Report of the meeting on operational research and strategies: OCP, Ouagadougou, 9-11 April 2001

fl.t( Oc //t-E c z? Z I{Ii\/ISI()N I ONCHOCtrRCIASIS CON'TROL I'I{OGRAMN,II' IN \\'I'ST AIIITTCA PIIOGITAN{N,{E DI' LUTTtr CONTRtr L'ONCI{OCtrRCOStr EN ATTRTQUE DE L'OUT'ST Rrponr oF THE MeErrnG oN OpEnmoNAL ResEnRCH AND SrnnrEGrES OCP, Ouagadougou, 9 - l1 April 2001 Document OCP/EAC2Z.2 rI'i\lll.li OIf C'ON'l'l'lN'l'S i\. IN'Illol)tl("f ION........... ,\trltcrtl potnts rtf lltc J['(' rttt'L'ltttg rrt 2000 ,.tlr.tptton c.{ tlta ugt,ntla rrrrrl rt,t,rctt ol'tltc r t'(ttntrttcttdoltons ttI llt<' t]t('altttg ltt'lrl in 2000 I]. I'}1LESEN'l'r\1'IONS -l .......1 Otttlrnc of tlte I/CU plun of octtott fot 200 I -)00) Enlorttological srluatron ttl Illc blsttts strltlectcrl to lart'icrrle sPt'avng rn 2000 Ilesttlts of studies conduclcd by natrcttrol enlotttologrstt Restits of test of diagilosttc lools . . .. . Rcsrr/Is rinrtplinningofentotnological researchwithrespecttothecessatronof lanictdttrg Proposetl concrete octtotts to tntprove lhe cottttttutti\' directcd Iredtmenl wrlh ivcrnteclu (CDTI) uprlate of research on lytnpl,nlirfilariass and oncltocet-ciasIs" ' OCP epirlemiological results in 2000 and PET untt plan of oction for 2001 '2002 . I nt e gra ted anal1,5 [5 u s i n g O n ch o s ittt'. -. -. - - - C. FINDINGS OIT GROUP SESSIONS '"""' IO c.1 - ANALYSIS OF THE RESULTS OF ENTOMO-EPIDEMIOLOGICAL STUDIES..... """"""" ' 10 Criteria for stopping lan'iciding-... ' ' ' l0 TlteMono-Sio basits artd therlibtttaries of Lake l/olta East (Ghana andTogo)- ' ' " ' " " 10 The Oti (Kara-kdran-Mo) tt'ibLttai'tes in'Ghana, Togo antl Benin "" " " " I I Tlrc n'ibirtaries of Lake Volta lyest - Pru (Ghana) ' "" ' I I The Ktilpawn-t iote , Iyhite Volto and low Black Volra basins (Ghatta)" ' ' ' I l The Diettkoa basin in Burkirta Faso ..-.-....... 12 The Miisassondra (Cite d'Ivoit.e) aid Upper Sassantlra (Guinea) basins . ' "" 12 The Sattkarani - Diort - Kotu'ai - Milo basins (Gttirtea) """"""" " "" 12 TheNiattdart, Kott1,s, Bali basirts (Guinea) ' 13 TheKolettte-Koba-l4ongobasitts(Guiner) -' ' " " 'l3 Tlte Niger basitr atul tribtttiries at tlte level of Bannko antl Ftd (MALD " "" l3 C2. - REVIEW OF THE CONCEPTUAL FRAMEWORK ON INTEGRATION AND TRANSFER....".........""""" 15 Proposecl solutions to intprot,e CDTI artd tunetablefor initiating actions """ " 18 plantirtg attcl intplemetfiation of evahtarion or entotno-epidemiological octit,ities and their integratiott itrto the (Jpdate of diagnosis / sun,etllattce tools to be transferred b rhe countries and transfer tinetable " "" " ' l 9 P)'oress i\rtitug down antl stopping tlre Prograntnrc activities" "" "" " ' ' 20 Capacity of the cotuiries ro unie-r'taie o,tchocerciasis control ' " " " 2 1 C.3 & C.4 _ PRACTICAL GUIDES FOR STOPPING IVERMECTIN DISTRIBUTION AND CERTIFICATION OF THE ELIMINATION OF ONCI-IOCERCIASIS IN THE OCP AREA 22 Ret,rctv of cxrsttttg OCP tlata ott lreott)tcttl tvith ivertttcctirt" 22 Resrrlts i1 ,tr,rtr"i o,, tlte ttttpacl of it'ertrtectttt ort lrartstttissiotr 22 ,4ttoly5i5 of prcdrctiorts trrtlt the ONCI-\OSI|I rnottct 2'i Ii. r\NNEXES... 25 z\nnex E I PLAN OF r\Nr\LYSIS OF 1'll11 IMPACT Ol IRANSN,IISSION. Anncx Il2 LIST OIr PAIiI-tCIPn N]'S Arrnt:x I:l I'llO\rlSlOr.\AL. A(IENDA Arrnt:x [:-1'tOl'}lCS l]()lL CiROI.Jl' I)lSC'IISSIONS Anncx il5 IrlGt Iltl:S IVIlltM trcl'lN D ISTI(I IIL i]'lON ON Tl III I .1 J 6 6 7 8 8 9 2s l0 ll _il \a -a 3 RF],PORT OF THE MEETING ON OPERATIONAL RESEARCH AND STRATEGIES OCP, OUAGADOUGOU,9-11 APRIL 2OO1 A. INTRODUCTION 1. The meeting on operational research and strategies was introduced by the Head of the Vector Control Unit (VCU), Dr L. Yam6ogo, who mentioned the particular nature of the meeting as it was combined with the meeting on insecticide research of the vector control unit. He then gave the floor to the OCP Director, Dr Boakye A. Boatin to proceed to the opening of the meeting. Dr Boatin welcomed the participants (see list in Annex E2) and made a special mention of the important role played by guests from outside namely Prof. S. Traor6, Entomologist and Dr N. Nagelkerke, Statistician, and especially by those who had previously worked in the Programme, i.e., Dr D. Boakye, Cystotaxonomist, Dr J.-M Hougard, former head of the vector control unit, Dr H. Remme, former head of the Biostastistics and Informatics Unit and Dr M. Sylla, formerly of the Devolution unit. 2. Dr Boatin then emphasized the importance of research work undertaken at OCP, not only for the purpose of publication but mainly for that of conducting field operations in order to better adjust onchocerciasis control strategies. The meeting, he said, would primarily focus on analyzing the results obtained. He recalled the importance of those results for the Expert Advisory Committee (EAC) and mentioned the salient points of the Joint Programme Committee's (JPC) meeting in 2000. He then invited the operations officer of the eastern Zone, Dr Agoua, to preside over the plenary sessions in replacement of the head of the vector control unit who could not be available after the opening of the meeting. Salient points of the JPC meeting in 2000 3. Dr Boatin, in his speech indicated that the JPC meeting that was held from the 14th to the 15th of December 2000 in Yaound6 (Cameroon) had run smoothly. The JPC had noted with satisfaction the improved results that had been obtained in difficult zones such as the Oti basins and its tributaries in Ghana, Togo, Benin and Burkina Faso. OCP had promised the JPC to carry on with the actions undertaken in order to improve the results and to thoroughly analyze the data collected over time on treatment with ivermectin at OCP, in order to elucidate the real impact of the drug on the transmission of onchocerciasis. Those results would be important for the strategy to be developed after the end of the Programme in 2002 and for APOC. The results of such analyses would be reviewed at a meeting to be held in October 2001 and a report submitted to the next JPC meeting to be held in December 2001, in Washington. Adootion of the agenda and review of the recommendations of the meeting held in 2000 4. The agenda of the meeting and the specific objectives of the group sessions (presented in Annexes E3 and E4) were unanimously adopted. Nevertheless, it was requested that the group sessions include discussions on onchocerciasis control in Sierra Leone and its repercussions on the achievements of the Programme. The recommendations of the meeting held in 2000 were reviewed and most of them had been implemented. Issues with respect to the recommendations on ivermectin distribution that had been partly implemented were taken up again during the group sessions of the meeting. a4 B. PRESENTATIONS f)rrf'linc nf fhc \/ccfnr Cnnfrnl I Tni lan of action fnr ?OO 1 )nn,')l'-I I\ ^ 5. The highlights of the past year and the forecast for the 200112002 period were presented. Larvicide coverage in 2001 and 2002 is indicated in figures I and 2. Given that larviciding was stopped in some basins in 2001, the VCU structures would will undergo a modification with the closing down of the operational bases of Hohoe (Ghana), Atakpam6 (Togo), Beyla and K6rouan6 (Guinea). F'or that reason, the entomoiogical network will be reduced in early 2002 to 52 points as against 107 in 2001 and routine entomological surveillance will continue until the end of 2002. 6. As part of strengthening the process of transferring entomological activities to the countries, the national entomologists will carry on with the studies on the entomological detection of recrudescence, the study on the impact of ivermectin on transmission and on the control of blackfly nuisance (with the material and/or financial contribution of the countries). These studies will be continued while keeping in mind the integration of these activities into those of the national health structures. The national entomologists will be strongly involved in the management and integrated analysis of the data. Thus training will remain a leading part of the unit's activities. 7. The feasibility studies on ground treatment now in progress in some specific basins of the Programme will help to undertake vector control on these basins during the dry season of 2003. Only three helicopters will be contracted with 1999.2 gtaranteed hours. The central and strategic warehouses will be maintained. An effort will be made to strengthen prospecting, larviciding and mapping activities. Operational research will continue on: blackfly movements with a component of experimental studies on transmission by S. sirbanunz on patients selected in the North of Sierra Leone, in Guinea and in Mali; the control of the quality of operational larviciding and the test of the new .8.r. H-14 formulation. Hydrological surveillance as well as environmental monitoring will continue until larviciding stops in late 2002. Entomological situation in the basins subjected to larvicide spraying in 2000. 8. In the eastem zone,larviciding was undertaken in a portion of the original Programme area and in the South-East extension. In the original area, on the Dienkoa basin (Upper Mouhoun (former Black Volta) in Burkina Faso, ground larviciding was conducted by the national team. In Togo, the tributaries of the Oti (K6ran, Kara and M6) were subjected to regular aerial larviciding. An experimental treatment was undertaken on the main Oti in January and February 2000 and 2001. From mid March 2001 onwards, ground treatments by boat were carried out on a portion of that basin. In the South-East extension, the aerial larviciding undertaken in 1999 was continued in 2000 on the tributaries of Lake Volta-East and West (Pru, Asukawkaw, Dayi), Mono and its tributaries, Sio, Ou6m6 and its tributaries and Kouffo I (Figure 1). It must be specified that ground treatments with Br H-14 were conducted during the dry season on accessible breeding sites in replacement of treatments by helicopter. These activities were conducted in excellent conditions. 9, The entomological situation is satisfactory in the wliole of the Eastern zone. Conceming transmission by savanna flies (Fig.3b), it is noted that in 2000, out a total of 5l catching points visited, only one point has an Annual Transmission Potential (ATP) which is above 100. Tliis is Djabata on the Okpara near the border of Nigeria (ATP of 244). The results recorded during the first quarter of 2001 are also satisfactory. All the other catchir-rg points have ATPs that are belorv 100 (Fig.3b). On the basins of Dienkoa in Burkina Faso and Lake Volta in Ghana and Togo whete vector control will stop in late 2001, the entomological results remain excellent r.vith adjusted O. volwrlus ATPs belorv 100, if not uil itt several catching points. l10. Larviciding in thc western zone concerns the following basins; Kolent6 - Kaba - Mongo, of Tinkisso, of Upper Niger - Mafou, olKouya, of Niandan, of Milo, of Sankarani, of Dion, of Kourai and Bagb6 in Guinea, of Sassandra in COte d'Ivoire and of Mid Niger and ground treated tributaries in Mali. (Figure 1). 11. The entomological results for 2000 in the western zone were satisfactory and the ATP trends were good or declining. Adjusted ATPs (ATPa) above 100 for all species, were observed only on four catching points : Vialadougou on the Sassandra (ATPa : 147), Yalawa on the Mafou (ATPa: 119), Badekanti on the Kaba (ATPa : 126) and Soumayerea on the Mongo (ATPa :193). Only one point has an ATPa for savanna flies above 100: Vialadougou on the Sassandra, ATPa:147 for savanna flies. On the Milo, Dion, Sankarani and Kourai basins where it is envisaged to stop vector control in late 2OOl, the entomological situation has, over the last three years, remained excellent if not nil with ATPs below 100. The same also applies to some catching points of the Kaba Avlongo basins bordering Sierra Leone where a static entomological situation is being observed with ATP below 100 (Figure 3). The strengthening of onchocerciasis control on the basins that had poor results on previous years and the on-going accompanying measures have made it possible to control transmission on the Niger-Mafou and the Upper Tinkisso at Fifa with ATPs below 100. Table L: Identification of infections in blackfly pool screening Results for 1999 and 2000 Country Basin Catching Point Catching Period No. Of treated females Infectivity rate (o/00) Interval (0/00) Burkina Faso Nazinon (Red Volta) Ziou 8199 to 2111100 41300 0,0485 [0,0059;0,1753] Bougounba Nab616 417100 to 29109100 9900 0 Ou6ssa 417100 to 2'l/10100 1200 0,8697 [0,021I :4,8462] Nakar 417100 to 29/09/00 5400 0,1 869 10.0047:1.04101 Bougouriba 417100 to 29109100 4300 0 Dan 417100 to 2619100 2300 0 Zambo 417/00 to18l0'7100 l 200 0 Bambassou 417100 to 2210910 5300 0 Nakambe (White Volta) Loaba 07/99 to30108100 400 0 Benin Sota Gbasse 07199 to 02100 I 7800 0,177 [0,035 ; 0,49661 Alibori Alibori 07199 to 12199 5200 0 Guinea Gambie Koukoutamba 1616100 to 2319100 4200 0 C6te d'Ivoire Bandama Blanc Badikaha 07/99 tolll99 6700 0 Bandama Bdriaboukro l2l1l00 to 2717100 r 3300 0,0755 [0,0019;0,4204] N'zi F6tekro 29/5100 to 2lll/00 44300 0,0679 t0.0144:0.19861 KhanAI'zi Assdrekro 29/5100 to 2/11100 r9200 0,1 575 10,0324; 0,46011 Comoe Amouakoukro 2915100 to 2/11100 16100 0,0623 10.0016:0.34711 Ghana Whrte Volta Zongorri 05199 ato28/08/00 r 6900 0,1 79 1 10,0368 ; 0,52331 Kulpawn-Mole Chiasa 3/7100 to 30/l l/00 l 6300 0,s031 10.216s,0,99t21 Bi6lrkpong 417100 to 30/ I I /00 20200 0,0496 [0,0013 ;0.2765] Togo oti Toutronqa 09/99 to 26112/00 20800 0,2433 t0.0788 .0.56171 Niger Tapoa Tapoa 08/99 to 23lll/00 21800 0,255 [0,r023 ,0,52531 Mali Bakoye Badala 09/99 ro 26/10100 I I100 0 Senegal Gambia Mako 07199 au 30/l l/00 '7200 0 12. The activities of the national entomologists of nine countries consisted of stlrveillance for recrudescence of infection or the monitoring of the impact of ivemrectin on transmission based on the technique of blackfly pool screenillg. These studies should pern-rit the setting up of a network of entomological information between the corrntries themselves and with the OCP possible. Results of studies conducted by national entomologists a6 13. For the second consecutive year, the results obtained confinn that there are no more risk of resumption of onchocercal infection in the basins of the original area where control stopped over more than nine years ago in Burkina Faso and in Ghana. Table I shows a summary of the cumulative results obtained over the two years. Infectivity rates above 0.5 females per thousand identified females were found only in the basins where the populations were treated with ivermectin. Results of tcst of dia.qnostteloals 14. Three diagnostic tests are currently being reviewed in the Programme area: the detection of onchocercal infection in blackfly pool screenings (entomological test based on PCR based DNA probe techniques), the Diethylcarbamazine patch test (DEC patch test) and the immunologic onchocerciasis detection test or ICT test. The training in the utilization of the DEC patch test is currently in progress in the countries and takes place during epidemiological evaluations. Until a "monotest" becomes available, this training is targeted on mastering the principle, the reading and analysis of results. A compilation of all the results collected to date was made. It shows that the performance of this test is equivalent to that of the prevalence of microfilariae (skin snip), but it is not adapted for counting microfilariae. 15. The immunological test for onchocerciasis is being experimented in both OCP and APOC. It is based on the detection of antibodies produced by the organism following infection. The test is user-friendly. However, it requires blood sampling. The material involved must be used only once for each person examined. In the OCP area, it was evaluated in various regions with varied bio- geographical and endemic characteristics. The first results show that the test detects exposure to onchocerciasis but not the presence of parasites. A proportion (30%) of the skin snip positive population does not respond to the test. It was observed that the highest microfilarial loads corresponded to the lowest scores of the test. Like the DEC patch test, the ICT test does not make it possible to count microfilariae. Results and planning of entomological research with respect to the cessation of larviciding 16. Entomological research in relation to the cessation of larviciding is basically focused on determining the bio-ecological and vector characteristics of S. sirbanum. In that case, it is a matter of enhancing our knowledge about i) the genetic diversity of that species, ii) its degree of involvement in seasonal migrations and iii) its ability to transmit the various strains of O. volvulus encountered in the foci through which migratory movements are recorded. Concerning the first two items, the studies use samples of larvae and adults that are collected at different points, on the assumed axis of seasonal migrations that take place from the South-west to North-east early in the rainy season by virtue of the inter-tropical conversion front (F.I.T). rise and in the reverse direction early in the dry season, due to the harmattan (Fig. 4). All the identification techniques currently available (morphology, morphometry, cytotaxonomy and molecular biology techniques) are applied for an expert analysis of those samples that are collected either directly in nature or from those bred in the laboratory €ig. 5). 17. Preliminary results obtained in the Western zone after the cytotaxonomic analysis of larvae samples, suggest that fomrs of S. sirbanmn seem to be involved in the wide range movements between the basin of the Upper Niger/Mafou in Guinea (Yalawa, Somrorea) and that of the Baoule in Mali (Madina Diassa). Further investigations will soon make it possible to confitm or deny this observation. The investigations aimed at detennir-ring the vectorial capacity of S. sirbarrunt wlll be n-rade with onchocercal patients frorn diflerent villages located on the seasonal migration axis of the S. sirbanutn popr-rlations. These patients were selected in the Nortli of Sierra Leone, in Gr,rinea 7(basin of the Upper Niger/Mafou) and in Mali (basin of Mid Niger). The xenodiagnosis studies are cumently in progress with onchocercal patients with flies caught at Morigbedougou on the Milo. 18. As part of the prioritized entomological research, in view of the very inrminent end of vector control operations, mesological studies (search of points of access to rivers involved and of test points for an enhanced entomological evaluation) are also being conducted in order to confirm the soundness of the decision to stopping larviciding envisaged for late 2001, and to conduct feasibility studies of ground spraying after 2002.In the zones where they can be performed, the treatments will help to extend the control of onchocerciasis transmission after OCP activities have stopped. The operations will be conducted by specialized national teams of the countries concerned working also within national structures. They must be designed and conducted in close conjunction with chemotherapeutic control through community directed treatment with ivermectin (CDTI) and the results of the monitoring of the entomological situation. 19. The partial results of CDTI in the year 2000 in the OCP foci subjected to that treatment (Fig. 5) show that 18,600 villages were covered in 9 countries out the 20,810 that had been earmarked for treatment with an average coverage rate of 97% if we consider the results of six countries where treatment was completed before the end of the year. This gives an average therapeutic coverage rate of 77.3oh (ranging between 72.4oA and 85%) over a recorded total population of 8,285,590. These data are incomplete due to late provision of treatment to the populations especially in Ghana and to the problems of sending reports (delay in sending reports, too long channels, difficulties of access and communication, <(nodes>) on the dispatch channels). Treatment is gradually being resumed in Sierra Leone after more than 5 years of intemrption in the South of the country. In the countries, we note a substantial contribution (training, financial, technical and logistic support, community sensitization, etc.) from Non govemmental organizations (NGOs) such as Sight Savers International, an organrzation for blindness prevention and, Helen Keller International. 20. However, CDTI is facing a number of constraints including the inadequacy of financial and logistic resources that impair the supervision and monitoring of activities; the delay in supplying Mectizan to health districts and centers in some countries; the fact that NGO support is not yet extended to all the countries; the unavailability of trained community distributors (CDs) in some communities making recording and reporting difficult; the persistent problem of incentives (lack of satisfactory and sustainable solution); the instability of CDs in some communities; the inadequate Mectizan doses applied by some CDs; the delay in sending treatment reports to the district or central level. In this situation, the major challenges to be taken up are those of finding ways and means to ensuring the funding of the activities after the year 2002 and to guarantee continuity after the end of OCP. 21. Possible solutions, among others, consist in sensitizing the countries to ensure right now the funding of oncho activities (including CDTI), urging the countries to establish partnerships around oncho activities, creating stakeholders' contacts or meetings, involving other partners, diversifying finance sources and seeking additional resources by actively mobilizing funds for the continuation of activities, timely allocating resources to the staff of the health centers and to the CDs, decentralizing activities by completing the transfer process and continuing, wherever necessary, the cycle of training and retraining of health agents and CDs, sensitizing, inciting the health staff at the operational level namely the district in order to strengthen supervision / n-ronitoring of the activities of the health centers and of the CDs, the need for each country to urge the communities to find solutions to the problem of motivating the CDs and that of the communities' own mearls and resources. The incentive to the CDs shor-rld also consist in recognizing their role by giving special t Proposed concrete actions to improve the community directed treatment with ivermectin (CDTI) a8 awards, rewards in kind, special cor-rditions of access to care in health centers, specific training and filancial bonuses (taken from the funds generated by the other health centers). Update of rch on lvmohatic hlariasis and onchocerciasis 22. The meeting looked into the results of the TDR working group in charge of research on filariasis control. This research focuses mainly on the sustainability of community directed treatment with ivermectin. The successive studies have shown that CDTI has demonstrated community capacity, the commitment of both the community and the health agents as well as a strategy to strengthen partners' commitment. The major conciusions an<i recommendations lay emphasis on the fact that onchocerciasis control Programmes should think of availing themselves of partners' meetings to encourage CDTI approval by the community and to improve the involvement of district health services. CDTI is recommended as a strategy of distribution of the two drugs for the elimination of lymphatic filariasis. The question now is whether decision-makers and planners also commit themselves to support CDTL A multi-centric study on advocacy for CDTI continuity is in progress. The objective of the study is to design and implement an advocacy framework that will help ensrre sustainable demand, supply, distribution and coverage of treatment with ivermectin due to CDTI. 23. The epidemiological mapping of lymphatic filariasis was carried out in four OCP countries : Benin, Burkina Faso, Togo and Ghana. The results show that lymphatic filariasis was rampant mainly in the north of Benin, Togo and Ghana and Burkina Faso and, the south of Ghana, Benin and Togo (Fig.6a). The lymphatic filariasis elimination Programme solely based on bi-therapy (iverme-tin * albendazole) will start step by step in Burkina Faso from the year 2002 rtp to the year 2006, which will make it possible to better coordinate the epidemiological surveillance of onchocerciasis (Fig. 6b). 24. Figure 7 shows the epidemiological results of villages evaluated between 1998 and the first quarter of tn" year 2OOL Between February 2000 and February 2001,371 villages were monitored as part of routine epidemiological evaluation and the decision to stop larviciding in 2001 and 2002- The countri", "or"i*.d by these evaluations were: Benin (17 villages), Burkina Faso (26 villages), C6te d'Ivoire (40 villages), Ghana (34 villages), Guinea (123 vlllages), Mali (21 vlllages), Niger (14 villages), Senegal (20 villages) and Togo (76 villages). ZS. In the villages evaluated in the initial area in Burkina Faso, in the major basins of Comoe, Ldraba, Koulpeolgo, White Volta (Nakambe), Red Volta (Nazinon) and Black Volta (Mouhoun) basins under epidemiological surveillance, the epidemiological situation remains excellent with prevalence of infection generally nil (the maximum being 4.Soh, observed in only one village on the White Volta). No new case has been detected. In C6te d'Ivoire in the Bafing, Bagbe, Bagoe, Baoule, Bandama, N'Zi and Comoe basins, the epidemiological situation is also excellent except ir-r the N'Zi basin where an incidence exceeding loh was detected in two villages. The national teatn of C6te d,Ivoire has planned to undertake complementary entomo-epidemiological investigations during this year 2001. 26. In the south-eastem extension basins of Okpara, Terou and Zou in Benin; Antou, Anie, Mono and Asukawkaw i1 Togo and Lake Volta East (Asukawkaw, Dayi) iu Ghana, the epidemiological situation is excellent *itl, "*p".ted prevalence below i0% (Fig. 9a and 9b). Incidence is zero itl the villages evaluated in the Mono and Asukawkaw basins. T a9 27. Tl-re epidemiological situation is cxcellent in the villages evaluated in 2000 in Guinea in the Niger, Kourai, Dion and Sankarani basins (Fig. 10a and 10b), the Niandan and Milo basins (Frg. lla and llb). Prevalence reach zero in most villages evaluated and the trends are good. The incidence of infection is nil in all villages evaluated except at Tere (0.|oh,1 case) on the Dion, and at Oulo-Ouloko (0.07%, 1 case) on the Sankarani, where it is insignificant. 28. In the western extension, in villages under treatment with ivermectin only in the Gambia, Faleme and Koila-Kaba basins in Senegal, the Baoul6 and Falem6 basins in Mali, the Bafing, Koulountou and Bakoye basins in Guinea, the prevalence and the incidence tend to zero and the prevalence is below l0% in most villages except in a village of the Falem6 in Mali (Mankouke, 13.5%) and in two villages of the Koulountou (Inaye and Saint Laurent, 2l.lo/o and 18.4% respectively). 29. OCP, through the national teams, will continue to provide technical and financial support to the countries for epidemiological evaluations until the first semester of 2002.It is hoped that the DEC patch test in pre-packed form will be available in early 2002 to be tested in the field. The national teams will be more involved in processing and analyzing the data transferred to them. Integrated analysis using Onchosim 30. After the cessation of vector control operations by OCP in 2002, disease and transmission control will exclusively rely on Community Directed Treatment with Ivermectin. However, this is only scheduled to be implemented in selected parts of the OCP area. To assess the risk of recrudescence of transmission and its implications for the burden of disease, we considered the worst-case scenario; that in the absence of control transmission the disease would revert to pre- control levels. To assess this scenario pre-control (baseline) epidemiological data were analyzed. As epidemiological data were available from selected villages only, continuous risk maps were constructed using Kriging. Many areas without scheduled future ivermectin distribution were predicted to have had high pre-control levels of infection and blindness. Perhaps, extra vigilance is necessary in those areas. a-10- C. FINDINGS OF GITOUP SESSIONS C.1 _ ANALYSIS OF THE RESULTS OF ENTOMO-EPIDEMIOLOGICAL STUDIES Criteria for stopping larviciding 31. In reference to the criteria for stopping larviciding in the various basins of the Programme as indicated by the meeting on Operational Research and Strategies which was held in March 2000, the group updated the annex to the EAC document ot June 2UU0 entitled "Timetable for stopping aerial larvicide treatments and undertaking required monitoring activities", after having reviewed in detail the entomo-epidemiological data for each operational zone and each basin based on the process of stopping larviciding and on the set criteria. THE EASTERN OPERATIONAL ZONE The Mono-Sio basins and the tributaries of Lake Volta East (Ghana and Togo) 32. In 2000, 11 catching points that were regularly visited (e.g.: Dodipapase, Dodji, Tinkiro) had ATP adjusted for savanna species that was nil or below 100. We may consider, based on all the entomological results obtained since the initiation of operations, that at the end of the year we shall have about 14 years of successful vector control activity. The epidemiological trends of the villages evaluated in these basins are good (Fig. 9b). The group takes good note of the end of larviciding and the closing down of the sub-sectors of Atakpame and Hohoe at December 31, 200I. Despite this closing down, the issue of carrying on or stopping CDTI after 2002 will depend on the results of the complementary epidemiological surveys that are in progress during this year, 2001. The Ouem6- Zou- Okpara basins (B6nin) 33. On the entomological level, the control has been globally successful. Blackflies coming from Nigeria are forest blackflies (5. soubrense beffa form) and account for the high ATPs at Kaboua (296) and Mbet6koukou (1039). Furthermore, concerning transmission by savanna blackflies, only one point Djabata (Okpara) has an ATP above I00 (244). An additional one year larvicide treatment can be justified due to : i) the proximity of Nigeria ii) the aim of achieving 14 years of vector control at the end of the year 2002. 34. However the meeting questions the adequacy of continuing ground larviciding for the purpose of controlling transmission (understandable only if it is a matter of protecting agro-industrial or hydro-electric zones from fly nuisance). Ivermectin distribution, which has not been really generalized before 1998, must be considered as an additional modality. A formal support was given to the recommendation formulated during the meeting of national Coordinators and Entomologists lreld on 12-14 March 2001 during which APOC was asked to coordinate CDTI actions with those of OCP in the various States bordering Nigeria. t- 11- The Oti (Kara-k6ran-Mo) tributaries in Ghana. Togo and Benin 35. We may have too much trivialized tl-ris basin which, in some zones, gives satisfactory results The cument entomological and epidemiological results are satisfactory : i) on the Mo in Togo : at Bagan the ATPa for savanna species has remained below 100 from 1998 to 2000 as well as at Mo on the lower K6ran and on the upper Kara (ATPa for savanna species below 100 at Landa- Pozanda and Sarakawa-Kp6lou from 1998 to 2000). ii) 36. On the other hand, they are unsatisfactory on the Ghanaian part of the Mo as well as on the upper Keran (adjusted ATP equal to 145 and 128 in 1998 and 1999, and 77 in 2000 at Titira) and the lower Kara. The forecasts for stopping larvicide treatments in April 2003 (early in the dry season of 2003) are based on a simulation showing that stopping larvicide treatments in late 2002 (or April 2003) is enough to avoid any recrudescence on condition that ivermectin be maintained until about 2OIO. Furthermore, it seems that the results of the simulation (made at Titira) are very optimistic and that it is desirable to have the exercise repeated. 37. The meeting is aware that this is the original area (treated since 1917) but it also believes that we should thoroughly consider the importance of a decision to prematurely stop larviciding that could annihilate fruitful efforts undertaken during the last four years. Whatever the decision taken, a regular (epidemiological and entomological) monitoring will have to be carried out by the national teams of Togo, Ghana and Benin after 2002 in order to follow the dynamics of transmission (protocol to be plannedin2002 with the technical support of the eastern zone). The tributaries of Lake Volta West - Pru (Ghana) 38. The 14 years of vector control would have largely been reached in late 2002. But the results recorded at Asubende (ATPa for savanna species of 181 in 1999 and 91 in 2000) do not make it possible to exclude risk of early recrudescence. Furthermore, the meeting observed that ground treatments were possible during the dry season and that a feasibility study would be conducted for ground treatments during the dry season. Subject to the findings of that study, the meeting recommends that ground treatments for the purpose of transmission control be continued for the time required for the risk of recrudescence to become insignificant. However, the entire problem of funding those ground treatments still remains. At the same time, epidemiological and demographic surveys will have to be conducted in order to determine how long treatments with ivermectin will be continued on twice a year basis after the end of OCP. Whatever the decision taken (ground treatment or not), an entomological monitoring is recommended after 2002. The Kuloawn-Mole . White Volta and low Black Volta basins (Ghana) 39. Ivermectin distribution was not thoroughly done in these basins in 1999 and the treatment in the year 2000 was effected only in early 2001, whereas the last entomo-epidemiological results were not satisfactory. Therefore, the nreeting recommends : (a) that an entomological survey be conducted this year and after the end of OCP by the national team of Ghana in order to monitor the evolution of transmission; (b) that the national team of Ghana reestablishes as soon as possible a biannual distribr"rtion of ivermectin until the year 2002 and beyond (duration to be determined after the integrated analysis of data using Onchosim and taking into account the recent results of the entomological and epidemiological studies). -12- The Dienkoa basin in Burkuia Faso 40. On the Dienkoa basin, ground larviciding has been carried out since 1990 by the national team of Burkina Faso. Four catching points have been regularly monitored. In 2000, only the point of the Dienkoa Falls had an Annual Transmission Potential (ATP) of 7. The other three points (Lanviera, Samandeni and upstream Guena) had zero ATPs. 41. The therapeutic coverage for ivermectin treatment has been effective over some twelve years. The meeting also recalls that the Dienkoa had been subjected to aerial treatment since the beginning of the Programme and that the benefit of such treatments should not be forgotten despite the demonstration of infected children in the late 1980s. The presence of a few infected migrants in that zone (surveys of 1999) in a new village that did not exist in the zone in the i990s, had been observed but it was still quite limited and ivermectin treatment could stop at the same time as ground larviciding in 2001. A post-treatment type entomological survey could be envisagedin2002 and 2003 in order to evaluate the risk of the resumption of the transmission. The Bougouriba basin (Burkina Faso) 42. The meeting noted that the Bougouriba basin had not been monitored in epidemiological terms since the initiation of CDTI in that zone in 1996 and suggests that a thorough update of the entomological and epidemiological situation and of the therapeutic coverage be made during this year 2001. THE WESTERN OPERATIONAL ZONE The Mid Sassandra (C6te d'Ivoire) and Upper Sassandra (Guinea) basins 43. Due to the difficulties in establishing CDTI in 2000, the seasonal treatments on the mid Sassandra in C6te d'Ivoire were continued during 2001. The epidemiological results recorded in 2OOO at Soribadougou (8.5% prevalence and 0.277 m/s of CMFL) and Vialadougou (3.4% prevalence and 0.120mls of CMFL) are satisfactory Gig. 8) but the group observed an unsatisfactory ATP of 147 in 2000 at Vialadougou. The meeting suggests that seasonal treatments be stopped in late 2001 subject to satisfactory entomological and epidemiological results (surveys in progress) but it recommends that CDTI be continued given the current entomological situation. The duration of CDTI should be determined in relation to studies in progress. 44. The Guinean tributaries of the Upper Sassandra have been subjected to at least 12 years of successful control of combined larviciding and ivermectin distribution. Following the examples of the Dion and the Sankarani, treatments will stop in late 2001 and CDTI will stop in late 2002, subject to the results of the last epidemiological surveys. The Sankarani - Dion - Kourai - Milo basins (Guinea) 45. This is a good example of 12 years of well conducted control combining insecticides / ivermectin, hence larvicide treatments will stop in late 2001. ATP at all catching points is below 100. The assumption of blackfly movements from Sierra Leone dictates the maintenance of ivennectin treatment until 2002 and possibly beyond based on the results of the entomo- epidemiological studies in progress. Conceming the Milo, in relation to the annex to the EAC June 2000 document "to define the genetic type of O. t,olvulus in the pockets", a sample collection has been rnade in the upper stream parl (forest zone), where prevaleuce of infectior-r is still relatively hrgh. The analysis of this sample is or-r course and another study is in progress in the salre zone. o t- 13 - The Niandan. Kouya. Bale basins (Guinea) 46. These basins have had the conventional scheme of 12 years of control combining insecticides / ivermectin, hence it is planned to stop larvicide treatments in March 2002. The results of an epidemiological survey in progress, will help to specify the duration of ivermectin distribution that could possibly extend beyond 2002. The Upper Niger - Mafou (Guinea) 47. Notwithstanding an improvement in entomological results at the Yalawa catching point, it rs planned to stop aerial larviciding in late 2002, after more than 12 years of control, combining insecticides / ivermectin, with the purpose of excluding any risk of early recrudescence. The first results of the feasibility study on ground treatments on the Upper Niger / Mafou, for the purpose of controlling transmission, seem to reveal the difficulty of those treatments. The recent epidemiological surveys, on the other hand, reveal a static epidemiological situation (l4.9oh prevalence at Herako on the Mafou), which dictates the continuation of ivermectin distribution until 2002 and possibly beyond (subject to simulation results). Due the proximity with Siena Leone, the meeting suggests that particular attention be paid to this basin after 2002. The Kolente - Kaba - Mongo basins (Guinea) 48. Conventional scheme of 12 years of successful control combining insecticides / ivermectin, hence it is planned to stop larvicide treatments in late 2001. The entomological results (ATP below 100 at all catching points) are good but the proximity of the basins of Sierra Leone and the uncertainty about the degree of isolation of fly populations and / or of parasites in the north of Sierra Leone would suggest the continuation of ivermectin distribution in 2002 and possibly beyond. Results of epidemiological and environmental surveys (search of breeding sites, catches at usual points) should be made available in June 2001 and thus provide additional information while the results of the studies on blackfly movements (studies in progress) are awaited. The Tinkisso basin (Guinea) 49. Notwithstanding satisfactory epidemiological results on the whole (the prevalence of onchocercal infection reduced from 17 .4o/o in 1993 to 4.3o/o in 2000 at Sidak6l6 and at Kign6ro from 28.6% rn 1994 to 7.loh in 2000), the migratory movements in the Fifa region and the proximity of the northern basins not treated with larvicides (Bakoye and Bafing) prompt not to stop larvicide treatments before late 2002 and to continue on the Tinkisso basin (subject to the findings of the feasibility study in progress), ground larviciding after 2002 (spraying facilitated by the existence of many farm businesses). However, the national team of Guinea should consider undertaking a parallel "post-treatment type" entomological evaluation of these ground larviciding (to be planned in2002 in the western zone). CDTI will be continued alongside until 2002 and undoubtedly beyond based on the simulation results. The Ni-eer basin and tributaries at the level of Bamako and Fi6 (MALI) 50. The ground larviciding undertaken since 1994 at the level of Bamako and its tributaries (as a follow-up to aerial treatrnents) will continue until late 2002 and probably beyond, given the on- going search of funding with partners (NGOs and development projects). As in the case of the Tinkisso basin, the national team of Mali will, however, have to consider conducting a parallel "post-treatment type" entomological evaluation of these ground treatments (to be planned h 2002 witlr the technical supporl of the westem zone). CDTI will continue alongside until 2002 and r-rndoubtedly beyond based on the sirnulation results. The Fi6 will also continue to be ground treated a-14- in its Malian side (whenever accessibility so permits) and ivermectin distribution carried out on the two sides of the border as long as required. The basins in the north of Sierra Leone 51. A few reminders On the basis of the CMFL and of blindness rates, the epidemiological parameters in the north of Sierra Leone is more similar to a forest onchocerciasis than to a savanna onchocerciasis. Although the forest blackfly species (Simulium squatnosutn, S. yahense) are largely represented during the rainy season, Simulium sirbanum, a savanna species, is abundant the rest of the year. The aerial larvicide treatments that were conducted until 1994 resulted in a drastic reduction of S. sirbanum. However, this population has built up again very gradually and it seems to have come back to its initial level. The results of the DNA probes have highlighted the fact that isolated infectious larvae in S. sirbanum were, in a very high majority, from forest onchocercal strains. Therefore, ,S. sirbanum does not seem to be involved in the transmission of savanna onchocerciasis in this zone. Furtherrnore, the "forced" suspension of aerial treatments in 1994 does not seem to have had a major consequence on the basins bordering Guinea. These results have made it possible to hypothesize about an isolated population of S. sirbanum or about an isolated savanna parasite population that is not transmitted by the savanna vector. Unfortunately, the persistent insecurity in the north of Sierra Leone does not make it possible to collect biological material (microfilariae and blackflies) in order to prove the hypothesis. 52. Studies in progress 1. Xenodiagnosis study, to investigate blackfly vectorial capacities in Guinea (in a first instance) against parasites from onchocercal areas in the north of Sierra Leone, of Guinea and Mali. 2. Utilization of microsatellite markers to study the degree of isolation of parasite populations coming from the above mentioned three onchocercal areas' 3. Utilization of microsatellite markers and cytogenetic techniques (cytotaxonomy) to study, at a given time, the degree of isolation of blackfly populations sampled on a South-East axis (Yalawa) / North-West (Tienfala). 53. Notwithstanding the absence of S. sirbanum in Sierra Leone, the cross-sectional results of these studies should indirectly make it possible to give a precise indication of the state of isolation of the populations of parasites and blackflies in the north of Sierra Leone. The following will depend on those results i) the strategy to be adopted in the north of Sierra Leone and ii) CDTI duration at the level of the basins bordering Guinea 54. Preliminary results should be available before the EAC of June 2001; however, we must emphasize the difficulties of the xenodiagnosis studies (disorientation of patients, previous therapeutic history, geographical origin of patients) and of the entomological studies (difficulties to have larval stages in the treated basins, difficulties to breed blackflies to induce oviposition). a- 15 - C7. _ REVIEW OF THE CONCEPTUAL FRAMEWORK ON INTEGRATION AND TRANSFER 55. The meeting recognized the relevance of the Conceptual framework which remains a tool for planning and evaluating activities made available to the participating countries in order to enable them to fully assume their onchocerciasis control related responsibilities before the end of the OCP and after 2002.In that respect, the meeting reviewed the major points, the activities and indicators and made some modifications. The various sections of the group of activities, the overall concept of the responsibility of the countries to control onchocerciasis, like the transfer of OCP expertise, CDTI and the integration of onchocerciasis control in the national health systems of the countries were evaluated. This has been an approach to answer the question whether the countries could successfully undertake onchocerciasis control after 2002. In that respect, the group regretted the absence of the national Coordinators of most countries who could have provided answers to some questions in relation to the specificities of their respective countries. The amendments made to the conceptual framework are shown in italics in table 2 below taken from the EAC of June 1998. Table 2: Conceptual framework on integration and transfer IndicatorsKey Issues Inputs and Activities Responsibi- lities(1) process/output outcome/impact A. Health System strucfural: Multi-disease surveillance & control units (MDSC) * establish/ review policy documents - are they being implemented? do they include oncho control activities? * establish effective units, or assess them ifthey are there; make sure they include oncho control activities * mobilize internal support * * MoH, NC, (ocP) * MoH, NC * MoH, NC * existence ofa policy doaunent including onchocerciasis * presence of integrated structures responsible for MDSC prograrnmes * contmitment of health authorities (at the central, regional and local levels), with programme fficers appointed * existence ofa control programme effectively taking into account onchocerciasis * MDSC-units functioning effectively * functioning operational links established structural: Decentrahzed structures * assess/ locate policy documents and regulations with particular attentlon to district health plans * determrne degree of functronahty of distnct health teams (actual autonomy of drstrrcts) * NC, (OCP) * NC, (MoH) * report outhning the place ofoncho control wrthin system on all the levels * DHMT rs established, meet regularly and plans include oncho control * report is used in planning for oncho control on all the let,els * oncho control ts an rntegrated part ofeach co n c e r n ed drstnct health plan - 16 - a IndicatorsKey lssues Inputs and Activities Responsibi- lities(1) process/output outcome/impact structural: Good communiry organisatron + evaluate how effectrve community organisatton rs rn rmplementrng and supervisrng CDTI and blackfly captunng processes * Mectizan ts given at the correct dosage * NC, (MoH, ocP) * trarn and sensitise thc contmunrtres for the catching of blockJlies and the drstributrcn of Meclizan * cottttnuntties are orgarused fot' the catchtng of blackflies and the drstribul rcn of Mectizcut structural: Drug system * review the drug supply system: composition, procurement, storage, distribution, rational use * determine degree of functionalrty of district health teams (actual autonomy of districts) * NC, (MoH, ocP) * MoH * report describing strengths and weaknesses of system * an appropriate system of drug supply and distribution is pttt in place * ivermectin is on essential drug list and included in procurement procedures * ivermectin is ordered by head pharmacy and available whenever vrllage dishibutors fetch it functional: Monitorilg, supervision, information, evaluation systems * assess existing and ensure adequate information system for oncho control * assess and ensure supervision and monitoring procedures * NC, (MoH, ocP) * NC, (MoH, ocP) + oncho control data are routinely collected and handled at all levels * oncho supervision is included in the district health plans * functional information system for oncho control is present * integrated supervision taking place, with oncho control activities on the supervision checklist functional: Motivation and incentive system + undertake research into motivation and factors influencing it * establish standards and schemes for rewards of good practice * OCP, NC (MoH) * MoH, NC * research report x special incentive packages for oncho control activihes wrthin overall motivation and rncentive schemes are rntroduced * research findings translated into action * incentives positively influence performance functional: Capacity for restdual oncltocercrasts contlol / detectron and management of recrudescertce * undertake penodtc eprdemrological surverllance * undertake perrodrc entorrologrcaI surveillance + NC, NOT * NC. NOT * enough eprdemiological surverllance teams constrtuted and trarned * enough entomologrcaI sun,erllance teaurs * tlte relevant rn'erbasins arc Ltrtder cotttrol e p r d e t t r i o I o gt ca I l.v' o n d enlotrto logtcally a-11 - Ke1, Issues Inputs and Activities Responsibi- lities(1) process/output outcome/impact * undertake ground larvrcrdrng against nuisance * use data for detection and management of residual activiry and recrudescence * NC, NOT, * NC, MoH conshh-rted and trained * nuisance control procedures are established * analysis of field data being done, and decisions being taken about control * nuisance control procedures are operational * effectrve management of residual foci and recrudescence functional: CDTI Financial resources * list villages to be included * prepare villages to participate * order the ivermectin * follow up and supervise activities *establish a budget for activities and insure resources allocation *NC * NC, DHMT * NC, DHMT * NC, DHMT * MoH, NC * list prepared and periphery informed * nurses trained, villages sensitised and distributors trained * nurses prepare and forward orders * nurses and DHMT undertake regular supervisory visits * oncho control activities are included on development action plans of the sanitary districts + l00%o oftarget villages covered and 65%o of village population covered * Resources for oncho control are available each year B. Staff / skills / training + train national teams in epidemiological evaluation and surveillance of onchocerciasis * identify critical trainee groups (including community distributors) + estintate trairung targets for sustaining the control programme * establish each leamer tasks * conduct training needs assessment, and identify knowledge and skills gaps, and resources needed * rdentrfy and ortent potentral trarners and trainrng rnstltutrons * NC, NOT * OCP, NC (MoH) * OCP, NC (MoH) * OCP, NC (MoH) * NC, NOT + NC, MoH * NC, MoH, Trarners, (ocP) * training sessions undertaken * trainee groups established * trarning targets for all trainee groups set * lasks of eoch trainee group cstabltshed * trarning needs assessment performed and resources rdentrfied * trarners/ tralnrng lnstitutes for each group rdentrfied The output of the teams a r e effe c tiv ely imp r ov e d Indicators rr - 18 - Indicators OCP; Central unit at Ouagadougou, MoH; Mrnistry of Health of the Country concerned, NC; National Onchocerciasis Coordinator, NOT; National Onchocerciasis Teams, DHMT; District Health Management Teams, (...) indrcates assistin9,6ackstopping authority Proposed solutions to improve CDTI and timetable for initiating actions 56. In order to maintain and strengthen the assets of the OCP, the meeting thought about ivermectin supply and distribution and about the required finance sources. Table 3 ofCDTI Key Issues Inputs and Activitics Responsibi- lities( I ) process/output outcome/impact * design and develop training strategles explore locol and regtonal opttotls existing/ innot,ative training approaches * develop/ adapt and test training materials * train all targeted groups according to schedule * monitor/ evaluate acquisition of knowledge and skills, as well as effectiveness oI training process and programme * OCP, Trainers, NC, (MoH) * Trarners, MoH, (OCP) + Trainers, NC, MoH * Approprrote training strategies developed for each trainee group * currrcula, manuals, tncludmg IEC nnterials developed and tested * number of persons trained for each trainee group * monitoring and evaluation reports provided Activities Constraints Solutions Supply of mectizan - Order: time limrt Estimation of quantities Problems of expiry date Procedures ofentry into the country - Channel of mectizan in the country Seeking the contribution of the WR* Evaluation of product availability in the village at the time of utilization Training Sensrtrzation ofhealth agents and CDs Workshops gathering all stakeholders both in the district and rn the village Associate the agents of the IEC services of the MoH to CDTI promotion activrties Integrahon of CDTI rnto the plans of actron of HDs The CDTI activity Lack of motrvation in health agents and CDs Delay in sending treatment reports Inadequate supervision and monitoring Inadequate logrstic means Fundrng Inadequate funding State , communltres, NGDO, Bilateral and multrlateral cooperatron(WHO Afropoc) j- t9 - elr integration into the national health systems 57 An efficient planning requires the following : . Choice of villages taking into account the entomo-epidemiological criteria, allowing each country to have an overall picture of the epidemiological situation. o Determination of a favorable period for the evaluation . Timely mobilization of resources Table 4 : P of activities and n Update of diagnosis / surveillance tools to be transferred to the countries and transfer timetable 58. The discussions, the outcome of which is recorded in the table below focused on monitoring, diagnostic tools to be transferred, the level of implementation, the users to be targeted as well as the transfer time table. It appeared that the transfer of skills for all the techniques will be effective only in November 2OOl, but the transfer of material for epidemiological evaluations like DEC patch will be effected in March 2002. Table 5: Diagnostic tools and transfer to the countries ExecutionIntegrationActivities Before late2002OCP- National teamsEntomological evaluation Districts / regions / Central level Post-treatment studies Central level/ regionEntomological surveillance for early detection of recrudescence and measurement of the impact of treatment with ivermectin on transmission : - Dissection - Blackfly pool screening Central level / regions / districts Epidemiological survey Center / regions / distnctsEpidemiological evaluatton Transferable tools Utilization Target User Transfer timetable Training Equipment Epidemiology Skin snip Complementary studres and operational research Individuals and communitres Drstrict / regronal level Effective Available in late 2002 DEC patch test Routine Communities District Fin Nov.2001 Mars2002 Entomology Pools screening Routine Communities Central and communrty level Effective / late Oct. 2001 Available / make provision for consumables Catchrng / dissechon Complementary studies and operatronal research Central and drstnct level Late Oct. 200 I Avarlable IZO 59. It was obser-ved that this activity had already started and had been on-going for some time. Table 6 proposes a timetable for stopping VCU and PET activities. Activities related to VCU are scheduled to stop based on the results of larvicide treatments carried out in 2002. For instance the beacons cannot be stopped because it will be necessary to know the discharge of rivers for the application of insecticides. Although OCP activities will stop in late 2002, the meeting recommends that a scheduled time in 2003 for the end of larviciding be given and budgeted accordingly with adequate explanations. Table 6: Process of closing down OCP Activities Stopping VCU -Treatments by helicopter (aerial treatment) -Ground treatments -Entomological evaluation : *Catching - dtssection *Breeding site prospecting -Hydro-biological surveillance - Hydrologic surveillance : *Beacons *Flood gauges -Entomological surveillance : *Post treatment xSpecial studies of national entomologists Mid December 2002 Late December 2002 Late October 2002 Mid December 2002 Late December 2002 Late December 2002 Late December 2002 Late December 2002 Late December 2002 PET Supervisron by OCP : -Epidemiological survetllance -Epidemiolo grcal evaluation -CDTI -Trainrng -Transfer of data Late December 2002 Late December 2002 Late December 2002 Late December 2001 Late December 2001 Process of closing down and stopping the Pro-eramnte activities -21 - 60. The group reviewed the major activities that should be taken over by the national systems and examined assets and constraints (Table 7). On that basis, the group recommends that the national teams should examine right now the capacity of their national system to undertake these residual onchocerciasis control activities after 2002 following the indicators mentioned in the conceptual framework of integration (Table 2) Table 7: Assets and constraints when the countries take over onchocerciasis control activities Activities Assets Constraints CDTI Order for ivermectin Skill (central and decentralized) Tools available (OCP : modules ; Countnes : register, height gauge...) Structure in place Community parlici pation Fundrng Motivation Supervision Epidemiological surveil lance I evaluation skill Tools available (OCP : modules) Decentralization Community participation Supervision Funding Tools Mono test Entomological surveillance skill Material Molecular Biology laboratory Community partic ipation Supervision Funding Transportation of biological material Analysis and decision-making skill Computer material Integration Monitoring and supervision Skrll Material CDTI Logistics Operational research Partial skill Material available Training Funding Community participation Logistics Decentralization and inte gration Decentralization of activities skill Integration of activities Consideration of onchocerciasis in SLPP reports Capacity of the countries to underlake onchocerciasis control )) C.3 & C.4 _ PRACTICAL GUIDES FOR STOPPING IVERMECTIN DISTRIBUTION AND CERTIFICATION OF THE ELIMINATION OF ONCHOCERCIASIS IN THE OCP AREA Review of existin-e OCP data on treatment with ivennectin 61, The group reviewed existing data on treatment with ivermectin. It observed that the data on ivermectin distribution by the national teams are available at OCP but they are too general. The same fact was observed with respect to CDTI data that are only available in detail in the countries in the form of global report to OCP. 'l'he group then determined the ideal statistical unit in order to conrplete the existing computerized data base. An example of aggregation of such data was proposed at the meeting and appears in table 8. The group recommends that a directory of OCP data be produced using the various indicators adopted. Table 8: Plan for the monitoring of CDTI data Results of studies on the impact of ivermectin on transmission 62. The results of the studies conducted in 1999 and 2000 are presented in Table 1 and they concem the basins of the Bougouriba in Burkina Faso, the Sota and Alibori in Benin, the Kulpawn Mol6 in Ghana, the Bakoye in Mali, the Gambia in Senegal and the Oti in Togo. The results are satisfactory for the 2 years.It is advisable that these activities be continued and extended to other catching points and to other countries. The countries were urged to find means of transportation other than the OCP shuttles to send material to the OCP for analysis. LCA 63. The LF mapping was carried out in 4 OCP countries: Benin, Burkina Faso, Ghana and Togo The results are shown in figure 6a. This mapping is in progress in COte d'Ivoire while Mali is getting ready to perform it. Two scenarios are being contemplated : Onchocerciasis endemic zone without lyrnphatic filariasis : ouchocerciasis control activities are running smoothly . Zone where onchocerciasis and lymphatic filariasis cohabit : the ar-rti-lymphatic filariasis treatment must be performed adequately (adequate geographic and therapeutic coverage) because ofits beneficial effects on onchocerciasis. 64. The anti-lymphatic filariasis treatment must last at least 5 years; the maximuur duration will be specified by the on-going studies. Epider-niological surweillance of onchocerciasis in the latter Beginning of the treatment Last treatment 2000 No.of treat- ments PREVELENCE CMFL Basins Health Districts No.of villages treated (Date). Geogra -phical cover. (%) Therape utical cover. No. of target villages Geogra -phical cover. (%) Thera- peutical cover. Start (%) Last (%) Start (mf/s) Last (mf/s) Bafing Bafoulab6 74 (tget) 29.2 66.44 253 9t.7 82.6 10 61.5 30.8 20.66 1.71 Banif,rng2 Bougount e2 (tee2) 18.2 17.93 506 96.6 19.4 9 24.1 2 1.09 0.02 Bakoye Kita 43 (le8e) 9.0 60.06 479 97.5 17.7 t2 63.1 21.3 13.95 r.22 Baoul6 Est Yanfohla 6l (1995) 41.2 77.03 148 100.0 69.3 6 68.4 0 t2.91 0 Baoul6 Ouest Kolokanr 143(ree0) 86.6 64.49 165 100.0 79.4 1l 70 3.1 4.3 0.5 Bago6 1 Diorla t4t(1992) 60.5 73.99 233 100.0 16.8 9 59.8 0 16.92 0 Nrger Koulikoro 43 (1e88) 33.9 61.78 127 98.4 66.8 l3 79.6 2.2 69.43 0.08 Fal6m6 K6ni6ba 6l (1990) t].t 14.63 351 88.0 80. I ll 40. I 0.5 6.23 0.01 a !23 zone mLlst nonetheless continue. In as much as the anti-lymphatic filariasis treatment will be gradually extended to the countries (Fig. 6b), surveillance will have to continue in the zolles which have not yet been treated. Analysis of predictions with the ONCHOSIM model 65. The general background of ONCHOSIM, as a micro-simulation fully dynamic model was discussed. The results of several simulations with ONCHOSIM were shown. First, the effect of different epidemiological conditions (biting rates) versus ivermectin coverage rates and the probability of elimination were discussed following different pre-ivermectin scenarios. It was then shown how recrudescence could take place if elimination was not achieved despite "good results" following control. Thereafter the required duration of intervention to achieve elimination with high (99%) probability as a function of pre-control CMFL and ivermectin treatment coverage rates was discussed. This was followed by a discussion with an emphasis on the limitations of ONCHOSIM (validation for parasite vector and s. damnosum s s vector) and its potentials. 66. The following points emerged from the discussions The model provides good predictions. Therefore it is reliable. But sometimes, an underestimation of the dynamics of recrudescence can be observed. This was the case with the Bougouriba basin where the speed with which recrudescence set in had not been predicted by the model. In order to secure good prediction, one must make sure that a number of parameters are taken into account : infectivity in vectors and microfilarial load in the human population. Notwithstanding the reliability of the model, one must be cautious with the interpretation, because recrudescence can always occur. The model is not yet valid for the forest zones, but a modification was made to the savanna model with the purpose of adapting it to the forest zones. Proposed timetable for stopping treatment with ivermectin after 2002 and guidelines for stopping such treatments 67. In view of recent initiatives, there is great interest in whether ivermectin is able to interrupt transmission of onchocerciasis by itself (i.e. without larviciding), either distributed annually or more frequently. This needs to be examined. As OCP has most relevant data on this subject, a special group was formed to explore this issue. A selection was made of several river basins where conditions are such that this question could likely be answered. This group was set up to provide the team of the Public Health Department of the Erasmus University in Rotterdam with all the available data about treatment with ivermectin at OCP as well as the entomo-epidemiological data for the purpose of analyzing the impact of ivermectin on transmission. The findings of this analysis that will be available in October 2001 will help to make decisions about stopping treatment with ivennectin. (See Annex E1). 68. It is also recommended to select the Dienkoa, Milo, Sankarani, Dion and Kourai basins for tlie purpose of checking the predictions of the ONCHOSIM rnodel with respect to the 12 yeat cornbination of larviciding and ivennectin distribution and to underlake a "post-treatment" type entomological study in those basins. 24 D. RECOMMANDATIONS 1. Given the need to pool all the epidemiological and entomological data as well as all the data on treatment with ivermectin in order to help make a decision, the meeting recommended that a document (statistical yearbook) gathering all this data should be prepared for each basin and for each country before December 2001 ( OCP, NC ). 2. The meeting took note of the proposal to stop larvicide treatments in 2001 and to suspend ivermectin distribution at the same date on the Dienkoa, Milo, Dion and Sankarani basins that have been subjected to combined control for 12 consecutive years. To that elI'ect, tt recommends the validation in 2002 of the ONCHOSIM model for these basins rvhile respecting the protocol for stopping larviciding and undertaking a "post-treatment" type entomological study (OCP, NC). 3. To study the impact of ivermectin on transmission, the meeting recommends the following: a) b) collect, enter and analyze existing data by late May 2001 (OCP,NC); use infectivity rates, prevalence, CMFL and incidence as indicators to analyze the data of the selected basins (OCP, NC) set up in June 2001 a catching network at Mako (Senegal) in order to compare the 1998 blackfly densities with those of 2001 (OCP, NC). c) 4. In order to guarantee the delivery of ivermectin in the countries while minimizing problems of entrance fees in the recipient countries, it is recommended to involve the WHO representatives in the countries in the reception of order for mectizan made by the countries (OCP, CN). 5. The meeting recommends that stakeholders' meetings should be organized in the countries in order to strengthen sensitization and advocacy of the opinion leaders, partners, health staff and the communities to ensure their effective participation in CDTI (NC, OCP) 25- E. ANNEXES Annex.E.l. PLAN OF ANALYSIS OF THE IMPACT OF MRMECTIN DISTRIBUTION ON THE TRANSMISSION Background With the winding-up of OCP by the end of 2002, all subsequent onchocerciasis control will be transferred to participating countries and will almost entirely be based on community directed ivermectin distribution. The questions to be answered are where this will be implemented, at what frequency (annually, semi-annually), and for how long. The latter question can only be answered if elimination (or preferably eradication) with ivermectin is possible. The same questions and answers are relevant for most of the rest of Africa where onchocerciasis is endemic (APOC countries), keeping in mind the absence of vector control in APOC countries. Rationale OCP has a large collection of data which may help answer these questions. However, conclusions may equally apply to APOC. Objectives 1. To describe in detail the impact of ivermectin on transmission, the parasite reservoir, and other epidemiological parameters, such as incidence, prevalence etc. 2. The potential for elimination of onchocerciasis by ivermectin, and under which conditions. 3. To compare data with predictions obtained by ONCHOSIM, in order to refine predictions. Time frame All data will be transferred as soon as possible to Rotterdam. Processing of these data will be given the highest priority. Responsibility for cleaning those data lies with OCP. All data should be transferred by 15 May 2001 at the latest. A preliminary analysis will be completed by early June. Complete analysis finished before the planned October meeting in Rotterdam. Report ready in November. Methodology First, the general pattern of pre-intervention epidemiological and entomological data should be 'mapped', followed by a global survey of interventions undertaken and current state of affairs. Classify the impact of operations. The basic purpose of this is to serve as a reference for readers of the report. Much of this has already been done. Pre-control conditions have been mapped using Kriging. Maps with phases of operation are available. Aerial larviciding operations are available in Mapinfo (the rivtrai files), although the effectiveness of these operations has not been constant. Actton. Maps showing ivermectin operations and their timing should be improved perhaps (E.S. Alley). The cument epidemiological situation can also be mapped using kriging (Rotterdam). Residual hot-spots can thereby easily be localized. The second part should be more analytical. This is intended to tease out the effect of interventions in particular ivermectin distribution on the successes (or failures) that l'rave been achieved. -26- A general causal model that should be kept in mind under all approaches is as follows Actron planned --------) What has really beenachieved (e.g. coverage) Failures may be caused by either problems occuffing with the first arrow from the left, or with the second one. Problems with the first affow could be failure to get proper coverage, larviciding not all important breeding sites etc. This would thus point to problems with the system of delivery. Problems with the second arrow coul<i be too high pre-corrtrol levels, or substautial (human, fly) migration taking place etc. These problems are more difficult to remedy. For this analytical part, several approaches have been considered. The first is to select sites on the basis of baseline characteristics, e.g. vector species, pre- intervention CMFL etc., then assess the interventions that have actually taken place (this should critically include coverage levels of ivermectin distribution, the effect of larviciding on biting rates etc) and then evaluate the effects these interventions had on results. a a a a The second approach would be a 'case-control' approach. In this failures (to be defined) and successes should be identified and the factors contributing to these outcomes analyzed. Alternatively sites with a range of different outcomes can be selected for in-depth study. A third approach would be to only identify problem spots, and to analyze which factors probably contributed or caused these problems. Then discuss whether these problems could be remedied. The focus here is to separate the potential impact of ivermectin distribution from the actual impact, falling behind due to operational problems. A fourth approach is to identify areas where control and pre-intervention conditions meet certain criteria and then assess results obtained. This is close to the first approach. After discussion of these approaches and a review of the available information, the OCP meeting on operational research and strategies recommended a combined approach and an analysis by the river basins listed below. End Points Results can be assessed in different ways. One classification could be whether transmission has been completely intemrpted or not. The key indicator is vector infectivity measured as the number of head L3 per 1000 parous flies. Other classifications are in terms of residual transmission, and (more difficult) on the basis of extrapolation whether the results are such that elimination can be expected to occur within the next few years. The latter could be concluded if prevalence (or any other measure) reached a certain low level and the trend is downwards. Other possible end-points are whether the (expected) equilibrium level would be low enough to prevent any serious public health problems (to be defined). Key epiderniological indicators of ir-rfection are (1) prevalence of mf, (2) incidence of mf, and the main indicator of the public health risk is the CMFL. Also, it may be of interest to cornpare observed results with those predicted under ONCHOSIM. ONCHOSIM serves as a reference by which the success of operations cau be measured. Outcome I -27 - Considerations We suggest to use all end-points discussed above. Action. Coverage levels of ivermectin distribution in these areas should be ascertained. Areas where control conditions meet certain criteria are the Gambia on the basis of consistent use of semi-annual ivermectin distribution. Actiort. An entomological survey should be carried out. The Bougouriba area, where a hot-spot (where relapse in transmission appeared to have occurred a few years after the end of larviciding) is being managed by ivermectin distribution2-3 times annually, would also qualify. In several parts of Mali, Guinea etc (see below), the only intervention has been annual ivermectin distribution. Similarly, in Mali the Tienfala focus has had unsuccessful larvicing for some years and control relied almost exclusively on annual ivermectin. In other places in Mali (Wili-Wili, bassin Faleme) the base-line prevalence was low, and results relied on ivermectin (annually) exclusively. These areas are therefore also ofgreat interest. Recommendations of OCP meeting on operational research and strategies, April 2001 Data processing Most epidemiological and entomological data required for the analysis are already available in OCP computer data bases. However, some urgently needed data are either not yet entered or not yet received in OCP. Priority should be given to the transfer and entry of the data needed for this analysis. These include epidemiological data from the Milo and Sankarani basins in Guinea (received but to be entered) and epidemiological evaluation data from Mako focus in Senegal (not yet received in OCP). Entomologial evaluation in Mako focus Special entomological evaluations in 1999 and 2000 had shown absence of infective larvae but the number of flies caught was very low and the experiment had therefore been stopped in 2000. It is recommended that a full regular entomological evaluation is done in 2001 in order to quantify not only vector infectivity but also biting rates. This is important as a decline in vector density over time may have significantly contributed to the improvement in the epidemiological situation. Without this information, the impact of ivermectin treatment could be overestimated. Epidemiological evaluation data for the Bakoye basin in Mali A new round of epidemiological evaluations is planned for the end of April 2001, and these data would be important for the current analysis. It is recommended, therefore, to transmit the results of these evaluations immediately to OCP/FIQ after completion of the fieldwork, and to give top priorities to their processing. Data on treatment coverage Treatment coverage data exist for most of the epidemiological evaluation villages in the selected foci. -28- For ar-ralysis of compliance pattems, individual treatment records are needed. These are available for Asubende where ophthalmolgical evaluation was done and probably also for at least one village from the Mako focus. Information on treatment coverage through the selected foci is not available digitally, but the relevant records exist at country level. It is recommended that national co-ordinators provide this information using a format developed during this OCP operational research meeting (see para 61). Ivermectin impact analysis group (IIAG) Most of the analysis will be undertaken by the Dept. of Public Health of the Erasmus University of Rotterdam. A joint OCP/Erasmus/TDR group has been created that will provide guidance and support to the analysis. The members of this group are: boatinb@oncho.oms.bfB. Boatin H. Agoua E.S. Alley Y. Bissan J.-M. Hougard N. Nagelkerke D. Som6 Remme catzonest@ho trnail. com soumbe)ralley@oncho. orns.bf yiribab@yahoo.fr .Tean-marc.Ho u gard @mpl. ird. fr nagelkerke@mgz. fg g. eur.nl sorned@oncho.oms.bf remmej@who.int River basins to be included in the analysis of the impact of ivermectin 1) Ivermectin only 6-monthly treatment a. R.Gambia, Mako focus 4-monthly treatment b. R. Corubal, Guinea Bissao c. R. Geba, Guinea Bissao Annual treatment since 1991; (Meso-endemic basins in western extension) d. Faleme e. Bafing. To be analysed as two separate sub basins: 1. Lower Bafing in Mali 2. Upper Bafing in Guinea f. Bakoye (to be analysed both as one basin and as two sub-basins, i.e. low Bakoye in Mali and upper Bakoye in Guinea g Baoule 2. Ivermectin and incomplete vector control Tienfala, hyper/holo-endemic focus in Mali. Since 1994, ground larviciding only. Vector control not very effective during most of transntissiotr season (entomologists to estimate the redLrction in biting rates) h. t -29 - J Bui gorge, hyper-endemic focus, Gl-rana. Limit of focus not clearly defined, contamination from rreighbouring basins may be a problem. Titira/Koupergou focus. Keran basin. Hyper/meso endemic. Vector control failures 3. lvermectin and vector control Vector control and ivermectin distribution in parallel k. Milo/Sankarani basin in Guinea; hyper endemic foci, good link epi and ento points l. Asubende focus, hyperendemic, Ghana Dienkoa (B.Faso) basin added during discussions 4. Recrudescence control m. Bougouriba -30- Annex E2 LIST OF PARTICIPANTS OCP 1- Dr Boakye A. Boatin, OCP Director, Ouagadougou 2- Dr H. Agoua, OCP, Kara, (Chairman) 3- Mr A. Ak6, OCP, Odienn6 4- Dr K.L.B. Akpoboua, OCP, Ouagadougou 5- Dr Y. Bissan, OCP, Ouagadougou 6- IvIr V. K6r6, OCP, Cuagadougou 7- M. S. N'Gadjaga, OCP, Ouagadougou 8- Mr M. Sarr, OCP, Odienn6 9- Dr K. Siam6vi, OCP, Ouagadougou 10- Mr D. Som6, OCP, Ouagadougou 11- Dr E. Soumbey Alley, OCP, Ouagadougou, (Reporter) l2-Dr L. To6, OCP, Ouagadougou 13-Dr L. Yam6ogo, OCP, Ouagadougou, APOC 74-Dr A. S6k6t61i, APOC Director, Ouagadougou AF'RO 15-Dr J.-B. Roungou, OTD/AFRO National Coordinators 16- Dr. G Attiah, Bouak6, C6te d'Ivoire, (Co-reporter) 17-Dr. J.E. Gaba, Cotonou, Benin, (Co-reporter) 18- Dr. S. Sanou, Ouagadougou, Burkina Faso (Co-reporter) 19- Dr. Traor6, Bamako, Mali, ( Co-reporter) Others 20-Dr. Daniel Boakye, NMIMR, Accra, Ghana, (Co-reporter) Zl-Dr. J.-M. Hougard,IRD, France 22-Dr. Nico Nagelkerke, Erasmus University, Rotterdam, Netherlands 23-Dr. J.F. Remme, TDR, Geneva, Switzerland 24-Dr. M. Sylla, Secretary-general of the Ministry of Health, Guinea 25-Prof S. Traor6, IPR, Bouak6 - 3l - Annex E3 PROVISIONAL AGENDA Monday 9.04.2001: 15H-18H, COFFEE BREAK : 16H30 - 16H45 l. Opening of the meeting by the Programme Director, 10 ' 2. Adoption of the provisional agenda: Yameogo, 5 ' 3. Review of the recommendations of last year's meeting: Soumbey, 5 ' 4. Main Points of the Plan of Action of the VCU Unit for 2001-2002: Yameogo, 10 ' 5. Entomological situation in the basins under larviciding: Agoua, Sarr, 15 ' 6. Results of the studies conducted by the national entomologists: Akpoboua, 10 ' 7. Results of the tests on diagnostic tools: To6, 10' 8. Results and planning of entomological research in relation to the cessation of larviciding treatments: Bissan, Boakye, 10' 9. Proposals of concrete actions to improve CDTI: Siam6vi, National Coordinators, 10' 10. Update on research work about lymphatic filariasis and onchocerciasis: Remme, 15 ' 1 1. Mapping of lymphatic filariasis and ivermectin treatment : National Coordinators, 10' 12. Epidemiological results and Plan of Action of the PET Unit for 2001-2002: Soumbey, 10 ' 13. Integrated analysis using ONCHOSIM : Dr. Nagelkerke, 15' 14. Discussion: 30' Tuesday 10.04.2001: 8H-12H and 15H-18H. Coffee breaks of 15 'at 10H and 16H30 15. Group work by groups I and2 on objectives I and 2 15.1. Plenary on the group work at 17H30 Wednesday 11.04.2001: 8H-12H and 15H-18H. Coffee breaks of 15'at 10H and 16H30 16. Continuation of group work by groups 7 and2 on objectives 3 and 4, drafting of the recommendations 8H00 - 12H00 17. Review of the results of the group work in plenary session: 15H 18. Conclusions and Recommendations 20. Closure of the nreeting. a-32- Annex E4 Group 1 TOPICS FOR GROUP DISCUSSIONS Theme I : Analysis of the results of tl-re complernentary entomo-epidemiological studies in the basins of the southern and westem extensions where larviciding treatments will cease in 2001. Review ancl integrated cletrdled analysis of entorno-eptdentiological data. Proposal for appropriate strategies applicable after the cessatiort of lan'iciding treatments (post- lan,icicling stuclies, corttinuation of ivenrtectin treatment, epideniological monitoring / evaluation). Results of the complernentary investigatiotrs in progress in the basins where lanticirling treatments will stop at the end of 200I and planning of activities for the rest of the year. Analysis of entomo-epideniological trends in the basins where control activities will continue in 2002 and even beyond; study of blackflv movenrcnts. Theme 2 : Analysis of the conceptual framework for the integration of the onchocerciasis control residual activities. Review of the conceptual framework for the integration of the residual activities of onchocerciasis control: Proposal of concrete solutions to improve CDTI and schedule of implementation of these actions; planning and effective execution of evaluation or entomo- epidemiological monitoring activities and their integration into national health systems. The iisue of the diagnostic/surveillance tools to be transferred to the countries and schedule for their transfer; the process of the closing/cessation of the activities of the Programme: Will the countries be able to undertake in all quietude onchocerciasis control after 2002? Group 2 Theme 3 : Practical guide for the cessation of ivermectin distribution and implementation of epidemiolo gical monitoring or complementary studies. Review of existtng data on ivermectin treatment in the various basins (beginning of the distribution, number of treatments carried out, therapeutic and geographical coverage rates, epidemiological data); Results of the studies on the intpact of ivermectin on transmiision,. Mapping of lymphatic filariasis and implication for onchocerciasis control; Analysis of the predicti.ons of the ONCHOSIM epidemiological model; proposal of a schedule for ivermectin treatments after 2002 and of guidelines for the cessation of these treatments. Theme 4 : Certification of the elimination of onchocerciasis in the OCP area. Valirlation of the ntodel for the I2 years of combined control through larviciding/iverntectin treatnrclt; reconunenfl actions to be taken after 2002 in the OCP cotrntries; the special stuclies ancl specific et,aluations necessary to certtfy the elinination of onchocerciusis: Detailerl anah,sis of OCP data on the long-term intpact of i'ennectin treatntent on trarts2tission and the resenoir of the pctrasite, prediction of thefeusibilitl'of elintinatiort / eratl iccttiort tuitlt ivennectut alone. - -)J - Annex E5. FIGURES Fig. 1 :Basins under larviciding in 2000 -2001 Fig.2: VCU Plan of operations for 2002 Fig. 3a : Annual. Transmission Potentials (O. r,olvulus) in the basins under larviciding in the OCP. Jan.-Dec.2000 Fig. 3b : Annual Transmission Potentials (O. volvulus, savanna species) in the basins under larviciding in the OCP, Jan.-Dec. 2000 Fig. 4 : Seasonal migration of Sinruliunt damnosum S.1. populations Fig. 5 : Ivermectin treatmentin2000-2001 in the OCP area Fig. 6a : Mapping of Lymphatic Filariasis in Benin, Burkina Faso, Ghana and Togo (Provisional results) Fig. 6b : Plan for Ivermectin + Albendazole distribution in the lymphatic filariasis endemic areas in Burkina Faso Fig. 7 : Epidemiological results of villages evaluated between 1998-2000 Fig. 8 : Upper Sassandra, C6te d'Ivote:1999-2000 Fig. 9a : Lake Volta East (Ghana) and Mono (Togo) : 1998-2000 Fig. 9b : Epidemiological trend in villages evaluated in Mono basin in Togo Fig. 10a : Sankarani, Kourai, Dion (Guinea) : 1998-2000 Fig. 10b : Epidemiological trend in villages evaluated in Sankarani basin in Guinea Fig. 11a : Milo, Dion in Guinea : 1998-2000 Fig. 11b : Epidemiological trend in villages evaluated in Milo basin in Guinea 1A Fig. I : Basins under larviciding in 2000-2001 I < ,;.' [:J:J,xi.i#" tl.'ffi:TJ:ff:fff::i." - Presenl OCP bourdary (ong'nal, weslem, sodhem and forest oncho exlenson bouMary) Lrmile actuelle OCP (arre m(€le, extensrcns ouest. sud et onchocer@se de forCt) - -- Ongrnal Prcgramme area boundary / Llm(e alre lnnrale weslem am sounem \ Fig. 2 : VCU Plan of operations for 2002 Rrver treated Rrvrere ra(6e Ground vedor @drcl Lune anlrvedonelle au so - Present OCP boundary (oogrnal, weslem, southem and foresl oncho exlenson boundary) Lrm[e actuelle OCP (arre rnilrale, exlensDns ouesl, sud el onchocer@se de fordl) Oflgrnal Prcgramme area bundary / Ltmie atre rn[lale Western aod southern extenson area boundary / Lrmie des exlensons ouest el sud t It -3-s- Fig. 3a : Annual Transmission Potentials (O.volvuftzs) in the basins under larviciding in the OCP, Jan.-Dec. 2000 sd.t mb,@s. & lq€o JAN. . OEC. 2m qEhd &€r-m -.ahd-y / umil. ar. rdrd. Espees du @mplcxe srmuhum dammsum rfiledacs par onclo@rca wlvulus- Smutrum dammsum @mplex sFc€s mfedcd w(h Oncfuere rclvulus W.sldn d sk.xt6s6 i.aMay/ U@1. &s.xldsrss Mst.l sd 1G199 2@399 4@7S >8m <1mo o o o O P..s.nl @P M-y (rynd sslsn, s@th d rq.sl d.idstr tudry) unl. &t6lc @P (arc nilrd.,.xldsr6s Msl, POTENTIELS ANNUELS DE TRANSMISSION ANNUAL TRANSMISSION POTENTNLS Fig. 3b : Annual Transmission Potentials (O.volvulus, savanna species) in the basins under larviciding in the OCP, Jan.-Dec. 2000 Espees savanr@les du @mplere srmutrum damrcsum tnfedees par Oncfuer@ volvulus Srmuhum damnosum @mpler savanna sEc€s rnledcd wnh Oncberca volvulus o o o o o 1@199 2m-3S 4@799 >6@ Wesl.,n a.d soulhe.n eilensron a.a bdily, Lrnr l. des etl.ns ds (usl .l sd G'E.J Pr€.&@ a.a d^day / L'm'1. ar. .nral. <1m Pr.s.nr @P bdry (dErnd w.sl.rn salh.rn ed lor.sl Mctu.tl.ns on bundily) Lrm l. rclcll. OCP (ar. lnilrd. .xl.nsrhs Msl POTENTIELS ANNUELS DE TRANSMISSION ANNUAL TRANSMISSION POTENTIALS JAN .DEC 2MO -36- Fig. 4 : Seasonal mrgratlon of Simuliunr donnosunt S.l. populatrons Beginning of the rainy season (Reactivation and recolonization of savanna breeding sites by blackfly populations moving northwards with the ITF) Beginning of the dry season Reverse migration of blackfly populations blown by the harmattan Fig.5 : Ivermectin treatment in 2000-2001 in the OCP areas ttz--n^-* r= h'b.€rErd - dP hnd,ry(4rn.l ssi.m dm.6.nd lo..t oncho.r'dbn bund.ry) Lmb Oe (.tr. n$.1. .rl..tDns oEsl rld .t6ch6.r.G.d. rodo h'..lPqr.'lre.G.tud.ry rL'mr..il.'n,u.r. orE,n.l..d *.sl..n.nd loulh Ldr..r. nt.1..l.rl.ns ds ou.3t.rsud /T- -31 - v a _fl____ Faso, 1 1 o Ghana and T, results lning of Lymphatrc F Prevalence of infection (rcr) % 2004 1O 2003 Fig. 6b : Plan for Ivermectin + Albendazole distribution in the lymphatic filariasis endemic areas in Burkina Faso I a-2 1 .*: 38 Fig.7 : Eprdemrological results of villages evaluated between 1998-2000 oo o 0r s O srls o 15 1,S O e1s a{ !^ tuEd..! - ocP bunday {onornd, wsldn, s@lkn hdlq.torch.rt.nsDn Lmil. @P (r. hilrd., .xl.nslons o@st, sd .l ft&d@s. & rd€l) ------ Og'6i ftqrmm d.a tMq/ Udl. ar. rn[d. qrgrnd d @stdn d sffin.xl6srn t.6 Udty Um(. ar. hil,d..l .xt.nsrG Mst.t sd - Nah6d dd4r.s / Frn[e..s 6 3 \ MOAKO 2, SAMALA OROSSIA 2 0 ORIDJIDOU VAHOUDOU TOURESSO II U 0 o VIALADOUGOU BOUNTOU NGORONOOUGOU Excellent results, no new case Need to rernforce the ongotng tvermecltn trealment Fig. 8 : Upper Sassandra, COte d 'Ivoire :1999-2000 PREVALENCE Oo O o1-s o 5 1,15 O ls 1-30 o 30 1-60 a' m 0 -39 - Fig. 9a : Lake Volta East (Ghana), Mono and Sio (Togo) : 1998 - 2000 o #tMOAHolG ffi O a,1: 0 PREVALENCE(J0 O or-s o 51-1s o 15 r-e oxr-@ a' & o 2 *"h ABd@{G 2A ETI@E I Fig. 9b : Epidemiological trends in villages evaluated in Mono and Sio basins in Togo t00 E E Jlo =o s ! L 20 t 4 t t4E-T@UGts____a)SV\N-@TNN Epidemiological trend in Mono and Sio basins (Togo) !75 l!5 1!!5 2000 2005t!40 Year c ,ll 106 5 0 40 Fig. 10a:Sankarani, Kourai, Dion (Guinea) : 1998-2000 C PREVALENCE Oo O o1-s o 51'15 o 15 1-I o s1-e o'@ I I I a cC d'** o, Fig. 10b : Epidemiological trends in villages evaluated in Sankarani and Dion basins in Guinea Epidemiological trend in Sankarani and Dion basins (Guinea) too i Jao =o ! c 20 t 4 t a NNN 120 1!!a 1!!6 2002 20oattaa t!10 !!t2 1!!l1 !!a Year o 0 o 2000 -41 - Fig. l la : Milo, Dion in Guinea : 1998-2000 i"^*-g"*.*^ PREVALENCE Oo O o1,s o s115 o rsr-r o r1,e a'@ C c "GlT;i* I(NrE(O d^*' 5 2 o Fig. 11b : Epidemiological trends in villages evaluated in Milo basin in Guinea i0o I JaoE =o 640 ca0 ! d 20 f t a ,\ r\ :-a\ t-'\ a\ a\ N r\-\N Epidemiological trend in Milo basin (Guinea) 1aa2 t20 ltaa 1tto 1lla ilta r!!, 2000 2007 2ooa Year o t!aa t 0 3 UE