Multi-Disease Surveillance Center (MDSC) 2008 : progress report

I a li',il'ol \ crganisat ion 'if i *r mondiale de la Sanrrr Multi-Disease Surveillance Center (MDSC) 2008 Progress Report Version 27 mars 2009 tMDSC 2008 Progress Report Table des matiires Pages l.INTRODUCTION 2. BACKGROUND 3. MENINGITIS SURVEILLANCE :.................... 3. I Main accomplishments during 2008 : ...,............. 3.2. Microbiology Laboratory of MDSC: 3.3. Molecular Biology Laboratory: 3.4. Support to countries by identification of meningitis germs......... 4. ONCHOCERCIASIS SURVEILLANCE.. 4.1 Background 4.2 Strengthening Onchocerciasis surveillance .. 4.3 Operational studies........ 4.4 Capacity building in onchocerciasis ........... 4.5 Evaluation of the grants of the World Bank 4.6 Meetings.... ,4 ..4 ..4 ..5 ..9 l0 10 6. DEVELOPMENT OF RAPID FIELD TESTS FOR DIAGNOSIS, CONTROL AND MANAGEMENT OF EPIDEMICS OF VIRAL HEMORRIIAGIC FEVERS......23 7. CAPACITY BUILIDING & TRAINING ACTIVITIES............. ...............25 7.1 Training in collaboration with the University of Ouagadougou...... .,....,.......25 7.2 Other training activities.... .....................27 8. OPERATIONAL RESEARCH ACTIVITIES & PRODUCTION OF BIOLOGICAL REAGENTS... 8.1. Burkina special study on the recurrent epidemic meningitis.. 8.1. MVP Carriage study ......... 8.2. Research projects 8.3. Development of new technologies................. 8.4. Monitori ng Ivermectine Effi cacy............... 9. MDSC BODIES MEETING:................. ..................31 10. ADMINISTRATMS SUPPORT& DUTY TRAVELS:.....,......... ...........31 r1. EXTERNAL & INDEPENDENT EVALUATION OF THE WB GRANT:..............31 12. MAIN CONSTRAINTS......... ..18 11 ll t2 14 l6 t7 .28 .28 .30 .30 .31 MDSC 2008 Progress Reporl Vs 27A4orch09 2 .31 I13. MDSC INSTITUTIONAL REFORM: Establishment of the Ouagadougou Centre for Disease Prevention and Control (O-CDC). ........32 r4. PERSPECTIVES .34 15. CONCLUSION ..J5 MDSC 2008 Progress Report Vs 27March09 J II. INTRODUCTION This progress report will present the activities carried out during the year 2008 while the Multi- Disease Surveillance Center (MDSC) was in transitional institutional period. 2. BACKGROUND Following the successful implementation of the Onchocerciasis Control Program (OCP) in 2002, the WHO Regional Office for Africa proposed the establishment of a West African Multi Disease Surveillance Centre (MDSC), in Ouagadougou, Burkina Faso, that would preserve the gains achieved in OCP as well as serve as a Centre of excellence for disease surveillance in Africa. The MDSC was officially established in 2003 with a professional staff of seven (7). The OCP Infrastructure such as laboratories, library and telecommunication equipments were donated to this new Centre. MDSC had 4 pillars comprising: 1) Network on enhanced surveillance on the framework of the integrated disease surveillance & response (IDSR) with information sharing for decision making 2) Reference lab support to country with quality control and biosecurity 3) Capacity building with research & training 4) Operation's hub for epidemic alert & response in the framework of International health regulation (IHR). Taking into account resource Iimited, the MDSC was to primarily focus on lab based surveillance of Onchocerciasis and epidemic Meningitis. As of 3l't December 2007, MDSC has maintained with the support of 2 main partners (African Programme for Onchocerciasis - APOC and Meningitis Vaccine Project - MVP). The MDSC has also established key collaborating partnerships with various partner agencies including CDC/Atlanta, Norway National Institute of Public Health (NIPH), University of Goettinggen in Germany, WHO-CSR Lyon. 3. MENINGITIS SURVEILLANCE: Since 2003 significant efforts have been developed by WHO-AFRO to support the countries' surveillance systems for generating epidemiological information that has improved substantially the understanding of the dynamics of meningitis epidemics in the Belt. Enhanced meningitis surveillance is one of the pillars to ensuring the effectiveness of disease control including epidemic control interventions and the monitoring and evaluation of their impact on the populations. The Centre coordinates all the meningitis enhanced surveillance activities, supporting countries in training on Standard Operating procedures (SOP), laboratory confirmation of aetiological agents, supervision and investigation during epidemics To support the implementation of the SOPs for enhanced surveillance, laboratory supplies and lumbarpuncture kits were distributed atthe beginning of the epidemic season December 2007 - January 2008 as planned. MVP disbursed a sum of $ 51 000 worth of laboratory reagents and equipment in support to countries for the laboratory confirmation of causal pathogens. These i,tDSC 2008 Progress Report Vs 27March09 4 materials include lumbar puncture kits, Tls (transport media) bottles, Pastorex kits (25 tests each), antisera for sero-grouping, and other lab reagents for confirmation and culture. The kits were distributed to l0 countries in the belt as wellas the MDSC microbiology lab. As a result of this support, more than2,675 CSF samples were taken and analyzed from week I to week 22 of the 2008 epidemic season. A rapid identification of the causing pathogens is critical in the decision making for the selection of the most appropriate vaccine for outbreak containment. Furthermore, the improved knowledge of the distribution of meningitis bacterial pathogens across the countries in the belt has and will continue to provide solid and crucial scientific evidence upon which future strategic decisions on vaccine introduction and development would be made. Given the success of the implementation of SOPs for enhanced surveillance and in prevision of the introduction of the new conjugate vaccine, it is time for the implementation of a more robust meningitis surveillance system in the countries (case based surveillance system), similar to that of polio, measles and yellow fever currently being implemented in the countries. MDSC and IST West are working at developing a guideline for bacterial meningitis case based surveillance in the belt in collaboration with partners. 3.1 Main accomplishments during 2008: o Monitoring the epidemiological situation bacterial meningitis: MDSC monitors the epidemiological situation of bacterial meningitis in l3 countries of the belt (Benin, Burkina Faso, Cameroon, central Africa, Cote d'Ivoire, Ethiopia, Ghana, Mali, Niger, Nigeria, RD Congo, Chad and Togo). For three consecutive years (2006-08) Burkina Faso has been the most severely hit country in terms of meningitis epidemics. During the 2008 epidemic season (week I through week 22), out of a total of 27 829 suspected cases of cerebrospinal meningitis, this country reported 9 467 cases followed by Nigeria (6 542 cases), DRC (3 958 cases), Niger (3 163 cases) and Mali (l 357 cases). Out of the 94 epidemic districts within the meningitis belt, Nigeria reported 5l epidemic LGAs and Burkina Faso 20 epidemic districts. DRC, Niger and Mali reported respectively 10, 5 and 3 epidemic districts. High CFR (ll % to 28 %) have been observed in central Africa, Cote d'Ivoire, Togo, Benin Chad and DRC, with CAR, Cote d'lvoire and Togo reporting the highest CFR. Mass immunization campaigns using bivalent AC vaccines have taken place in Burkina Faso, Niger, Nigeria, Mali, DRC and CentralAfrica. Mass immunization campaign reports from Burkina Faso show that the vaccine coverage rates are high around 100 % and above; although some districts vaccinated are facing epidemic in the consecutive coming years. Monitoring the bacterial meningitis situation: Neisseria meningitidis A has been the main causal pathogen reported in the epidemic districts this epidemic season. Out the l35l positive CSF analysed by the national laboratories, I 052 cases of NmA were isolated, representing 78%o of the confirmed cases. a MDSC 2008 Progress Report Vs 27March09 5 I a Weekly feedback bulletins: Twenty-two weekly (out of 22 weeks) feedback bulletins on the epidemiological situation of cerebrospinal meningitis were produced and distributed to countries and partners. Cross border activities: A trans-border meeting between Burkina Faso and Cote d'lvoire to harmonize control measures for the CSM meningitis at the border. The meeting was held in Bouna (Cote d'Ivoire) on 20 February 2008. Adaptation of the IDSR Guideline: MDSC participated from 03 to 08 May 2008, in Ouidah, Benin, in the orientation meeting of the 16 West African ECOWAS countries (and Mauritania) for the adaptation of the Integrated Disease Surveillance and Response (IDSR) guidelines. The meeting was organized by WHO/ISTiWA in collaboration with the West African Health Organization (WAHO) and the Projet Rdgional Sant6 Afrique de l'Ouest (PRSAO) funded by the European Union. Participants include National focal points/officers for surveillance and laboratory, national universities (public health departments) as well as WHO country disease prevention and control officers. Subsequently the team went on in the countries to supervise the adaptation and validation of the guidelines by the countries. In addition, a series of laboratory workshops on behalf of the ECOWAS countries and Mauritania (funded by PRSAO) were held at the Biomerieux Centre in Bamako, Mali to support surveillance activities in the countries. Country visits, supportive Supervision and Training: o The team organized the carriage study preparatory meeting in Ouagadougou, from 23 to 24 January 2008. This is the first of a number of studies linked to the introduction of the conjugate vaccine in Africa. The present series of carriage study will be conducted longitudinally every quarter in 3 districts of Burkina Faso (Bogodogo, Dandd and Kaya) before and after the introduction ofthe conjugate vaccine. o MVP/MDSC staffs attended a trans-border meeting befween Burkina Faso and Cote d'lvoire to harmonize control measures for the CSM meningitis that broke out at the border of the two countries. The meeting was held in Bouna (Cote d'Ivoire) on October 20 February 2008. o Investigation of the causes of the 2008 epidemics in southern Chad from 23 March to 1l April 2008, Isolation of Neisseria meningitis Wl35 as the main causal pathogen of the epidemic in this country o The MDSC team, in collaboration with CDC and WHO/HQ has been actively involved in the studies aiming at understanding the recurrence of meningitis epidemics in Burkina Faso through data analysis, reports and field visits in various districts of the country (e.g. Boulsa, Reo from 07 to20 April2008. o The MVP team attended the 7th Project Advisory group meeting in Accra, Ghana from 8 to 9 May 2008. o The MDSC team, in collaboration with colleagues from CDS/EPR/IST conducted a review of the surveillance and laboratory performance in the control of the 2008 meningococcal disease epidemic in Nigeria, in Jigawa and Kebbi States, from l0 to 20 May 2008. a a a MDSC 2008 Progress Report Vs 27A.larchl9 6 L o The team organized a workshop on the SOPs for enhanced surveillance of meningitis in Moundou, Chad from 2l to 28 May 2008. The workshop was attended by 70 surveillance and laboratory officers from l9 districts and 5 regions of this country. o The team supported countries in the adaptation of the IDSR guidelines to the countries context in Mali from 01 to 05 June 2008 and Nigeria (northern States) from 20 to 27 June 2008. o The team participated in the training of the West Africa countries laboratory focal points in the diagnostic of priority diseases in Bamako form 0l to 13 June 2008. This training was organised also to strengthen the IDSR strategy, mainly laboratory capacity for the confirmation of priority diseases. o In preparation for the introduction of the conjugate vaccine and for a better control and understanding of the bacterial meningitis disease and epidemic patterns in Africa, the team is coordinating the development of a guideline for case based surveillance of bacterial meningitis in the African meningitis belt. The aim of this guideline is to switch from the current system (SOPs for enhanced surveillance) based on the reporting suspected cases to the reporting of confirmed cases with complete description of their epidemiological and laboratory characteristics. The deadline for the first draft of this document is end August 2008. The activity is done in collaboration with IST, HQ and CDC. o MDSC recruited two short term consultants to support the team in meningitis epidemic surveillance and support to countries. This activity was planned given the risk of major epidemic in 2008 in the countries of the belt. The consultants were able to work for two months May-June only due to administrative procedures that delayed their recruitment. The two STCs have supported the investigation of recurrent epidemics in Burkina Faso through field visits, and also supported the organization of the first short course in Field Epidemiology and Laboratory Training Program for French speaking West Africa countries. o The MVP team was invited by EMRO in Cairo/Egypt to attend and contribute in a workshop on the elaboration of a strategic document for the control of meningitis in WHO/EMRO member states. The workshop was held from I to 3 July 2008. This is part of an inter-regional exchange of experiences between 2 WHO regions (AFRO and EMRO). o Contribution/facilitation of the workshop for the adaptation of IDSR technical guidelines in the Southern States of Nigeria. The workshop was held in LagosA{igeria from 7 to12 July 2008. o Participation in Cotonou/Benin, from l5 tolT July 2008, in the workshop for the end of mission debriefing of the consultants recruited to support countries for the adaptation and validation of the IDSR guidelines in the West African ECOWAS countries and Mauritania. o Training in data management of the surveillance officers, laboratory technicians and data managers of Mali (from 14 tol8 July 2008) and Togo (from 28 July to 02 August 2008). o Organization in Bobo-Dioulasso, Burkina Faso, from l9 to22 August 2008 of a workshop for the elaboration of the guidelines for case based surveillance of bacterial meningitis in Africa. 7A,IDSC 2008 Progress Report Vs 27March09 o Participation at the 16th International Neisseria Pathogenic Conference (INPC) in RotterdamA.,letherland from 07 to l3 September 2008. The MVP team presented 2 posters and an oral presentation. o Elaboration of the end of meningitis epidemic season annual report (week I to 26 of 2008). The report highlights the management of meningitis epidemics and outbreaks in various countries and the support of the MVP team to these countries between January and June 2008. o Contribution in the conduct of the carriage study which lst round started in September 2008 in Burkina Faso. This study aims at getting baseline data on the carriage of meningococcal meningitis germs before the introduction of the new conjugate vaccine and thereafter. o Participation in the MVP annual evaluation and planning retreat, organized in Mijoux, France from l6 to l7 October 2008. o Participation in the organization and conduct of the 2nd short course in epidemic investigation of the West African Field Epidemiology and Laboratory Training Programme, in Ouagadougou from 2l to 3l October 2008. o At the beginning of the epidemic season, the World Health Organization (WHO) Multi- Disease Surveillance Centre (MDSC) team in Ouagadougou, Burkina Faso, reports that the situation remains calm despite some rumors in Shagari LGA, SokotoA{igeria, alerts in the districts of Ouelessebougou (Mali) and Sapouy (Burkina Faso). o On November 12-21, the MDSC team made a follow-up country visit to the Democratic Republic of the Congo (DRC) and provided a refresher training course on the standard operating procedures for enhanced surveillance of meningococcal meningitis in Kisantu (14-17 November 2008). While DRC lies outside the official meningitis belt, the increasing number of cases reported in the country (5 6la suspected cases of meningitis from January I - November 02, 2008) confirms the suspicion that the African meningitis belt may be expanding south on the corrtinent, touching regions that have been spared untilnow. o The MDSC team organized workshops on standard operating procedures for enhanced surveillance of meningococcal meningitis in Benin (November 24-29) and in Chad (December 12-20). During these visits, the team revised the national work plan for meningitis activities and provided technical support to ministry of health surveillance units. Local surveillance staff was specifically trained on data management and laboratory techniques that enable identification of disease-causing serogroups. o An advanced draft of the new guidelines for case-based surveillance of meningococcal meningitis in the African meningitis belt has been finalized. Under the old system suspected cases were reported. Under the new guidelines, confirmed cases will be reported with complete descriptions of epidemiological and laboratory characteristics. The new system will enable better control and understanding of bacterial meningitis and epidemic patterns in Africa. o The MVP team in collaboration with the WHO office in Geneva has begun to enhance meningitis case-based surveillance capabilities in preparation for vaccine introduction in Burkina Faso in 2009, and the subsequent introductions in Mali and Niger. Vaccine introduction activities: In preparation for the introduction of the conjugate vaccine and for a better control and understanding of the bacterial meningitis disease and epidemic patterns in Africa, MDSC is coordinating the development of a guideline for case based a MDSC 2008 Progress Report Vs 27March}9 8 surveillance of bacterial meningitis in the African meningitis belt. The aim of this guideline is to switch from the current system (SOPs for enhanced surveillance) based on the reporting suspected cases to the reporting of confirmed cases with complete description of their epidemiological and laboratory characteristics. The activity is done in collaboration with IST, HQ and CDC. ln the context of the preparation of the first introduction of the new conjugate vaccine against N. meningitrs serogroup A, a consultant from NIPH/Oslo visited the MDSC with the support of Meningitis Vaccine Project. The objective of his consultation was to improve laboratory- based confirmation of bacterial meningitis and strengthen surveillance in sub-Saharan Africa through training for MDSC staff, on-site expert collaboration to establish new processes or improve existing processes at MDSC, and assessment of existing national laboratories in Burkina Faso. Dr Norheim Gunnstein stayed three months in the MDSC laboratories from August to November. The main achievements: - Current protocols were evaluated and methods performed by bench work together with MDSC laboratory employees. Improvements were suggested and implemented. - Documents for the most central procedures were developed and finalized. Some of the documents were not finalized due to time constraints and need to be finalized. - The laboratory assessment was developed by the MDSC in collaboration with national reference laboratories and the Ministry of Health. Twelve laboratories were assessed using a predefined questionnaire. Data were entered and analyzed at MDSC, and the report "Assessment for laboratory-based diagnosis of meningitis in selected laboratories in Burkina Faso" was sent to partners. Consultants for epidemic response: MDSC recruited two short term consultants to support the team in meningitis epidemic surveillance and support to countries. This activity was planned given the risk of major epidemic in 2008 in the countries of the belt. The consultants were only able to work for two months (May-June) due to administrative procedures that delayed their recruitment. Meanwhile, they have supported the investigation of recurrent epidemics in Burkina Faso. a a West Africa Field Epidemiology and Laboratory Training Program (WA FELTP): The MVP team supported the organization and conduct of the first and second short courses of the West Africa Field Epidemiology and Laboratory Training Program (WA FELTP) for French speaking West Africa countries. These courses were held in May and October 2008. 3.2. Microbiology Laboratory of MDSC: The microbiology laboratory of MDSC has produced more than 3 000 Trans Isolate media (TI). These were distributed to the countries of the belt for the transport of CSF specimen from peripheral health centres to national reference laboratories. The microbiology laboratory has also contributed to the identification of strains as Quality Control coming from Mali and Chad and most of the strains were sent to WHO Collaborating MDSC 2008 Progress Report Vs 27March09 9 Centre/Oslo in depth -identification(Typing, sub typing, sequence type and Minima Inhibitrice Concentration: MIC) The MDSC team, in collaboration with CSR/IST conducted a review of the surveillance and laboratory performance in the control of the 2008 meningococcal disease epidemic in Nigeria, in Jigawa and Kebbi States, from l0 to 20 May 2008. 3.3. Molecular Biology Laboratory: The Molecular Biology Laboratory is contributing to the general effort by bringing its expertise for the gerrns and serogroup identification of N. meningitidis, the confirmation of identification performed by national laboratories, and by the training of personnel in the use of molecular markers. 3.4. Support to countries by identification of meningitis germs a) Identification of samples received from Mali The network of laboratories is developing. The link between MDSC laboratories and the national reference laboratories is growing. Trough this relationship, 37 CSF in cryotubes were received for identification. All of them were found negative by culture. Results of Latex were available. The laboratory performed the identifications and results were sent back to the National Reference laboratory in Bamako (Table...) Table 8: Identification of CSF from Mali Latex results N. meningitidis N meningitidis A N. meningitidis w135 N69ative s.pneumoniae Total N6gative 1 1 1 12 7 22 NmA 1 5 4 10 Y/W135 1 3 1 5 Total 3 6 4 17 7 37 b) Identification of samples received from Burkina Faso A close collaboration exists between MDSC Molecular Biology Laboratory and the National Reference laboratories in Burkina Faso. The laboratory contributes to the management of the epidemic trough regular identification of samples sent by the nationals. Due to administrative constrains mainly lack of contracts for the personnel and problems delivery of reagents on time, the laboratory was not present on time to actively participate in the 2007 epidemic. Nevertheless, the Molecular biology Laboratory received and processed CSF. In October suspected cases of meningitis were detected in the health district of Sapouy (south of Ouagadougou). Nine CSF samples collected and sent to MDSC trough Charles De Gaulle's pediatrics hospital. Three of them were confirmed to be N, meningitis serogroup A. MDSC 2008 Progress Report Vs 27March19 10 A comparison study was carried to determine the performances of three techniques: PCR, Culture and Latex. It is shown that PCR detects 24o/o more samples de meningitis than culture (Table...). One of the advantages of using PCR is the use of genomic material even if the CSF is not well preserved. Table 9: Performances of meningitis gerrns identification technics Results of Test Nb Positive Nb Nesative Total PCR 137 77 214 Culture 86 128 214 Latex 48 45 93 4. ONCHOCERCIASIS SURVEILLANCE 4.1 Background After several difficulties in the start of implementation of its activities, the MDSC plays progressively its role inthe sub regionalsurveillance of onchocerciasis. The grants received from the World Bank, and the funds made available through the Memorandum of Understanding signed with APOC were favourable factors for the strengthening of surveillance activities. The activities are carried in collaboration with the countries, APOC and WHO/TDR. In northern area of West African savannah, the entomological season covers the period of May to November. In southern limit, this period expend from April to December. The entomological surveillance needs to be prepared before and carried on time. The MDSC is currently using a network of sixty-nine (69) sites chosen on the basis of existing OCP points for the purpose of entomological surveillance activities in the I I ex-OCP countries. The purpose is to early detect any eventual risk of recrudescence through the continual monitoring of potential resumption of transmission due to localised relapse or the migratory behaviour of vectors and movements of human population from unclean to cleaned areas. Analysis are done based on fly samples received from each site (6000 minimum recommended) to determine the infectivity rate in S. damnosum or screening for Onchocerca volvulus parasites. All results are shared with the different countries and control programs. In the season2007, MDSC was late on the field to bring technical support to country because of the lack of contracts for the onchocerciasis surveillance team members during the six first months. Nevertheless, several activities were carried out such as planning of entomological surveillance, laboratory identification, and attendance at meeting. Countries sent flies to the MDSC and feed back of the results was done. The activities started earlier in 2008 for the molecular biology laboratory team by the determination of infectivity rate for the onchocerciasis elimination study. A new context of work was designed through a Memorandum of Understanding (MoU) signed with APOC. The terms of reference were: a) Strengthen onchocerciasis surveillance in the I I ex-OCP countries b) Build capacity in ex-OCP countries and in 4 APOC countries MDSC 2008 Progress Report Vs 27March09 ll This MoU has been the back bone of activities of the MDSC onchocerciasis surveillance team. 4.2 Strengthening Onchocerciasis surveillance 4.2.1 Entomological surveillance in the ex-OCP countries Supervision of the field activities and in site trainings were planed with the national onchocerciasis controlteams of Benin, Niger and Togo. In Benin, it was possible to carry a joint supervision of activities of routine surveillance and of the study on transborder movement of ,L damnosum. In the other countries, a close communication was maintained. MDSC played an advisory role in the countries' plan, the organization of the vector collection and transfer to Ouagadougou. On this last point, one should notice that since the end of the OCP shuttles, transfer of biological material remains a preoccupation. Several contacts have been made with Transport companies to use their service. The cost of the expedition and the problems that can appear at the customs level need to be more documented in collaboration with the national onchocerciasis control teams. In the MoU signed with APOC, a financial support of $5000 was planed for each country for the implementation of entomological surveillance activities. This support was not sent because of the delay in the signature of the MoU and the fact that the entomological season was already advanced. Four countries (Cote d'Ivoire, Ghana, Guinea Bissau and Sierra Leone) are characterized by low levels of onchocerciasis surveillance. These countries require special attention and support. MDSC laboratory received and treated more than 100 000 flies collected in Ghana and Sierra Leone. In Ghana the infectivity rate is above the threshold (0.5/1000) at Zongoyiri-rapids, Gyankobaa and at Kwakwekrom. In Sierra Leone, one can note that the infectivity rates are very high. This fact can be correlated with the epidemiological situation in the country, Control activities should be intensified. Advantage was taken of the presence of the national coordinator of C0te d'Ivoire, Ghana and Guinea Bissau at meeting at Ouagadougou to discuss and plan activities. A technical support was given to the coordinator of C0te d'Ivoire in entomological surveillance. The matter of the training of entomologicaltechnicians was raised and coordinators were invited to submit a list of candidates and CVs. Cdte d'Ivoire and Guinea Bissau do not have a functional entomological team. The training of managers and technicians is essential before the start of the activities. The team of Ghana needs to be strengthened in the objective of implementation of the recommendations done on the bad resultants obtained in several surveillance sites. MDSC 2008 Progress Report Vs 27\vlarch09 t2 ln Sierra Leone, with the interruption of the study of fly migration, the entomological activities ceased. A plan of work should be designed beginning by capacity building. Sierra Leone team could follow the impact of ivermectin of transmission in several river basins were effective CDTI is carried. 4.2.2 Activities carried out by the molecular biology laboratory During the period of June to December, the laboratory was active without interruption. Reagents were available for the identifications, The following activities were done: - Finalisation of procedures of procurement of reagents, equipment and supplies for vectors and parasites identification. Following the terms of the MoU, the list of the items was transmitted to APOC management. - Reception and archiving of blackflies (126 122) collected by surveillance teams in Burkina Faso, Guinea and Togo. - Reception and archiving of blackflies collected in the frame of the study on trans-border movement of S. damnosumbetween Benin and Nigeria - Reception and archiving of blackflies collected in the frame of the study on "Elimination of onchocerciasis by Ivermectine in Mali and Senegal - Identification of parasite for infectivity rates is the mane activity of the laboratory. More than 559 000 black flies were processed and feed back of the results were done to the countries (Annexe...) 4.2.3. Results of Onchocerciasis surveillance activities The activity of MDSC Molecular biology laboratory consisted mainly in determining the infectivity rates in the vector populations collected by the national. The laboratory was able to run the experiment on time and give a feed back of its results by 2 months after the reception of the flies. The two main difficulties of the laboratory are the delay in getting the necessary reagents on time, and the lack of personnel to run the pools screening technique. The laboratory screened more than 500 000 Simulium vectors and 800 parasites collected in 2006 in the 8 ex OCP countries. ln 2006-2007, the network of entomological surveillance was developed and made more effective. The active surveillance covers 8 countries out of the 1l ex-OCP countries. ,S. damnosum flies collected in the field were sent to the laboratory where infectivity rates were determined and then sent back to countries for decision making. Results of 2007 season Finalanalysis of 2007 entomological season was done in 2008. The number of vector collected is above the minimum number requested (6000 flies). Generally, the infectivity rate observed are satisfactory (<0.5/1000). Figure l: Final results of entomological surveillance carried out in 2007. Benin has five active surveillance points. All of them have infectivity rate lowerthan the threshold: 0.5/1000 Togo team followed one point. The result obtained is good; In Ghana, nine points were visited . At Zongoyiri and Gyankobaa the infectivity rates are above the threshold. It is recommended to visit these points again for confirmation of the result and strengthen CDTI activities. MDSC 2008 Progress Reporl Vs 27March09 l3 Results of 2008 season All the samples of 2008 have not been yet analysed. Entomological surveillance was done in Benin, Burkina Faso, Ghana, Mali and Togo. Partial results are available. The global situation is satisfactory. Infectivity rates are below the threshold except at Kati in Togo. This is a signal of alarm even if the number of flies does not reach the minimum number requested. Figure 2: Partialresults of entomologicalsurveillance carried out in 2008. Conclusion: The entomological surveillance data show a satisfactory situation in most of the countries. For this reason, the field team should apply the site rotation strategy to cover the maximum of site in the country. Regarding the data in Ghana, special attention should be paid to the infectivity rate of 2006 and 2007. CDTI activity should be strengthened and epidemiological investigation should be done to better understand the situation around the foci with high infectivity rate. 4 .2.4 Other onchocerc i as i s surveil lance activities Collaboration with < Institut National de Recherche en Santd Publique ) (INRSP) at Bamako, Mali : INRSP participates to onchocerciasis surveillance by following four points in the western area of Mali in the Bakoye river basin. The first round of surveillance provides good result: all the infectivity rate found were below the threshold. In 2008 flies have been collected and their identification is in process. Supervision of the teams of Benin and Nigeria: A mission visited Abeokuta and Parakou were the teams are based. The following points were reviewed: entomological activities of 2008; strengths and weaknesses of the teams, sensitization of the authorities and the field workers. Advantage was taken to carry back to Ouagadougou the last collections of flies for analysis. Network of molecular biology laboratories: APOC plans to implement surveillance in some countries of its area. Several laboratories will be needed to perform the identification. In this perspective, the laboratories listed below have been contacted: "laboratoire de la filariose lymphatique d Yaound6, Cameroun", the laboratory of the Vector Control Division of the Ministry of Health of Uganda; The National Institute of Medical research of Yaba, Lagos, Nigeria; the "Carter Center" in Khartoum, Sudan. An evaluation of their technical suitability should be done to assess their needs. 4.3 Operational studies 4.3.1 Study on the feasibility of elimination of Onchocerciasis by Ivermectin treatment This study was launched in 2005 under the external supervision of MDSC. It is the result of collaboration between: national onchocerciasis teams of Mali and Senegal, MDSC, APOC and WHO/TDR, with fund provided by Melinda and Bill Gates Foundation. The Molecular biology laboratory is involved in the study by making the follow up of the transmission trends in the vectors. Surveillance site are selected on the Gambia River basin, the Faleme and the Bakoye River basins. Over 246000 vectors were collected from 14 sites MDSC 2008 Progress Reporl Vs 27March09 t4 distributed on the three rivers basins. The flies were sent to the laboratory for determination of their infectivity rate. The analysis of the entomological data merged with epidemiological data concluded that ivermectin treatment could be stopped experimentally as indicated in the table bellow. Following the threshold established, the results produced show a good situation (Tablel and 2). A workshop was organized in March 2008 at Ouagadougou to review the activities and to make decisions: On river Gambia, Senegal where 6-monthly treatments were done, no recrudescence of infection was observed 2 years after stopping treatment; no recrudescence in transmission was noticed 1.5 years after stopping treatment. The data is consistent with elimination of onchocerciasis in this focus. Decision was to stop treatment in all villages in the R. Gambia focus (Figure: 3) On river Bakoye, Mali, where annual treatment was carried: no recrudescence of infection was observed 2 years after stopping treatment; no recrudescence in transmission was noticed 1.5 years after stopping treatment. The data is consistent with elimination of onchocerciasis in this focus. The decision was taken to stop treatment in all villages in the R. Bakoye focus. (Figure: 4) On river Faleme, Mali/Senegal where annual treatment was also carried out: there is no recrudescence of infection 2 years after stopping treatment; there is no recrudescence in transmission 1.5 years after stopping treatment. The situation is not uniform in this focus. The date shows more infection and transmission in the Southern part. More information is required to make decision on this river basin. (Figure: 5) The main recommendation of the workshop addressed to APOC concerned the future of Oncho Control in Africa: "APOC should develop the evidence base to determine when and where ivermectin treatment can be stopped, and provide guidance to countries on how to prepare for and evaluate cessation of treatment." 4.3.2 Study on S. damnosum fTies migration from river basins of Sierra Leone to Mali. The number of blackflies collected in 2007 and 2008 is very low, due to the delay in the implementation of the study. The analysis of flies obtained from Sierra Leone reveals infectivity rate above the threshold of 0.5/1000 (Figure l). This situation is consistent with the epidemiological data. 4.3.3 Study on trans-border movement of S. damnosum between Benin and Nigeria Studies on reinvasion have shown that the savannah species of S. damnosum s.1., particularly S. sirbanum and ^S. damnosum s.s., are involved in two migratory currents, under the influence of dominant winds. In an area such as Nigeria-Benin where blackly movement takes place, the epidemiological situation could gradually deteriorate by disease transmission. A protocol was developed with APOC to assess the disease transmission in Nigeria, and the risk of reinvasion of oncho-freed zones in Benin by black fly populations. The main objective of the study is to determine the extension and impact of black fly cross- border movements between Nigeria and Benin on the epidemiology of onchocerciasis. (Figure: 6) MDSC 2008 Progress Report Vs 27A4arch09 l5 The specific objectives are as follow: a) Improve knowledge about Nigeria-Benin cross-border black fly movements; b) Assess the onchocerciasis endemicity level in the river basins along the border between Nigeria and Benin c) Determine the level of black fly infestation in the river basins of Nigeria and Benin before, during and after the period of migration. The data of year I of the study were not enough to draw conclusion. Year 2 should have given more information, but due to administrative constrains the field work started with delays in Benin and Nigeria. Nevertheless, infectivity rate were determined by the laboratory from the flies collected. In Benin they were all below the threshold. In Nigeria, it was not possible to perform analysis because of the low numbers of vectors preserved. Samples of flies were identified using combined morphology and Hetero Duplex Analysis. The result confirmed the identity of the migrating flies as S. beffa. The biting rates observed indicate a reduction of number of S. beffa along the month, and form Benin to Nigeria. Technical support was given to the two countries through workshop and supervision of field activities. 4.3.4lmpact of ivermectin on transmission in Guinea Bissau Three surveillance points provided black flies samples for analysis. The data of transmission show that infectivity rate is stillbelow the threshold. (Figure 1) 4.4 Capacity building in onchocerciasis 4.4.1 Training of entomology technicians for ex-OCP countries and 4 APOC countries Capacity building in onchocerchiasis is a key point for the sustainability of surveillance in countries. The countries should have the capacity of early detecting any recrudescence of the disease. Performances of surveillance depend on the quality of the personnel in charge of the activities. 4.4.2 T raining of techn icians With the support of APOC, a plan of training was made by MDSC. The national coordinators were contacted to submit candidates. A selection committee was called on l4 December 2008. The training should last 3 weeks and should take place at Kara (Togo). Tienfala, near Bamako Mali, is the second choice. Due to administrative constrains, the first round of training will take place in the first quarter of 2009. (Voir rapport en Annexe 12) 4.4.3 Training of managers of coordination team The onchocerciasis surveillance team has trained two coordinators from Burundi and Centrafrique on entomological surveillance. This training was done during a short course on Field Epidemiology and Laboratory training at Ouagadougou. The trainees worked during three MDSC 2008 Progress Report Vs 27March09 t6 months on a research subject and their findings were presented in the following session of FELTP. 4.4.4 Training in the molecular biology laboratory A student of Georgetown university Washington USA, visited during three months the MDSC for international field experience in public health. The subject of her research is: Retrospective analysis of CDIT in the South West of Burkina Faso. 4.5 Evaluation of the grants of the World Bank MDSC has benefited of World Bank grants in 2004,2006 and 2007 aiming at supporting the activities of monitoring onchocerciasis and other target diseases, as well as the functioning of the centre. At the end of the time covered by the grants (2004-2008), and after 6 years of MDSC activities, a final review was planned, aiming to assess the progress and the situation of the implementation, suggesting avenues for future orientations, consolidation or improvement of outcomes, usable for the preparation of a new project. The terms of reference of this evaluation are: - Performance assessment including the results reached by MDSC and the evaluation of its capabilities in terms of functioning and epidemiological monitoring - Proposing a set of recommendations aiming at the reinforcement of the MDSC capabilities and the redirecting of goals, strategies and activities to be implemented within a future project for epidemiological control by MDSC. The positive outcomes of the MDSC have been highlighted by this evaluation among which the role played by the molecular biology laboratory; the support and technical assistance to the countries in the implementation of field entomological activities. The report of the evaluator demonstrates that despite important efforts of MDSC and involved partners, the follow-up indicators point out a global inadequacy of the results obtained over the reviewed period. MDSC was not in a position to fulfil its duties, that being mainly due to political and institutional issues which have hindered its functioning, notwithstanding the presence between 2004 and2007 of adequate and qualified staff. In view of the dysfunctional situation, it was difficult to precisely assess the level of implementation, and the absolute or relative value of the human and financial resources assigned to the management of the MDSC. The evaluation pointed that concerning the coming reinforcement of the MDSC, mention was made of strong commitments of the regional Office towards the transformation of MDSC in a regional reference centre of Excellency for prevention and control of mainly vector borne diseases, including neglected diseases and based on laboratory, research and training services. MDSC 2008 Progress Reporl Vs 27March09 17 The evaluation recommended that the reorientation of MDSC would be to fully use the specific competencies that were developed by MDSC: monitoring of onchocerciasis and meningitis and to provide it with a new framework which would grant the necessary means to perform activities. 4.6 Meetings During 2008, the team of onchocerciasis surveillance attended several meeting: - Meeting on onchocerciasis surveillance tools, January 2008 - Workshop on elimination study in Mali and Senegal, March 2008 - Technical Consultative Committee/APOC March 2008 - Technical Consultative Committee/APOC September 2008 - First post SIZ annual meeting, November 2008 - l4th JAF Kampala, December 2008 - Transborder meeting Benin-Togo, Parakou December 2008 MDSC 2008 Progress Report Vs 27March19 l8 Figure I : Final results of entomological surveillance carried out in 2007 Mapping entomological surveillance results 2007 Figure 2: Partial results of entomological surveillance carried out in 2008. Mapping entomological suweillance Paftial results 2008 L^-. NIGER movements ffiOilOSCrcsFdou$u @ tntoavry nrr . o ltoo ! lma"ty nr , O,ltm \ a a NIGER ffiO/MDSC/Ou.g.dou8u movements O ld.ctYry ht. < O,tl@ ! tntctvrry rrh ' o vtm a turi@. rt. a MDSC 2008 Progress Report Vs 27March09 t9 Figure 3: Entomological and epidemiological situation in the Gambie river basin Figure 4: Entomological and epidemiological situation in the Bakoye river basin +Jg o 6O o NR. OF FLIES INF. RATE (0/00) 95% CONF INTERVAL SITE BANTACOKOUT A SEKOTO SOUKOUTA YAMOUSSA 29,831 28,523 38,59,f 11,986 0 0 0 0 o.22 0.228 0.1Tt 0.304 blc Nr, 775 0 0775 pos SKIN SNIP DEC PATCH Nr. Examined # of infective flies per 1000 flies ,o 9-o o o a oq p rQ o aa a a NR. OF INF. RATE (0/00) SITE FLIES 95% CONF INTERVAL Prevalence ofmf: o,260/o ) R. Bokcyc E vd.nodn tt) O 080001 O 0001 to 5 O sto10 O l0 to 15 BADALA KOLONTAN TIEOUROU TOUFINKO 9,903 12,315 10,435 22,741 0 0 0 0 0 0 0 0 0.177 0.156 0.266 0.114 0 0 SKIN SNIP DEC PATCH Nr. Nr. Examined positive 1066 680 MDSC 2008 Progress Report Vs 27March09 20 0 0 0 0 0 t 0 0 0 per 1000 flies # oa at a a to SITE INF. RATE(0/00) 95% CONF. INTERVAL NR. OF FLIES fr o rOo FADOUGOU MAHINA MINE MANANKOTO SATADOUGOU BAMBADJI SAROUOIA 12,389 1r,996 14,091 10,760 14,974 8,833 0.62,f 0.228 0.228 0.647 0.336 0.71 0 0 0 0 0. 86 0.0038 0.'t21 0.003 Prevalence ofmf: 0.85o/o Nr. Examined Nr. positive SKIN SNIP DEC PATCH 442 409 0 0 P I a a a # of infective flies r 1000 flies 0.r2 0.19 Figure 5: Entomological and epidemiological situation in the Faleme river basin Figure 6: Surveillance site for the trans border study between Benin and Nigeria Benin Nigeria I Benin Nigeria Couffo KaJola llsa Ogun panmae MDSC 2008 Progress Report Vs 27March}9 2t 0 a 0 0 Jgbo-lJary6 oyo PYe Zou Table 1: Vectors collection in Mali (September to December 2008) and Senegal (August to December 2008) Country Site River No. of flies No. L3T MALI BADALA BAKOYE 7954 26 MALI KOLONTAN BAKOYE 1 8639 33 MALI TIEOUROU BAKOYE 12586 24 MALI TOUFINKO BAKOYE 17326 7 MALI FADOUGOU FALEME 37537 50 MALI MAHINA MINE FALEME 27502 73 MALI MANANKOTO FALEME 24385 59 MALI SATADOUGOU FALEME 26264 61 SENEGAL SAROUDIA FALEME 13242 0 SENEGAL BAMBADJI FALEME 9778 0 SENEGAL SEKOTO GAMBIE 36752 0 SENEGAL SOUKOUTA GAMBIE 29930 0 SENEGAL YAMOUSSA GAMBIE 5471 0 SENEGAL BANTACOKOUTA GAMBIE 22120 0 Table 2: Decision making scheme Ivermectin treatment EPI data in test areas ENTO data Decision R Gambia 6 monthly Bellow threshold Bellow threshold Stop treatment in 2008 inall the study area R Bakoye Annual Bellow threshold Bellow threshold Stop treatment in 2008 in all the study area R Faleme Annual Bellow threshold Bellow threshold Stop treatment in 2008 in centre and south of the study area MDSC 2008 Progress Report Vs 27March09 22 6. DEVELOPMENT OF RAPID FIELD TESTS FOR DIAGNOSIS, CONTROL AND MANAGEMENT OF EPIDEMICS OF VIRAL HEMORRHAGIC FEVERS The VHF project is done in the context of a consortium composed of three (3) European laboratories and four African laboratories and institutions among which the MDSC plays a role. It should last three years from 2007 to 2009. During 2007, WHO has requested the revision of the MoU in order to take into account MDSC status as a WHO component. A new agreement has been signed the l6th January 2008 by Dr John Martin, Director of WHO office at the European Union. The signature has been follow by the first instalment transferred to AFRO via HQ, and VHF allotment has been created for MDSC the 6'h June 2008. . Initially planned for 36 months from 2007 to 2009, the project has been extended to 48 months due to the delay observed in the implementation of activities. The project will end in December 2010. The consequence of the extension there will be one additional reporting period of 12 months, but the project budget remains the same. In this project, the MDSC has in charge the expression and purification of recombinant viral proteins using the RTS 500 expression system and streptavidin-matrix purification, which is needed for the development of the Line Assay test. For that, a technology transfer from the University of Gottingen in Germany to MDSC was planed, and Dr Adjami went to Gottingen from 28'n April to 22th June 2008. As result of this working trip: . Yellow Fever, Dengue and Lassa virus strains are cloned into the two expression vectors pIVEX 2.8 and plYEX2.7. o Proteins has been expressed for these proteins o RNA transcription of recombinant plasmids carrying the target genes of Rift valley, Marburg and Ebola Zaire has been done. At this stage of the project the University of Gdttingen and WHO-MDSC succeeded to ligate all of the genes targeted in its workload of WP3 into the pIVEX system. This includes the genes for specifics proteins of viruses of Ebola Zaire, Ebola Soudan, Marburg, Rift Valley Fever, Crimean-Congo hemorrhagic Fever, Dengue 4 and Dengue 2, Lassa Josiah, Lassa AV and Lassa CSF. At the point of reporting expression of the proteins had been shown for the nucleocapsids of RVFV.N, CCHFV-N, EBOZV-N, EBOSV-N, MARV-N, LASVJOS.N, LAS(AV)-N LAS(CSF)-N by detection of the biotin-TAG (Strepavidin-POD conjugates) on Western Blot. Specific detection (specific antibodies) was shown for all but for the LASV-N proteins. This seems to indicate that the LASV-N epitopes are conformational epitopes, which cannot be detected on denatured proteins in the Western Blot. In the western blot analysis some of the expressed proteins showed poor expression of the biotin TAG, whether ligated into pIVEX 2.8 or pIVEX 2.7 (EBOZY-N, EBOSV-N). In the case of MARV-N there was a preferentialexpression of the biotin-TAG in pIVEX 2.7. Whereas the biotin detection showed clear bands, smears from premature translation stops where observed when using specific antibodies. MDSC 2008 Progress Report Vs 27March}9 23 All relevant plasmids have been passed on to private company of the consortium, Mikkrogen, for purification and application on line assay membranes. The project document for submission to the national ethical committee of Burkina Faso has been prepared and given to the national project partners for their inputs. The protocol includes the organization of a repository and activities for a better understanding of the epidemiology of viral hemorrhagic fever in Burkina Faso. For future activities to be conducted, a list of laboratory equipment and reagents has been sent to Supply officer at WHO-AFROIBrazzaville for purchase. The VHF project aims to develop and validate rapid diagnostic tests for the early detection of epidemics of viral hemorrhagic fevers. The targeted fevers are: Dengue, Rift valley fever, Lassa fever, Ebola, yellow fever, Crimea Congo and Marburg fever). The project focuses on two types of test: o Development of line assays using antibodies of viruses causing African hemorrhagic fevers. The project will also validate the test for large scale use in peripheral health centers. The test should satisfli to the following criteria: be easy to be use; provide results which are easy to interpret; low cost and long period before expiring. . Development of a PCR test (F-RT-PCR) formatted for a mobile thermocycler that is usable by field investigation teams. The test should: - use molecular markers able to detect all the targeted viruses with a high specificity - be adapted to a simple protocol for extraction of nucleic acid - use pre lyophilized PCR mix The final tools should increase the possibility of early detection of viral hemorrhagic fevers in Africa. In the framework of the Consortium, the Molecular Biology Laboratory is engaged to produce for the development of the line assay proteins necessary for specific diagnosis of viruses of Lassa fever, Yellow fever and Dengue by cloning and sequencing. MDSC laboratory will lead the coordination of the field validation of the line assay. MDSC molecular biology laboratory will be in charge of the validation of the molecular tests developed for F-RT-PCR. The availability of this tool will strengthen MDSC capacities during investigation on viral hemorrhagic fevers. During 2007,the Molecular Biology laboratory carried the following activities: - Participation to the start up meeting in Dakar in February 2007 - Participation to a workshop of introduction to the project - Implement a technology transfer for molecular cloning in March 2007 - Meeting on role and participation to the VHF project of national actors in the surveillance of Yellow fever in Burkina Faso - Laboratory work on cloning of genomic materialof viruses in plasmid vector. MDSC 2008 Progress Report Vs 27March09 24 The VHF project is an important opportunity of development of the MDSC laboratory. It is also an avenue to support countries in investigation of viral hemorrhagic fevers. Unfortunately the project suffers of major administrative constrain: the signature of the contract of the Consortium by WHO. The signature of the document will allow MDSC to received fund for laboratory researches, and administrative support. 7. CAPACITY BUILDING & TRAINING ACTIVITIES 7.1 Training in collaboration with the University of Ouagadougou The Centre has conducted training on surveillance, epidemic investigation, entomology, laboratory techniques, data management, and mapping for participants from within and outside the African Region. This training has focused mostly on operational and applied aspects of Onchocerciasis and epidemic meningitis control. The MDSC has hosted the training programme on "Strengthening Capacity of National Reference Laboratories" for Africa on behalf of WHO/CSR/Lyon and WHO/AFRO. The West African Field Epidemiology and Lab Training Program (WA-FELT): it is a regional program for French speaking countries in West Africa. It includes four countries to start with (Burkina Faso, Mali, Niger & Togo) and aims to progressively cover other French speaking countries in the region. It is based at WHO Multi Disease Surveillance Centre in Ouagadougou, Burkina Faso. The programme started on November 2007 (recruitment of an interim coordinator, Advocacy, networking, designation of national focal points in all four countries) with the support of African FELTP (AFENET), CDC/Atlanta (NICD), USAID Washington, WHO-APOC. AFENET is the key partner and offers technical and financial support. The objectives of the short course were to: . Discuss surveillance in participating countries and describe the structure of surveillance in participants, (including IDSR and International Health Regulation) . Interpret laboratory results in the context ofan outbreak investigation . Formulate a hypotheses that identifies the potential source of the outbreak . Collect and describe epidemiologic data during an outbreak investigation . Select the appropriate analytic study design to test hypotheses . Apply analytic measures to determine frequency and association . Describe the key elements required for documenting an outbreak and how these may be used to prepare concise reports and recommendations . Improve communication skills during and after an outbreak . describe and understand the role ofthe laboratory in outbreak response . Monitor routine laboratory data and interpret trends . Provide specific instruction to clinicians and public health personnel for specimen collection and transport . Accurately interpret laboratory reports and communicate this effectively . Apply principles of Quality control in their base laboratory and region . Describe the concept of Quality Management Systems . Describe the process clinical specimens according to accepted SOP. MDSC 2008 Progress Report Vs 27March09 25 The short course was a competency based workshop designated to strengthen adults and professionals capacity in outbreak investigation and response in the field. Each participant developed a "Mini-project". The Mini-project is 3 months operational research in surveillance and epidemic response and is designed to foster participant's skills in protocol writing, study report writing, scientific communication, oral presentation. Results of the mini-projects have been presented at a communication conference in Ouagadougou in October 2008. Main Achievements WA-FELTP has trained 42 Ministries of Health staff drawn from national, regional and district levels in 2 short courses. The 2 short courses have been on outbreak investigation with focus on meningitis and cholera. During the l't course (23 May - 6 June 2OO8)22 students have been trained while duringthe 2d course (21-31October 2008) l9 students have trained. Trainees and facilitators are all four countries and are drawn from epidemiology, laboratory, and internal medicine departments. These have all completed their three months fieldwork which culminated in the presentation of their field works and award of certificate of achievement. AII of the participants are still in their position with the exception of two (Dr Bernard Sawadogo from Burkina Faso & Dr Landoh Dadja from Togo) from the first short course who are current residents in the full course of the South Africa FELTP. The 3'd short course is about to launch in March 2009. The 3'd short course will have a specific focus on viral hemorrhagic fevers, avian flu and meningitis. l13 of the trainees are veterinarians from all four countries (Burkina Faso, Mali, Niger, and Togo) and facilitators include 2 veterinarians from a research centre and the national reference lab for avian flu in Burkina Faso. a a . The WA FELTP is affiliated to the University of Ouagadougou, Burkina Faso o Supervisors are drawn from the collaborating universities in all four countries, CDC, WHO, Ministries of health and research centres in all participating countries. The master program plan is to be launched in the first cohort in October 2009 7.1.1 "Utilisation d'une technique de PCR multiplex pour l'identification de trois principales bact6ries responsables des m6ningites au Burkina Faso" by Dr Abdoulaye Nikiema. Different techniques of identification of meningitis germs are available for laboratories: GRAM staining, serological agglutination test (Latex) and Culture. Recently with the introduction of molecular biology, an important progress was made that allows for the quick process and better specificity in identification of the various bacteria and diverse types of sample. The present study aims to compare the performances of a multiplex PCR technique for the identification of main germs involved in bacterial meningitis with the classical techniques such as serological agglutination test (latex) and bacterial culture. Based on the results of the study, it was possible to conclude that: MDSC 2008 Progress Report Vs 27March19 26 the multiplex PRC is more sensible and specific than culture and serologicaltest the confirmation rate with PCR method during the epidemic season is higher than in the non epidemic time; this result is not influence by age or sex parameter during epidemic season N. meningilrs is the germ predominant in identification wile ,S. pneumoniae is predominant during the non epidemic season PCR can be of an important interest for the diagnosis and the surveillance in countries experiencing frequent epidemics. Because of constrains due to the cost of the exam of samples, it was recommended that PCR be used in Reference laboratories. 7.1.2 6'Identification immuno-chromatographique et diversit6 g6nomique des Rotavirus chez les enfants en milieu p6diatrique i Ouagadougou - Burkina Faso" by Isidore J.O. Bonkoungou. The current study was carried out with the technical assistance of the Multi Disease Surveillance Centre. Results of this study were among the first researches on molecular characterization of rotavirus in Burkina Faso. The aim of this study was to determine the prevalence of rotavirus infection and characterized group A rotavirus in stool by immuno-chromatographie test and Polyacrylamide Gel Electrophoresis (PAGE). Polyacrylamide gel electrophoresis of genomic RNAs was performed on ICG rotavirus positive stool sample from children to screen for the rotavirus electrophoretypes identification with MDSC molecular laboratory facilities. Research paper: I.J.O. Bounkoungou, N.Barro, I.Sanou, L. Toe,, M.S. Sanfo, R. Ouedraogo- Traore and A.S. Traore. Electrophoretypes Characterization of Human Rotavirus in Two Pediatric Services, Ouagadougou, Burkina Faso.J.Med. Sci.. 8(4): 371-377 l5thJune, 2008. 7.2 Other training activities MDSC has also hosted postgraduate Research Fellows from various universities who have come to conduct research in areas of mutual interest. In particular, MDSC has established partnership with the University of Georgetown (USA) for the internship in international health and tropical medicine of their students. Since 2007 two (2) students have been sent in MDSC. In 2008 one student performed her internship. MDSC 2008 Progress Reporl Vs 27March09 27 8. OPERATIONAL RESEARCH ACTIVITIES & PRODUCTION OF BIOLOGICAL REAGENTS 8.1. Burkina special study on the recurrent epidemic meningitis MDSC coordinate in collaboration with CDC and WHO/HQ the studies aiming at understanding the recurrence of meningitis epidemics in Burkina Faso through data analysis, reports and field visits in various districts of the country (e.g. Boulsa, Reo from 07 to 20 April 2008). 8.2. MVP Carriage study The Norwegian government funded the carriage study application (Impact of a new and affordable conjugate meningococcal vaccine on carriage of serogroup A Nm and disease transmission) tlvough the Norwegian Institute of Public Health (NIPH, with Pr Dominique Caugant as Principal Investigator). The Meningitis and Vaccine development Branch at CDC in Atlanta provides technical and logistic support for field survey and data collection, management and analysis. WHO (MDSC and IST WA) and Burkina Faso Ministry of health provide assistance for logistic, data management and project coordination at country level. The carriage studies aim to measure the effect of MenAfriVac in reducing carriage in the vaccinated population and its potentialto affect transmission of the pathogen and thus, to provide a hard effect. INsrrruuoNAL PARTNERS . Norwegian Institute of Public Health (NIPH), Norway . Meningitis Vaccine Project (MVP), France . Centre for Disease Control and Prevention (CDC), U.S.A. . World Health Organisation (WHO), Switzerland . Direction de la Lutte contre la Maladie (DLM), Ministry of Health, Burkina Faso . WHO Multi-Disease Surveillance Centre (MDSC), Burkina Faso . Centre Hospitalier Universitaire (CHU) Pddiatrique Charles de Gaulle, Ouagadougou . Centre Hospitalier Universitaire Yalgado, Ouagadougou . Centre Hospitalier Universitaire Sourou Sanou, Bobo-Dioulasso Sruuy Srrps Three study sites situated in Burkina Faso in West Africa have been selected, one urban site and two semi-rural sites: . The district of Kaya, situated in the Eastern part of the country, is a semi-rural site. Kaya will receive support from the Centre Hospitalier Regional (CHR) of Kaya and CHU Yalgado; . The district of Dand6, situated in the Western part of the country, is a semi-rural site. Dand6 will receive support from the CHY Souro Sanon of Bobo-Dioulasso; . The urban district of Secteur 30 is located within the Ouagadougou the capital city of Burkina Faso. It will receive support from the CHU Pediatric Charles de Gaulle. MDSC 2008 Progress Report Vs 27l,tarch09 28 PnorBcr Goal axn RBr,rcvlNcn Meningitis due to Neisseria meningitidis serogroup A represents an important public health problem in sub-Saharan Africa. The aim of the current project is to demonstrate the ability of a new, affordable meningococcal serogroup A conjugate vaccine, MenAfriVac, to reduce pharyngeal carriage and thus, transmission of the bacterium Neisserio meningitides serogroup A. The study will also investigate the vaccine's impact on mucosal antibody levels. Reduction in carriage prevalence is a major factor in a conjugate vaccine's ability to confer protection to the population (i.e. herd immunity). Preventing carriage of the bacterium by vaccination reduces transmission and circulation in the overall population. This mechanism will protect from disease those who are vaccinated as well as the unvaccinated. According the results of clinical pivotal studies conducted in Africa (l), MenAfriVac has the potential to prevent significant morbidity and mortality especially among those aged below 30 years in sub-Saharan Africa, and to eliminate the devastating epidemics regularly occurring in these countries with devastating effects for the population and the healthcare systems. Sruoy Onrncrrvns . Overall objective: To study the ability of MenAfriVac to reduce pharyngeal carriage of serogroup A meningococci as a reflection of herd immunity. MDSC 2008 Progress Report Vs 27March19 29 . Specific objectives: a. To determine pre-vaccination carriage prevalence of serogroup A meningococci in l-29 years old in Burkina Faso b. To determine post-vaccination carriage prevalence of serogroup A meningococci in the same population c. To determine the impact of the MenAfriVac vaccination on pharyngeal carriage of other meningococcal serogroups d. To analyse the genetic and phenotypic characteristics of meningococcal isolates retrieved from the carriage study, in relation to invasive isolates in the same districts collected through enhanced surveillance e. To determine risk factors for pharyngeal carriage of disease-associated clonal complexes f. To assess the mucosal antibody mediated immunity against serogroup A meningococci in a subset of individuals After a pilot test, the first round of the carriage study started on October 2008, followed by a wrap up meeting with all the stakeholders (8-9 January 2009). The second round is planned for January 2009 after taking into account lessons learnt from the l't round. MDSC gave a significant support 8.2. Research projects MDSC has had a track record in Onchocerciasis and meningitis research. The centre is currently involved in a various research projects such as: o MVP clinical trials on meningitis vaccine candidates in the Gambia, Mali & Senegal . Feasibility of the elimination of Onchocerciasis by lvermectine treatment . Development and evaluation of Onchocerciasis rapid diagnostic tests o Study on the Influence of environmentalfactors on the incidence of meningitis . Influence of vector movement on the epidemiology of Onchocerciasis o A study to understand the factors contributing to the reculrence of Meningitis in Burkina Faso 8.3. Development of new technologies MDSC has been involved in the development of new technologies for the transportation and rapid diagnosis of epidemic meningitis and viral hemorrhagic fever including Lassa fever respectively. Ln2007, MDSC produced 3,000 trans-isolate (TI) media of which 2,500 were distributed to countries in the meningitis belt including Sudan. Rapids diagnostics tests for viral hemorrhagic fever are in the process of being developed through a collaborative project with University of Gottingen, Germany. This diagnostic test will make it possible for test result to be available within minutes of testing. MDSC 2008 Progress Report Vs 27March}9 30 8.4. Monitoring Ivermectine Efficacy Osei et al. published on 2007an article in the Lancet describing a faster repopulation of the dermis with microfilariae than usually expected by mathematic models. They concluded to a possible apparition of resistance in adult worms of O. volvulus. WHO and the World Bank initiated a consultative meeting in Washington meeting (Sept 2007) on the "Efficacy of preventive mass drug administration". APOC took the lead for a working group on the "Monitoring Ivermectine Efficacy" and convene a meeting in Geneva (3-6 March 2008), to develop a scope of work. MDSC attended the meeting with the WE| grant support. MDSC will play a role on the bio-banking and development of genetic marker within a 3 African lab network in close collaboration with APOC, WHO-TDR and New Zeeland and Canadian teams. 9. MDSC BODIES MEETING: With the support of the World Bank grants MDSC could be able to organize 2 meetings of the MDSC Scientific Committee. The first meeting discussed the draft projects submitted by the MDSC management but the main issue raised was the status of the Center. The second meeting was held on January 2008 where the members discussed the MDSC paper requested by the WHO-AFRO Regional Director. 10. ADMINISTRATIVES SUPPORT& DUTY TRAVELS: The World Bank (WB) was the only source of funding to support MDSC functioning including running and operational cost. The WB grant also allows 2 staff from MDSC to attend the l3th JAF meeting in Brussels (December 2007) as well as the l4th JAF meeting in Kampala (December 2008). 11. EXTERNAL & INDEPENDENT EVALUATION OF THE WB GRANT: According to the MDSC signed agreement, an independent and extemal evaluation of the period of the 3 consecutive grants has been performed on October 2008 by the selected institution "Unitd de Santd Internationale - USI du CHU Montr6al, Canada" through WHO procedures. USI made a debriefing to MDSC and WHO in Burkina Faso. The report confirmed the weakness of the centre since his inception and noticed the way forward by the institutional project for the establishment on legal basis of a new Centre of Excellence (Ouagadougou Center for Disease Control, O-CDC). The report has been sent to the Bank as requested in the signed agreement. 12. MAIN CONSTRAINTS The functioning of the Centre has been hampered by a number of constraints since its creation. These challenges include: - The absence of establishment on legal basis - The lack of financialand administrative autonomy to function efficiently - Lack of MDSC designated staff MDSC 2008 Progress Report Vs 27March}9 31 Short term contracts for seconded staff. [Contracts for most of these staff have not been renewed since 3l December 2007) The recruitment of the 2 short consultants took long time. They have been hired at the end of the epidemic season. Limited financial, infrastructural and equipment to support future expansion of the centre There was also some misunderstanding of the position for the formal staff working in MDSC who had a new contract under IST position. There still remain some communication gap between the different WHO structure and level in Burkina (HQ, AFRO, IVD-IST, CSR-IST, APOC, MDSC); Although the Centre has the capacity to perform at even better heights, these constraints limit the speed and performance with which this can be achieved. 13. MDSC INSTITUTIONAL REFORM: Establishment of the Ouagadougou Centre for Disease Prevention and Control (O-CDC) The WHO Regional Director for Africa, in consultation with Member States, has given orientation for the establishment of centres of excellence for disease prevention and control in the Region. The following sections present a proposal to transform the existing Multi Disease Surveillance Centre of Ouagadougou into a laboratory-based reference centre for disease prevention and control. Because of the comparative advantage of the MDSC in the surveillance of onchocerciasis, epidemic meningitis, dracunculiasis and loaiasis, it is being suggested that the new reference centre for disease prevention and control initially concentrates on these four diseases. The purpose of the Ouagadougou Centre for Disease Prevention and Control (O-CDC) as a part of a network of Regional Centres of excellence for Disease Prevention and Control is to be a sub regional centre of excellence providing high quality technical support to countries in the prevention and control of endemic, epidemic and pandemic disease threats, including neglected tropical diseases. The mission is to provide technical support for the strengthening of regional and national capacities for the prevention and control of major communicable diseases, in particular onchocerciasis, dracunculiasis, loaiasis, Buruli ulcer, human African trypanosomiasis, schistosomiasis, soil-transmitted helminthiasis, trachoma and epidemic meningitis through the provision of quality laboratory diagnosis, research and training. The major goals are to: L Establish the O-CDC as a regional laboratory-based reference institution focusing on integrating multi disease surveillance of onchocerciasis, dracunculiasis, loaiasis, epidemic meningitis, Buruli ulcer, human African trypanosomiasis, schistosomiasis, soil-transmitted helminthiasis and trachoma. MDSC 2008 Progress Reporl Vs 27March19 32 I tJ t 2. Develop O-CDC as the lead collaborating institution for relevant research and training in onchocerciasis, dracunculiasis, loaiasis, epidemic meningitis, and other diseases of public health importance. The functions of the Ouagadougou Centre for Disease Prevention and Control are to: (a) Serve as a hub between national health systems, institutions and agencies involved in onchocerciasis, dracunculiasis, loaiasis, Buruli ulcer, human African trypanosomiasis, schistosomiasis, soil-transmitted helminthiasis, trachoma and epidemic meningitis detection and control; (b) Contribute to the sharing of knowledge, technologies and materials necessary to ensure rapid and reliable identification of onchocerciasis, dracunculiasis, loaiasis, epidemic meningitis and other diseases of public health importance in the African Region; (c) Promote the exchange and dissemination of relevant and good quality disease surveillance and control information amongst Member States and partner agencies and institutions in the subregion; (d) Improve skills and competencies of health workers involved in onchocerciasis, dracunculiasis, loaiasis, epidemic meningitis epidemiological surveillance, laboratory diagnosis, as well as disease mapping; (e) Compile and analyze data on epidemic-prone diseases, including onchocerciasis, dracunculiasis, loaiasis, Buruli ulcer, human African trypanosomiasis, schistosomiasis, soil-transmitted helminthiasis, and trachoma and epidemic meningitis, from Member States in order to establish regional epidemiologicaltrends and predict future epidemics as well as information sharing; (f1 Develop vector-based epidemiological surveillance tools for the early detection of onchocerciasis recrudescence before the establishment of the disease in human populations; (g) Develop a reliable system for surveillance and monitoring resistance to preventive mass treatment, including ivermectin; (h) Strengthen the information and strain repository for onchocerciasis and epidemic meningitis and thus facilitate information sharing through an information technology network and ensure health information alertness for timely updating in publications; (i) Provide relevant information and support to countries in order to allow adequate response to epidemiological events, including epidemic response; O Contribute to the response to outbreaks of epidemic-prone diseases, in particular epidemic-meningitis. The proposed Disease Priorities: The comparative advantage of the existing MDSC facility lies in the laboratory-based capacity for diagnosis, training and research in onchocerciasis, dracunculiasis, loaiasis and epidemic meningitis. It is therefore being recommended that OCDC initially specialize in the prevention and control of four diseases, namely, onchocercaisis, dracunculiasis, loaiasis and epidemic meningitis. MDSC 2008 Progress Report Vs 27MarchO9 JJ , l, ( The proposed Implementation Plan will take into consideration the current strengths and weakness of the MDSC, it is proposed that the transition to establishing the OCDC be implemented, over a period of 18 months, under 5 main strategic interventions: l. Provide epidemiological, microbiological and molecular surveillance service 2. Develop information management systems and services 3. Train professionals in surveillance and information management, 4. Build networks and partnerships to enhance knowledge and resource base, 5. Upgrade infrastructure and re-equip facility, Expand and develop new Centre complex to include ultra-modern laboratorv facilities The proposed organizational set-up will include the Joint O-CDC Board (JOB), the Co-Sponsors Committee (CSC) and the Scientific and Technical Advisory Committee (STAC), Director's office, and six technical units. WHO will be the Executing Agency and a memorandum of understanding (MoU) will be developed and signed by the co-sponsoring agencies and will cover issues related to administrative, technical structures and bodies of the O-CDC. 14. PERSPECTIVES Meningitis su rveillance : Based on the successful experience of MDSC implementing the meningitis enhanced surveillance in the African meningitis belt, MDSC could play a major role in the implementation of the studies related to the new Men A conjugate vaccine introduction (MenAfriVac). MDSC has started developing a guideline for bacterial meningitis case based surveillance. This tool will allow countries to implement a strong surveillance system in order to assess the impact of the introduction of the MenAfriVac vaccine. Using the balance of the World Bank grant MDSC has upgraded the Bio-molecular lab in term of technical capability as well as bio-security. The valuable support of CDC by giving a real time PCR machine in 2008 helped MDSC to fulfil his coordinating role of supporting National reference lab in the sub region as well as quality control support. The production of transport media (Trans Isolate, Thyer Martin media etc) gave a new opportunity and advantage comparative to MDSC to be developed in the fourth coming year. Onchocerciasis su rveillan ce plan of acti on 2008-20 12 The Onchocerciasis surveillance plan of action2008-2012 of the MDSC has been prepared based on the countries own plans. The keys points are: - Entomological surveillance : technical support (planning, supervision, advices) Laboratory analysis, financial support and logistics - Epidemiological surveillance : technical support (planning, supervision, advices) Laboratory analysis, financial support and logistics - Capacity building : entomology, epidemiology, biology and data management MDSC 2008 Progress Report Vs 27March09 34 . ti L Research : Feasibility of elimination of onchocerciasis with ivermectin; Tools for entomological and epidemiological surveillance; susceptibility of O.volvulars parasite to ivermectin treatment Advocacy: development of communication plans, sensitization of national authorities and stakeholders Resource mobilisation Other disease surveillance and disease control activities: the involvement of MDSC in other surveillance and disease control actitivities will depend on the statut of MDSC and the future of the new O-CDC. Once OCDC has established itself as a centre of excellence for the diseases mentioned above, it may choose to expand its work to include additional regional priority diseases such as malaria, tuberculosis, HIV/AIDS, Buruli ulcer, human African trypanosomiasis, schistosomiasis, soil-transmitted helminthiasis and trachoma. Such expansion, however, will have to consider the existing institutional, national and sub regional capacities and competencies. 15. CONCLUSION The spirit of a centre like MDSC has been relevant despite implementation and operational challenges. The new vision of the WHO regional office for Africa will critical to disease and epidemic control. The Ouagadougou Centre for Disease Prevention and Control (O-CDC) as a part of a network of Regional Centres of excellence for Disease Prevention and Control will certainly play a major role as a sub regionalcentre of excellence if the centre has some degree of autonomous and flexibility. 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