Moving from control to elimination where feasible: forecasting and categorization of APOC projects: document for the 129th session of the Committee of the Sponsoring Agencies (CSA), 02 July 2010

MOVING FROM CONTROL TO ETIMINATION WHERE FEASIBIE: forecosting ond cotegorization of APOC projects Document for the 129th session of the Committee of the Sponsoring Agencies (CSA) 02 July 2010 World Health Organization African Programme on Onchocerciasis Control (wHo/APoc) APOC monogement, 29 June 2010 MOVING FROM CONTROL TO ELIMINATION WHERE FEASIBLE:/orecasting categorization of APOC projects Background Studies in Senegal and Mali (ex-OCP countries) provide scientific evidence that elimination of onchocerciasis in Africa using ivermectin alone and by annual treatment is feasible. Subsequent epidemiological evaluations of APOC projects in onchocerciasis hyper and meso-endemic communities that have distributed ivermectin for more than l0 years show a drastic reduction of prevalence level, in some foci to zero. Given the approval of the Joint Action Forum (JAF) to continue in the coming years to evaluate progress towards elimination, and in response to the decision of the l28th session of the CSA, the Management of APOC has categorized countries and projects into four groups. It is impo(ant to note that although elimination may occur in several foci in a given country, we still cannot declare the country free of river blindness until the certification of WHO Elimination Committee of the entire country, and not foci. The basis of the categorization is explained below. We have also indicated major activities countries are most likely to takeover by the end of 2015. This short note summarizes the findings: 1. What is achievable: is elimination of lransmission of onchocerciasis in Africa feasible and where? Our response is, it is doable by 70 projects by 2015. In March 2010, APOC Management requested some experts to advice on technical issues related to onchocerciasis elimination. They came up with a broad classification of projects into three categories - elimination eminent, feasible and not envisaged for the foreseeable future. We have maintained this broad categorization and included future time factor in year (anticipated year of elimination) and performanoe of projects based on a weighting of geographical and therapeutic coverage level to come up with foui categories: (Please see also Table 1) I . Elimination eminent (very likely) before 2012 2. Elimination possible by phase II end of 2012 3. Elimination feasible by end of 2015 4. Elimination not envisaged for the foreseeable future We also used as additional factor, the results of epidemiological evaluations (completed between 2008 and 2010) and stability of the countries to further refine the categorization. This classification assumes that the performance of projects will improve or at least follow a similar . CATEGORY I: Elimination very likely before 20L2: The projects in this category either have already eliminated onchocerciasis transmission or are on the verge. A project is included in Category I if epidemiological evaluation results demonstrated elimination or near elimination (zero prevalence) of onchocerciasis infection when compared to the predicted level in the ONCHOSIM model. Based on the evaluation result these projects are likely to elimination trarsmission before 2012 (end of Phase II oFAPOC program). A total of 6 projects (5.6 %) fall under this group. o CATEGORY II: Elimination possibte by Phase II end of 2012: A project needs to fulfill the following major categorization criteria to be included in this category:(i) At least l0 years of annual treatment in 2Ol2 and (ii) at least 72%o weighted therapeutic coverage for 8 years in2012. The weighted therapeutic coverage was calculated based on the history of the geographical coverage for the past five years. Here we considered only the projects with very high geographical coverage 90Yo and above (as a rveighing scale). A total of 29 projects (27oh) fall under this group. Table 3 Table I Showing the basic characteristics and criteria of categorization of projects Category Characteristics Criteria Country/Projects [orecasting l. Elimination eminent before 2012 . Trmsmrssron close to ehmrnatron . Most of the pro.;ect rn thrs category erther hs already ekmrnated onchocercirets or ae on the verge. . Pilastte numbers loo low to Matter . Bued on the evaluatron result these pro.;ects ae hkely to declue eLmrnation before 2012 (end of Phree II of APOC program) The proJects ile categoflzed here rfafter eprdemrologrcal evaluation demonstrated elrmlnatlon or ner elrminatron of Onchocercrxis rnfechon when compiled to ONCHOSIM model Nigeria (Kaduaa, Cross river, Ta raba) Uganda (Phase l, Phase 2) Chad (Bebedja, Danamadji) A toral of6 proJecrs (5 6 %) fall under thrs group 2. Elimioa'tion possiblc by end ofPhase II in 20I2 Trmsmissron reduced to very low level , low but do ma(er . Al lffit l0 yws of mnual treaunent in 20 l2 md ar leat 72oZ werghred (herapeutrc coverage for 8 yeus rn 2012 . The werghted therapeutrc mverage wr calculated bued on hlstory ofthe geographical coverage . Here we only consrdered proJects with very high geographrcal coverage 90Zo md above as a weighing scale A total of 29 pro.lects (27%) fall under thrs group Most proJrcts from :Tanzrnia, Cameroon, Uganda, Ethiopia, Nigeria 3. Elimination feasible by end of Phase out period in 2015 o Trmsmissron reduced to very low level , low but do matter o Most late launched proJ€ts wtth very good perfommce . At l6t l0 yeas of mual treatsnent tn 2015 md at leat 72%" weightd therapeuttc coverage for 8 yers in 201 5 . The werghted therapeuhc coverage was calculated based on hrstory of the geographrcal coverage . Here we only considaed projcts witlr very hrgh geographrcal coverage 90o/o md above r a werghrng scale . A total of35 projects (32.7 o/o) fall under thrs group . Most projects from :Tanzooia, Crmeroon, Ug8nd., Ethiopia, Nigerie I 4. Elimioation Not fcasiblc for lhc forescerblc futu re Control objetive not met (low thempeutic and geographic covemge, rnomplete REMO dat4 ac) Most projects in post conflrct countries Late launched projects those who do not fulfill the criteria to be rncluded rn the above two projects and most projects rn post conflict comtries were categonzed here Some ofthe prcjects categonrcd undfr thrs group lrke two projats from Burundr ue categonzed here because they have been launched reently md would not make rt by 20 I 5- We have 38 pro.;ecs (35.5 %) fall under this group by 2015 Most projets from pos @nflrct ountries: Angola, DRC, CAR, Sudan . CATEGORY III: Elimination feasible by end of 2015: A project needs to fulfill the following major categorization criteria to be included: (i) At least l0 years of annual treatment by 2015 and (ii) at least 72Yo weigfited therapeutic coverage for 8 - years in 2015. The weighted therapeutic coverage was calculated based on the history of the geographic coverage for the past five years. Here we only considered projects which maintained very high geographical coverage,90o/o and above as a weighing scale. A total of 33 projects (30.8 %) fall under this group. Table 3 . CATEGORY IV: In elimination not envisaged for the foreseeable future: The projects that did not fulfill the criteria to be included categories I, II, III and most projects in post conflict countries were include here. We considered that at least 39 projects (36.5 "h) will remain in this category by 2015. Some of the projects, despite there good performance, are categorized under this group (e.g. two projects from Burundi) because they were launched recently and would not have distributed ivermectin for 10 years to achieve the level of elimination of transmission by 2015. SUMMARY In summary, based on the result of epidemiological evaluations conducted and the current performance of projects it is forecasted that in 70 (65.4oh) of the 107 existing projects will achieve elimination of transmission of onchocerciasis by 2015 i.e. allCDTI projects within categories I to III. (Table 2 below) Table 2: Number of projects by country and our forecast of elimination status (by June 2010) Count of Proiect Elimination Status Country Very likely before Dec,2012 Possible by end of 2012 Possible by end of 2015 Not feasible by 2015 Grand Total Ansola 6 6 Burundi I 2 3 Cameroon 7 5 3 l5 CAR I t Chad I I Conqo 2 2 DRC 4 l6 20 Eq. Guinea l I Ethiopia 2 6 I 9 Liberia I 2 3 Malawi I I 2 Niseria 3 l4 8 2 27 Sudan I 5 6 Tanzania 3 4 7 Uganda 2 2 4 Grand Total 6 6.6Yol 29 OTYol 33(30.6%) 39 /,36.570l 107 2. Which countries fall into the different categories? Based on the above classificatior'most of the projectsjn categories I to III are in 7 countries- namely- Cameroon, Chad, Ethiopia, Malawi, Nigeria, Tanzania, and Uganda. Several projec6 in counhies in post conflict situation fall under the category IV: Angola, CAR, DRC, Liberia and South Sudan. See Table 1& 2. Table 3: Forecasting projects where elimination is very likely, possible or not envisagedinthe foreseeable future Category Characterbtics Action to be tuken C o u n t r y/P r oj e cts fo r e c a s t i n g I. Elimination very likely beforc 2012 (6 projects or 5.6 Yo) Trmsmrssron close lo elrmrnatron Pilasrte numbers too low to rnatter Slop treatment afler adequale prepilatron including prosp6tion of ahe etrtire Nigerir (3): Kadun4 Cross nver md Taraba populatiotr), s€nsrlizatron of communitis Strt post-treatment suruerllmce md contlnue for at le6t J yeils Undertake eva.luatlons ln th€ adJacent reas durrng the post treatment survelllmce Uganda (2): Phroe I ad Phre Il Chad (l): Bebedla, Danamadji 2. Elimination possible by end ofPhase II in 2012 (29 projects or 27o/o'1 Trmsmrssron reduccd to very low level Pildlte levels low but do matter Contrnue wrth ivemectrn treatment, Undertake extra cntomo/epidemrologrcal evaluatron rn the adlacent rea Good trends rn the core ueas md reductron in trilsmtsston but localrtres ofhrgh trilsmrssron ln ileas adja@nt to the trmsmrssion zone Ptrasrte level also on domwud trend but shll remarns srgnificmt Contrnue with rvemslin trea0nent Redefine trmsmrssion zone rncluding the adlacent localrties with high transmrssron Cameroon (7): Adamaoua 2, Centre 2, Cenhe 3, Northem Provine, South West l, South West II md Western projects Ethiopia (2): Kafa-Shekka CDTI md North Gondu Irtalawi (l): Thyolo-Mwma Nigeria (14): Admaw4 Edo-Delta, Ekitr, Enugu- Anmbra-Ebony, FCT, Gombe, Jigawa, Plateau-Nasilaw4 Kmo,Kwra, Ondo, Oyo, Yobe md Zmfra Tanzanie (3) .Krlos4 Tuga ad Tukuyu Uganda(2): Phme III md Phae IV Bu rundi (l): Cibrtoke-Bubanza 3. Eliminetion fcesiblc by 2015 (33 projects or 30.8%) Control obJective not met (low therapcutic and geographrc coverage, rnomplete REMO data, etc) Continue ivemectrn tseatment unttl programme obJectlves ( control) ue fully met Cemeroon (7): Adamaoua l, Centre l, Est" Fu North and Lrttoral II Chad (l) : Chad Congo (2): Congo I and Congo Exrension DRC(4) : Bandundu, Lualabao Sankuru and Udlis Ethiopia (6): Bench Majr,East Wolleg4 Gambella, Illubator, Jimma md West Wollega Liberia (l):Souihwestm Melawi (l): Malawi Extension Nigcria (8) : Bauchi, Bomo, lmo-Abi4 Kebbi, Kogi, Nrgu, Ogun and Osun Sudan(l): Northem Sector Trnzrni{4): Mahcngc, Morogco, Ruvurna od Tundm Angoh (Q: Bcngo, Huill Kuando-Kubango, Luada- Nortc Lunda-Sul od Moxico 4. Eliminetion Not fcesible for thc foresccrblc futurc (39 projects or 36,5"h) Conrol objectrve not mct (low thaapeutic md geographic coverage, incomplete REMO data, etc) Continue rvermectin tseatm€nt until progrmme objrcuve re fully met Burundi (2): Bururi and Rutana Cemercon (3): Littoral I, Northwest md South ProvincB CAR(l): CAR DRC(16):Bc-Congo, Butembo-Beor, Equatfl r-Krn, Ituri-Nord, Kasai, Kroogo, Katmga-Nord, Katanga-Sud, Lubutu, Masisi-Wdikal€, Mongal4 Rushuru-Ngom4 Tshopo, Tshuap4 [Ibmgr-Nord ad Ubmgr-Sud Equatorial Guina (l) : Broko Ethiopia(l): Metekel Lrberia (2): Noflh west ild South eastem Nigeria (2): Akwa-lbom ild Benue South Sudan(S): East Bahr El Gazal Esl Equatoria Upper Nrl West Bahr El Gazal West Equatona 3. What activities countries can tak-e over (doable) By 20 l5 APOC supported co-untries and projects will have to take over a number of essential activities that are critical for sustaining the control of the disease. These include: o Distribution of Ivermectin o Health education, Sensitization, Advocacy and Mobilization (HSAM) o Monitoring & Evaluation of IVM distribution o Resource mobilization & NGDO support o Impact assessment of operations e Review of annual technical reports of projects . Epidemiological evaluation and capacity to apply criteria to stop treatment o Entomological evaluation . CapaciU building (human resource development) . Data management and reporting to WHO country offices, AFRO and HQ Figure l: Elimination status of onchocerciasis in projects by project countries (bosed on Management session held in June 2010) Status Possble by €nd of 201 5 by end of 201 2 Not leasrbls by 201 5 lmmrn€nt bofore 2012 IBtqEs$sggg$ "tfi_<zE"F_E; laomltl