Report of the nineteenth session of the Technical Consultative Committee (TCC): Ouagadougou, 13-18 September 2004

REPORT OF THE NINETEENTH SESSION OF THE TECHNICAL CONSULTATIVE COMMITTEE (TCC) Ouagadougou, 13-18 September 2004 AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) i LIST OF ACRONYMS AFRO WHO Regional Office for Africa APOC African Programme for Onchocerciasis Control ATO Annual Treatment Objective CBM Christoffel Blindenmission CBO Community-Based Organization CDC Center for Disease Control CDD Community-Directed Distributor CDI Community-Directed Intervention CDTI Community-Directed Treatment with Ivermectin COSA Comité de Santé CSA Committee of Sponsoring Agencies CSM Community Self-Monitoring DEC Diethylcarbamazine DPM Director, Programme Management DRC Democratic Republic of Congo FCT Federal Capital Territory FLHF Front Line Health Facility IEC Information, Education and Communication JAF Joint Action Forum KAP Knowledge, Attitudes and Practice LF Lymphatic Filariasis LGAs Local Government Area LMCT Lutte contre les maladies transmissibles et carentielles LOCT Local Onchocerciasis Control Team MACROFIL Macrofilaricidal drug research project MDP Mectizan Donation Program MDSC Multidisease Surveillance Centre MEC/AC Mectizan Expert Committee/Albendazole Coordination MI Micronutrient Initiative MITOSATH Mission to Save the Helpless MOH Ministry of Health NGDO Non-Governmental Development Organization NGO Non-Governmental Organization NOTF National Onchocerciasis Task Force OCRC Onchocerciasis Chemotherapy Research Centre ONCHOSIM Oncho simulation OPC Organisation pour la Prévention de la Cécité PHC Primary Health Care PRSP Poverty Reduction Strategy Paper RAPLOA Rapid Assessment for Loa loa REA Rapid Epidemiological Assessment REMO Rapid Epidemiological Mapping of Onchocerciasis SAE Serious Adverse Event SHM Stakeholder Meeting SIZ Special Intervention Zones SWAP Sector-Wide Approach TCC Technical Consultative Committee TDR Research and Training in Tropical Diseases TOR Terms of Reference UTG Ultimate Treatment Goal ii TABLE OF CONTENTS Opening ....................................................................................................................................... 1 Adoption of the agenda ............................................................................................................... 2 Matters arising from the 105th and 106th sessions of the CSA .................................................... 2 Matters arising from the Donors Conference .............................................................................. 4 Matters arising from 24th NGDO meeting .................................................................................. 4 Matters arising from the 32nd meeting of the Mectizan Expert Committee ................................ 4 Update on the REMO/GIS in APOC countries ........................................................................... 5 Update on the RAPLOA in Angola, Cameroon and DRC .......................................................... 5 Update on Operational Research ................................................................................................ 6 Update on MACROFIL ............................................................................................................... 6 Follow-up of the recommendations of TCC18 ........................................................................... 7 Report on the review by the APOC Management of 1st, 2nd, 3rd, 4th and 5th year progress reports and subsequent year budgets ....................................................................................................... 8 Review of new project proposals ................................................................................................ 8 BURUNDI Bururi Province CDTI Project Proposal ....................................................................... 8 Rutana Province CDTI Project Proposal ...................................................................... 9 DRC North Ituri CDTI Project Proposal ............................................................................... 10 Review of operational research proposals ................................................................................... 11 Review of 1st, 2nd, 3rd, 4th and 5th year annual technical reports .................................................. 11 ANGOLA NOTF Secretariat: 1st year report ................................................................................. 11 CAMEROON NOTF Secretariat: 6th year report ................................................................................. 11 Center 1 Province CDTI Project: 3rd year report .......................................................... 12 Center 2 Province CDTI Project: 2nd year report ......................................................... 12 CHAD Chad CDTI Project: 5th year report .............................................................................. 13 DRC NOTF Secretariat: 4th year report ................................................................................. 14 Bas Congo CDTI Project: 1st year report ..................................................................... 15 Kasai CDTI Project: 4th year report ............................................................................. 16 Bandundu CDTI Project: 2nd year report ...................................................................... 17 LIBERIA South-East CDTI Project: 1st year report ..................................................................... 18 Lofa Bong, Nimba & Montserrado CDTI Project: 4th year report .............................. 18 iii MALAWI Thyolo & Mwanza CDTI Project: 6th year report ........................................................ 18 Extension Districts CDTI Project: 6th year report ........................................................ 19 NIGERIA NOTF Secretariat: 6th year report ................................................................................. 20 Cross River State CDTI Project: 6th year report ........................................................... 20 FCT CDTI Project: 5th year report ............................................................................... 21 Kano State CDTI Project: 5th year report ..................................................................... 21 Jigawa State CDTI Project: 3rd year report .................................................................. 22 Yobe State CDTI Project: 5th year report ..................................................................... 23 Gombe State CDTI Project: 4th year report .................................................................. 23 TANZANIA Kilosa Focus CDTI Project: 3rd year report ................................................................ 24 UGANDA Phase II CDTI Project: 5th year report .......................................................................... 24 Update on vector elimination activities with special emphasis on Tukuyu Focus ...................... 25 Phase II of the long-term impact assessment of APOC operations ............................................. 27 Report on tool for rapid monitoring of treatment coverage ........................................................ 27 Update on sustainability of CDTI ............................................................................................... 29 Report on the financial management of APOC-funded projects ................................................. 29 Report on cost per treatment with ivermectin ............................................................................. 30 Integrating Vitamin A supplementation and CDTI: Updates ...................................................... 31 Additional matters discussed by TCC19 ..................................................................................... 31 Format for technical reports ............................................................................................... 31 Progress report on South Sudan ........................................................................................ 31 Update on the Bill & Melinda Gates Foundation Meeting on Integration ......................... 32 External Review of APOC and SIZ ................................................................................... 32 Information on APOC contribution to SIZ ........................................................................ 33 Other matters .... .......................................................................................................................... 34 Dates and place of the twentieth and twenty-first sessions of TCC ............................................ 34 Conclusions and recommendations of TCC19 ............................................................................ 35 Closure of the session ................................................................................................................. 35 Annex 1: List of participants ..................................................................................................... 36 Annex 2: Provisional agenda .................................................................................................... 39 Annex 3: Conclusions and recommendations of the 24th Meeting of the NGDO Coordination Group for Onchocerciasis Control ............................................................................ 41 Annex 4: Summary of the conclusions of the MEC/AC32 Meeting ....................................... 44 Annex 5: Summary report of the Bill & Melinda Gates Foundation Meeting on Integration of Community-Based Programmes .............................................................................. 46 Annex 6: Conclusions and recommendations of TCC19 ......................................................... 49 1 THE APOC TECHNICAL CONSULTATIVE COMMITTEE Nineteenth session Ouagadougou, 13-18 September 2004 OPENING: Agenda item 1 1. The Technical Consultative Committee (TCC) of the African Programme for Onchocerciasis Control (APOC) held its nineteenth session from 13 to 18 September 2004 at the APOC Headquarters in Ouagadougou, Burkina Faso, under the chairmanship of Prof Ekanem Braide. The list of participants is attached as Annex 1. 2. At the opening of the session Dr Alhouseini Maiga, representing Dr Mohamed M. Hacen, WHO Representative to Burkina Faso, welcomed the participants to the session and wished them success in their proceedings of the week. 3. Dr Sam Bugri, acting Director of the Multidisease Surveillance Centre (MDSC), expressed his appreciation of the technical guidance received from TCC for onchocerciasis control in Africa, which greatly contributed to the execution of effective control of the disease. He and his staff were available for any support required by the Committee. 4. Dr Azodoga Sékétéli, Programme Director of APOC, thanked TCC members for their never-failing readiness to convene in Ouagadougou. He also thanked the Carter Center and Global 2000 for the invitation to hold the current session in Atlanta, as originally planned. However, following the practically unanimous agreement of TCC members the venue was returned to Ouagadougou. 5. The Programme Director specifically welcomed Ms Nancy Haselow who was attending the TCC session for the first time as a member of the Committee; Dr Grace Saguti, National Onchocerciasis Coordinator of Tanzania; Dr Yisa Saka, Deputy Director of the National Onchocerciasis Control Programme (NOCP) of Nigeria, Mr Bruce Benton, Manager of the Onchocerciasis Coordination Unit at the World Bank and current Chair of the Committee of Sponsoring Agencies (CSA); Dr Hans Remme of WHO/TDR and Dr Janis Lazdins, Manager of WHO/MACROFIL. 6. Dr Sékétéli introduced the newly-appointed professional staff at the APOC Headquarters, namely: Mr Issaka Niandu (Information Systems Officer), Mr Koffi Benoît Agblewonu (Budget and Finance Officer); Ms Néné Keita (Finance Officer); and Mr Samuel Bamfo (Translator). 7. Dr Sékétéli informed the Committee, with much regret, that Bruce Benton will be retiring at the end of 2004. Mr Benton has been a stalwart supporter of the onchocerciasis control programmes for many years. He has not only been securing the necessary funds for OCP and APOC operations but also has been following up closely on control operations and helping to bring into play new strategies designed to ensure sustainability of APOC activities. His departure was not without concern to the Programme. 2 8. The Programme Director also informed the Committee about the recent nomination, by the WHO Regional Committee for Africa, of Dr Luis Gomes Sambo, currently Director of Programme Management (DPM) at the WHO Regional Office, to the post of Regional Director of that office. The Programme Director had forwarded a formal message of congratulations to Dr Sambo in which he underscored the importance of continuous support of AFRO to APOC in order to facilitate the achievement of the objective of the Programme. 9. The Programme Director listed a few items on the provisional agenda of TCC19 which, he felt, required particular attention, namely the: 1) update on RAPLOA and its link with the SAEs in onchocerciasis endemic zones; 2) integration of Vitamin A supplementation within CDTI projects; 3) update from TDR on the research proposals submitted to the Bill & Melinda Gates Foundation on the impact of ivermectin on transmission, the community-directed intervention (CDI) studies and financing for a macrofilaricidal drug research; 4) update on monitoring the implementation of sustainability plans of evaluated CDTI projects; 5) update on sustainability of projects; 6) report on the cost per treatment study. 10. In her opening remarks, the Chair, Prof Braide, reiterated the welcome to participants. She remarked that the new reporting format would enable the Committee to spend less time reviewing technical reports, thus allowing more time for discussing technical issues. She emphasized that TCC must be firm on the deadlines for the submission of proposals and technical reports by projects and suggested that the Committee may consider extending sanctions to the NOTF Secretariats concerned for not effectively coordinating the activities of their projects; and for not reporting adequately to the Ministry of Health. She added that the Committee would also need to decide on what remedial actions to take against projects that were not making progress, such as projects with low coverage; inadequate funding; delays in providing financial returns; slow in implementing activities that enhanced sustainability. 11. Prof Braide commended APOC Management for the progress made in the implementation of the CDTI projects in South Sudan, for completing REMO in the conflict zones and for validating RAPLOA as planned. She thanked TDR, the WHO Country Office in Burkina Faso and MDSC for their presence at the meeting. Finally, she requested the Programme Director to convey the congratulations of the Committee to the Regional Director elect. 12. Agenda Item 2: The Committee approved the provisional agenda (attached as Annex 2) as well as the draft provisional annotated agenda and suggested additional issues to be discussed during the session. It was suggested that for future TCC sessions the schedule of project reviews should be arranged in a way to avoid having all the reports from the francophone countries being reviewed first. This would lessen the stress of preparations on the TCC members concerned with those reviews during the first days of the meeting. 13. Agenda Item 3: A summary of matters arising from the 105th and 106th sessions of the Committee of Sponsoring Agencies (CSA) held in Geneva and Washington D.C. from 30 March to 1 April 2004, and on 20 and 22 June 2004 respectively, was presented by Mr Abdulai Daribi, acting as Secretary of CSA. The 20 June meeting essentially reviewed the final preparations for the Donors' Conference whereas the meeting on 22 June was to review the outcome of the Conference. The main conclusions of the meetings were summarized as follows: 3 1) CSA was informed that an investigation mission was to be undertaken in July to help clarify the cause of the SAEs reported in DRC; 2) the Committee was also informed that the Special ad hoc Committee (SAC) for the Special Intervention Zone (SIZ) had accepted to undertake a mid-term review in July 2005 of the ongoing activities in the SIZ; 3) the Committee expressed concern about the slow progress in the preparations for the APOC External Evaluation but was later reassured that the draft Terms of Reference (TOR) were being finalized and would be circulated for final approval at the JAF in December 2004; 4) the Committee was concerned about the irregular attendance of UNDP and FAO at CSA meetings and the chairman of CSA was in contact with the two organizations to try to rekindle their interest in APOC; 5) CSA suggested that Ministries of Health be encouraged to use the Poverty Reduction Strategy Paper (PRSP) and Sector-Wide Approach (SWAP) schemes for funding APOC activities as government financial contributions to onchocerciasis activities were usually little or not forthcoming; 6) CSA also suggested that an article be written to correct the wrong data in the article published in the Lancet on the impact of OCP activities on disease transmission; 7) it was established that the CDTI structure was most ideal for improving and expanding coverage of Vitamin A supplementation and a stronger collaboration was building between the Micronutrient Initiative (MI) and APOC; 8) MI was requested to draw up a concept paper for pilot studies on the integration of Vitamin A supplementation into CDTI projects in four selected countries - DRC, Nigeria, Sudan and Tanzania; and MI was to be invited to JAF10 in Kinshasa to present the proposed plans; 9) it was suggested that Guinea (Conakry) be invited to JAF10 to present its field experience in reproductive health service delivery through the CDTI. 14. Mr Bruce Benton expressed his pleasure to be attending his first TCC19 session in this Phase II of APOC. He informed the Committee that the forthcoming CSA session in Paris would deal essentially with preparations for JAF10 in Kinshasa and the preparations for the External Evaluation of APOC in 2005. It was expected that the conclusions of the evaluation would allow a better planning of the closure of APOC in 2010 or the possibility of an extension of the Programme. Mr Benton also referred to plans for a mid-term review of the SIZ activities in former OCP countries. 15. Finally, Mr Benton informed TCC that the presentation on, “Defeating Riverblindness: Success in Scaling up and Lessons learned” made by Dr Sékétéli at the Shanghai Conference in May 2004 was well received at the Conference as being an example of scaling up - a programme that started in seven African countries and now covering the entire African continent and creating an effective partnership. 4 16. Agenda Item 4: In reporting on the Donors' Conference, held at the World Bank Headquarters on 21 and 22 June 2004, Mr Benton indicated that the Conference had been a success and was glad to welcome Saudi Arabia as a new donor to APOC. Following the Conference, Belgium, Germany, Poland and OPEC had increased and/or confirmed their annual contributions, reducing the funding gap of APOC from US$18 million to US$14 million. 17. The final communiqué of the Conference contained a strong statement of commitment of the donors to APOC: "not to abandon the Programme before the end of its operations in 2010". Donors also recognized CDTI as being an ideal vehicle that could be used by other health interventions such as Vitamin A supplementation to improve their coverage. 18. TCC was also informed that donors were requesting that the Plan of Action and Budget of APOC should be presented in a way that showed the link of specific activities to their expected results - performance-based or result-based budgeting. 19. It was also reported that the high number of sustainability plans being submitted by NOTFs for review by APOC Management was of concern to donors and APOC Management was asked to look into ways of reducing the workload which that activity created on its staff. 20. Agenda Item 5: Dr Tony Ukety, Coordinator of the NGDO Group, informed TCC of the 24th meeting of the NGDO Group which was held in Atlanta from 9 to 11 September 2004 at which a number of issues and concerns were raised. These included: 1) the lack of a coordination mechanism for ex-OCP countries; 2) low or absence of government financial contribution to CDTI activities; 3) absence of treatment data from Ghana; 4) delays in the release of APOC funds for some projects; and 5) that NGDO Headquarters or Regional offices were not consistently informed when their field staff members were invited to attend APOC meetings. 21. The concern regarding NGDO staff attending APOC meetings expressed above generated extensive discussion in TCC. APOC Management informed the Committee that all invitations sent to any NGDO country representative or field staff were systematically copied to the NGDO Group Coordinator. APOC Management also assumed that the NGDO staff concerned would clear, through the proper channels of their organizations, their participation in APOC-related missions or any commitments made to APOC. 22. A draft summary of the conclusions and recommendations of the 24th NGDO Group meeting is attached as Annex 3. 23. Agenda Item 6: Dr Mary Alleman of the Mectizan® Donation Program (MDP) reported on the highlights of the 32nd meeting of the Mectizan® Expert Committee/Albendazole Coordination (MEC/AC) held from 28-30 April 2004 in Atlanta, Georgia, USA as follows: 1) updates were presented regarding RAPLOA, mass treatment with Mectizan® in Loa loa endemic areas, and research on potential measures to reduce the risk of Serious Adverse Events (SAEs) in Loa loa endemic areas; 2) revisions to the MEC/TCC guidelines for mass treatment with Mectizan® for onchocerciasis in areas co-endemic for onchocerciasis and Loa loa, which reflected 5 the TCC18 recommendations, were finalized at the meeting and distributed by MDP to programme partners, including APOC Management and TCC members, in June 2004. The revised guidelines also take into account the endemicity of Loa loa when assessing the risk of SAEs occurring after Mectizan® treatment for onchocerciasis and include guidance for the clinical management of cases of Loa loa encephalopathy and a list of suggested medical supplies and equipment for the management of such cases; 3) concerned about the very high incidence of SAEs reported in the Bas Congo CDTI project area in DRC, the MEC recommended that mass treatment in the project area be halted for a time, a mission be conducted to investigate the potential causes of the SAEs, and an extensive RAPLOA be conducted in the area to better define the risk of SAEs. The recommended mission, jointly sponsored by MDP and APOC Management in collaboration with the NOTF of DRC, took place in July 2004; 4) after reviewing requests for Mectizan® for six new CDTI projects in DRC, the MEC made several recommendations that pertain to all new CDTI projects in DRC (and will likely pertain to any new project areas potentially, or known to be, endemic for Loa loa); 5) updates were provided to the MEC regarding various ongoing/proposed research studies; 6) the evaluation of the impact of the Mectizan® Donation Program was published in the March 2004 issue of Tropical Medicine and International Health. 24. TCC noted the report of the MEC meeting. A broader summary of the MEC/AC32 is attached as Annex 4. 25. Agenda Item 8: Mr Issaka Niandou of the Epidemiology and Vector Elimination Unit presented an update on the latest REMO/GIS activities in APOC. He informed the Committee that REMO exercises had been undertaken in Burundi, Cameroon, Congo, DRC, Ethiopia and Tanzania and were yet to be finalized in Uganda and South Sudan. 26. The refinement of the REMO map of Tanzania enable clear delineation of CDTI areas in Morogoro district where zones still remain to be assessed. In Burundi the foci were confirmed as meso and hyperendemic and (two) 2 new CDTI projects had been approved for implementation. Likewise, the Ituri zone in DRC was also confirmed as meso and hyperendemic and a CDTI project proposal had been submitted to TCC for approval. 27. To date, REMO surveys have been carried out in all APOC countries. 28. The question was raised as to the reliability of the results of some REMO exercises tending to overstate the problem and it was suggested that a critical review be made of REMO results before deciding on the need for CDTI operations, e.g. sufficient data to justify such operational decisions. In the meantime, APOC Management would undertake a critical review of the REMO approach and its implementation in the field and report to TCC20. 29. Agenda Item 9: Mr Issaka Niandou also provided an update on RAPLOA activities carried out in Angola, Cameroon and DRC. 6 30. During the discussion, particular attention was given to the situation in Angola. It was agreed that the CDTI project would start in low/no Loa loa risk areas while training and community sensitization on the diagnosis and management of SAEs were being intensified. It was suggested that an expert be made available to study and to advise on onchocerciasis control in Loa loa areas and that perhaps the expert assigned to this task in DRC or in Cameroon could also cover Angola. 31. It was strongly warned that CDTI be avoided in the Tshela zone in DRC as it was hyperendemic for Loa loa. 32. Agenda Item 15: Dr Hans Remme of TDR provided an update on operational research activities which included: RAPLOA, community-directed interventions (CDI), feasibility studies on the cessation of ivermectin treatment and the status of funding of research proposals submitted to the Bill & Melinda Gates Foundation. 33. The validation studies of RAPLOA had now been completed in all the study sites in Congo and DRC. The results were consistent with those from the original RAPLOA study in Cameroon and Nigeria and compared well with the predictions of the Environmental Risk Model. Hence, RAPLOA can now be used extensively in all project areas as also recommended by the MEC/AC32. 34. The first phase of the multi-country study to explore the introduction of CDI, which started in March 2004, consisted in introducing the CDI concept at different levels of the health system and at the community level. This had now been completed. A training workshop for advanced methods for computer-assisted analysis of qualitative data would be organized later in the year for the social scientists from the 9 research teams. This would provide an opportunity for a first standardized cross-site analysis of processing data on the introduction of CDI. Data on coverage by the different interventions would become available during the first half of 2005. 35. There had been some progress with regard to the proposal submitted to the Bill & Melinda Gates Foundation for the proposed research in Mali and Senegal on the feasibility of local elimination of onchocerciasis transmission and cessation of ivermectin treatment. External reviews were positive and the revised proposal that addressed some of the comments of the reviewers would be submitted on 15 September 2004 as requested by the Foundation. A final decision was expected shortly. 36. TCC once again endorsed the study and requested the CSA (World Bank) to follow up on the proposal. 37. Agenda Item 16: An update on MACROFIL was provided by Dr Janis Lazdins who stressed that the discovery and development of products for onchocerciasis control were driven by the needs and presence of APOC. The target product profile focused on efficacy to eventually control transmission and safety compatible with use at the community level. Screening for active molecules had yielded two interesting molecules: cyclodepsipeptides (new class of antihelminthics) and a novel tetracycline derivative that would target wolbachia. 38. Extensive work conducted by Wyeth, TDR and the Onchocerciasis Chemotherapy Research Centre (OCRC) on moxidectin had prepared the ground to initiate the efficacy studies in infected patients in OCRC. The recent emergence of a potential safety issue related to a veterinarian moxidectin product had forced the Phase II clinical study to be put on hold. 7 MACROFIL would follow up on the issue to determine the implications for the development of moxidectin for use in humans. 39. The first prototype of DEC skin patch was evaluated in infected individuals and further optimization work was required. The study to evaluate safety and drug blood levels of ivermectin, albendazole and praziquantel given concomitantly had been concluded and the final report was to be available shortly. This would be important to guide proposals for disease control integration initiatives. Several potential genetic markers had been identified for the development of an ivermectin resistance detection tool and a strategy to investigate these in the field was being considered. 40. The development of a clinical project aimed at assessing (i) the use of multiple doses of albendazole as pre-treatment strategy to reduce the load of Loa loa, and (ii) the safety and efficacy of ivermectin alone or in combination with albendazole in patients with low load of Loa loa, had not progressed due to lack of funds. 41. Dr Janis Lazdins recently attended a meeting at the Bill & Melinda Gates Foundation which was defining its funding strategy towards discovering and developing macrofilaricidal drugs. He made a presentation of MACROFIL's strategy and activities and highlighted the need to support a "pipeline" concept with rational resource distribution from discovery to development, including strengthening of the participation of endemic countries. 42. It was recommended by MACROFIL to: 1) pursue further evaluation of recently identified new molecules; 2) continue informing APOC on the issues relating to recent withdrawal of the veterinarian moxidectin product and its impact on moxidectin development for humans and the strategic options for pursuing moxidectin development; 3) assess the possibility of evaluating moxidectin in the monkey/Loa loa model developed in Cameroon; 4) continue activities related to DEC patch test and the development of ivermectin resistance detection tool; 5) encourage the World Bank to propose a funding strategy as soon as possible to support the initiation of the clinical studies aimed at establishing a treatment strategy of patients in onchocerciasis and Loa loa co-endemic areas with the aim to reduce the Loa loa load. FOLLOW-UP TO THE RECOMMENDATIONS OF TCC18: Agenda Item 7 43. In reporting on the follow-up to the recommendations of the eighteenth session of TCC, Dr Laurent Yameogo, Coordinator of the Office of the Programme Director, informed the Committee that APOC Management had implemented most of the recommendations it was concerned with and reassured TCC that the few remaining would be implemented as soon as possible. 8 REPORT ON THE REVIEW BY THE APOC MANAGEMENT OF 1ST, 2ND, 3RD, 4TH AND 5TH YEAR PROGRESS REPORTS AND SUBSEQUENT YEAR BUDGETS: Agenda item 18 44. The Committee was informed that a total of 115 projects had been approved by APOC Management as at 31 August 2004, i.e. 104 CDTI projects, 4 vector elimination projects and 7 NOTF Secretariat projects. Furthermore, financial support was required for 18 projects in their sustainability era, i.e. projects that had received 5 years of APOC funding already; and for 24 projects in their 2nd, 3rd, 4th and 5th years. 45. It was noted that delays in finalizing the process of funding of projects were, in most cases, due to the late submission of subsequent year proposals or financial returns by NOTFs. However, it was acknowledged that there may also have been some delays caused by the transition in the finance department of APOC. 46. APOC Management provided detailed explanation regarding a specific case of financial management irregularities in Equatorial Guinea where a solution was however being reached with the national authorities. APOC Management also informed TCC about restrictions imposed by WHO/AFRO on the release of funds to any bank account under government control in Burundi, a measure which made it difficult for APOC funds for approved projects to be sent to, and managed by, the NOTF. REVIEW OF NEW PROJECT PROPOSALS: Agenda item 19 47. Mr Koffi Benoît Agblewonu, Budget and Finance Officer, informed TCC that, of the total amount of US$6,106,854 available in 2004 for funding “National Projects”, APOC had set aside US$6,036,854 for approved projects being implemented as well as for sustainability plans to be submitted by NOTF Secretariats. This left a balance of only US$70,000 for any new proposals to be approved before the end of 2004. BURUNDI Bururi Province CDTI Project Proposal 48. The project is located in the South-West of Burundi and covers an area with a total population of 170,501. The eligible population is estimated at 161,976 and located in 6 Communes, 16 Zones and 62 Collins or Communities which are mainly mesoendemic and hyperendemic. REMO surveys were conducted in 14 Provinces in 2001 and 2002 and refined in 6 of these Provinces in 2003. The remaining Provinces of the project area therefore still needed REMO refinement. 49. There was no indication of the presence of Loa loa in the area and no NGDO partner had been identified to support the project. 50. TCC felt it was unrealistic that the number of communities to be treated remained unchanged from the 1st to the 5th year. 51. Although project funding was for a period of 5 years, the guidelines for new proposals required that a 3-year budget be submitted initially. The budget of US$446,206 was considered 9 to be too high, particularly the amount requested from the NGDO for salaries and IEC materials. In addition, TCC considered that 4 computers requested from APOC were excessive. 52. Overall, this was a good proposal however it lacked some basic information listed below and required clarification on some issues: a) status of Loa loa in the project area; b) the Annual Treatment Objective (ATO) for population and communities which were not consistent; c) objective on IEC such as the number of communities mobilized per year; d) annual objective for training at the different levels (cascade); e) how reinforcement of capacity-building will be carried out at all levels; f) choice of CDDs and determination of the number of CDDs by the communities themselves; g) use and management of the money recovered; h) specify the NGDO partner; i) reduce the budget. 53. TCC recommended the approval of the proposal with the understanding that the clarification sought and the issues raised above would be fully addressed in a revised proposal to be resubmitted to APOC Management before implementation. Rutana Province CDTI Project Proposal 54. This proposal could be considered as being a reactivation of the LMCT project which was functional between 1993 and 1997. The project extends across the Rutana and Makamba Provinces in 39 Collins or Communities and covers a total population of 285,379. 55. The REMO surveys conducted in 2001 and 2002, as well as the REMO refinement in 2003, confirmed the historical foci which include 39 hyperendemic and 112 hypoendemic communities. 56. No NGDO partner commitment had been obtained yet. 57. Although the 5-year budget of US$304,060 showed a progressive decrease in APOC funding from 2005 (US$103,686) to 2009 (US$14,391), communication, transportation and travel, which are important indicators of sustainability, are completely covered by APOC funding throughout the 5 years. In addition, the government's financial contribution of less than 5 000 Francs/month for supervision, water and electricity charges gave TCC reason to be concerned about the sustainability of this project. 58. TCC commended the project for a well-written proposal but requested that the project: a) clarify the status of Loa loa endemicity in the project area; b) revise downwards the budget line for sensitization, training, supervision, transportation and equipment; c) specify the number of people to be trained; d) estimate the increase of the people to be treated; e) harmonize the period of treatment with the timetable; f) confirm the participation of NGDO (namely CBM) in the project and obtain its endorsement; 10 g) prepare a 3-year budget; h) start thinking about drawing up a sustainability plan for year 3. 59. TCC recommended the approval of the proposal which should be reviewed in the light of the above and resubmitted to the reviewers through APOC Management before project implementation. DEMOCRATIC REPUBLIC OF CONGO North Ituri CDTI Project Proposal 60. The project area lies in the north-eastern part of DRC with 18 Health Zones in the District. However, due to civil unrest in the area, particularly in the South of the District, REMO survey was only conducted in 7 Health Zones in 2002. The current proposal therefore covers only those 7 Health Zones with 812 villages and a total population of 335,162 of which 221,207 are eligible for treatment. 61. It was difficult for TCC to understand how the eligible population and subsequently the treatment figures were calculated. There also appeared to be some inconsistency between the REMO map and the project area described. 62. Prevalence ranged between 20% (West Laybo) and 100% (East Laybo, Biringi, South West Aru), and the TDR study carried out in March 2004 confirmed the absence of Loa loa in the project area. 63. Although the proposal was well-written, TCC requested the project to provide additional information on, or clarify, the following: a) the letter of endorsement of the government and the request for APOC support were not attached; b) the government contribution was not specific in the document; c) although no commitment had been obtained from any NGDO partner, a corresponding NGDO financial contribution of US$102,650 was indicated in the budget; d) several budget items need to be clarified (community mobilization, health education, problems and constraints, treatment). 64. The Committee recommended the rejection of the proposal to be resubmitted to the reviewers through APOC Management and requested that the project provide the missing information above, as well as: i. specify the endemic zones of the project; ii. ensure that the preparation of IEC material are preceded by a KAP survey; iii. harmonize the figures presented in the document in the text and in the tables. REVIEW OF OPERATIONAL RESEARCH PROPOSALS: Agenda Item 21 “Studies on the possible macrofilaricidal effects of 10 years of ivermectin treatment on Onchocerca volvulus from endemic communities in rain forest areas in South-eastern Nigeria” 11 65. This proposal was a resubmission to TCC. The Committee felt that the protocol, as elaborated, still lacked adequate orientation that would enable the investigators to achieve the expected results. TCC therefore recommended the rejection of the proposal. However, as the study could be of operational interest to APOC, it was suggested that Dr Janis Lazdins of MACROFIL could contact the investigators with a view to helping them improve on the research protocol for resubmission to the next TCC in March 2005. REVIEW OF 1ST, 2ND, 3RD, 4TH AND 5TH YEAR ANNUAL TECHNICAL REPORTS: Agenda item 20 ANGOLA NOTF Secretariat (1st year report) 66. This was by standard a scanty report. Although it was noted that no CDTI activities had actually been undertaken during the reporting year, TCC would have expected to receive such basic information as: a) the genesis of CDTI in Angola; b) the number of proposals submitted to APOC Management and their status; c) the status of REMO and RAPLOA activities in the project areas; d) clear figures of eligible populations and communities for treatment and for training. 67. It was deduced that the NOTF might be lacking guidance on how to report on NOTF Secretariat activities, hence the inadequacy of the report. 68. TCC recommended that the report be withdrawn and the following actions taken: i. APOC Management to give more guidance to the NOTF on how to report on NOTF Secretariat activities; ii. APOC Management to also send an example of a good report of NOTF Secretariat report (in French) to the NOTF; iii. the project be requested to re-write the report in the light of the above and resubmit to TCC20. CAMEROON NOTF Secretariat (6th year report) 69. TCC felt that the report did not reflect the great effort made in the field. The report was written in a very illogical format, covering part of the 5th year and part of the 6th year activities (6 July 2003 - 31 July 2004). Therefore, the period described in the text did not match the funding period of the project. It was noticed that the same subjects were found in different paragraphs. In addition, some activities and subjects described in this report were already reported in the previous technical report submitted to TCC17. The Committee was astonished that the North-West CDTI project was not mentioned in the report. 70. The following TCC17 recommendations were not addressed: 12 1) present future reports in a more logical and simple format and indicating the reporting period; 2) ensure that MOH contributions are actually paid, this in the interest of sustainability; 3) continue providing support to CDTI projects to put in place a clinic-based distribution system in hypoendemic areas. 71. However, the Committee noted: a) an increase in therapeutic coverage, over 65% in most CDTI projects; b) an improvement in the detection and management of SAEs in co-endemic areas as a result of the appointment of a technical adviser on Loa loa; c) the preparation of specific IEC materials; 72. TCC rejected the report to be resubmitted to the reviewers through APOC Management and requested that the project should: i. resubmit the report using the new reporting format (to be sent to the NOTF Secretariat soon by APOC Management); ii. address all the recommendations of TCC17; iii. provide information on the North-West CDTI project; and iv. include information on the release and utilization of financial contributions approved by the MOH. Center 1 CDTI Project (3rd year report) 73. TCC noted with satisfaction that the project had achieved over 65% therapeutic coverage for two consecutive years. The Committee commended the project for the great efforts being made in advocacy, mobilization of the communities and the CDDs; and for the integration of CDTI activities into the health system and encouraged the project to pursue those efforts. 74. However, the following issues had been identified which the project was requested to address: a) inaccurate estimation of the population leading to shortage of Mectizan® stock during the treatment campaign; b) lack of motivation of CDDs which led to a high CDD attrition rate of 20%; c) CDTI activities were not integrated into the district health budgets. 75. The Committee requested that the financial contribution from the various partners for any given year be clearly indicated. 76. TCC accepted the report with the expectation that the above issues would be fully addressed and reported on in the next technical report of the project. Center 2 CDTI Project (2nd year report) 77. TCC commended the project for the high level advocacy activities carried out within the local communities and particularly for reaching out to top political leaders. This had resulted in the participation of the Minister of Health and the Minister of Youth and Sports at the launching 13 of the advocacy and sensitization day. The increased sensitization had been due to a good media plan. 78. Therapeutic coverage was 66.82% which denoted a continuous improvement over the years, e.g. 37.8% in 2001. 79. The Committee also applauded the project for efficiently managing the SAEs that occurred. 80. However, TCC remarked that government contribution was not explicit; funding for CDTI activities was not integrated into the national budget and logistics at the district health service were inadequate. In addition, a number of operational issues below were identified: a) inadequate cascade supervision at the frontline health facility (FLHF) level; b) delay in sending reports; c) lack of interest of CDDs leading to high CDD attrition rate; d) lack of motivation of some health workers; e) difficult access to some areas; f) 50% of equipment not operational; g) pooling of resources. 81. TCC accepted the report and recommended that the project address the above issues by; i. seeking possible solutions for strengthening the motivation of CDDs; ii. reinforcing supervision of CDDs and training them for recordkeeping; iii. working out a plan for replacement of non-functional equipment; iv. making the participation of the government (provisional/district) more visible; v. encouraging integration of financial resources; vi. making increasing use of community structures (COSA) for broadcasting messages; vii. training a large number of people in the management of SAEs; viii. following up on the SAEs. CHAD Chad CDTI Project (5th year report) 82. The report was a resubmission of a previous report rejected by TCC17 for lack of details on some activities; and for inconsistencies in figures provided in the text and in the tables. 83. TCC commended the project on the improvement in reporting. The current report addressed all TCC17 recommendations. It summarized the CDTI activities carried out by the MOH, Africare and OPC although it was brought to the attention of the Committee that no NGDO was currently supporting CDTI activities in Chad. Community participation was not well explained. 84. Therapeutic coverage was 65% which was inadequate for a project in its 5th year. 85. In addition, a number of other issues were identified, namely: 14 a) low CDD/population ratio (1:599) and a high CDD attrition rate; b) there was no work plan presented for CDTI implementation; c) although the method of calculation was correct, almost half of the figures of therapeutic coverage presented were wrong; d) the expected NGDO financial contribution was indicated but no activity was linked to it. e) several results from Africare and OPC do not match those given in the executive summary (e.g. number of villages treated, total population, eligible population, treated population, number of tablets used, amount collected - cost recovery). 86. TCC rejected the report to be resubmitted to the reviewers and recommended that the project: i. take the Africare and OPC documents into account in their executive summary; ii. harmonize the figures taken from different sources; iii. verify the results presented in the tables; iv. give reasons justifying therapeutic coverage rates lower than 50% in some areas; v. explain how monies collected are managed; vi. provide information on the NGDO partner financial contribution, if any; vii. include/maintain a technical adviser in its team. DEMOCRATIC REPUBLIC OF CONGO NOTF Secretariat (4th year report) 87. TCC was quite concerned about the report which did not reflect at all the volume and nature of activities carried out by the NOTF Secretariat and those being carried on in the various projects of the country. 88. In addition, the Committee noted that the following TCC17 recommendations were not addressed by the project: 1) the need to provide a summary of treatment figures of all CDTI projects in the country (total population, eligible population, UTG, ATO, geographic and therapeutic coverage); 2) a detailed report on SAEs that occurred in the country during the reporting period (total number of cases, sites and management of the cases, measures to be taken to improve management of future cases such as training of staff); 3) integration of CDTI projects into the PHC (concerns about sustainability of CDTI projects); 4) MOH financial contribution not released. 89. There was neither indication of the author of the report nor of the reporting period. The NOTF also failed to report adequately on the following: a) IEC issues: KAP survey and materials produced; b) Mectizan® supply: when, how and problems; c) report of CDTI activities in conflict zones; d) details of the constraints and challenges. 15 90. TCC rejected the report to be resubmitted to the next TCC and requested that the NOTF Secretariat resubmit a complete report addressing both the TCC17 recommendations and all the issues and concerns raised above. Bas Congo CDTI Project (1st year report) 91. TCC was aware of the difficult circumstances in which the project operated - limited equipment, communication and transportation problems. In spite of that, the Committee noted with satisfaction that therapeutic coverage was over 54% for the first year of CDTI implementation. 92. However, it would appear from the report that SAEs were not taken seriously by the project as indicated by the following: a) no mention of SAEs in the executive summary; b) no reference to SAEs in the challenges; c) the list of reported cases was incomplete with a footnote of "the list is not exhaustive"; d) lack of information on the actions taken for the SAEs; e) lack of information on the management of SAEs; f) it was highlighted that SAEs led to the suspension of the project, without giving due consideration to the negative impact of SAEs on the victims and on their families; g) no reference was made to the different missions undertaken to the field to investigate the SAEs; h) no mention of the RAPLOA survey in Bas Congo; i) Loa loa status was not cited in the report. 93. In addition, sensitization, health education, advocacy and supervision had been poorly implemented as indicated in the report and also shown in the analysis of the expenditures on the related budget line. Overall, the report failed to satisfactorily address several of the basic elements of CDTI implementation. 94. TCC rejected the report to be resubmitted to the next TCC and recommended that the project address all the issues and concerns raised above as well as: i. provide more details on different activities undertaken and yet to be undertaken with regard to training, advocacy, sensitization and supervision; ii. give information on actions to be taken in order to minimize the problem of SAEs in the future; iii. consider the possibility of submitting proposals for operational research with regard to the occurrence of SAEs in Bas Congo. Discussion on Bas Congo 95. Dr Michel Boussinesq summarized the report of the team that visited the Bas Congo area in July 2004. Previous missions included that of the Project Coordinator (Dr Tambwe) from 26 December 2003 to 2 January 2004 and that conducted by Dr Adrian Hopkins from 2 to 7 February 2004. 96. It was stressed that, according to Dr Hopkins' mission report training and sensitization had been carried out satisfactorily in the Health Zone of Boma Bungu and Seke Banza. 16 97. A number of issues were raised during the discussion that followed. Even as cases of SAEs had been referred to hospitals within a couple of days after the onset of the symptoms, the case fatality rate remained high, possibly due to excessive levels of the microfilariae load in the blood and brain. 98. The anthropological part of the study had been an essential element including interviews with focal groups and discussions with families of those suspected to have died after treatment with ivermectin. 99. TCC endorsed a suggestion by the team that a number of operational research studies be undertaken including one aimed at developing a diagnostic tool for detecting those individuals harbouring Loa loa microfilaraemia; and operational research aiming at evaluating the possible role of Plasmodium infection as a co-factor favouring the incidence of Loa loa-related SAEs. 100. To a question regarding the facilities in the area for carrying out operational research recommended by the team, the Committee was assured that the local hospital was well equipped for the purpose. 101. The Committee noted the report presented by Dr Boussinesq and acknowledged the considerable efforts that had gone into the study and the preparation of the report. 102. The Programme Director informed the Committee about a request from the NOTF in DRC for guidance on the follow-up to the recommendations for CDTI implementation in Loa loa endemic areas and quoted to the Committee his response and recommendations to the NOTF as follows: 1) Reinforcement of the RAPLOA team with internal and external expertise; 2) REA to be combined with the RAPLOA exercise; 3) decision on continuation of the CDTI campaign to be based on the RAPLOA/REA findings; 4) the strategy adopted for Bas Congo would be extended to all areas in DRC with high risk of SAEs. 103. The Programme Director's correspondence to the NOTF in DRC on the above issue were to be copied to Merck and MDP. 104. TCC endorsed the recommendations above embodied in the Programme Director’s response to the NOTF in DRC. Kasai CDTI Project (4th year report) 105. The Committee commended the project for a well-written and informative report. It noted that, in spite of a difficult terrain, geographic and therapeutic coverage were good. 106. TCC also noted with satisfaction the integration of some interventions such as cataract case-finding into CDTI activities. It was also recorded that some communities provided support to their CDDs. 107. A number of issues were identified which TCC encouraged the project to address through: 17 a) intensifying advocacy towards the Government at the central and provincial levels in order to ensure they effectively contribute to the CDTI project finances; b) continuing sensitization of the communities in motivating CDDs; c) improving the request of Mectizan® tablets needed. This would avoid a large quantity of tablets remaining at the end of the treatment campaign. In addition, the project should also: d) distinguish the strengths from the weaknesses in its future reports; e) include the "plan of action of the MOH" as an annex in the next technical report as indicated in the report; f) provide more details on the activities and methods of community mobilization and CSM; g) clarify what is meant by "non respect of management standards of Mectizan® in some Health Zones"; h) increase the number of CDDs, particularly female CDDs. 108. TCC accepted the report but requested that the project address all the above issues in its next report. Bandundu CDTI Project (2nd year report) 109. There seemed to be a misunderstanding of the definition of UTG and ATO; and monitoring and operational research. In addition, the number of CDDs selected and trained was inconsistent throughout the report. 110. The report indicated that some effort had been made to improve coverage rates as well as several other aspects of CDTI implementation. TCC would, however, need clarification on the exact number of Health Zones covered by CDTI activities as it was unclear from the report if it was 6 or 9 Health Zones. 111. Like in the first year, the project continued to face a number of problems such as: a) high number of refusals and absenteeism; b) poor CDD motivation; c) poor recordkeeping by CDDs. d) low participation of women in CDTI activities; e) lack of feedback on training; 112. TCC accepted the report with the understanding that the project would address the above issues by taking the necessary measures to: i. reduce refusals and absenteeism; ii. improve community sensitization to encourage more CDDs to participate in CDTI; iii. improve the quality of training of CDDs on recordkeeping; iv. increase participation of women; v. conduct CSM and improve feedback; vi. intensify advocacy in order to secure government financial contribution for CDTI. 18 LIBERIA South-East CDTI Project (1st year report) 113. TCC recommended the withdrawal of the document which was presented to the Committee and requested that the project submit a comprehensive report on its activities to the next TCC using the standard CDTI project reporting form. Lofa, Bong, Nimba & Montserrado CDTI Project (4th year report) 114. Due to civil unrest in the country, no funding was requested by the project and no treatment was done during the reporting period. The project reported cases of looting of project office equipment and it was unclear if the 3 million Mectizan® tablets were also looted. 115. TCC was informed that an entirely new team had been put in place at the MOH and now that peace had returned to the country, CDTI activities could hopefully resume. 116. TCC recommended that the report be withdrawn and the project requested to submit a comprehensive report to the next TCC using the standard CDTI project reporting form. MALAWI Thyolo & Mwanza CDTI Project (6th year report) 117. The report was not endorsed and the TCC17 recommendations to the project were not addressed, namely the project was to: 1) address issues identified in evaluation reports, especially improvement of coverage rates and financing; 2) finalize and submit sustainability plans rapidly to avoid interruption of treatment. 118. For a project in its 6th year of implementation, 54% therapeutic coverage and 66.8% geographic coverage were unsatisfactory. 119. The Committee noted some discrepancies between figures reported for 2002 in the report submitted to TCC17 where therapeutic coverage was 60.8% and geographic coverage 85%; and figures given in this report (49% and 61.9% respectively), which portrayed a worrying inconsistency in reporting of actual treatment figures. Also the amount of $2,480.97 given on page 20 of the report as being the financial contribution from the MOH did not tally with the amount of $145 reported as having been received from the MOH within the same period. 120. Several other issues and weaknesses were noted in the report and TCC requested that the project take the following measures: a) determine conclusively communities eligible for CDTI, in other words, conclude REMO; b) provide accurate figures for total population of the project area, total population in meso and hyperendemic communities and the UTG; c) intensify HSAM at all levels; d) conduct training, particularly CSM and SHM, at all levels and provide information on the number of district and health facility staff trained and involved in CDTI; 19 e) encourage communities to participate in supervision activities in Thyolo; f) request communities to select and train more CDDs; g) indicate all sources of funding; h) procure Mectizan® early enough and not one month before distribution; i) provide more information on integration of CDTI into the PHC system. 121. TCC rejected the report to be resubmitted to the reviewers through APOC Management and recommended that technical assistance should be provided to the project by APOC Management for retraining of implementers on all aspects of CDTI. Extension Districts CDTI Project (4th year report) 122. The project did not fully address TCC17 recommendations. Geographic and therapeutic coverage rates remained low at 26.7% and 19% respectively which was worrisome and unacceptable for a project in its 4th year. With regard to financing, some progress seemed to have been made as Districts provided US$1,764.10. However, no progress had been made on the other recommendations of researching into reasons for low coverage, commencing CDTI in Chirandzulu (by June 2003) and completing training in Blantyre (by January 2003 and yearly thereafter). So the number of communities implementing CDTI was low. 123. The level of integration was reported as high but had no visible impact on coverage. 124. The quality of the report was poor and could have been improved upon if it had been reviewed and endorsed by the NOTF. Planning of CDTI was also very poor and the consequence was the low coverage rates observed. 125. TCC observed that: 1) health workers were delivering Mectizan® to communities and that was unacceptable; 2) there were health personnel within districts who could be trained to empower the communities; 3) donated equipment was functional and available and should be used for programme activities. 126. Overall, the project seemed to have a poor understanding of the CDTI philosophy and a problem of communication between the various levels of CDTI implementation in the country. 127. TCC rejected the report to be resubmitted to reviewers and requested the project to: i. address all the recommendations of TCC17 summarized above; ii. improve planning with communities and empowerment of health staff and communities; iii. urgently introduce CSM and SHM in all districts; iv. produce IEC materials for use in advocacy, sensitization and mobilization; v. APOC Management to provide support for CDTI monitoring and implementation. 20 NIGERIA NOTF Secretariat (6th year report) 128. TCC commended the NOTF Secretariat for a good report, for playing a key role in coordinating and monitoring CDTI projects, for the procurement of Mectizan®, and to some extent for advocacy aiming at ensuring that States and LGAs contributed financially to CDTI activities. This had helped in putting weak CDTI projects back on course, resulting in a general improvement in coverage. 129. However, there was no information provided on core CDTI activities such as training. There was often no discussion of the figures in the tables which were very often intriguing. 130. TCC noted the many challenges to sustainability of CDTI projects discussed in the report and outlined below: a) poor or no funding from many States and LGAs; b) low CDD/population ratios in many projects; c) common issues regarding CDD incentives and complications arising from incentives provided by other public health and disease control programmes; d) lack of involvement of women in CDTI in some States; e) delay in salary payments of health workers in some States affecting motivation for CDTI activities. 131. TCC accepted the report but recommended that: i. the NOTF Secretariat should provide information on State and LGA financial contributions; ii. the project analyze the information given in the tables on training, treatments, etc. and try to list lessons drawn from them in order to improve CDTI activities; iii. the NOTF secretariat be encouraged to work proactively towards resolving the concerns and challenges cited above regarding the sustainability of CDTI. Cross River CDTI Project (6th technical report) 132. TCC commended the project for an excellent report and for its orientation to problem- solving and managerial attentiveness. 133. Although no APOC funds were received during the reporting period, the Cross River State had come forward to support CDTI activities. This was a significant accomplishment and reflected consistent attention to mobilization at all political levels and commitment of local Non-Governmental Organizations (NGOs) and Community-Based Organizations (CBOs) as advocates and partners. 134. Given the large number of local NGOs and CBOs involved in CDTI and new add-on activities (Vitamin A supplementation and prevention of blindness), TCC requested that subsequent technical reports discuss the coordination and networking of all these various organizations. 135. TCC accepted the report. 21 FCT CDTI Project (5th year report) 136. The report was well-written, comprehensive, and informative although efforts should be made to include a more comprehensive summary of project activities in the executive summary of future reports. 137. The presentation of MOH expenditures was confusing, since expenditures were described in the absence of release of funds. Likewise, no expenditures were described for the available APOC funds. The TCC requested clarification on the various expenditures. 138. TCC was concerned about the level of integration of the project as it was noted that training, supervision and monitoring were not integrated into those of other programmes. Although CDTI activities were budgeted for in the MOH budget, funds were not always released. There was lack of support from communities to CDDs and a decline in the performance of some LOCTs and FLHFs staff due to lack of support. 139. TCC however commended the project for maintaining excellent therapeutic coverage of over 84% and 100% geographic coverage for several years. 140. TCC accepted the report but recommended that the project: i. perform planned operational research on incentive options for CDDs; ii. assess onchocerciasis endemicity in FCT satellite communities after consultation with APOC Management; iii. continue to increase the number of CDDs; iv. train MOH staff at all levels on the management of SAEs; v. strive to reduce the number of refusals and absentees; vi. integrate project activities into PHC and into other health programmes for the sake of sustainability; vii. submit its 3-year post-APOC sustainability plan to APOC Management as soon as possible. Kano State CDTI Project (5th year report) 141. The report was well-written and faithfully followed the reporting format. 142. Geographic and therapeutic coverage rates were sustained at a high level. 143. The report stated that reaching women in purdah was a problem but the treatment figures were quite high. Lack of female CDDs was also noted as an issue but treatment coverage remained high. The Committee wondered if there was any direct impact of the low number of female CDDs on treatment coverage. 144. Integration into the PHC system appeared to be weak and more emphasis should be placed on this aspect of CDTI. If integration was occurring, the project should provide details in the next report. 145. The report noted that add-on interventions had potential to extend CDTI but there was nothing mentioned regarding plans or opportunities for such interventions and details of implementation. 22 146. Although financial support from the MOH at all levels was listed as zero, there was considerable support being provided by the State and the LGA. The project may not receive State or LGA funds directly. For example, fuel and maintenance were provided by the State but no funds were noted. More information would give TCC a better assessment of the value of State and LGA funding. 147. TCC accepted the report but recommended that the project: i. provide details of integration of CDTI in PHC in its next report; ii. describe any plans for add-on interventions in future years; iii. provide more details about State and LGA contributions; iv. provide evidence, if any, of the impact of lack of female CDDs on treatment coverage. Jigawa State CDTI Project (5th year technical report) 148. TCC acknowledged that the report was well-written, comprehensive and informative although it requested that future reports should include a more comprehensive summary of project activities in the executive summary. 149. The Committee commended the project for maintaining high coverage for several years (100% geographic and over 83% therapeutic). 150. The project raised a number of issues and the necessary actions taken to resolve them. However, TCC noted the following issues which were also identified but still remained unresolved: 1) inadequate support of CDDs by communities; 2) minimal supervision by LOCTs; 3) payment of incentives to village workers by other health programmes has caused problems with CDTI implementation; 4) low participation of women in CDTI. 151. TCC requested that the project: a) explain the UTG of 150,000 (94% of total population). This figure seemed high since it was unlikely that 94% of the total population would be eligible for treatment; b) use the figure of 150,000 in all calculations requiring a percentage UTG coverage (ref. last column, Table 10), rather than using a different denominator for each calculation; c) explain what expenditures were covered by funds released by the NGDO and communities. Funds were released by these partners but were not indicated in the expenditures in Table 12; d) explain expenditures made by the State since no release of funds by MOH was indicated in Table 11; e) continue to encourage the selection of additional CDDs. CDD/population ratio was approximately 1:466 during the reporting period; f) train MOH staff at all levels on the management of SAEs; g) continue efforts to involve women in all project activities. 23 152. TCC accepted the report with the understanding that the project would address all the above issues in its next report. Yobe State CDTI Project (5th year report) 153. This was a well-written, comprehensive and informative report. 154. TCC commended the project for seeking technical support from an experienced local NGDO (MITOSATH) that had been involved in CDTI for a number of years. The project was also applauded for efforts made in securing government and community support for CDTI activities. TCC encouraged the project to continue operational research activities. 155. The Committee had difficulty in determining the correct therapeutic coverage since the total population used in the calculations varied; e.g. therapeutic coverage for 2003 given in the executive summary did not match that provided in Table 10. 156. TCC also noted with concern the lack of commitment of the FLHF staff in the supervision of CDTI activities and the too few number of CDDs for the population eligible for treatment. During the reporting period the CDD/population ratio was approximately 1:1000, of which very few were women. 157. TCC requested that the project: a) include a more comprehensive summary of its activities in the executive summary in its future reports; b) be consistent with total population figures for the meso and hyperendemic area and UTGs throughout future reports. Figures differ from table to table and those in the executive summary did not match all the figures found in the body of the report. The correct figures for the current reporting period should be submitted to APOC so that therapeutic coverage and UTG can be evaluated; c) continue to encourage the selection of additional CDDs and particularly involve women in all project activities. 158. TCC accepted the report with the understanding that the project would address all the above issues in its next report. Gombe State CDTI Project (4th year report) 159. TCC commended the project for a good presentation of the report which was concise and comprehensive. 160. The project reported a geographic coverage of 82% which was rather unsatisfactory for a project in its 4th year. Although the ATO had always been exceeded, therapeutic coverage was 67% for the reporting period which was a decline in the coverage of previous years. 161. There seemed to be a good integration of CDTI into the PHC and TCC encouraged the project to continue its efforts in the mobilization of communities, advocacy visits and sensitization. 24 162. It was brought to the attention of TCC that the project had still not resubmitted its sustainability plan since the rejection of the last one. 163. TCC requested that the project provide more information on: a) clinic-based treatment; b) outcome of supervision used to improve implementation; c) absentees and refusals as these were not noted in table 8. 164. TCC accepted the report with the understanding that the project would address all the above issues in its next report and resubmit a proper sustainability plan prepared by the stakeholders themselves as requested by APOC Management. TANZANIA Kilosa CDTI Project (3rd year report) 165. This was a resubmission of the technical report of Year 2. TCC commended the project for making significant progress in reporting. 166. The project reported a therapeutic coverage of 65% although some discrepancies were noted in the number of persons treated. The project appeared to confuse the UTG and ATO and thus was requested to reconcile slight differences in treatment population and number of treatments in subsequent reports. UTG should be used to calculate coverage. 167. TCC noted that the project had equal number of male and female CDDs which suggested that the project may be dictating the number of CDDs per community. 168. TCC requested that the project: a) provide more details in the executive summary of subsequent reports about specific activities undertaken in the reporting year; b) finalize the REMO exercise and provide an updated map in its next report; c) ensure that communities take independent decision regarding the selection of CDDs; d) provide more information to distinguish urban from rural CDD attrition rates; e) develop health education materials and messages that emphasize sustainability in addition to other messages. 169. TCC accepted the report with the understanding that the project would address all the above issues in its next report. UGANDA Phase II (5th year report) 170. With a therapeutic coverage of 78.3% and 100% geographic coverage, TCC commended this project which was in its 5th year and had consistently sustained high therapeutic coverage for the past 4 years. 25 171. The Committee noted with satisfaction that CDTI had been well integrated into the PHC system. All districts had developed post-APOC sustainability work plans and were advised to include CDTI activities in their plans to get funding. In addition, national onchocerciasis coordinators were also focal persons for vector-borne diseases and there seemed to be joint supervision with other programmes (Malaria being an example). Mectizan® was delivered through the essential drugs delivery channel. 172. However, TCC also noted that there was a lack of adequate IEC materials. The involvement of health workers in the supervision of CDDs was also judged inadequate and there seemed to be delays in the release of funds by the district and NOTF for CDTI activities. 173. The report was well-written and although the executive summary was in the form of tables, not all the columns were completed and there was no indication of the author. 174. TCC accepted the report but recommended that the project should, in its future reports: i. state clearly the author of the report; ii. provide an executive summary in prose not in tabular form; iii. complete information in all columns; iv. check population figures; v. account for some 51,570 tablets of Mectizan® and 13,424 expired tablets. UPDATE ON VECTOR ELIMINATION ACTIVITIES WITH SPECIAL EMPHASIS ON THE TUKUYU FOCUS: Agenda Item 10 TUKUYU FOCUS 175. The first ground larviciding took place from July to December 2003. The results indicated that no blackflies were collected between July 2003 and January 2004 at the following catching points several months after the treatment: Tapio (4 months), Lufilyo (5 months), Lwanga-Masako (8 months), Ntaba (8 months), Kapeta (9 months) and Kambasegela (10 months). The persistence of blackfly presence on Upper Lumbira seemed to be due to local treatment failures. 176. TCC reviewed the problems (logistics, personnel, temephos importation, central level involvement, financial management of project) and the proposed solutions. 177. Given the present isolation of the focus, and the accessibility of the breeding sites of the main watercourses and tributaries, and in the light of the data collected during the 2003 campaign, TCC suggested that APOC Management accept a second and last vector elimination campaign in the Tukuyu focus subject to the following conditions: 1) obtain commitment from the State (MOH, National Coordinator) to assume responsibility of project management (technical activities, follow-up of funds outlay, forwarding of financial returns to APOC Management) (Oct 2004; National Coordinator); 2) obtain from project, financial returns for all funds that were already committed by APOC Management for the implementation of the vector elimination project in Tukuyu (end Sept 2004; Project Manager, National Coordinator); 26 3) draw up an accurate timetable indicating deadlines of activities to be undertaken: preparation, implementation, surveillance (Oct 2004, Project Manager, National Coordinator, APOC Management); 4) draw up a budget for the next campaign (Dec 2004, Project Manager; National Coordinator, APOC Management); 5) update the 2003 map of larvae breeding sites before the next campaign (Oct-Dec 2004, Project Manager, National Coordinator, APOC Management); 6) determine the duration of the campaign and the quantity of additional insecticide required (Dec 2004, Project Manager, National Coordinator, APOC Management); 7) obtain authorization for the importation of temephos in time for launching the 2005 campaign (Dec 2004, National Coordinator); 8) conduct river trials of temephos phytagri (Oct-Dec 2004, Project Manager, National Coordinator, APOC Management); 9) provide adequate external personnel support during the first 6 weeks of the campaign, and thereafter, as may be required. This expertise should preferably be in the field of entomology, should be somebody familiar with larviciding (July 2005, APOC Management); 10) submit monthly reports to the National Coordinator and APOC Management on project activities completed during the month and on those planned for the subsequent month (from Oct 2004 through the end of the 2005 campaign, Project Manager and National Coordinator); 11) submit to TCC20 a progress report on the planned activities mentioned in points 1 to 10 listed above (Jan 2005, Project Manager, National Coordinator, APOC Management). MPAMBA-NKUSI 178. APOC financing for vector elimination in the Mpamba-Nkusi focus which started in 2002 was renewed in 2003. For the 2002-2003 exercise, only 4.3% of crabs had pre-imaginal stages of S. neavei (368 positive/8509). The 2003-2004 report would enable us assess the progress of the project towards a definitive elimination of the vector. 179. Larviciding and entomological surveillance were to continue in this focus. ITWARA FOCUS 180. Since 1997, the main Itwara focus had been free of blackflies. The same can be said of the sub-foci of Siisa and Aswa since 2002. Currently, only entomological surveillance was ongoing in the focus and should be continued. Meanwhile steps were being taken to define criteria for the certification of eradication of the vector in these foci. 27 BIOKO FOCUS 181. Due to late delivery of the larvicide, the second round of larviciding which was scheduled for 2004 had to be postponed to the dry season of 2005. 182. Preparations for the 2005 larviciding campaign had been undertaken during 2004. Emphasis was placed on entomological surveillance (followed by Simulium density fluctuations) and on the typology of larvae breeding sites. The latter would help in targeting future treatments properly. PHASE II OF THE LONG-TERM IMPACT ASSESSMENT OF APOC OPERATIONS Agenda Item 11 183. Prof Braide informed TCC that the Phase I impact assessment had been carried out in 13 sites across 8 countries. Preparatory visits had been completed for Phase II in 7 countries (Ethiopia, Sudan, Cameroon, Tanzania, CAR, Nigeria and Uganda) and the clinical and socio- anthropological studies had been completed in Ethiopia (1), Sudan (1), Cameroon (1 out of 2), Uganda (1) Nigeria (2 out of 3) and Tanzania (1). The studies were still ongoing in the two sites of CAR. 184. Preparatory visits and the execution of clinical and socio-anthropological studies in the two sites in DRC were planned for Nov-Dec 2004 and entomological studies were ongoing in all the sites except those in DRC. 185. Prof Braide also informed the Committee that all the results would be ready for TCC21 in September 2005 but that partial results could be made available for TCC20 in March 2005. 186. Dr Sékétéli insisted that the results should be ready before the External Evaluation of APOC. 187. It was suggested that the first batch of articles on the impact assessment be submitted for publication by the end of October 2004. REPORT ON TOOL FOR RAPID MONITORING OF TREATMENT COVERAGE: Agenda Item 12 188. Dr Uche Amazigo presented the results of a multi-country study on the assessment of the effectiveness of different channels for rapid monitoring of treatment coverage, using school children as proxy. The study was coordinated by Prof A. Abiose and Dr Onwujekwe. 189. CDTI had been identified as an effective strategy for meeting the principal challenge of sustained delivery of ivermectin to all endemic communities. The ONCHOSIM simulation model for onchocerciasis estimated that, depending on the prevailing level of endemicity, an annual therapeutic coverage of at least 65% of the total population of a community, for a period ranging from 15 to 35 years, was required to eliminate the disease as a public health problem. This calls for regular monitoring of the implementation of CDTI. 28 190. The school-based monitoring method had been reported in a study in Uganda as an effective and low-cost approach to monitoring CDTI. The objectives of the multicountry study were: 1) to validate the Uganda study on the relationship between treatment coverage of school children and community treatment coverage; 2) to identify and describe other alternative rapid and reliable methods of delivering monitoring tools and collecting data for treatment coverage from schools; 3) to assess the effectiveness of various methods of delivering monitoring tools to schools and collecting data for monitoring treatment coverage. 191. The study was conducted in three sites, namely Enugu and Kaduna States in Nigeria, and Abu Hamad Province in Northern Sudan. A cross-sectional design was used to collect data from primary school pupils, households and CDD registers on ivermectin treatment coverage rates, five to six weeks after the distribution of ivermectin in the study sites. The level of correlation of the methods was tested using the Pearson correlation coefficient. 192. The school monitoring form was delivered to the schools through different media. In Enugu, it was delivered to the head teachers through the Local Education Secretary. The head teachers in Sudan received the forms from public transporters, while the health system was used in delivering the form to head teachers in Kaduna. The researchers trained the head teachers in Kaduna and Sudan on how to complete the form. 193. The correlation of household survey and school-based strategy was 10%, 49% and 72% in Kaduna, Enugu and Abu Hamad respectively. The combined data from the three study sites gave a correlation coefficient of 68% (p<0.0001). The Pearson correlation coefficient for household survey with CDD register was low and not significant in Abu Hamad and Kaduna but high and significant at less than 0.0001 level in Enugu. However, the combined data revealed that the treatment coverage rates from the CDD registers correlated highly with household survey (86%). All the same, the results identified the school-based monitoring provided effective, simple and a low-cost approach to providing reliable data on community treatment coverage. 194. No matter the channel used for the delivery of the forms to the schools, substantial success was recorded in relation to the valid return of the forms sent to the schools. 100% valid return of the school forms was recorded in Sudan and Kaduna, while 70% valid return was recorded in Enugu. The period between delivery and return of the school forms ranged from one to three weeks. 195. It was thus recommended that the school-based monitoring approach be further validated on a large-scale by programme managers and adopted for low-cost rapid monitoring of coverage with ivermectin in the different CDTI projects. 196. TCC commended the research team, endorsed the report and encouraged the use of the school-based monitoring approach by NOTFs for rapid monitoring of treatment coverage 2 months after distribution. 29 UPDATE ON SUSTAINABILITY OF CDTI: Agenda Item 14 197. Dr Uche Amazigo informed the Committee that the following guidelines and instruments for conducting sustainability activities had been revised and were now available: 1) Guidelines for conducting an evaluation of the sustainability of CDTI projects; 2) Guidelines for developing a CDTI sustainability plan (for 3rd and 5th year projects). 198. Also, “Criteria for reviewing sustainability plans developed and pre-tested” were now available. The tools for monitoring the implementation of sustainability plans were to be finalized after they had been pre-tested in Tanzania. 199. By 31 December 2003, 35 projects had been evaluated and 19 were planned for 2004. In all, 382 sustainability plans from districts were expected, 275 had been received and 238 had been reviewed and new Letters of Agreement had been signed. 12 projects were still to submit their sustainability plans. 200. As to the findings of the evaluation exercises, it was agreed that APOC should focus monitoring on the district/LGA, FHLF and community levels and feedback given to the higher levels afterwards. Monitoring of the implementation of sustainability plans should be carried out by an external team at the end of the 4th year for projects evaluated in their 3rd year. Projects evaluated in their 5th year should be monitored for the implementation of their sustainability plans at the end of the 6th and 8th year. 201. Monitoring of the implementation of sustainability plans was carried out in three CDTI projects: Phase I in Uganda, Kaduna & Taraba in Nigeria. The findings of the implementation of sustainability plans included: satisfactory delivery of ivermectin at all levels; effective integration of CDTI within the overall health system (Uganda); and continuous and satisfactory accomplishment of the work of CDDs. Thus, sustainability of CDTI seemed achievable. 202. The challenges were for APOC to review the current indicators for assessing the sub- district level, the FLHF. It would appear that the role of the FLHF was perhaps more important at the beginning of a project than it was in subsequent years. 203. TCC recommended that APOC funds could be made available to finance training of more CDDs and other members of the community when justified. 204. The eventual role of NGDOs in the post-APOC sustainability phase would be determined by the governments and partner NGDOs. REPORT ON THE FINANCIAL MANAGEMENT OF APOC-FUNDED PROJECTS: Agenda Item 17 205. The Committee was informed that CDTI activities in Liberia were resuming, after the civil strife, with the gradual disbursement of funds for the accessible areas, especially in the South-Western CDTI projects. 206. In CAR, the resumption of CDTI activities would be determined after a post-war assessment by the APOC Management before the end of 2004. 30 207. In Equatorial Guinea, activities would resume after the reimbursement of outstanding funds. 208. It was reported that 17 projects did not submit their budget proposals for activities of subsequent years and 37% of all projects failed to transmit their financial returns. APOC Management was requested to ask projects to adhere strictly to their reporting obligations. REPORT ON COST PER TREATMENT WITH IVERMECTIN: Agenda Item 13 209. Prof McFarland presented the results of the CDTI cost per treatment study commissioned by APOC Management. She emphasized that the results presented were preliminary and data were still being refined and additional data analysis were being done. 210. Cost data were presented for 8 CDTI projects in Cameroon, Nigeria and Uganda by: 1) source of funding, 2) financial/economic input, and 3) CDTI activity. Projects selected for study were in their 5th year of CDTI implementation; this was in order to determine cost per treatment in mature projects which were moving towards the end of APOC funding. Projects were also selected to reflect differences in size, geographic dispersion, NGDO partner and Loa loa endemicity, variables that would be likely to influence cost of treatment. 211. The cost per treatment ranged from $0.26 to $1.36. These costs were baseline figures for CDTI only and did not include costs of add-on interventions, the monetary value of volunteer time of CDDs and other community members, nor did it include the monetary value of the Mectizan® donated by Merck and Co., Inc. 212. A separate analysis of the monetary value of CDD time and the time of community volunteers illuminated the significant contribution of volunteers in CDTI. 213. TCC congratulated Prof McFarland on the considerable progress made in the planning and implementation of the cost per treatment study. 214. Dr Sékétéli stressed the importance of the study for national governments to enable them make their own estimation of the cost implications for planned CDTI operations and looked forward to the finalization of user-friendly guidelines to be made available for use by project staff through workshops. 215. Mr Bruce Benton also emphasized the importance of the cost per treatment study. He found it reasonable to exclude the volunteer time from the study as the monetary value of the ivermectin tablets was also not included in the calculations. Volunteer time was, however, an important value in CDTI operations, he stressed. 216. For discussions with governments, donors and other partners, Prof McFarland indicated that the figure of US$0.50 per person treated would be a reasonable estimate to use. This, however, did not include the monetary value of volunteer time. 217. As to what it would take to include the cost of add-on interventions in the estimates, Prof McFarland explained that an attempt might be made to work with project staff in key projects where add-ons had been implemented. Any cost estimates for CDTI projects supported 31 by national NGDOs could be worked out locally. Finally, any calculation of the cost/effect of SAEs and of CDTI projects in conflict areas would require additional data. 218. The final report would be ready for consideration by TCC20 in March 2005. INTEGRATING VITAMIN A SUPPLEMENTATION AND CDTI: Agenda Item 22 219. Dr Siméon Nanema of the Micronutrient Initiative (MI) summarized the activities, progress and plans of MI regarding integration of Vitamin A supplementation into CDTI in 4 countries, namely: DRC, Nigeria, Sudan and Tanzania. Dr Grace Saguti, the National Onchocerciasis Coordinator of Tanzania and Dr Yisa Saka, Deputy National Onchocerciasis Coordinator of Nigeria, both provided details regarding the progress and future plans for integrating Vitamin A supplementation into CDTI in their respective countries. These included activities for supplementing children of 6-59 months of age and women within 6-8 weeks post partum with Vitamin A. 220. Mr Benton expressed his satisfaction with the considerable progress in the move towards integrating other health activities into CDTI projects which, he stressed, had the full support of the donor community for the APOC Trust Fund to be used for such activity on a pilot basis, as stipulated in the Memorandum for APOC Phase II. He also referred to the Copenhagen Consensus, where improving micronutrient status was listed as the number 2 most cost-effective intervention among 17 priorities for development in developing countries. The importance of integration in strengthening national health services was also stressed. 221. Dr Sékétéli indicated that if the APOC Trust Fund was to be used, integration must be done into existing CDTI proposals, which should first come to TCC in March 2005 for consideration. 222. The Programme Director added that the original plan to hold meetings in each of the 4 pilot countries to develop proposals for submission to APOC had been replaced with 4 missions by MI staff and other stakeholders to develop concept papers in collaboration with the NOTFs and NGDOs involved. The concept papers were to be presented at the next CSA and/or at the JAF10 sessions. ADDITIONAL MATTERS DISCUSSED BY TCC19: Agenda Item 23 FORMAT FOR TECHNICAL REPORTS 223. The formats for NOTF Secretariat reports and CDTI technical reports were reviewed by TCC working groups. The new formats would now be sent to the NOTF Secretariats for comments with a view to using them before TCC20 in March 2005. PROGRESS REPORT ON SOUTH SUDAN 224. The Committee was informed about a workshop for CDTI workers held in Rumbeck at the end of August/early September 2004. The facilitators were, among others, Dr Adrian Hopkins representing CBM, the coordinating NGDO; APOC Management (Mr Aholou, Ms Keita, Dr Amazigo); Prof Eka Braide, chair of TCC and Mr C. Okwonkwo of the NOTF/Nigeria. 32 225. The agenda of the workshop dealt with such matters as the CDTI philosophy, strategy and implementation, the annual technical reports and the role of TCC as the overseeing technical body of APOC. Dr Hopkins explained the role of NGDOs in CDTI projects particularly those projects in areas of civil conflict. 226. The project teams in South Sudan needed some kind of operational support and it was suggested that the teams could visit CDTI projects in neighbouring countries in order to exchange views with them. This visit should however only be envisaged once the teams had accumulated some degree of operational experience. 227. Dr Sékétéli was pleased with the progress made in South Sudan where 2 out of 5 projects approved were ready to start operations by October 2004. He expressed his gratitude to CBM for its readiness to coordinate the activities of NGDOs in South Sudan and to financially and technically support the implementation of approved CDTI projects there. UPDATE ON THE BILL & MELINDA GATES FOUNDATION MEETING ON INTEGRATION 228. Dr Uche Amazigo reported on a meeting held at the Bill & Melinda Gates Foundation, Seattle, Washington on 29-30 July 2004 on “Integration of Community-based Programmes”. The meeting was attended, among others, by representatives of the World Bank, the Lymphatic Filariasis (LF) Elimination Programme, the Global Fund, TDR, the Carter Center, Trachoma Initiative, Center for Disease Control (CDC), Micronutrient Initiative (MI) and APOC. 229. Dr Amazigo outlined the objectives and proceedings of the meeting. Key issues discussed at the meeting included obstacles to integration at different levels – national and international; opportunities and overcoming critical barriers to integration. The meeting suggested that the focus should be on the integration of 6 neglected diseases: guinea worm, LF, onchocerciasis, schistosomiasis, soil-transmitted helminthes, and trachoma. However, integration with other programmes, such as immunization, respiratory illness and diarrhoeal diseases should be considered. Integrated programmes also needed to link to other sectors, including agriculture and education sectors. 230. The Bill & Melinda Gates Foundation had written to disease control programmes (including APOC) that were willing to request funding for integration to submit a Letter of Intent to the Foundation for review. 231. A copy of the summary report of the meeting is attached as Annex 5. EXTERNAL REVIEW OF APOC AND SIZ 232. Mr Bruce Benton informed TCC that the Terms of Reference for the APOC External Evaluation had been drafted, discussed at the recent NGDO Group meeting, and would be finalized at the October 2004 session of CSA. The Evaluation would focus on what was required to ensure a successful end of APOC operations in 2010 – or beyond. The evaluation team was being put together and the cost of the exercise would be borne by the World Bank and APOC Trust Fund. 233. As to matters concerning SIZ operations, WHO as the executing agency, and the World Bank as the fiscal agency, assumed joint responsibility. 33 234. In this regard, Dr Sékétéli added that the Special ad hoc Committee of SIZ (SAC) had accepted to undertake the planned Mid-term Review of SIZ activities in the former OCP countries in 2005. The team was to include Dr Bernard Philippon and Mr Georges Koulischer who were both familiar with OCP. The SAC had already prepared the TORs and a work plan on which comments by TCC members were sought. 235. The following comments and suggestions were put forward by TCC on the TORs of the External Evaluation of APOC: 1) The objective of APOC should be clearly stated in another paragraph (i.e. paragraph 2) under the "Introduction and Background" section; 2) The TORs should include specific objectives of the evaluation in Section 2, "Objectives of the Review"; 3) Section 3, Terms of Reference, needs to be reorganized as follows: a) Section 3.2 should be renamed to read “Evaluation of Results” with two sub- sections, namely: 1) Coverage and 2) Sustainability of the CDTI strategy; 2.1 Integration of CDTI into the PHC system; and 2.2 Financial Integration of APOC Management; b) Programme Management can stand as a separate section on its own; 4) A section on "Capacity-building" should be added; 5) The TCC discourages the use of the word “impact” as that is beyond the scope of the evaluation (in section 3.2, point 3 and section 3.3, point 3) and suggested replacing “impact” in those bullet points with “assess the evidence regarding the impact of … "; 6) Given that APOC and SIZ are two separate legal entities with different objectives, TCC suggests that the external evaluation of APOC and the Mid-term Review of SIZ be conducted separately, with separate reports prepared, but the teams of both evaluations may be brought together to produce a consolidated document of their findings. 236. The above comments were submitted to Mr Bruce Benton by APOC Management on behalf of TCC. 237. There were no specific suggestions of modification made with regard to the TORs of the Mid-term Review of SIZ. INFORMATION ON APOC CONTRIBUTION TO SIZ 238. Dr Laurent Yameogo, Coordinator of the Programme Director’s Office, explained that APOC support to SIZ activities were mainly technical and administrative, and did not include any financial contributions. For example, APOC Management was organizing a meeting to be held from 17-19 November 2004, bringing together all ex-OCP National Coordinators and other partners, including NGDOs concerned with SIZ operations. 34 239. APOC Management was also in contact with high level authorities in the SIZ countries concerned to ensure the best possible implementation of the planned activities and provided technical advice to the countries whenever required. 240. Mr Benton informed TCC that the current balance of the SIZ budget was US$6.5 million only. OTHER MATTERS: Agenda Item 24 241. The Committee expressed its thanks to Mr Bruce Benton on the occasion of his retirement from the World Bank, for his consistent devotion to the control of onchocerciasis since the inception of APOC. The Committee highly appreciated his support for the work of TCC and his personal attention to the technical and financial aspects of APOC. The TCC expressed to Mr Benton its best wishes for a happy and well-deserved retirement. Pooling of Mectizan® orders by participating countries 242. TCC noted that many projects reported that their Mectizan® tablets were requested from the Mectizan® Donation Program by NGDO partners on behalf of the National Onchocerciasis Control Programmes (NOCPs). TCC recommended that the responsibility for ordering Mectizan® should be gradually devolved to the NOCPs. NOCPs could then request Mectizan® for the entirety of their countries, if possible, using requests submitted from individual CDTI projects. Support to NOTFs in the implementation of TCC recommendations 243. The Committee was concerned that there could be difficulties at the country level in effectively translating some of the TCC recommendations into action. Ways and means would therefore need to be found to help the projects and NOTFs in arriving at a clear understanding of what was the intention of TCC in expecting implementation of these recommendations. Suggestions were made such as: 1) inviting National Coordinators to attend TCC sessions on a rotational basis; 2) promoting operational research aiming at elucidating solutions to overcome implementation constraints; 3) discussing problem-solving at the community level and transmitting their findings to the national level. 244. The possibility of TCC members helping NOTFs in the effective implementation of the Committee's recommendations was also raised. It was suggested to take up the issue again at TCC20 for further discussions. DATES AND PLACE OF THE TWENTIETH AND TWENTY-FIRST SESSIONS OF TCC: Agenda Item 25 245. TCC agreed to meet in Ouagadougou from 14 to 19 March 2005; and from 19 to 24 September 2005 for its twentieth and twenty-first sessions respectively. 35 CONCLUSIONS AND RECOMMENDATIONS OF TCC19: Agenda Item 26 246. A draft report was approved by the Committee with the understanding that all suggested modifications would be included in the final report which will be circulated to TCC members. A list of conclusions and recommendations of the meeting is also attached as Annex 6. CLOSURE OF THE SESSION: Agenda Item 27 247. The Programme Director thanked the Committee for having done a thorough job. He warned that TCC would be called upon to advise on the possibility of an extension of APOC operations beyond 2010. He stressed that such extension would not require additional donor contributions to the Trust Fund. He referred to the forthcoming JAF10 session to which the TCC Chair, NGDO Group representatives, Merck and MDP would be invited. Documentation for the session would be scrutinized at the CSA session in October 2004. He specifically referred to the cost per treatment study with its implications for planning at the country level and for donor support. 248. Dr Sékétéli also thanked Dr Saguti of Tanzania and Dr Saka of Nigeria for their contribution to the discussions of the Committee. 249. Prof Braide praised that the development of the TCC agenda, and the discussion thereof, had enabled the Committee to devote more time to discussing technical issues. She looked forward to the views of TCC on how to support NOTFs in addressing their problems identified by the Committee. She finally stressed the need for sanctions against those projects that delayed in submitting or did not submit their technical reports. 250. After thanking TCC members and all other participants, the APOC staff and the interpreters, Prof Braide declared the TCC19 session closed. 36 Annex 1 LIST OF PARTICIPANTS TCC MEMBERS 1. Prof Ekanem Braide, Chair of TCC, Dept. of Biological Sciences, University of Calabar, P.O. Box 3679, Calabar, Nigeria, Tel: (234) 87 230 452, Fax: (234) 087 230 914/ 087 230 911, E-mail: ekanem_b@hotmail.com; onchocal@skannet.com 2. Dr Elizabeth Elhassan, Country Representative of Sight Savers International, 1 Golf Road, P.O. Box 55, Kaduna, Nigeria, Tel: (234) 62 24 83 60 or 62 24 89 73, Fax: (234) 62 24 89 73, E-mail: ssing@infoweb.abs.net 3. Dr Mary Alleman, Associate Director, Mectizan® Donation Program, 750, Commerce Drive, Suite 400, Decatur, GA 30030, Atlanta, USA, Tel: (1) 404 371 1460, Fax: (1) 404 371 1138, E-mail: malleman@taskforce.org 4. Dr Michel Boussinesq, s/c Valérie Delplanque, IDR, 213 rue La Fayette, 75480 Paris Cedex 10, France, Tél/Fax: (33) 1 42 49 38 15, Email: michel.boussinesq@wanadoo.fr 5. Dr Peter Enyong, Tropical Medicine Research Station, P.O. Box 55, Kumba, Cameroon, Tel: (237) 35 42 31, Fax: (237) 35 42 31, E-mail: penyong@camnet.cm 6. Dr Moses Katabarwa, The Carter Center, Global 2000, 2nd Floor, Kirbo Bldg, 1149 Ponce de Leon Av, Atlanta, GA 30306, USA, Tel: (1) 404 420 3830, direct: (1) 770 488 4511, E-mail: mkataba@emory.edu 7. Prof Soungalo Traoré, c/o African Programme for Onchocerciasis Control (APOC), P.O. Box, 549 Ouagadougou 01, Burkina Faso, Tél: (226) 33 48 39, Cel: (226) 78 85 24 56, Fax: (226) 32 63 35, E-mail: pefoungo@yahoo.fr 8. Dr Christine Godin-Benhaïm, 33 rue Brun Larochette, 26220 Dieulefit, France, Tel : (33) 6 08917193 ou (33) 4 75464059, Fax: (33) 4 75463934, E-mail : godin@wanadoo.fr 9. Prof Deborah McFarland, Associate Professor, Department of International Health, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, Georgia 30312, Tel: (1) 404 727 7849, Fax: (1) 404 727 4590, E-mail: dmcfarl@spj.emory.edu 10. Ms Nancy Haselow, Director, Onchocerciasis Programs, Helen Keller Worldwide (HKW), P.O. Box 14227, Yaounde, Cameroon, Tel: (237) 220 9771 or (1) 212 532 0544, Fax: (237) 220 9771 or 1 212 532 6014, E-mail: nhaselow@hki.org OBSERVERS 11. Dr Grace Saguti, National Eye Care and Onchocerciasis Control Programme Coordinator, NOCP, Ministry of Health, P.O. Box 9083, Dar-es-Salaam, Tanzania, Fax: (255) 22 2130 009, Email: gracejengo@yahoo.fr. 12. Dr Yisa Saka, Deputy Director, National Onchocerciasis Control Programme (NOCP), Federal Ministry of Health, Federal Secretariat, Shehu Shagari way, Maitama, Abuja, Nigeria, Tel/Fax: (234) 1 269 6013. 37 WHO/GENEVA 13. Dr Hans Remme, Coordinator, Intervention Development and Implementation Research (IDE), World Health Organization (WHO), 20, Avenue Appia, CH-1211 Geneva 27, Switzerland, Tel: (41-22) 791 3815, Fax: (41-22) 791 4774, E-mail: remmej@who.int. 14. Dr Tony Ukety, NGDO Coordinator, Prevention of Blindness and Deafness, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, Tel: (41-22) 791 1450/3416, Fax: (41-22) 791 4772, E-mail: uketyt@who.int 15. Dr Ole W. Christensen, Consultant, Poppelhuset, Jespervej 274, DK-3480 Fredensborg, Denmark, Tel: (45) 48 24 88 68, Fax: (45) 48 23 28 68, E-mail: owc@mail.dk 16. Mr Abdulai Daribi, (co-rapporteur), AFRO/APOC Liaison Office, World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland, Tel: (41-22) 791 3883, Fax: (4122) 791 4190, E-mail: daribia@who.int 17. Dr Janis Lazdins-Helds, Manager, Filariasis R & D (Macrofil), World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland, Tel: (41-22) 791 3818, Fax: (41-22) 791 4774, E-mail: lazdinsj@who.int. WORLD BANK 18. Mr Bruce Benton, Manager, Onchocerciasis Coordination Unit, Population and Human Resources Division, Western African Department, (AF 5PH) African Region, World Bank, 1818 H Street, N.W. Washington DC 20433, USA, Tel: (1) 202 473 5031, Fax: (1) 202 522 3157, E-mail: bbenton@worldbank.org. MICRONUTRIENT INITIATIVE 19. Mr Siméon Nanéma, National Representative of the Micronutrient Initiative, c/o Helen Keller Worldwide, 04 P.O. Box 8150, Ouagadougou, Burkina Faso, Cel: (226)78 82 73 17, E-mail: sn92@cornell.edu MDSC 20. Dr Sam Bugri, Acting Director, MDSC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: bugris@oncho.oms.bf 21. Dr Alhouseini Maïga, Coordinator, GWE/AFRO, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: maïgaa@oncho.oms.bf 22. Dr M.H. Djingarey, Epidemiologist, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: djingareym@oncho.oms.bf 23. Dr Laurent Toé, Responsible, Molecular Biology Laboratory, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: toel@oncho.oms.bf 38 24. Dr Yiriba Bissan, Entomologist, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: bissany@oncho.oms.bf WHO/APOC 25. Dr Azodoga Sékétéli, Director, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: seketelia@oncho.oms.bf 26. Dr Laurent Yaméogo, COORD, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: yameogol@oncho.oms.bf 27. Dr Uche Amazigo, CSD, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: amazigouv@oncho.oms.bf 28. Dr Victoria Matovu, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: matovuv@oncho.oms.bf 29. Dr Lamissa Bangali, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: bangalil@oncho.oms.bf 30. Mr Koffi Benoît Agblewonu, BFO, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: agblewonuk@oncho.oms.bf 31. Miss Néné Keïta, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: keitano@oncho.oms.bf 32. Mr Issaka Niandou, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: niandoui@oncho.oms.bf 33. Mr Saïdou N’Gadjaga, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 34 29 53, Fax: (226) 34 28 75, E-mail: ngadjagas@oncho.oms.bf 39 Annex 2 PROVISIONAL AGENDA (REV. 2) 1. Opening 2. Adoption of the agenda 3. Matters arising from the 105th and 106th sessions of the CSA 4. Matters arising from the Donors’ Conference 5. Matters arising from the 24th NGDO meeting 6. Update on the 32nd meeting of the MEC 7. Follow-up of the recommendations of TCC18 8. Update on the REMO/GIS in APOC countries 9. Update on the RAPLOA in Angola, Cameroon and DRC 10. Update on vector elimination activities with special emphasis on Tukuyu focus 11. Phase II of the long-term impact assessment of APOC operations 12. Report on tool for rapid monitoring of treatment coverage 13. Report on cost per treatment with ivermectin 14. Update on sustainability of CDTI: i) Update on tools ii) Review of sustainability plans: update iii) Monitoring the implementation of sustainability plans 15. Update on Operational Research 16. Update on MACROFIL 17. Report on the financial management of APOC-funded Projects 18. Report on the review by the APOC Management of 1st, 2nd, 3rd, 4th and 5th year progress reports and subsequent year budgets 19. Review of new project proposals 20. Review of 1st, 2nd, 3rd, 4th and 5th year annual technical reports 21. Review of operational research proposals 22. Integrating Vitamin A supplementation and CDTI: update on the collaboration between APOC and Micronutrient Initiative partners 23. Additional matters discussed by TCC19 i) Format for technical reports ii) Progress on South Sudan iii) Update on the Bill & Melinda Gates Foundation Meeting on Integration iv) External Review of APOC and SIZ v) Contribution of APOC to SIZ activities 40 24. Other matters 25. Dates and place of the twentieth and twenty-first sessions of TCC 26. Conclusions and recommendations of TCC19 27. Closure of the session 41 Annex 3 CONCLUSIONS AND RECOMMENDATIONS OF THE 24TH MEETING OF NGDO COORDINATION GROUP FOR ONCHOCERCIASIS CONTROL 1. The Group reviewed and approved with a few changes the report of the 23rd meeting held in Nairobi on 10-11 March 2004 and the ad hoc meeting held in Washington, D.C. on 21 June 2004. Former OCP countries and SIZ 2. The Group expressed concerns on the lack of a coordination structure in place for OCP countries at the end of programme, especially those in Cote d’Ivoire and Guinea Bissau, which were not included in the SIZ. There was an urgent need for coordination between different partners including countries involved, SIZ staff, APOC Management, NGDO concerned, West African Health Organization (WAHO) and WHO/AFRO. The Group recommended that this issue be discussed at the next CSA meeting in October 2004. 3. The Group recommended that the WAHO leadership be briefed on this issue during the next IAPB meeting in Dubai at the end of September 2004. 4. The Group recommended a close coordination of activities in the SIZs between different partners, in order to review and plan the programme, especially in view of the fact that funding for the SIZs expires in 2007. SSI was requested to take this issue forward. 5. The Group noted the lack of information on onchocerciasis control activities in Ghana. The Group recommended therefore a joint meeting of APOC, SIZ, the national onchocerciasis coordinator and the NGDO partners in order to clarify the issue. APOC Issues 6. The Group recommended that when an NGDO staff member was invited to attend an APOC meeting or evaluation, the NGDO concerned should also receive a copy of the letter of invitation. 7. The Group agreed that there was a need for all partners to develop strategies and mechanisms to ensure that national governments contributed financially to CDTI. 8. It was agreed that the NGDO Coordinator would revise the treatment figures with the new information available and re-circulate to Members in order to correct some outstanding issues. 9. In reference to the JAF presentation, it was agreed that other activities of the Group should be emphasized, such as involvement in operational research and technical assistance to performance implementation and evaluation. 10. The Group was concerned about potential competition between individual NGDOs and APOC for funding for integrated activities (onchocerciasis and “add-on” activities) and urged that every effort be made to share information about proposed approaches. 42 11. The Group was concerned that MDP had not received requests for ivermectin tablets from some countries such as Nigeria, Tanzania and Angola. Members were requested to follow up urgently with their respective national onchocerciasis coordinators. 12. The NGDO Group noted that release of funds for some CDTI projects had been delayed for more than six months. The group recommended that efforts be made by all parties to identify the bottlenecks and speed up the process to prevent treatment delays. 13. The Group noted the frequent utilization of key resource persons from NOTF to assist onchocerciasis programmes in other countries and recommended that APOC Management extend the invitation to others with appropriate experience. 14. Information on current IEF involvement in Malawi was lacking and the Group requested the NGDO Coordinator to follow up with IEF in order to clarify their intention. 15. Following the appointment of a new national coordinator in Chad, the NGDO Coordinator was requested to ascertain from OPC their future intention in support of the CDTI project. 16. The Group recognized that there were still projects in Angola, DRC, Ethiopia and Sudan without national or international NGDO support. Members were invited to consider supporting these projects. 17. In view of the importance of the study on the endpoint of ivermectin treatment/ transmission study, Dr Bjorn Thylefors and Mr Bruce Benton were requested to follow up to ascertain the state of the application by TDR to the Bill & Melinda Gates Foundation. 18. The Group expressed deep concern about the sustainability of CDTI projects at the end of APOC in 2010. The Group agreed to allocate more time to discuss sustainability issues in depth during the next NGDO Group meeting. 19. The Group requested the Onchocerciasis Coordination Unit at the World Bank to obtain more information and advocate on the mechanisms available to Highly Indebted Poor Countries (HIPC) and the Poverty Reduction Strategy Papers (PRSP) to access additional funds for health and development activity mechanisms that would enable participating countries to access funding to sustain CDTI projects. At the country level, ministries, through the NOTF, should be made aware of the possibilities of accessing support from these funding mechanisms. 20. Following the Donors’ Conference in Washington, D.C. in June 2004 and discussions with the Micronutrient Initiative, the Group requested the World Bank to finalize details on the implication of the APOC Trust Funds in order to integrate Vitamin A supplementation projects into existing CDTI. 21. The Group thanked Ms Nichole Brown and Dr Tony Ukety for preparing the draft concept paper. The Group requested the members to react to the document within one week so that it could be finalized. 22. The Group requested the World Bank to include the NGDO Group as potential partners in the implementation stage articulated in the project proposal to the Gates Foundation. It was noted that the Letter of Intent had to be submitted by the end of September 2004. 43 23. In view of issues of sustainability, integration and potential funding sources, there was a need for the NGDO Group to establish its own strategic plan and this should be a topic for the 25th meeting. 24. The Group recommended that the Terms of Reference for the External Evaluation of APOC be expanded to include former OCP countries; focus on the impact beyond 2010; and review section 3.2 on sustainability to make recommendations on the adequacy of the sustainability, evaluations and plans. 25. The NGDO Group recommended to the Members and other partners to look at different options for the elimination of onchocerciasis in Africa. 26. On behalf of the Group, the Chair thanked Mr Bruce Benton for his long commitment to onchocerciasis control since its inception and wished him an enjoyable retirement. 27. The Chair also expressed a profound gratitude to the Carter Center in general and particularly to Ms Lindsey Rakers and Mrs Rosalyn Ajigbeda for successfully handling the logistics and arranging the venue for the 24th session of the NGDO Group meeting. 28. The 25th session of the NGDO Group meeting will be held in Ouagadougou from 9 to 11 March 2005. The first day will be devoted to specific matters of the Group. 44 Annex 4 SUMMARY OF THE CONCLUSIONS OF THE MEC/AC32 MEETING 1. The representative of the Mectizan® Donation Program (MDP) reported on the highlights of the 32nd meeting of the Mectizan® Expert Committee/Albendazole Coordination (MEC/AC) held from 28-30 April 2004 in Atlanta, Georgia, USA. The onchocerciasis research agenda was an important theme of the meeting. For example, updates were presented regarding RAPLOA, mass treatment with Mectizan® in Loa loa endemic areas, and research on potential measures to reduce the risk of Serious Adverse Events (SAEs) in Loa loa endemic areas. 2. Revisions to the MEC/TCC guidelines for mass treatment with Mectizan® for onchocerciasis in areas co-endemic for onchocerciasis and Loa loa were finalized during the meeting following suggestions made during MEC31, subsequent feedback from TCC18, and reports on the validation of RAPLOA. The revised recommendations take into account the endemicity of Loa loa when assessing the risk of SAEs occurring after Mectizan® treatment for onchocerciasis. Included in the revised recommendations are annexes that provide guidance for the clinical management of cases of Loa loa encephalopathy and a list of suggested medical supplies and equipment for the management of such cases. The revised recommendations were distributed by MDP to program partners, including APOC Management and TCC members, in June 2004. 3. The MEC expressed concern over the unexpected high incidence of SAEs reported during Year 1 of mass treatment with Mectizan® from the Bas Congo CDTI project area in DRC, a region suspected to be highly endemic for Loa loa. Consequently, the MEC recommended that mass treatment in the project area be halted for a time; that a mission be conducted to investigate the potential causes of the SAEs; and that extensive RAPLOA be conducted in the area to better define the risk of SAEs. The recommended mission, jointly sponsored by MDP/APOC in collaboration with DRC’s NOTF, took place in July 2004, and the results of that mission can be found elsewhere in the MEC/AC32 report. 4. After reviewing requests for Mectizan® for six new CDTI projects in DRC (Equateur-Kiri, Mongala, Tshuapa, Ubangi Nord, Katanga Nord and Katanga Sud), the MEC made several recommendations that pertain to all new mass treatment projects in DRC (and will likely pertain to any new projects areas potentially, or known to be, endemic for Loa loa). These recommendations are: 4.1. before beginning Mectizan® distribution in areas suspected, or known, to be endemic for Loa loa, RAPLOA should be undertaken to assess the prevalence of Loa loa; 4.2. mass treatment should start/occur only in health areas where completed REMO has confirmed the presence of meso or hyperendemic onchocerciasis and only after RAPLOA has been completed and the revised MEC/TCC guidelines are applied; 4.3. in health areas where REMO refinement was indicated (yellow REMO zones), the refinement should be conducted simultaneously with RAPLOA as soon as possible and before any mass treatment with Mectizan®; 4.4. in those areas with RAPLOA results of 40% or more, it was advised that, in addition to implementing the revised MEC/TCC guidelines, Mectizan® distribution should be 45 introduced gradually (no more than 300,000 treatments in Year 1) and in a coordinated fashion to allow for close medical supervision; 4.5. in order to better understand the etiology of the encephalopathic SAEs and to reduce the associated mortality, it was advised that support be given to the project, overall, to facilitate: 1) appropriate laboratory and clinical diagnosis and treatment of SAEs, including co-morbidity from other diseases; 2) assurance that medical facilities are prepared and consumables for management of cases are provided as needed; and 3) immediate reporting of SAEs to the appropriate authorities, including MDP. 5. Updates were provided to the MEC regarding the following ongoing/proposed research studies (detailed information is in the MEC32 report, available upon request): 5.1. the spatial distribution of encephalopathy cases following Mectizan® treatment in Cameroon; 5.2. the genetic heterogeneity in Loa loa parasites from southern Cameroon; 5.3. a case-control study on Loa loa encephalopathy cases following Mectizan® treatment—an investigation of possible Loa loa strain differences; 5.4. the analysis of an autopsy from a Loa loa encephalopathy case following Mectizan® treatment; 5.5. the development of a Loa loa encephalopathy animal model; 5.6. studies on the pre-treatment of Loa loa with low dose Mectizan® or multiple treatments with albendazole; 5.7. a literature review on other possible compounds with efficacy against Loa loa; 5.8. safety studies on the use of albendazole and ivermectin in LF/Loa loa endemic areas. 6. The evaluation of the impact of the Mectizan® Donation Program was published in the March 2004 issue of Tropical Medicine and International Health. The publication was presented at a symposium held at the Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA, in May 2004. Reprints of the publication were distributed to APOC Management and TCC members during TCC19. 7. The 33rd meeting of the MEC was to take place from 13-14 October 2004 in Paris, France. 46 Annex 5 SUMMARY REPORT OF THE BILL & MELINDA GATES FOUNDATION MEETING ON INTEGRATION OF COMMUNITY-BASED PROGRAMMES, SEATTLE, WASHINGTON, USA, 29-30 JULY 2004 Key Issues 1. There was general agreement that programmes addressing diseases of neglected populations should be integrated but that the evidence base for doing so was lacking, including the cost-effectiveness, risks, documentation of the factors that foster and impede integration, and sustainability. There was need for “proof of concept.” 2. The field would benefit from a systematic inventory of what had been done in integration and a careful review of the literature (A literature review was underway). 3. There was a lack of policy on integration and commitment at national and international levels. Even when they targeted specific diseases and required objective measures of success, donors should be open and flexible to new initiatives for integration. They and other partners may need to make their special interests and objectives secondary to achieving integration. Also, public-private partnerships needed to be convinced of the value of integration and should be encouraged to avoid setting agendas that would impede integration. 4. The pharmaceutical industry had its own constraints, including the objectives and targets of their donations. Pharmaceutical donations both offered opportunities and brought limitations. Only some of these could be addressed by demonstrating that drugs can be administered safely together. 5. Leadership and management skills for integration were lacking at international, national, and local levels. Leaders and managers should provide guidance for country programmes and help to decide on the unit of integration (community, district, other). 6. Long-term government support and financing, as well as political commitment, were needed. Short-term measures should lead to long-term solutions with sustainable financing and frameworks that provided lasting support. 7. Sector-wide approaches (SWAP) were becoming more common and should foster integrated programmes. The goal should be to give more responsibility to governments for decisions about their programmes, though it was unclear that this actually happened. Moreover, SWAP may lessen the focus on diseases of neglected populations, and there was still no evidence that they resulted in improved health outcomes. 8. Integrated programmes should probably be implemented nationally, though they could begin in selected communities, especially if pilot programmes were needed to test strategies and approaches. 9. All integrated programmes would require community participation at the local level. However, communities had limited manpower and capacity. One must be careful not to overburden local personnel, who would have limited knowledge and training. Integrated 47 programmes should probably be kept simple initially and could be expanded in scope and geographic area after they had been established. 10. Judging from the experience of the African Programme for Onchocerciasis Control and a few other programmes, community-directed interventions (interventions delivered by community members under community leadership) appeared to be a promising mechanism for delivering integrated programmes. There was need for a better understanding of the types of communities in which community-directed interventions would be effective and what was needed to make them sustainable. The relationship between community-directed interventions and regular health services, which may or may not participate in the delivery of the intervention, needed to be clarified. 11. If primary health care services were to deliver integrated programmes, as was the case in many countries, the primary health care infrastructure would have to be strengthened. 12. Integrated programmes needed to focus on health outcomes and not only on disease control or prevention. For example, there would be a need for indicators of child health. However, such programmes also needed to have disease-specific monitoring and evaluation. 13. Hybrid approaches to community-based programmes should be considered, such as working with schools, community-directed treatment and campaigns. Adequate communication facilities needed to be included or provided. 14. The focus of the meeting was on 6 diseases: guinea worm, lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminths, and trachoma. However, integration with other programmes, such as immunizations, respiratory illnesses, and diarrhoeal diseases, should also be considered. 15. Integrated programmes needed to link to other sectors, including education and agriculture. 16. Programmes for diseases of neglected populations had specific targets, including age groups and geographic areas. While the targets for different programmes often did not match, programmes needed to be flexible and find ways to harmonize, if integration was to succeed. Programmes must also harmonize incentives for local staff, to eliminate competition and conflict (such as different per diems). 17. Consideration should be given to developing tools that could be provided to countries to select and adapt. Some of the tools would be disease-specific but developed for integration with other programmes. Other tools would be common to all programmes, such as computer mapping, logistics, geographical information and surveillance systems and management training. 18. Monitoring and evaluation of integrated programmes was essential. Methods should be developed and shared, and more capacity for monitoring and evaluation should be fostered. Possible Ways Forward 19. Develop a conceptual framework for integration that would identify actions needed at international, national, district, and community levels. 48 20. Create a partnership forum to enhance communication about, and advocate for, integration. Decide whether such a forum should have a formal or informal structure. 21. Support operational research to resolve issues about cost-effectiveness, risks, sustainability, drug management, communication, and social and behavioral aspects of integration. 22. Develop tools for integration that could be adopted by countries, including disease-specific tools (for lymphatic filariasis, schistosomiasis, trachoma, etc.) and general tools (for computer mapping, logistics, surveillance, etc.). The development and implementation of tools for monitoring and evaluation would be essential and should be a part of all programmes. 23. Link integration with programmes supported by the Global Fund, as had been done with malaria and lymphatic filariasis control in Togo. Linkage with the Country Coordination Mechanism (CCM) may provide a means to foster integration in countries. 24. Demonstrate the impact of integration on the health of poor populations. 25. Support national scale-up of integration to address the issues listed above, facilitate analysis of problems, and better understand how to build national capacity. Take advantage of existing programmes that were beginning or could begin to integrate in selected countries, such as Tanzania, Burkina Faso, Nigeria, and Malawi. 49 Annex 6 CONCLUSIONS AND RECOMMENDATIONS OF TCC19 Conclusions and endorsements 1. The Programme Director informed the Committee about the recent nomination of Dr Luis Gomes Sambo to the post of Regional Director of the WHO Regional Office for Africa to whom he was sending a letter of congratulations. TCC requested the Programme Director to convey to Dr Sambo the Committee's congratulations as well (paras 8 & 11). 2. The schedule of future TCC sessions to be arranged in a way to avoid having all the reports from the francophone countries being reviewed first (para.12). 3. TCC was informed that the APOC budgetary shortfall of US$ 18 million had been reduced to US$ 14 million following the recent APOC Donors' Conference in June 2004 in Washington, D.C (para. 16). 4. CDTI project to start in low/no Loa loa risk areas in Angola while training and community sensitization on the diagnosis and management of SAEs were being intensified. In the meantime, the technical advisor on onchocerciasis control in Loa loa areas in DRC or in Cameroon could also provide support to Angola (para. 30). 5. TCC endorsed the TDR study on the feasibility of local elimination of onchocerciasis transmission and requested CSA to follow up on the matter (paras 35 & 36). 6. TCC endorsed a proposal that operational research be undertaken on a diagnostic tool to detect individuals harbouring high loads of Loa loa microfilaraemia; as well as a study to evaluate the role of Plasmodium infection as a co-factor favouring the incidence of SAEs (para. 99). 7. TCC noted the report of the investigation mission to DRC in July 2004 presented by Dr Boussinesq and acknowledged the considerable efforts put into the study and the preparation of the report by the team (para. 101). 8. TCC endorsed the recommendations of the Programme Director to the NOTF in DRC on actions to be taken to prevent future SAEs in the Bas Congo area and all high risk areas in DRC (para. 104). 9. Partial results of the impact assessments of APOC Phase II could be available for TCC20 in March 2005 while full results would be ready for TCC21 in September 2005 (para. 185). 10. The first batch of articles on the Phase I impact assessment to be submitted for publication by the end of October 2004 (para. 187). 11. TCC endorsed and encouraged the use of the school-based monitoring approach by NOTFs for rapid monitoring of treatment two months after distribution (para. 196). 12. The Committee reviewed 3 new CDTI project proposals; recommended the approval of 2 projects and the rejection of 1. 50 13. TCC recommended the rejection of one operational research proposal to be reviewed in consultation with MACROFIL and resubmitted to TCC20 (para. 65). 14. TCC reviewed 22 technical reports, accepted 13 reports, rejected 6 and recommended the withdrawal of 3 reports. 15. TCC expressed the need to take strong action against all projects that were late in submitting, or failed to submit, their technical reports to TCC (paras. 10 & 208). 16. TCC reviewed and modified reporting forms for CDTI projects and NOTF Secretariats (para. 223). 17. TCC congratulated Prof McFarland on the progress of the cost per treatment study which would be finalized for TCC consideration in March 2005 (paras 213 & 218). 18. TCC reviewed and commented on the draft TORs for the APOC External Evaluation in 2005. The comments were submitted to the Chair of CSA (para. 235). 19. The Committee expressed its sincere gratitude to Mr Bruce Benton for his never-failing support to, and involvement in, APOC activities and wished him a happy retirement at the end of 2004 (para. 241). 20. TCC20 to be held from 14 to 19 March 2005; and TCC21 from 19 to 24 September 2005, both at the APOC Headquarters in Ouagadougou, Burkina Faso. Recommendations and Specific requests 21. The need to critically review the REMO results presented by countries. APOC Management to review REMO approach and its implementation in the field for submission to TCC at its next session (para. 28). 22. APOC Management to provide more guidance to the NOTF Secretariat of Angola on how to report on NOTF Secretariat activities. An example of a good report (in French) to be sent to the NOTF (para. 68). 23. APOC Management to send an example of a good report of NOTF Secretariat report (in French) to the NOTF Secretariat in Cameroon (para. 72). 24. TCC recommended that technical assistance should be provided to the Thyolo & Mwanza CDTI project by APOC Management for retraining of implementers on all aspects of CDTI as well as provide support to the Extension District CDTI project for CDTI monitoring and implementation (paras. 121 & 127). 25. TCC requested that subsequent technical reports discuss the coordination and networking of all the NGOs and community based organizations involved in CDTI and new add-on interventions in the Cross River CDTI project (para. 134). 26. TCC suggested that APOC Management accept a second and last vector elimination campaign in the Tukuyu focus subject to specific conditions (para. 177). 51 27. TCC recommended that APOC funds could be made available to finance training of more CDDs and other members of the community when justified (para. 203). 28. TCC recommended that the responsibility for ordering Mectizan® should be gradually devolved to the NOTFs (para.242). 29. TCC suggested that APOC Management invite National Coordinators to attend TCC sessions on a rotational basis (para. 243). 30. TCC to look for means and ways of helping NOTFs in the implementation of TCC recommendations. This item to be discussed further at TCC20 in March 2005 (para. 244).