Onchocerciasis Control Programme in West Africa Programme de Lutte contre l'Onchocercose en Afrique de I'Ouest JOINT PROGRAMME COMMITTEE Office of the Chairman JOINT PROGRAMME COMMITTEE Eighteenth session Liverpool. 1-3 December 1997 JPC . CCP COMITE CONJOINT DU PROGRAMME Bureau du Pr6sident JPCI&.2 ORIGINAL : FRENCH September 1997 Pase ..3 11 t3 t3 t4 t4 t4 15 16 t7 18 18 18 18 19 19 Provisional agenda item 5 PROGRESS REPORT OF THE WORLD HEALTH ORGANIZATION FOR 1997 (1 September 1996 - 31 August 1997) Table of contents EXECUTTVE SUMMARY VECTOR CONTROL Climatic conditions Aircraft fleet and aerial operations . Treated areas . Insecticides and control strategy Hydrology and teletransmission Entomological surveillance and evaluation network Monitoring of the aquatic environment TVERMECTIN (MECTIZAN@) DISTRIBUTION AND EPIDEMIOLOGICAL ACTTVITIES Ivermectin treatrnent Epidemiological evaluation . . Evaluations in the Original Area Evaluations in the extension areas Ophthalmological evaluations BIOSTATISTICS AND INFORMATION SYSTEMS TRANSFER OF ACTTVITIES TO THE PARTICIPATING COUNTRIES Trarsfer of residual activities Training Public awareness and population mobilization effort by OCp SUPPORT OF WHO/AFRO TO THE OCP ACTTVITIES IN THE PARTICIPATING COUNTRIES . . . Political level . Managerial level Technical level . Future support activities 6 6 6 7 8 9 9 01 i 1 I ) , JPCI&.2 Page 2 INTERDTSCPLINARY RESEARCH Insecticides Vector identification Parasite identification Special entomological studies Diagnostic tools . Macrofil Chemotherapy Project Potential macrofilaricidal drugs Preclinical shrdies Detection of ivermectin resistance Epidemiological modelling . . Epidemiological modelling of recrudescence of infection in the Bougouriba basin Model simulation of ivermectin resistance ADMINISTRATION AND SUPPORT SERVICES Objectives, organization and functioning of services Administrative costs Budget and Finance Personnel Supply and services . . . Transport and communications PUBLTC RELATIONS, INFORMATION AND DOCUMENTATION ACTTVITIES With the World Health Organization . With the Participating Countries With the statutory bodies With the donors With the aerial spraying contractor . With the scientific community With the general public Public relations and documentation FIGURES Fig. 1 VCU Plan of operations for 1997 Fig. 2 Annual transmission potentials (May 1996-April 1997) Simulium damnosum complex species infected with Onchocerca volvulus . . Fig. 3 Annual transmission potentials (May 1996-April 1997) Simulium damnosum complex savanna species infected with Onchocerca volvulus Fig. 4 Zones for large-scale ivermectin treatment in OCP as from 1997 Fig. 5 Prevalence of microfilariae in villages evaluated between 1995 - 1997 . Fig. 6 Impact of the control in the Kankelaba basin in Mali Fig.7a Changes in ocular lesions of the anterior segment of eye after nine rounds of annual ivermectin treatrnent combined with vector control in Niger basin in Guinea Fig.7b Changes in ocular lesions of the posterior segment of eye after nine rounds of annual ivermectin treatrnent combined with vector control in Niger basin in Guinea Fig. 8 Epidemiological modelling of recrudescence . t 20 20 2t 2t 22 23 24 24 24 25 25 25 26 27 27 27 28 28 29 29 30 30 31 31 3L 3t 31 32 32 33 34 35 36 37 38 39 t 40 40 4l t aJPC18.2 Page 3 EXECUTIVE SUMMARY a) In 1996, the rainy season was relatively abundant during the months of August, September and October. However, this was not evenly distributed, Ieading to some rain deficits in most of the basins under larviciding (between 15 and 30%).In1997, the dry season was clearly marked in the Western zone. A reverse trend was observed in the Eastern zone where the rains came relatively early. b) The aircraft fleet used during the period under consideration ranged in number between seven helicopters (May-December 1996) and four (April 1997). This year 1977 is the second year of the three-year aerial contract signed between OCP and the Evergreen Helicopter Inc. (EHI) Company. The terms of the next contract will have to be carefully considered as vector control operations are drawing to a close. The significant reduction of larviciding coverage resulting from the probable cessation of treatments in Cdte d'Ivoire at the end of 1998 should particularly be taken into account. c) Compared to the period from May 1995 to April 1996 the Programme was able to save US $ 133 000 on flight hours and US $ 643 000 on insecticides. The decrease in larviciding coverage alone cannot explain these differences which are probably also related to the rainfall deficit recorded in most of the basins during the period. d) In accordance with the plan of operations of the previous year, aerial larviciding was definitively stopped on the lower Black Volta in Ghana (Bui area) in January 1997 and on the Kank6laba in Mali (a tributary of the Bagoe) in March 1997. Aerial larviciding is continuing on the tributaries of the Oti in Togo (K6ran, Kara, M6) and ground larviciding on the Dienkoa in Burkina Faso. e) The insecticide rotation strategy, aimed at preventing blackfly resistance and keeping the effects of larviciding on the non-target aquatic fauna to a minimum, was the same as that of the previous years. The use of the insecticides took into account the usual restrictions related to their toxicity, their cost- effectiveness and the level of susceptibility of the blackflies to the different chemical insecticides, particularly the organophosphorous group (temephos, phoxim and pyraclofos). D At present, the OCP hydrological monitoring network comprises of about 150 water-gauges including 78 equipped with hydrological telebeacons which, for the most part, belong to OCP (seven beacons belong to the "Hydroniger" network and four belong to the hydrological service of Benin). The ground satellite reception stations are located at Odienne and Kara, the two aerial operations bases, and in Ouagadougou, at the Programme's headquarters (backup station). g) In the period from May 1996 to April 1997 , l0 catching points (out of 126 monitored regularly) showed Annual Transmission Potentials of human onchocerciasis above 100. If the transmission due to the savanna species of the S. damnosum complex alone were considered, only four catching points, including two on the tributaries of the Oti in Togo, one in southern Benin and one in the Tinkisso basin in Guinea, had an ATP above 100. h) The technique of the DNA probes applied to pool screening of blackflies to determine the prevalence of infection, is now operational. A first feasibility study carried out on the Baoul6 in Mali in the context of an entomological post-treatment evaluation gave encouraging results. A simplified protocol is being developed so that this simple and cheap method can rapidly become available as an entomological tool for the early detection of recrudescence in the oncho-freed areas. D The definitive cessation of larviciding on the lower Black Volta in Ghana had as a direct consequence the closure of the Kintampo subsector at the end of 1996 and, indirectly, the closure of the Tamale sector. Another major event was the closure of the Parakou sector at the same period and the strengthening of the Kara sector which now caters for the Parakou and Bohicon subsectors in Benin, the Kara and Atakpame sub-sectors in Togo and the Hohoe subsector in Ghana. JPC18.2 Page 4 j) The redefinition of the aquatic environment monitoring activities which occurred after the expansion of the mandate of the Ecological Group led the Programme to organize a short training course in environmental impact studies for the national hydrobiologists. The evaluation of the impact of factors other than the insecticides on the aquatic environment is henceforth one of the major components of the monitoring activity. Environmental monitoring is now carried out almost exclusively by the national hydrobiology teams. k) So far in the i996l97-year period, more than 1.6 million people living in over 6000 villages and hamlets have been treated with ivermectin, mostly through the community-directed treatment with ivermectin which is replacing the mobile means of delivering ivermectin treatment. The mean coverage, in terms of percentage of treated people per census population, was 77.6% No severe adverse reactions were recorded. l) Five NGOs participated in the ivermectin distribution in five of the Participating Countries giving support mainly for training towards the installation of community-directed treatrnent with ivermectin. m) Epidemiological evaluations were carried out in the Kankelaba basin in the original Programme area to help in the decision-making on the cessation of larviciding. The results were excellent with the downward trends in prevalence being similar to the predicted trends by the ONCHOSIM model. n) In the northern part of the western extension where the only means of control is treatment with ivermectin, evaluations in several villages in Guinea-Bissau showed 0-0.9% and less than 4% prevalence in the Rio Geba and the Rio Corubal basins respectively. o) Ophthalmological evaluations carried out in the lower Como6 basin in C6te d'lvoire showed rare ocular disease and a blindness rate of about 0.6%. With the very high skin microfilarial prevalence of up to 70% in some villages and the highest CMFL of 17 mf/s in this area without control, the pattern of onchocerciasis conforms to the forest type. p) The ophthalmological and parasitological assessment of the medium and long-term effects of the combined larviciding and large-scale ivermectin treatment after nine annual cycles of treatment in the Niger basin in Guinea showed satisfactory results. The skin microfilarial load has decreased markedly and there have been significant improvements in lesions of the anterior segment of the eye. q) The data analysis of the Progr:unme is under way under the coordination of the Biostatistics and Information System (BIS) sub-unit of the PET unit. A trial of data integration of the enromological and epidemiological evaluations and the predictions of the ONCHOSIM model in the Geographic Information System Arc-View was done, facilitating also the analysis of the epidemiological situation for the basins in the original area from where some historical data were collected. To prepare the nationals in epidemiological analyses, continued emphasis was placed on the training and transfer of data for the Participating Countries. BIS also continued to give its asssistance to the other Prograrnme Unis in the use of the computer. In this regard, a computer network is functional and OCP has been connected to the INTERNET. r) The countries carried out, under the coordination of PET, some activities of sensitization of the communities, epidemiological surveillance and ivermectin treatment. These different activities were reviewed this year during the meeting of the Coordinators which was attended by the WHO Representatives in the 11 Participating Countries and their country epidemiologists. The Ministers of Health of the Participating Countries facilitated the setting up of the action plans for the community- directed treatment with ivermectin i.nd the decentralization of the epidemiological surveillancc of onchocerciasis through on-the-job training of personnel at the peripheral level and the village communities. These activities are recorded in JPC18.5 and JPC18.6 documents . t tJPC18.2 Page 5 s) The WHO Regional Office in Africa reinforced its support to the Prograrnme activities by the AFROPOC financial contributions and the active participation of the WHO Representations in the 11 Participating Countries in the residual activities of onchocerciasis control. 0 In the course of the previous year, the OCP followed is habitual policy of training, and granted 14 training fellowships between August 1996 and July 1997 in the fields of public health, health management, molecular biology, computer and environmental sciences. The number of the nationals of the Participating Countries of the Programme who have benefitted from the OCP fellowships between 1974 and JuJy 1997 has risen to 462. Research is under way with respect to the beneficiaries of these followships through the Ministries of Health of the Participating Countries to better supervise the impact of the OCP financially supported training on these beneficiaries. u) As the evaluation of new larvicides was no longer a priority, research efforts were now being orientated towards the quality control of operational batches and the improvement of the existing formulations of B.r. H-14. No decrease of blackfly susceptibility to B.t. H-14 has yet been observed in the Programme area after more than 15 years of use of this product. In respect to the chemical insecticides, the priority was given to the organophosphorous compounds (temephos, phoxim and pyraclofos), especially in the basins where a resistance to these products had been detected. The results obtained during the period under review showed that the restrictions imposed on the use of these products and rigourously observed during the past several years have made it possible to gradually lower the level of resistance in the basins concerned. v) The identification of female flies of the S. damnosum complex through the heteroduplex analysis of the DNA is now operational. However, its validation in the field in parallel with the cytotaxonomic method is continuing in the forest/savanna transition zones where several species of blackfly cohabit and where hybrids are encountered. These two methods of identification, however, continue to remain in agreement in most of the basins treated. This validation also concerns the morphological and/or morphometric identification methods because of the overlapping of the criteria used for certain differentiations. w) Since 1995, special studies have been undertaken in order to gain a better knowledge of the transmission conditions and epidemiology of onchocerciasis in the forest zones situated outside the Programme area and which have been more and more marked by intensive deforestation and/or human migrations. The zones concerned by this research are those of the south-west of Ghana in the Pra and Tano basins, of the south-east of C6te d'Ivoire on the Bia and lower Comoe, and of the south-east of Guinea on the river Diani. x) Following the detection of a case of recrudescence of infection in the Bougouriba basin in Burkina Faso, special entomological studies were initiated during the rainy season of 1996 to assess the level of the transmission of onchocerciasis. This entomological evaluation will be pursued in 1997 in order to monitor the trend of the transmission parameters in the presence of an intensive distribution of ivermectin. y) Shortly after the definitive cessation of larviciding on the Kulpawn and Mole in 1995, a special entomological study was initiated to determine whether the distribution of ivermectin twice a year had any impact on the transmission of onchocerciasis. The final results of this study will be made available at the conclusion of a subsequent entomological evaluation to be carried out in 1998. z) Considering the results of the Phase II clinical tests of amocarzine for the treatment or onchocerciasis a scientific research group of the WHO recommended to stop the research in the usagc of this drug against onchocerciasis. However, the experiments of amocarzine against lymphatic filariasis continue in India. The pre-clinical development of UMFO7S continue too. The evaluation of the macrofilaricidal action and/or prophylactic activity of Moxidectin, an analogue of ivermectin is on course. The studies on the mechanisms of resistance to ivermectin continues in a very satisfactory JPC18.2 Page 6 manner and the process for the identification of the genes responsible for resistance of O.volvulus to ivermectin is also on course. aa) The Administration and Support Services Unit has continued to support all the OCP units and programme activities by managing in the most rational way possible and in the best interests of the Programme, the human, material, financial and informational resources at its disposal. This period has been marked by organizing training sessions and seminars to reinforce the performance of the personnel with the goal of reducing cost. ab) The Programme has pursued is liaison, information and public relations activities and continued to keep the Donors, the Participating Countries, the countries not included in the Prograrnme area, the scientific community and the public at large regularly informed about these activities. VECTOR CONTROL Climatic conditions l. The rnonths of August, September and October 1996 were relatively wet. However, the rainfall was not evenly distributed, leading to some rain deficits in most of the basins under larviciding (25 to 30%o in the eastern zone, l3 to 24oh in the western zone). Western Ghana, eastern Togo and central C6te d'Ivoire in the Marahoue basin were exceptions to this general trend. In 1997,the dry season was clearly marked in the western zone. The inverse of the trend was observed in the eastern zone where the rains came relatively early. As a result, all the main watercourses of the eastern zone were in full flow at the end of April 1997 , that is one month earlier than in 1996. Aircraft fleet and aerial operations 2. The number of helicopters used under contract during the period under review ranged between seven(from MaytoDecember)andfour(April 1997). From lstto 12April 1997,only threehelicopters were actually used due to very low discharges, especially in the basins of the eastern zone of the Programme. Aerial larviciding was totally interrupted in this zone for six consecutive weeks from I I March to l8 April 1997. 3. 1997 is the second year of the three-year aerial contract signed between OCP and the Evergreen Helicopter Inc. (EHI) Company. The terms of the next contract will have to be carefully considered as vector control operations are drawing to a close. The significant reduction of larviciding coverage resulting from the probable cessation of treatments in C6te d'Ivoire at the end of 1998 and in several hydrological basins of the western and south-eastern extensions in 2001 should particularly be taken into account. 4. During the period of May 1996 to Aprll 1997,the helicopters used 4668 flight hours for larviciding (none for prospecting) as against 4850 hours during the same period in 199511996 (Table l).This slight decrease (less than 4%) is due to the fact that the decrease in the number of flight hours related to the definitive cessation, at the end of 1996, of aerial larviciding on the lower Black Volta was compensated for by the resumption of aerial larviciding in the basins of northern Sierra Leone in March 1997. 5. Compared to the previous period, the diminution of the expenses of flight hours amounts to only US $ 722 X 182 viz. about US $ 133 0u0 (US $T22representing the cost of one overtime unit hour, including fuel cost, knowing that the guaranteed hours are paid as a priority). I JPCI8.2 Page 7 Table 1. Use of larviciding flight hours from May 1996 to April 1997 and comparison with the previous period. Months Flight hours Difference between 95196 and96197May 95 - April 96 May 96 - April9T May June July August September October November December January February March April 322 s38 379 497 345 246 576 480 472 559 288 148 385 388 433 480 385 416 391 389 469 404 308 220 + 063 - 150 + 054 - 017 + 040 + 170 - 185 - 091 - 003 - 155 + 020 + 072 Total 4 850 4 668 - 182 (-3,75"/0) 6- Compared to the period of May 1995/April 1996, the Programme has reduced its larvicide cost by US $ 643 000 (17%o approximately) (Table 2). This difference is due to a general decrease in rhe consumption of all the insecticides with the exception of permethrin and phoxim. This decrease in the consumption of the larvicides cannot be due to the reduction of the larviciding coverage alone , it is also due to the overall rainfall deficit recorded during the period. Table 2. Larvicide consumption from May 1996 to April 1997 and comparison with the previous period Larvicides Quantity used (litres) Difference between 95196 et96/97 Cost US$ May 95-April96 May 96-April 97 Temephos 40 432 27 396 - 13 036 (-32%) - l&t 722 B.t. H-l4 228 773 177 392 - sl38r (-22%) - 238 408 Phoxim 20 361 26 409 + 6 048 (30 %) + 102 937 Permethrin 15 155 2t 360 + 6 20s (41 %) + 63 849 Carbosulfan 19 l6s 7 366 - tt 799 (- 62 %) - 245 655 Pyraclofos 3s 053 34 231 - 822 (- 2%) - 21 742 Etofenprox t6 825 tl 760 - s 06s (-30%) - 122 320 Total 375 764 30s 914 - 69 8s0 (-r9 %) - 643 060 (-17%) Treated areas (Fig.l) 7 . In the original Programme area, in accordance with the plan of operations of the previous year, aerial larviciding has definitively ceased on the lower Black Volta in Ghana (Bui area) in January 1997 and on the Kankelaba (a tributary of the Bagoe) in Mali in March 1997. Treatment operations, however, are still continuing on the tributaries of the Oti in Togo (Keran, Kara and Md) and on the Dienkoa in Burkina Faso I JPC18.2 Page 8 with ground larviciding. With respect to this latter basin, after a detailed analysis of the situation, it was suggested that the national team of Burkina Faso continue the ground larviciding in combination with ivermectin distribution until the end of the Programme (with technical and financial support from OCP). 8. In the basins of the southern extension in C6te d'Ivoire, there has been no change in the larviciding coverage during the period under review. However, larviciding on the Marahoue is planned to be stopped as of June 1997 . The definitive decision will be made after a review of the results of the parasitological surveys and posrtreatment entomological evaluations in the absence of larviciding and ivermectin distribution. 9. In the basins of the south-eastern extension, and those in Guinea, which have been under larviciding respectively since February 1988 and March 1989, there has been no change in the larviciding coverage during the period under review. It must be recalled that the tributaries of the Oti, even though within the original Programme area, are now considered part of the south-eastern extension because of the permanent infiltration, up to 1988, of infective blackflies originating from adjacent basins situated further south. 10. In northern Sierra Leone where larviciding operations had been suspended as a result of persistent insecurity (three years in the basin of the Rokel and two years in the basins of the Kolente, Mongo and Kaba) aerial larviciding were resumed in March 1997. Unfortunately, as, by May 1997 , the security of the pilots and of the staff on the ground could no longer be guaranteed, aerial treatments have to be suspended once again. 11. Ground larviciding on the Niger, near Bamako, and some of its tributaries Fie, Faya and Dylamba continues to be carried out entirely by the national team of Mali with financial support (through a letter of agreement) and technical supervision (decision to treat or not and choice of insecticides) from OCP. Similarly as in the case of the Dienkoa, after a detailed analysis of the siruation, it was suggested that the national team of Mali continue the ground larviciding in combination with ivermectin distribution until the end of the Programme. Insecticides and control strategy ' 12. The insecticide rotation system, which is aimed at preventing possible blackfly resistance and keeping the effects of larviciding on the non-target aquatic fauna to a minimum, has been the same as in previous years. The insecticides have been used by taking into account the usual restrictions related to their toxicity, their cost-effectiveness and the blackfly susceptibility levels, particularly with regard to the organophosphorous compounds (temephos, phoxim and pyraclofos). 13. Asforeach year,thebasinsof thesouthernextensioninCOted'Ivoire,especiallythebasinsofthe lower Bandama, N'Zi, lower Comoe and Marahoue have been the subject of particular attention on account of the noted resistance to the organophosphorous, especially temephos. Therefore, this product continues to be excluded from use in these basins where pyraclofos and phoxim are used instead because of the improving susceptibility to the latter, as well as etofenprox particularly, the only non-organophosphorous insecticide that can be used at discharges between 15 and 70 m3/s. 14. In the basins of the western extension, no particular restriction was observed during the period under consideration, with the exception of the Niger, in the Bamako area, where the savanna blackflies which continue to show a moderate susceptibiliry to temephos, developed resistance to pyraclofos in 1995. Blackfly susceptibility levels to this latter compound has improved however, but its use as well as that of temephos remains limited to a few cycles per year. For these reasons, permethrin, carbosulfan and etofenprox are used preferentially compared to the other insecticides. In the basins of the south-eastern extension, temephos and phoxim are used cautiously on the tributaries situated to the east hke Volta as well as on the Mono and Oueme rivers. t )JPC18.2 Page 9 15. A11 the insecticides were used in accordance with the recommendations of the Ecological Group. However, there was a departure once again from the rule in that permethrin was used for more than six consecutive cycles on the Niger near Bamako because of the very high discharges recorded over several weeks and the restrictions on the use of the organophosphorous. Carbosulfan, as before, was not used on the Sankarani, the Milo and the Niandan so as to allow the continuation of the long-term impact studies of permethrin on the non-target aquatic fauna. 16. During the period under review, the qualiry of the operational batches of B.r. H-14 (Vectobac@) was significantly improved and is now close to meeting the terms of the initial specifications of the contract signed between OCP and the Abbott Company for the period 199511997. Furthermore, some first field trials of another formulation of B.t.H-14 (Teknar@) were carried out on the White Bandama, the Black Volta and the Niger, and proved to be promising. These trials are to continue during the 1997 rainy season so as to get maximum information before a new invitation to bid is issued for 1998. 17 . In 1997 , the total length of rivers likely to have aerial or ground treatment for the purpose of preventing transmission is 11,220 km. This maximal larviciding coverage is, of course, theoretical as it includes the basins of northern Sierra Leone which are currently not treated. During the week of 4 to 10 November 1996, a period of fall in water level and therefore of high larval productivity,4,563 km of river stretches were treated, mobilizing the seven helicopters under contract. Conversely, the week of 7 to 13 April 1997, a low-water period and therefore of low larval productivity, saw the lowest coverage with 1,268km of river treated and the use of only three helicopters. Hydrology and teletransmission 18. At present, the hydrological monitoring network consists of 150 water-gauges including 78 equipped with hydrological telebeacons belonging, for the most part, to OCP (seven beacons belong to the "Hydroniger" network and four to the hydrological service of Benin). This system allows the transmission of water levels by satelllite. This hydrological system, which is linked to a discharge forecasting software that relies on teletransmitted data, makes it possible to considerably improve the efficacy of larviciding by providing hydrological data in real time on one hand, and on the other, by providing forecast of the hydrological conditions of the rivers after an analysis of the data by a specialized software (PERLES system). The utilization of all the beacons (with the exception of the "Hydroniger" network) is made on the basis of a flat annual charge under a contract signed between OCP and a company in charge of teletransmission (Argos company). The satellite reception stations are located at Odienne and Kara, the two aerial operations bases, and in Ouagadougou, at the Programme's headquaters (backup station). 19. As in the previous period, five hydrologist brigades comprising two OCP brigades (one at Odienne, one at Kara) and three national brigades (two in Guinea and one in Sierra Leone) carried out the dayto-day maintenance of the network. The brigades have the capacity to diagnose any failure in the beacons, make the necessary repairs and redeploy them if needed after performing a new gauging of the stations and readjusting the former hydrography chart. As a result of the training seminars organized in 1995 in Ouagadougou for two OCP hydrologists and three electronic technicians, more than 80% of the defective parts of the beacons can now be repaired on site. Entomological surveillance and evaluation network 20. At present, the entomological evaluation network in the treated zone comprises 126 catching p rints that are visited regularly, 66 of which are monitored eve y week (point A) and 60 every fortnight (point B). Catches can be organized on demand in occasional monitoring points (point C) for the purpose of finding explanations or solutions to incidental entomological problems raised during the weekly briefings. JPC18.2 Page 10 2I. On the whole, the results of the entomological evaluation were satisfactory in all of the treated zones of the Programme. In some basins, however, transmission of the savanna strain of the parasite by savanna blackflies remained difficult to contain despite continued larviciding and the distribution of ivermectin. Yet, a significant decrease of Annual Transmission Potential (ATP) was observed in these basins even though the values remained high each year, sometimes above the threshold of 100 infective larvae per person per year (example of the tributaries of the Oti in Togo). These basins were the subject of special attention aimed at determining the origin of this counter-performance and to take the appropriate corrective measures before the end of the Prograrlme. 22. After having separated through specific DNA probes the parasites of animal origin from the human onchocerca, l0 catching points (out of the 126 monitored regularly) showed ATPs of human onchocerciasis above 100 (Fig.2) during the period under review. Half of these points are located in the border zones of the Programme area, four in the basin of the Oueme and one on the Tinkisso. If only transmission by the savanna species of the ^S. damnosum complex (Fig.3) is considered, only four points show ATPs above 100: two located on the tributaries of the Oti (Titira : 170 and Taponde : 207), one in southern Benin (Konfokpa:149) and one in the basin of Tinkisso in Guinea (Fifa : 182). Transmission was negligible in the dry season (only two infective females were caught during the week of 1-5 April 1997) but more intense during the periods of high larval productivity and of increased man/vector contact (25 infective females caught during the week of 29 July - 3 August 1996). 23. The application of the new techniques for the identification of the vectors and parasites sheds new light every year on the conditions of transmission in natural environment. Different entomological, parasitological and ophthalmological cross-studies carried out in the forest/savanna transition zones seem to suggest the existence, in the parasite, of different pathogenicity levels or, of immunological predispositions which may or may not give the development of onchocercal blinding lesions in man. 24. The definitive cessation of larviciding on the lower Black Volta in Ghana had as a direct consequence the closure of the Kintampo sub-sector at the end of 1996 and, indirectly, the closure of the Tamale sector. Maintaining this latter structure could no longer be justified as only one entomological sub- sector remained in Ghana (Hohoe). It was in keeping with the same line of reasoning that the decision was made to close the Parakou sector also at the end of 1996, and to strengthen the Kara sector which now caters for the Parakou and Bohicon sub-sectors in Benin, the Kara and Atakpame sub-sectors in Togo and the Hohoe sub-sector in Ghana. Monitoring of the aquatic environment 25. The redefinition of the aquatic environment monitoring activities which occurred after the expansion of the mandate of the Ecological Group, led the Programme to organize a short training course in enviromental impact studies for the national hydrobiologists. The evaluation of the impact of factors other than the insecticides on the aquatic environment is henceforth one of the major components of the monitoring activity. However, the study of the long+erm impact of the less selective Iarvicides (permethrin, carbosulfan, pyraclofos and etofenprox) on the non-target aquactic fauna is continuing. Environmental monitoring is now carried out almost exclusively by the national hydrobiology teams. The entry and partial processing of the data, the coordination of monitoring activities as well as the liaison between the teams in the field and the Ecological Group are ensured by the Hydrobiological Monitoring sub-unit of the Prograrnme. 26. The consolidation in 1996, of the environmental impact studies initiated in 1995 in different r'ver basins has confirmed the capacity of the hydrobiologis'r to carry out this type of activity. With reference to the situation prevailing on the Sassandra, for instance, and in view of the quality of the data collected, the Ecological Group thinks that this could form the basis for a large-scale pilot study in the upper basin of the Sassandra. E tJPC18.2 Page 1l 27. The routine monitoring shows a decrease in the densities of the non-target insects and some modifications of their population structures in the form of the rareness of some taxa such as the Tricorythidae. These modifications do not seem to be prejudicial to the energetic balance between the different guilds of benthic invertebrates. With regard to the fish fauna, most of the species which had been noted as having become rare in 199411995 were better represented in the 1995/1996 catches. The other parameters used to evaluate the structure and health of the fish populations showed some slight variations but remained within acceptable limits. 28. Overall, the larvicide treatments carried out over more than 20 years on some of the watercourses did not cause any significant modihcations in the fish populations. Even if there was an impact, it was short-lived and masked by other factors. A trend towards a return to normal is shown by the abundance of the different guilds of invertebrates during the periods of suspension of larviciding or of its definitive cessation. It would therefore seem that the taxonomic and functional groups have not been altered beyond the normal variations which could occur in the basins of the rivers concerned. IVERMECTIN (MECTIZANR) DISTRIBUTION AND EPIDEMIOLOGICAL ACTIVITIES Ivermectin treatment 29. This year saw a complete reorientation in the manner in which ivermectin was distributed in the OCP area. At the beginning of the treafinent season in September 1996, treatment with ivermectin by the mobile means was abolished. The Programme put all efforts into providing financial and technical support to the countries to help them install communitydirected treatrnent with ivermectin in the areas hitherto treated by the mobile national teams. The practice of CDTI is that the communities are themselves in charge of the ivermectin treatrnent in their respective areas. They are allowed to choose their own distributors and which manner (door-to-door, central ) they wish to carry out the distribution. The distributors are trained by health staff, themselves trained by the national teams with support from OCP and some Non-Governmental Organizations (NGOs). 30. Treatment was carried out as before in the areas which were previously of high risk, medium risk and more recently low risk of onchocercal eye disease and/or blindness. Treatment was also extended to all the endemic.areas in the southern extension: Benin, C6te d'Ivoire, Ghana and Togo, and the southern part of the western extension in Guinea. Plans to extend treatment to other areas in Sierra Leone could not materialize due to problems of insecurity. Ivermectin distribution had been restarted in a limited area in the north of Sierra leone in March 1996 after having been suspended for three years due to the uncertain security situation in the country. This however has had to be suspended again because of continuing security problems in the country. Treatment was also carried out in the northern part of the western extension, in the area nonh of the Tinkisso river basin in Guinea, where there is no larviciding. 31. Large-scale distribution was enlarged to cover other villages in the endemic areas to include villages within areas with Community Microhlariae l-oads (CMFL) of less than 5 mf/s. It is recalled that all the areas with CMFLs of 5 mf/s or more have previously been covered (Fig.a). 32. As in previous years, large-scale ivermectin treatment was carried out in certain parts of the original Programme area, but this time through the CDTI method. The areas concerned were Dienkoa, the Bougouriba and the Black Volta near Batie basins in Burkina Faso, the previously reinvaded zones - Kara-Keran-M6 in Togo - as well as the intermediate zones in the Comoe, Nzi and Bandama basins in Cdte d'Ivoire. Treatment was also carried out in the Kankelaba basin in Mali. 33. Community-directed treatrnent with ivermectin is fully established in Senegal and Burkina Faso covering all the areas that need treatment. Most of the zones for ivermectin treatment are in hands of the conmunity through the CDTI in C6te d'Ivoire, Guinea, Guinea-Bissau, Mali and Togo. Training for CDTI which was very well advanced in Sierra Leone had to be suspended for security reasons. JPCI8.2 Page 12 34. The training for the installation of CDTI was carried out by technicians and nurses who were trained by the national teams with technical and financial support from OCP. Supervision was therefore carried out by the technicians/nurses who were responsible for a set number of villages within their catchment areas. They were responsible for collecting the data on the number of people that had been treated in their respective villages. The results were passed on to the District medical officers who then passed them on the National coordinators. These technicians/nurses were responsible for any severe adverse reaction that the village distributors would report. No such reactions were reported during the period under review. 35. Several NGOs notably the Sight Savers, Organisation pour la Prdvention de Ia C6cit6 (OPC) and Christoffel Blindenmission (CBM) also provided financial support for rhe training of the technicians/nurses and the community distributors. Table 3 sets out the NGOs that were involved in the ivermectin distribution in the OCP area in the 1996/97 period. Table 3. NGOs involved in ivermectin distribution in the OCP area - 1996197. ORGANIZATION COUNTRY MODE OF TREATMENT CBM (Lunsar) Sierra Leone CDTI CFAR Mali CDTI OPC Senegal Mali CDTI PhilAfricaine Suisse Guinea Passive Sight Savers Mali,Ghana, Guinea CDTI CBM : Christoffel Blindenmission OPC : Organisation pour la prevention de la c6.cit6, CFAR: Centre de formation d'animatrices rurales. 36. During the period under review, more than 1.6 million people were treated with ivermectin. These were carried out in 6000 villages and hamlets Iocated in the zones showed in the map of figure 4. The average coverage, i.e., the number of people treated divided by the to[al census population was 77 .6%. The reduction in the numbers of people treated and the villages with respect to what was obtained the previous year is due to the fact that the CDTI is being implemented and not all the villages had been treated at the time of reporting. It is expected that the figure will reach and surpass last years treatment by the end of this year. 37. Following the country-specific workshops which were held last year at which plans for the change from mobile means for ivermectin treatment to community-directed treatment with ivermectin were drawn up, OCP together with the national teams embarked on the training of Medical officers, technicians and nurses as trainers for the community distributors. The countries are at different levels with respect to the completion of the training and the implementation of ivermectin distribution by the communities themselves. Thus, so far, 101 Medical officers and 918 technicians/nurses have been trained in the countries. These trainers have trained 4913 community distributors in six countries. Epidemiological evaluation 38. One of the criteria used to help decide the cessation of larviciding is the epidemiological parameter in the particular basin. As in the past, epidemiological evaluations were carried out in the OCP area, with the help of the national onchocerciasis teams, with the objective of providing information: \ , 39 JPC18.2 Page 13 - to help decide on stopping larviciding in the original Programme area; - to "sriss the impact of the control activities through the measure of incidence in the northern part of the western extension under only ivermectin treaffnent, and other specific areas in the original area which are subjected to both ivermectin distribution and larviciding. The skin-snip method of diagnosis was used in all the evaluations. Figure 5 shows the overall epidemiological resuls for villages evaluated between end 1995 and June 1997 Evaluations in the Original Area 40. Epidemiological evaluations were carried out in the Kankelaba basin in Mali in February 1997. This was a repeat of the evaluations which were done in January 1996 as a first step towards obtaining results to help with the decision to stop larviciding. Given that ivermectin treatment is also carried out in the aria, the results of the subsequent evaluation in 1997, at least two years after the last ivermectin treatment in the area were needed to be able to take the decision of whether or not larviciding could be stopped in the basin. 41. Six villages were evaluated. Two of these were indicator villages, that is, first -line villages which have had several evaluations in the past. The rest were newly selected villages around the indicator villages. The procedure used for the examination was the same as in the past: by the classical parasitological method in which skin snipping was used to assess the prevalence of infection, the intensity oi infection and the presence of any new infections. New infections were defined as infections in children of five years of age or less and who do not receive ivermectin treatment or in individuals who were known to have been negative on at least two subsequent previous examinations. 42. The epidemiological results were excellent. The prevalence of infection in all the villages was less than l.0oZ except in one village, Kankela, where the prevalence was 5.2%ohaving dropped from the 8.1o% recorded the previous year. No new infections were observed. The positive cases detected were either, previously positive cases, or migrants that had come from the southern part of C6te d'Ivoire. The downward trend of the prevalence of infection closely matched the predictions by the ONCHOSIM model (Fig. 6). 43. Other evaluations were carried out in the Oti basin and its tributaries Pendjari in Benin and Kara- Keran-Mo in Togo ro assess the epidemiological situation in the light of unsatisfactory entomological results. It will be recalled that the Oti-Pendjari basin has been under larviciding since 1977 but has consistently had poor epidemiological results. The reason for this is thought to be contamination from the south of Togo and Benin. The evaluations which were carried out in nine villages towards the end of 1996 in Benin, and in 26 villages in June 1996 and early 1997 in Togo showed unsatisfactory results. In addition to relatively high levels of prevalence of up to 48.4% in one village in Benin and as high as 65% in one village in Togo, several villages showed new infection i.e infections in individuals who were born after control started in the area. 44. This year a cross-sectional evaluation was carried out in 28 sentinel villages located on the Oti- Pen-djari, Koulpeologo, the Black Volta and the kraba-Comoe basins in Burkina Faso. New villages surrounding the sentinel villages were examined. The prevalence was zero in the majority of the villages. Three villages in the Oti-Pendjari basin had relatively high prevalence of up to 14.6% and two villages in Poni/Bambassou basin near Batie had crude prevalences of 7.7% and23.9%. The objective for the evaluations in these two ;asins (Oti-Penjari and Poni/Bambassou) was to help decic : on the extension of the treatment with ivermectin. Evaluations in the Extension Areas 45. Evaluations undertaken in Guinea-Bissau involved 15 villages in the Rio Corubal basin and 13 in the Rio Geba respectively. No larviciding is carried out in these two basins. Ivermectin JPC18.2 Page 14 distribution has, however, been carried out in the Rio Corubal basin since 1988 at various frequencies per year the maximum being three times per year, as from 1992, while treatment with ivermectin started in the Rio Geba in 1992 as an annual cycle. 46. In both basins treatment with ivermectin was interrupted for at least 12 months before the evaluations. The results were excellent. The highest prevalence in the Rio Corubal wasT% in one village, while most of the other villages showed prevalence of l% to 4%. The highest precontrol prevalence in this basin was 72%. No new infections were found using the skin-snip method. In the Rio Geba basin where the pre-control prevalence was 23.5% only two individuals out of 1706 examined in the eleven villages evaluated were found to be infected. The maximum prevalence was 0.9% and no new infections were detected. Ophthalmological evaluations 47 . As part of an ophthalmological evaluation in the lower Comoe in C6te d'Ivoire, six villages were surveyed in February 1997. These are villages in the "forest zone" in an area where there has been neither larviciding, nor ivermectin distribution nor the combination of the two. The prevalence of infection was generally high in all the villages. The maximum prevalenc e was 77 % obtained from one village. The CMFLs were however, relatively low with the highest being 17 mf/s. Ocular lesions in the lower Comoe in C6te d'Ivoire were rare and blindness was about 0.6%. This suggest that a forest form of onchocerciasis may be prevalent in this area. Rapid Epidemiological Mapping will be undertaken in the area later in the year to help delineate the zones to be eligible for large-scale ivermectin distribution. 48. Ophthalmological evaluations were also carried out in Guinea and Togo in January and March 1997 respectively. In Guinea, the evaluations were carried out in five villages in the Niger basin. This was a follow-up ophthalmological survey in a basin which is under larviciding and ivermectin distribution. After nine rounds of annual treatment with ivermectin, the results showed a decrease of the microfilarial load of the anterior chamber of the eye which has changed from an average of 5. 1 mf before the start of treatment to 0.32 mf. In particular, there was absence of microfilariae in the eye and of ocular lesions for the sample of 243 examined children aged 5 to 14 years. Figures 7a & 7b show the changes in ocular lesions for the cohort regularly examined. A statistically significant improvement of the lesions of the anterior segment of the eye was noted (P > 0.00 1 for the sclerosing keratitis and P>0.01 for iridocyclitis, Fig.7a). With respect to posterior segment lesions although there was some improvement in the chorio-retinal lesions, no such improvement was observed in optic nerve disease(Fig.7b). The overall results indicated a progressive beneficial effect on the eye. BIOSTATISTICS AND INFORMATION SYSTEMS 49. The Biostatistics and Information Systems sub-unit (BIS) of the PET Unit continued to carry out the coordination of the processing of the entomological and epidemiological evaluation data, with emphasis on supervision of data entry and validation by the staff of the technical units of the Programme. The sub-unit also continued to play a major role in computer assistance within the Programme. This assistance concerns training, management of the different data banks and their backup, and the routine maintenance of the various computer equipment installed in OCP. BIS also continued to give its asssistance to the other Prograrnme Units in the use of the computer. In this regard, a computer network is functional and OCP has been connected to the INTERNET. 50. The use of the SE)T-ONCHO software package (Epidemiological Surveillanr : and Treatment of Onchocerciasis) for the transfer of OCP data to the Participating Countries has continued to be the subject of training of the nationals. This computer programme and the epidemiological data have been transferred to the seven countries of the original area making it possible for the national epidemiologists to start onchocerciasis epidemiological data management and exchange later with OCP the results obtained. To carry out this transfer correctly, the checking and general update of the epidemiological data bank remains still a priority at BIS. \ JPC18.2 Page 15 51. The intensive use of the Geographical Information System (GIS) has facilitated the analysis of the entomological and epidemiological data. The computerized mapping component of the system has allowed the Programme's cartographer to produce maps which can easily be updated. A training in Atlas/GIS was organized at the end of 1996 for the informatics technicians of OCP as well as selected personnel of the Participating Countries from the Ministries of Health. In the course of the training, the link was made between the softwares Atlas/GIS and Map-Info which OCP has been using for the last two years. 52. An important question raised following the training was how to present eprdemiological and entomological trends as well as the epidemiological predictions made with the ONCHOSIM model on the same map. The software Arc/View was used to address this problem in developing a simple and effective system which perfectly integrates these data. An attempt was made to apply this software this year to the data collected from the basins of the Kankelaba in Mali, Oti in Togo and the Bougouriba in Burkina Faso. The results were encouraging, and Arc/View will equally be used to facilitate the tranfer of the data. To that effect, the GIS already introduced at the level of the national teams will be improved, and supplementary training sessions will be programmed for the end of 1997. 53. Routine analyses has continued in the BIS sub-unit. Thus, the analysis of the ophthalmological data, those of the epidemiological studies on ivermectin and those collected during the study on new diagnostic tools were made. A protocol has been developed and applied in the Kankelaba and Marahoue basin. This is to help appreciate better the real epidemiological trends observed in a basin under both larviciding and ivermectin distribution for deciding on when to stop larviciding. The epidemiological data observed have made it possible to monitor and improve the predicted trend and to validate the important parameters of the ONCHOSIM model along the way. TRANSFER OF ACTIVITIES TO TIIE PARTICIPATING COT]NTRIES 54. Asregardsthetransferof theresidualactivitiesof the Prograrnmetothecountries, thegoalof OCP is to strengthen the capaciry in the countries to be able to carry out epidemiological evaluation, epidemiological surveillance to detect early recrudescence and to control by means of ivermectin treatment, and to carry out residual entomological activities which would remain after 2002. The control activities directed against morbidity as well as those activities aimed at detecting and controlling recrudescence will have to be integrated into the national Multi-Disease Surveillance and Control(MDSC). One of OCP's major roles is to see to it that this transfer of the residual activities of the Programme is carried out in the best possible way. To that effect, OCP, in collaboration with WHO/AFRO and other interested institutions will provide technical, logistic and financial support to the countries. Transfer of residual activities 55. These activities have both the epidemiological and vector control components. Table 4 shows the activities to be transferred, the reasons for the transfer and the time frames for the transfer. During the various OCP meetings organized in March 1997, these different activities were reviewed and it was recommended that: epidemiological surveillance and evaluation, ivermectin treatment and diagnostic tools be transferred as of now to the countries; ground larviciding and entomological evaluation be transferred as of now to the countries; entomological surveillance be transferred to the countries as soon as the methods to be used are functional; hydrological monitoring be transferred to the countries after further training of the existing staff; JPC18.2 Page 16 financial resources have to be found to enable hydrobiological monitoring of the rivers to continue after the end of the Programme; the transfer of research on biological insecticides, should take place at the end of the Programme. Table 4. OCP residual activities to be transferred. 56. As in the previous years, OCP's efforts in the transfer of residual onchocerciasis control activities to the countries have included training, raising of awareness of the authorities and the general public, and support to operational research. OCP has worked in close collaboration with the WHO Regional Office for Africa (see para. 62to76) to implement these activities. Furthermore, contacts between OCP and the Participating Countries have continued, notably through the annual meeting of National Coordinators held in March 1997 n Ouagadougou and through missions and meetings organized in the countries. The report in the documents JPC18.5 and JPC18.6 shows the impact of OCP's transfer activities. Training 57 . In order to guarantee the success of the transfer process, the Programme has pursued its training policy by awarding fellowships to nationals of the Participating Countries for specialization in the following main fields: health services management, public health, molecular biology, environmental sciences and informatics. Between August 1996 and July 1997, the Programme awarded 14 fellowships broken down by discipline as follows: Public health (5), Health services management (l), Molecular biology (2), Environmental sciences (4) and Informatics (2). Type of activity Reasons Timetable PET l. Epidemiological evaluation 2. Epidemiological surveillance 3. Ivermectin treatment 4. Diagnostic For the follow-up of onchocerciasis control activities For the detection of recrudescence For the control of morbidiry For I and 2 Now Now Now As soon as possible VCU 5. Ground larviciding 6. Entomological evaluation /surveillance 7. Hydrological monitoring 8. Hydrobiological monitoring 9. Research on biological insecticides For nuisance control For follow-up of ground larviciding, post-treatment studies and detection of recrudescence For ground treatment in some areas For ground treatment and impact study of the development of the oncho-freed areas For ground treatment Now Now As soon as possible. Some communities trained and used in the context of ground treatment for nuisance control As soon as possible. National staff trained and used to do the work now. Need for financial resources h2ao2 JPC18.2 Page l7 58. This figure increases to 462 the number of beneficiaries of OCP fellowships from 1974 to July L997 . The first part of the survey which was carried out in the Ministries of Health of the 11 Participating Countries on the utilization of the trainees after their return from training showed that out of the 438 OCP fellows considered at the time of the survey in February 1996, 65.5% worked for OCP, for the national onchocerciasis control prograrnmes of the countries and in the Ministries of Health, while 9.4% worked in the other departments. It was noted that 7 .8% were still in training whlle I7.3% were not in active employment or were not identified (Table 5). The second part of the survey of beneficiaries of OCP fellowships began in May 1997 through the Ministries of Health of the Participating Countries with the objective of better supervise the impact of the OCP financially supported training on these beneficiaries. The analysis is in progress. Table 5. Beneficiaries of OCP fellowships per type of service joined after training and per country 59. As in the past, OCP continued to provide in-service and field training centred mainly on the methodology of epidemiological evaluation of onchocerciasis, ivermectin distribution and post-treatrnent monitoring (see also para.37), the different blackfly identification and control techniques and finally, management. Special emphasis continues to be laid on the training of the National Coordinators and other national team members in the OCP methodology for the analysis and interpretation of active epidemiological surveillance data and in the use of computers. 60. As regards the blackfly control methods, OCP is training technicians and villagers in the ground larviciding technique in order to prepare the nationals to control by themselves any blackfly nuisance detrimental to socioeco..omic development activities, if need be. Such training ^ras taken place principally in Burkina Faso, Guinea and C6te d'Ivoire this year. Service Country OCP + National Programmes Ministries of Health Other Services Beneficiaries in training Beneficiaries not in active employment Not identified Total benefi- ciaries Benin 5 28 6 5 2 1 47 Burkina Faso 5 33 6 13 t7 J 77 C6te d'Ivoire 5 7 5 2 5 8 30 Ghana 8 4 8 I 8 ') 3l Guinea 32 12 1 3 5 0 53 Guinea Bissau 7 0 0 0 2 0 9 Mali 10 46 l0 I l0 I 78 Niger 2 27 0 J I 0 33 Senegal l0 9 3 2 I 0 25 Sierra [,eone L2 2 2 I 7 0 24 Togo 8 15 0 J 5 0 31 Total 104 I83 4t 34 61 15 438 Percentage 23.7% 4t.8% 9.4% 7.8% 13.9% 3.4% 100% JPC18.2 Page 18 Public awareness and population mobilization effort by OCP (see also para. 130 to 154) 61. The unit continues to coordinate, in close collaboration with the Vector Control Unit, an information campaign conducted every week by sub-sector and sector chiefs during their routine field visis. The main themes treated during these sessions are still the same, i.e., the return of the blackfly after the cessation of larviciding, the role of ivermectin in the control of onchocercal morbidity and in the prevention of blindness, the need for communiry participation in all activities aimed at detecting early recrudescence of onchocerciasis or controlling this recrudescence, if necessary. SUPPORT OF WHO/AFRO TO TIIE OCP ACTIVITIES IN TIIE PARTICIPATING COI-INTRIES (Contribution of the WHO Regional Office for Africa) 62. The support of WHO/AFRO to OCP in the past years was oriented towards the developmenr and the establishment of the process of integration of OCP residual activities into the health system of the Participating Countries. Conforming to the mandate of the WHO and the commitments undertaken by AFRO as regards transfer of the OCP residual activities, the surveillance in public health and the integrated disease control are the privileged fields in which essential efforts are concentrated. These efforts also concern the political, management, as well as technical issues. The Regional Office and the Representation Offices in the countries take active part in establishing the processes of transfer of the OCP residual activities. Political level 63. The Regional Director, Dr. Ebrahim M. Samba has given in a memorandum dated 22 January 1997 to all the WHO Representatives in the 11 countries of OCP, precise orientation to render effective the commitments taken during the seventeenth session of the Joint Programme Committee (JPC) which took place in Cotonou in December 1996. The commitment and the determination of the Regional Director had a clear procedure on the transfer of the OCP residual activities . This was renewed on April26,1997 ina memorandum addressed to the Director of the OCP. This memorandum exposes the vision of the Regional Director concerning the joint action of the WHO/AFRO and the OCP to realize in an effective and efficient manner the integration of OCP residual activities in national health systems. 64. The Regional Director has always included the OCP Programme in the subjects of discussion when he meets the Heads of States, and Ministers of Health of the OCP countries and the donors. Managerial level 65. A budget allocation of US$ 250,000 is put at the disposal of the OCP by the Regional Office every year for its operations. Besides, the Representation Offices in the countries apportion their budgets to AFROPOC to sustain the activities being integrated into the health systems. The Regional Office has also authorized the hiring of an epidemiologist to help the OCP in the training of district health teams in epidemiological surveillance and in the training for the installation of CDTI. The emoluments for the epidemiologist comes from the budget of AFRO. In addition, the Representation Offices were reinforced with epidemiologists to help the countries in the public health surveillance and the integrated disease control. 66. In applying the directives of the Regional Director, the WHO Representatives in the countries are directly involved in the mobilization of national resources for onchocerciasis control.This has resulted in ten countries out of the eleve,. creating a line item in their national budges for onchocercia ,is control by allocation of funds ranging in amounts from US$ 5,000 to more than US$100,000 in 1997. 67. For the first time, the WHO Representatives in the OCP countries as well as their respective country team epidemiologists took part in the annual meeting of the National onchocerciasis JPCI8.2 Page l9 Coordinators and actively contributed to the reflexions on the transfer of residual activities of the OCP to countries. 68. During the year, the professional staff of the WHO Country Teams, including the Representatives contributed in the implemen[ation of field activities of and sent reports to the Regional Office. Feedback was provided by the Director of the Integrated disease control Division. The Regional Office and the WHO Representations in the OCP countries have actively contributed to the training process of the teams at district level on the integrated epidemiological surveillance and for the installation of the CDTI (see para. 37,57 and 58). 69. The meeting of the Ministers of Health and the Ministers of Territorial administration on the preparation in the prevention and control of the epidemic which took place in Ouagadougou in November 1996 created a renewed interest in the surveillance of the infectious diseases during the year. The WHO Representation Offices in the countries have already started and will pursue their efforts and support to the health authorities with the view to the integration of onchocerciasis control in the national health system at all the levels and particularly at the district and community levels. This effort of integration is commonly noticed in the manner in which the personnel, however limited in number, work in the field (at the health centre), but also in the organization of integrated training. In the meantime, there is still a lot to be done for onchocerciasis to become part of the preoccupation of development or of the revision of health policies. Technical level 70. The epidemiological surveys in the sentinel villages are more often carried out by the national teams with funding from AFROPOC. During the training workshops for the implementation of CDTI, the nurses at the health posts received support from the WHO Representations for their micro-planning. This was the case in Benin where the training for the surveillance of the potentially epidemic disease was combined and carried out with the setting up of the CDTI. The efforts in this regard will be intensified within the coming months and year. Future support activities 71. In spite of the important efforts already made, it is noted that in some countries, onchocerciasis does not receive the expected attention of policy decision-makers and highly placed health officers. This is due to the verticality of the control operations and to the success of OCP. The efforts made in integrating onchocerciasis control in the health system seem to have omitted the crucial process of including onchocerciasis within the national preoccupation with development or the revision of the documents on the general health policy. This is a weakness that the WHO Representatives have identified which requires an investment of their efforts. 72. The performance of the system of management of health in general remains insufficient. There is a need for monitoring activities in the health systems. The efforts at the level of AFRO as well as the WHO Offices in the countries will be oriented towards the development of the national capacities in management. 73 . As mentioned above, there is a renewed interest to enhance epidemiological surveillance in the countries generally. As a result, there is an increasing number of training sessions on surveillance of endemic diseases for the district health teams. Meanwhile, it has been observed that the realization of this training is insufficient for the expected improvement of the surveillance of these endemic diseases to occur. It is more and more urgent that the trained personnel be regularly supervised in order to help them to do better. The WHO will endeavour to arouse and support the initiatives in this area in the Participating Countries. 7 4 . It is currently noticed that one of the causes of the weak performance of the integrated surveillance of the disease is the absence of an evenly organized system or the existence of several parallel systems JPCI8.2 Page 20 without efficient coordination. Although the organizational structure of the Ministries of Health hold high the sovereignity of the countries, the WHO is prepared to give the necessary technical assisrance to countries wanting to organize a functional and efficient system of health surveillance. There are already inter-country epidemiologists in place who have this as part of their responsibility. 75. Currently, there is a concern in scientific forums of an eventual or even eminent appearance of resistance of microfilaria of O. volvulus to ivermectin. Conforming to the mandate, in the course of year, WHO will strengthen its vigilance in the countries on this phenomenon which risk to endanger the hopes in using this drug to completely eliminate onchocerciasis as a public health problem. The Regional Office, in collaboration with the WHO/HQ, OCP and APOC, will study the mechanisms for establishing very rapldly a process of detection of possible appearance of this resistance in the countries. 76. If the community-directed treatment with ivermectin (CDTI) proves effective, its sustainability will remain to be proven. TDR has already planned a second study on CDTI, to determine which factors could permit the prediction of the sustainability of CDTI. AFRO and the WHO Offices/countries will support the realization of this important srudy. INTERDISCIPLINARY RESEARCH Insecticides 77. As in the previous years, the seven insecticides retained by OCP (temephos, phoxim, pyraclofos, B.t. H-14, permethrin, carbosulfan and etofenprox) were used in accordance with the insecticide rotation strategy aimed at preventing blackfly resistance and keeping the effects of larviciding on the non-target aquatic fauna to a minimum. The evaluation of the efficacy of new larvicides being no longer a priority, research efforts are now being placed on quality control of operational batches and the improvement of the existing formulations of B.r. H-14. 78. During the period under review, the quality of the operational batches of B. r. H- 14 (Vectobac@) had been notably improved and was now close to meeting the terms of the technical specifications (CL50 below 115 mg/l during the first six months after delivery) of the contract between OCP and the Abbott Company. The said contract is due to expire in December 1997. At the same time as these trials were being carried out, some operatiorial batches of another formulation of B.r. H-14 (Teknar@) were tested this year both in the laboratory and in rivers. The first results were very promising and more fine-tuned comparative trials of the two formulations are scheduled to be carried out before the issuing of the next invitation to bid. 19. Research on the formulations of recombinant strains of B.t. H-14 is being continued in collaboration with the Entomopathogenic Bacteria Laboratory of the Institut Pasteur in Paris. In addition to the interest in increasing the efficacy and stability of the commercial formulations (a gain by only one third of the operational dose would make it possible to use B.t. H-14 at a discharge of 100 mr/s), this research has allowed the major activity of the hemolytic protein of B.t. H-14 on the larvae of S. damnosum s.l to be confirmed. This characteristic will be taken advantage of in the attempt to develop a simple method for the correct proportioning of this protein (colourimetric method) for the purpose of determining the efficacy of the formulations at both the production and reception sites. 80. No decrease of blackfly susceptibility to B.t. H-14 has yet been observed in the Prograrrme area after more than 15 years of use of this product. With respect to the chemical insecticides, the priority for testing was given to the organophosphorous compounds (temephos, phoxim and pyraclofos), especially in the basins in which cases of resistance to these products had been detected in the past (basins of southern C6te d'Ivoire, Niger near Bamako, Milo, Niandan, Oueme and Mono). The results JPC18.2 Page 2l obtained this year show that the restrictions imposed on the use of these products, if rigorously observed, would make it possible to gradually lower the level of resistance in most of the basins concerned. Vector identification 81. Cytotaxonomystillremainsthereferencetechniqueforthe identification of thespeciesof the S. damnosun complex. Besides, it was widely used in the investigations undertaken to evaluate and validate the other methods of vector identification, namely the morphological-morphometric and heteroduplex methods. A cytotaxonomic data bank strictly controlled by the research teams constitutes a precious working tool as it is a compilation of all the identification results obtained since 1980. Indeed, the specific composition of the blackfly populations studied is regularly checked against the data in this bank, which also makes it possible to monitor any changes in the susceptibility of the different species to the insecticides used by the Programme. 82. The morphological data bank, which has been regularly updated since 1993, makes it possible to consistently monitor the seasonal dynamics of the populations of savanna and forest species of S. damnosum s.l. in all the basins treated. Such monitoring has allowed a precise determination of the zones in which savanna and forest species cohabit, with a more or less clearly marked predominance of either species according to the season. As regards bioclimatic conditions, they are generally characteristic of the forest/savanna transition zones or degraded forest areas. 83. The identification of female flies of the.!. damnosum complex through the DNA-based heteroduplex technique is now operational. However, its field validation in parallel with the cytotaxonomic method is continuing in the forest/savanna transition zones where several blackfly species cohabit and where hybrid species are encountered. This validation also applies to the morphological and/or morphometric identification technique because of the overlapping of the criteria used for certain differentiations. These two methods of identification, however, remain in agreement in most of the basins treated. Parasite identification 84. The identification of parasites from infective blackflies has been going on satisfactorily at the Bouake laboratory for five years now. It must be recalled that the Programme has at its disposal four specific DNA probes. Two are species specific (O. volvulus and O. ochengi) and the other two are strain specific (forest strain and savanna strain of the human parasite). As is the case every year, this technique combined with the morphological identification of vectors makes it possible to provide, for the entomological evaluation of larviciding, two types of results. The first type concerns the transmission of human onchocerciasis by all the species of the Simulium damnosum complex (Fig. 2) whereas the second type relates to the transmission of human onchocerciasis by the savanna blackflies alone (Fig. 3). The type relating to the transmission of the savanna strain of the parasite is still not yet retained, because in the forest/savanna transition zones there seem to be intermediate pathogenicity levels which are difficult to differentiate through the techniques currently used (see para.22). 85. The technique used to determine the prevalence of infection by pool screening of blackflies was tested in 1996 on the Bougouriba, the kraba and the White Volta then, in 1997, on the Baoule. The results obtained were not significantly different from those yielded by routine dissectiors. The protocol has alread- been finalized for the post-treatrnent studies and the last adjr strnents are under way to allow its use by the Participating Countries as an entomological tool for the early detection of recrudescence. 86. Quality control of the identifications made in the Bouake laboratory is being pursued each year by the forwarding of coded samples to the laboratory in the University of Alabama. The verifications JPC18.2 Page 22 made so far show perfect agreement between the identifications made in Bouake and those made in the United States. These results confirm the reliability of the technique and the quality of the work done in Bouake. Quality control has also just been instiruted for the heteroduplex analysis of the DNA. 87 . With regard to entomological research, the investigations will be pursued for the adaptation of the heteroduplex technique to the parasites of onchocerca with a view to determining the phylogeny between the "blinding" savanna strains and the "less blinding" forest strains. The preliminary investigations have made it possible to detect a polymorphism the scope of which is being evaluated. The purpose of these investigations is to establish a correlation between parasite strains and pathogenicity and to reveal possible intermediary levels. Another line of research being carried out relates to the capacity of DNA microsatellites to be used as markers of the different vector and parasite populations. Collaboration for these subjects is under way with the University of Alabama on one hand, and the ORSTOM Centre in Montpellier on the other. Special entomological studies 88. Since 1995, some special entomological studies have been undertaken with the purpose of strengthening current knowledge about the transmission and the epidemiology of onchocerciasis in the forest zones situated outside the Programme area which are more and more marked by intensive deforestation and/or by human migrations. The regions concerned by this research are those of south- western Ghana in the Pra and Tano basins, south-eastern C6te d'Ivoire on the Bia and lower Comoe, and south-eastern Guinea on the Diani river. The results would make it possible to determine which of these areas are to be placed on CDTI. 89. The study carried out in the south-west of Ghana has benefitted from the technical collaboration of a team from the Noguchi Memorial Institute for Medical Research in Accra. The results show the existence of a mixture of forest and savanna species. The forest species transmit both the forest and savanna strains of the parasite and are present all year round. The savanna species are more subject to seasonal variations (the highest densities being observed during the dry season) and are little involved in transmission. 90. The lower Comoe and south-western Ghana regions show numerous similarities, particularly in respect to the specific composition of the S. damnosum s.l. populations and the dynamics of the savanna species. On the other hand, in the south of the Prograrnme area (Bia river and the downstream portion of the lower Comoe), few larval breeding sites are found and these are colonized exclusively by forest species. 91. In the south-east of Guinea, the routine evaluations carried out in this region have revealed the almost total non-existence of savanna vectors regardless of the season. The only forest species encountered were S. yahense and S. squamosum which only transmit the forest strain of O. volvulus. The predominant vector is S. yahense which represents more than 80% of the blackfly populations observed. 92. Following the detection of a case of recrudescence of infection in the Bougouriba basin in Burkina Faso, special entomological studies were initiated during the rainy season of 1996 to assess the level of transmission of onchocerciasis. Out of the six catching points selected, three show a transmission level above 100 infective larvae per person per year. This entomological evaluation will be pursued in 1997 in order to monitor the trend of the transmission parameters in the presence of an intensive distribution of ivermectin (three to four treatments per year with one just before the rainy season). 93. ShortlyafterthedefinitivecessationoflarvicidingontheKulpawnandMoleinlgg5,aspecial entomological study was initiated to determine whether the distribution of ivermectin, as currently carried out (twice a year), would have any impact on the transmission of onchocerciasis. To that effect, JPC18.2 Page 23 the Programme carried out a post-treatrnent entomological evaluation during the rainy season of 1996 with the aim of determining infectivity levels in the absence of larviciding. The final results of the study will be made available at the conclusion of a subsequent entomological evaluation to be carried out in 1998. Diagnostic tests for surveillance of onchocerciasis 94. The classical skin-snip method has continued to be the diagnostic method used for epidemiological surveillance and evaluations. Validation of the diethylcarbamazine (DEC) test which could be an alternative method of diagnosis to the skin-snip was pursued during the year. In this respect, the hyper- sensitivity of the patients to "Nivea cream" which is used as "carrier" for DEC was carried out in a sample of ll2 children from the village of Gbletia in the Sassandra basin in C6te d'Ivoire. The application of Nivea Cream alone without DEC caused no skin reaction. However, the application of Nivea cream mixed with DEC showed skin reactions in 29.4% of the cases among the same children after 48 hours. 95. The validation of the test in a low infection area was carried out in the Bougouriba, Oti-Pendjari and kraba-Comoe basins in Burkina Faso to study the sensitivity of the DEC patch test compared to the other tests (skin-snip and serology based on the tri-cocklail antigens). The comparison of these three test methods carried out in a sample of 553 people in six villages in the Bougouriba basin is shown in Table 6. Table 6. Comparison of three methods for detecting onchocerciasis infection *The result of the DEC patch test being the best reading after 48 hours 96. In conclusion, the results show that the DEC patch test has a reasonable sensitivity and can detect a higher prevalence than the skin-snip method. The prevalence shown by the serology and the DEC patch tests are not statistically different. The DEC patch test appears more acceptable to the population than the other tests. Nevertheless, the test for species specificity is being pursued in areas of other filarial infection like Mansonella perstans and Mansonella streptocerca but where there is no onchocerciasis. The results will be available by the end of the year. Skin-snip (a) versus (vs) Serology (b) Serology (b) y.s DEC patch test* (c) Skin-snip (a) y.t DEC patch test* (c) Sampling size s53 492 481 Prevalence (a) t5.6% (b) 20.r%(P: 0.05 ) (b) 23.2% @) 25.a% (Ns ) (a) t6.6% (c) 23.9% (P:0.005) Sensitivity 76.7% 7t.t% 63.8% Specificity 90.4% 88.4% 84.0% Positive predictive index 0.56 0.61 0.42 Negative predictive index 0.9s 0.91 0.92 JPCI8.2 Page 24 Macrofil Chemotherapy Project Potential macrofilaricidal drugs 97. A Phase II clinical study using amocarzine in 100 onchocerciasis patients was completed at the Onchocerciasis Chemotherapy Research Centre in Ghana, and the results discussed at a scientific working group meeting held in Geneva in November 1996. It was concluded that amocarzine, using the maximum safe dose of 3 mgikg, bid after food for three days, either alone or in combination with ivermectin, showed no macrofilaricidal action. The Group recommended that amocarzine should no Ionger be developed for use in African onchocerciasis. Phase II trials of amocarzine for lymphatic filariasis are continuing in India, as clinical adverse effects were not a limiting factor in the Ghana study. 98. During the year 1996, another scientific working group prepared a protocol for a study to determine whether monthly dosing of ivermectin would have a prophylactic effect in onchocerciasis in humans, as had previously been demonstrated in the O.ochengilcattle model. This three-year study, which would have involved over 2 000 children, was discussed by EACl8, which concluded that such a lengthy study, involving a large study population, should not be initiated. Preclinical studies 99. Following promising early studies of safety and efficacy in both the Onchocerca ochengilcattle and Brugia pahangildos models, UMF 078 has undergone preclinical bacterial and mammalian mutagenicity studies both ln vitro and in vivo. i00. Initialmutagenicitystudies invitro inbacterialsystemswerenegative. In vlrrosrudiesusing human lymphocytes indicated that while UMF 078 iself is not mutagenic, activation by rat liver microsomes generates a metabolite which is mutagenic. One possible metabolite, UMF 060, was also tested, and shown to be mutagenic in the human lymphocyte system. even without rat microsome activation. 101. An in vivo system,.in which the effects on mouse bone marrow cell division by single oral doses of UMF 078 were studied, showed that mutageniciry occurred at all doses higher than 100 mg/kg body weight. As indicated by the in vitro studies noted above, it is known that rodent liver will activate UMF 078 to mutagenic metabolites, so this result is not unexpected. IO2. The recommendation of the UMF 078 Development Group was therefore to repeat the in vitro experiments on human lymphocytes, but to utilize human (and dog) liver microsomes rather than rat microsomes. This experiment will indicate whether human liver will also produce mutagenic metabolites from UMF 078. The metabolic products from both the in vitro and in vivo mutagenicity studies will be analysed to identify any toxic metabolites. 103. Efficacy studies in dogs and cattle, using high, three-day, oral dosing schedules, indicated acute toxicity after the second dose, which in cattle (given doses of 150 mg/kg) led to death in two of the six cattle treated. Further studies are in progress: if these studies preclude dosing of UMF 078 by the oral route, then the intramuscular route will be further examined, but this may involve lengthy studies including potential carcinogenicity. All work on UMF 078 to date has used the racemic mixrure, but the two enantiomers will be separated and the efficacy and genotoxicity of each will be assayed. 104. Compounds WR 251993 and WR 129577 failed to give sufficient efficacy inthe O.ochengilcattle model to justify further development. Pharmacokinetic studies of PD 105666 in uninfected calves have been completed, and it will be tested against O.ochengi when current work on UMF 078 is completed. JPC18.2 Page 25 105. Ivermectin is one member of the large family of compounds known as avermectins and milbemycins, and was originally selected as a widespectrum drug for parasitic nematodes of the gastro- intestinal tract. It is possible that an alternative compound of this type has better activity against filariae than ivermectin. Thus other analogues of ivermectin, both marketed and unregistered have been tested. Moxidectin (Fort Dodge Animal Health) has shown enhanced activity against several filarial worms, probably due to its physicochemical and pharmacokinetic properties. Further protocols to study its effects on O.ochengl in cattle and B.pahnngl in the dog have been developed in collaboration with Fort Dodge Animal Health. If increased "macrofilaricidal" action and/or prophylactic activity is shown in these studies, the possibility of clinical studies in man will be discussed with Fort Dodge. Detection of ivermectin resistance 106. Macrofil has supported work on the mechanisms, and genetic basis of resistance to ivermectin, in four of the parasitic nematodes where resistance has developed as a result of veterinary use in the field. To date three specific mechanisms of resistance have been identified involving: a) Changes in the dynein of the sensory amphids b) Changes in membrane transporter proteins c) Changes in the ivermectin receptor (a glutamate-controlled chloride channel) This work is progressing well, and the genes responsible for ivermectin resistance by the above mechanisms, are now being sought in o.volvulru (see para.1l3 and 114). Epidemiological modelling Epidemiological modelling of recrudescence in the Bougouriba basin 107 - Epidemiological modelling has been used to study the recrudescence observed five years after the stopping of larviciding in the Bougouriba basin (a tributary of the Black Volta) in Burkina Faso. As a background information it may be noted that larviciding had been carried out from February 1975 to September 1990, a period of 15 and a half years. In December 1989, one year before the cessation of larviciding, a 6% plevalence of infection was observed in Zoulo, one of the villages of that area. Subsequent epidemiological evaluations in March 1991, February 7994, and Novembir 1995 showed prevalences of 5%,ll7o and25% respectively. The epidemiological results in the surrounding villages of Zoulo and the entomological studies (see para. 83) confirmed the relapse of the transmission on the Bougouriba. Figure 8 shows the observed epidemiological data for the indicator village Mouvielo during the vector control period and for the village Zoulo during the epidemiological surveillance period. 108. To explain such a rapid occurrence of recrudescence, different hypotheses or questions were considered and tested against the epidemiological data observed in the sentinel village of Zoulo and Mouvielo using the ONCHOSIM model. The first logical step considered whether thi rising trend of the prevalence observed in this area after 1994 confirms the hypothesis that vector control had not been carried to its term. The dynamics of the recrudescence projected from different hypotheses taking into account the effectiveness of vector control were studied. Such effectiveness is represented as the percentage of the decrease of the biting rate compared to the situation prior to vector control operations. All the simulations presented supposed that during the first two years of vector control, the effectiveness reached 75% because of reinvasion into the Bougouriba basin at that time and afterwards ranged between 80 and IoO%. All the projections were compared to the prevalence trends observed in the villages of Mouvielo and Zoulo. The trend during vector control is in accordance with that observed at Mouvielo if we start from the hypothesis that the effectiveness of vector control ranged from 95 to 100%. However, none of the projected trends of recrudescence conforms with that observed at Zoulo where a very rapid increase of the prevalence was noted. JPCI8.2 Page 26 109. Attempts at explaining the trend at Zoulo, on the basis of two external factors were set through several simulations: immigration of infected individuals and invasion by infective blackflies : a) The simulations have led to assuming that during the 1989-1992 period, 38 adult migrants arrived in the village whose total population would be around 400 people. The migrants are presumed to have settled in the village of Zoulo and to have created a zone with very high endemicity (similar to Mouvielo before the beginning of control operations). With such an important flow of the infection at the end of vector control, we can adjust simultaneously the trend observed at Mouvielo and Zoulo. b) It is supposed that from 1986 to 1996 the village was reinvaded by infective blackflies. If this scenario had actually taken place, it would have meant that there was an unknown or a new breeding site; that the blackflies originating from that breeding site had been feeding in an hyperendemic village up to now undetected as regard its epidemiological situation; that the blackflies had carried their L3 Larvae from this site to Zoulo. The simulations showed in this case also that the observed trends at Mouvielo and Zoulo could be adjusted simultaneously. 110. The sociological as well as entomological studies carried out showed that it was difficult to give credit to the hypotheses made in the simulations in an attempt to adjust the observed trends. As a result, other possible causes which might be linked to the ONCHOSIM model itself were considered: could there be some hypotheses which have always been used (given the available data) that needed to be revised in the light of the present situation in the Bougouriba? One such attempt was made in simulations where the risk of recrudescence due to an insignificant residual reservoir of infection was studied. 111. From these different simulations, it was clear that one should not rely only on a single factor, but rather should investigate a set of possible causes to be defined by an indepth study of the available data from the Bougouriba region. Il2. Different simulations which showed the impact of the introduction of a biannual ivermectin treatment from 1996 to the end of OCP in 2002 to control this recrudescence of the infection were studied. The simulations showed that none of the scenario projects the elimination of the problem before 2002, after seven years of ivermectin treatement (Fig. 8). Ivermectin distribution needs to be continued for at least a total period of l0 years. The scenario adviced to the Bougouriba basin in Burkina Faso is to put in place an intensive distribution of ivermectin (three to four treatrnents per year with one just before the rainy season; see para. 92). Model simulation of ivermectin resistance I 13. In order to investigate the likelihood of resistance occurrence in areas where regular ivermectin treatment is being or planned to be carried out for long periods, the ONCHOSIM model has been extended with a sub-model for the genetics of such resistance. The following assumptions were made: (i) resistance is the result of mutation of a single gene, (ii) resistance is complete, i.e., genetically resistant microfilariae (ml) do not at all respond to ivermectin, (iii) there is no selective disadvantage (resistant mf or worms are as viable as wildtype). ll4. The simulations enable one to conclude that a) Mutation of recessive genes which lead to resistance to ivermectin is probably not important in the endemic situation, but could be dangerous in previously treated populations. JPC18.2 Page 27 b) Dominant mutations will be dangerous: one or two resistant heterozygotes worms may spread the resistance. c) Shift from sensitive to resistant genes occurs when mfdensity is low. This has to be taken into account in detection strategies. d) Intensive treatment (high coverage and or high frequency of treatment) will not always lead to higher risks of resistance (in spite of the high selection pressure). ADMINISTRATTON AND STJPPORT SERVICES Objectives, organization and functioning of seryices 115. The basic function of the Administration and Management Unit is to support the activities of the operational, technical and scientific units of OCP and to assist in assuring that these activities are carried out efficiently and at optimum cost. The unit manages the Programme's infrastructure and its human, financial, material and information resources. It is structured to offer services in the areas of Purchasing, Finance, Personnel Management, Transport and Communications Management, and General Administration. During the period under review the Unit provided special support to the following activities, with a view to improving performance and reducing costs: (i) training for all the 19 secretaries and clerical staff to upgrade and/or update their computer skills to handle WINDOWS, WORDPERFECT 6.1 for WINDOWS, and EXCEL. (November 1996); (ii) a series of two-day courses on road safety and vehicle maintenance for 138 chauffeurs in bases across the Programme area. (February 16 to April 13, 1997); (iii) a management seminar in which the field staff and the national coordinators examined the critical issues facing the Programme during its final phase. (March 14-15, 1997); (iv) a management training course for OCP professional staff, to sharpen their skills in communication and leadership. (June 9-13, 1997); (v) the refurbishing of the electrical system and the replacement of a voltage stabilizer for the computer circuits in the Ouagadougou office, (February-April 1997). Administrative costs 116. Administrative costs in the Programme are defined as those associated with the budget items for the Office of the Director, Administration and Support Services (Ouagadougou) and Support Services (Geneva). For the years 1992-1996, expendirure on Administrative Support costs as a percentage of Programme expenditure is shown in Table 7. Il7. Annual Programme expenditure as a whole has been falling more rapidly than expenditure on administrative costs. The ratio rose to 14.04 percent in 1995 and has attracted the attention of the Programme management. One response has been the decision to fill vacancies only where necessary and then by using short term Special Service Agreements in preference to the more expensive WHO fixed term con' 'acts. The duties being performed by staff members are beinl continually reviewed with a view to rationalization. This ratio of expenditure on administrative costs to total expendinrre, is a parameter which is being kept in view and monitored. For 1996, the percentage fell to 13.57 percent. JPC18.2 Page28 Budget and Finance 118. The 1997 budget was prepared using an average exchange of US$ 1: 500. The dollar held firm in 1996 atjust under $ 1 : 510 for most of year. Since January 1997, it has climbed steeply to 583 in May, but fell to 574 in June. Since this rise may be a peak, the 1998 budget was prepared on a prudent average rate of US$ 1 : 500 FCFA, the same as for the 1997 budget. Table 7. Cost of the Administration and percentage 1992 - 1996 (us $) *(767,161): Expenditure under Office of the Director ($ 1,411,554) adjusted for comparison purposes by removal of $ 529,393 spent on training and $ 115,000 for a technical staff member from the PET unit, assigned for 1996 only. 119. The Finance section operates 14 bank accounts in the eleven countries and reconciles them monthly with the accounts sent in from the National Teams and those sent in by the Eastern and Western operational zones. 120. The section took on board the work arising from the start up of the African Programme for Onchocerciasis Control (APOC) and established the necessary accounts and financial control mechanisms. In this regard contact was made with WHO-HQ and the World Bank, leading to releases from the Trust Fund of US$ 800,000 in April 1996, and $ 2,452,W0 in 1997 . At the operational level, the Finance Officer undertook missions to Uganda, Nigeria and Malawi, to verify the NOTF accounting systems, and to assist in establishing procedures compatible with WHO rules, before APOC funds were released. Personnel l2l. The period under review was marked by the closure in December 1996 of the entomology sectors of Parakou (Benin), Tamale (Ghana) and sub-sector of Kintampo (Ghana). The closure of the sub-sector of Bondoukou lCdte d'Ivoire) took place at the end of June 1997. The staff members whose employment with the Programme ended with the closure of the sectors listed above, received all the pertinent information concerning their separation. Unit t992 t993 t994 1995 r996 Office of the Director 743,449 585,650 656,831 718,500 767,161* Administrative and Support Services Ouagadougou 2,622,244 2,679,531 1,842,485 1,910,737 1,842,570 Support Services Geneva 398,577 408,451 45I,274 405 480 348,451 Total Administrative costs 3,764,270 3,673,632 2,950,590 3,034,717 2,959,192 Total Prograrnme Expendirure 31,716,t97 26,503,663 23,150,289 2L,614,710 21,792,694 Administrative costs % tr.g % t3.86 % 12,75 % t4.04 % t3.57 % JPC18.2 Page 29 122. Staff cost reduction was consistently pursued as dictated by the annual reductions in the budget. At the general services level there was increasing use of temporary and short term staff on Special Services Agreement contracts. To ensure that the required technical competence is maintained, it has been decided to employ National Professional Officers, when posts occupied by International Professional Staff become vacant. Supply and Services 123. This section deals with the purchases of goods and services, the maintenance of the projects' inventories and the disposal of items which are no longer useful or in excess of the Programme's needs. On the other hand, it supervises administrative services such as office management, air travel and visas, registry and mailing, and fax and telephone. It also supervises the contractors to whom OCP has out- sourced securiry and cleaning services. I24. During the year under review, the subunit saw to the installation of services and furniture in the APOC building, which it had renovated. The electrical system of the OCP headquarters building was also refurbished. A large number of meetings were held in the OCP conference room, and received the logistic and administrative support of the Supply and Services section. 125. The expenditure on the purchase of larvicides, vehicles, equipment and other goods and services from the 1996 budget was $ 6,889,074. Larvicides accounted for US$ 3,274,592, while spare parts and vehicles for US$ 710,818. Five hundred and sixteen (516) local purchase orders, amounting to $ 532,203 were prepared to cover 674 articles bought directly in Participating countries. Two hundred and fifty seven (257) purchase orders, amounting to $ 4,460,2'77, were processed through the central purchasing division of WHO in Geneva. Transport and Communications 126. This section is responsible for all aspects of the management of the fleet of nearly 300 vehicles as well as the OCP telecommunications network (radio/teletype) covering all the countries. The policy of reducing the fleet is proceeding in line with the reduction of vector control activities, and as countries [ake over responsibility for onchocerciasis detection and control. As at 31 August 1996 there were 305 vehicles in circulation. As at 31 August 1997 there were 285 vehicles in circulation. 127 . Twenty eight new vehicles were put into service in 1996 and29 old vehicles were retired. For 1997 thirty-three vehicles were ordered and 41 vehicles over 10 years old will be taken out of the fleet. It is projected that at the end of 7997 there will be275 vehicles in circulation. For the period under review, the vehicles covered 5,863,686 kilometres and consumedTgI,62S litres of fuel. The fleet availability was 95.36 percent. 128. Out of the fleet, nearly 100 vehicles were loaned to the Western Extension countries to support operational activities of the national teams. The maintenance of these vehicles was carried out by the national teams, while OCP supplied fuel, lubricants and spare parts and retaining responsibility for technical supervision. The vehicle maintenance sheds in Faranah, Kankan and Makeni were refurbished. In the context of continuing education a training seminar was organized for the mechanics and storekeepers of the national teams. In addition, OCP sponsored three mechanics to a training course organized by Toyota Motor Coorporation, in Johannesburg, South Africa. 129. The radio/teletype stations of OCP's telecommunications network were serviced to improve the performance of the system. A refurbishing exercise is being studied. JPC18.2 Page 30 PTJBLIC R-ELATION, INFORMATION AND DOCUMENTATION ACTTVITIES With the World Health Organization 130. The Programme Director took part in the following statutory meetings: the 46th session of the WHO Regional Committee for Africa inBrazzaville, from September 1 to 13, 1996; the 99th session of the WHO Executive Committee from January 12 to 23, L997 in Geneva; the 50th session of the World Health Assembly from May 3 to20, 1997 in Geneva. The Programme Director seized the opportunity offered by these meetings to maintain relations and to discuss informally with other divisions and programmes of the WHO. 131. The WHO Regional Director for Africa accompanied by the Programme Director made a field visit to Bobo-Dioulasso from September 24 to 25, 1996. 132. The annual meeting of Vector Control Unit (VCU) operational zones which was held in Bouak6 from November 4 to 9, 1996 and which for the first time brought together both Eastern and Western zones, benefitted from the active presence and participation of the Programme Director and the WHO Representative in C6te d'Ivoire. I33. For the first time the WHO Representatives in the l1 Participating Countries and their respective country epidemiologists took part in the annual meeting of the National onchocerciasis Coordinators which was held from March 17 to 19, 1997 at the Programme headquarters in Ouagadougou. The WHO Regional Office in Africa also participated in the meeting. 134. The Programme Director as well as his closest collaborators took part in the various meetings and workshops concerning the implementation of the African Programme for Onchocerciasis Control (APOC) activities and the consolidation of its partnership, namely: TDR symposium on REMO in Ouagadougou from September 3 to 6, 1996; TDR workshop on CDTI in Ouagadougou from September 8 to 13, 1996; NGDOs APOC meeting from September 30 to October l, 1996 in Ouagadougou; The 2nd session of APOC Technical Corsultative Committee in Ouagadougou from October l to 4, 1996; APOC Joint Action Forum in Cotonou from December 5 to 6,1996; NGDOs APOC meeting from April 4 to 5, L997; The third session of APOC Technical Consultative Committee in Ouagadougou, from april 7 to lI, 1997; TDR workshop on a Protocol Development on Onchocerciasis research in Ouagadougou from June L6 to20, 1997. Seminar on APOC Philosophy and the Communiry-directed treatment with ivermectin in Ouagadougou from June 23 to 28, 1997. An APOC staff member and the Finance Officer went on a mission to Uganda and Nigeria to verify the NOTF accounting system and to assist in establishing procedure compatible with WHO rules before the release of APOC funds. With the Participating Countries 135. The annual meeting of Hydrobiologists from the Participating Countries was he -d on January 27 and 28, in Accra (Ghana) and the meeting was attended by the Programme Director, the OCP Vector control Unit Senior staff and ORSTOM experts. A day of joint meeting with Ecological Group members was held. JPC18.2 Page 3i 136. The National Onchocerciasis Coordinators and OCP personnel attended a seminar on management from March 14 to 15, 1997 in Ouagadougou during which issues related to the final phase of the Programme were discussed. 137 . The National Coordinators annual meeting which was held from March 17 to 19, 1997 at the Programme headquarters, in Ouagadougou, brought together exceptionally this year, National Coordinators for Onchocerciasis Control and the WHO Representatives in Participating Countries with their country epidemiologists. Furthermore, this meeting was attended by the OCP External evaluation team. It dilated on the relationship between the OCP, the Participating Countries and WHO/AFRO and the progressive transfer of residual activities of OCP to the 1l countries. 138. The Chief of Planning, Evaluation and Transfer (PET) Unit and his collaborators parricipated in the planning and the training of trainers for the implementation of the community-directed treatment with invermectin in the countries within the context of the follow-up of the country-specific workshops which took place in all the Participating Countries in 1996. They also took part in the different training sessions of the nationals in the decentralization of epidemiological surveillance. With the OCP statutory bodies 139. The ecological group held its eighteenth session from January 29 to 3I, 1997 in Accra (Ghana) and the Expert Advisory Committee (EAC) also met for their eighteenth session in Ouagadougou (Burkina Faso) from June 2 to 6, 1997. 140. The Committee of Sponsoring Agencies (CSA) met on September 20 and October 21, 1996 in Paris, December 1 and 6, 1996 in Cotonou, April 29 and 30, 1997 in Washington, July 17 and 18 1997 in London. With the Donors l4l. The Programme Director paid visis to Donor Representatives in Paris, Brussels, Amsterdam, London and Rome.These visits provided occasions for briefing on the progress in the programme and permitted the Programme Director to express the Participating Countries' and the Programme's appreciation of the generous contributions of the Donors. The Director also attended a Donors' meeting in Paris from September 15 to2l, 1996. With the aerial spraying contractor 142- OCP with the assistance of WHO Legal held a meeting with the Evergreen Helicopters Company (EHI) on 23 October 1996 in Geneva. Discussions centred on ensuring adequate numbers of pilots and engineers to satisfy OCP needs, as well as general relationship. OCP renewed its confidence in EHI during the June 23, 1997 meeting in Ouagadougou. With the scientific community 143. The Programme took part in the meetings mentioned below the Programme Director attended two Mectizan Expert Committee meetings from October 16 to 18, in Riom (France) and from April 30 to May Z,1997 in Atlanta (USA); The Chief of the Planning, Evaluation and Transfer (PET) Unit attended two seminars from November 7 to 9, 1996 in Geneva on: a) the safety and efficacy of amocarzine as a macrofilaricide for onchocerciasis control, and b) protocol development for the use of invermectin as a prophylactic. From November 14 to 18, 1996, he attended the Congress on Tropical Medicine and Malaria in Nagasaki (Japan). JPC18.2 Page 32 With the general public 144. The opening session meeting for the Vector Control Unit operational zones which was held from November 4 to 9, 1996 in Bouak6 (Cdte d'Ivoire) was covered by national media (press, television and radio). Interviews were organized with the media on topics regarding OCP activities, and on the objectives of the meeting. 145. The OCP periodical "Oncho Information" which has been issued since 1986 in both working languages, English and French, has undergone some modifications in presentation and content in order to be more attractive. "Oncho Information" is distributed to Participating Countries, Donor countries and bodies, donor representations in the Participating Countries, media, universities, research institutes, schools, health structures, and others. 146. The annual meeting of the National Onchocerciasis Coordinators held in Ouagadougou from March 17 to 19,1997 had a vast media coverage in the Participating Countries as a result of the help of WHO representatives, and at the international level. The opening and closing sessions were covered by the national press, television and radio and interviews were given by the Coordinator, a.i., of the Programme Director's Office and the National Coordinators in French as well as in the local language (Jula). The Programme Director had a short telephone interview with the BBC French service on March 17 , 1997 on the objective of the meeting and the success of onchocerciasis control. An agency telegramme was broadcast by AFP in Abidjan (March 15,1997) and two articles were published in the Burkina Faso daily paper SIDWAYA (March 18 and 2l-23,1997 editions). 147 . Two recorded radio and television programmes were broadcast on June 4 and 6, 1997 on the proceedings of the 18th session of the Experts Advisory Committee and, on the process of transfer of skills and responsibilities to the Participating Countries. These recordings were broadcast again on Channel UNO and Frequency UNO in Ouagadougou in July and August 1997. 148. The Prograrnme co-produced a film with ORSTOM entitled "The heritage" Public relations and documentation 149. OCP is represented at the level of sub-committees of the Coordination in charge of administration, emergencies, communication and programmes of the United Nations agencies. At the Communication sub-committee the OCP is represented by the officer in charge of Communication. 150. The Documen[ation Centre continues to improve its services to the users and to enrich its stock of documentation. The stock has 5640 volumes and general works, 125 periodicals 72 of which being live,24 films(16mm-films), l08videotapes,and3,500slides,CDROM,seriesof CurrentContents on diskettes and data banks of OCCGE on tropical diseases, FAO on food and WHO on all the issues. 151 . During the period under review, the Documentation Centre received 1,920 internal and external users, recorded 4,314 applications for documents, lent 1200 books, made 50,426 photocopies, shipped 6,030 newspaper cuttings and reports, distributed 5,500 prospectus, 3,800 brochures and magazines, 5,000 pins and 150 video cassette copies from OCP and APOC films. Among the users who come to the Documentation Centre are professionals from the Programme Headquarters, sectors and sub- sectors, member countries, health planners and administrators, experts and consultants in health, health professionals (students, physicians and para-medical workers), NGOs, health research institutes, development agencies, junior and senior high school students. 152. The Centre gave a new look to its Summary Bulletin. In addition to periodical summaries received at the centre, this Bulletin now contains a list of new acquisitions, bibliographical listings, a list of available periodicals and announcement pages. JPC18.2 Page 33 153. The Documentation Centre has good relationships with other documentation units in Burkina Faso. Among its partners, are the Centre national de lutte contre le Paludisme (CNLP), OCCGE, ORSTOM, Health Department , ONAT and SYFED (French-speaking edition and diffusion system) documentation centres. Internal meetings 154. The Programme organized several internal meetings, the most important of which were Meeting of Vector Control Operational zones, in Bouak6 (C6te d'Ivoire), from November 4 to 9, 7996; Meeting on "Operational Research and Strategies" in Ouagadougou, from March 11 to 13, t997; Seminar on management, in Ouagadougou on March 14-15, 1997; Meeting on entomological research and on insecticides, in Bouake, from April 21 to 26, t997: Seminar on management, in Ouagadougou from June 9-13, 1997. 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World Health Organization (WHO) · Technical Documents
Progress report of the World Health Organization for 1997: 1 September 1996 - 31 August 1997
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