of strengthening the national teams to master the processes for planning, implementation, reviewing and decision-taking for the achievement of onchocerciasis elimination.
5.3. Programme expenditures and income5.3.1. Direct financial support to countries and management of the APOC Trust Fund
As part of the 2012-2013 Programme budget implementation, a total of 23 countries received direct financial support in 2012. So far, 21 countries have received direct financing during the first semester of 2013. Table 9 shows the list of countries and projects that were funded through APOC Trust funds.
A total of 126 CDTI project/programmes and six NOTF secretariats supporting proj-ects have benefited from financial support in 2013.
As at July 18, 2013, the total funds contrib-uted to countries during the 2012-13 bien-nium amounts to USD 37,87 million, out of which USD 20,2 million were disbursed in 2012 and USD 12,67 million disbursed in 2013. Given the fact that this update was prepared at mid-point of 2013, the disbursement rate is comparable for the two years of the current biennium.
5.3.2 Programme Budget Allocation
Based on the JAF final communiqué, the approved Programme budget was broken down into different major activities following the CSA and JAF strategic orientations as follows in Table 10.
From the above budget allocation in 2013, Technical/Operations activities account for 86.35% of the total approved budget while Human Resources and Equipment/Supplies represent 10.83% and 2.82% respectively. The same budget items in
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Table9:Countries / Projects direct Financing
Country No.ongoingprojects/Totalproject
No.DFCpreparedbycountry(specificactivitiesincluded)
Year/Period 2012 2013* 2012 2013*
Angola 9/9 9/9 10 10
Burundi 3/3 3/3 7 4
Cameroon 16/16 16/16 21 20
CAR 1/1 1/1 6 1
Chad 1/1 1/1 6 4
Congo 2/2 2/2 7 2
DRC 22/22 22/22 36 22
Equatorial Guinea 1/1 0/1 2 0
Ethiopia 09/10 9/10 10 10
Liberia 3/3 3/3 3 4
Malawi 2/2 2/2 5 3
Nigeria 28/28 28/28 42 31
South Sudan 5/5 11/11 6 11
Sudan 1/1 1/1 NA NA
United Republic of Tanzania 6/6 6/6 10 6
Uganda 7/7 5/7 5 3
Benin 1/1 1/1 2 1
Bissau Guinea 1/1 1/1 1 1
Burkina 1/1 1/1 0 1
Ghana 1/1 1/1 1 1
Guinea 1/1 0/1 0 0
Mali 1/1 0/1 1 0
Niger 1/1 0/1 1 0
Côte d'Ivoire 1/1 1/1 3 1
Sierra Leone 1/1 1/1 2 1
Togo 1/1 1/1 1 1
Total 126/127 126/133 188 138
* Data as of 18th July 2013
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Table10:Breakdown by major activities of APOC 2012-13 budget
Year/Period 2012 2013
Implementation of CDTI 47.46% 35.02%
Monitoring/Evaluation/Surveillance 17.03% 21.%
Contribution to Strengthening of community health systems
7.46% 13.90%
Co-implementation of multiple health intervention 3.72% 5.81%
Research & Development 0.31% 1.66%
Partnerships 7.93% 7.46%
Mainstreaming gender in APOC operations 0.83% 1.50%
Human resources 12.92% 10.83%
Equipment/ Supplies and utilities of HQ/APOC 2.35% 2.82%
100% 100%
2012 represented respectively 84.73%; 12.92% and 2.35%. The budget allocation for 2012 and 2013 are structured in a similar way, and in fact, the ratio between tech-nical activities on one hand and human resources and logistic support on the other hand remain within the range of 85-15 for the two years of the biennium.
5.3.3. Financial Reporting
Financial Cooperation Agreements are the main committal documents used for direct transfer to projects/ national programmes. Under this mechanism, three hundred and forty four (344) direct funding authoriza-tions and certifications of expenditure reports (FACE) were received from projects. Out of these submissions, 71% (245) have been analyzed/certified by APOC Finance Team.
As of July 2013, only six (6) FACE were received out of a total 172 expected reports. This gives a very low submis-sion rate (3.48%) reflecting the delay in submitting mid-term FACE reports by Project Coordinators. Efforts will be made using field missions to ensure that the FACE submission rate is improved before December 2013 as part of project coordina-tor’s accountability in utilizing APOC Trust Funds. Table 11 indicates the number of financial returns submitted by countries as well as the number of FACE reports submitted and certified.
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Table 11: Financial reporting and monitoring as of 18 July 2013
Country
Nooffinancialreturnssubmittedbycountry/Noofreturnsexpected
(includingpreviousyears)
NoofFACEsubmittedbycountry/NoofFACE
expected(includingpreviousyears)
NoofFACEcertified(in-cludingpreviousyears)/
NoofFACEsubmittedbycountry
2012 2013 2012 2013 2012 2013
Angola 78/108 20/84 15/27 1/19 6/15 0/1
Burundi 43/48 10/29 6/14 0/7 0/6 0/0
Cameroon 192/192 9/96 56/68 0/28 29/56 0/0
CAR 12/12 5/6 11/12 0/2 0/11 0/0
Chad 12/12 6/6 8/8 2/2 0/8 0/2
Congo 40/40 10/12 11/11 0/2 4/11 0/0
DRC 264/264 58/132 65/76 0/33 54/65 0/0
Equ. Guinea N/A N/A N/A N/A N/A N/A
Ethiopia 86/141 2/57 19/30 0/11 19/19 0/0
Liberia 39/39 0/18 14/14 0/3 14/14 0/0
Malawi 24/24 12/12 6/7 0/3 0/6 0/0
Nigeria 336/336 72/168 83/85 2/30 81/83 0/2
South Sudan 60/60 0/0 17/17 0/0 17/17 0/0
Sudan N/A N/A N/A N/A N/A N/A
United Republic of Tanzania
72/72 13/36 5/17 0/18 0/5 0/0
Uganda 84/84 0/0 11/11 0/0 11/11 0/0
Benin 12/12 0/1 2/4 0/2 0/2 0/0
Guinea Bissau 14/14 0/0 0/3 0/3 0/0 0/0
Burkina Faso 0/0 0/1 1/1 0/1 0/1 0/0
Ghana 24/24 0/0 4/4 0/0 4/4 0/0
Guinea 0/12 0/12 0/4 0/4 0/0 0/0
Mali 0/12 0/12 1/1 0/0 1/1 0/0
Niger 0/24 0/24 1/2 0/1 1/1 0/0
Côte d’Ivoire 12/12 0/6 4/4 0/1 4/4 0/0
Sierra Leone 13/13 6/6 3/3 1/1 0/3 0/1
Togo 0/24 0/25 1/1 0/1 0/1 0/0
Grandtotal 1417/1579 223/743 344/424 6/172 245/344 0/6
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6.1. Paradigm change for eliminationThe control of Onchocerciasis, or river blindness, is based on annual or six-monthly treatment with ivermectin of populations at risk. This has been effec-tive in controlling the disease as a public health problem but it was not known whether it could also eliminate infec-tion and transmission to the extent that treatment could be safely stopped. Many doubted that this was feasible in Africa. The proof of principle was provided by a study in three hyper endemic onchocer-ciasis foci with seasonal transmission in Mali and Senegal where treatment had been given for 15 to 17 years. As a result of this treatment, infection and transmis-sion levels had fallen everywhere below postulated thresholds for elimination. Treatment was therefore stopped in each focus. Follow-up evaluations up to five years after the last treatment showed no evidence of recrudescence. The results of this study led to the paradigm shift from control to elimination. The question of whether transmission of the parasite could be eliminated and mass treatment safely stopped is being answered in some foci: Burundi (Cibitoke-Bubanza), Chad
Part 2: WaY FOrWarD
6. elimination of Oncho-cerciasis and co-implementa-tion of PC/nTd interventions within peripheral Health systems strengthening
(Logone Orientale and Occidental), Niger (Niger Basin), Nigeria (Kaduna, Zamfara, Plateau/Nassarawa), Malawi (Thyolo-Mwanza and Malawi extension) and United Republic of Tanzania (Tanga). As APOC is at a turning point two key chal-lenges need to be addressed viz: (i) the determination of long-term impact of ivermectin treatment alone on lymphatic filariasis (i.e. can ivermectin treatments for onchocerciasis control be safely stopped without jeopardizing LF programme oper-ations); and, (ii) the implementation of alternative treatment strategies in areas where onchocerciasis is hypo endemic but is co-endemic with lymphatic filariasis and loiasis.
6.2. Cross-border collaboration to achieve eliminationAs the spread of infectious diseases does not respect administrative bound-aries, protection of the public’s health often depends on effective cross-border collaboration among public health offi-cials in the respective countries. As an infectious tropical disease, onchocerci-asis is not an exception. This has been well demonstrated during OCP operation
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when black flies, assisted by harmattan winds, infected already cleaned areas and caused recrudescence thus constraining OCP’s efforts to eliminate onchocerciasis in 11 West African countries. This issue has become more important than ever in respect to onchocerciasis elimination in Africa.
The need for cross-border collaboration in the context of elimination is best illus-trated by the situation in Uganda and DRC. Uganda has embarked on elimination of onchocerciasis and is making significant progress towards this goal. However, most of the onchocerciasis-endemic foci lie along the border with DRC and South Sudan where implementation of CDTI is just beginning or has been unsatisfactory due to security or post-conflict issues(see Figure 8).
Consequently, the Ugandan authorities cannot take any decision on suspending treatments in such border areas without taking into consideration what is going on in DRC or South Sudan. Recognizing the
importance of cross-border collaboration in addressing diseases of public health importance, JAF, at various sessions, has commended cross-border collaborative ventures but has urged that these efforts be further strengthened. Therefore, in 2012 and 2013 a number of cross-border activi-ties were facilitated by APOC Manage-ment as discussed below.
6.2.1. Cross border meetings
6.2.1.1. Uganda and democratic Republic of Congo
A cross-border meeting between the Democratic Republic of Congo and Uganda was held from 18 to 21 July 2013 in Kinshasa (DRC) in the context of the implementation of one of the resolutions of JAF17 which requested strengthening such cross-border cooperation. During the meeting the countries reviewed the implementation of CDTI activities as well as the entomological and epidemio-logical situations in the border areas. A joint action plan was developed for the
Figure8: Map showing onchocerciasis endemic transmission areas across the border of Uganda and DRC
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implementation of synchronized inter-ventions in those border areas. The key challenge is the funding of the plan of action developed.
6.2.1.2. democratic Republic of Congo and Burundi
Recent epidemiological evaluation find-ings indicated that one of the endemic foci of Burundi (Cibitoke-Bubanza) may have interrupted transmission of onchocerci-asis infection. However, there were issues with the CDTI implementation situation in DRC which shares border with Burundi. Therefore it was important that the coun-tries start collaborating on cross-border issues. The two countries met in Kinshasa, DRC, from 22 to 24 October 2012 to discuss CDTI implementation for elimination of onchocerciasis in the border areas. Major outcomes of the meetings were:
• A situational analysis on CDTI imple-mentation in the border areas.
• Agreement on strategies to address identified issues constraining improved CDTI implementation in both countries.
• Determination of limits of transmis-sion zone and ivermectin treatment boundary along the border areas.
• Agreement on synchronized CDTI implementation in the border areas. Consequently, a joint plan of action for cross -border activities was developed.
6.2.1.3. Cameroon – CaR – Chad
As seen in Figure 9 onchocerciasis is widely prevalent across the three countries. The map shows a vast hyper-endemic trans-mission zone that extends even to North Eastern Nigeria. The results of recent epidemiological evaluations conducted in these countries along the border area indicate that most of the evaluated villages may have achieved elimination of onchocerciasis infection.(see the empty pies which correspond to zero prevalence of microfilarea in the population surveyed in each village on Figure 9). In the context of elimination, the three countries met in Maroua, Cameroon, from 3 to 5 July 2012 in order to discuss synchronization and coordination of cross border activities.
Figure9: Map showing onchocerciasis endemic transmission areas across the border of Cameroon, CAR and Chad and results of epidemiological evaluations
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At the end of the meeting each country drafted an elimination plan and budget for the border areas to be finalized in their respective countries and shared with APOC Management. Major recom-mendations concerned the finalization of LF mapping in the border areas of Chad and CAR; reinforcement of synchronized CDTI activities to improve treatment coverage of all transmission zones at the border areas; continuation in holding cross-border review meetings. A review meeting is being organized by Chad and is scheduled to take place soon.
6.2.1.4. Republic of Congo and democratic Republic of Congo
The two countries met 29-31 October 2012 in Kinkala, Pool Department of Republic of Congo. The two bordering areas are the Pool Region in Congo and the Bas Congo Province in DRC. The meeting observed that in spite of the relatively good treat-ment coverage on both sides of the border there is need for a synchronized imple-mentation of activities. However, it was noted that several challenges face joint implementation of activities at the borders of the two countries. These include occur-rence of SAEs in the Bas Congo Province, high attrition rate of CDDs due to lack of motivation, inconsistencies in thera-peutic coverage which sometimes could be reported to be as high as 90%; lack of supervision and population movements. At the end of the meeting the two coun-tries developed draft strategic elimination plans which took into account:
• Extension of treatment to include all transmission zones. This would require epidemiological evaluations in 21 districts in Congo (d’Igné, Mayama, Kindamba, Kingoué; Boko-Songho, Kibangou, Makabana, Nyanga, Divénié, Moutamba, Yaya, Sibiti, Mayoko, Kimba, Vindza, Loudima, Louvakou, Banda, Mvouti, Madingo- Kayes, and Kaka-moeka) and in all the districts in Bas Congo especially Mayama, Kindamba,
Nyanga, Divenié, Moutamba and Kaka-moeka districts that are co-endemic for Loaloa.
• Reinforcement of CDTI in poor performing CDTI districts after a proper situational analysis and identification of strategies to improve performance.
• Enhancement of monitoring and eval-uation activities including epidemio-logical and entomological evaluations. This should also involve building local capacity in the performance of these activities.
• Development of BCC and IEC materials on preparing communities to stop iver-mectin treatment.
At the end of the meeting the two coun-tries agreed to synchronize CDTI activi-ties especially supervision of CDDs to ensure that expected treatment coverage is reached. They also agreed that sentinel sites should be identified. The final joint plan of action and budget was to be shared with APOC Management.
6.2.1.5. Benin, Burkina Faso, ghana, Côte d’ivoire and Togo
As part of periodic consultations and sharing of experiences relating to oncho-cerciasis control especially at the borders, the first meeting of a pool of 5 ex-OCP countries made up of Benin, Burkina Faso, Côte d’Ivoire, Ghana and Togo, was held in Lomé, Togo, 18-19 July 2012.
The goal of the meeting was to put in place strategies that will improve performance of country programmes at their borders. It gave the opportunity for the participating countries to review entomo-epidemiolog-ical situation as well as the implementa-tion of control/elimination activities at the border areas. It also afforded them the opportunity to develop joint synchronized action plans.
Countries reported on the entomo-epide-miological situations and the on the imple-mentation of CDTI activities as follows:
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• In 2012 the situation in Benin had been encouraging. Out of 11 villages situ-ated along the Togo Benin border that were evaluated 09 villages had zero prevalence for oncho and prevalence was 0,58% and 0,83% in two villages respectively. In 2010 all three capture points evaluated had zero infectivity rate. In 2011 one capture point had 0.5 infectivity rate.
• In Burkina Faso the epidemiological situation in 2011 was alarming in the Comoé river basin especially the border area with Côte d’Ivoire. Prevalence in 13 villages assessed ranged from 5,61% to 70,97% with CMFL that ranged from 0,13 - 5,17/skin biopsy The situation in the other river basins were satisfactory except in Bougouriba and Bas Mouhoun where prevalence levels were still above the threshold.
• The situation in Côte d’ivoire was alarming along its border with Burkina Faso (the Comoé river basin) as well as along the Côte d’Ivoire /Ghana border (in the Black Volta river basin) and the Cote d’Ivoire/Liberia border (in the Cavally River basin).
• For the Ghana programme epidemiolog-ical results in the different river basins as at 2012 were as follows:
- Mô and Wawa river basin: out of seven villages evaluated 02 villages had prevalence of 6.9% and32.4% with CMFL of 0,1 and 1,02 respectively. All the other villages had prevalence levels that ranged from 0% et 3.8%.
- Sissili river basin: of 11 villages evalu-ated 03 villages had prevalence from 6,9%-11,6% with CMFL less than 0.5 in all villages.
- Black Volta river basin: the epide-miological situation was satisfac-tory with prevalence levels below the threshold.
• Results of epidemiological evaluations that took place in 21 villages in Togo in
2012 along the Togo- Benin and Togo- Ghana border areas were satisfactory with prevalence ranging from 0% to 3.9%.
The meeting noted that challenges impeding correct implementation at the boundaries included: lack of financial and adequate human resources for the organization of synchronized activities and regular review meetings; existence of different motivation policies by health programmes causing de-motivation of CDDs who retain or refuse to give treat-ment data (Benin); lack of trained ento-mology technicians; several specific groups that miss treatments (gold miners; fishermen; nomads, sand diggers etc); inac-cessibility of hamlets that subsequently could not be reached with treatment.
Recommendations made to Ministries of Health, APOC and Partners included increasing funding for elimination, ensuring reinforced and synchronized activities at the borders of these coun-tries, harmonization of incentive policies for CDDs, and development of treatment cards for nomads.
6.2.1.6 mano River Cross-border meeting (guinea, liberia, sierra leone and Cote d’ivoire)
From 3rd to 4th of October 2012 at Abidjan, Côte d’Ivoire hosted the 7th cross-border meeting of the Mano River Union in the context of the fight against onchocerciasis and other Neglected Tropical Diseases (NTDs). Coordinators from Guinea, Liberia, Sierra Leone and Côte d’Ivoire as well as the Regional Directors of Health of Côte d’Ivoire’s Health regions bordering Guinea and Liberia attended the meeting. Tech-nical and financial partners involved in the control of NTDs such as APOC, the Center of Neglected Tropical Diseases (CNTD), Sightsavers, Helen Keller International (HKI), and Schistosomiasis Control Initia-tive (SCI) were also represented at the meeting.
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This group of countries meets regularly to:• Review the implementation of activities
for the elimination of onchocerciasis and other NTDs especially at the border areas.
• Identify the challenges related to the implementation of activities and propose solutions.
• Propose a common plan of action for the implementation of synchronized activities at the border areas.
At the end of the Abidjan meeting the following recommendations were made to countries and partners:• Establish an inter-country coordination
committee responsible for facilitating the implementation of activities for the control of neglected tropical diseases in border areas of the Mano River Union.
• Define the terms of reference of the coor-dinating committee by October 2012.
• Advocate to governments and partners to increase financial support to coun-tries’ NTD programmes for the strength-ening of technical and managerial capa-bilities of NTD program managers in the Mano River region before December 2013.
• Complete mapping of NTDs in the Mano River countries.
• Organize a midterm evaluation of the recommendations of the seventh meeting in April 2013.
Overall, even though there has been a number of activities (particularly meet-ings) undertaken with APOC support to enhance cross-border collaboration the major challenge has been the implemen-tation of resolutions reached at these meetings. A key constraint for APOC is the inability to financially support the implementation of the joint plans of action developed at these meetings due to budgetary constraints. Meanwhile, APOC Management has assigned a focal person for cross-border activities.
6.3. Transition Task Force of the CsaAs part of its efforts to guide APOC Management within the context of the paradigm shift from control to elimina-tion, the CSA recommended the review of the constitution of the Technical Consul-tative Committee of APOC for the transi-tional period of 2013-2015. It advised that sound scientists in epidemiology, ento-mology, parasitology, public health, opera-tional research, and NTDs management should be considered as members of the TCC. In addition, the CSA decided to create a Transitional Task Force (TTF) to provide technical advice to APOC on aspects of the new elimination targets (ConceptNote, StrategicPlanofActionandBudget2016-2025, reform of governing bodies) during the transition period of 2013-2015. The TORs for the TTF were drafted by the World Bank, reviewed by the NGDOs in conjunction with WHO Legal, and finalized by APOC Management.
The TTF members were identified based on their technical competence in relation to the ultimate goal of elimination. They have started working virtually, contrib-uting to the preparation of the ConceptNote and Strategic Plan of Action andBudgetofthetransformedAPOCfortheperiod2016-2025. They would, however, meet once a year, preferably in Ouaga-dougou, on important technical and stra-tegic matters to ensure good preparation for the post-2015 era.
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7. support to peripheral health systems
7.1. Peripheral health systems strengthening
7.1.1. Technical Support
APOC provided support in the develop-ment of the Regional NTD Action Plan 2014-2020 (towards elimination of NTD) initiated by AFRO Regional office. The goal of this plan is to establish, by 2020, sustainable integrated national NTD control programmes capable of achieving elimination of NTDs as public health prob-lems in endemic countries in the African Region. APOC also supported the devel-opment and/or review of various NTD/CDI documents viz: National NTD Stra-tegic Plans for some countries, training manual and slides on CDTI/CDI, protocol for independent evaluation of therapeutic coverage, protocol for the multi-country study on CSM, and, a strategy/plan for communication. APOC organized a series
of inter-country capacity workshops in some countries which focused on various themes.
Another highlight of APOC’s support was in the development of funding proposals in three countries (DRC, Ethiopia and CAR) and the proposals submission to GNNTD for mobilization of additional resources for the implementation of the countries’ NTD Master Plans.
To strengthen CDTI performance APOC supported the improvement of training modules on CDTI and the training of 73 trainers in three countries (Angola, DRC and South Sudan) on the use of the revised training modules. These TOTs were followed by the training of health personnel and CDDs. 28 data managers from 2 countries (Cameroon and Liberia) were trained to manage monitoring and evaluation data on onchocerciasis and other PC-NTDs.
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7.1.2. Master and Bachelor Degrees in Public health
In 2012, APOC continued to provide finan-cial support for seven (7) fellowships/schol-arships earlier awarded as part of efforts to increase the number of public health professionals in APOC countries. Seven health personnel from CAR (2), Chad (2), Cote d’Ivoire (1) and DRC (2) benefitted from the scholarships. Six (6) were for the award of a Masters in Public Health at IRSP and one (1) was for the award of a Bachelor Degree in public health at CFSP. These health professionals have finished their training and resumed duties in their respective countries.
Overall, within the reporting period, more than 82,000 health professional (all catego-ries combined) from 22 countries were trained in various areas. Out of this total, 81,520 health workers from 20 countries were trained on CDI strategy (28% newly trained and 72% retrained), 7 for Master and Bachelor Degrees in Public Health (71% female), 73 in training on CDI strategy and 490 persons in 13 countries trained in 5 other areas (entomological evaluation, data management and GIS, cytotaxonomy, financial management, and epidemiolog-ical evaluation). See Table 12 for details.
In 2012 (Figure 10) a total of 668,094 CDDs in 22 countries were trained (23% newly trained and 77% retrained) on CDI strategy.
APOC continued to support countries to improve leadership, ownership, commit-ment and governance and to reinforce the role of Ministry of Health in resource mobilization, and in ensuring better coor-dination among stakeholders and imple-menting partners.
7.1.3 Gender Mainstreaming
APOC continued to provide support for monitoring gender issues in onchocer-ciasis endemic countries especially among CDDs. Programme managers and APOC continued to work to improve gender balancing at all levels both for equity and for enhanced functioning and sustain-ability of CDTI. At community level, whilst respecting cultural sensitivity, NOCP and project teams continued to encourage communities to select women as CDDs. Out of 697 921 CDDs involved in CDTI activities in 22 countries in 2012, 30.8 % were female. Overall, the proportion of female CDDs has increased from 25.0% in 2010 to 29.0% in 2011 and to 30.8% in 2012.
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Table12:Number of Health Professionals trained/retrained in 2012
Areaofcapacitybuilding Countriesoftrainees NBofpeopletrained
CDTI/CDI Strategy 20 countries 81,520
TOT in CDTI/CDI Strategy Angola, DRC and South Sudan 73
Entomological evaluation Nigeria 21
Data Management and GIS Cameroon, Liberia 28
Master and Bachelor Degrees in Public Health
CAR, Chad, Côte d’Ivoire, DRC 7
Financial Management
Burundi, Cote d’Ivoire, Congo, DRC, Nigeria, United Republic of Tan-zania
181
Cytotaxonomy Congo 4
Epidemiological Evaluation
Benin, Burundi, Cameroon, CAR, Chad, Congo, DRC, Malawi, Nigeria, United Re-public of Tanzania, Uganda
256
Total 22countries 82,090
Figure10:Numbers of health workers and CDDs trained/retrained in CDTI strategy in 2012
81,520healthworkers 668,094CDDs
58,853 persons re-trained
514,188 persons re-trained
22,667 persons newly trained
153,906 persons newly trained
28% 23%
72% 77%
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aNNExTableA1:Cytotaxonomy identification of S. damnosums.l. larvae collected from rivers in Cameroon, CAR, Chad and Nigeria
COUNTRYRegion or State
Periodofcollection
No.ofsitesvisited No.positive Species
identified
CAMEROON
South West Dry 43 32S. mengense (15), S. squamosum (20), S. soubrense-Beffa (1)
North West Dry 36 15 S. mengense (10), S. squamosum (12)
North Dry 78 5 S. damnosums.s. (5), S. sirbanum (4)
North Rainy season 40 14 S. damnosums.s. (14), S. sirbanum (1)
Extreme North Rainy Season 17 6 S. damnosums.s. (6), S. sirbanum (1)
NIGERIA
Cross River Dry Season 10 3S. squamosum (3), S. damnosums.s. (1), S. sirbanum (1)
CHAD
Dry Season 4 3 S. damnosums.s. (3), S. sirbanum (3)
CENTRALAFRICANREPUBLIC
Dry Season 24 17
S. squamosum (17), S. yahense (5), S. damnosums.s. (11), S. sirbanum (11)
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Registration of community members for epidemiological evaluation.
Training of trainers on CDTI, Juba, July 2013, South Sudan.
Stakeholder meeting in Juba, 17-18 July 2013, on “the road map for reorganization of Community Directed Treatment with Ivermectin (CDTI) to control/eliminate Onchocerciasis and other Preventive Chemotherapy (PC) Neglected Tropical Diseases (NTDs) in South Sudan”.
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APOC Stakeholders Meeting, Ouagadougou, 4-5 November 2013.
4th Session of NNN/NGDO Network, Brighton, 18-20 September 2013.
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37th Session of the Technical Consultative Committee, Ouagadougou, 9-13 September 2013.
10th NOTF meeting, Ouagadougou, 23-27 September 2013.
African Programme for Onchocerciasis Control (APOC)World Health OrganizationB.P. 549 – Ouagadougou – BURKINA FASOTel: +226-50 34 29 53 / 50 34 29 59 / 50 34 29 60Fax: +226-50 34 28 75 / 50 34 26 [email protected]/apoc
AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL
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