7JOINT ACTION FORUM Office of the Chairman JAF-FAC: NINTH SESSION Gatineau. -1-5 Deeember, 200-1 FORUM D'ACTION COMMUNE Bureau du Pr6sident African Programme for Onchocerciasis Control Programme africain de lutte contre l'onchocercose The World Health Organization Year 2003 Progress Report: l't September 2002- 31 August 2003 t JAF 9.5 ORIGINAL: ENGLISH .lul-v 2003 I i '$ II L I* [, f I t' .!.1r -- i F t nF, I .h.- \ a q s, ,ffi lltll vrr t JAF 9.5 Page a AAKN)WLeDqEHeNT We are grateful to all APOC partners for their contribution to the improvement of the hedth of the poorest populations in Sub-Saharan Africa. t '. ./ .. ,/:a ,. .,/ ,' I JAF 9.5 Page i TABLE OF CONTENTS LIST OF TABLES, FIGURES .lll .tv ..tY ,Yu LIST OF APPEI\IDIXES I. INTRODUCTION.......... 2. ACTIVITIES OF THE NATIONAL ONCHOCERCIASIS TASK FORCES AND COMMUNITIES2 2.1 CoUNrRv PRoFTLES oFCDTI IMPLEMENTATIoN............. ................'...........2 I 2.t.t 2.1.2 2.1.3 2. t.4 2. t.5 2. t.6 2.1.7 2.1.8 2.1.9 2. t. t0 2.r.tI 2.I.t2 2.t.t3 2.1.t4 CAMEROUN CENTRAL AFRICAN REPUBLIC . CHAD.. CONGO BRAZZA I/I LLE.,......... DEMOCRATIC REPUBLIC OF CONGO.,., EQUATONAL GUINEA. ETHIOPIA,.. GABON....... LIBENA,..,.. MALAWI..,... NIGENA SUDAN TANZANIA 2 3 3 4 4 5 6 6 7 7 8 9 9 UGANDA..,.. ...................... I 0 2.2 Dnuc sulptvtENT AND sroRACE...... .................1 I 2.3 SrRrus oF IvERMECTIN TREATMENT INAPOC coUNTRIES tN2002: Suuutnv..... ........12 2.4 IEC AND ADVOCACY BY NATIONAL ONCHOCERCIASIS TASK FORCES 2.6 OpsRnrroNal RESEARCH (OR) PRoPoSALS. l5 3. ACTTVTTTES OF THE TECHNICAL CONSULTATM COMMITTEE (TCC) .........15 3.I MEMBERSHIPoT TCC 3.2 ROLE AND FUNCTION Or TCC........ 3.3 HlcHLrcHTsorTCCACH|EVEMENTS................ 4. VECTOR ELIMINATION............. 4.1 BtoKo, EeuAToRrALGunpn 4.2 ITWARA Focus, Uceuoe...... 4,3 MPAMBA-NKUSI FOCUS, UCRNOA 4.4 TUKUYU FOCUS, TANZANIA 5. GEOGRAPHICAL INFORMATION SYSTEM: MAPPING OF THE DISEASE... 5.I RepIUEPIDEMIOLOGICALMAPPINGOFONCHOCERCIASIS.,...... Ango\o......... sudan............................ :. :.. : :. :. : :... : : : :. :. : Democratic Republic of Congo........... Burundi....... REFINEMENT oF EXISTIIS REMO MAPS .......,.,. RISK ASSESSMENT OF SEVERE ADVERSE EVENTS........ 6. EVALUATION OF THE SUSTAINABILITY OF CDTI PROJECTS AND POST-APOC PLANS.27 6.I ASSESSMENT OF THE SUSTAINABILITY OF CDTI ,..,.,..,........,27 6.2 DEvELopMENT oF susrAINABILrrY PLANS.......... ................28 7. OTHER ACTMTTES OF APOC MANAGEMENT............ .......................29 7.1 STATUS OF FINANCING FIRST, SECOND, THIRD,FOURTH AND FIFTH YEAR PROJECTS .29 7.2 FTNANCIALIVLANAGEMENTopCDTI PRoJECTS ....................30 7.2.1 Submission offinancial returns to APOC from the proiects 8.2 BUILDING CAPACITY FoR ASSESSMENT oF THE SUSTAINABILITY OF CDTI PROJECTS. .30 8.3 MlssroNs, CouNTRy suppoRT vtstrs AND sPECIAL vtstrs.......... .............31 8.3.1 Support visits/missions by Manogement staff: overtiew...... ...............31 8.3.2 Missions to donors ..... ...........i I 8.3.3 Support missions to countries ,.,..3 l l5 l5 t6 l6 l6 t7 l8 l9 2t 2t 5.1.t 5.t.2 5. t.3 5.1 .4 5.2 5.3 .21 .2t .21 .23 .23 .26 ........,..,.,.,.,. 30 JAF 9.5 Page ii 8.3.4 Support visits by Temporary Advisors and Consu1tanrr................. -.....32 8.4 MAJOR MEETINGS AND WORKSHOPS., .32 8.3.3.2 8.3.3.3 8.3.3.4 8.4. I Statutory meetings....... 8.4.2 NGDO Coordination meeting........ 8.4.3 Meetingwith CIDA 8.4.4 lmpact assessment of APOC operations 8.4. 5 Francophone meeting on 9ustainabi|ity..................... 8.4.6 Workshop on APOC philosophy ond CDTI Strategt . OVERVIEW OF COLLABORATION WITH OTHER WHO GROUPS AND THE ...........,...,.,32 ..................32 ..................32 ..................32 ..................33 ..........,.,..,,,33 WORLD9. 9.1 colleeonarroNwrrHWHo/AFRO......... 34 9.2 COLLABORATIoN wtrH WHO/HQ..... .............34 9.3 Cot-LnsonenoN wtrH WHO/TDR: OPERATIONAL RESEARCH............... ...........34 9.3. t RESEARCH by Product Research and Development (PRD) WHO/TDR.... .............34 9.3.1.1 Drug Discovery 34 9.3.1.2 Product development (Moxidectin).. ........35 9.3.1.4 Ivermectin resistance detection tool and clinical research.......... ..........'.35 9.3.2 Llpdate on Onchocerciasis Implementation Research (WHO/TDR) .................'.......35 9.3.2.1 The use of Community-directed treatment approach for other diseases......... ..............35 9.3.2.2 Multi-country study on additional health tasks of CDDs......... ..............36 9.3.2.3 Field validation of RAPLOA and Environmental risk mapping 36 9.4 CollegonartoN wtrH rHE woRLD BnNr - ONCHoCERCIASIS UNlr.... ............'......'...36 9.5 CooRolulrroN AND MANAGEMENT oF THE ACTIVITIES IN THE SpecteL lutgnveNlolgoNEs......37 IO. CONTRIBUTION OF THE NON.GOVERNMENTAL DEVELOPMENT ORGANIZATIONS (NGDOS) COORDINATION GROUP...... ....................37 II. AUDITING THE PROGRAMME..... ll.2 EXrERNALAuotr.......... .38 I I.3 INTERNAL APOC AUDIT IN THE FIELD..... ..'.....38 JAF 9.5 Page iii LIST OF TABLES Table I Table 2 Table 3 Table 4 Table 5 Table 6 Table 7 Table 8 Table 9 Table l0 Table I I Table 12 Table 13 Table 14 Ivermectin tablets shipped by Mectizan Donation Programme to APOC countries in 2001 and2002 Extemal support to the NOTF of Equatoiral Guinea Monthly biting rate in2002 and 2003, in Bioko lsland ... Adult S. neavei catches in Itwara focus, Kabarole, Uganda in 2002 Results of dissections of S. damnosum from Tourist catching site in Aswa sub focus, Kabarole, District, Uganda, 2002 ... Summary of Crab collection and examination in ltwara focus in Kabarole disffict, January to December 2002 ......... Personnel of vector elimination projects in Uganda Expertise involved in the implementation of vector elimination in Tukuyu Population at risk for onchocerciasis and ultimate treatment goal (UTG) by country as at July 2003 Number of villages by levelof risk for SAE in Cameroon,2003 ........ Projects evaluated in 2002-2003 (as at July 2003) ... Summary of projects evaluated in 2002-2003 (as at July 2003) ........ Profile of trainees on assessment of the sustainability of CDTI projects in2002-2003 ....... lnvolvement of CDDs in other health and development activities and the process of their selection . Table 15 NGDO partners in onchocerciasis control in APOC countries LIST OF FIGURES ll l6 17 t7 l8 l9 20 24 26 29 29 30 t8 36 37 Figure I Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure l0 Figure I la Figure I lb Figure l2 Figure 13 Figure l4 Figure l5 Geographical coverage of 8 CDTI projects of Cameroon in2O02 as reported by the NOTF . Therapeutic coverage of 8 CDTI projects of Cameroon in 2002 as reported by the NOTF . . . Geographical coverage of 3 CDTI projects of DRC in 2002 as reported by the NOTF ... ..... Therapeutic coverage of 3 CDTI projects of DRC in2002 as reported by the NOTF Geographical coverage of 26 CDTI projects of Nigeria in2002 as reported by the NOTF ... Therapeutic coverage of 26 CDTI projects of Nigeria in2002 as reported by the NOTF ... Geographical coverage in2002 of 4 CDTI projects of Tanzania Therapeutic coverage in2002 of 4 CDTI projects of Tanzania Ivermectin tablets shipped in APOC countries between 1998 and 2002 . . . . . . Number of persons treated in APOC countries between I 998 and 20OZ . . . CDTI projects with a geographical coverage below 80% in2002 CDTI projects with a geographical coverage greater or equal to 80%o in 2002 CDTI projecs with a therapeutic coverage below 65% in 2002 CDTI projects with a therapeutic coverage greater or equal to 650/o in 2002 Monthly transmission rate, Sioni catching point before and after treatment, MpambaNkusi Monthly transmission rate, Rulembo catching point before and after treatment, Mpamba- Nkusi ... Monthly transmission rate, Nyabugando catching before and after treatment, Mpamba- Nkusi Monthly biting rate in Tukuyu Transmission potential in Tukuyu focus ......... Rapid epidemiological mapping of Onchocerciasis results in Angola as at June 2003 ...... Rapid epidemiological of mapping Onchocerciasis results in Sudan as at June 2003 ... ...... Rapid epidemiological of mapping Onchocerciasis results in DRC as at June 2003 ... ... ... Rapid epidemiological of mapping Onchocerciasis results in APOC countries as at July 2003......... Distribution of risk for SAE in the Northwest Province of Cameroon Distribution of Risk for SAE in the Nanga Eboko health district of Cameroon . . . . . . 2 2 5 5 8 8 9 t0 il t2 l2 l3 l3 t4 l8 t9 Figure l6 Figure l7 Figure l8 Figure 19 Figure 20 Figure 2l Figure 22 Figure 23 Figure24 l9 l9 20 22 22 23 25 26 27 JAF 9.5 Page iv LIST OF APPEIYDIXES Appendix I Appendix 2 Appendix 3 ACRONYMS 39 39 40 ADB AFRO APOC ATO BASED CBM CC CDD CDI CDTI CEO CHAL ComDT CSA CSM DEC DMO DO DOTs DIG EPI ERM FLHF GIS GRBP GTZ HIS HKI Summary of average geographical coverage of projects in 2002 in APOC counffies . Sum mary of average therapeutic coverage of projects in 2002 in APOC countries . . . Summary oftraining in2002 in APOC countries African Development Bank African Regional Office (WHO Regional Office for Africa) African Programme for Onchocerciasis Conffol Annual Treatment Obj ective Bahai Agency for Social Economic Development Christoffel-Blindenmission (German NGO) Carter Center (The Carter Presidential Center) Com mun ity-Directed Distributor Community-Directed Interventions Commun ity-Directed Treatment with Ivermectin Chief executive Officer Christian Health Association of Liberia Comm unity-D i rected Treatment Committee of Sponsoring Agencies (and APOC sponsors which include representatives of UNDP, FAO, The World Bank, WHO, the NGDO Group and Merck & Co. Inc.) Com munity Self Monitoring Diethylcarbamazine District Medical Officer Dermal Onchocerciasis (see OD, OSD) District oncho teams Director's Initiative Grant Expanded Programme of I mmunization Environmental Risk Mapping Front line health falicility Geographical Information System Global 2000 River Blindness Program (Carter Center) German Technical Cooperation (German research support agency) Health Information System Helen Keller International (US NGO) JAF 9.5 Page v HMIS HNI HSA IDP IEC IEF IFESH IMA ITN JAF KAP LA LF LGA MDP MEC MIS MITOSATH MoH MSD MZ NDS NGDO NGO NOCP NOTF OCP OPC OSD OV PHC PRD RBM RAPLOA REA REMO SAE SB Health Management Information System HealthNet International Health Surveillance Assistants Ivermectin Delivery Program lnformation, Education, Communication International Eye Foundation (US NGO) International Foundation for Education and Self-Help Interchurch Medical Assistance (US NGO) Insecticide Treated Nets Joint Action Forum (APOC participant body) Knowledge, Attitude, Practice Lefter of Agreement Lymphatic Filariasis Local Government Area MectizanrM Donation Program MectizanrM Expert Committee Management of Information System Mission To Save The Hopeless Ministry of Health Merck Sharp & Dohme MectizanrM (ivermectin, MSD) National Drug Service Non-Governmental Development Organization (see NGO) Non-Governmental Organization (see NGDO) National Onchocerciasis Control Program National Onchocerciasis Task Force Onchocerciasis Control Programme in West Africa Organisation pour la Pr6vention de la Cdcit6 (French NGO) Onchocercal Skin Disease (see OD, DO) Onchocerca volvulus Primary Health Care Product Research and Development Roll Back Malaria Rapid Assessment Procedure of Loa loa Rapid Epidemiological Assessment Rapid Epidemiological Mapping of Onchocerciasis Serious Adverse Event SmithKline Beecham (pharmaceuticals producer) JAF 9.5 Page vi stz SNNPR SRRA SSI SSOTF TCC TDR I.]NICEF USAID VC WB wHo WHO/AFRO wHo/HQ WHO/OCP WHO/TDR WR Special Intervention Zones South Nations Nationalities and People Region Sudan Relief and Rehabilitation Association Sight Savers International (British NGO) Southern Sector Onchocerciasis Task Force Technical Consultative Committee (APOC scientific advisory group) Special Programme for Research and Training in Tropical Diseases (part of CRD, a department of CDS, WHO) United Nations Children's Fund Agency for International Development (United States agency) Vector Control World Bank (The World Bank) World Health Organization see AFRO World Health Organization's Head Quarters see OCP see TDR WHO Representative (country-specific) JAF 9.5 Page vii SUMMARY During the period being reported, the APOC partnership comprising of the endemic communities, National Onchocerciasis Task Forces (NOTFs), the NGDO Coordination Group, the Technical Consultative Committee (TCC), the Committee of Sponsoring Agencies (CSA), Merck & Co., and its Mectizan Donation Program (MDP) have made a number of achievements here summarized: ( i.) (ii.) (iii.) (iv.) (v.) (vi.) (vii.) (viii.) (ix.) (x.) More than 27 million (27,380,015) persons were treated in 2002 out of a total population of 47,120,113 people distributing in 53 CDTI project areas in l4 countries. Five countries provided partial or no data for 2002. The Mectizan Donation Program shipped 98,520,000 ivermectin tablets to these APOC countries. This represents an increase of 3% in the number of tablets shipped by MDP to APOC Countries in 2001 (95,746,500 tablets). 52,819 communities had been ffeated with ivermectin in 2002; 107,008 CDDs and 13,713 health workers were trained or retrained in CDTI approach. 9 projects did not provide datafor 2002. During the period under review a total of 17 CDTI projects were evaluated for sustainability. The evaluation conducted by independent scientists, project coordinators, NGDO partners covered more than 42 local authorities in seven countries. APOC Programme supported National Onchocerciasis Task Forces (NOTFs) (a) to undertake the rapid epidemiological mapping of onchocerciasis (REMO) in the conflict zones and (b) to refine the existing REMO maps. The onchocerciasis prevalence data available for the 19 APOC participating countries enable the estimation of the Programme's ultimate treatment goal (UTG) at 86,311,329 persons. From the results of the REMO in several countries, 107 CDTI projects were forecasted, and 73%o ofthese have been approved for APOC Trust Fund support. Vector elimination activities through ground larviciding (Tukuyu focus/Tanzania and Mpamba-Nkusi/Uganda) and aerial spraying (Bioko/Equatorial Guinea) have been implemented with encouraging results. For the past 6 years, Itwara focus in Uganda has remained vector free. The TCC reviewed 66 annual technical reports and 24 project proposals. The commiffee undertook technical missions to DRC and Ethiopia to advise projects on CDTI implementation and to assist the NOTFs in formulating new project proposals. APOC Management conducted capacity building activities in sustainability of CDTI projects, data management and geographical information system, financial accountabi I ity in the participating cou ntries. A workshop on APOC philosophy and CDTI was organized for four countries (DRC, Burundi, Angola and Congo). The Programme Director in joint missons with the Oncho Unit of the World Bank, visited I I donors countries and institutions for mobilization of resources. APOC Management reviewed l4l projects documents including 78 budget proposals. Sixty-four (64) letters of agreement (LA) were prepared and processed. During the period under review, the OnchocerciasisUnit ofthe World Bank" the NGDOs partnens, Merck and Cie Inc. and its donation Programme, MDP, had provided invaluable supports to APOC activities.
JAF 9.5 Page I 1. INTRODUCTION In preparationfor the Post-APOC Era: exit strategt Since Decemberl995, the year the African Programme for Onchocerciasis Control (APOC) was launched in Washington D.C, the partners have kept foremost in mind a framework in pursuit of an exit strategy of APOC. The first step was the search to identifu alternative drug(s), microfilaricide and /or macrofilaricide, an effort that began also in 1995. Since then, concrete steps have been taken in preparation for APOC exit and a take-over of ivermectin distributions by participating governments and endemic communities. Between 1995 and 2003, specific exit milestones have taken place. In 2000, the report of the mid-term External Evaluation of APOC concluded, "Communities hqve been deeply involved in their own health core on a massive scale." However, the evaluation accentuated the need to devolve more rapidly to NOTFs the management of CDTI in order to accelerate the achievement of the objective of APOC. It was this challenge that led to the genesis of the evaluation of the sustainability of CDTI and development of post-APOC plans by participating governments. As at the time of writing this report, post-APOC plans have been developed in39 local authorities in Cameroon, Nigeria, Tanzania and Uganda and submitted to APOC management Seeing the potential for synergies, country programs (i.e. NOTFs) are increasingly relying upon CDTI as springboard to add on other community-based health interventions (e.9. vitamin A supplementation, eye care services, and home management of malaria). An objective of this bold step is to enhance the likelihood of establishing sustainable CDTI projects integrated with other programs before the final exit of APOC in 2010. Examples of these synergies and add-on interventions will be presented to the JAF9 in December 2003. Further, a multi-country study commissioned by the JAF8, which will examine the sustainability of CDTI, feasibility and cost-effectiveness of adding other programmes to CDTI has been launched in 2003. This report gives prominence to partners' achievements in (i) ivermectin distribution results ; (ii) vector elimination activities in the Island of Bioko, Equatorial Guinea; (iii) the potential for synergies by adding on other health interventions for underserved populations using funds and infrastructure of CDTI and (iv) progress on the assessment of the sustainability of CDTI projects. JAF 9.5 Page2 2. ACTIVITIES OF THE NATIONAL ONCHOCERCIASIS TASK FORCES AND COMMUNITIES 2.1 Country profiles of CDTI implementation 2.1,1 CAMEROI-]N Community-Directed Treatment with Ivermectin (CDTI) The CDTI was launched in Cameroon in October 1998 and to date l0 projects have been approved including that of Northwest province although the latter project is yet to start. The NGDO partners of the Ministry of health in implementing CDTI projects are: BASED, GRBP, HKI, IEF and SSI. Status of ivermectin treatment: geographical and therapeutic coverage ln 2002,8 out of the 10 CDTI projects treated 5815 communities out of a total of 5905 with an average geographical coverage of 95%o ranging from 91%o to 100% (fig l). These projects treated 1,547 3gi peironr out of a total population of 2,882,932 people. This represents an average therapeutic coverage of SSi% varying from 28%o to 82oh as shown in figure 2 (data from North Province and Centre 2 are not available). Government and community contribution For the fiscal year 2OO1-2002, the Government allocated FCFA 95,000,000 (equivalent US$ 135,714) for onchocerciasis control from which FCFA 39,232,850 was used to pay the CDDs in cash. Training A total of 9,991 Community-Directed Distributors (CDDs) and 1,198 health workers were trained in 2002.Health workers from referral hospitals were also trained in management of adverse reactions. Challenges The main challenge of the CDTI projects in Cameroon is to reach and maintain a therapeutic coverage of 65%o.lvermectin distribution was not carried out in 2002 in the CDTI project area of Centre 2 because of fear of occurrence of severe adverse events in this project zone where onchocerciasis and loiasis are co-endemic. Rapid epidemiological assessment of Loiasis (RAPLOA) was carried out to identiff the risk communities where TCC/MEC guidelines will be strictly applied in subsequent treatment. Eg1: Geographical coverage of 8 CDTI projects of Cameroon in2002 as reported by the NOTF [!g.!: Therapeutic coverage of 8 CDTI projects of Cameroon in2002 as reported by the NOTF to I - D o o a T D t0 o t00 eo lo 10 0 s 4o 30 ,o l0 o a aI I Ii toslh AdmM Cffi 3 Xorth llcdm tlrltl I FEvhca Prdfrca Meqrr rhd 2 c.ml LIo.di w.d2 Nod ftmur Cdn I L[d I ril r.:l el 3I t II t2!t JAF 9.5 Page 3 2.1.2 CENTRAL AFRICAN REPUBLIC Community-Directed Treatment with Ivermectin (CDTI) The CDTI was launched in CAR in July 1998 by the Ministry of Health and the NGDO partner Christoffel BlindenMission (CBM). Status of ivermectin treatment: geographical and therapeutic coverage The country has experienced intermittent civil unrest since 2001, which disrupted the implementation and reporting of CDTI activities from communities to the National Secretariat. At the time of writing the present report the NOTF was still trying to compile the data for 2002 CDTI activities. In 200 I , 4,594 communities were treated out of a total of 5,014 (geographical coverage of 92%). The project reached a therapeutic coverage of 78%o by treating 778,989 persons out of a reported total population of 998,102 people. Notably, the number of persons treated dropped by 18% between 2000 (950,000 persons treated) and 2001 (778,989 persons treated), which may be due to civil unrest. Government and community contribution The Government released l0%o of the amount of US$ 46,000 budgeted for onchocerciasis control in 2002. ln addition, US$ 37,375 were used to pay salaries to the civil servants involved in onchocerciasis programme and cover administrative costs. The funds collected from cost recovery that was initiated in 1993 was used to cover the operational expenses when there were delays in the replenishment of the project account. Training The partial training data reported by the NOTF revealed that 3,897 CDDs and 488 health workers were trained/retrained. Training and supervision of CDDs were hampered by periodic social unrest. Challenges During the period of social unrest, project office equipment and vehicles were looted. The main challenge of the project is to reorganizethe NOCP secretariat's office, rebuild the CDTI database and continue the CDTI processes throughout the country with an emphasize on the areas that were inaccessible for supervision in 2001 and2002. 2.1.3 CHAD Community-Directed Treatment with Ivermectin (CDTI) The APOC Funded CDTI project was launched in January 1998. Africare and "Organisation pour la Pr6vention de la C6cit6" (OPC) are the NGDO partners of the Ministry of Health in CDTI implementation. Status of ivermectin treatment: geographical and therapeutic coverage In 2002, a total of 3,250 communities were treated out of 3,265 (geographical coverage of 99%). 15 villages are yet to be covered by the ivermectin mass distribution. The project treated 992,542 persons out of a total population of 1,506,575 people (therapeutic coverage of 660/o). Government and community contribution The contribution of communities to cost recovery fund has yielded 46,654,981 FCFA (equivalent to us$ 93,310). Training A total of 2,881 CDDs and 201 health workers were trained in2002. Main accomplishment Therapeutic coverage has now reached the threshold of 65%o. JAF 9.5 Page 4 Challenges There is an increase in the population size of the project area due mainly to the return of migrants who had emigrated at the time of conflict and the immigration of people coming from CAR following the civil unrest there. The project should maintain the therapeutic coverage at least at its present level and improve the geographical coverage to reach 100%. The NOTF should find a way of providing in a timely manner to APOC Management the technical and financial reports as well as treatment data. 2.1.4 CONGO AVILLE Comm unity-Directed Treatment with Ivermectin (CDTI) The APOC Funded CDTI project was launched in January 2001. The NGDO partner involved in CDTI activities with the Ministry of Health is OPC (Organisation pour la Pr6vention de la C6cit6). Status of ivermectin treatment: geographical and therapeutic coverage Partial results indicate that 468 communities out of a total of 674 were mobilized in 2002; they collected ivermectin from the central point of drug collection. In 2002 the project had reached a geographicalcoverage of69%o,andithadtreated 191,780personsoutofatotalpopulationof583,480 people (therapeutic coverage of 33%\. Government and community contribution The contribution of communities to cost recovery has yielded 2,379,360 FCFA (equivalent to US$ 3,966). The Government contribution for onchocerciasis activities for the fiscal year 2002 was 20,686,800 FCFA (equivalent US$ 34,478) of which 8lolo represents payment of salaries. Training ln 2002, a total of 1,414 CDDs and 57 health workers were trained to implement ivermectin distribution in the project zone including urban and rural areas of Brazzaville. Main accomplishments The partners have succeeded in establishing a viable CDTI delivery system in urban endemic areas (Brazzaville). Challenges Some populations express reservation to mass treatment and the cost recovery, particularly in Brazzaville and in the Poolarea. There are areas where onchocerciasis and loiasis are co-endemic. To prevent occulrence of severe adverse events following ivermectin distribution, the NOTF will conduct RAPLOA to determine the areas for mass distribution of ivermectin and those where the TCCIVIEC guidelines should be strictly applied. For its third year of implementation of CDTI, the project should reach65%o therapeutic and a 100% geographical coverage as the country is more or less coming back to stability. 2.1.5 DEMOCRATIC REPUBLIC OF CONGO Comm unity-Directed Treatment with Ivermectin (CDTI) The first CDTI project (Kasai) was launched in April 2000. DRC now has l4 CDTI projects since the approval of 8 new proposals by the Technical Consultative Committee (TCC) of APOC in March 2003. The NGDO partners involved in CDTI activities with the Ministry of Health are CBM, CRS, IMA, IRC, Lions Club and SANRU. Five of the newly approved projects are yet to find NGDO partners to support them. JAF 9.5 Page 5 Status of ivermectin treatment: geographic and therapeutic coverage ln 2002, three projects (Kasai, U6l6s and Bandundu) treated 4,273 communities out of a total of 12,722 (partial data). CDTI activities have been severely affected by a long-standing civil unrest. The three projects treated in 2002 1,685,775 persons out of a combined total population of 7,074,245 people. Partial data on geographical and therapeutic coverage reached by these projects are shown in figures3and4below. Government and community contribution The Government contribution for the fiscal year 2002 is US$ 21,510 to cover salaries and office facilities. Training A total of 9,348 CDDs and 1,067 health workers were trained or retrained in 2002 by the three projects. In Bandundu, KasaT and U6l6 CDTI projects, each CDD treated an average of l19, 186 and 204 persons respectively. Main accomplishments The strong commitment of the Ministry of Health to CDTI has enabled the submission of 8 new CDTI project proposals that have been approved by the TCC of APOC. The NOTF has built capacity in geographical information system and data analysis at the project (zonal) level to promote the use of CDTI data for planning and decision-making. Challenges Timely reporting of CDTI results from communities and peripheral health structures to the project coordination offices is delayed due to civil unrest. NOTF should explore innovative ways of improving the geographical and therapeutical coverages within the context of CDTI. The NOTF should seize all opportunities to complete REMO in the remaining districts, including areas where conflict is going on. The aim of the NOTF is to submit all the outstanding CDTI project proposals to APOC TCC by March 2004. EgJ: Geographical coverage of 3 CDTI projects Fie.4: Therapeutic coverage of 3 CDTI projects of of DRC in2002 as reported by the NOTF DRC in 2002 as reported by the NOTF a3 lndndu !frlu!(fu Xrd lo0 00 80 ?0 00 50 a0 30 20 't0 0 a! I ! el I I I roo eo c) fo 0o 50 40 3o 20 t0 0 tbbX0dthL 2.1.6 EOUATORIALGUINEA Community-Directed Treatment with Ivermectin (CDTI) The CDTI project was launched in December 1998. The partner involved in CDTI activities with the Ministry of Health is the University of Barcelona. Bioko lsland CDTI project is a reorientation of a formerly vertical ivermectin distribution programme, which was initiated in 1988 II21 - I II I IA - I11 - I I I JAF 9.5 Page 6 Status of ivermectin treatment: geographical and therapeutic coverage ln the initial CDTI project proposal, the NOTF estimated the number of persons to be treated at the fifth year of the project at 85,000 people. Since the discovery of oil, a high population movement from rural to urban areas for better opportunities was observed on the island of Bioko. In this context of population movement, the Management of APOC commissioned a rapid epidemiological assessment (ngA) study combined with a population census. The census results indicated a total population of 72,682 persons out of which 55,691 are urban (Malabo city) and 16,991are rural. The REA survey revealed that almost the entire island of Bioko is hyper endemic. Challenges Poor involvement of the NOTF in managing CDTI activities leads to a lack of reliable data. Both rural communities and urban population including Malabo City should benefit from ivermectin distribution through CDTI. Government and community contribution is not evident and this threatens the sustainability of the project. 2.1.7 ETHIOPIA Commu nity-directed treatment with ivermectin (CDTI) CDTI started in Ethiopia in 2000. The Rapid Epidemiological Mapping of Onchocerciasis was partially completed in 2001 and it enabled the estimation of the Ultimate Treatment Goal at 8,216,996 pe.sors. The first CDTI project (Kaffa/Shekka), a partnership between the Ministry of health and the NGDO GRBP Carter Center, was approved in 2000 and launched the same year. In 2002,the National Onchocerciasis Task Force (NOTF) submitted two additional CDTI projects, which were approved. These projects are getting ready to launch CDTI activities. Ivermectin treatment: geographical and therapeutic coverage In 2002, all the 2,086 communities of Kaffa/Shekka benefit from ivermectin ffeatment. The project reached a therapeutic coverage of79o/oin2002 by treating 516,077 persons out ofa total population of 651,223. Training ln 2002, the NOTF trained or retrained 2,389 community-directed distributors (CDDs) and 204 health workers. Challenges In treating 516,077 persons in 2002, the NOTF reached only 6%o of the country's Ultimate Treatment Goal. Efforts should be made to expedite the commencement of ivermectin distribution in the newly approved CDTI project areas and in completing REMO. The project should increase the number of trained CDDs/Community. 2.1.8 GABON Status of ivermectin treatment: geographical and therapeutic coverage Ivermectin distribution was going on in l8 villages on a clinic-based approach since 1999. It has been extended to the village of Mbelenaletembe during year 2002, bringing the total villages under treatment to 19. The NGDO partner is OPC. In these 19 villages, 5,935 people were treated in 2002 out of a total population of 9,434. This represents a therapeutic coverage of 630/o. In addition, the health centers reported treatment of 38 onchocerciasis patients. JAF 9.5 PageT Training ln 2002, training of peripheral health personnel was not carried out because of lack of financial resources. However, the coordination team took the opportunity of supervisory visits to train some new health personnel. 2.1.9 LIBERIA Community-directed treatment with ivermectin (CDTI) The first project was approved in 1999 but lvermectin distribution using the CDTI strategy started in 2002.ln the period under review, Liberia had three approved CDTI projects and the Ministry of health is in partnership with Sight Savers International (SSI) and Christian Health Association of Liberia (cHAL). The two projects approved in 2002 (Southern-eastern and Southern-west CDTI projects) could not commence CDTI implementation in 2003 as scheduled because of the civil unrest which is still going on in the country. Status of ivermectin treatment: geographical and therapeutic coverage Out of the three approved projects, only Lofa, Bong, Nimba, Montserrado CDTI project is implementing ivermectin mass distribution. [n2002, the project reached a geographical coverage of 63%by treating 1628 communities out of the 2596 meso and hyper endemic communities and treated 900,000 persons out of a total population of 2,214,610 people (therapeutic coverage 4l%). The low therapeutic coverage recorded by the project is mainly due to civil unrest. Training ln 2002, a total of 6,925 CDDs and 104 health workers were trained or retrained. Challenges The main challenge of the NOTF is to develop innovative approaches for ensuring community directed reatment with ivermectin despite the on going civil unrest. 2.I.IO MALAWI Community-directed treatment with ivermectin (CDTI) Community-directed treatment with ivermectin was launched in Thyolo and Mwanza districts in 1997. In 1999, the project was extended to 5 other districts. The NGDO partner of the Ministry of Health in the implementation of ivermectin distribution in Malawi is International Eye Foundation (lEF). From the Rapid Epidemiological Mapping of Onchocerciasis results, the ultimate treatment goal of Malawi is estimated at 705,695 persons living in the 7 endemic districts. These districts are Thyolo, Mwanz4 Blantyre, Chiradzulu, Mulanje, Phalombe and Chikwawa. Status of ivermectin distribution: goographical and therapeutic coverage The geographical coverage of 80% reached in 2001, dropped to 73Yo in 2002. The same trend is observed with the therapeutic coverage. At first it increased from 45oh in 1999 to 57o/o in 2001, and then droppe d to 56% in 2002. The reason for this drop is not clear; effofts are being done to determine the limiting factors to maintaining high geographical and therapeutic coverage. The evaluation of the sustainability of the project revealed that support from the national level to CDTI is weak. Training Ln2002, a total of 2,224 CDDs and 472 health workers were trained or retrained. Challenges The NOTF in collaboration with APOC Management need to address, the key constraints limiting full geographical and optimal therapeutic coverage. JAF 9.5 Page 8 2.I.II NIGERIA Community-Directed Treatment with Ivermectin (CDTf) The distribution of ivermectin using the CDTI strategy started in 1997 and it is done in partnership with the endemic communities, the Federal and State Ministries of Health and the NGDO partners, SSI, GRBP, HKI, MITOSATH, IFESH, CBM, UNICEF. The recent completion of the Rapid Epidemiological Mapping of Onchocerciasis in Nigeria, enabled the estimation of the ultimate treatment goal of Nigeria at30,521,713 persons. Status of ivermectin treatment: geographical and therapeutic coverage In 2002,26 CDTI projects treated 33,839 out of a total of 35,484 communities. Figure 5 shows the geographical coverage of these projects in 2002, the average being 95o/o. In total, 18,552,844 persons out of a total population of 25,239,894 were treated. The therapeutic coverage recorded in2002 varies from 46%o to 89%o (figure 6) with an average of 7 4%o. Training ln 2002, the NOTF trained or retrained 58,1 84 CDDs and 9,204 health workers Main accomplishments !n2002, the CDTI projects of Nigeria (26 out 27 approved) reached 60% of their ultimate treatment goal. Delineation of area co-endemic for onchocerciasis and loiasis in Akwa Ibom was performed and the NOTF is about to launch the 27th CDTI project of Nigeria. Challenges Reaching and maintaining 100% geographical coverage remain the main challenges of l8 projects. Fie.5: Geographicalcoverage of 26 CDTI projects of Nigeria in2002 as reported by the NOTF Fis.6: Therapeutic coverage of 26 CDTI projects of Nigeria in2002 as reported by the NOTF 100 c0 80 f0 !0 50 ao 30 20 t0 0 el I I I 100 90 80 lo a0 50 a(, fit 20 t0 0 / a' aF +rP' aid...'d *r$r S' " *' dr)'".r' d "'y' av"//f,._$dd1*c"'r.r' .f'rfrrf.y dj/.i.r '6 d JAF 9.5 Page 9 2.1.12 SUDAN Community-directed treatment with ivermectin (CDTI) Ivermectin distribution using CDTI strategy started in 1997. Today APOC supports two CDTI projects in Sudan. The Northern Sector project for areas under the control of the Federal Ministry of Health is supported by GRBP. The Southern Sector project under the Sudan Relief and Rehabilitation Association (SRRA), is in collaboration with a coalition of NGDOs which are coordinated by Healthnet International. The recent Rapid Epidemiological Mapping of Onchocerciasis (REMO) conducted in Southern Sudan revealed that 4,099,760 persons are at risk of onchocerciasis. The Southern sector onchocerciasis Task Force (SSOTF), based on the REMO results has elaborated five (5) new CDTI projects proposals to be submitted to APOC Technical Consultative Committee for consideration. Ivermectin treatment: geographical and therapeutic coverage Ivermectin mass distribution is being carried out in the Northem and Southern Sectors in areas accessible to the Government of Sudan (GOS) and SSOTF respectively. In these accessible areas there are a total of 594 communities. In 2002, 275 communities were treated in the Northern Sector leading to a geographical coverage of 88% in this zone. The number of communities treated in Southern Sector was not reported. In 2002, the southern sector treated 437,670 persons out of a total population of 640,200 (therapeutic coverage of 68%) while the northern sector CDTI project recorded a therapeutic coverage of 60%o, treating 357,329 people out a total population of 592,412. Training in 2002 1,012 CDDs and 60 health workers were trained by the Northern Sector while I 16 health workers were trained in the South. Challenges Ivermectin mass distribution is mostly in areas under Government (GOS) and SSOTF control. It is expected that with the peace talk, allthe meso and hyper endemic communities will be covered. 2.1.13 TANZANIA Community-Directed Treatment with Ivermectin (CDTI) The distribution of ivermectin using CDTI strategy started in 1997. Currently, the population at risk of onchocerciasis is estimated at 2,619,792 persons and the ultimate treatment goal is 2,290,851 people. Seven CDTI projects have been approved for Tanzania to enable ivermectin mass distribution in the meso and hyper endemic foci. Five of the approved CDTI projects (Kilos4 Mahenge, Ruvumq Tanga, Tukuyu) have started community-directed treatment with ivermectin while the newly approved projects (in 2003) of Morogoro and Tunduru are in the process of starting ivermectin mass distribution. Ej*],: Geographicalcoverage in2002 of 4 CDTI projects of Tanzania as reported by the NOTF 0 I I T I1' Ii' i"I I n tr t g! n) JAF 9.5 Page l0 Status of ivermectin treatment: geographical and therapeutic coverage ln 2002, 5 of the CDTI projects of Tanzania treated 583 communities out of a total of 590. Three out of the five projects presented a geographical coverage of 100% (figure 7). In the same period, 866,527 persons were treated out of a total population of 1,203,504 people. The average of the therapeutic coverage increased yearly from 64%o in 2000 to 72o/o in 2002. The 2002 data from four projects are shown in figure 8. Training A total of 7,376 CDDs and 302 health workers were trained or retrained in 2002 in five CDTI projects areas. Challenges EgE: Therapeutic coverage in2002 of 4 CDTI projects of Tanzania as reported by the NOTF 100 00 80 70 6o 50 ,10 30 20 l0 0 3 3 ; a 'I Mrhcn0. TuIuyr.r Tang. 9o Xlloaa The ultimate treatment goal (UTG) of Tanzania is estimated at2,290,851people. By treating 866,527 persons in2002,the CDTI projects achieved only 38% of the UTG. Therefore, there is a need forthe NOTF to commence CDTI in the remaining endemic foci and to verifu that all the communities in need of ivermectin treatment are reached. 2.1.14 UGANDA Com munity-d irected treatment with ivermectin (CDTI) Community-directed treatment with Ivermectin using CDTI strategy began in 1997 in partnership with the Ministry of Health in partnership with the NGDOs of CBM, GRBP, GTZ, SSI and West Ankole Diocese. The ultimate treatment goal is approximately 2,141,839 people. Status of ivermectin treatment: geographical and therapeutic coverage Four CDTI projects are implementing CDTI in Uganda. The geographical coverage increased from 84o/o in 1999 to 99% in 2001. Partial treatment data for 2002 indicates that 1,592 out of 3,740 communitiesand 1,069,645 personsoutofatotal populationof l,s66,lg3weretreated.Thedatafor 2002 are being validated by the NOTF and complete geographical and therapeutic coverage will be reported to the Joint Action Forum. Challenges The NOTF needs to ensure the timely submission of data as was done before. 73 0eI If I*^"*-r*IIIIII -r I IIIIIII JAF 9.5 Page I 1 2.2 Drug shipment and storage In 2002, Mectizan Donation Programme (MDP) shipped 98,520,000 tablets of ivermectin in 14 APOC countries. This represents an increase of 3o/o of the number of tablets shipped to APOC countries in 2001 (95,746,500 tablets) (see table I and fig. 9). Table I Ivermectin tablets shipped by Mectizan Donation Programme to APOC countries in 2001 and 2002 Country Year 2001 Year 2002 Tablets shipped o/ ,o shipned Tablets shipped Y" shipped Cameroon 4.853,500 5.07 9,985,000 9.12 C.A.R. 4,350,000 4.54 3,goo,ooo 3.86 Chad 2,897,500 3.03 3,055,500 3.10 Congo (Brazza\ 1,304,000 1.36 635,500 0.65 Eq. Guinea 61,500 0.06 66,500 0.07 Ethiopia 1,645,500 1.72 3,02l,ooo 3.07 Gabon 13,000 0.01 15,000 0.02 Liberia 4,232,000 4.42 4,509,500 4.58 Malawi 2,295,500 2.40 750,000 0.76 Nigeria 59,082,000 61.71 54.005,500 54.82 Sudan 3,114,000 3.25 2,250,000 2.28 Tanzania 2.s07.s00 2.62 2,588,000 2.63 Uganda 5,008,000 5.23 5,034,000 5.1l DRC 4,382,500 4.58 9,804,500 9.95 Total 95,746,500 100.00 98,520,000 100.00 Source: Data provided by Mectizan Donation Program (MDP) Fis.9: Ivermectin tablets shipped in APOC countries between 1998 and 2002' 120,000,000 100,000,000 80,000,000 60,000,000 i10,000,000 20,000,000 81,725,500 2000 xe -4 !f 5! E z 1999 2001 2002 ' Source: Data provided by Mectizan Donation Program (MDP) 0 1998 JAF 9.5 Page 12 2.3 Status of ivermectin treatment in APOC countries in 2002: Summary ln 2002,53 CDTI projects, with a total population of 47,120,1 l3 persons, treated 27,380,015 people (figure I 0), in 52,819 communities (out of a reported total of 73,280 communities). Nine CDTI projects provided partial or no data for 2002. Twelve (12) projects reported in2002 a geographical coverage below 80%. These projects (figure ll-a) are from Cameroon (l project), Congo (l), Democratic Republic of Congo (3), Liberia (l), Malawi (l) and Nigeria (5). Forty-one projects (figure 11-b) had in2002 a geographical coverage ranging between 82.6 to 100%. The threshold of 65oh therapeutic coverage, established for the CDTI projects, was not yet reached in 2002 by 23 out of 53 projects (figure 12). Seven of these 23 projects with therapeutic coverage below 65%o are located in countries in conflict situation: Democratic Republic of Congo (3 projects), Liberia (l), Congo (l), Sudan (2). The remaining 30 CDTI projects reached the 65Yo ihreshold (figure 13). A summury of the average geographical and therapeutic coverage as well as the training figures are presented country by country in appendixes l, 2 and 3. ElglQ: Number of persons treated in APOC countries between 1998 and2002 27,3m,0t5 1998 Eg. 11-a: CDTI projects with a geographicalcoverage below 80% in 2002 as reported by the NOTFs 100 90 80 70 00 50 40 30 20 10 0 30,m,000 26,m,(m rc,un,000 {6,U),(m l0,u),(m 5,qD,(m Et ! E T!I I 0 28nxD1zno198,9 a6a bI ! t * oto 2rJ0:1,t46I I r6,B,500It4,079,654 I II I I 79.1 69.4 69.7 00.6 "'.**'-o d"f, JAF 9.5 Page 13 Fis.ll-b: CDTI projects with a geographical coverage greater or equal to 80%o in2002 as reported by the NOTFs 100 90 t0 E,, o Beo a o3ro6 o =Iro B6o30 20 t0 0 Fie.l2: CDTI projects with a therapeutic coverage below 65%o in2002 as reported by the NOTFs -:.r'r:ru, n c $ dd',-#r'-t?,, :r-ru #SS"Sn.C 1q, 90 g) 70 60 50 & 30 n 10 0 $ f 'F'df rd d'l r f '*$'/ d s r d h € ,9 dff 51.t 52.3 53.1 {ll5 IIJ 3t.z 323 2ti 1tt JAF 9.5 Page 14 Ee.l3: CDTI projects with a therapeutic coverage greater or equal to 650/o in 2002 as reported by the NOTFs too 90 80 870 o E*3co oE3roAa !eo x) t0 0j $"r jjd $**r_g$c-,f,d d-dgfsEnF*F f d$*"$ sa s #gsf $I F 2.4 tEC and advocacy by Nationa! onchocerciasis Task Forces NOTFs have continued to strive for behavioural change of target communities by employing print and electronic media and training materials. This is exemplified by Cameroon, where the NOTF pre-tested and produced IEC materials on CDTI incorporating issues on Severe Adverse Events tSepr); and Di.C where IEC materials were developed by the CDTI project in Kasai, reviewed by APOC management and advice for improving them provided. However, a workshop to evaluate IEC materials and their effectiveness that had been planned to take place in CAR was cancelled due to the prevailing socio-political situation. Advocacy for inclusion of CDTI in the health delivery system and for enhanced budgetary allocation to onchocerciasis activities by the countries has increased throughout the APOC countries. This information is obtained from the findings from evaluationsof the sustainability of CDTI projects which show a high dependency of projects on APOC funds and poor demonstration of the commitment of govemments (lack of release of counter part funds) towards sustaining CDTI. NOTFs of Nigeria, Camiroon, Uganda and Tanzania have therefore increasingly employed advocacy as a tool intenJed to target policy makers to increase their budgetary allocation to onchocerciasis control activities. Some of the positive results attained by projects accruing from the advocacy missions are increased awareness of the responsibilities expected from governments in the APOC partnership; changes in leadership ofprojects were necessary and increased allocation offunds. 2.5 Community Self-Monitoring (CSM) An aspect of sustainability is community ownership in selecting CDDs, planning and managing ivermectin distribution. To promote this critical aspect of sustainability, Comnunity self- monitoring (CSM) was initiated in year 2000 following a research undertaken by the Programme management in 1999. CSM is a participatory monitoring activity to enable the communities identifu strengths and weaknesses in CDTI implementation that need to be addressed, and to strengthen community participation and enhance ownership. CSM need to be undertaken annually in each - di* JAF 9.5 Page 15 community. A facilitator's guide on CSM in French and English language has been made available to NOTFs in 14 countries. However, the national Task forces for Onchocerciasis Control have been slow in upscaling CSM. ln the reporting period, CSM took place in more than 600 communities in Nigeri4 and Uganda but a higher number was expected to have begun with this activity. The management of APOC plans to release a user-friendly version of the guide by December 2003 and to conduct country workshops on CSM in 2004 to encourage rapid introduction in other countries. Lessons on CSMfrom Cross River, Kaduna, Adamaua and Borno state CDTI projects The results of CSM carried out by four projects in Nigeria have highlighted both the benefits and challenges of CSM and point to local measures to address them: . Following the CSM exercise, communities took appropriate actions to deal with low therapeutic coverage resulting from absentees and refusals. Community method of dealing with the challenges included imposition of fines for defaulters and appropriate decisions on period of treatment and census update; . Monitors report highlighted the lack of adequate support for CDDs and some communities have taken measures to address issues relating to welfare of CDDs and selection of more CDDs. A review of 2002 implementation of CSM in these states showed that lack of adequate skill by Front Line Health Staff (FLHS) to facilitate CSM was also a handicap to promotion of the exercise. Training was organized to properly orientate the health staffon concept and procedure of CSM. These lessons will be applied in other APOC projects in the coming year. 2.6 Operational reaearch (OR) proposals APOC Management is set to support action oriented field operational research as a way of responding to critical issues that arise in the process of implementing CDTI. In the period under review, 6 operational research proposals were reviewed by TCC and 4 were approved. In addition, three (3) operations research studies each with a budget not exceeding US$5,000 were approved under Director's Initiative Grant (DIG). The following are proposals approved in the reporting period and for which funds are to be released as soon the reviewers' comments are appropriately addressed: (i) Relation between attrition rates of Community-Directed Distributors (CDDs) and effectiveness and sustainability of CDTI in Kogi State CDTI Project (Nigeria). (ii) Investigation of factors, which determine treatment-seeking behaviour in CDTI programmes (Uganda). (iii) Determination of success and failure of the CDTI programme in Imo/Abia States (Nigeria). (iv) Evaluation of the impact of the strike action by PHC workers on CDTI implementation (N igeria). 3. ACTTVTTIES OF THE TECHNTCAL CONSULTATTVE COMMITTEE (TCC) 3.1 Membership of TGC Three new members have joined the Committee during the period following their appointment by the Director General of WHO as full members of the TCC for a period of 3 years. One more expert is expected to be appointed in the near future in order to bring the total membership to 12 in accordance with the Phase II and the Phasing out Period Programme Document. 3.2 Role and Function of TCC The TCC continued to provide technical guidance to APOC management by vefting new CDTI projects and research proposals; reviewing projects' annual technical reports and providing technical advice; and making follow-up on technical matters related to implementation of APOC activities. JAF 9.5 Page 16 3.3 Highlights of TCC Achievements During their 15'h and l6th sessions the Committee reviewed a total of 66 annual technical reports, 2 national plans, 24 new CDTI project proposals and 6 research proposals. TCC paid special attention to several issues critical to program implementation and sustainability such as MACROFIL, training in data management and Geographical Information System (GIS), study on cost per treatment estimates, RAPLOA and environmental risk mapping for loaisis, assessment of the sustainability of CDTI projects and the development of sustainability plans. Other issues included independent monitoring, vector elimination activities, financial management of APOC funded projects, and a new format for CDTI projects' annual technical reports. At the recommendation of the Committee, TCC members undertook missions to the Democratic Republic of Congo (lg'h-z3'd May) and Ethiopia 116th-lgthJuly) to advise the respective NOTFs on CDTI implementation issues and to assist them to revise project proposals as appropriate. Both missions were successfully completed and the issues raised by TCC such as delimiting the project areas basing on the updated REMO maps, refining REMO maps where applicable and provision of adequate medical supervision for case management in areas of co-endemicity of onchocerciasis and loiasis. The TCC addressed the problem of lack of NGDO partners faced by the respective NOTFs. Eight members of the TCC had participated in evaluation of CDTI Projects for sustainability. This rich experience has enabled TCC members to further appreciate the operational realities, strengths and weaknesses of implementing CDTI in APOC countries with varied health systems. This hands-on encounter with this important evaluation exercise has enhanced TCC members' understanding of the implementation challenges faced by the countries and by APOC management. 4. VECTOR ELIMINATION Four vector elimination projects were approved during the Phase I (1996-2001) of the APOC Programme: Bioko Island (Equatorial Guinea), Itwara and Mpamba-Nkusi (Uganda) and Tukuyu (Tanzania). In ltwara, Mpamba-Nkusi and Tukuyu ground larviciding is the only control strategy used while in Bioko Island, in 2003, aerial spraying was combined to ground larviciding. 4.1 Bioko, Equatoria! Guinea The island of Bioko is part of territory of Equatorial Guinea. It is located in the Gulf of Guinea, offthe coast of Cameroon und Gabon. It is a mass of earth volcanic origin with a surface area of 2,107 kni (72 km long and 35 km wide). The climate is of equatorial type, with two seasons (dry and wet). The island of Bioko belongs to the tropical forest belt. About 40o/o of the surface is inaccessible by land due to the vegetation. The hydrological network is made up of smalldischarge rivers (0.01 to 5 m'/s), however in thi south the discharge could be greater (5-30 m3/s). The vector of onchocerciasis is Simulium yahense Bioko form. The meteorological conditions severely impede the movement of black lles ,,om rne conunenr rowaros rne Table 2 : External support to the NorF of Equatorial Guinea island; in addition it improbable to have black flies coming from the North or West because this will be against the dominant winds. All above shows the degree of isolation of Bioko onchocerciasis focus. The impact of ground larviciding (initiated in 2001) on pre- imaginal vector population was encouraging. However, evidence showed that vector elimination through Institution Area ofsupport Expert Water Research Institute, Accra/Ghana Environmental impact assessment Dr. Kofti Abban Special intervention Zones(sz) Aerial larviciding Mr. Ake Assi Institut pour la Recherche au Developpement (lRD), Paris/France Post treatment evaluation Dr.B. Philippon Coordination team Ouagadougou /Burkina Faso Aerial & ground larviciding, pre & post entomological surveillance Prof. T. Soungalo, Mr. T. Barro, Mr S. Coulibaly, Mr. A. Diallo Catchins points in the Northern Bioko Island Catching points in Southern Bioko Island Sampaka Barleycorn Musola Balacha Riaba Ureca Moaba Osa 2002 20032003 2002 2003 2002 2003 2002 2003 2002 2003 2003 2003 January 654 30 906 l 503 3,084 4,520 2,260 6,483 6,735 t2,033 5,850 10,920 10,958 February 340 8 780 r 598 3,615 3,278 3,030 4,403 4,360 9,017 3,480 t2,195 6,270 March 593 0 1,013 r8 r,545 198 4,074 73 4,240 1,770 80 234 40 April 702 0 1,980 33 I, 155 65 2,115 0 3,540 32 6 0 0 May 480 0 t,&3 l5 840 0 2.168 0 4.140 0 0 0 0 June 0 9 0 0 0 0 0 0 July 0 5l 0 0 6 0 0 6 August 0 405 150 0 0 0 0 0 JAF 9.5 Page 17 ground larviciding cannot be achieved because of inaccessibility of some rivers mainly in the south of the island. Based on this fact, a decision was made to complete vector elimination in Bioko Island through aerial larviciding. From May 2002, the Management of APOC set up a coordination team (table 2) to assist the National Onchocerciasis Task Force (NOTF) of Equatorial Guinea. From September 2002 the coordination team supported the NOTF in improving data collection on fly catching, dissection, river prospection, preparation of aerial larviciding. Large scale aerial spraying was launched in February 2003. This first aerial campaign in the history of APOC Programme revealed that vector elimination is feasible in Bioko. Post treatment entomological surveillance is on going (table 3). A second aerial larviciding in 2004 may free Bioko Island from S.yahense. rate in 2002 and 2003 in Bioko Island * Larviciding started in February 2003 4.2 ltwara focus, Uganda The Northern onchocerciasis focus of Kabarole district is mainly located around the Itwara forest reserve. The main focus is not completely separated from the two smaller secondary foci on the Siisa and Aswa river system further east, Simulium neovei is the only vector. The focus covers approximately 600 km2 that now lies in the districts of Kyenjojo and Kabarole. River prospections were conducted through crab trapping and examination of S. neavei immature stages in Itwara focus and the two sub foci of Siisa and Aswa. The results of the crab collection and examination reveal that Itwara main focus still maintains the vector free status over 6 years. Positive breeding sites were registered in July 2002 in the sub foci of Siisa and Aswa that were now cleared after three treatment cycles. Table 4: Adult S. neavei catches in Itwara focus, Kabarole, Uganda in2002 Catching sites Month Kiiure Soshi Siisa fourist Andrewrs January 0 0 0 0 0 February 0 0 0 0 0 March 0 0 0 0 0 April 0 0 0 0 0 May 0 0 0 0 0 Iune 0 0 0 0 0 luly 0 0 0 0 0 August 0 0 0 0 0 September 0 0 0 0 0 October 0 0 0 0 0 November 0 0 0 0 0 December 0 0 0 0 0 Total 0 0 0 0 0 catching site in Aswa sub Table 6: Summary of Crab collection and examination in ltwara focu focus fierce biting of S. in Kabarole district, January to December 2002 JAF 9.5 Page 18 No S. neavei has been caught during the period under review (table 4); consequently adult fly catching had been suspended in most of the sites leaving only three operational sites in Siisa and Aswa Sub foci. At one of the damnosum has been reported. An attempt has been made to dissect the flies caught to verifo their vector competence and infection status. The results of S. damnosum fly dissection (table 5) show that S. damnosum are not infected with onchocerca volvulus parasite. Further dissection will continue to rule out the threat of this species on the elimination effort. Activities are closely monitored in Siisa and Aswa sub foci on monthly basis to avoid re-infestation while entomological surveillance is conducted quarterly in the vector free ltwara focus (table 6). 4.3 Mpamba-Nkusifocus,Uganda The Mpamba-Nkusi focus is a small focus of not more than 300 km2. It is located 20 Km northeast of the ltwara Table 5: Results of dissections of f,3!ry from Tourist catching site in Aswa sub focus, Kabarole, District, Uganda' 2002 number of flies number of parous infected with Period Caught Dissected Parous Zo Pdrous LttLztL3 LIILz L3 all L3 head 26-Aue-02 20 20 7 35 0 0 0 0 I -Oct-02 55 54 9 l7 0 0 0 0 2-Oct-02 75 75 6 8 0 0 0 0 8-Oct-02 288 288 48 t7 0 0 0 0 Total 438 437 70 l6 0 0 0 0 Number of crabs Total number of Site Caught Positive % positive Larvae Pupae Cases ltwara main focus l 330 0 0 0 0 0 Siisa sub focus l517 4 0 4 I I Aswa sub focus 2813 3t) 13 939 178 397 Total s660 377 7 943 179 398 Fis. 14: Monthly transmission rate, Sioni catching point before and after treatment, Mpamba-Nkusi focus bordering the Bugoma forest reserve. Feasibility studies on vector ,o elimination commenced in 1999. Very ,E productive breeding sites of S. neavei !{ were found on Mpamba River and its ! tributaries, a southern tributary of Nkusi i-: (Nyabugando sub focus) and a stretch of i'" Nkusi before it enters Lake Albert. i " Mapping in Nyabugando sub focus was I o completed in October 2002. T\e focus is { sufficiently isolated and access to most a rivers is easy. The first treatments of o Mpamba river systems and lower Nkusi were carried out in June and August 2002 .T c I a il IT ta n ! Iti! /././,.'/Jrun,//fll with encouraging results (figures 14, 15 & l6). Later, treatments were extended to cover the whole focus. The personnel involved in the vector elimination project is presented in table 7. '{ ,.r \ 71 JAF 9.5 Page 19 Fis. 15: Monthly transmission rate, Rulembo catching point before and after treatment, Mpamba-Nkusi II I I - a u 6 - I I i ///t,tttt/"ft/ EU15: Monthly transmission rate, Nyabugando catching site before and after treatment, Mpamba-Nkusi 0 t0 la - a a o a a s a a It E a -!{ftl,f,f-/lffn 4.4 Tukuyu focus, Tanzania Simulium damnosum Kiwira form is the vector of onchocerciasis in Tukuyu focus. The vector elimination project of Tukuyu is the last of the four vector elimination projects funded by APOC Trust Funds to initiate large-scale treatment. Extensive ground larviciding campaign is scheduled from July to December 2003. Preparation for this important exercise is processing well: Eg!]: Monthly biting rate in Tukuyu focus T z ln E xm zm am t5dl lE) 5qt odlll IwBl o.cnl Jen.ll2 F.b.(P l.r{n APr.02 I.yIl2 Jun02 Jul{P Aut.O2 s.p02 I The required quantity of temephos is already in place in the project site; Equipment and supplies are made available to the project;I I Il=M8R'1 \ I }!!q/: Personnel of vector elimination proiects in Uganda t=ffi-l l..rnr-l I I -d to ra National level I Operational level W.W.Onapa Mr. T. Lakwo Mr. A. Mr. J. Oryema Mr. G. Barisigara Mr. F. Tweigomwe Mr. H. Tusingwire Ms. C. Adikinyi Mr. E. Balaba Mr. V. Kaserebe Mr. D. Hazimana JAF 9.5 Page20 . Investigation ofthe degree ofisolation ofTukuyu focus from re-invasion has been conducted; . Environmental impact Fig. 18: Transmission potential in Tukuyu focus assessment studies Prior to treatment have been completed. Figures 17 & 18 show monthly biting rate and the transmission potential in Tukuyu focus from October 2001 to September 2002. The expertise involved in the implementation of this project is presented in table 8. 100 t5t) a(n 350 XD 250 zn t50 tm 50 80 I I e60 t I .i Ero @TTP +LYlm p..oB !I E a m 0 Od{f iwl)t D.c{l J.nlll Fobltrl I..{n Arr& ItyltrI Junlp Julln AUgIP SeP(n Table 8: Expertise involved in the implementation of vector elimination in Tukuyu focus Dr. Koffi Abban, Mr. J.S. AmakYe, G. Amegbe. M. K. Abakah Ghana impaclEnvironmental assessment studies Water Research Institute Prof. Traord Soungalo, Mr. Barro Tdld, Mr. Siaka Coulibaly, Mr. Bendd Kissi Ground larviciding operationsAPOC Burkina Faso Institute I-ocation Domain of suoport Team comDosition Bernhaut Nocht Institute of Trooical Medicine Germany Isolation of Tukuyu focus Cytotaxonomic identification Dr. Krueger National Team Tanzania Ground larviciding operations Entomological and epidemiological surveillance Dr. Bertha Maegga, Dr. Bilali Kabula, Mr Akili k. Kalinga, Mr. Karoli D. Malley, Mr. Clement Mweya, Mr. Addow Kibweja, Mr. Adam Mwaikonyole, Mr. Donald Charle, Mr. Peter Abilu, Mr. Beatus Kitwange, Mr. Adeni Mwakasitu JAF 9.5 Page2l 5. GEOGRAPHICAL INFORMATION SYSTEM: MAPPING OF THE DISEASE In 2003, the African Programme for Onchocerciasis Control (APOC) supported the National onchocerciasis task forces to: . Implement Rapid Epidemiological Mapping of Onchocerciasis (REMO) in countries in conflict situation: Angola, Burundi, Democratic Republic of Congo, and Sudan; . Refine the REMO map of Cameroon, Congo, Ethiopia, and Nigeria. 5.1 Rapid epidemiological mapping of onchocerciasis The REMO is the entry point for Community-directed treatment with ivermectin (CDTI) activities in countries. The National Onchocerciasis Task Forces, by mapping the distribution of the disease in war-torn or in unsecured areas (with land mines), have shown that ivermectin treatment in remote hyper and meso endemic communities is feasible despite the challenges. 5.1.1 Angola The country is located in the western region of Southern Africa. It has an estimated population of 15,224,151 inhabitants (in 2003) living in an area of 1,246,700 km2 (density of l2 inhabitants/km2). It is divided in l8 provinces composed by 163 districts (or municipios). Angola experienced 22 years of civil war that delayed the implementation of rapid epidemiological mapping of onchocerciasis (REMO). The African Programme for Onchocerciasis Control (APOC) initiated the first REMO exercise in the country in early 2002. Due to security reasons, only 275 out of 535 villages sampled were covered in 9 provinces. In 2003, the NOTF extended the REMO exercise to 9 provinces that were not included by the previous exercises. However, due to land mines and broken bridges some villages were inaccessible and the REMO survey could not be carried out in 278 villages. Figure l9 shows the results of the REMO exercises in Angola. 5.1.2 Sudan Sudan is the largest country of Africa with approximately 2 505 800 km2 out of which 30%o is desert. The National Onchocerciasis Task Force (NOTF) carried out a REMO exercise in Sudan in 1997 and 2000. The data collected by the NOTF were limited to the Northern Sector; in the Southern Sector only 7 villages were covered. In 2003, the Southern Sector Onchocerciasis Task Force (SSOTF) of Sudan in collaboration with APOC Management extended the rapid epidemiological mapping of onchocerciasis to areas in Southern Sudan. In 194 villages, the prevalence of onchocerciasis was determined based on the presence of palpable nodule. The data collected were integrated into the geographical information system (GIS) to define the CDTI areas (figure 20\. The partial REMO/CDTI results revealed that 4,099,760 persons are at risk of onchocerciasis in Southem Sudan. Actions are being taken by the SSOTF to complete REMO in Southern Sudan and to elaborate CDTI project proposals to cover the population in need of ivermectin treatment. The project proposals will be reviewed by the TCC in September 2003. 5.1.3 Democratic Reoublic of Congo The National Onchocerciasis Task Force (NOTF) of DRC developed an innovative approach for implementing the REMO despite on going conflict in the country. At the national level, external advisors had trained a core team in the REMO methods. The core team formed two groups which trained both the provincial and district onchocerciasis teams on REMO in their respective districts. This approach enabled the NOTF to conduct REMO in 26 out of 30 remaining districts. The exercise have either been completed or partially completed in the 26 dishicts. The districts yet to be covered include Maniema, Sud-Kivu, Ituri and Tshopo. An update of the REMO results in the Democratic Republic of Congo is presented in figure 21. JAF 9.5 Page22 Eg. 19, Rapid epidemiological mapping of onchocerciasis @EMO) results in Angola as at June 2003 Fie.20 Rapid epidemiological mapping of onchocerciasis @EMO) results in Sudan as at June 2003 _tlcdnd.lT- Lcgcnd Ir* !ncon ! o"r"rrcon rcfrc ffi nwop,a4 KM I------l0 1m2m Lagend /fi1 t.,ru*o RrfD ! conrrr"rr-o ! nocon- ffii norop*3 KMr--l0 200 @ JAF 9.5 Page23 Fiq.21: Rapid epidemiological mapping of onchocerciasis (REMO) results in DRC as at June 2003 5.1.4 Burundi The country comprises of l5 provinces. In 2002,the NOTF of Burundi carried out a nation- wide rapid epidemiological mapping of onchocerciasis. Unfortunately because of security reasons, four provinces were not surveyed. In 2003, the NOTF decided to complete the REMO exercise in the zones where additional data are needed to determine areas for ivermectin mass distribution. Planning of the completion of the REMO map of Burundi is underway as this report is being written. The results of the REMO exercise will be repofted to the Joint Action Forum. 5.2 Refinement of existing REMO ,app In 2003, two countries (Nigeria and Cameroon) finalized their REMO maps. In Congo Brazzaville and Ethiopia the NOTFs are carrying out refinement exercises of the REMO/CDTI maps. As foreseen in the Programme Document for Phase II (2002-2007) and the Phasing:out period (2008-20 I 0), the NOTFs are likely to conclude REMO in all the participating countries in 2005. From the available REMO results (figure 22\, the ultimate treatment goal (UTG) of APOC Programme is estimated at 86,3 I I ,329 persons as at July 2003 (table 9). Legend I r"rrrnr""r"o ! r*. cnn R.trrc Driilb CDTI KM r-l 0 100 200 Ea$-Uele \ Kwilu Sanfuru Haut-Lomami Lualabl JAF 9.5 Page24 Table 9: Population at risk of onchocerciasis and estimated ultimate treatment goal (UTG) by countra as at July 2003 l05 ll 6t7 126 J1.002,I I I 1,032,476r.192,989 1,229,138 l53,744,264 4,309,7324,457,457 5,1 30,633 767,804 I914,052 706,758841,379 545,397 I649,283 487,664580,553 2l19,169 122,052141,867 145,300 2019,408,614 21,067,65321,915,017 25,080,539 75,599 I99,999 68,983I 82,122 8,216,966 98.474,337 9,782,103 7,118,443 I0 00 0 00 0 00 l,l19,835 31,216,462 1,333,137 1,021,828 I634,653 705,693755,540 840,1 I I 0 00 00 30,521,71333.544,266 36,335,373 28,177,183 00 00 0 10,3 I I ,834 6I 1,505,148 8,488,72910,105,630 2,290,851 72.417,494 2,727,203 2,030,695 4I,913,685 2,141,8392,159,148 2,549,808 86J11J29 107101,980,737 76,439,90590,999,887 Population at risk Ultimate treatment goal Forecasted CDTI ProiectsCountry 2007 2010 2007 2010 Ansola 3.081,885 Burundi Cameroon CAR Chad Congo DRC Ethiopia Gabon Kenya Liberia Malawi Mozambique Niseria 27 Rwanda Sudan Tanzania Uganda TOTAL EH E' E :g 3 Et! H 6 3 o o a-l- {i,? =o u o o o- ? ,i G ol- G -F cI o EEHfi'fi$ I**IN ! 6 a ra) ( o. C-l ?$ tt N l- GI anc oq) l- o C) U o Cr E o thq) L th o 6l c)trcIo I o o a0 aq cl 6lI a0 o o o) oq) q 6lil oit 1I al frl t g Ef T ! E 6 JAF 9.5 Page26 5.3 Risk assessment of severe adverse events To prevent severe adverse events (SAEs) following mass distribution of ivermectin in areas where onchocerciasis and loiasis are co-endemic, APOC has funded studies to assess the prevalence of loiasis in CDTI areas. Rapid assessment of loa loa (RAPLOA) was therefore carried out in the Northwest province and the Nanga Eboko health district in Cameroon. The results presented in table l0 show that22oh of the villages in the Northwest province and 96%o of the villages in Nanga Eboko health districts are at risk of SAE. Figures 23 and 24 show the spatial distribution of the villages surveyed for loa loa in 2003. p!!g!!: Number of villages by level of risk for SAE in Cameroon' 2003 Level of risk for SAE No risk Low risk High risk Prevalence of history of Number of villages eye worm Northwest Nanga Eboko (restricted definition) province health district 0 - 19% 19 (20o/o) 0 (0%) 20 -3e% s6 (s8%) 3 (4%) 40 - se% ts (ts%) 3e (48%) 60 - 100% 7 (7%) 3e (48%) Fis.23:Distribution of risk for SAE in the Northwest province of Cameroon + ,+ + + + + + ++ + + a + + + + + + KU + . Tub. + aJ.kir i + + B rli atibo a E] , w abrr RAPLOA rcsults Nord-wcst Provincc, Camcroon * Parronr rcpordng ayaworm . 0 - tg'l (Nc rlsl) + 20 -39't (Low rlsk) + '10 -59* (Hlgh rl.k) + 60 - roo$ (Y.ry Hagh rirk) Rlv.r! Lek.. Arondiaaanrantt ProYincal H O/iAP O lAprl Very high risk t JAF 9.5 Page27 Fie.24:. Distribution of risk for SAE in the Nanga Eboko health district of Cameroon 6. Evaluation of the sustainability of CDT! projects and post-APOC plans 6.1 Assessment of the sustainability of GDTI Ln2002, APOC management began the evaluation of CDTI projects to assess their ability to continue functioning optimally after the withdrawal of APOC support. In the reporting period, projects in their 5th and 3'd year of CDTI implementation were assessed by independent teams. The evaluation teams not only assessed the likelihood of the projects achieving sustainability but they assisted the authorities to address weaknesses and develop sustainability plans. The evaluations have re-awakened both project management and NOTFs to examine their capability to operate without APOC Trust Funds and decide on mechanisms that must be established to ensure the sustainability of CDTI projects, especially due to the need for continued treatment with ivermectin over a long period of time in the absence of a macrofilaricide. During this reporting period a total of l7 CDTI projects were evaluated: 6 of them are in their 3'd year and I I were in their 5th year. The first part of the table I I shows projects that were evaluated before the current reporting period. Such projects are included in the table in order to show their progress as regards the post-APOC planning. For sustainability assessments, this report will concentrate on the projects listed in Part II ofthe table. Essentially these evaluations were conducted in different geographical locations depending on their administrative set up. Therefore, the number of projects evaluated does not necessarily correspond to the number of reports obtained. More so the number of post-APOC plans in each project depends on the number of administrative areas that have a planning and resource allocdion function. The details of the process have been outlined in this report (table I I ). + + + + + ii + ++ i ++ + + + + --J r ++ RAPLOA rcBultE ",} I 0 - +. ArfondlssenEils P?bYlncos I L-' 00 tt (v6q, rl8fi) * Pelsom rep6f][ rye rorm o 0-l9f GoriC() !t (Lor rbh) tt (Hl0h rl3k) ^yo8 JAF 9.5 Page28 6.2 Development of sustainability plans As a follow-up of the assessments for sustainability of CDTI projects, APOC management was preoccupied with the all-important process of developing sustainability plans for the projects that were evaluated since 2002 (tables I I & l2). Most of the technical missions therefore concentrated on this vital aspect. The 5'h year projects prepare and submit post-APOC sustainability plans together with comprehensive health plans of either the state/district implementing the projects. A total of five (5) post-APOC sustainability plans have been received during this reporting period. The CDTI projects that submitted plans are Mahenge (Tanzania), Taraba and Kogi (Nigeria), South West I (Cameroon) and Uganda Phase I CDTI. In Uganda, special workshops of the NOTFAJganda were held in August, 2002 to plan for the sustainability of CDTI in all the endemic districts. The workshops involved political, administrative and technical leadership of the districts concerned and highly placed officials of the Ministry of Health. The key recommendation of these workshops was that CDTI should be fully integrated in the PHC system and implementation of activities should be devolved to sub county levels. A meeting was organised by the NOTF/IvIalawi and the participants included the District Health Management Teams of the 2 districts and the NGDO staff. The meeting identified issues that were constraining the attainment of sustainability. Technical assistance was provided to the NOTFs of Malawi and Tanzania on the process of development of post-APOC sustainability plan for fifth year CDTI projects. In Nigeria, four advocacy missions to Kaduna, Taraba, Kogi and Cross River state governments have been held to advocate for stronger political and financial commitments in ensuring the sustainability of CDTI. The missions facilitated workshops to develop post APOC plans for fifth year projects. In summary, the missiors on sustainability mentioned above were intended to facilitate the complex process of preparing the exit of APOC. There has been tremendous learning, both of APOC management staff and the various NOTFs. Important lessons have been drawn from these exerciss and steps to ameliorate situations are on going. Notably, it is a challenging task that calls for the commitment of all partners. As a way of facilitating the process, APOC _management prepared guidelines for developing sustainability plans by CDTI projects in their 3'd and 5'n year of implementation. NOTFs are proactively increasing their advocacy role to participating governments so they can commit themselves to supporting CDTI. NOTFs must also be braced for a new role of spearheading post- APOC planning in each country and to monitor progress in that area. JAF 9.5 Page29 Eble--Ll: Projects evaluated in 2002-2fi)3 (as at July 2003) : Summary of projects evaluated in2002-2003 (as at July 2003) 7. OTHER ACTIVITIES OF APOC MANAGEMENT 7.1 Status of financing first, second, third, fourth and fifth year proiects During the reporting period, APOC Management reviewed l4l project documents including 78 budget proposals. Sixty-four (64) Letters of Agreement (LA) were prepared and processed. The first installments of funds were released to enable the launching of 6 projects approved for the first year of funding including 5 CDTI projects (Nigeria: (l), D.R. Congo: (l), Cameroon (l), Tanzania (l), Angola (l)) and I project for strengthening the NOTF Secretariat office in Angola. Country CDTI Project # Administrrtive divisions # Local euthorities sampled Reports Status of Post AFOC plans PART I: EVALUATED BEFORE SEPTEMBER 2002 Nigeria Kaduna Kaduna 3 LGAs I Yet to be elaborated Nieeria Cross River Cross River 3 LGAs I Yet to be elaborated Nigeria Taraba Taraba 3 LGAs I - 12 LGA submitted and under review Tanzania Mahenge Ulanga Kilombcro 2 districts I 2 disrict plans completed and approved Uganda Phase I Kasese, Hoim4 Masindi, Kisoro 4 districts 4 4 dishict plans submitted and under review Malawi Thyolo and Mwanza Thyolo, Mwanza 2 districts I 2 district plans submitted and under review PART II: EVALUATED DURING PERIOD OF REPORTING Nigeria Kogi Kogi 3 LGAs I 2l submitted and under review Sudan Northcrn Sector Khartoum, Nahr-Nil, Southem Darfur, Eastern Balr el Ghazal, Westem Bahr El Ghazal, Bahr- el-Jcbel 5 Provinces I Yet to be elaborated Malawi Malawi Extension Blantyre, Chikwawa, Chiradzulu Mulanie Phalombe 4 districts I Yet to be elaborated Tanzania Tanga Korogwg Muheza, Lushoto 3 Districts I Yet to be elaborated Niseria Bauchi Bauchi 3 LGAs I Yet to be elaborated Niseria Gombe Gombe 3 LGAs I Yet to be elaborated Nieeria Yobe Yobc 3 LGAs I Yet to be elaborated Nigeria Platead Nassarawa Plateau, Nassarawa 6 LGAs 2 Yet to be elaboratcd Cameroon Adamaoua Adamaoua 3 health district I Yet to be elaborated Camcroon South West II South West II 3 health districts I Yet to be elaborated Cameroon Cenfe 3 Centre 3 3 health districts I Yet to be elaborated Cameroon West West 3 health districs I Yet to be elaborated Cameroon Norttr North 3 health districts I Yet to be elaborated Cameroon South West I South West I 3 health Districts I t health district plans submitted and under review Chad Chad Logone occidental, Logone oriental, Mayo Kebbi, Moyen Chari, Tandjile 5 Health Districts I Yet to be elaborated 7 2t 42 70 25 CDTI projects epprovd Implemented Evaluated Reports received SUSTAINABILITY PLANS Completed and approved Submitted and under review Yet to be elaborated 78 65 2t 24 I 8 l5 JAF 9.5 Page 30 7.2 Financial Management of CDTI proiects 7.2.1 Submission of financial returns to APOC from the projects As stated in the letters of Agreement signed between the APOC Management and the National Onchocerciasis Task Forces, the monthly expenditure returns should be submitted regularly by the on- going projects receiving funds from APOC. Unfortunately many projects are still experiencing more than 3 months delays and the Management of APOC continues to work towards solving the problem. The submission of the expenditure returns have enabled the Management to veriff that funds are being utilized in accordance with the approved budget. Few deviations were discovered and feedback was sent to the concerned projects for reimbursement and/or immediate corrections. Some visits in the field were organizedto cross check the information received through the expenditure reports foraccuracy. The checking visits were conducted in Angola, Cameroon, CongolBrazzaville, Nigeria, Tanzania and Uganda in the reporting period. 8. IN.COUNTRY CAPACITY BUILDING Capacity building has concentrated on strengthening the capability of APOC countries to assess their progress towards establishing sustainable CDTI projects and maintaining viable information databases. 8.1 Training in data management In order to improve the quality and the use of the data generated by CDTI projects, the Management of APOC conducted two training sessions in data Management and geographical information (GIS). One of the sessions was held in Nigeria (Lagos) and the second in Democratic Republic of Congo (Kinshasa). Of the 46 trainees,2 were from CongolBrazzaville 2l from D.R. Congo, 3 from Ethiopia, 2 from Gabon and 18 from Nigeria. The training sessions targeted CDTI project coordinators, supervisors and data managers, who were trained in the use of Healthmapper (software developed by WHO/CDS/Healthmap). At the end of the training sessions the participants standardized the indicators for CDTI implementation, the level (communities, districts, health zones) of collecting and analyzingthe cDTI activities data' Tabre 13: profire of trainees on assessment of the sustainability of CDTI projects in 2002-2003 8.2 Building capacity for assessment of the sustainability of GDT! proiects In establishing the process of evaluating 3'd and 5th year CDTI projects, APOC has defined new critical areas, paved the way for CDTI and other community health interventions. Through this exercise APOC has built capacity at four levels (national, District/State, FLHF, Community) in the countries where projects are located. In the period under review (as at June 2003) the Programme has trained 57 persons on the guidelines and instruments for assessing the sustainability of CDTI projects. A strong feature ofthe evaluation Discipline Number trained AROC Country /partner MEDICINE Dermatology ophthalmology, Public Health, Community Health 24 Tanzania, South Africa, Carneroon, Uganda, Nigeria, CAR, DRC, Sudan, Congo Brazzaville, HKI ECONOMY Health Economists 4 Nigeria" Uganda, Sudan, Cameroon, Tanzania, CAR BEHAVIOURAL SCIENCE IEC specialist, anthropologists 5 Cameroon, Nigeria, Tanzania MANAGEMENT Proiect manageni 4 Cameroon, Nigeri4 Chad, Tanzania, SSI PARASITOLOGY Parasitologist 7 Uganda, Nigeria, Cameroon SOCIAL SCIENCE t3 Cha4 Nigeric Uganda, Malawi, Sudan Cameroon JAF 9.5 Page 31 teams has been the rich mix of relevant disciplines of the evaluation teams. As shown in table 13, the teams are thoroughly international. Evaluators are drawn from academic and research institutions, national health services, UN Agencies. Both international and national NGDOs participate in the evaluation. 8.3 Missions, Country support visits and specialvisits 8.3.1 Support visits/missions by Management staff : overview During the period, the APOC Management staff, often in joint mission with the Technical Consultative Commiftee (TCC) members, the Non Governmental Development Organizations (NGDOs) Coordination Group, Mectizan Donation Program, other external experts, made a total of twelve (12) support visits to the National Onchocerciasis Task Forces (NOTFs) in 9 countries: Democratic Republic of Congo, Congo, Angola, Equatorial Guinea, Sudan, Cameroon, Malawi, Tanzania and Nigeria. The objectives of these visits included facilitating CDTI implementation and vector elimination activities, sustainability evaluation of CDTI Projects, advocating for stronger partnership, collaboration and political commitment to CDTI activities, training in financial accounting, data management and Geographic Information System, providing technical advice and assistance in management and implementation of projects, facilitating communicatior, building capacity in IEC, sensitisation and mobilization. 8.3.2 Missions to donors Together with the fiscal agent, the Onchocerciasis Unit of the World Bank, the Director of APOC went on joint missions for resource mobilization. In the reporting period, eleven (11) donor countries and institutions were visited. These visits were opportunities to inform donors on progress in Programme activities and solicit for even stronger commitment to APOC. 8.3.3 Support missions to countries 8.3.3.1 Mission to Angola In the third quarter of 2002, a support mission to Angola assisted the NOTF/Angola to finalize the National plan and formulate a proposal for Community-directed treatment with ivermectin (Lunda Norte & Lunda Sul). In May 2003, six members of the National Onchocerciasis Task Force (NOTF) of Angola were trained in financial management and budgeting according to WHO regulations. The trainees were from the National Secretariat (3) and the CDTI project of Lunda Norte and Lunda Sul (3). A review and analysis of the REMO data of Angola was carried out in the same period. From the results of the analysis in geographical information system (GIS), five new CDTI project areas were identified and the NOTF was assisted to develop two CDTI project proposals for Cabinda and Moxico. 8.3.3.2 Mission to Demouatic Republic of Congo (DRC) At the invitation of the Ministry of Health (MOH) of Democratic Republic of Congo (DRC), the Director undertook a mission to DRC in February 2003. The mission provided technical advising to the NOTF on the control of nuisance due to black flies in Inga, and (ii) planning ivermectin mass distribution in Bas Congo where areas are co endemic for onchocerciasis and loasis. 8.3.3.3 Mission to Sudan Twenty-five (25) members of the Southern Sector Onchocerciasis Task Force (SSOTF) were trained in REMO method and field operations. Mapping of onchocerciasis in Southern Sudan was O JAF 9.5 Page32 largely implemented in allthe areas accessible to SSOTF. The results of the REMO enable the SSOTF to plan the elaboration of five CDTI project proposals. 8.3.3.4 Mission to Tanzania The Mahenge CDTI Project being of the first evaluated for sustainability, The Management of APOC undertook a mission toTanzania in order to address the issues raised by the evaluators and help the NOTF/Tanzania prepare the first post-APOC sustainability plan. 8.3.4 Support visits by Temporary Advisors and Consultants During the period under reporting 57 Temporary Advisers were engaged to assist countries in the evaluation of projects and developing sustainability (post-APOC) plan; 9 technical advising on CDTI implementation; and 12 on advocacy. These advisers are drawn from a rich mix of scientists, project managers and national coordinators within the APOC countries. Consequently, APOC has built a viable technical expertise that is capable of evaluating CDTI projects by use of the guidelines and instruments developed. This process has also favored the cross-fertilization of ideas across projects, countries and disciplines. 8.4 Major meetings and workshops 8.4.1 Statutory meetings In the period under review, the director participated in four CSA meetings. These were: the 99th session in Washington; the l00th session in Luxembourg; the l0l't and 102 sessions in Ouagadougou. These meetings discussed among others issues the use of ComDT in other health development programs; preparations for the donors conference of October 2002 in Luxembourg; preparations for JAF 8, JPC 23 and the joint JAF-JPC sessions; the new era after the closure of OCP; the rapid development of APOC and the start of the Multi-Disease Surveillance Centre. The l5th and l6'h TCC meetings were held in Ouagadougou to discuss the technical implementation of APOC activities as indicated under " activities of the TCC" in this report. 8.4.2 NGDO Coordination meeting The NGDO Co-ordination Group held its 20th and 2l't meetings in September 2002 and March 2003 respectively. At the 20th meeting in Dar es Salaam, the group was honoured by the presence of the CEO and Senior Vice President of Merck and Co., Inc. lssues discussed included the closure of OCP and the use of CDTI as a vehicle of other health interventions. At the 2l't meeting the Group discussed the rapid expansion planned by APOC during Phase II in a bid to accomplish its mandate by 2010 and the many projects that lacked NGDO support in DRC, Burundi, Cameroon and Ethiopia. 8.4.3 Meeting with CIDA In March 2003, APOC management received a mission from the Canadian Development Agency (CIDA). At this meeting held in Ouagadougou, the CIDA team wanted to know more about the operations of APOC programme including the way CDTI is implemented throughout the APOC countries and the challenges of the Programme. 8.4.4 Impact assessment of APOC operations To assess the impact of APOC operations, the Programme had designed three cross-sectional studies to be implemented at five years interval. The baseline studies initiated in 1998 were concluded in 2000. In March 2003, a planning meeting on the second phase was held in Ouagadougou from March 24th to zgth,2OO3. The meeting composed of four teams to carry out the studies in eight countries (Angola, Cameroon, Democratic Republic of Congo, Ethiopia, Nigeria, Sudan, Tanzania and Uganda) beginning from January 2004. - JAF 9.5 Page 33 Each study team is composed of dermatologists, ophthalmologists, entomologists and social scientists. The hypothesis for the impact assessment studies is that regular ivermectin treatment will: . Reduce severe itching; . Prevent development of onchocercal skin disease or may regress early skin lesions; . Prevent or delay progression of onchocercal eye lesions and blindness and may regress early stages of ocular lesions; . Lead to reduction in vector infectiviU; . Lead to improvement in socio-economic status of the community. 8.4.5 Francophone meeting on SustainabiliB A meeting was held in Ouagadougou from 24'h-28'h February for representatives of the NOTFs, research scientists of 6 APOC countries and coordinators from the Special Intervention Zones (SIZ) of the former OCP. Participants came from Cameroon, Central African Republic, Chad, Congo, Democratic Republic of Congo, Equatorial Guinea, Benin, Guinea Conakry, Mali, Senegal and Togo. The objectives of this meeting were to have a common and clear understanding of the definitions of sustainability, the indicators, the evaluation instruments, and the processes of carrying out evaluation of projects. The meeting therefore reviewed and amended the instruments and guidelines in French and English. A tentative plan for evaluating CDTI projects in the Franco-phone countries was also drawn up. 8.4.6 Workshop on APOC philosophy and CDTI Strategy In June 2003, the APOC management and NOTF/DRC jointly organized a workshop on APOC Philosophy and CDTI strategy. The objectives were to strengthen partnership, have a common understanding of the Philosophy of APOC and the CDTI strategy, discuss special training of health personnel on the management of Serious Adverse Events (SAEs), and the assessments of the sustainability of 5s and 3'd year CDTI projects. Fifty-two participants attended from Burundi, Angola, Congo Brazzaville and the host country, DRC. Eleven (l l) work group (by country or mixed) sessions were held to discuss aspects of the philosophy of APOC, partnership, aspects and critical elements of CDTI including sustainability. Facilitators of the workshop included NOTF members from Cameroon with long-standing and solid experience on the management of Serious Adverse Events. The important role of family members and the health care services were presented and discussed. Given these are countries in conflict situation the feasibility of using commurity-directed approach for other health interventions and maintaining the desired treatment coverage in communities in conflict zones were discussed at lenglh during plenary sessions. Presentations and discussions centered on devolving the responsibilities for the planning and management of ivermectin distribution to communities directly affected by the disease and the health care services, from the first year of CDTI implementation. The limited duration of APOC support also for projects in conflict were discussed. Three project coordinators presented success stories on how they procure and deliver Mectizan to front line health facilities and communities in conflict areas outside the government controlled boundaries. An important challenge to ivermectin distribution programs in the four countries is the co-endemicity of loiasis and onchocerciasis In conclusion, participants agreed to seize every opportunity of the cease-fire to complete Rapid Epidemiological Mapping of Onchocerciasis (REMO) in areas where it has not been completed. JAF 9.5 Page34 9. OVERVIEW OF COLLABORATION WITH OTHER WHO GROUPS AND THE WORLD BANK APOC has continued to benefit from the fruitful collaboration with various WHO groups and the Onchocerciasis Unit of the World Bank Washington during the period under review. 9.1 Collaboration with WHO/AFRO WHO/AFRO has continued to support the Programme. In addition to advocacy in the Africa Region, the WHO offices in l2 APOC countries are assisting administratively by the procurement of Capital Equipment and by taking the appropriate actions to facilitate the entry/ procurement of ivermectin in the endemic countries. The WHO country offices played an important role in the replenishment into the various imprest accounts opened in the country for the CDTI and vector elimination projects and for transferring funds to the partners to cater the in-country ad hoc project activities. The WHO offices also assist in the organization of various workshops and meetings, providing transport to consultants and temporary advisors recruited by APOC to conduct activities such as sustainability studies, monitoring exercises and facilitation of workshops. The budget and finance office of WHO/AFRO has played an important role by providing support to the country offices for the transfer of funds to the project. They assisted also in the training of APOC project financialofficers in the accountability procedures of WHO. 9.2 Collaboration with WHOTHQ During the period under review, the collaboration with WHO/HQ has continued as during the previous years. HQ has provided administrative and financial support in funds transfer, purchase of Capital equipments for the projects and for APOC Headquarters. An internal audit of APOC financial and technical management has been conducted. The auditor from WHO/HQ conducted an audit of a CDTI project (randomly selected) and advised the Management of APOC on how to improve budget control of the projects in the field. 9.3 Gollaboration with WHO/TDR: OPERATIONAL RESEARCH 9.3.1 RESEARCH by Product Research and Development (PRD) WHO/TDR With the closure of the OCP, progress made on MACROFIL and other activities of the WHO/TDR Product Research and Development (PRD) will be reported to the governing body through WHO/APOC Progress report. A detailed presentation will be provided to the JAF9 under the Agenda item 10. The highlights of these activities are presented below WHO/TDR research agenda on onchocerciasis is formulated through consultation with APOC partners based on the needs that emerge from disease control strategy. After the close of OCP, APOC and TDR continued to co-finance the activities of the PRD addressing the needs of APOC. During the period under review, APOC contributed US$570.000.on Drug discovery, Product development (Macrofil, DEC patch test, Ivermectin resistance detection tool) and clinical research on onchocerciasis. 9.3.1.1 Drug Discovery The TDR/PRD has pursued the identification of new lead components (anti-filarial drugs) that would merit more extensive medicinalchemistry and entry into clinical trials. This effort has produced a few very active components in vitro with sufficient efficiency to warrant further progression in vivo analysis. JAF 9.5 Page 35 9.3.1.2 Product development (Moxidectin) PRD, in the reporting period has made remarkable success in the search to identifu additional drug candidate that will act as macrofilaricide or significantly reduces the fecundity of adult O. volvulus. The drug, Moxidectin is a Fort Dodge Animal Health product registered for the treatment of ecto and endo parasites in sheep, cattle and horses (cydectiri) and for the prevention and treatment of canine heartworm (Proheart@). Animal studies (in vitro and in vivo) suggest that moxidectin has superior anti-parasitic activity compared to ivermectin including a cidal effect on the adult worms of O. volvular. Between September 2002 and August 2003, the PDR/TDR designed and coordinated an accelerated development which will likely result in the registration of Moxidectin for the control of onchocerciasis in 2008. Details of this effort will be presented to JAF9 in Canada in December 2003. 9.3.1.3 DEC patch test The need for surveillance to detect out breaks of infection in the onchocerciasis free and in the special intervention zones has become paramount. This surveillance will be extremely beneficial in no distant future to the conffol programmes in the APOC countries. This requires a simple, cheap, non- invasive but highly specific diagnostic test to replace the skin snip method. The DEC patch has found to best fit the required criteria. In the period under review, WHO/TDR working closely with LTS Lohmann Therapy System AG of Germany produced and tested 3 prototypes of different permeation rates with DEC, and concluded arrangements for clinical evaluation (safety & efficacy) one of the three prototypes for field use. These evaluation studies will serve as a basis for regulatory submission and registration of DEC Patch test endemic countries. The current cost estimate is US$O.10 per unit. 9.3.1.4 lvermectin resistance detection tool and clinicol research lvermectin (Mectizan@) impairs the normal functioning of nematode (a parasite) neurons thus reducing this parasite morbidity. It reduces the reproductive capacity of the adult female worrn. Although no resistance to O.volvulus, the causative agent of human onchocerciasis has not been documented; the project on the identification of ivermectin resistance candidate genes has advanced. Analysis of differences in polymorphism between large samples of the untreated and worms exposed to ivermectin have been studied. Studies on sub-optimal response to ivermectin launched in 2001, based on the result of a survey, which revealed individuals with persistent, significant microfilaridermia after multiple treatments with ivermectin, continued during the reporting period. Likewise, progress reports of studies on ivermectin resistance detection tool and sub-optimal response to ivermectin will be presented to the Forum. 9.3.2 Uodate on Onchocerciasis Implementation Research (WHO/TDR) Following consultations with APOC partners, the focus of TDR onchocerciasis implementation research during the year under review explored further delivery strategies for high and sustained treatment coverage in onchocerciasis control. 9.3.2.1 The use of Community-directed treatment approachfor other diseases In the second quarter of 2003, a multi-centre scientific evaluation study on community directed interventions (CDI) and of the effectiveness and sustainability of CDTI with integration of other health care services will commence in six sites in 3 countries, Cameroon, Nigeria, Uganda. The objectives of the study are to determine the effectiveness and efficiency of CDI compared to current systems, the extent to which the CDTI process can be used for the delivery of other health interventions and critical factors that facilitate or hinder achieving integration of interventions. The JAF 9.5 Page36 study design will examine the complexity of integrating CDTI with vitamin A supplementation, ITN, DOTS and home management of malaria. 9.3.2.2 Multi-country study on additional health tasl<s of CDDs During the period under reporting, the multi-country study on additional health tasks of CDDs was completed. The study reported on the experiences of CDDs and what, if any, action needs to be taken to ensure that integration of other activities in CDTI strengthens rather than weakens its effectiveness and sustainability. The findings of this study showed among others: . that 82%o of the CDDs were involved in additional health development activities, mainly in Expanded Programme of Immunization (EPI) {table l4) o additional activities do not constitute an important burden nor affect CDD performance; . most health programmes build on the experiences and structures of CDTI by involving CDDs in their activities; o AlthouBh EPI was found more popular than CDTI among CDDs (table l4), the results of the study suggest that provision of incentives by other programmes does not have a negative influence on CDTI. It was found that communities often take advantage of opportunities of programmes that provide incentives to include CDDs into such programs thereby reward them. @-14: Involvement of CDDs in other health and development activities and the process of their selection Health and development activity No. of CDDs Started activity after becoming CDD Selected for other activifillY Health perconnel Village leeder/ Committee Village meeting EPI, including polio 154 9lo/o 47o/o 32% 2t% Community development proiect 137 690/o 0o/o 53% 4r% Water and sanitation 124 680/o 2o/o 47o/o 45% 9.3.2.3 Field validation of RAPLOA and Environmental risk mapping It should be noted that a Task Force advanced arrangements on the field validation of environmental risk mapping (ERM), Rapid Assessment Procedure of Loa-loa (RAPLOA) and the combined application of the two approaches. Progress report on the outcome of the validations of these tools will be presented to the Forum. 9.4 Collaboration with the World Bank - Onchocerciasis Unit During the period under review, the Onchocerciasis Unit of the World Bank, Washington DC has continued his invaluable collaboration with APOC. At the cost of the Onchocerciasis Unit of the World Bank its technical staff members have supported the Management of APOC in the areas of internal auditing of an APOC funded project with the aim of assessing the weaknesses in the field of monitoring donors' funds and advising projects on corrective measures. The Onchocerciasis Unit of the World Bank has also provided technical assistance in: . Conducting the evaluation of the sustainability of APOC projects, which has already benefited from five years support. JAF 9.5 Page37 Preparing the meeting between the Republic of Benin and Nigeria to plan for a joint action to control the disease. Assisting with the preparation and co-facilitating the multi country-workshop organized in Kinshasa (DRC) on the APOC philosophy for the countries with newly approved CDTI projects. This includes DRC, Angola Burundi and Congo Brazzaville. Preparation of a manual on financing and administrative procedures for APOC and the Special Intervention Zones (SIZ). 9.5 Coordination and Management of the activities in the Special lntervention Zones For the control and evaluation operations in the so called Special Intervention Zones (SIZ) of the former OCP, the WHO Regional Director for Africa has mandated some designated staff of APOC to centrally support and manage the activities in the SIZ. APOC management has therefore given administrative and technical support to SIZ, without direct financial implication. The activities have fully resumed in most parts of Sierra Leone; the former operational bases of Makeni, Kabala and Bo have been rehabilitated. In Benin, Ghana, Guinea/Conakry and Togo, steps have been taken to strengthen CDTI activities in the SIZ areas, and aerial larviciding is carried out in the Kara-Keran-M6 focus in Benin and Togo to supplement the ivermectin distribution. A report on the activities has been prepared and will be presented at the JAF meeting as an information document. 10. CONTRIBUTION OF THE NON-GOVERNMENTAL DEVELOPMENT ORGANIZATIONS (NGDOs) COORDINATION GROUP APOC continues to derive its strength from the unique partnership it enjoys with governments and NGDO. The NGDOs (see the list in table l5), continued to provide the critically needed technical and financial support to CDTI implementation, especially in this current rapid expansion phase. They assist governments (table l5) especially to reach the communities at the end of the road. Many NGDO staffof the APOC programme have also participated in joint missions including: . HKI and CBM provided technical support to CDTI implementation in DRC and Burundi; . HK, SSI, AFRICARE, GRBP, IEF, IMA, UNICEF have all participated in evaluations for sustainability of CDTI projects; . SSI provided technical backstopping to CDTI implementation in Ethiopia; . GOAL, MLAL and World Vision in partnership with the nationals developed new CDTI project proposals to control onchocerciasis in Angola. NGDO in onchocerciasis control in APOC countries Countrv NGDO Pertner GOAL, WORLD VISION, APPAV, MLALAngola CBMBurundi Cameroon GRBP, HKI,IEF, SSI, BASED Central African Republic CBM OPC. AFRICARE,Chad OPCCongo Brazzaville CBM,IMA, Lion's Club, CRS, SANBU,IBqDernocratic Republic of Congo University of BarcelonaEquatorial Guinea GRBPEthiopia Gabon OPC SSI, CTIAL,Liberia IEFMalawi CBMGRBP, HKI, IFESH, SSI, MITOSAIITI'NICEEINigeria GRBP. HNI,Sudan Tanzania ClubSSI,IMA, Rotary Int€rnational, HKI, CSSC, SSI, CRBP, CBM, GTZUganda + n I JAF 9.5 Page 38 11. Auditing the Programme During the period under review, both the Internal WHO auditors as well as the External Auditors have audited the Programme. 11.1 lnterna! WHO audit: In April 2003, an internal WHO auditor audited the accounts of the Programme. The objective of the audit was to determine whether there were effective controls and processes in place, in particular, concerning the Grants to institutions representing almost 70%o of the Programme's budget. With a request from the Management of APOC, the WHO internal auditor has also conducted forthe first time a financial audit in one of the APOC countries namely Nigeria. Two projects in that country, the CDTI project in Taraba state and the project to strengthen the NOTF Headquarters were audited. The Internal auditor recommended that the Management of APOC should strenglhen the scrutiny of the expenditure reports from the projects (field) in order to provide more directions for the use of the funds in the field. 11.2 ExternalAudit During the month of July 2003, the external auditors had verified the status of APOC funds to ascertain whether the budgetary and financial systems comply with the WHO rules and regulations and are in line with policy guidelines of the donor community. The opinion of the extemal auditors will be presented to the Forum. 1{.3 lnternalAPOC audit in the field In April 2003, an internal APOC audit team made of representatives from the Management of APOC and from the Ministry of Health, with the collaboration of a member the Onchocerciasis Unit of the World Bank, Washington DC, visited Malawi to audit the ongoing CDTI project which has been benefiting from APOC Trust funds for five years. The work focused on the administrative and financial operations conducted by the project i mplementers. The result of the audit indicated that the general internal control system in place should be improved in many areas such as the management of the vehicles and the motorcycles, the control of other Capital Equipment, the utilization of fuel, the usage of telephone and the monitoring of stationeries. a I 'D a, JAF 9.5 Page 39 12. APPENDIXES Appendix l: Summary of average geographical coverage of projects in 2002 in APOC countries .::,i! "d Totdcoaitrrftiq ,\i.. €]:ri 1:1-t*crege GGEilft1Esonlnme of nnhEtFffi 9 5,8151 5,905 97.7E i[Sr, I Not availabld 5,014 Not available ffid; I 3,25d 3,265 99.54 M{pndd I 4681 674 69.44 DRe {ry@ 3 4J73I 12,722 34.12 Eerffim I esl 95 100.00 En*lad. I 2,08d 2,086 100.00tu I rel l9 100.00 I 1,6281 2,596 62.71 l.fit&mri I s7d 776 73.45 FI*# 26 32.26s1 36,615 E9.06 SntureMrS 2 27sl 594 88.42 m*ffi*mful 5 s83l 590 98.80 tffir 4 l,5g2l 3,740 96.24 rrym#t 57 52,8191 74,691 88.08 Appendix 2: Summary of average therapeutic coyerage of projects in2002 in APOC countries Cffi.w lfffirm rqF6 nr*trd c@ treScd Totel nopuhtion Cmm 9 1,547,399 2,822,932 54.26 CAB I Not available 1,495,62E Not available cbd I 992,542 1,506,575 65.88 Cm{n@} I 191,780 583,480 32.87 DmC,fDM') 3 1,685,775 7,074,245 21.79 Eo,4lniem' I 10,874 72,682 14.96 I 516,077 651,223 79.25 ebs0 I 5,935 9,434 62.91 tibcdn I 900,000 2,214,610 40.64 i I 377,020 678,492 55.57 Niffiio 26 tE,552,844 25,765,056 74.37 'Sds'&trdal) 2 663,597 1,232,612 54.0t Tumh 5 866,527 1,203,504 72.06 U-srn& 4 1,069,645 l,g66,193 s9.79 TOSAil" 57 27J80O1s 47,175,804 64.46 a a, [,fril{*' :. , Averege Tttrnpqtie Govcrrgc ofpnolefr(chl Eei* I t a o a rhq) L A oI U o 0r E N N E b0 E c,L f- o h G a .nl xl EItrl G)l olol <I o\\t. 9od(d \o c.t NC.l ca o c- r+ c?l = \o ca \o c.l o\ $N $ o\ r-c.l c.l coc?t .<f ol t- (\I\o (t) E$r gf,E o\o ($ c.l \o co or- sfr- \o c\l o c.l €\o c.t(a c.t ra(\l €6 EIr EE- € o\ E00sf oC\ r- rrl c\\oo ra c.t tco(\l so otr-t g\o$ o\ \9r- c\o c.l FIItr r) ffiesE o\o\ o\ o\a ci a € N rrt sf € .+ c.) o\ c-$ o\€ aa C\l n(\l o\ \o s .+ c{(\l s € co o\(A c\ o \t) r- ca r- F r*c \ro ng r$€ EHE o\ c.t \oc{ c\ r sf t-lft E'DE , o) I li.tt) Eql(J & () iE GI L) o E3 o C) ()&6 d lD CI odE] cl ao tD o -o(€ o 6 llDo J ' c al c|, 0a z trct a "!d fr E:6J4 6ttrc o05 Fl t{ oH J.J, l. .I a ,Eo Et E.o - llt E .e}. 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