Moving from control to elimination: forecasting and categorization of 107 APOC projects in 15 countries

(AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL Moving I t E E n: HIIL Forecasting and categorization of 107 AP0C projects in 15 countries J '] ,i :'!, I I ]Il ,fI , t, November 2010 f /ilit I I World Health Organization {{$ .6(r) I I II 2BACKGROUND Studies in Senegal and Mali, countries of the former Onchocerciasis Control Programme IOCP] in West Africa, have provided scientific evidence that elimination of onchocerciasis in Africa using lvermectin alone and by annual treatment is feasible. Subsequent epidemiological evaluations of APOC ivermectin treatment projects in onchocerciasis hyper and meso-endemic communities that have distributed the drug for more than 10 years show a drastic reduction in prevalence of infection, in most communities to zero level. Given the approval of the Joint Action Forum (JAF) to continue to evaluate progress towards elimination, and in response to the decision of the 1 28th session of the Committee of Sponsoring Agencies (CSA), the Management of APOC has categorlzed countries and projects into four groups. lt is important to note that although elimination may occur in several communities in foci of infection in a given country, we still cannot declare the country free of river blindness until the entire country, and not just foci, has received certification from the WHO Elimination Committee. The basis of the categorization is explained below. We have also indicated the major activities that countries should take responsibility for before the end of 201 5. This short note summarizes the categorlzation of countries and projects and actions to be taken: 1. What is achievable: is elimination of infection and interruption of transmission of onchocerciasis in Africa feasible and where? Our response is: it is doable by77 out ol1O7 proiects by 2015. ln March 2010, APOC Management requested some experts to advise on technical issues related to onchocerciasis elimination. They developed a broad classification of projects into three categories - i) elimination imminent, ii) feasible and iii) not envisaged for the foreseeable future. We have maintained this broad categorization and included a future time factor (year of anticipated elimination) and graded performance of prolects based on a weighting of geographical and therapeutic coverage to come up with four categories: (see also Table 1) l. Progressing towards elimination by the end of 2012: elimination is imminent (very likely) or has already taken place ll. Elimination possible by end of 2013 lll. Elimination feasible by end of 2015 lV Elimination not envisaged for the foreseeable future We also used as an additional factor, the results of epidemiological evaluations (completed between 2008 and 2010) and stability of the countries to further refine the categorlzation. This classification assumes that the performance of projects will improve or at least follow a similar trend in the coming years. We also assumed that the information provided by prolects on geographlcal and therapeutic coverage is accurate and rellable. We want to caution readers here that the projects categorized into the dlfferent elimination status categories using the criteria mentioned above will only be confirmed when the standard epidemiological and entomological evaluations are completed, Therefore this categorization is not final but will be refined as additional information about the projects becomes available. CATEGORY l: Progressing towards elimination by end of 2012 The projects in this category either have already eliminated onchocerciasis infection and interrupted transmlssion or are on the verge of doing so. A project is included in Category I if epidemiological evaluation results demonstrated elimination or near eli mi nation (zero prevalence) of onchocerciasis infection. Entomological studies will also be necessary to confirm that transmission has stopped. Based on the epidemiological- evaluation results these projects are likely to interrupt transmission by the end of 2012 (end of Phase ll of the APOC programme). Of the '18 projects from which hyper-endemic foci were selected and evaluated from 2008 to 201 0, a total of 8 project foci (7.5o/o) fall under this group. Projects in this category will only need confirmation of elimination and attainment of the breakpoint"where the parasite population is believed to be irreversibly moving to its extinction in a defined geog raph ica I a reai' by cond ucti ng fu rther epidemiolog ica I and entomological studies in the area. CATEGORY ll: Elimination possible by end of 201 3 A project needs to fulfil the following major categorizatlon criteria to be included in this category: (i) At least 10 years of annual treatment by 2012 and (ii) at leastT2o/o weighted therapeutic coverage for 8 years by 2012. The weighted therapeutic coverage was calculated based on the history of the geographical coverage for 3Table 1: Summary of characteristics and criteria for project categorization Characteristics Criteria Country/Projects forecasting CaEgory I Progresring towads fucal dlminadon by end of 2ol2 . The categorization is based on the epidemiological . The projects are categorized here if epidemiological evaluation conducted in the projects showing evaluation demonstrated focal elimination (zero infection level is zero or close to zero - elimination and prevalence) or near elimination of Onchocerciasis interruption of transmission is highly likely. infection and the data are consistent with . Most of the projects in this category have either already predictions of the ONCHOSIM model. eliminated onchocerciasis or are on the verge. . Parasite numbers are too low to sustain transmission. . Based on the epidemiological evaluation results these p@ects are likely to declare focal elimination before 2012 after conducting further entomological end epidemiological evaluations. Category [: Hlmlnation possiHe by end of 20t 3 . Nigeria (Kaduna, Cross river, Ebonyi and Zamfara) - 4 PQects . Uganda (Adjumani, Kasese, Moyo andNebbi)-2Pojects . Chad (two Districts: Bebedja. Danamadji) - 1 Pro.Ject. . Tanzania (Tanga) - 1 Project. . Atotal of 8projects(7.5%)fall under this group. . Transmission reduced to very low level, but may still be sustained. . Further epidemiological and entomological evaluations to be conducted. Category llt Elimhafon feadble.by 201 5 . Transmission reduced to very low level, but may still be sustained. . A few of these projects were launched more recently but show very good performance. Gtegory M Elmination notfcaslbleb€fiore 2Ol5 . Control objective not met (low therapeutic and geographic coverage, etc). . Most p@ects in post conflict countries. . Recently launched projects. . At least 1 0 years of annual treatment by 201 3 and at least 72% weighted therapeutic coverage for 8 yean in 201 3. . The weighted therapeutic coverage was calculated based on history ofthe geographical coverage. . Here we only considered projects with very high geographical coverage 90% and above as a weighting scale. . At least 10 years of annual treatment by 2015 andTvo weighted therapeutic coverage for 8 years by 201 5. . The therapeutic coverage was weighted using data on the history ofthe geographical coverage. . Here we only considered projects with very high geographical coverage 90% and above as a weighted scale. . A total of 29 projects (27.1%) fall under this group. . Most projects from:Tanzania, Cameroon, Uganda, Ethiopia, Nigeria, Burundi, Equatorial Guinea, Malawi. . A total of 40 projects Q7.a%) fall under this group. . Most projects from:Angola, Chad (some Districts), Congq DRC, Liberia, Malawi, 5udan, Tanzania, Cameroon, Uganda, Ethiopia, Nigeria, Burundi. . Those which do not fulfil the criteria for inclusion In the above three categories. . Most p@ects in post<onflict countries fall under this category . Some projects categorized under this group, such as two projects from Burundi, are categorized here because they have been launched recently and would not achieve elimination by 201 5. . There are 30 projects (28.0%) under this category. . Cameroon, and the following, post confl ict countries: Angola, DRC, CAR, Liberia, Sudan. the past five years. Here we considered only the projects with very high geographical coverage 9070 and above (as a weighing scale). A totalof 29 projects (27.1o/o) fall under this group. CATEGORY lll : Elimination feasible by end of2015 A project needs to fulfil the following major categorization criteria to be included: (i) At least 10 years of annualtreatment by 2015 and (ii) atleastT2o/o weighted therapeutic coverage for 8 years by 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, 90% and above as a weighting scale. A total of 40 projects (37.4Vo1fall under this group. CATEGORY lV: Elimination not envisaged for the foreseeable future The projects that did not fulfil the criteria to be included in categories l, ll, lll and most projects in post conflict countries were included here. We considered that at least 30 projects (28.Oo/ol will remain in this category by 2015 t CATEGORY l: Progressing towards elimination by end of 2012 (8 projects or7.5o/o) r/ Conduct Phasel.b. Epidemiological and entomological studies and confirm that the breakpoint has been reached and that treatment can be safely stopped/ Stop trealment after adequate preparation including prospection of the entire transmisslon zone (vector studies and population), sensitization of com munities./ Start post-treatment surveillance and continue for at least 3 years.y' Undertake extra Evaluation in the adiacent areas during the post treatment surveillance. CATEGORYII: Elimination possible byend of 2013 (29 projects or27.1%l Continue with ivermectin treatment. Undertake extra entomological /epidemiological evaluation in the adjacent areas. Define transmission zone including the adjacent localities with high transmission - I 187,143 1,727 A86 2,305,877 208 208 488 222 507 1,610 478 505 2,597 6,407 129 129 3202 848 4,050 672 672 2,784 1,000 422 559 1,024 111 885 8r0 r,069 579 f 20< 1,509 247 13,384 970 298 7,2@ 1,985 892 2,877 2&905 794,907 794,N7 386,690 102,468 292,947 527,238 387,207 236,212 1,654,938 3,587,7OO 80,206 80,206 1,161,273 280,259 1,441,532 859336 859,335 1,540A76 1,576,068 1,171,143 377,795 1,709,913 305,71 3 1,454,051 6U,832 1,0&,572 1,297,498 1,036,329 1,808,393 540,633 14,563,416 482,954 107,155 590,1G' 1,219,150 767,533 1,986,683 23803,889 BURUNDI Cibitoke-Bubanza SubTotal CAMEROON Adamaoua 2 Centre 2 Centre 3 Northern South West I South West ll Western EQ. GUINEA SubTotal Bioko SubTotal ETHIOPIA Kafa-Shekka North Gondar NIGERIA Kaduna Enugu-Anambra-Ebonyi Cross River Zamfara SubTotal 7,159 2,677 3,408 958 'l 16 1,309 1,309 1,155,2',r 1 241,808 5,430,382 698,070 302488 302/488 TANZANIA Tanga SubTotal SubTotal Thyolo-Mwanza SubTotal Adamawa Edo-Delta Ekiti FCT Gombe Jigawa Plateau-Nassarawa Kano Kwara Ondo oyo Taraba Yobe SubTotal Kilosa Tukuyu SubTotal Phase lll Phase lV SubTotal 29 CDTI projects MALAWI NIGERIA TANZANIA UGANDA Action to be taken Country Project Name Comm.Tot (200e) Pop.Tot (200e) 8 countries 4 2.Which countries fall into the different categories? Based on the above classification most of the projects in categories lto lll are in l3 countries, namely Angola, Burundi, Cameroon, Chad, Congo, DRC, Ethiopia, Liberia, Malawi, Nigeria, Sudan, Tanzania and Uganda. Several projects in post conflict countries fall into category lV: CAR, DRC, Liberia and the southern part of Sudan. (See tables below) Action to be taken Country Project Name Comm,Tot (2009) Pop.Tot (200e) 187,143191CHAD 191SubTotal UGANDA SubTotal 406 1,461 1,867 1,06,2,292 Phase I Phase ll 4 countrier,''s coTI pde(ts &2disnricta {0.526 6982,305 Action to be taken 5 CATEGORY lll: Elimination feasible by 2015 (40 projects or37.4%l r/ Continue ivermectin treatment until programme objectives (control) are fully met. ANGOLA r/ Reinforce support to countries to improw ivermectin treatment untll programme objectives are met./ Complete REMO where necessary r/ Consider other strategies to improve tleatment coverage and applywhere necessary. ANGOLA MALAW 80r 452 1,253 76 84 160 439 551 275 291 7@ 738 ffi 3,5r1 3,059 3,059 748 22 770 3,606 38r 1,396 2,535 770 1,275 4,29 36 3,791 4,125 2W 4,120 18,26 3,196 3,196 1,514 1,574 '13 988 1,689 2,211 26 2,544 3,026 952 1,550 13,2ffi 143 143 531 871 1,127 536 3,065 l5iffi 211 340 336 415 1,302 324 324 5,0t4 5,014 3,058 1,473 1,621 1,614 9,627 2,1 38 705 1,1 08 1,003 1,388 1,286 636 2,754 1,997 1,065 1,091 32,5A 1,686 598 2,2U 2,382 2,395 1963 s60 5y 2,522 904 6503 tt,l$ BURUNDI CAMEROON CHAD CONGO DRC flHtoPtA LIBERIA Lunda Norte Lunda-Sul SubTotal Bururi Rutana SubTotal Adamaoua I Centre l East Far North Nonhwest South Province Littoral ll SubTotal Chad (18 districts) SubTotal Congo 1 Congo Extension SubTotal Bandundu Lualaba Sankuru Ueles SubTotal Bench MaJi EastWollega Gambella lllubabor Jimma Metekel WestWollega SubTotal Southwestern SubTotal Malawi Extension SubToal Akwa-lbom Bauchi Borno lmo-Abia Kebbi Kogi Niger Ogun Osun SubTotal Northern Sector SubTotal Mahenge Morogoro Ruvuma Tunduru SubToul 280,817 237,631 510,ffi 343,659 268A17 612,076 474,060 426,449 108,659 269,145 784,952 289,687 153,4U zsoz0l6 1,684,031 1,684,031 759,199 5,716 74,915 1,269,333 193,971 912,780 1,237,093 74,915 674,954 808B58 99,037 730,03s 887,344 147,524 966,757 4,314,6O!t 559,549 559,549 1118970 1,118,970 27,532 1,622,814 1,017,607 1,230,056 386,694 1,605,291 2,253,858 327,805 'r,536,014 9,980,135 31 5,488 31S,a3g 466,122 346,777 37,687 125,449 976,035 za,{.Eygz CAMEROON CAR DRC LIBERIA NIGERIA SUDAN 7 countries Bengo Huila Kuando-Kubango Moxico SubTotal Littoral I SubTotal CAR SubTotal Bas-Congo Butembo-Beni Equateur-Kiri IturFNord Kasai Kasongo Katanga-Nord Katanga-Sud Lubutu Masisi-Walikale Mongala Rutshuru-Ngoma Tshopo Tshuapa UbangFNord Ubangi-Sud SubTotal NorthWest South Eastern SubTo,tal Benue SubTotal East Bahr El Gazal East Equatoria Upper Nile West Bahr El Gazal West Equatoria SubToul 'r0ffiflsi0 e(ali' 1s5964 2@,759 43,485 78,654 $7,852 283,5M 283,5M 1,408,824 1,40,8,824 843,1 30 1A28,752 1,083,91 3 957,629 9,431464 1,168,205 s38, r 83 595,1 65 327,688 913,1 56 1,261,975 458,085 1,486,@9 1,207,270 695452 1,027,251 23A23,927 1,215,387 301,347 1,516,734 3,281,985 3,309,517 761,917 963,727 487,939 2,702,724 689A19 5,@5,726 r132866r' NIGERIA SUDAN TANZANIA Action to be taken Country Project Name Comm.Tot (200e) Pop. Tot (2009) Country Project Name Comm.Tot (200e) Pop. Tot (200e) - CATEGORY lV: Elimination not feasible for the foreseeable future (30 projects or 28.0%) I \-- -q-- i t: 6 SUMMARY ln summary, based on the results of epidemiological evaluations conducted and the current performance of projects it is forecast lhat77 (72o/o) of the 107 existing projects will achieve elimination of transmission of onchocerciasis by 2015, i.e. all CDTI projects within categories I to lll (see Table 2). 3. Activities countries should completely take responsibility for before 2015 Before 2015 APOC supported countries and projects will have to take over a number of essential activities that are criticalfor sustaining the control of the disease and significantly increase their financial contributions from the national budget if they want to achieve elimination. These activities include: . Distribution of lvermectin . Core CDTI activities:Advocacy, Health education, Sensitization, and Mobilization of communities to sustain high coverage r Monitoring & Evaluation of lvermectin distribution Resource mobilization & NGDO support o Review of annual technical reports of projects o Epidemiological evaluation and capacity to apply criteria to stop treatment o Entomologicalevaluation . Post-treatment surveillance and evaluation . Data management and reporting to wHo country offices, AFRO and HQ Table 2: Showing number of projects with their elimination status by countries, June 2010 *Some Districts of Chad are still under Category lll as shown in the table that details this category. This is because the project has transmission zones that are still insecure or cross international borders. +Elimination status: Category l: Progressing towards elimination by end of 2012. Category ll: Elimination possible by end of 2013. Category lll: Elimination feasible by 2015. Category lV: Elimination not feasible for the foreseeable future. f L t Elimination status* rI Grand total Country IV ) WHO/APOC/MG/10.2 @ African Programme for Onchocerciasis Contro! (WHO/APOC) 201 0 All rights reserved. The use of content from this health information product for all non-commercial education, training and information purposes is encouraged, including translation, quotation and reproduction, in any medium, but the content must not be changed and full acknowledgement of the source must be clearly stated. A copy of any resulting product with such content should be sent to WHO/ APOC No 1473, Avenue Zombre,0l B 549, Ouagadougou 01, Burkina Faso. The use of any information or content whatsoever from it for publicity or advertising, or for any commercial or income-generating purpose, is strictly prohibited. No elements of this information product, in pan or in whole, may be used to promote any specific individual, entity or product, in any manner whatsoever. 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Any alteration to the original content brought about by display or access through different media is not the responsibility of WHO/APOC and WHO/APOC accept no responsibility whatsoever for any inaccurate advice or information that is provided by sources reached via linkages or references to this health information product. African Programme for Onchocerciasis Control (APOC) World Health Organization B.P 549 - Ouagadougou - BURKINA FASO Tel. +226 50 34 29 s3 | 50 34 29 59 I s0 34 29 60 Fax +226 50 34 28 75 | 50 34 26 48 di ra poc@oncho.afro.who.i nt www.who.inVapoc Anqola 2 4 6 Burundi I 2 3 Cameroon 7 7 I 15 CAR 1 1 Chad* I 1 Congo 2 2 DRC 416 20 Eq. Guinea 1 1 Ethiopia 2 7 9 Liberia I 2 3 Malawi I 1 2 Nigeria 4 13 v I 27 Sudan 1 5 6 Tanzania I 2 4 7 Uganda 2 2 4 I