African Programme on Onchocerciasis Control: progress report

e<a*, WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR AFRICA @ ORGANISATION MONDIALE DE LA SANTEBUREAU REGIONALE POUR L'AFRIQTIf, REGIONAL COMMITTEE FOR AFRICA RC55, Maputo, Mozambique,22-26 August 2005 lnformation document AFRICAN PROGRAMME ON ONCHOCERCIASIS CONTROL: PROGRESS REPORT EXECUTIVE SUMMARY Onchoncerciasis also known as River Blindness is a dreaded, disfiguring disease caused by parasitic worrns which enter the body via the bite of a small blood-sucking fly, Similium Damnosum or blackfly. Onchocerciasis occurs in thirty (30) countries in Africa 29 of which belong to the African Region. It is estimated that 173 million people were at risk of the disease in the Region as of 2000 (OCP countries: 103 million persons and APOC countries: 70 million persons). Blindness is by far the most serious manifestations of onchocerciasis, afflicting up to one third of individuals living in communities hit by the disease. It is reported in the literature that onchocerciasis causes 46,000 new cases ofblindness annually and that at least 15 million people are heavily infected and at risk ofdeveloping skin disease. The importance and the devastating effects ofonchocerciasis skin disease have been documented during the recent decades. Blackflies infest those areas that are most productive, the river banks. Because ofthe threat blindness caused by the biting of the blackflies entire communities are forced to abandon their fertile lands for less productive ones. River blindness therefore affects the economic wellbeing of communities. ln 1974 the international community established the Onchocerciasis Control Programme (OCP), which covered ll affected countries in West Africa. In 1987 Ivermectin was registered for human use and Merck made the decision to donate it free ofcharge as long as it is needed for onchocerciasis treatment. Since 1989 OCP adopted mass treatment with ivermectin as its second strategy. The OCP has achieved its objective and was closed on 31 December 2002. With the advent of lvermectin in 1987, the initial successful implementation of mass treatment for onchocerciasis within the OCP area and the existence of a well organized NGDO (Non-governmental Development Organizations) for ivermectin wide-scale distribution, it became possible to address the problem of onchocerciasis in the remaining endemic countries of the Region and Sudan. This led to the establishment of the African Programme on Onchocerciasis Programme (APOC) in December 1995. In 2003, 57 CDTI projects were implemented covering a total population of 48,057,039. During the same year 31,700,570 people living in 65,575 communities received ivermectin treatment. Overall, this represents 65.9%o treatment coverage rate, which is above the set threshold therapeutic coverage rate of 65%0. lt also represents 84.5%o of the annual treatment objective of the same year. However, only 26 projects reached 100% geographic coverage in 2003 and I I projects (192%) were below the threshold of therapeutic coverage rate of 650/o. APOC has successfully fulfilled its mandate so far as evidenced by the results of ivermectin treatment using the CDT approach, the progress towards eradication of blackflies in selected foci, the capacity built in affected countries for programme implementation and progress made with regard to integration of other public health interventions into the CDTI. It is expected that APOC will achieved its objective by 2010. TABLE OF CONTEI{TS SECTION 1 PARAGRAPH BACKGROI.IND AFRICAN PROGRAMME ON ONCHOCERCIASIS Scope Goal Objective Strategy Structure PROGRESS MADE IN PROGRAMME IMPLEMENTATION Epidemiological and Impact Assessment Establishment of Proj ects Implementation of CDTI projects Implementation of Vector Control Projects PROGRAMME MONITORING AND EVALUATION ENABLING FACTORS AND CHALLENGES Enabling Factors Challenges WAY FORWARD CONCLUSIONS t-7 8-17 8-9 10 11 t2-t3 t4-t7 18-33 19-22 23-24 2s-30 31 32-33 34-41 34-36 37 -41 42-43 2 at t 2 BACKGROUND 1. Onchoncerciasis also known as River Blindness is a dreaded, disf,rguring disease caused by parasitic worms which enter the body via the bite of a small blood-sucking fly, Similium Damnosum or blackfly. 2. Onchocerciasis occurs in thirty (30) countries in Africa 29 of which belong to the African Region. It is estimated that 173 million people were at risk of the disease in the Region as of 2000 (OCP countries: 103 million persons and APOC countries: 70 million persons). 3.The manifestations of river blindness are related to the huge number of microhlaria (immature worms) released regularly by the adult females in the body of the infected persons. These immature worrns migrate through the skin and particularly in the eye. The infected persons suffer terrible, continuous itching, develop severe skin disease and eventually, visual impairment as a result of death of microfilaria in the eye. 4. Blindness is by far the most serious manifestations of onchocerciasis, afflicting up to one third of individuals living in communities hit by the disease. It is reported in the literature that onchocerciasis causes 46,000 new cases of blindness annually and that at least 15 million people are heavily infected and at risk of developing skin disease. The importance and the devastating effects of onchocerciasis skin disease have been documented during the recent decades. 5 Blackflies infest those areas that are most productive, the river banks. Because of the threat blindness caused by the biting of the blackflies entire communities are forced to abandon their fertile lands for less productive ones. River blindness therefore affects the economic wellbeing of communities. 6. In 1974 the intemational community established the Onchocerciasis Control Programme (OCP), which covered 11 affected countries in West Africa. The initial main strategy of the OCP was aerial spray of insecticides in rivers with fast-flowing water. In 1987 Ivermectin was registered for human use and Merck made the decision to donate it free of charge as long as it is needed for onchocerciasis treatment. Since 1989 OCP adopted mass treatment with ivermectin as its second strategy. The OCP has achieved its objective and was closed on 31 December 2002. 7. Many other countries affected by onchocerciasis were not covered by the OCP mainly because aerial spray of insecticides was not feasible in those countries. With the advent of Ivermectin in 1987, the initial successful implementation of mass treatment for onchocerciasis within the OCP area and the existence of a well organized NGDO (Non- governmental Development Organizations) for ivermectin wide-scale distribution, it became possible to address the problem of onchocerciasis in the remaining countries of the Region and Sudan. This led to the establishment of the African Programme on Onchocerciasis Programme (APOC) in December 1995. J AFRICAN PROGRAMME ON ONCHOCERCIASIS CONTROL (APOC) Scope 8. The African Programme on Onchocerciasis Programme covers 18 countries in the African Region and Sudan (See Figure 1 below). ftrti.ll rflr I rrc-ntu.dt Figure 1: OCP and APOC countries 9. The APOC is a partnership between the governments of affected countries, the affected communities, international organizations co-sponsoring the prografirme (WHO, FAO, UNDP, World Bank), the donor countries, Foundations, the Mectizan Donation Programme (MDP), the Non-governmental Development Organizations, researchers . It is conceived to be implemented in three phases: Phase I 1996-2001, Phase II2002-2007 and Phasing Out Period (2008-2010). The APOC embodied a strong public-private mix. Goal 10. The ultimate goal is the elimination of onchocerciasis as a disease of public health importance and socio-economic importance throughout Africa and so improve the welfare of its people. Objective 1 1. To establish, within a period of 12 to 15 years, effective and self-sustainable, community-directed ivermectin treatment throughout the endemic areas within the 4 geographic scope of the Programme, and, if possible, in selected and isolated foci, to eradicate the vector by using environmentally safe methods. Strategy 12. APOC has adopted since its inception the community-directed treatment with ivermectin (CDTI) as its major strategy. This is a strategy whereby beneficiary communities are involved in the planning, implementation, monitoring and evaluation of interventions, especially the distribution of ivermectin tablets to those who need them. As a result, affected communities own the programmes. Community Directed Treatment (CDT) is also viewed as a tool that can be used for other public health problems involving the distribution of drugs or related products. From APOC's perception CDT is also believed to be an effective tool for integration of public health interventions. 13. In selected and isolated foci, spraying of insecticides is also used with the view to eradicated the vector. Struture i4. WHO is The Executing Agency of APOC. The Headquaters of the Programme is located in the premises of the former OCP in Ouagadougou. APOC is managed by a Director appointed by WHO. The Director is assisted by a Coordinator of the Office of the Director. The APOC Secretariat is composed of the following units: Administration, Finance and Budget, Epidemiology and Vector Control, Community Directed Treatment and Community Empowerment. 15. The Joint Action Forum is the body that makes final decisions with regard to political, strategic and managerial issues; for example annual plan of action, allocation of resources. The JAF meets annually alternatively in a donor country and in affected country. The JAF is composed of representative of govemment of affected countries, representatives of donors, representatives of NGDOs, representatives of the co- sponsoring agencies, representatives of MDP and representatives of the Executing Agency as ex-officio. 16. The Committee of Sponsoring Agencies (CSA) follows up on decisions made by the JAF and acts on its behalf during the intervening time of the JAF meetings. 17. The Technical Consultative Committee (TCC) is the body that advises the Director of the programme on technical matters. It is composed of 11 members selected on their personal merits. PROGRESS MADE IN PROGRAMME IMPLEMENTATION 18. The APOC launched its operations in 1996. The progress made so far is reviewed against the targets set in the prograrnme document. 5 Epidemiological and Impact Assessments 19. The Rapid Epidemiological Mapping of Onchocerchiasis (REMO) developed during the era of OCP has been extensively used in the APOC progralnme to determine communities needing ivermectin mass treatment. As of July 2004 nine countries (Cameroon, Chad, Malawi, Nigeria, Tanzania, Kenya, Gabon, Mozambique and Rwanda completed their REMO exercises. In ten countries (Angola, Burundi, CAR, Congo, DRC, Equatorial Guinea, Ethiopia, Liberia, Sudan and Uganda) REMO is partially completed (see figure 2 below). Data generated by the REMO have been used to prepare 111 CDTI projects. To insert REMO MAP here 20. However there are concerns that some results of the REMO tend to overstate the problem of onchocerciasis. Therefore its reliability needs to be critically reviewed. 21. Serious Adverse Events (SAEs) to ivermectin treatment were reported in 5 countries where onchocerciasis and Loa loa co-exist. These SAEs occurred individuals who had high level of Loa loa microfilaremia and took ivermectin in the context of mass community treatment. This led the APOC in collaboration with TDR to develop a rapid assessment tool (the RAPLOA) to detect communities where people may have heavy loads of Loa loa microfilaremia as this is a contraindication to ivermectin treatment. The RAPLOA has been validated in Cameroon, Nigeria, Congo and DRC. RAPLOA has been used in field conditions in Angola and it is expected to be widely used at field level very soon. 22.Itwas planned to conduct three cross-sectional studies at five years interval in order to assess the long-term impact of APOC operations. These studies are intended to test the following hypotheses: regular ivermectin mass treatment will (i) reduce severe itching, prevent the development of onchocercal skin disease, may regress early skin lesions; (ii) prevent development or delay progression of onchocercal eye lesion and blindness and may regress early stages of ocular lesions; (iii) lead to reduction of vector infectivity and (v) lead to improvement in socio-economic status of community members, reduce or remove adverse socio-economic consequences of onchocerciasis. The impact assessment is therefore composed of four tlpes of study: dermatology, ophthalmology, entomology and socio-demography. Phase I or baseline studies started in 1998 and were completed in 2000. Sites in 8 countries instead of 9 as initially planned have been assessed. Phase II is ongoing and will be completed by end of 2005. 6 Establishment of Projects 23. As of August 2004 a total of 115 projects had been approved by the APOC Management: (i) 104 CDTI projects (85 projects were supposed to be supported in 2004); (ii) 4 vector elimination projects, and (iii) 7 National Onchocerciasis Task Force (NOTF) Secretariat projects. 18 CDTI projects have received five years of APOC funding and are in their sustainability eruwhereas 24 projects are in their 2nd, 3'0, 4'n and 5'h years. 24. It is observed that non-compliance to good financial practices of WHO (timely submission of financial returns) by some recipient countries is affecting negatively the pace of approval of projects by the APOC Management. Implementation of CDTI Projects 25. Since 1996 the progression of CDTI implementation has been very good as summarized in the figure 3 below. Numb.r of pcEons tn.t.d b.twn 1997 and 2m3 in APOC countrEs 35,000,000 30,000,000 25,000,000 20,000 000 15,000,000 10,000,000 5,000,000 F t tr Projected tr Treated E -4 c ^d ,s '*i "s ,s Figure 3: Number of persons treated against number projected 26. In 2003, 57 CDTI projects were implemented covering a total population of 48,057,039. During the same year 31,700,570 people living in 65,575 communities received ivermectin treatment. Overall, this represents 65.90/o treatment coverage rate, which is above the set threshold therapeutic coverage rate of 65%. h also represents 84.5% of the annual treatment objective of the same year. However, only 26 projects reached 100% geographic coverage in 2003 and 11 projects (19.2%) were below the threshold oftherapeutic coverage rate of 65Yo. l 2l.The cost per treatment ranged from 0.26 USD to 1.36 USD. These figures do not include the monatery value of the volunteer time of CDDs and other community members. The costs of add-on interventions are not included also. 28. Achievement of sustainability is at various levels in countries. For example, CDTI projects in Uganda and in parts of Nigeria (Kaduna and Taraba) have almost achieved sustainability whereas the situation in Malawi and Cameroon raises some concerns. 29.In2003, more than 150,000 community directed distributors of ivermectin (CDDs) and 15,542 health workers were trained in 14 countries and have participated in the implementation of CDTI projects. This represents a significant contribution to health system strengthening. 30. Integration of other public health interventions onto CDTI has already commenced. Vitamin supplementation is being integrated into CDTI projects in four selected countries of the Programme (DRC, Nigeria, Tanzania and Sudan) Implementation of Vector Control Projects 31. Aerial spraying or ground larviciding were implemented in the targeted foci as described below: Tukuyu Focus: the first ground larviciding was done in 2003 and a second last vector elimination campaign in this focus from October 2004 through the end of 2005. O Mpamba-Nkusi focus: larviciding started in this focus in 2002 and is still planned to continue as well as entomological surveillance. Itwara focus: since 1997 the main focus of Itwara focus is free of blackflies. The sub-foci of Siisa and Aswa are also free of blackflies since 2002. Bioko Focus: A first larviciding was completed by 2003. The second planned for 2004 has been rescheduled for 2005 due to late late delivery oflarvicides. Programme Monitoring & Evaluation 32. Self-monitoring has been introduced by APOC and is being implemented by each CDTI project. In addition the APOC management has initiated since 1999 independent monitoring of CDTI projects by external experts. The results of the independent monitoring are used to continuously improve the performance of the specific project and the performance of the APOC programme as a whole. 33. The mid-term external evaluation of Phase I of APOC was completed in 2001. In general, the opinion of the experts was that the programme was performing. o a o 8 ENABLING FACTORS AND CHALLENGES Enabling factors 34. APOC enjoys a sustained generosity of the international community as was the case of OCP. It also benefits from a strong commitment of the NGDO community. 35. Government of affected countries are committed to the programme and are providing necessary support for the implementation of the prograrnme. 36. Members of affected communities were made to understand the problem of river blindness and are participating in all aspects of the prograrnme at the implementation level. Challenges 37. There is a need to put in place effective coordination mechanisms for Ex-OCP countries as well as for the Multi-disease Surveillance Centre. 38. It is still possible to do more with regard to integration of other interventions into CDTI. The programme should innovative avenues to establish linkages with other public health interventions at country level in order to realize the full potential of the CDT approach. 39. The co-endemicity of Loa loa with onchocerciasis is impeding the pace of the scaling of CDTI coverage rates (geographic and therapeutic) and is obstacle to the realization of the objective of the APOC. In addition, achieving and sustaining high geographical and therapeutic coverage rates in conflict zones is critical in reaching the the set treatment target. 40. There is a financial gap of .......USD that needs to be filled 41. Sustainability of CDTI projects is still to be fully achieved. Increasing and sustaining goverunent financial commitment to onchocerciasis control will play an important. WAY FORWARD CONCLUSIONS 42. APOC has successfully fulfilled its mandate so far as evidenced by the results of ivermectin treatment using the CDT approach, the progress towards eradication of blackflies in selected foci, the capacity built in affected countries for programme 9 implementation and progress made with regard to integration of other public health interventions into the CDTI. It is expected that APOC will achieved its objective by 2010. 43. The programme needs to work closely with government of affected countries in order to ensure that sustainability of CDTI projects is achieved satisfactorily. APOC needs also to find effective mechanisms for collaboration with the MDSC and coordination with the ex-OCP countries. 10