The World Health Organization : year 2002 progress report : 1st September 2001 - 31 August 2002

tJOINT ACTION FORT]M Office of the Chairman ( JAF-FAC: EIGHTH SESSION Ouagadougou, December, 2002 FORI.'M D'ACTION COMMI.]NE Bureau du Pr6sident JAF 8.4 ORIGINAL: ENGLISH August 2002 t African Programme for Onchocerciasis Control Programme africain de lutte contre I'onchocercose The World Health Organization Year 2002 Progress Report: lst September 2001- 31 August 2002 I 0 a,q\* t 7 P* il:I t. GT JAF 8.4 Page a AAK\tOWI^tuqNENl We would like to sincerely thank all the APOC partners for their tireless efforts in the period under reporting. This report could only paftially document their countless contributions and achievement. t JAF 8.4 Page i TABLE OF CONTENTS LIST OF TABLES, FTGURES AND APPENDIXES Iu lv I. SUMMARY..... 2. INTRODUCTION..... 3. ACTIVITIES OF THE NATIONAL ONCHOCERCHIASIS TASK FORCES AND COMMUNITIES........ 3.I COTXTNYPROFILESOFCDTI IMPLEMENTATION 3.1.1 CAMEROON 3.].2 CENTRAL AFRICAN REPUBLIC 3.1.3 CH4D........ 3.1.4 CONGOBRAZZAVILLE.............. 3.T.5 DEMOCRATIC REPUBLIC OF CONGO 3.1.6 EQUATONAL GUINEA 3.1.7 ETHIOPIA. ......... 10 3.1.8 GABON...... ........- t 1 i.l.g LIBENA .--.......... 12 3.1.10 MAI-4W1............... ................. Is 3.1.1I NIGENA -.--....-.-. 14 3.1.12 SUDAN...... ......... t5 3.1.13 TANZANIA ...-...-. 17 3.1.14 UGANDA... ........ 18 3 .Z Sre,rus oF TvERMECTTN TREATMENT rN APOC couNTzuES rN 200 t : Suuu,q.nv ........ 19 3.3 IEC aNo ADVOCACY BY NATIONAL ONCuOCpncIASIS TASK FORCeS...... ................20 3.4 ComunrNrrv Sslr-MoNlroRING (CSM) """""20 3.5 It,orpBNoeNT MoNIToRING oF PRoJECTS........'...... """"""'21 3.6 OppnantoNAlRESEARCu (OR) PRoPosArs. """""""""""'21 3.7 Dnuc sHIPMENT AND sroRAG8................. """"22 4. ACTTVITIES OF THE TECHNICAL CONSULTATM COMN{ITTEE (TCC) - 23 4.1 MBNaSBRSHP oF TCC ....."."..."""'23 4.2 Rols aNo FlwcrroN oE TCC..-... """""""""" 23 4.3 HtCULtCnTS Or TCC ACHIEVEIVGNTS ......--...... """""""""'23 4.3.1 Mission to Ondo and Niger States....-.-.. """"""""""' 23 4.3.2 Mission to Littoral II Provincial, Cameroor' """"""""' """"' 23 4.3.3 Country Studies on cost per treatment estimates for ivennectin. ....-.... -- 23 4.3.4 DeJinition of ATO and UTG and other indices """""' 24 5. ACTIVITIES OF THE MANAGEMENT OF APOC 24 5.1 EVATUETION OF SUSTAINABILITY OF CDTI PROJECTS ,........24 5.2 Srerus oF FINANCING FIRST, SECOND, THIRD, FOURTH AND FIFTH YEAR PROJECTS .25 5.3 FrxeNcnr MaNncBvreNr or CDTI PRoJECTS """"""""""26 5.3.1 Auditing..... """"' 26 5.3.2 Submission offinanctal returns to APOCfi'om the projects............................26 5.3.3 Capacity building..--- """ " ' 26 5.3.4 Maior achievemenls................ """"""" ' 26 5.4 tN-COUXrrX.v CAPACIry BUILDING: OVERVIEW """"""""""26 5.5 MISSIoNs, CouvrRv suPPoRT vISITS AND sPECIAL vISITS """"""""""'21 5.5.1 Missions..... """"' 27 1 3 4 4 4 5 6 7 8 9 JAF 8.4 Page ii 5.5.1.1 Mission to the African Development Bank (ADB)...-.... .-..-.---.--27 5.5.1.2 Mission to donor countries.... .....-......--27 5.5.1.3 Mission to Southern Sudan .-.-.-.-----.....27 5.5.1.4 Mission to Democratic Republic of Congo (DRC) ...................28 5.5.2 Support visits/missions by Management staff : overview (Table 5) . ....... .... .. 28 5.5.3 Support vistts by Temporary Advtsors and Consultants ..........'...'...'.""'....""' 29 5.5.4 Special visits by APOC Managemenl.................. ...-....29 5.6 MAJoRMEETINGS AND woRKSHoPS........... .......29 5.6.1 Statutory meetings..... .........-.. 29 5.6.2 Meeting on sustainability and country p\an................. -.-...-.......... 30 5.6.3 Review meeting on vector elimination activities in APOC countries............... 30 5.6.4 Mectizan Expert Committee meeting-.-... .......-.. . ....... 30 5.6.5 Eradicabiltty meeting...... ""' 30 5.6.6 NGDO Coordination meeting """"""""' 30 5.6.7 Meeting on moxidectin................ ...'...""' 30 5.6.8 2nd APOC NOTFs Representatives' meeting in Ntgeria, l7-22 June, 2002 ... 3l 5.7 Sprcrer Pnocnernnre AcTTvITIES .........-.-....... 31 5.7.1 Publication of APOC activittes as special supplement in the Annals of Troptcal Medicine and Parasitologt......... """"' 31 5.7.2 Mission to Koma Hitts in Nigeria """""' 32 5.7.3 Validatton of rapid monitoring of treatment coverage """"""""' 32 6. VECTOR ELIMINATION ACTTYTTIES............ 6.1 ITweRe.ANDMPAMBA-NKUSIFocI, UGANDA... 6.2 Btoro IsLAND, Equeronrar Gunrpe 6.3 Turtm-iFocus,TelzeNn 6.4 NrnseNcp oF BLAcK FLIES........... 32 1. RAPID EPIDEMIOLOGICAL MAPPING OF ONCHOCERCIASIS (REI\{O) AND GEOGRAPHIC INFORMATION SYSTEM (GIS)......... ............-.........3s 1.1 Sra.rus oF REMO/GIS rN APOC couNrzuEs """""""""" 35 7.1.t REMO in Angola """""""" 35 7.1.2 REMO in Burundi.. """""""' 36 7.1.3 REMO in Democratic Republic of Congo-... """"""" 36 7.1.4 REMotnEthiopia. " """"'38 7.1.5 kEA and population census in Bioko Island, Equatorial Guinea . .... .. ...---.. 38 7.2 IITapI-eTuTgNTe.TioN oF CDTI IN oNCHOCERCIASIS AND LOAISIS CO-ENDEMIC AR-EAS . 38 8. O\tsRVIEW OF COLLABORATION WITH OTHER WHO GROUPS AND THE WORLD BANK....... ....39 32 J5 34 34 8.1 Cot-lelonerloN wITH WHO/OCP 8.2 CoLre-eoRAtION wITH WHO/AFRO INCLLIDING ITS CoUNTRY oFFICES--..... 8.3 Cot-Le..BoRArIoN wrrH WHO/FIQ 8.4 COTLAEORATIONWITHWHO/TDR: OPE,RATIONALRESE,ARCH 8.5 CoNrzusu-tloNOFWHO/AFRO................ 8.6 Cor-Le,soRATION yITH W6RLD BANK (WB) ONcUOCERCIASIS UNtr.......... 9. CONTRIBUTION OF THE NON-GOVERNMENTAL DBVELOPMENT oRGANIZATIONS (NGDOS) COORDINATION GROUP 39 40 40 40 40 4l 4t 10. EXTERNAL AUDIT.. .................42 ......43 TABLES Table t : Operations research status in APOC countries.....""""""" Table 2 : lvermectin tablets (3 mg equivalent) shipped by Mectizan Donation Programme 2000 and 2001 Table 3 : lndicators of sustainability................... Table 4 Capacity building in 2001 Table 5 : Country support visits/missions by APOC Management'.""" Table 6 : Country support visits by temporary advisors Table 7 : Cost (US $) of Invara (Feb. 1999 - Aug.200 I ) and Mpamba- elimination activities Table 1t NGDO Partners in onchocerciasis Control in APOC countries """"""' FIGURES JAF 8.4 Page iii .............25 Nkusi(May Iil -';;..zooij;;;; .....28 29 .27 33 34Table 8 : Cost (US $) of Bioko vector Elimination activities (March 1999 - February 2002) -.... Table 9 : Cost of Tukuy,u vector elimination activities (October 1998 - September 2002) ........ Table l0 : Status of REMO/GIS in APOC countries........ ..............3 5 ..............4 I Figure I Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Figure 7 Figure 8 Figure 9 Figure l0 Figure I I Figure l2 Figure 13 Figure l4 Figure 15 Figure 16 Figure 17 Figure l8 Figure 19 Figure 20 Figure 21 Figxe22 Figure 23 Figure 24 Figure 25 Figure 26 Figure 27 Figure 28 Figure 29 Trend of the therapeutic coverage from 1996 to 200 I , Cameroon Geognphical coverage in 2000 and 2001, Cameroon Therapeutic and geographical coverage in 2000 and 2001 , CAR - --- Trendoftherapeutic coverage from 1998 to 2001, Chad Trend of geographical coverage from I 998 to 200 I , Chad 2001 therapeutic and geographical coverage, Congo Therapeutic and geographical coverage in 2000 and 2001, Kasar/D'R Congo Therapeutic and geographical coverage in 2000 and 200 I , Equatorial Guinea 2001 therapeutic and geographical coverage, Ethiopia Therapeutic and geographical coverage in 2000 and 200 I , Gabon Therapeutic and geographical coverage for 2000 and 200 I , Liberia - Trend of therapeutic coverage from 1996 to 2001, Malawi Trend oftherapeutic coverage from 1996 to 2001, Nigeria Trend oftherapeutic coverage from 1998 to 2001, Northem Sudan - - 16 Geographical coverage for 2000 and 2001 , Northern Sudan ---- I 6 Therapeutic and geographical coverage for 2000 and 2001, Southern Sudan _ __ 16 Trend oftherapeutic coverage from 1996 to 2001, Tanzania - 11 Geogaphical coverage for 2000 and 200 1, Tatuania ----_ 11 Trend oftherapeutic coverage from 1996 to 2001, Uganda ___- 18 Geographical coverage for 2000 and 2001, Ug*du 18 4 4 5 6 6 7 8 9 10 ll t2 13 t4 Geographical coverage in 2001 in APOC countries Therapeutic coverage in 2001 in APOC countries Iverrnectin tables (3 mg equiv.) shipped in APOC r9 19 Programme area from 1988 to 2001 __22 Provisional REMO map and CDTI areas of Angola Provisional REMO map and CDTI areas of Burundi REMO results in D.R. Congo as at June 2002 -- Provisional CDTI areas of D.R. Congo Provisional REMO map and CDTI areas of Ethiopia SPOT Vegetation model applied to the region Summary of geographical coverage in 2001 in APOC countries Summary of therapeutic coverage in 2001 in APOC countries Summary of training in 2000 and 2001 in APOC countries Summary of Govemments contribution in 2001 rn APOC countnes Projects reviewed by APOC Management _35 36 31 31 38 39 1) 43 44 M 44 A< APPENDIXES Appendix I Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 Main Findings And Recommendations On Evaluated Projects --,-- - JAF 8.4 Page iv ACRONYMS ADB AFRO APOC ATO BASED CBM CC CDD CDTI CHAL ComDT CSA CSM DMO DO GIS GRBP GTZ HIS HKI HMIS HNI HSA IDP IEC IEF IFESH IMA JAF KAP LA LF LGA MDP MEC African Development Bank African Regional Office (WHO Regional Office for Africa) African Programme for Onchocerciasis Control Annual Treatment Objective Bahai Agency for Social Economic Development Christoffel-Blindenmission (German NGO) Carter Center (The Carter Presidential Center) Community-Directed D istributor Communiry-Directed Treatment with Ivermectin Christian Health Association of Liberia Community-Directed Treatment Committee of Sponsoring Agencies (OCP and APOC sponsors which include representatives of IINDP, FAO, The World Bank, WHO, the NGDO Group and Merck & Co. Inc.) Communiry Self Monitoring District Medical Offi cer Dermal Onchocerciasis (see OD, OSD) Geographic Information System Global 2000 River Blindness Prograrn (Carter Center) German Technical Cooperation (German research support agency) Health Information System Helen Keller International (US NGO) Health Management Information System HealthNet International Health Survei llance Assistants Ivermectin Delivery Program Information, Education, Communication International Eye Foundation (US NGO) International Foundation for Education and Self-Help Interchurch Medical Assistance (US NGO) Joint Action Forum (APOC participant body) Knowledge, Attitude, Practice Letter of Agreement Lymphatic Filariasis Local Government Area MectizanrN{ Donation Program MectizanrM Expert Commrttee MIS MITOSATH MoH MSD MZ NDS NGDO NGO NOCP NOTF OCP OPC OSD OV PHC REA REMO SAE SB SNNPR SRRA SSI SSOTF TCC TDR JAF 8.4 Page v Management of Information System Mission To Save The Hopeless Ministry of Health Merck Sharp & Dohme MectizanrM (ivermectin, MSD) National Drug Service Non-Governmental Development Organization (see NGO) Non-Governmental Organization (see NGDO) National Onchocerciasis Control program National Onchocerciasis Task Force Onchocerciasis Conhol Programme in West Africa Organisation pour la Pr6vention de la Cecit6 (French NGO) Onchocercal Skin Disease (see OD, DO) Onchocerca volvulus Primary Health Care Rapid Epidemiological Assessment Rapid Epidemiological Mapping of Onchocerciasis Serious Adverse Event SmithKline Beecham (pharmaceuticals producer) South Nations Nationalities and people Region Sudan Relief and Rehabilitation Association Sight Savers Intemational (British NGO) Southern Sector Onchocerciasis Task Force Technical Consulrative Committee (APOC scientific advisory group) Special Programme for Research and rraining in Tropical Diseases (part of cRD, a department of CDS, WHO) United Nations Children's Fund Agency for International Development (United States agency) Vector Control World Bank (The World Bank) World Health Organization see AFRO World Health Organization's Head euarters see OCP see TDR WHO Representative (country-specific) LINICEF USAID VC WB wHo WHO/AFRO wHo/HQ WHO/OCP WHO/TDR WR JAF 8.4 Page I 1. SUMMARY In 2001 the APOC partnership comprising of the endemic communities, National Onchocerciasis Task Forces (NOTFs), the NGDO Coordination Group, the Technical Consultative Committee (TCC), the Committee of Sponsoring Agencies (CSA), Merck & Co., and its Mectizan Donation programme have made a number of achievements here summarized below: (i.) Over fifty four thousand (53,646) communities were treated by CDTI method. A total of 16,235 Health workers and 125,249 CDDs were trained respectively to form the main workforce implementing CDTI. (ii.) More than 24 million (24,443,955) persons were treated with ivermectin compared to the overall Annual Treatment Objective (ATO) of 23,000,000 for all APOC countries. And the number of tablets shipped to member countries was 95,746,500. (iii-) In 200112 a study on the sustainabiliry of CDTI projects was conducted in Malawi, Nigeria, Tanzania and Uganda covering 7 projects in ten (10) geographically distinct areas that aie in their fifth year of APOC funding. The study examined progress made by the CDTI projects towards the sustainability after the withdrawal of ApOC funds. (iv.) At the second meeting of NOTF Representatives in Abuja, Nigeria the key elements of the Evaluations including the methodology, indicators of sustainabiliry, instruments and findings were discussed- Out of the 9 projects assessed 7 were found to be making satisfactory progress while 2 did not have evidence of satisfactory pro$ess in this respect. ThtT projects were asked to make their post-APOC sustainability plans prior to seeking for any furthei APOC support while the 2 were asked to fundamentally redress their position. The meeting agreed on the criteria for determining eligibilily of projects for additional APOC funding und ulro discussed sustainability of projects in conflict areas, and the use of CDTI as vehicle foi other programmes. (v.) h 2001/2 Rapid Epidemiological Mapping of Onchocerciasis (REMO) activiries were undertaken in Ethiopia, Burundi, D.R. Congo and Angola; and the result integrated in the Geographic Information System (GIS). (vi.) Four Vector Elimination projects in Tanzania, Equatorial Guinea and Uganda were approvedduring 1996-2001 and a decision to continue their activities was reiched after critically reviewing their progress at a meeting in Ouagadougou. The nuisance of black flies in D.R. Congo, Congo Brazzaville and Chad is real and requests from participating governments to address this problem are a challenge to ApOC Management. (vii.) As recommended by the Phase II and Phasing out Period Programme Document, the membership of the Technical Consultative Committee (TCC) was increased by appointment of new experts by the Director General of WHO so as to strengthen the capacitv oi thi-comminee. (viii.) The TCC reviewed technical reports and project proposals. The committee undertook technical missions to Nigeria and Cameroon to advise projects on CDTI implementation, defined ATO, UTG and other indices, discussed country studies on cost per treatment and mapping of onchocerciasis in Sowda areas. (ix ) APOC Management has strengthened capacities of project rnanagers in Operational Research. This was done by promoting the training of 22 project managers in research methods, computer applications and intensifying technical support to projects. (x) APOC Management reviewed l4l documents including technical and financial reports, budgets and action plans. Twelve (12) support visits to NOTFs in 8 countries \\,ere made during the reporting period. (xi.) .A' total of 55 Leners of Agreement were processed making a financial commitment of US$ 1,926,389 (Sept 2001 - June 2002). The Finance office has continued with its audir checks so as follorv-up on the proper utilization of APOC Trust funds. Capacity buildrng for good financial management in the CDTI projects has also been undertaken. JAF 8.4 Page2 (xii.) (xiii.) (xiv.) (xv.) Add one additional point about the training of nationals in the field of GIS & Healthmapper(e.g. in DRC). APOC Management participated in joint missions to donors with the Onchocerciasis Unit of the World Bank for resource mobilization. Special program activities have included the production of a special supplement on ApOC published in the Annals of Tropicat Medicine and Parasitologt; a mission io Koma Hills; the validation of a rapid tool for monitoring treatment coverage; and various missions of npOC management staff consultants and temporary advisers. APOC has continued to enjoy good collaboration with WHO/AFRO; WHO/TDR, WHO/OCp, WHO country offices, the Onchocerciasis unit of the World Bank and NGDO coalition in technical support, research and development of strategies to enhance CDTI application, administrative support and funds transfer. The most important challenges to APOC include: . Ensuring the sustainability of all CDTI projects; ' Implementing CDTI in conflict zones and urban areas; ' Achieving high coverage in area co-endemic for loaisis and onchocerciasis. JAF 8.4 Page 3 2. INTRODUCTION Sustainability of CDTI projecls: where are we? In the frrst six years of APOC with the support of donor community, partnerships between communities, Ministries of Health (MoH), NGDOs and civil society have been established at different levels. The different stakeholders have pooled their ideas and resources in planning and executing theCommuniry- Directed Treatment with Ivermectin (CDTI) programme in t+bf the tg epoc countries. During that period it was not clear whether the sustainabiliry of APOC related activiry at all levels within projects and countries will happen, once APOC funding comes to an end since much of the core activity (training, supervision, NOTF meetings etc.) were directly funded from ApOC Trust Funds. The External mid-Term evaluation team was therefore concerned about lack of strategic plan on sustainability of approved projects. In october 2001, APoc Management took a decision that all projects that rvill attain theirfifth year by December of 2002 should be assessed, to find out how sustainable they were. Seven (7)CDTI projects in Nigeria, Uganda, Malawi, and Tanzania are in this category. The piojects are locatedin 10 geographically separate areas. Evaluations were conducted in 9 of these "."ri."f".."d to in thisreport as "projects". These evaluations were co-funded by APOC and the Onchocerciasis Unit of theWorld Bank with strong logistical support from the NGDO coalition, WHO country offices andMinistries of Health. The co-ordination of this special activify of the first year of phase Ii and phasing- out Period was assigned to two experts on sustainability and district health management. In Novembe r 2001, the Evaluation team developed a strategic plan of assessing sustainabiliry and which main kust is the full integration of Programme activitieJ into MoH strucruris at all levels, community and MoH ownership of CDTI and treatment coverage among other indicators. Seven (7)projects out of the 9 evaluated were found to be progressing towards sustainability and these were requested to make their Post-APOC sustainability plans. The other 2 that had not made satisfactory progress towards sustainability were to stop receiving APOC Trust funds and were asked to devise corrective strategies that would re-orient their programs towards sustainability. This year's WHO Progress report elaborates on sustainability of CDTI projects and the way forward. (see JAF8,{NF/DOC.3, and section 5.1 of this report). In addition, theieport includes other activities on Vector Elimination, work done by TCC and APOC Management; and coilaboration u,ith NGDOs, WHO/AFRO/HQ, WHO country offices, the Onchocerciasis unit of the \\rorld Bank and other organizations. It also presents profiles of CDTI implementation of each mernber country. Commun'rty Direbted Treatment Wth lvermectin *i- 1I CDTI JAF 8.4 Page 4 3. ACTIVTTIES OF THE NATTONAL ONCHOCERCHIASIS TASK FORCES AND COMMUNITIES 3.1 Country profiles of CDT! implementation 3.1.1 CAMEROON Community-Directed Treatment with Ivermectin (CDTI) The CDTI was launched in Cameroon in October 1998. As of today, 9 CDTI projects are being implemented within a national cost recovery policy. Implementation of cost recoi,ery in CDTI was reviewed at a General Assembly meeting. One of the recommendations was to have i single rate for all the eligible persons. The meeting also recommended that cost recovery funds should b-e managed and supervised frorn district level. It was agreed that32% of the cost recovery llnds rvill go towards the motivation of cDDs. The NGDO partners are: BASED, GRBP, HKr, IEF and SSI. Status of ivermectin treatment: geographic and therapeutic coverage In 200 I , 4,987 communities were treated out of a total of 5,22L The average geographical coverage of 960/oranges between 73%o and 100%. Out of a total population of 2,777,723 reported by the NOTF, 1,387,433 persons were treated giving an average therapeutic coverage of 5OYo *ith u range of 26% to 76%. Management of Serious Adverse Events (SAEs) REA surveys were carried out in some districts at high risk of loaisis to identifo hypo-endemic communities included in CDTI zones. Government and community contributiou For the fiscal year 2001-2002, the Government allocated US$ 135,7 l4 for onchocerciasis equivalent to 95,000,000 FCFA. Communities contribute to the cost recovery fund. Training A total of 7,530 Community-Directed treatment with ivermectin Distributors (CDDs) and 1,703 health workers were trained in 2001. Health workers from referral hospitals were also trained in management of adverse reactions. Main accomplishments The CDTI projects have made progress in developing a SAE Management plan based on feedback from health districts, community members and TCC recommendations. Special IEC meeting was held to identify ways of strengthening CDTI implementation by using IEC to deal with SAEs. Challenges The strategies for management of SAEs need to be strengthened in all the communities at-risk of loaisis. Clinical description of all SAEs needs to be provided to Mectizan Donation programme(MDP) and guidelines need to be srrictly followed. Geographical coverage has not yet reached 100% while therapeutic coyerage remains below the threshold of 65%. Fig. I : Trend of the therapeutic coverage from 1996 to 2001, Cameroon Fig. 2 : Geographical coverage in 2000 and 200 l, Cameroon 100 G80f'*o'-65qo oo20 0 100 G80 [* a o40 oo20 0 Cameroon: Year 2001 figures Total population reported: 2,777,723 Persons treated: 1,387,433 Total Number of communities:5,221 Communities treated: 4,987 CDDs trained 1,530 Health workers trained: 1,703 Commruritics nrobihzed: n<tt rcportcd 3B35 1996 1997 1998 1999 2000 2001 2000 2001 96 JAF 8.4 Page 5 3.1.2 CENTRAL AFRICAN REPUBLIC Community-Directed Treatment with Ivermectin (CDTI) The CDTI was launched in CAR in July 1998 by the Ministry of Health and the NGDO partner Christoffel BlindenMission (CBM). Status of ivermectin treatment: geographic and therapeutic coverage In 2001,4,594 communities were treated out of a totalof 5,014 (geographical coverage of 92%). The project reached a therapeutic coverage of 78% by treating 178,989 persons out of a reported total population of 998,102 people. Notably, the number of persons treated dropped by 18% between 2000 (950,000 persons treated) and 2001 (778,989 persons treated) which may be due to civil unrest. Government and community contribution The Government made a financial contribution of $23,100 in 2001. The Ministry of Health has provided office premises for the NOTF's Secretariat, and has integrated 80% of the contractual staff of the program into the public service. In the reporting period, l0% of the communities motivated the CDDs in cash or kind. Training A total of 4,995 CDDs and 93 I health workers were trained./retrained. Workshops on the integration of the CDTI in the Primary Healthcare have been organized for health personnel in all the regions. Main accomplishments Although there is social instabiliry, the therapeutic coverage remains above l5%o and geographical coverage of over 90%. Challenges The main challenge of this project is social securiry that hampers training and supervision of CDDs resulting in delays in the transmission of treatment results. Ivermectin distribution is also delayed because of movement of populations in search of secure living areas. Fig.3 : Therapeutic and geographical coverage in 2000 and 2001, CAR EI2000 t2001 100 100 ^80E o60o 3340 ot20 0 Therapeutic Coverage (o/o) Geogmphrc Coverage (%) 76 78 C.A.R.: Year 2001 figures Total Population reported : 998,102 Persons heated: 77 8,989 Total number of communities: 5,014 Communities treated: 4,59 4 CDDs hained:4,995 Health workers kained: 93 I Communities mobilized: not reported << CDTI ie an original etrat€qy that openo the door to other health proqrammea such ae vitamin A aupplementation. In fact, the NOCF with the eupport of t)NtCEF ie inLroducinq Lhe dietribuLion of vitamin A to ta the network of CDTI. >> team. - : t- JAF 8.4 Page 6 3.1.3 CHAD Community-Directed Treatment with Ivermectin (CDTI) The APOC Funded CDTI project was launched in January 1998. Africare and "Organisation pour la Pr6vention de la C6cit6" (OPC) are the NGDO partners of the Ministry of Health in CDTI implementation. The cost recovery system is in place in Chad and considered a possible solution to programme sustainability. The contribution of communities to cost recovery fund has yielded US$ I1,995 (equivalent to 8,396,525 FCFA). Status of ivermectin treatment: geographic and therapeutic coverage In 2001, a total of 3,169 communities were treated out of 3,265 (geographical coverage of 97%). The project treated 85l,ll1 persons out ofa reported total population of 1,506,575 people (therapeutic coverage of 56%). A review of therapeutic coverage based on a denominator of total population is shown in figure 4 below. This is lower than treatment coverage rates provided previously which were based on eligible population. Therapeutic coverage has not yet reached satisfactory level. Geographical coverage is progressing satisfactorily although still under 100yo. Training A total of 2,881 CDDs and287 health workers were trained in 2001. Main accomplishment A geographical coverage ofover 95% has been reached in 2001 Challenges This project entering in its fifth year and yet it has not reached the required geographic of 100% and the threshold therapeutic coverage of 650/o, mainly due to unsatisfactory performance of the NOTF secretariat resulting in poor collaboration belween NOTF partners. There is also high CDDs attrition probably due to better employment opportunities existing in the oil- bearing sites. Fig.4 : Trend oftherapeutic coverage from 1998 to 2001, Chad Fig. 5 : Trend ofgeographical co\/erage from 1998 to 2001, Chad 100 ^80 iooo oo20 0 1998 1999 2000 2001 100 90 80 Szo a tU$so940 330 20 10 0 1998 1999 2000 2001 Chad: Year 2001 figures Total population reported: 1,506,575 Persons treated: 85 1,1 1 I Total number of communities: 3,265 Communities treated: 3, 169 CDDs trained: 2,881 Health workers trained: 287 Comrnunitics mobilized: nol reported o7 co -.{,.@F .. ., ._. '. : '- - .,_' i'.".':-?:'i":''li trF a\ . l:--*r .: I :'--Y -' -L--# JAF 8.4 Page 7 3.I.4 CONGO BRAZZAVILLE Community-Directed Treatment with lvermectin (CDTI) The APOC Funded CDTI project was launched in January 2001. The NGDO partner involved in CDTI activities with the Ministry of Health is OPC (Organisation pour la Pr6vention de la C6cit6). Status of ivermectin treatment: geographic and therapeutic coverage For its first year (2001) of implementation,423 communities out of the 593 in the project area were mobilized, they collected ivermectin and were treated; this represents 100% of the Annual Treatment Objective. The CDTI project of Congo has treated 228,361 persons out of a total population of 404,324 people (therapeutic coverage of 56%). Government and community contribution The Govemment released US$ 40,000 for onchocerciasis activities for the fiscal year 2001. Training A total of 1,109 CDDs and 9l health workers were trained to implement ivermectin distribution in the urban and rural areas ofBrazzaville. Main accomplishments The partners have succeeded establishing a viable CDTI delivery system in urban area (Brazzaville). Challenges The major challenge the NOTF is facing is extension of CDTI to rural area because of civil unrest. Loaisis is co-endemic with onchocerciasis in some CDTI areas. To overcome this challenge, the NOTF in collaboration with APOC management and TDR will determine the prevalence of loaisis prior to mass distribution in the affected zones. Fig.6 : 2001 therapeutic and geographical coverage, Congo 56 t00 90 80 x" s6o UI ,t 50 a,l<o o0:o 20 D o Therapcutrc Cryeraqe(q0 Geographrc Coverag€ (es Congo Brazzaville: Year 200 1 figures Total population reported : 404,324 Persons treated: 228361 Total number of communities: 593 Communities treated: 423 CDDs trained: 1,109 Health workers trained: 9l Communities mobilized: 423 JAF 8.4 Page 8 3.I.5 DEMOCRATIC REPUBLIC OF CONGO Community-Directed Treatment with lvermectin (CDTI) The first CDTI project (Kasai) was launched in April 2000 and the second (U6l6s) in December 2001 The NGDO partner involved in CDTI activities with the Ministry of Health is CBM. Status of ivermectin treatment: geographic and therapeutic coverage In 2001, the projects of Kasai and Ueles treated 1,823 communities out of a total of 3,900 communities. The mean geographical coverage of 31.32% ranging from 18.50% (Uel6s) to 56.13%o (Kasai). The two projects treated in 2001 665,763 persons out of a combined total population of 2,421,383 people (mean treatment coverage of 26.13%). Kasai CDTI project reached in 2001 a therapeutic coverage of 28.72% by treating 530,813 persons out a total population of 1,848,123 people. U6l6s CDTI project treated 134,950 persons out of 573,260 people (therapeutic coyerage of 23.54%). Government and community contribution The Government contribution for the f,rscal year 2001 is US$ 16,430. Training A total of 8,066 CDDs and 830 health workers were trained in 2001 (Kasai). Main accomplishments Nation-wide Rapid Epidemiological Mapping of Onchocerciasis (REMO) is about to be completed despite civil unrest. The strong commitment of the Ministry of Health to CDTI has enabled submission of 4 project proposals which were approved between 2001 and March 2002. Challenges The phased implernentation of REMO exercise due to civil strife is consequentll' delaying CDTI activities. Low therapeutic and geographical coverage are due to limited access of CDTI areas leaving out communities and population in need of treatment. There is delayed ivermectin delivery to peripheral health structures and communities due to civil un-rest. Temporarily solutions used by the NOTF and the country WHO office is to channel ivermectin tablets tfuough United Nations securiry system in D.R. Congo. Population movements in search of more secure areas lead to under reporting of trealment results. The NOTF has planned to submit for approval, 12 additional CDTI proposals behveen September 2002 and September 2003. This is a big challenge for all the partners of the MOH in DRC. Fig. 7 : Therapeutic and geographical coverage in 2000 and 2001, Kasa'r/D.R.Congo tr2000 12001 100 56 ^80 iooo 940 ou20 u It: l.=E D.R. Congo: Year 2001 figures Total population reported: 2,421,383 Persons treated: 665,7 63 Total number of communities: 3,900 Communities heated: 1,823 CDDs trained: 8,066 Health workers trained: 830 Communitics mobilized: not reported0 Therapeutic Covemge (%) Geographrc Coverage (91,) JAF 8.4 Page9 3.I.6 EOUATOzuAL GUINEA Community-Directed Treatment with Ivermectin (CDTI) The CDTI project was launched in December 1998. The partner involved in CDTI activities with the Ministry of Health is the Universiry of Barcelona. Bioko Island CDTI project is a reorientation of a vertical ivermectin diskibution programme which was initiated in r988. Status of ivermectin treatment: geographic and therapeutic coverage The number of persons to be treated in the fifth year of project is 85,000. Because of insufficient demographic and treatment data, the Management of APOC commissioned a Rapid Epidemiological Assessment (REA) study combined with a census of all CDTI communities. This was done in order to have update data on the prevalence ofonchocerciasis and the total population to be treated in a context of high population movement from rural to urban areas in search of better opportunities since the discovery of oil. Unforturnately the exercise was conducted only in the rural areas excluding the city of Malabo previously reported as hyper endemic for onchocerciasis. As a result, this census exercise shows a total population of slightly over 16,000 persons, which is far from the 85,000 persons the project has initially planned to treat. The coverage data shown in Fig.S below is based on reporred total population of only 16 241 persons. Challenges Poor involvement of the NOTF in managing CDTI activities leading to a lack of reliable data. Ivermectin distribution seems to be carried out on a vertical approach by mobile teams. Fie. 8 : Therapeutic and geographical coverage in 2000 and 2001, Equatorial Guinea EI2000 12001 100 90 80 s70 ;606_-c 5{)i*3so 20 .10 0 -ta. 75 66 r:.r I flI --- -- t Therapeutic Coverage (%) Geographic Coverage (%) Equatorial Guinea: Year 2001 figures Total population reported: 16,241 Persons teated: 10,672 Total number of communities: 9t Communities treated: 68 CDDs trained:42 Health workers trained: l8 Communities mobilized: not reported JAI'8.4 Page 10 3.1.7 ETHIOPIA Community-Directed Treatment with Ivermectin (CDTI) APOC supports three CDTI projects in Ethiopia. In 2000, the first project was launched in Kaffa and Sheka zones of South Nations Nationalities and Peoples Region (SNNPR); ivermectin distribution began in 2001. During the reporting period, two new CDTI projects - in North Gondar and Benji-Maji- areas were approved but distribution of ivermectin has not yet begun. Meanwhile, the respective roles and responsibilities of MoH (Central, regional, Sub-regions, Woredas), NGDO, WHO and the communities have been defined by the partners in the three project areas. After the launching of CDTI, Kaffa and Sheka zone was split into two independent zones- Kaffa and Sheka resulting in a significant change in the number of villages - the new figures will be reported as from year 2003. The NGDO partner is Global 2000. Status of ivermectin treatment: geographic and therapeutic coverage in Kaffa and Sheka zones In the first year of keatment, 2001 , 233,309 persons were treated out of a total population on 306,088, leading to a therapeutic coverage of 76%o. The geographical coverage of this area is 100% (500 communities). In Kaffa and Sheka zones drug procurement and delivery system was effective. Out of 652,220 Mectizan tablets received, CDDs distributed 618,366 (95%) tablets; 3,078 (0.5%) tablets were wasted and30,776 (4.5%) tablets were left over. Management of Serious Adverse Events (SAEs) In 2001, there were 3 SAE reports of individuals who presented with gastrointestinal complaints after receiving Mectizan. Following these, NOTF/Ethiopia with financial support from APOC undertook rapid assessment of communities for loaisis. The result of the exercise will be used to strengthen the management of side effects in CDTI areas. Training In 2001,934 CDDs, 183 health workers and 205 school teachers were trained in CDTI but 63 CDDs left the program. Main accomplishments The Kaffa-Sheka project achieved 100% geographical coverage in the first year of CDTI. The community stnrcture lends itself well to the application of CDTI approach. The decentralizations of power decisions in the Ministry of Health makes the regional bureau directly responsible for supervising projects. Reports on SAEs were made available to MDP. NOTF undertook a resensitization of communities on side effects following cases of SAEs. Challenges No NGDO partner to support new projects e.g. in Pawi area. Tracking absentees and defaulters. CDD attrition is high. Fig.9 : 2001 therapeutic and geographical coverage, Ethiopia 100 100 80 si- ooo6 940 oo 20 76IIIH KAFFA AND SHEKA: Year 2001 figures: Total population reported: 306,088 Persons treated: 233,309 Total number of communities: 50C Communities treated'. 5 0 0 CDDs trained: 934 Ilealth workers rrained: 183 Communities mobilized: 500 0 Therapeutic Coverage (%) GeograPhic Cove€Ee (%) JAF 8.4 Page I I 3.I.8 GABON The APOC Funded project for ivermectin distribution was launched in September 1999. The distribution is not based on CDTI approach. Mobile teams distribute ivermectin. The NGDO partner is OPC. Status of ivermectin treatment: geographic and therapeutic coverage Onchocerciasis is hypo endemic countrywide. However, REMO has revealed I8 mesoftryper endemic communities which are receiving treatment by clinic-based approach. The total population of these l8 villages is 7,904. In 2001, 4,228 people were treated giving 53% therapeutic coverage. Training In 2001, ll health personnel were trained in hypo endemic zone for treatment of onchocerciasis patients. Challenges The main challenge is to attain a therapeutic coverage of 65% or above as long as onchocerciasis prevalence rate remains high in the l8 villages concerned. There is need to maintain a compliance to taking ivermectin in the t8 communities for 12-15 years by motivated health workers. Fig. l0 : Therapeutic and geographical coverage in 2000 and 200 1, Gabon 82000 I2001 100 100 C*ogephrc Coverage (o/o ) 100 G' 80 Euo @bao oo20 0 TheEpeutc CoveGge (%) GABON: Year 2001 figures Total population reported'. 7 ,904 Persons treated: 4,228 Total number of communities: l8 Communities treated: l8 CDDs trained: 0 Health workers trained: 11 Communities mobilized: not reported 63 511 JAF 8.4 Page 12 3.I.9 LIBEzuA Community-Directed Treatment with Ivermectin (CDTI) The first APOC Funded project (Lofa, Bong, Nimba and Montserrado) for ivermectin distribution was launched in February 2000. The NGDO partners are Sight Savers International.(SSl) and Christian Health Association of Liberia (CHAL). In the period under review, two new projects were approved bringing the total to 3 CDTI projects. The newly approved projects will begin distributions in 2003 in 9 of 13 counties in south-eastern and south-western rcgions. Status of ivermectin treatment: geographic and therapeutic coverage The Lofa, Bong, Nimba, Montserrado project covers 26 districts with 2,596 communities of which 1,988 (77%) received treatment in 2001. This represents 7 times the number of communities (2gl) treated in year 2000. Due to civil un-rest, 608 communities could not be reached, horvever, some of the inhabitants in these counties received ivermectin in displaced camps. In the period under review, 497,662 persons were keated out of a total population of 2,083,435. This re resents 5goZ of the Annual Treatment Objective in 2001. Government and community contribution The Government has contributed US$ 12,738 to CDTI implementation. Training In 2001, a total of 5,738 CDDs were trained, a 3 times increment of the number (1,831) trained in 2000. The corresponding number of health workers trained in the same year is 104 compared to 79 trained in 2000. Main accomplishments There is active involvement of communities and local government personnel in CDTI activities and willingness of CDDs to work with little or no incentives. Challenges Devising innovative and safe methods of delivery of ivermectin to communities in conflict hence inaccessible arcas - " we walk about 7-10 hours to reach some of our villages." Coverage remains very low because of civil unrest and high migration. Migration of populations from C6te-d'Ivoire into South-eastern Region and Lofa region is another challenge to national onchocerciasis control program ofLiberia. Fig. l1 : Therapeutic and geographical coverage for 2000 and 2001, Liberia tr2000 r2001 Liberia: Year 2001 figures: Total population reported: 2,083,43 5 Persons keated: 497,662 Total number of communities: 2,596 Communities treated: 1,988 CDDs trained: 5,738 Health workers trained: 104 Communities mobilized: I,988 77 Therapeutrc Coverage (%) Geographrc Coverage (%) objective." 100 G80 l*6-' o40 o o20 0 r 't1 Z1 q - I ,:I - ' CulieA frcm tlOTF Lib.;ria Annual Te,clmical reporL d ZOU: of the local authoritiee, it will be difficult to lf"'ii 3.I.IO MALAWI Community-Directed Treatment rvith Ivermectin (CDTI) Community-Directed Treatment with Ivermectin was launched in Thyolo and Mwanza districts in 1997.In 1999 the project was extended to 5 other districts. CDTI activities started in Mulanje in 2000 and Phalombe in 2001. The NGDO partner of the Ministry of Health is the lnternational Eye Foundation (IEF). Status of ivermectin treatment: geographic and treatment coverage CDTI implementation in 2001 took place in the 4 districts of Thyolo, Mwanza, Mulanje and Phalombe. Whilst geographical coverage rate increased from 80% in 2000 to 83o/o in 200 I , there was adrop in treatment coverage from74%o in 2000 to 57%o in 200 l. The reason for this drop is not readily available. There were minor side effects which were treated by Health Surveillance Assistants (HSAsi. Training In 2001, a total of 1,949 cDDs and 647 health workers were trained/retrained. Government contribution In 2001, whilst the district governments contributed US$ 107,020, national government provided US$ 7,987 making a total of US$ I15,007. Challenges Support to Mulanje and Phalombe districts to complete implemenLation of CDTI in all communities; developing new colrlmunication strategies to improve compliance to long-term treatment and discontinue the downward trend in treatment coverage, improve support of national level govemment to CDTI project. Another major challenge is extension of CDTI to three of the fir,e districti delineated for mass-treatment in 1999. Fig. l2 : Trend of therapeutic coverage from 1996 to 2001, Malawi 100 80 3 ;60o e 8ooo 20 57 57 0 1996 1997 1998 1999 2000 2oo1 Malawi: Year 2001 figures Total population reported: 648,990 Persons treated: 367,298 Total number of communities727 Communities treated: 606 CDDs trained: 1,949 Health workers traned: 647 Communities mobilized: 697 JAF 8.4 Page 14 3.I.I I NIGEzuA Community-Directed Treatment with lvermectin (CDTI) ln Nigeria, about 23 million people are at risk of onchocerciasis in 36 states. Nigeria started CDTI approach in 1997 and has steadily built up to a total of 27 Projects approved and being implemented. However, data is being updated currently. In 200 I, a nation-wide REMO refinement exercise was carried out. Some communities that were covered by mass treatment using CDTI approach have now been dropped because they have been found to be hypo-endemic after the REMO exercise. This has caused a change in the figures provided earlier and verification is on going. The year 2001 is now considered as the base year for improved data. The NGDO partners are SSI, GRBP, HKI, MITOSATH,IFESH, CBM, and UNICEF. Status of ivermectin treatment: geographic and therapeutic coverage The geographical coverage ranges between 59o/o and 100% with an average of 94%o ( I 7 projects out of 25 projects that provided data). The projects reached a therapeutic coverage of 75o/o in 2001 with I 6,586,354 persons treated. Government and communify contribution In 2001 the Federal and State Governments released US$ 30,000 and US$ 99,650 respectively. The LGA gave US$ 42,619 bringing the total to US$ 172,269. This is less than US$ 456,573 of goYemment contribution in 2000. Training In 2001 a total of 56,797 CDDs and 9,835 health workers were trained. Main accomplishments Ar average of 94o/o of the communities had been mobilized and treated, an impressive improvement on previous year's result. Most of the onchocerciasis-affected communities are covered and what needs to be done is to consolidate the achievements in all projects. Several Project managers have been trained and their competence in handling project activities greatly enhanced. Communiry self-monitoring has been launched in 2l states to enhance participation and ownership of CDTI. Challenges Inadequate counterpart funding from government is a challenge to the sustainabiliry of CDTI implementation. Complete in all states verification of census figures to improve the qualily of treatment data. Bureaucratic interference by policy makers in some states in the release of funds for CDTI field activities. Fig. 13 : Trend of therapeutic coverage from 1996 to 2001, Nigeria 100 Nigeria: Year 2001 hgures Total population reported : 22,047,388 Persons treated: I 6,586,354 Total number of communities: 31,369 Communities treated: 22,931 for l8 projects CDDs to be trained: 55,883 CDDs trained:56,797 Number of Health workers trained: 9,835 Communitics mobilized: 30,8 I4 86 7t 80 s -60oo 340 o 20 0 1996 1997 1998 1999 2000 2001 66 64 JAF 8.4 Page I 5 3.I.I2 SUDAN APOC supports two projects - the Northern sector project for areas served by the Federal Ministry of Health and the Southern sector for areas served by NGDOs under the umbrella of Operation Lifeline Sudan in collaboration with Sudan Relief and Rehabilitation Association (SRRA). A national plan for the control of onchocerciasis and CDTI project for Northern sector were approved in 1997. The southern sector project was approved in 1998. The major collaborating partners are Global 2000 and HealthNet International GINI). In 200 l, to improve community involvement in CDTI, a Southem sector onchocerciasis Task Force (SSOTF) was formed and a secretariat for the Southern sector partners in Rumbeck counry is underway. Community-Directed Treatment with Ivermectin (CDTI) ln the reporting period, in Northem and Southern sectors, the partners continued to implement CDTI in areas with severe social constraints; communities in Southern Sudan torn by conflict and hobbled by poverty. Treatment of over 600,000 people was accomplished in 2001 and details are provided in the figures below. Northern sector project In 2001, 80% of Annual Treatment Objective (437,894) was achieved due to intensified activities in Juba area. Census update was carried out by CDDs in all sites. ln 2002, NOTF devised innovative methods of " moving CDTI implementation with the people," set up three treatment camps in Raja for displaced persons. CDDs and supervisors with treatment records distributed ivermectin in the camps, achieving a coverage of 40o/o. Overall therapeutic coverage is 60%. The Ministry of Health has integrated four control programmes- oncho, Guinea worm, LF and Trypanosomiasis. S o uthern secto r p roj ect There are an estimated 640 communities for mass treatment. In 200 l, treatment figures did not meet the expectations due to serious adverse events (SAEs) and withdrawal of some key, implementing NGOs over the "Memorandum of Understanding with the SRRA. More than 55,000 rreatments were delayed or not given resulting in a coverage of 40o/o compared to year 2000 (see figure below). NGOs continue to supervise and monitor the activities. Management of Serious Adverse Events (SAEs) Minor side effects (17,214 cases) occurred in the Northern project. In the southern sector project, cases ofminor and six (6) serious adverse events occurred in 2001. To address these challenges, 34 health workers were trained on management of SAEs in Maridi County where many of the cases occurred. No cases have been reported in2002. Government contribution The contribution of the Government of Sudan for the Northern sector in 200 I is US S 3 3 ,500. Main accomplishments In the northem sector, main accomplishments were: improved treatment coverage; de-emphasizing the demand for incentives by CDDs and active communiry participation in CDTI have been achieved in Abu Hamad. Better management of SAEs in southern sector counties. Challenges: Northern sector Major constraints remain long-standing war and natural disasters. In Abu Hamad Sheraik area there was delayed distribution due to flooding of the Nile River. ln 2002, rhe NOTF undertook reconstruction of the programme in the area. S o ut hern secto r p roj e ct The southern sector project faced numerous challenges rncludrng (i) SAEs related to Mectizan treatment in counties where loaisis and onchocerciasis coexrst; (ii) cases in children of " Nodding disease" and "Nakalanga-like syndrome." Though there is no apparent confirmation that "nodding JAT'8.4 Page l6 disease" is related to Mectizan treatment what effect this drug may have in children with nodding disease remain unresolved. Advised by MDP " people with serious acute or chronic illnesses should not be treated with Mectizan", therefore children with "nodding disease" are excluded from treatment. Children in southem Sudan, in particular in Mvolo, Maridi and Mundri counties are in doublejeopardy faced with blinding onchocerciasis and "nodding disease". Yet, they cannot benefit from Mectizan. Fig. 14 :Trend of therapeutic coverage from 1998 to 2001, Northern sector Fig. l5 : Geographicalcoverage for 2000 and 2001, Northern sector 53 il60 100 ^80E o60o G Eoo oo20 0 1998 1999 2000 2001 _ ,00t 880 e !oo =10o 320 (9 0 2000 2001 Northern sector: Year 2001 figures: Total population reported: 59 1,884 Persons heated: 352,269 Total number of communities: 471 Communities heated: 270 CDDs trained: 1,533 Health workers trained: I 15 Communities mobilized: 270 Fig. 16 : Therapeutic and geographical coverage for 2000 and 2001, Southern sector E2000 12001 100 95 ^80t o60E o @40 oom 0 Therap€utrc Coverage (%) Geographrc Coverage (%) 404C Southern sector: Year 2001 figures Population at-risk: 1,562,500 Target population: 1,068,500 Target Population accessible: 7 32,500 Number of persons heated: 219,937 Total number of communities: 640 Communities treated: 4,987 CDDs trained: 7,530 Health workers hained: 1,703 Comrnrrnities mobilized: 5,577 i buthia reha becabilitation u9e,w ilding which hae been a weakneeo ofth HNI reVrescnLatle,2OO2 refemi4 to the 59O1Y JAI'8.4 Page 17 3.I.13 TANZANIA Community-Directed Treatment with lvermectin (CDTI) Tarzania has onchocerciasis in Ruwma, Morogoro, Tanga, Iringa, Mbeya regions each of them having either hyper or meso-endemic foci or both. Ivermectin treatment started in 1989 and mass treatment in 1992. The first APOC supported CDTI project was launched in 1997 in Mahenge focus. To date five CDTI projects are underway and financed from the APOC Trust Fund. The NGopartners are SSI, HKI, IMA and Rotary lntemational. Status of ivermectin treatment: geographic and therapeutic coverage In 2001,806,136 persons were treated out of a total population of 1,330, I48, leading to a therapeutic of 6I%. The geographical coverage is 100% (588 communities). The trend of treatment over thcyears has been increasing gradually until 2000 as shown in the figures below. Government and community contribution In 200 l, Govemment contributed US $ I 54,340 to CDTI implementation. Although communities make substantial contributions to CDTI in terms of time and goods in kind much of iiis not well estimated and documented. Training over 7,328 cDDs and 392 health workers have been rrained by the year 2001 . Challenges Maintaining high therapeutic and geographical coverage rates; improving community mobilization, sensitization and participation in CDTI; strengthening supervision by the health care system; improving district health authorily involvement in planning and implementation of CDTI. Fig. l7 : Trend of therapeutic coverage from 1996 to 200 l, Tanzania Fie. l8 : Geographical coverage for 2000 and 2001, Tanzania 61ET 41 u 100 80 60 40 20 0 s oo o o o(J 1996 1997 1998 1999 2000 2oO1 100 100 ^80E o60 @ 940 oo20 0 2000 2001 Tanzania: Year 2001 figures: Total population reported: 1,330, 148 Persons treated: 806, 136 Total number of communities: 588 Communities treated: 588 CDDs hained:7328 Number of Health workers trained;392 Communities mobilized: 588 b5 JAF 8.4 Page I 8 3.I.14 UGANDA Community-Directed Treatment with lvermectin (CDTI) In Uganda mass treatment with Ivermectin started in 199 t with GTZ and then SSI and GRBp joined inby 1992. To date NGO partners involved in onchocerciasis control include GTZ, SSI, GRBP, CBM and West Ankole Diocese and they cover 20 districts in all. Status of ivermectin treatment: geographic and therapeutic coverage All four projects have well established CDTI implementation and have registered good progress in 2000 and 2001 with geographical coverage remaining at lO0% for both years and therapeutic coverage reaching 77%o and 78% respectively (see graph and figure below). There have not Leen reports of severe side effects meanwhile; health staff handles the minor adverse reactions, which occui during treatment with Ivermectin. Government and community contribution: The Government of Uganda released to GDTI implementation US$ 51,480 and 6l,gg0 in 2000 and 2001 respectively. Training In 2001 a total of 26,856 CDDs and 1,062 health workers were trained bringing the ratio of CDD per population to l:79 and that of health worker to population to 1:1994 as shown below. These ratios have reduced the workload especially of CDDs and they greatly ease distribution and supervision. Achievements In 2001 Uganda maintained high levels of community participation, which in turn led to h igh treatment coverage. Challenge Penpheral health facilities are mamed by insufficient numbers of health workers. To address this dehciency the NOTF resorted to using educated members in communities as "volunteer supervisors', who are remunerated from APOC funds. While this innovation has improved supen,ision in the reporting period, it has been considered unsustainable and may negatively impact on the qualiry of supervision when APOC funding ceases. The split of original administrative areas to many more makes unprecedented requirement for recruitment, training and more training materials rvhich were not budgeted for. Fig. l9 : Trend oftherapeutic coverage from 1996 to 2001, Uganda Fig. 20 : Geographical coverage for 2000 and 2001, Uganda Uganda: Year 2001 figures Total population reported: 2,117 ,878 Persons treated: 1,645,241 Total number of communities: 3,583 Communities treated: 3,583 CDDs trained: 26,856 Health workers trained: 1,062 Communities mobilized: 3,583 100 ^80 i' oo a 940 ot20 0 1996 1997 1998 1999 2000 2001 /b 77 79 37 100 100 2000 2001 'r 00 ^80E o60o E340 ot20 0 JAF 8.4 Page 19 3.2 status of ivermectin treatment in Apoc countries in 2001 : summary The overall status of.treatment coverage as it stood in 2001 is shown in figures 2I and22.Five out of l3 countries achieved the desirable geographicalcoverage of 100;/o while g others have not yet reached that level. There are plausibl" i"uionr to explain the lower-than-expected levels including civil unrest, insufficient number of health care personnel, poor mobilization and sensitization and weak supervision. Figure 2l: Geographical coverage in 200I in ApOC countries 100 94 96 97 100 100 r00 r00 t0092 90 80 s ;70 o06b60 o -i ro *<o b!8ro 20 l0 0 o"" u.'o "S **d "S g*"'*".*d Ct """- ".o'd """.Ot" "-" Figure22: Therapeutic coverage in 2001 in ApoC countries 100 90 ^80 o\ ;70 oo6b60 oso ai-Elo 6bso tr 20 I(} 0 78 79 61 3l 27 C !9c .""" o."" o""" "."- C *."**rCd -.-"",."." .S on"" 80 JAr'8.4 Page20 . In 2001, therapeutic coverage was higher than the threshold figure of 65yo in 9 out of 13 countries. Four (4) counkies had levels of treatment coverage higher tnailoy". Low coverage rates inthe reporting period are attributable to civil conflict (Liberia, bRC, Sudan), poor mobilijation and sensitization (Tanzania, Malawi, Chad), weak IEC components of CDTI (Tanzania, Cameroon), the occurrence of SAEs (Cameroon, Sudan, Gabon) and teething problems in first year of CDTI implementation (Congo Br azzavllle). 3.3 !EC and Advocacy by National onchocerciasis Task Forces The use of IEC as a support tool to CDTI implementation has continued in all countries with some countries specifically developing strategies while other have continued to routinely produce educational and training materials. Tanzania Notably Tanzania has developed an IEC strategy for CDTI work and has trained program and project managers and artists in the process of materials development. The strategy developed includes key issues in CDTI that need to be addressed, target audiences, channels, message concepts and the media to be used. ln addition to this the Materials Development Workshop imparted skills to participants on the key processes to be followed in developing IEC materials, including pre-testing. In the spirit of partnership, APOC Management organized this worlcshop in collaboration with the NOTF, Tanzania and Helen Keller International. The workshop on Materials development drew participants from N igeria, Uganda and Nigeria to support the replication of similar activities in other countries Further, the Knowledge Attitude and Practices (KAP) studies for 4 projects out of 5 have been completed and these will aid the NOTF/Tanzania in identification of critical issues in CDTI and designing culturally relevant IEC materials. APOC Trust Funds supported these studies. It is envisaged that NOTF/Tanzania will expeditiously develop and distribute the materials. Cameroon A workshop to specifically address the problems of Serious Adverse Events (SAEs) in relation to CDTI implementation was conducted. APOC Management organized this activity in collaboration with the NOTF Cameroon, MDP and HKI. As a result, an Action Plan was made including a recommendation to develop a detailed IEC strategy for CDTI which also focuses on SAEs. Other NOTFs are continuing to develop and reprint IEC materials in order to increase their supply in the target communities, thus improving information dissemination on CDTI. Programs need to strengthen IEC to dispel misconceptions, ensure compliance and improve sustainability of CDTI. 3.4 CommunitySelf-Monitoring(CSM) The key element of CDTI is communify ownership in selecting CDDs, planning and managing ivermectin distributions. As lead parfner, communities should be empowered to monitor CDTI, through individuals chosen from among their own ranks, and feedback to the health system the results of the performance of CDTI programs. Community setf-monitoring (CSM) enables the communities to identify strengths and weaknesses in CDTI implementation that need to be addressed to strengthen community participation and enhance ownership. CSM need to be undertaken annually in each communify. Evidence from Uganda has shown that CSM improves community participation in decision-making process. This initiative introduced by APOC Management in 2000 rvas extended in .\lC^trI I JAF 8.4 Page 2 I the reporting period to more than 200 communities in Nigeria, Tanzania and Uganda. preparations areunderway to upscale this activity in the countries where I tur u""n i"unched and to introduce it to allthe other APOC countries. In cAR it is to be introduced after a workshop in mid-August to orientate and train project andMoH staff on this important activity. A facilitator's guide on cSM in French and English language has been made available toNoTFs in l4 countries; the printed version will be availabi-e by the "first quarter of 2003. 3.5 lndependent Monitoring of projects Preparatory arrangements for independent participatory monitoring of CDTI projects areunderway' This is planned and to be undertaten uy tnl NorE, of Nig".lu, Ug"anda, t-iue.i{-cameroonand Tanzania'Ln2002, hvo community representatives will partici[ate fully in field data collectionand report findings during c.ommunity meeting. In countries *he.e ihe activity has never been carriedout APoc Management will support the haining of local expertise to undertate the exercise. In manyinstances, the activities are scheduled to take place from Aulust through November 2002. T\eresultsof this activiry will be presented at the Joint Action Forum in December 2002. 3.6 Operational research (OR) proposals APOC Management has been running a fund to support operational research and Director's initiative grants(DIG) as a way of responding to critical issues that arise in the process of implementing CDTI. This fund is estimated ar US$ I50,000 comprising tenper cent (10%) of amual approved budget. Despite repeated upp"it, to projects to submit research proposals, the response of the NOTFs to opeiations research has been unsatisfactory. Over the years, there was growing ton..* among members of the TCC and ApOC Management that many program and project managers do not access this fund due to their limited research knowledge. It was also observed that there is lack of collaboration befween research scientists and program managers. . Currently ApOC Management is promoting capacify building progrumfor project managers "rp"Ciutty inproblem identification, resiarch methods, data analysis and basic computer applications so as to enable them conduct operations research. In the period under review, I3 operational research proposals were reviewed by TCC and five were approved. Threl Table I : Operations research status in APOC countries Corintry CAMEROON CAR MGERTA SI.]DAN UGANDA Topic of research approved " Does alcohol consumption incrdase the riskof adverse reaction to ivermectin in the treahnent of onchocerciasis? .. wdi'approved by the 146 session of the TCC. r- '{r-- ' '- "Assessment of factors inflUeqcing the ownership of CDTI project , by the communities in C.A.R" - DIG " Determinant of absenteeism :and refusals during ivermectin distribution in Kwara SLte, Nigeria". "The knowledge and atdrude .of..Nigeriantowards charitable ,oo.goVErni"ohl organizations: .. .case of oncho coniiol" Submitted tlree final researih---re$9rts of studies approved befween 2000 ji_._0_l ' "The interaction of ivermecti" -u"d.Cltrctot.,, " Factors inlluencing "ornpU*#,ffiin,cortin Bushenyi Dishict ih Uganda.;i ,.i,:. ' "Causes of low ivermecti and strategies to,"ri;nTqjq'$;?;:T-,;Uganda" -' . - Submitted a final research report of a study approved in 2001. operations research each with a budget not exceeding US$5,000 were approved under Director,sInitiative Grant (DIG). In the table l, pioposals upprou"d in the reporting period are presented. JAF 8.4 Page22 3.7 Drug shipment and storage Table 2 : Ivermectin tablets (3 mg equivalent) shipped by Mectizan Donation Programme to APOC countries in 2000 and 2001 Figure 23 1 20,000,000 1 00,000,000 80,000,000 40,000,000 20,000,000 in 2001, Mectizan Donation Program (MDP) shipped a toral of 95,746,500 of ivermectin tablets (3 mg) to 14 participating countries to projects supported by APOC Trust Fund. As seen in table 2 below. when compared to the previous year: in 2001 ivermectin quantity shipped to APOC funded projects increased by l7%o. In both years Nigeria alone had a proportionately large share of the tablets exceeding 60% although its share reduced from 70%o in 2000 to 6l% in 2001. The proportions of Ivermectin shipped to other countries also increased in 200 I as compared to 2000 due to the increase in numbers of persons treated. Overall, the amount of Ivermectin shipped to member countries has been increasing as seen in Figure 23. Ivermectin tablets (3 mg equivalent) shipped in APOC Programme area from 1988 to 2001 s6 e) 6' ,\* 60,000,000 o cg (g 2 (t o o, E c) og -o(E c o o E Lq) .: 0 Countiy Year 2000 Proportion(%l Year 2001 Proportion(%\ Cameroon 4,874,000 5.96 4,853,500 5.07 C.A..R. 3,019,000 3.69 4,350,000 4.54 Chad 1,860,000 2.28 2,891,500 3.03 Congo 450,000 0.55 I,304.000 r.36 D.R Congo 2,019,000 2.47 4,382,500 4.58 Eq..Griinea 74,000 0.09 61,500 0.06 Ejhjgpiq 629,000 0.77 1,6a5,s00 1.72Ga'bon 0 0.00 13,000 0.01 Liberia 916,000 t.t2 4,232,000 4.42 [,IAEl+i 1.226.000 1.50 2.295.500 2.40 Nigeria s7.746.000 70.66 s9.082.000 6t.71 Sii-EEii' . 'r,902;ooo 2.33 3,114,000 3.2s Tanzania 1,474,000 1.80 2,507,500 2.62 ui-eii--ae 5:536.s00 6.77 5.008.000 5.23 Total tablets 81.725,500 100.00 95.746.500 100.00 6'tr c, os6 3 oo 6' O) s oa cn so vs o98 3G) v' 1988 1989't990 1991't992 1993 1994 1995'1996 1997 1998 1999 2000 2001 JAT'8.4 Page23 4. ACT|V|TTES OF THE TECHNTCAL CONSULTATTVE COMMTTTEE (TCC) 4.1 Membership of TCC In accordance with the Phase II and Phasing out Period Programme document, two additional persons have been formally appointed during the period under review, by the Director General of WHO as full members of the TCC to serve for 3 years each. More experts will be appointed in the near future in order to bring the total membership to 12. 4.2 Role and Function of TCC The TCC continues to provide shong technical support to APOC Management by reviewing new national plans and project proposals as well as technical reports of the ongoing projects. It is involved in establishing APOC research agenda, guiding Management on various salient and challenging issues as CDTI implementation in loaisis and onchocerciasis co-endemic areas, harmonizing deirnitions and participating in missions. tn the period under review the TCC held 2 sessions during which it reviewed a total of 60 Annual Technical Reports, l3 CDTI project sals and 4 research 4.3 Highlights of TCC Achievements 4.3.1 Mission to Ondo and Niger States Poor leadership and bureaucratic bottlenecks within the MoH had paralyzed CDTI in Ondo and Niger states, Nigeria for several months. TCC responded swiftly by a mission visit to these states to assist in solving adminiskative problems and provide them with technical support in CDTI implementation. The mission members noted considerable improvement in project activities after their visit to Niger. In Ondo the team noted that most of the problems relating to CDTI implementation had been attended to by the project except for the prompt approval and release of funds by the state Ministry of Health. TCC recommended that these projects be monitored closely by NOTF in order to consolidate the achievements of the mission. 4.3.2 Mission to Liftoral II Provincial. Cameroon Management of serious adverse events (SAEs) and inadequate social mobilization had resulted in poor performance of CDTI in Littoral II. The comminee during its fourteen session scheduled a visit to the projects in the fourth quarter of 2002 to provide technical support. 4.3.3 Country Studies on cost per treatment estimates for ivermectin Studies on cost per treatment serve as advocacy tool to resource mobilization, improve support and provide data for the evaluation of the economic impact of Programme activities. A study on cost per treatment by CDTI for program management and with a special emphasis on "sustainabiliry" had been launched in the year under review The study will delineate drrect and indirect costs and the need to identify all costs at all levels including APOC, NGDOs, MOH and communities. t- Parttcipants to the l4'h session of the TCC, L[arch 2002 l\ r' i JAI'8.4 Page 24 4.3.4 Definition of ATO and UTG and other indices The Committee agreed on the definitions of Annual Treatment Objective (ATO), Ultimate Treatment Goal (UTG) and reaffirmed other key indices including total Population, Eligible Population, therapeutic coverage and geographical coverage. TCC recommended that these indices be monitored from time to time in all projects. 5. ACTIVITIES OF THE MANAGEMENT OF APOC 5.1 Evaluation of sustainability of CDTI projects The most significant challenge of APOC during its Phase II and Phasing-out Period is to provide evidence that CDTI projects will be sustainable before exit of APOC in 20 10. To achieve this objective, the partners underscored in the Phase II document that "APOC will monitor progress towards the establishment of sustuinable CDTI and determine, on the basis of criteria ... if and when a project has been successful" (Phase II Programme Document- page 15, JAF7.8). The Report of the External mid-term Evaluation of APOC also underscores the importance of this subject. In 2001, APOC Management began to coordinate a special evaluation exercise of 7 CDTI projects located in I0 geographically distinct areas referred to in this report as "10 projects". They are in: Nigeria (4), Malawi (l), Tanzania (l) and'Uganda (Phase I consisting of 4 projects). These l0 projects willhave received five years of APOC financialsupport by December 2002. The main objettive of the evaluation was to determine the level of sustainability of each project, in order to know whether it can function optimally after the withdrawal of APOC support and to assist the country to develop action plans with set targets that can put the project on course to sustainability. Two experts were mandated with the coordination of this activity. Follorving a preparation meeting held in Geneva, in October 2001, extensive literature review on sustainabiliry, consultations with WHO/EPI, GAVI and other programs, a working document was prepared and an expert panel of 13 members (core group) formed. The core group held its first meeting on sustainability in Ouagadougou in November 2001, agreed on indicators and developed 4 instruments for data collection on sustainability. These instruments were pre-tested in Kaduna, Nigeria in January 2002, reviewed and refined by the two coordinating expefts in April 2002. The core goup defined 'sustainability' as "the likelihood that a project will conttnue to function effectively after APOC support comes to an end" this also means the "abiliry of a project to continue functioning effectively, using both its own resources and those provided from outside - provided the latter are dependable." An altemative concept is: Self-sufiictency: the ability of a project to continue functioning effectively, using only resources generated within the country itself. For the purposes of the evaluation, the core group used sustainability' as the guiding concept and as def,tned above. The instruments were used to generate information on nine goups of indicators of sustainability classified into three categories * Indicqtors of Results: Coverage- geographical and therapeutic We divided ouraelves into twA llaq.l?: Ru n u m i we nt t o Ki I o mb e ro d i stri ca.: a n d 1',\r: a\i to Ulanqa diEtrict. We viaited O area:5 ,.,.::yt!h low and hi7h coverage." iThe exercise waa a'little bit harshia, to walk in eome oituationo c.g. km tb Mselezi becauae the biidge' and walkcd 3 km ta-Ndindo becauae (landcruiaer) could not manage -: Or Oaine, Heallh Economiel from U4anda, Cord 4lou? member JAF 8.4 Page25 * Indicators of CDTI support activities: planning, leadership, monitoring and supervision, Ivermectin procurement and distribution, training and sensitization/mobi Iization; * Indicutors of Resources provided: Funding/ financing, transport, other material resources and human resources. Each indicator was graded between 0 (not sustainable) to 4 (fully sustainable). The evaluation was conducted at four levels (table 3 below), relating to the organisation of the health care services of APoc countries and project's organisational framework. Table 3 : Indicators of sustainability' Groups of indicators Level of operation HQ/ province/ region/ State District/LGA SubdistricU First line facility Village/ Com- munitv Coverage x x x x Indicator of results achieved Planning x x x x Indicators of activities which support CDTI Providing leadership x x x x Supervision and monitoring x x x Ivermectin procuement and distribution x x x x Training and sensitization/ mobilization x x x x Financing/ Iirndine x x x x Indicators of resources provided Transport and other material resources x x x Human resources x x x Between May and June, 2002, assessments of sustainability of 9 projects were successfully completed. Preparations to assess the CDTI project in Kogi, Nigeria are under rvay. The evaluations comprised of two major activities (i) Assessment of the status of sustainabiliry using the group of indicators as shown above and (ii) Feedback/Planning meetings in which plans u,ere made with politicians, technical staff and policy makers in the health care systems, held at each level where major decisions about the CDTI projects are made. At these Planning meetings, evaluation team set in motion a process of plaming based on its findings. The team's findings were presented to all the relevant project staff and political figures, u,ho have responsibiliry for the CDTI programme. The study came up with varied and very rich information about sustainabiliry of the projects. The key Jindings were that most (7 out of 9) projects evaluated had made satisfactory progress towards sustainability while two did not (see Appendix 6). There were various sfengths and weaknesses at national, district, sub-district, village levels but overall all communities were rated highly for sustainability. See document JAF8/INF/DOC.3 At the 2"d NOTF Representatives Meeting in Abuja, Nigeria (see section 5.6.8), the main tenets including the background, concepts, methodology, results of the evaluations \\,ere presented and discussed by participants. Details of this meeting are in the full workshop report, u,hich is summarized in the document JAF/8/INF/DOC.3. 5.2 Status of financing first, second, third, fourth and fifth year projects During the reporting period, APOC Management reviewed l4l project documents including 78 budget proposals (Appendix 5). Sixty-four (64) Letters of Agreement (LA) \\,ere prepared and processed. The first installments of funds were released to enable the launching of CDTI activities in 8 new projects Q.{igeria: l, D.R, Conqo: 3, I-iberia: 2, Ethiopia: 2) approved for the first year of funding. JAF 8.4 Page26 5.3 5.3.1 Financial Management of CDTI projects Auditing APOC Management reviewed monthly expenditure returns submitted by the NOTFs of the on- going projects receiving funds from APOC. This exercise enabled the Management to verifo that funds are being utilized in accordance with the approved budget. Few deviations were immediately conected and feed-backs were sent to the projects. Visits in the field were organized to cross check the information received through the expenditure reports for accuracy. The audiVchecking visits were conducted in Cameroon and D.R.C in the reporting period. 5.3.2 Submission of financial rerurns to APOC from the projects There has been an improvement in the submission of financial returns frorn the projects to APOC management. While in 2000 the figure for late submissions was35%o the same figure for 2001 is I8%. The Management of APOC continues working to reduce further the delays in submission of financial returns in collaboration with the WHO country offices. 5.3.3 Capacitv building In countries with more than four ongoing CDTI projects, the Management of APOC with the technical and financial support of the Onchocerciasis Unit of the World Bank are developing computerized spreadsheet to improve hnancial record keeping and good monitoring at the country Ievel of the cash flows between the NOTF Secretariat and the project sites. 5.3.4 Maior achievements . More than 60 participants including accountants and NOTF staff members were trained during the period under review. The contents of the training include monitoring of the approved budget to avoid overspending. . The computerized financial monitoring system has been installed and staff trained in Uganda with 6 projects in 20 districts and in Tanzania in 7 ongoing projects. . Plans to conduct training in computerized financial monitoring in Cameroon and Nigeria are already underway 5.4 ln-country capacity building: overview Developing the human resource in APOC member countries is critical as such personnel are the driving force in the implementation of programs. Building capacity of nationals is also a way of ensuring sustainability of CDTI and related programs. In the period under reporting a total of 141,843 persons were trained/retrained in various fields of expertise with APOC funds and the breakdown of the relevant training/retraining is shown in the table 4 below. t JAF 8.4 Page27 Table 4 Capacity building in 2001 5.5 Missions, Country support visits and special visits 5.5.I Missions 5.5.1.1 Mission to the African Development Bank (ADB) Following the announcement made during the 7d session of the Joint Action Forum (JAf) by the African Development Bank (ADB) Group to maintain its support to ApOC for its phase lI and Phasing out period, the Director of APOC undertook a mission it the headquarters of the ADB inAbidjan (C6te-d'Ivoire). This mission aimed to understand the conditions to be fulfilled by ApoC in order to be eligible for ADB support and to update the ADB on the ongoing and planned activities of APOC. ADB has reaffirmed its commitment to continue financing epOC. In ionformity rvith theADB's procedures and as a follow up of the Director's mission, fourteen (14) APOC countries lave individually requested ADB to finance APOC during the Phase II and phasing out period. 5.5.1.2 Mission lo donor countries During this reporting period, the Director of APOC has conducted a series of joint resource mobilization visits with the Onchocerciasis Unit of thre World Bank responsible for mobilizing funds. Nine (9) countries were visited to inform donors on progress in Programme activities and solicrt for even stronger commitment to ApOC. 5.5.1.3 Mission to Southern Sudan In the period under reporting, the Director of APOC went on a fact-finding mission to Southern Sudan in order to reinforce the implementation of onchocerciasis control, by alvocating for the improvement of the involvement of indigenous healthcare personnel and communiiies in CDTI. As a result, the newly formed Southern Sector Onchocerciasis Task Force (SSOTF) was reinforced. It is chaired by a Southern Sudanese. Its immediate task is to coordinate the formulation and implementation of new CDTI projects. As a follou,-up of this visit, REMO is scheduled to start early Area of capacity building Countries Number of people trained./retrained 12002 Financial Management Refresher course have been conducted in financial management of APOC Trust Funds, monitoring of approved budgets and preparing timely expenditure reporls Ethiopia, Democratic Repubtic of Congo, Cameroon, Uganda and Tanzania 60 Training of nationals including oncho coordinators on computer skilUOp. Research Uganda 22 Evaluation studies on sustainability of CDTI Malawi, Nigeria Uganda, Tanzania 56 Vector Elimination Taruania, Eq. Guinea, Uganda 9 Training/retraining Health Care Personnel 13 countries 16,274 Training/rehaining CDDs 13 countries 125,291 REMO/REA Burundi, DRC, Congo, 37 Training oncho coordinators management. on GIS and data D.R.C, Cameroon, Eq. Guinea s6 Parasitological surveys to determine loa loa endemic villages Ethiopia JJ Training in control of nuisance from Blacklly D.R.Congo 5 Total 141,843 JAF 8.4 Page 28 in 2003; and consideration for the integration of the control of sleeping sickness into CDTI. This mission was a turning point of the understanding of the extent of applicabiliry of CDTI in areas under civil strife and the willingness of communities to participate in CDTI even in the conflict areas. 5.5.1.4 Misston to Democratic Republic of Congo (DRC) At the invitation of the Ministry of Health (MoH) of the Democratic Republic of Congo, the Director undertook a mission in October 2001. The outcomes of this visit were: (i) release of funds for the pilot CDTI project in Sankuru province; (ii) plans for the completion of a nationwide REMO and the release of funds by APOC to conduct that survey; (iii) capacity building in entomology for black fly nuisance control; (iv) sin:ational analysis of black fly nuisance in Inga with respect to larviciding operations; and (v) advice on the integration of onchocerciasis control activities with human trypanosomiasis in Inga. 5.5.2 Suoport visits/missions by Manaeement staff : overview (Table 5) The APOC Management staff, often injoint mission with the Technical Consultative Committee (TCC) members, the Non Governmental Development Organizations(NGDOs) Coordination Group, Mectizan Donation Program, other external experts made a total of twelve (12) support visits to the National Onchocerciasis Task Forces (NOTFs) in 8 countries during this reporting year: Democratic Republic of Congo, Ethiopia, Congo, Sudan, Cameroon, Uganda, Tanzania, and Nigeria. The objectives of these visits included facilitating CDTI implementation and Yector elimination activities, advocating for stronger partnership, collaboration and political commitment to CDTI activities, training in financial accounting and in data management and Geographic Information System, providing technical advising and assistance in management and implemcntation of projects, facilitating communication, building capaciry in IEC, sensitisation, mobilization. Table 5 : Country support visits/missions by APOC Management Country Mission/purpose Sudan visit in Southem Sudan. Fact Ethiopia Support visit in implementation of CDTI, proposal writing an4 frrq4gtellgp!{rtqC. Nigeria Up-scaling of Community self-monitoring (CSM) of implementation in l8 projects Training on Stakeholders' Meetings (SHM) module Follow-up visit to assess onchocercal skin disease, social life and marriage of Agnes since 1995 Visit to Koma Hills in Adamawa state, Nigeria- communities neglected the by health care services, ivermectin is available in Koma Hills. Training 20 district oncho coordinators in financial monitoring; instalment of rnonitoring system national secretariat level and WHO office. Site visits to Itwara and Mpamba-Nkusi foci to superrrise entomological activities and advise on frequency of fly collection in Itwara focus. Technical Technical support mission to assist NOTFfuganda in meeting ol district aulhorities on post-APOC sustainabil plan Uganda a iH""; 5.5.3 Support visits by Temoorary Advisors and Consultants APOC Management has identified a core group of temporary advisors and consultants to provide additional assistance to the NOTFs in planning and implementing technical activities. Management organized technical support missions and travel of the temporary advisors and consultants to 9 countries for the period being reported: Burundi, Nigeria, Liberia, Ethiopia, Angola, Tanzania, Equatorial Guinea, Malawi, Uganda. The assistance provided by the temporary advisors and consultants included haining and implemeniation of Rapid Epidemiological Mapping of Onchocerciasis (REMO), parasitological survey for assessing loaisis in CDTI areas, exchangJof intts in planning and elaborating CDTI project proposals, evaluation of the implementation of CDTI projects, capaciry building in monitoring sustainability of on going CDTI projects (table 6). Table 6 : Country support visits by temporary advisors 5.5.4 Special visits by APOC Management At the invitation of The Carter Center, APOC Management staff paid visits to the Rollins School of Public Health at the Emory University, The Carter Center and Center for Disease Control (CDC) all in Atlanta, Georgia, USA. These visits took place immediately following the meeting on Eradicabiliry of onchocerciasis (section 5.6.5). 5.6 5.6.1 Major meetings and workshops Statutory meetings (i.) In the period under review, the Programme Director attended the 97u and 98'h CSA meetings where the reports of participating countries were discussed, in particular CDTI in conflict zones, utilization of CDTI as a vehicle for the distribution of drugs for other public health problems, among other things. (ii ) The thirteenth session of APOC Technical Consultative Committee (TCC) was held in Paris hosted by the Merck, Sharp and Dohme, Inc., office. The fourteenth session of TCC was held as usual in Ouagadougou, Burkina Faso. Numbai-of "tiiistilifntsirseti Countries visited REMO Technical support to CDTI projects Planning and execution of REMO Fact finding mission on implementation of CDTI projects in Ondo and Niger States, Nigeria and in Littoral II, Cameroon. Assistance to Liberia NOTF in revising CDTI projects proposals for submission to TCC for consideration .of the Kaduna of-CDTI projects and of 9 CDTI projects. on (REA) and cominunities in Nigeria t4 Nigeria 6 2 Liberia a1 Angola, Burundi, Ethiopi4 Equatorial Guinea Nigeri4 Malaw'i, Tanzanra, Uganda JAI8.4 Page 30 5.6.2 Meeting on sustainabiliry and countr.y plan As recommended by APOC external mid-term evaluation and stated in APOC Programme Document for Phase II and Phasing out period,'the Management of APOC facilitate a meeting in Ouagadougou (13 participants) to review and standardize the indicators and data collection forms for carried out evaluation of sustainability of CDTI projects. The meeting also designed a canevas for elaborating country working plans. The meeting identified countries in which to carry out the first evaluations for sustainability, which are Malawi, Nigeria, Tanzania, Uganda, which have projects entering in the fifth or sixth year of implementation. 5.6.3 Review meeting on vector elimination activities in APOC countries ln the Programme Document for Phase II (2002-2007) and the Phasing-out period (2008- 2010) it is observed that " No new vector eradication activities will be undertaken during Phase II and the Phastng out period. Existing activities will be critically reviewed early in Phase II, to determine the cost benefit of each project, and whether the project should be completed'. To this effect, APOC Management organized a five days review meeting on vector elimination activities in May 2002. The rneeting was attended by National Coordinators, entomologists from the three concerned countries (Equatorial Guinea, Tanzania, and Uganda) and independent consultants experts with extensive experience on the foci and vector control activities. The outcomes of the meeting are presented in details in the section 6 on vector elimination activities. See also document JAF8/INFiDOC.2 5.6.4 Mectizan Expert Committee meeting APOC Management participated in the Mectizan Expert Comminee (MEC) meeting held in in Atlanta in January 2002. The meeting reviewed progress in the onchocerciasis control progralnmes in Africa (APOC and OCP) and in the Americas (OEPA), and in tlie management of serious adverse events (SAEs); discussed planning and forecasting Mectizan requirements of onchocerciasis control programmes. The participants discussed onchocerciasis in Yemen with "sowda" form of skin disease manifestation, tlie elimination of onchocerciasis in that country, and recommended that the APOC provide support to Yemen in this respect. At the meeting a scientific working group as requested by JAFT u,as constituted to review all SAEs reported cases, advise whether revision of the MEC/TCC guidelines for treatment in Loa-Loa and oncho co-endemic areas is necessary and if there is a risk for SAEs rvhen alcohol is consumed around the time of Mectizan administration. 5.6.5 Eradicabiliqy meeting In January 2002,a panel of 64 experts in the domain of onchocerciasis in Africa and in the Americas met at The Carter Center in Atlanta, Georgia, USA to discuss whether onchocerciasis is eradicable with current knowledge and tools. The meeting agreed that onchocerciasis in Africa is not eradicable now using current tools due to the major barriers to eradication. However in some sites in Africa, transmission can be intemrpted using current tools. Also, the meeting recognized the urgent need for additional operational research on macrofilaricides and tools for diagnosis of the presence of viable adult worrns of Onchocercia volwlus. 5.6.6 NGLolsardra4tionmeetins The nineteenth meeting of the non-Governmental Development Organizations Coordination Group for onchocerciasis meeting was held in February 2002 in Durban, South Africa. The group was pleased to accept the application of MITOSATH, a local Nigerian NGDO, as member of the international group. The group stressed the need for a collaborative effort to make available treatment data of previous year by March of the following year. 5.6.1 Meeting on moxidectin In continuation of the aggressive development plan lor moxidectin, APOC Management participated in two recent meetings with Drug Regulatory Authorities in the United Kingdorn and France. The objectives of the meetings were to present to the Regulatory Boards progress in the if"'ii development of moxidectin, impact of the drug on onchcerciasis as a public health problem, immediate and long term expectations if moxidectin becomes available including its impact on Prograrnme operations before and after the exit of APOC in 2010. 5.6.8 Second APOC NOTFs Reoresentatives' meetine in Nieei.a,lT-22 June. 2002 If APOC Trust Funds are to form part of the future scenario for funding of a CDTI project after the first five years, it is "on condition that serious efforts have been made in trying to establislr sustainable CDTI within a period of 5 years, and that this is likely to succeed within the near future" (APOC Programme Document, page l5). It is therefore crucial to identify early other intemal reliable resources and develop country plans for sustaining the programmes after the exit of APOC. At the second meeting of the NOTFs Representatives held in Abuja, Nigeria, the main focus was therefore sustainabiliry. The major objective was to create a common understanding of the meaning, importance and measurement of sustainabilily of CDTI projects as well as practical implications on the future work of countries and APOC support. The participants prepared and discussed the individual project plans for sustainability and developed criteria for determining exceptional APOC support beyond 5 years. The meeting discussed sustainability in conflict areas. (see JAF8/INF/DOC.3 and section 5.1 of this document). At this meeting, the evaluators presented their findings. A major outcome of the Abuja meeting was that Ministries of Health representatives and NGDOs in the 13 countries are to develop post -APOC country plans for sustaining CDTI. 5.7 5.7.1 Publication of APOC activities as special supplement in the Amals of Tropical Medicine and Parasitology The Management of APOC together with other scientists and partners produced a supplement on APOC: The African Programme for Onchocerciasis Control (APOC) at Mid-point: History, Achtevement and Future challenges in Annals of Tropical Medicine & Parasitology. Vol 96, Supplement l, March 2002 (JAF8/rNF/DOC. l). The supplement consists of a preface and seven (7) original articles: a. Partnership and promise: evolution of the African river- blindness campaigns b. The achievements and challenges of the African Programme for Onchocerciasis Control (APOC). c. Rapid epidemiological mapping of onchocerciasis (REMO): its application by the African Programme for Onchocerciasis Control (APOC). d. The challenges of communiry-directed treatment with ivermectin (CDTI) within the African Programme for Onchocerciasis Conkol (APOC). e. Gender issues in the communiry-directed treatment with ivermectin (CDTI) of the African Programme for Onchocerciasis Control (APOC). f. Monitoring community-directed treatment programmes for sustainability: lessons from the African Programme for Onchocerciasis Control (APOC). g. APOC's strategy of community-directed treatment with rvermectin (CDTI) and its potential for providing additional health services to the poorest populations. APOC Management would like to thank the Editor-in-chief of Annals of Tropical Medicine & Parasitology, research scientists, NGDO Coordination Group, WHO/ TDR, country representatives of NGDOs and MoH pcrsonneI for their hard work in the production of this supplement. Special Programme Activities JAF 8.4 Page32 5.7.2 Mission to Koma Hills in Nigeria A fact-finding mission to Koma Hills in Adamawa State Nigeria was organised by ApOCManagement to profile CDTI activities in very difficult-to reach settlements in the Hills. The mission reported that Koma Hills comprises of 13 communities that are located in ruggedterrain, essentially forgotten and neglected. Government presence is nil with regard to basicinfraskucture or amenities such as education, safe water ant health facilities "*";;;;; the pHCnumbers on some of the mud walls. The people have a high disease burden with malaria, leprosy,tuberculosis, onchocerciasis and epilepsy. Ivermectin distribulion started in 1999 by cBTi una tr,"." i.on-going effort to re-orient to CDTI. Mectizan is the only drug readily available to inhabitants inKoma Hills. As a follow-up of the mission, APoc Management and NorF Nigeria plan to improvecommuniry participation; organize health education foithe community and itl leaders; *d u..ung"advocacy visits of senior govemment officials in order to get their attention for this aep.iuJ a.ea. 5.7.3 In 2001, a new tool for "Rapid monitoring of treatment coverage using schools,, rvas developed byNorF of Uganda' The Management of APoc has identif,red tivo advisers to coordinate to test itsrobustness and applicabiliry in other countries. Plans for the validation exercise in Cameroon, Nigeria and Sudan are underway and the results will be available by December 2002. 6. VECTOR ELIMINATION ACTIVITIES Four vector elimination projects were approved during the phase I (1996_ 2001) of the Programme: Bioko Island(Equatorial Guinea), Itwara focus and Mpamba-Nkusi (Uganda), and Tukuy,u (Tanzania). In May 2002, a meeting of experts assessed the status of progress made towards the vector eradication elimination operations between lg96- 2001. The meeting decided that all 4 projects should receive continued funding. The highlights of the recommendations for each focus are presented below. (JAF8/rNF/DOC.2). ! -5-. -1,5 I t tt I ; $E 6.1 ltwara and Mpamba-Nkusi foci, Uganda In Ilwara the onchocerciasis vector is Simulium neavei s.s. Uganda is the first APOC country where vector elimination has been successfully achieved. In the ieporting period, no female ofSintulium neavei had been collected in the Itwara main focus in spite oflhe pe-rsistence of some larvae and adults of Simulium neavei in the sub foci of Siisa and Aswa.iu".. up to 200l.The absence of adultS' neavei in the Itwara main focus is recorded since 1997 despite the cessation of the larviciding operations. Pontcrmnls to the Rdttu of Vector Eltmtno!@n orotecs. Mn 2002 JAF 8.4 Page 33 The vector in the focus Mpamba-Nku si is Simulium neavei that is rnore vulnerable to vector elimination operations because of its bio-ecological peculiarities (i.e. relatively reduced flight range, long duration of larval development, sensitivity to eiological changes, phoreticlife). There are sufficient data, human, material andfinancial resources available to begin a large_scale campaign by ground larviciding. In view of this, lariiciding has been scheduled to begin after July 2002. The cost incurred on both foci is shown in table 7. Based on the success of the vector elimination activities in the Main focus of Itwara focus, the meeting recommended: Table 7 : Cost (US $) of lhvara (Feb. 1999 - Aug.200t) and Mpamba_ Nkusi (May 1999 _ Oec.ZbOr; vector elimination activities A think tank be put in place aiming at formulating an official recognition of the elimination of Simulium neavei in the Itwara main focus as wellas the modalities of recogaition; Entomological surveillance be reduced in the Itwara main focus and to lesser degree in the subfoci of Siisa and Aswa; The distribution of ivermectin be continued, at least, at the present level of coverage in all thefoci; In the Itwara ma'in focus, the reduction of onchocerca (macro and microfilariae) populationsto be followed up until the extinction of the parasite in man. Bioko lsland, Equatoriat Guinea Because of its unique nature as an island, Bioko offers an opportunity for the eradication ofthe disease, especially as the local vector is a unique form of Simulim yahense not found even in thenearest mainland in Cameroon. Ground larviciding, carried out in 200 l, was effective on developingstages. However', this treatment was incomplete because of inacces sibility of some rivers, mainly inthe south of the island. The meeting of experts mentioned above agreed to plan for vector eliminationby aerial larviciding (most of the breeding sites of the southern island are not ground accessible)provided that a small fleet of helicopters equipped for the application of larvicides can be retained inthe OCP zone by the aerial larviciding company partner of the Programme beyond the closing date of OCP (December 3l.t,2002). Based on above, the meeting recomrnended The refinernent as soon as possible, of the Rapid Epidemiological Assessment and census data of Bioko, notably in Malabo city in order to have a true picture of the population to protect. The Island is experiencing population migration from rural zones to urban areas; The intensification, by all means, of the community directed treatment with ivermectin; a a 6.2 a a Amount in US$ I 5,915 30,6&Field Activities Total A small riverJlow in the Biokofocas 5 JAF 8.4 Page 34 a a Contacting the OCp subcontracting companyif applicable, to find out the porriUitira unO contractual conditions of the use of its helicopters for an anti-simulium campaign in Bioko; In case of agreement with the company, the campaign should be conducted during the dry season 2003 (January to April); The campaign's objectives should be to demonstrate that it is possible to obtain full Table 8 : Cost (US $) of Bioko vector Elimination activities (March 1999 - Febru 2002 a coverage of 8. all breeding sites of the island. The cost incurred for this focus in shown in table Table 9 : Cost of Tukuyu vector elimiuation activities(October t99g mber 2002 6.3 Tukuyu focus, Tanzania The insecticide treatment, 2ool-2002 was not carried out in the period of low water volume asfo-reseen initially in the plan of operations due to delay in the clearance for temephos and sensitizationof national authorities and population. In spite of ihe shortcomings, the experiences of this firsttreafment enabled the meeting to envisage an optimum larvicide "orr".-ug" and reiommend: ' The execution of the first vector elimination campaign by ground larviciding in the Tukuyufocus. The objectives will be: o To eliminate the vector populations within the limits of the focus ; o To measure the risk of recontamination by immigrant Simulium flies. This campaign be executeci in the dry season 2003 taking into account the delays in the preparation of the campaign and the constraints of the time frame of the Phase II of APOC; That after the analysis of the results by an Ad Hoc committee and according to ApOC,s initial guidelines, a second and last treatment round be carried out in 2004, if necessary; The cy.totaxonomic studies be re-activated within the a a a focus (examination of fixed and fresh materials) and in the adjacent foci. Table 9 shows the cost incurred for Tukuyu focus. 6.4 Nuisance of black flies The conhol of black flies as a nuisance in some socio-economic areas is becoming a challenge to APOC Programme. The govemments of the Democratic Republic of Congo, Congo and Chad are requesting this service. Although control of nuisance were not io."r""n in the prograirme Document,it is becoming an issue to face in order to have the support of concerned communities andgovemments to CDTI activities. Large-scale campaigns for vector control is unrvorkable in theframework of APOC, however, attention should be given to methods that can be applied byindividuals and communities to protect themselves from vector nuisance. In that ..rp"it, ApOCManagement, in close collaboration with WHO/AFRO and OCP, has undertaken to train nationalsfrom the concerned countries. These training sessions will be followed by the initiation of limited nuisance control activities which will be continued by the National Authorities themselves withfinancial support from wHo/AFRo and/or other partners if necessary. diture ltemE 4295s0 Cost in US$ Cost in US$nditure I JAF 8.4 Page 35 7 RAPID EPTDEMIOLOGICAL MAPPING OF ONCHOCERCIASTS (REMO) ANDGEOGRApHtc TNFORMATTON SYSTEM (cts) Status of REMO/GIS in ApOC countraes7.1 Table l0 : Status of REMO/GIS in ApOC countries Figure 24: Provisional REMO map and CDTI areas of Angola social security has delayed completion of Rapid Epidemiological Mapping of onchocerciasis(REMo) in some participating countriei: Angola, Burundi, Democratic Republic of congo, Ethiopiaalthough tremendous progr"r, hu, been made'by the NOTFs. 7.1.1 REMO in Angola Because of social. insecurity, rapid epidemiological mapping (REMO) was carried out in six(6) of the 9 selected provinces in the year und". ,-"ui"ri. 535 viiiage"s were selected in 9 provinces inthe northern part of the country where conditions for onchocercias[ ex.ist but I 12 villages (2r%) onlywere accessible' Following the integration and analysis of provisional REMO.esults-in c"og,.upticInformation System (Figure 24), iPoc Management advised the NorF of Angora to compreteREMO, elaborate a provisional National plan anJa CDTI project proposal. Status of REl\{O Status in 2001 Status in 2002 REMO Partially Burundi, D.R. Congo, Sudan, Kenya, Angola, Burundi, D.R. Congo, Sudan, REMO completed Nigeri4 Tanzania, CA& Cameroon, Equatorial Guinea, Mozambique, Gabon, Liberia, Chad, Congo Brarr2y11 Mala' Ut Rwanda Liberia, Nigeria, Tanzania, CAR, Cameroon, uatorialEq, Guinea, Mozambique, Gabon, Chad, U Congo Rwanda Ldgende/Legend &,e&r/& E-----] Zon6.rlu6 '.x.luJ.d &6 NoduL6 (%) o0 o l-9 o l0- 19 o 20-39 o 40-100 bn6aafin..!o&rcfin.d non TIDC/no CDTt r*x EIX REMor f.,.e RE\iorocfidund p ,,* o.onr,-r.o.u- .o, - JAF 8.4 Page 36 7.1.2 REMO in Burundi Following the REMo exercise carried -out during the last quarter of 2001, the NorFconducted a Rapid Epidemiological Assessrnent (REA) to ;*;r";; the REM9 map orthe counrry.To date' because of security p--ut"* tt" ,ltiorut teams werJ noi uur" to cover the provinces ofcankuzo' Ruyigi and Kirundo.'rn" p.ouirio*r REIrao and cDrr map of Burundi below (Figure 25)indicates that additional informatio, rrroriJ'u" collected. ro. tr," p.ouin_"es of Bururi, Makamba, andRutana with known onchocerciasir f""i L;r;ion skin snip of rga!-igsz rhe NorF has deveroped a fli:.H,,i,r1rl,X,:":llr|a: and cDrr p.oi".i p.oposal ror bitiuor. una euuun,u rb, ,,;;lon to the Figure 25: Provisionar REMO map and CDTI areas of Burundi 7 .t.3 Until 2001' REMO results were available-only for Kasai, Bandundu and Ueles. Since then theNOTF has made o"*"ldol^t^:no.t to ""rrpi"" the REMo in til. "ount y. As ar iune 2002,REMOwas largely completed in.73yo^of the r 1 ni""ii."r. "f th"-.;;;;,'iu, congo, Kinshasa, Equateur,Bandundu' Katanga, Pro-vince o.ientate, tiasai occidental, rurui ii.rcrtal. The REMO exercise is ongoing in the remainins three provinces oirta-ie,r,u, Nord Kivu uJira Kir,. The district of Ituri inthe Province orientalJ is also "o*pt"i"a. -i st ouu be stressed ,no, ,n" NorF has used innovativeapproaches to implemen-t REM7 io gou"ro*"nt-controlled attd notr-governntent-controlred zones.Figure 26 and Figure 27 berow sho* t-he prouiriorur REMO und cDi; areas in D.R.congo. Cankuzo ! rroc e;o;oi* Nodules (%) TIDC probable IElr"", - RivcrvRividres L6gende Province Kr,tr-=-l 0 20 40 o0 o r-9 o l0- 19 o 20-39 o 40-r0o [-l neMo non.ncorc ratisi ffil nonnoc JAF 8.4 Page 37 Figure 26: REMO results in D.R. Congo as at June 2002 Fieure 27: Provisional CDTI areas of D.R. Congo Nodules (%) 0 l-9 l0-19 20-39 40- 100 KM r---l 0 200 Legend ! cortpaoav* ! ro bc rcfin.2 m RfMowhcnfdiblc El nocDn ffi D*n&. no .n"o* ,"9u* I nruooneoine T---l0 200 JAF 8.4 Page 38 7.1.4 REMO in Ethiopia A REMO refinement exercise was carried out to improve the existing REMO map and delineation of communities that require CDTI (see Fig. 28 below). Based on the results of this exercise, the NOTF/Ethiopia sutmitted two CDTI project proposals (Bench-Maji and North-Gondar), which were approved by the 146 session of the TCC in March 2002. Figure 28: Provisional REMO map and CDTI areas of Ethiopia eub$) o0{ o l-9 o 10-19 o 2G39 o 40-t00 E ,".;.;,,* lEl No"a,i *^ f-l to bc rcfinca I melecteam - fuves KM r------l0 100 200 7 .1 .5 REA and population census in Bioko Island. Equatorial Guinea Bioko CDTI project enters in its fifth year of implementation (1998 to 2002).In rhe reporting period, APOC Management commissioned a study to conduct REA and a population census of CDTI communities to reassess changes in endemicity levels and distribution of the disease given possible changes in population dgramics due to migration from rural areas to oil-rich zones and main towns. Only 68 villages were surveyed for REA and 91 for population census. Malabo, although known to be hyper-endemic for onchocerciasis was not covered either by the census exercise or by the REA survey. It is planned to complete these investigations by conducting the appropriate survey in Malabo. The study when completed will provide important information to APOC Management for further action. 7.2 lmplementation of CDTI in onchocerciasis and loaisis co-endemic areas Serious adverse events (SAEs) following ivermectin distribution in areas co-endemic for onchocerciasis and loaisis pose a serious threat to sustainabiliff of CDTI. Following previously reported cases of severe adverse reactions in Cameroon in areas co-endemic for onchocerciasis and loaisis, WHO/TDR developed the Rapid Assessment Procedures (RAPLOA) rvhich shall be used in conjunction with the remote sensing map developed by Liverpool school of Tropical Medicine (See Fig.29 below) JAF 8.4 Pagc 39 While awaiting the validation of RAPLOA for use in the scope of Programme, APOC Management has been supporting the use of parasitological surveys based on blood smear examination in areas where loaisis is suspected, prior commencement of ivermectin distribution. Akwa-lbom (Nigeria), Bench Maji (Ethiopia), extension of CDTI project of Congo Brazzavrlle are some examples where this has been done. Studies on loaisis will be carried out in Democratic Republic of Congo mainly in the Province of Equateur, Bandundu and Bas-Congo. Figure 29 : SPOT Vegetation model applied to the region 8. OVERVIEW OF COLLABORATION WITH OTHER WHO GROUPS AND THE WORLD BANK APOC has continued to collaborate with various WIIO groups and the onchocerciasis Unit of the World Bank in the period under reporting for, without this partnership, progress u,ould have been slou, and difhcult. 8.1 Collaboration wath WHO/OCP o Administrative and financial support in transfer of funds, pa)rrnent of emoluments of APOC staff, purchase of capital equipment for APOC in Ouagadougou and in the countries. . Collaboration in setting up an efficient and reliable communication system. o Allocation of ofhce space to APOC Management. e Technical and./or logistic support for vector elimination activities in Tanzania, Equatorial Guinea and Uganda. o DNA laboratory facilities available to APOC for analysis of entomological data. -ltor prbra/c0Tt -.ato6(cort r:_16lr0bl0 Prr:l re atr oi E ba o)EIE -r rfl)r -5 iEls -rorElo-a rEIE-x rE'rafl xo ozr e 0.n. c0Tt t )JA.F 8.4 Page 40 8.2 Collaboration with WHO/AFRO including its country offices . Advocacy for onchocerciasis control in the Africa Region . Monitoring of CDTI and Vector elimination projects o Facilitation of Mectizan entry in endemic countries o Transfer and replenishment of funds for CDTI . Procurement of capital equipment, audit of imprest returns 8.3 Collaboration with WHO/HQ . Financial and administrative support in funds transfer, purchase of equipment o Internal annual audit of APOC financial and technical management and administration 8.4 Collaboration with WHOffDR: OPERATIONAL RESEARCH The WHO/TDR Filariasis Intervention Research continued to respond rapidly to the research needs of APOC field operations. In the year under review, a report and Guidelines for field application of Rapid Assessment Procedures for loaisis (RAPLOA), community diagaosis of Loa-loa endemicity has been developed by WHO/TDR and printed copies made available to APOC countries where onchocerciasis and loaisis co-exist. The new tool, RAPLOA is now available for use in Cameroon and Nigeria. Following a recent meeting in Liverpool in May 2002, validation surveys of combined approach (the remote sensing map with RAPLOA) in four counkies in central and North Eastern Africa are underway. Following a request by JAF in December 200 1, a brainstorming meeting was held in Ouagadougou in March 2002 on the use of the Community-Directed Interventions (CDI) approach for other diseases and interventions. Consultations with other prograrnmes in the WHO/IIQ have been on- going. The outcomes of these consultations as well as future plans of a multi-country shrdy will be presented to JAF8 meeting in December 2002. WHO/TDR continued to exploit other rapid methods/tools for monitoring trearment coverage, including using school children. As a follow-up to the first study in Uganda which showed significant correlation befween ivermectin treatment coverage in school children monitored by schoolteachers and coverage by household survey, the Task Force supported a new study, this time using the postal and district educational systems in seven (7) districts in Uganda. The current study will be completed before December 2002 ard the results made available to JAF8. A multi-country (Sudan, Cameroon, Nigeria) study of additional health & development activities of Community-Directed Drug Distributors (CDDs), and their impact on the effectiveness of the CDD and the sustainability of CDTI would be completed before the end of 2002. Also, this year,a new research study on the feasibility of applying the Community-directed treatment (CoMDT) approach for combined treatment of onchocerciasis, schistosomiasis and intestinal helminthes was launched by TDR in Uganda. The results of this study rvill be compared rvith a study on the use of CDTI as separate intervention. The study on advocacy (multi-site and multi-country) to ensure sustained demand, suppiy, distribution and treatment coverage of ivermectin in CDTI for onchocerciasis control which rvas launched in the third quarter of year 2000 will be completed by December 2002. The results of the Phase II of this study will be presented to the Joint Action Forum in December 2002. 8.5 Contribution Of WHO/AFRO l. The visit of WHO/AFRO Regional Director in Democratic Republic of Congo has strengthened the involvement and the support of the Ministry of Health to APOC activities; 2. Participation of DDC in the sessions of the Cornmittee of Sponsoring Agencies underscores WHO/AFRO involvemcnt in APOC policy; JAF 8.4 Page 4l 3. The budget and finance office of WHO/AFRO as in the previous year has been playing an important in the implementation of the Programme activities by providing support to the country offices for the transfer of funds to the projects, the replenishments of NOTFs' bank accounts. A planning process has been put in place by WHO/AFRO budget and finance office to forecast the need of APOC Programme in financial resources quarterly in order to make funds available at country office level and to solve the issue of the imprest account ceiling. WHO country offices are playing key role in facilitating the implementation of CDTI and vector elimination projects. Some of the country offices pivotal role included: organization of various workshops and meetings, providing transport to consultants and held staff for various activities such as community-self monitoring, sustainabiliry studies, ground larviciding operations, facilitating entry of ivermectin. 8.6 Gollaboration with World Bank (WB) Onchocerciasis Unit APOC has had invaluable collaboration with the Onchocerciasis Unit of the World Bank based in Washington. In particular, technical staff have supported; at the cost of that Unit, APOC Management and member countries in the areas of financial management and training, community mobilization and facilitation. The Onchocerciasis Unit supported APOC Management headquarters to review and identify weaknesses in the computerized financial information system. This has eased f,tnancial operations, enhanced integrity and the automation of returns and computerization of the financial management systems of programs within countries. In a joint visit to Tanzania and Uganda APOC Management together with the WB Onchocerciasis Unit trained country staff in f,rnancial monitoring, planning and analysis of country portfoiios, improving record keeping and updating accounts. This has eased information flow behveen APOC headquarters and these National Coordinators. APOC Management and the WB Onchocerciasis Unit co-facilitated a workshop on Community self-Monitoring (CSM) and Stakeholder Meetings in Nigeria; trained nationals of Central African Republic in Community Self-Monitoring. The Unit also provided technical support at the Second meeting of NOTF Representatives in Abuja, Nigeria. 9. CONTRIBUTION OF THE NON.GOVERNMENTAL DEVELOPMENT ORGANIZATIONS (NGDOs) COORDINATION GROU P APOC has continued to collaborate with its NGDO partners (see table I l) both local and international. NGDOS are working in the member countries and they have contributed technically and hnancially to CDTI implementation. Within the countries the individual NGDOs have contributed substantially to onchocerciasis control programs. They have worked closely with ministries of Health and lower administrative units to ensure progress of activities. They have provided technical expertise in executing programs especially in training and supervision. Further, in the reporting period, the Coordinator of the NGDO Coordination Group has participated in several joint missions including: a) Heading a team to Liberia to assist the Table 11 NGDO Partners in onchocerciasis Control in APOC countries * Although LINICEF and University of Barcelona are included here, thev arc partners but not NGDOs a a Country Cameroon Car Chad Coqgo Brazzaville D.R. Congo Equatorial guinea Ethiopia Gabon Liberia Malawi Nigeria Sudan Tanzania NGDO partner GRBP,HKI, IEFI, SSI, BASED, CBM Africare, OPC OPC CBM,IMA University of Barcelona* GRBP OPC SSYCHAL, I.-INICEF+ IEF CBM, GRBP, HK], SSI, IFESH, MITOSATH, UNICEF+ HKI, GRBP IMA/CSSC, SSI, HKI CBM GRBP SI JAF 8.4 Page 42 NOTF formulate 2 project proposals for onchocerciasis control in the South West and the South East b) Mission to Kisangani in D.R. Congo and the meeting of NOTFs representatives in Abuja Nigeria in the period under review. Helen Keller lnternational has provided technical assistance to the IEC materials development workshop in Tanzania and gave similar support to a workshop that assisted the NOTF Cameroon to come up with an action plan on IEC in general and specifically targeting Serious Adverse Events. APOC Management is very proud of this strong relationship with NGDOs and is exploring possibilities of involving more local NGOs and Community Based Organization in CDTI. 10. External audit In the reporting period, auditors had verified the status of APOC funds statements to ascertain whether budgetary and financial systems comply with the rules and regulations, and are in line with policy guidelines of the donor Communiry. This annual activity keeps Management on track with its finances and budgets. a JAF 8.4 Page 43 11. APPENDIXES Appendix l: Summary of geographical coverage in 2001 in APOC countries Country Communities treated Total communities Geographical coverage (%o) Cameroon 4,987 5,221 95.52 CAR 4,594 5,014 91.62 Chad 3,1 69 3,265 97.06 Congo Brazza 423 423 100.00 D.R. Conso 1,823 3,900 46.74 Equatorial Guinea 68 9l 74.73 Ethiopia s00 500 100.00 Gabon l8 l8 100.00 Liberia l,988 2,596 76.58 Malawi 606 727 83.36 Nigeria 30,963 3 l,66s 94.00 Sudan 474 589 80.00 Tanzania 588 s88 100.00 Uganda 3,445 3,445 r00.00 Grand Total 53,646 58,042 92.43 Appendix 2: Summary of therapeutic coverage in 200 I in APOC countries D Country Persons treated Total population Therapeutic coverage (7o) Cameroon 1,387,433 2,771,123 49.95 CAR 118,989 998, l 02 78.05 Chad 851.111 I,506,575 56.49 Congo Brazza 229,361 404,324 56.48 D.R. Congo 665,763 2.421.383 27.50 Equatorial Guinea 10,672 16,099 66.29 Ethiopia 233,309 306,088 76.22 Gabon 4,228 1,906 53.48 Liberia 497,662 2,083,435 23.89 Malawi 367,298 648,990 56.60 Nigeria 16,586,354 22,041,388 75.23 Sudan 595,111 1,904,384 80.00 Tanzania 806, r 36 1,330, r 48 60.60 Uganda r.441.534 1,833,581 78.62 Grand Total 24,454,627 38,286,126 63.87 JA.F 8.4 Page 44 Appendix 3: Summary of training in 2001 in ApOC countries \ *NA : Not applicable Appendix 4: Sumnrary of Governments contribution in 2001 in APOC countries Appendix 5: Projects reriet.ed b5' APOC l\{ana nt tl Country CDDs trained Health workers trained 2,000 2,001 2,000 2,001 Cameroon 5,896 7,530 59s 1,703 CAR 4,995 4,99s 451 931 Chad 2,546 2,881 176 287 Congo Brazza NA r,109 NA 9t D.R. Congo 3,431 8,066 268 830 Eq.Guinea I5 42 148 18 Ethiopia 934 934 183 r83 Gabon NA NA NA l1 Liberia 1,831 5,738 79 104 Malawi r,899 1,949 653 647 Nigeria 48,793 56,750 9,298 9,835 Sudan 1.900 1,998 128 r80 Tanzania 4.t02 7,328 339 392 Uganda 24,884 25,971 1,165 t,062 Grand Total 100,282 125,291 13,300 16,274 COUNTRY GOVERNMENT CONTRIBUTION IN US$ Cameroon 135,714 CAR 23, 100 Chad 298,s00 Congo Brazza 40,000 D.R. Congo 16,430 Eq. Guinea NA Ethiopia NA Gabon NA Liberia 2,738 Malawi I15,007 Nigeria 182,985 Sudan 33,500 Tanzania 154,340 Uganda 347,600 Total 1J26,814 Country Number oI Interim Technical Report Number of Financial Reports and budgets, Action Plans for 1,ears 1,23,4,5 Cameroon 4 t7 CAR I 2 Chad 2 Congo 2 DRC ) 4 Equatorial Guinea 3 Ethiopia 4 Gabon 0 Liberia 2 Malawi 3 Nigeria t'7 58 Sudan 6 Tanzania ll Uganda 3 TOTAL 24 tt7 * NA : Information not provided by NOTF JAF 8.4 Page 45 a Appendix 6 : Main Findings And Recommendations On Evaluated Projects + Phase I covers 4 districts. Each district was evaluated separately and had specific f, ) L PROJECT STATUS FINDINGS & RECOMMENDATIONS I CROSS zuVER . Coverage was satisfactory . There is integration into the health system . Routine supervision and training on APOC funds APOC Project has made satis[actory progress towards sustainability. Prepare sustainability plan Seek local dependable sources ofpost- 2 KADUNA Routine planning at the State level is made State sometimes give financial support LGA leadership is not fully sensitised Heavily dependent on APOC funds Seek local dependable sources of post- APOC Sensitize and involve LGA leadership Prepare sustainability plan 'roject has made satisfactory progress sustainability. 3 TARABA . Well integrated into the health system . Communities are well mobilized and involved . Heavily dependent on APOC funds Project has made satisfactory progress towards sustainability . Prepare sustainability plan . Seek local dependable sources ofpost_ APOC 4 MALAWICDTI (MWANZA, TLTYOLO) . Not integrated into the health system . Unsatisfactory geographicalcoverage ' CDTI not in place . Heavily dependent on APOC fi.rnds Project is not making satisfactory progress towards sustainability. . APOC funding should cease after the fifth year until satisfactory evidence that critical issues raised in the evaluation report are being addressed by the government at all levels, especially changes in leadership. . New leadership should prepare plan to establish a sustainable CDTI plan . Seek local dependable sources ofpost- APOC 5 MAHENGE . CDTI is not understood by CDDs . Training of CDDs was done only once to a few in two years . Not integrated into health system . Communities are not involved . Heavily dependent on APOC funds Project is not making satisfactory progress ton'ards sustainabilitl,. . APOC funding should cease until satisfactory evidence that critical issues raised in the evaluation report are being addressed by the govemment at all levels, especially changes in leadership. . New leadership should prepare plan to establish a sustainable CDTI plan . Seek local dependable sources ofpost- APOC 6 UGANDA *PHASE I CDTI (HOIMA, KASESE, KISORO, MASINDI) . Geographical coverage is high . Integrated into the PHC at the district level . Heavily dependent on APOC funds . Routine training and supervision . There is budgetary allocation for CDTI at district level . Political commitment is high . Staff are well trained and motivated . Inefficient use of resources ' Low level of community ownership of CDTI Proj ect has made satisfactor)' progress towards sustainabilitl, . Prepare post-APOC sustainability plan . Seek local dependable sources ofpost- APOC tunding . Address the sustainability of using paid ' voluntary' supervisors . Intensifu sensitization and mobilization of communities have been collapsed to one row remarks but all of them