FORUM D'ACTION COMMUNE Bureau du Pr6sident , 2001 African Programme for Onchocerciasis Control Programme africain de lutte contre l'onchocercose ( I TheWorld Health Organ Year 2001 Progress Report: 1 September 2000- 31 August 2001 ization IAF7.4 ORIGINAL: ENGLISH October 2001 c o r.:"ti,jart ,r*:afii t' a- { I -\ ,l42 - t trf trtrf trtrtrf trtrf trtrtrtrf trtrtrtrr-trtrr=trtrtrf r-rr*r AcFnow fe[gements We would like lo sincerely thank all of the APOC partners for the ffirts this year. This report could only partially document their countless contributions and achieve' ments. trtrtrtrtrfufE TABLE OF CONTENTS LIST OF ACRONYMS 1. SUMMARY INTRODUCTION ACTIVITIES OF THE NATIONAL ONCHOCERCIASIS TASK FORCES AND THE COMMUNITIES 3.1 Community -Directed Treatment with Ivermectin (CDTI) iv 22 J 3.1.1 3.t.2 3.2 3.2.r 3.2.2 3.2.3 3.2.4 3.3.1 3.3.2 3.3.3 Status of CDTI projects Status of ivermectin treatment Establishing sustainable drug delivery systems Status of establishing sustainable ivermectin delivery systems APOC's CDTI strengthening health care delivery system Main Accomplishments Main challenges J J J 4 6 6 7 8 8 93.3 Working Hard to achieve sustainability of CDTI strategy Cameroon: Management of severe adverse experiences (SAEs) Strengthening Health Care System through CDTI Cost recovery Government and Communiry Commitment 3.4 Advocacy and IEC by National Onchocerciasis Control Task Forces Sratus of Drug shipment and storage ACTIVITIES OF THE TECHNICAL CONSULTATIVE COMMITTEE (TCC) Role and Function of TCC Highlights of TCC Achievements ACTIVITIES OF THE APOC MANAGEMENT STAFF Preparation of APOC Phase II and the Phasing out Programme Document Status of financing first, second, third, fourth and fifth year projects Financial Management of CDTI projects 3.5 4.1 4.2 5.1 5.2 5.3 9 9 10 4 5 10 11 t2 t2 13 t4 t4 t4 t4 5.3.1 5.3.2 s.3.3 5.3.4 Capacity building Auditing/Checking Timely disbursement of installments of funds to projects Major achievements 5.4 Inventory of capital equipment delivered to Projects in the countries t4 t4 15 15 15 5.5 In-Country capacity building t5 5.6 Country support visits 16 5.6.1 5.6.2 5.6.3 5.7 .t 5.7.2 5.8.1 s.8.2 6.3 Support visits by Management scaff CDTI implementation in onchocerciasis and loasis co-endemic zones Support visis by Temporary Advisors and Consultants 5.7 Major meetings and workshops CONTRIBUTION OF THE NON-GOVERNMENTAL DEVELOPMENT ORGANIZATIONS (NGDOs) COORDINATION GROUP l6 T7 T7 l8 NOTF meeting in Ouagadougou Inter-Agency meeting in Uganda 5.8 Special Programme Activities 5.8.3 5.8.4 5.8.5 First Programme booklet Publication of APOC activities as special supplement in the Annals of Tropical Medicine and Parasitology Video film production in Cameroon Special Film mission to Uganda Meeting of Impact Assessment teams I and [I 6.1 VECTOR ELTMINATION ACTIVITIES Itwara Focus, Uganda Mpamba-Nkusi Focus, Uganda Bioko Island, Equatorial Guinea Tukuyu Focus, United Republic of Tanzania RAPID EPIDEMIOLOGICAL MAPPING OF ONCHOCERCIASIS (REMO) AND GEOGRAPHICAL INFORMATION SYSTEM (GIS) OVERVIEW OF COLLABORATION WITH OTHER WHO GROUPS Collaboration with WHO/OCP Collaboration with WHO/AFRO Collaboration with WHO/HQ Collaboration with WHO/TDR: OPERATIONAL RESEARCH CONTRIBUTION OF WHO/AFRO 6.2 18 19 6 q 19 19 19 20 20 20 2t 22 23 24 25 26 28 28 28 28 29 31 32 33 7 8 6.4 8.1 8.2 8.3 8.4 10 9 11. CONCLUSION TABLES Table l: Table 2: Table 3: Table 4: Table 5: Table 6: Table 7: Table 8: Table 9: Table l0: Figure 1: Figure 2: Figure 3: Figure 4: APPENDICES: Appendix 1: Appendix 2: Appendix 3: Approved projects by country Number of Mectizan Tablets shipped to countries Project Proposals, Technical and Financial Reports reviewed by TCCI2 in 2001 Nationals trained in specific areas for project implementation Country support visits by APOC Management Country support visits by Temporary Advisors and Consultants Vector Elimination Projects Examination of river crabs for immature stages of S. neavet in Itwara and sub foci Status of REMO/GIS in APOC countries as at 3l August 2001 Countries where NGDO Group Members collaborate with APOC Treatment coverage by country Geographic coverage by country Rapid Epidemiological Mapping of Onchocerciasis, Mozambique CDTI Areas for large-scale ivermectin distribution in APOC countries (a) Annual treatment objective (ATO) and persons treated as at 31 August 2001 (b) Communities treated as at 31 August 2001 Equipment distributed to projects (1997-}Nl) Financial overview-Letters of Agreement finalized for the 2001 budget J 1l T2 16 16 18 2t 34 34 35 36 23 26 32 5 5 27 27 t CC ADB AFRO APOC ATO CBM CDC CDD CDTI CSA DMO EAC GRBP GTZ HIS HKI HMIS IEC lv LIST OF ACRONYMS African Development Bank African Regional Office (WHO Regional Office for Africa, WHO-AFRO) African Programme for Onchocerciasis Control (Programme Africain de Lutte contre l'Oncho- cercose) Annual treatment objective Christoffel-Blindenmission (German NGO) Carter Center (The Carter Presidential Center) Centers for Disease Control and Prevention (US Public Health Service) Community-directed distributor Community-directed Treatment with Ivermectin Committee of Sponsoring Agencies District Medical Officer Dermal onchocerciasis (see OD, OSD) Expert Advisory Committee (OCP scientific advisory group) Geographic Information System Global 2000 River Blindness Program (Carter Center) German Technical Cooperation (German research support agency) Health Information System Helen Keller International (US NGO) Health Management Information System Information, Education, Communication DO GIS IEF JPC LF IMA JAF KAP LGA MDP MEC MIS MOH NDS NGDO NGO NOCP NOTF OCP OPC OSD OV PHC REA REMO International Eye Foundation (US NGO) Interchurch Medical Assistance (US NGO) Joint Action Forum (APOC governing body) Joint Programme Committee (OCP governing body) Knowledge, Attirude, Practice Lymphatic Filariasis Local Government Area MectizanrM Donation Program MectizanrM Expert Committee Management Information System Ministry of Health National Drug Service Non-Governmental Development Organization (see NGO) Non-Governemental Organization (see NGDO) National Onchocerciasis Control Program National Onchocerciasis Task Force Onchocerciasis Control Programme in West Africa Organisation pour la Pr6vention de Ia C6cit6 (French NGO) Onchocercal Skin Disease (see OD, DO) Onchocerca Volvulus Primary Health Care Rapid epidemiological Assessment Rapid Epidemiological Mapping of Onchocerciasis SmithKline Beecham (pharmaceuticals producer) 3 SB SSI TCC TDR UNICEF WR VC WB Sight Savers International (British NGO) Technical Consultative Committee (APOC scientific advisory group) Special Programme for Research and Training in Tropical Diseases United Nations Children's Fund Vector Control World Bank (The World Bank) World Health Organization WHO Representative (country-specific) wHo Scprcmber. 20() I vl JAF 7.4 Page I )( 1. SUMMARY The major activities undertaken by endemic communities, the National Onchocerci- asis Task Forces (NOTFs), the NGDO Coordination Group, the Technical Consultative Commit- tee (TCC), the CSA and APOC Management in the year under review (September 2000-August 2001) were as follows: (i) More than sixty thousand (61,930) communities are participating in decision-making in the planning and managing the distribution of ivermectin. Over eighty thousand ( 89,173) Community Directed Distributors (CDDs) and 34,172 health care personnel had been trained in CDTI. (ii) Through Community-Directed Treatment with Ivermectin (CDTI),20,684,068 people (89% of the Annual Treatment Objective (ATO) for 2001) had been treated in 44,057 communities by August 2001, in 42 projects. Ivermectin distribution is continuing in many projects. Complete treatment data will be available in March 2002. (iiD Rapid epidemiological mapping of onchocerciasis (REMO) surveys to select commu- nities for mass treatment with ivermectin were carried out in four countries. This exer- cise has been completed in 13 APOC countries and the results integrated into the geo- graphical information system (GIS). (iv) Evaluation of the Itwara focus in Uganda in March 2001 revealed the focus has re- mained vector free. Ground larviciding in the sub-foci of Siisa and Aswa to prevent re-invasion of the Itwara main focus and large-scale ground larviciding with temephos in the Bioko island were remarkably successful. (u) The TCC members reviewed forty+wo (42) technical reports, seven (7) new Project Proposals for ivermectin distribution and nine (9) operational research proposals. ("i) APOC Management reviewed financial reports and budgets from 25 projects and processed 54 [,etters of Agreements. The total financial commitment in the Year 2001 for these projects to be paid from the APOC Trust Fund is US$4,922,025. (vii) More than 80% of the approved CDTI projects have submitted timely and satisfactory expenditure returns in the year under review. (viii) Through joint effort of the APOC Partners, the Programme Document to cover the op- erations of APOC during is Phase II and the Phasing out Period has been prepared for consideration at the seventh session of the Joint Action Forum. (ix) APOC Management staff undertook six (6) support visits to four (4) countries. Two of the visits were joint missions with representatives of The World Bank, the Non- Governmental Development Organizations (NGDOs) Coordination Group and TCC. The purpose of the visits included advocating for strong partnerships, attending NOTF Review meetings and Inter-Agency meeting on Community-Directed Interven- tions (CDI), providing technical advising in CDTI project implementation and man- agement and providing training in financial accounting. (x) Six local NGOs: Mission to save the Helpless (MITOSATH), Nigeria, Christian Health Association of Liberia (CHAL), Mundri Relief Association and Sudan Health Association (S. Sudan), Association des Techniciens de Sant6 Publique (Congo Braz- zaville) and Christian Social Services Commission (CSSC), Tanzania have been offi- cially recognized by the NOTFs and actively involved in ivermectin distribution. .t JAF 7.4 Page 2 2. INTRODUCTION Today at the threshold of a new millennium, more than 70 million people in APOC coun- tries remain at risk of contracting onchocerciasis- a blinding, disfiguring and debilitating disease which is preventable. APOC faces a particular challenge in achieving its goals in member coun- tries where there is significant civil unrest. In Liberia, Sudan and DRC the Programme is going ahead, but it is constrained by civilunrest and the breakdown of the official health care service. It is to reach the people including those in war-torn countries that the partners of APOC adopted the CDTI strategy and worked hard during the year under consideration to strengthen and improve flexibility in CDTI implementation in conflict areas with a view to attaining the Programme's objective: 'To establish, witltin a period of 12 to 15 years, effective and self-sustainable, community-directed ivermectirt treatment throughout the endemic areas in the geographic scope of the Prograntnte, and, if possible, in selected and isolated foci to eradicate the vector by using environmentally safe methods." J APOC in Southem Sudan: program manager experiences and views "One of the major assumptions of the CDTI strategy is that communities are stable. Be- cause of the protracted conflict, Southern Sudan remains an exception. The frontline of the con- flict transects some of the major endemic counties in northern Bahr el Ghazal and eastern Equato- ria. Displacement of the population continues to be a major obstacle in our ability to provide pre- cise census data and annual coverage figures to MDP and APOC. Despite these circumstances, there have been a few positive developments in adopting CDTI. The Health Policy of the New Sudan recognizes onchocerciasis as a priority public health problem in its PHC health service package and supports the CDTI concept of community owner- ship. The Southern Sudan health authorities have taken the initiative to form an onchocerciasis task force to further expand the CDTI strategy and involve affected communities. There are large endemic areas in southern Sudan that have adopted CDTI and have begun to understand it. Our aim over the next two years is to ... focus more on community education on CDTI. The major impediments are the absence of a functioning health system... and underde- velopment. We are moving away from reliance on NGO partners and working with the develop- ing County Health Departments and newly formed Onchocerciasis Task Force of the New Sudan. The forced withdrawal of some of our NGO partners revealed a weakness in this environment but uncovered our strength in our ability to focus on local capacity. We greatly appreciate the attention APOC and the NOTF have paid to the difficulties in implementing CDTI in conflict areas. Flexibility must be allowed, especially for programmes working in areas where there is no government support or health system to integrate CDTI". Southern Sudan, Year 3 CDTI, 6 ntonth interim technical report. Dec.2000 ,,F |1 , 1a -'. t 0 af i:5 - I .r-t" l*t t. 'i "'i!'"1: JAF 7,4 Page 3 3. ACTMTIBS OF TI{E NATIONAL TASK FORCES (NOTFs) AND COMMUNITIES 3.1. Community-DirectedTreatmentwithlvermcctin(CDTI) APOC's Community-Directed Treatment with Ivermectin (CDTI) is a strategy that focuses on the control of onchocerciasis through communiry capacity-building and empowerrnent. It em- braces joint initiatives such as joint advocacy, monitoring and supervision by MOH, NGDO and Community as well as decentralisation of decision-making and devolution of powers to endemic communities. The CDTI aims to foster sustainable ivermectin distribution and attainment of ac- ceptable treatment coverage through strong community participation and ownership. Endemic communities organize durable systems for procuring ivermectin from the nearest health facility, for storing the drug in appropriate conditions, and for treating all eligible individuals. In the year under review, the communities and the NOTFs have made encouraging progress in implementing CDTI. 3.1.1 Status of CDTI projects ./ Rapid Epidemiological Mapping of Onchocerciasis (REMO) has been completed in thir- teen (13) of the nineteen (19) countries. This tool is useful to delineate communities and population eligible for mass treatment by CDTI method. The most recent REMO exercise was in Mozambique, in July 2001 (Figures 3 and 4). { Three (3) new CDTI projects were approved as at August 2001 ( Kilosa in Tanzania (l), Ulele in DRC (l) and Center I Province in Cameroon (l). ./ To date ( August 2001),66 projects in l4 countries have been approved comprising of 56 CDTI projects, six headquarters strengthening projects and four vector elimination projects ( table I below). There are 8 CDTI projects in Year l, 17 in Year 2,21 in Year 3 and I0 in Year 4. Fifty-five (98%) of the approved 56 CDTI projects are well underway, and im- plementing CDTI in the l4 countries. { Thirty-six (36) CDTI projects submitted technical and financial reports which were re- viewed during the twelfth session of the TCC. The remaining reports are expected at the forthcoming session of the Committee in September, 2001. Table I : Approved Projects by Country as at August 2001 COUNTRY No. of Projects LIBERIA MALAWI I NIGERIA 27 SUDAN 3 TANZANIA 7 UCANDA 6 TO'TAL 66 COUNTRY No. of PROJECTS CAMEROON l0 CAR CHAD I CONGO BRAZZ- VILLE 1 DRC 3 ETHIOPIA 2 EQ GUINEA 2 GABON I I JAF 7.4 Page 4 3.1.2 Status of ivermectin treatmenl ./ The Programme's Annual Treatment Objective (ATO) for the Year 2000 is to treat 20 million people with ivermectin. Over 22 million people (22,837,378) were treated dur- ing this period. ./ The ATO of APOC for the Year 2001 is 23,000,000 people. At the end of August 2001, only 42 CDTI projects in nine countries had submitted complete or partial results with geographical and population coverage rates. 20,684,068 people (89% of ATO for 2001) had received ivermectin in 44,057 communities (Appendix I and figures I and 2). Ivermectin treatment is continuing in many projects. This provisional data indicate that by December 2001 the ATO of the Programme will be reached. ./ APOC's target is each project to achieve and sustain treatment coverage of 65%o for at least 20 years. The trend (1997 -2001) of the treatment coverage for thirteen (13) of 24 projects in the third or fourth year of CDTI implementa- tion has remained above 65%o.The projects are: Phase II and III in Uganda; CAR; Chad; Taraba, Cross River, Plateau/ Nasawara, Bomo, Edo/Delta, Adamawa, Kano, Osun, Yobe in Nigeria. r1*.., In 2001, 23 CDTI projects provided complete treatment data, as at the end of August. Of these 23 projects :- 57o/o achieved treatment coverage of at least 70o/o and 43o/ohad treatment cover- age below 65%. a { Through support from APOC Trust Funds, 2l NGOs facilitated by Health Net Interna- tional conducted ivermectin distribution in 712 communities torn by conflict and war in Southern Sudan. The number of communities under treatment increased from 79 in 1997 to 712 communities in 2000. 125,248 out of eligible population of 268,000 re- ceived ivermectin given a treatment coverage rate of 47%o. A total of 1011 CDDs, 293 community based health workers, 62 medical assistants and 63 supervisors were trained on CDTI strategy. Nineteen (19) expatriate health care personnel are in'r,olved in oncho- cerciasis control activities in southern Sudan. " I had great dfficulty inserting thread in the needle of my sewing machtne, but since I started taking Mectizan, I can see very clearly now and I can insert the thread without dfficulty. Thanlrs to Mectizan." Community member, Tailor, Kaduna State, Nigeria i JAF 7.4 Page 5 t0,00 70,00 60,00 50.00 ,a0,00 30,00 20,00 10,00 0,00 Figure I : Treatment coverage* (%) by country for 42 projects as at August 2001 Camar@n CAR Congo O.R C6go ll.Lwi Nlg.rl. Sud.n TaM6L Ug.nd. Figure 2: Geographical coverage (%)by country for 42 projects as at August 2001 tm.0 9., tm,0 10,0 CA Coneo O.f Cqo Iff Xboe M.n T.Md lrs.d I . -_, i@,@ t0,00 t0.00 ?0.m s,m $,@ {.00 $.m 20,m t0.m 0,00 t1.170,3 59,t s2 y,152t t0,5 23,0 $J 3l,i!!.4 CAMEROON : CDTI project in Adamoua Province: Experience of health center personnel. " This is the head of a health center who used to go for immunizztion in the villages of his health area. When he arrives in a village, he waits in front of the chief s house for the parents to bring the children for immunization. He would wait a whole day only to vaccinate 20 children, and thus spent more than l5 days to cover his health area to obtain a treatment coverage of 23%o. Today, with the implementation of the Community-Directed Treatment with Ivermectin (CDTI) in the province, the same nurse obtains a treaunent coverage of almost 6lYo. He arrives in a village, con- tacts the CDD who is in charge of the census register and then goes from one household to another where there are children aged 0 to 5 years. In one day; he can make a round of l0 villages and cover the entire population." (Adamoua, Canteroon, 2nd Year Technical Reporl, Decentber 2000, culledfrom reporl ofthe health cen- ter stafJ) + Treatment ongoing in ntany siles JAT,- 7.4 Pag,e 6 3.2 Establishing Sustainable Drug Delivery System 3.2.1 Status of establishing sustainable ivermectin delivery system By August 2001, through CDTI, over sixty thousand communities (61,930) have be- gun to be actively involved in planning and managing the distribution of ivermectin to eligible members of the communities. The communities decide on distributors, choose the time and method of drug distribution. In Nigeria, Tanzania and Uganda, communities have also begun Community self- monitoring (CSM). They select monitors from among their rank and determine indi- cators to assess their performance. In this reporting period, over eighty thousand ( 89,173) Community Directed Dis- tributors (CDDs) were trained or retrained in 53 projects.34,172 health care person- nel were also trained in CDTI. As at the time of reporting, training of CDDs and health personnel is on-going in many projects. Population census recommended by APOC has been completed by CDDs inTanza- nia, Northem Sudan, CAR, Uganda and Liberia. This activity has helped project managers to adjust to more realistic estimates of population under treatment, im- proved ordering and inventory supplies of ivermectin. HOW TO TREAT OV ONCHO ./ O@ by MECTfk,ght (6) HEIGHT TABLEIS (3ms) NO MECTIZAN FOR ./ { I l?.a*G ffi 5r'.\ ' ,' :i' ,/-ctl'-, * ...: , ,-\i1 Community meeting to decide on ivermectin distribution tsffi-l,ra:Eltu sli4qAr-::q-"-_: , l.G JAF 7.4 PageT 3.2.2 APOC's CDTI strengthening health care delivery systems Health care delivery systems in APOC countries have deteriorated progressively and are ill equipped to cope with the needs of economically poor populations. Encouraging progress has been made by NOTFs in bolstering integration of onchocerciasis control into health care sys- tems to strengthen the systems and as entry points for implementing other health interventions. The CDTI approach in 4 countries (Sudan, Uganda, Cameroon, Nigeria) have provided opportunities for strengthening Primary Health Care by bringing medical care to thou- sands not reached by the health care seryices. Examples of Practical Innovations: CDDs are being used in immunization. In December 2000, 25%o of vaccinators in Raja in Northem Sudan were CDDs. Vaccination of 300 children in Diem Zabir ( ouskirts of Raja) were carried out by CDDs using CDTI bicycles. [n Northern Sudan, CDDs distributed Epanutin (an antiepileptic drug) to 815 patients in Raja. This is their third treatment cycle administered by CDDs. There is a deliberate policy in Central African Republic to use CDDs in Vitamin A distribution. In Tanzania the national onchocerciasis control programme involve CDDs in the distribution of Vitamin A, immunization and health education of communities on other preventable diseases. In Jigawa, Cross River, Zamfara, Kaduna and Yobe states in Nigeria and in Northem Sudan, CDDs act as case finders (cataract, childhood blindness and re- fractive errors). In PlateauA{asarawa states, CDDs are trained to distribute iver- mectin and albendazole for the Elimination of Lymphatic Filariasis Program. ln southern Sudan,2l NGOs including two Sudanese local NGOs, Mundri Relief and Development Association; and Sudan Health Association were involved in onchocerciasis control. These NGOs distributed ivermectin as part of their PHC service. Eleven (l l) of them are committed to and implementing CDTI with varying degrees of flexibility. To promote PHC activities in difficult - to-reach communities which are often underserved by the national health care services, the NOTFs notably of Tanzania, Sudan, Nigeria, Uganda and Cameroon embarked upon collaborative use of CDTI resources and equipment for health delivery services. { { .J ../ { { " The greatest impact CDTI has made on peipheral health workers is move' ment of these health workers from the health centers to the communtties during ivermectin distribution and routine supervision. Other PHC programmes manned by these health workers benefit immenselyfrom thts." Member, Monitoring team, 2000 tl JAF 7.4 Page 8 3.2.3. MainAccomplishmenls Considerable improvement in community participation was recorded by 27 (75%) out of 36 CDTI projects which technical reports were reviewed during TCCI2. Decentralized training of CDDs to health facilities nearest to communities and health education at community level were achieved in most countries. In l0 of the 17 onchocerciasis endemic districts in Uganda, health education in 1,890 communities now take place at kinship zones. This special initiative enhanced community involvement and treatment coverage of more than75%o in the l0 dis- tricts. << Creation of zones in all communities along kinship structures has enabled communities to select CDDs who are their relatives. ll/ilh this arrangements, the CDDs havefew households to treat and this has reduced the demands for incentives l Report from NOTFNganda. Community self-monitoring (CSM) was initiated in new project sites in Nigeria and Uganda bringing the number of CDTI projects implementing CSM to 12. Joint participatory monitoring of eight (8) CDTI projects in Nigeria was carried out this year. The exercise which includes all partners (MOH, NGDO personnel, scientists and community members ) has enabled project managers to share ex- periences in other sites. An important outcome of monitoring is a renewed spirit of competition among implementers of projects. During this reporting period, over sixty thousand (61,930) communities have been involved in ivermectin distribution. Of this, 85.5% (52,935) and 74.2o/o (45,922) communities selected CDDs or collected drug respectively. 3.2.4. Main Challenges Incentives: There is lack of a clear policy on providing incentives among health care providers. A number of community-based disease control programmes sponsored by multi-lateral agencies and bilateral donors provide huge monetary incentives to community members including CDDs when they participate in other health interventions. Examples :- In Cameroon, though remuneration of CDDs has gone up from 25%o to 32o/o of cost recovery funds, regional commercial projects such as the "Pipe Line Chad- Cameroon" has recruited CDDs paying them financial incentives; as conse- quence, there is high attrition of CDDs from CDTI projects. In Nigeria, Uganda and Central African Republic (CAR), the National Programme on Immuniza- tion (NPI) pays community guides handsome amount of money upon completion of three days exercise in the presence of CDDs from the same community who are not paid for their assignment in CDTI. To protect the achievements of APOC at community level there is need to sensitize funding agencies including WHO sponsored projects to harmonize forms of support to communitl' members and agree on de-emphasizing in- centives which disrupt activities that are otherwise sustainable. ./ ./ { { { ./ JAF 7.4 Page 9 Treatment coverage: Notable problems with achieving and maintaining high therapeutic coverage rates in most projects areas are absenteeism, inadequate fol- low-up of untreated persons and inadequate supervision by health care personnel at the health posts. Reasons attributed for this include inadequate logistics and lack of health facilities in remotely located oncho-endemic communities. Unforeseen activity: A drop in treatment coverage in Masindi district (Uganda), from 7l%o in 1999 to 68% in 2000 occurred as a result of Ebola epidemic. Health workers were involved in the control of Ebola and had little time for su- pervision of Mectizan distribution. Severe Adverse Experiences: In Sudan, both African Trypanosomiasis (sleeping sickness), severe skin and blinding onchocerciasis are serious health problems. Recently, following a notification about Severe Adverse Experience (SAE) that allegedly occurred after ivermectin treatment of a patient with sleeping sickness in Southem Sudan, concern about the safety of ivermectin administration in per- sons who are infected with Trypanosome brucei gambiense ( African sleeping sickness) was raised. However, considerable data from Tambura county show no evidence of an increased risk of SAEs when asymptomatic persons with stage I (hemolymphatic) trypanosomiasis take ivermectin. 3.3 WORKING IIARD TO ACHIEVE SUSTAINABILITY OF CDTI STRATEGY Encouraging Results Few initiatives have been taken by individual projects to improve treatment coverage and sustainability of CDTI strategy. Examples: 3.3.t CAMEROON Management of Severe Adverse Experiences (SAEs) " By successfully treating 7 out of8 reported SAEs, the project has regained the confidence of the population that started to think that SAEs will inevitably lead tofatality" Report from Centre 3 Province, Cameroon,2001 3.3.2 Strengthening Health Care System through CDTI Cost Recovery Cameroon practices cost recovery on Mectizan as it does on other medications and health care services. During distribution, all funds collected by CDDs are used towards sustaining the PHC structures now and onchocerciasis programmes later, and payment of incentives to CDDs in the following proportions: - [ncentive to CDD:32o/o - Money kept in a separate bank account for sustainment of CDTI programme when external funding ends:25%o c'*l'flff*,1i11.p1g::':T: Lt funding activities by the nurse for oncho programme: l57o ./ ./ ./ JAF 7.4 Page l0 Vour is appreciated { ./ { i.3.3 Governmenl and Community Commitment { The NOTFs continued intensive, and largely successful efforts to marshal Gov- ernment support for its campaign to strengthen CDTI. The release of counterpart funds from governments improved in some countries, e.g. Nigeria and Tanzania. Financial and political support to CDTI projects from few state/district and Local Government (perhaps because they are close to affected communities) is impres- sive. However, there are several projects not receiving support from government. Nigeria In the period under reporting, APoc supported ivermectin treatments in 27,000 communities in 32 states in Nigeria; over l5 million people were treated in 2000. Below we report on governments in Nigeria that released to projects substantial amounts in addition to palng salaries of health staff involved in onchocerciasis control. In 2001, the Federal Govemment of Nigeria pledged USS 200,000 to support on- cho control activities and released US$45,000. Kebbi State Government released uS$24,090 to Kebbi State GDTI Project. Gombe and Bomo states released uS$ 24,000 and US$30,000 respectively for first year ivermectin distributions. Jigawa state released US$35,000 for Year 2; Ekiti state provided US$5,000 Non-release of counterpart funds from state governments such as Osun, Edo, Delta, Plateau and Nasawara, may impact negatively on sustainability of these programs. { Projects managers have begun also to document amount released by communities to support their CDDs. In Imo/Abia, Nigeria, 1378 villages supported their CDDs with N487,140 (US$4,871.40) in the reporting period. Tanzania In Tanzania, onchocerciasis control receive more than US$7,000 from the MOH general fund to the CDTI training program. 3.4 Advocacy and IEC by national onchocerciasis control task forces { During the reporting period, information contained in 36 annual and/or interim technical reports on CDTI submitted to TCCI2 in March 2001 show the NOTFs of 8 countries optimised their efforts to advocate for strong po- litical support for CDTI from Policy-makers, de- cision-makers in and outside the health care sys- tem. ./ J Translation of APOC CDTI Practical Guide for Trainers of CDDs into Amharic for projects in Ethiopia. Four thousand copies (4000) were printed in the period under review. i I I I I i\ I I L l\i / ril.it.' 'i . 'I ';i,\i't ) ,l r-,' ii l,l r::\..' ,. ), ., r- o Iro o JAF 7.4 Page I I 3.5 Status of Drug shipment and storage During this reporting period, over 64 million tablets of ivermectin (3mg) have been shipped by MERCK & Co., Inc. to the NOTFs in l3 countries (Table 2 below) for APOC supported CDTI projects. NGDO partners in Nigeria and Federal Ministry of Health jointly financed relocation of storage for ivermectin from Lagos to Abuja. Shipment of Mecti- zanto Abuja will begin in2002. Fourteen countries where large-scale distribution is on-going have developed specific guidelines and made adequate arrangements for the safe storage of ivermectin. Table 2: Number of Mectizan@ tablets shipped to APOC countries Country October 2000- July 2001 Cameroon 4 441 000 CAR 3 000 000 Chad 597 500 Congo 876 500 DRC I 019 000 Equatorial Guinea 6t 269 Ethiopia 629 000 Gabon 13 000 Liberia 1 500 000 Malarvi 2 29s s00 Nigeria 42 858 500 Sudan I 800 000 Tanzania 406 000 Uganda 4 790 000 Total 64,287 269 { { { . , '.|:: : i:-i,' ';+(,r': =.1 ";..' , i':.tt. t l-r .i - i/i i'-.- I .i.J;".'j' -'. I -.1' -' ---- JAF 1.4 Page 12 4 ACTIVITIES OF THE TECHNICAL CONSULTATIVE COMMITTEE (TCC) Role and function of TCC { Redefinition of the role of the TCC 4.1 Table 3: ./ In line with the recommendation of the External Evaluation to realign the focus of the TCC's to more technical advisory role with less involvement in active pro- ject management, in the period under consideration, the TCC's reviewed mainly technical and financial reports (table 3) and advised Programme Management on broad policy considerations. Review of six-monthly technical repo(s previously done by the TCC was undertaken by the NOTFs and APOC Management after the l2th session of TCC in March 2001. It was also agreed that from subsequent meeting (TCCl3), financial reports and budgets will no longer be submitted to the TCC. In the period under reporting, the Committee held one session (TCCl2) during which it reviewed forty-two (42) technical and financial reports, seven (7) new ivermectin distribution proposals and nine (9) operational research proposals from NOTFs (Table 3 below). Project Proposals, Tcchnical and Financial reports revierved by TCC12 in 2001 COUNTRY Technical report Projects proposals Financials reports & budgets for Year 1,2,3 &4 CAMEROON CAR DRC CHAD CONGO EQUATORIAL GUINEA ETHIOPIA GABON LIBERIA MALAWI NIGERIA RWANDA SUDAN TANZANIA UGANDA TOTAI, 5 I 9 0 4 I 0 n I 0 0 U t9 0 6 5 8 0 0 2 0 0 0 2 0 0 0 0 0 20 0 0 0 0 0 3 0 4 6 42 2 7 5l JAF 1.4 Page 13 4.2 Highlights of TCC Achievements In 2001, the TCC assisted the Programme to respond effectively to a number of chal- lenging issues and tasks besides the usual fulfilment of its mandate. Highlights of the TCC's contribution are: ./ Mission to Cameroon A joint mission by members of the TCC and APOC Management was under- taken. The main objective of the mission was to review progress made by NOTF Cameroon in the management of SAEs and to provide further techni- cal advice on prevention and management of cases of SAEs. Phase II of APOC Another major activity of TCC during the reporting period was the review of the preliminary draft of the Programme Document for Phase II and Phasing - Out Period and the corresponding budget proposal, as presented by the Pro- gramme Director to the Committee. The TCC amended the Draft and this version was submitted to CSA for its consideration. ! External Evaluatiott Recommendation TCC discussed the recommendations for Phase II in the report of the Extemal Midterm (Phase I) Evaluation Team; in the report of the lTth NGDO Group session and the report of the NOTF Representatives' Meeting during February 2001 regarding the composi- tion and mandate of TCC in the Phase II and Phasing-Out Period. The committee agreed with the recommendation in the Extemal Review report "The role of the TCC should ur- gently be redefined, to align it v'ith its technical ntandate ... . TCC should ... streamline the process of revtew and build capacity for review and decision-making at the nattonal level { Operatiorts Research by NOTFs In the period under review, TCC reviewed eight (8) research proposals from the NOTFs- Cameroon (l); Democratic Republic of Congo (l); Nigeria (3), Sudan (l) and Uganda (2). The committee received progress and final reports of completed studies. { We would like to congratulate the NOTF Uganda for the article on a study funded by APOC, "Involvement and Performance of Women in CDTI for the control of Onchocerciasis in Rukungtri dtstrict, Uganda", published intheAnnals of Tropical Medicine and Parasitologl'. Vol. 95, No.5 485 - 494 (2001). APOC Management 5. 5.1. JAF 7.4 Page 14 ACTIVITIES OF THE APOC MANAGEMENT STAFF Preparation of APOC Phase II and Phasing out Programme Document APOC Management assisted by the National Onchocerciasis Task Forces (NOTFs) (see 5.7.1), the Technical Consultative Committee (TCC), the Committee of Sponsoring Agencies(CSA) and the NGDO Coordination Group has coordinated the preparation of the Programme Document for Phase II and Phasing out Period. This new Programme document will be submir ted to the seventh session of the Joint Action Forum for its consideration and approval (see doc. JAF7.8). In a joint mission with the Chair of the Committee of Sponsoring Agency, representing also the Fiscal Agent, the Director of APOC undertook missions to donor countries to raise funds for Phase II and Phasing out Period. The Memorandum for Phase II and Phasing out Period (Part II) was prepared by the legal de- partment of WHO headquarters with inputs from the NOTFs, the CSA, APOC Management, the NGDO Coordination group and Merck & Co. Inc. Part I of the Memorandum was pre- pared by the fiscal agent (see doc. JAF7.9). s.2. Status of Financing First Second, Third, Fourth and Fifth Year Projects During the reporting period, APOC Management reviewed I l0 project documents in- cluding 55 budget proposals and the same number of interim financial and technical reports. Fifty-four Letters of Agreements (LAs) were prepared and processed (appendix 3). The first instalments of funds were released to enable the launching of CDTI activities in two out of the three new projects (Cameroon and Tanzania) approved for the first year of funding. Ad- ministrative activities are on-going for the third new project (in DRC), which will be launched very soon. 5.3 Financial Management of CDTI Projects 5.3.1 Capacity building ln Cameroon and Uganda the Management of APOC conducted national training workshops for national staff newly assigned to APOC projects in financial management of Trust Funds and budget monitoring. Prior to launching of CDTI activities in Congo Republic, APOC Management facilitated a special training workshop for CDTI Stakeholders on financial regulations of the executive Agency, the im- portance and implications of the [rtter of Agreement signed between APOC and the Ministry of Health. 5.3.2 Audtting/Checktng The Management of APOC continues to conduct reviews of the monthly expenditure returns sent by the NOTFs in connection with all on-going projects receiving funds from APOC. The purpose of the exercise is to ensure that funds are utilized in accordance with the approved budget. Joint country visits were undertaken by APOC's finance office staff and the WHO country offices to provide financial technical support to projects. In addition, audit/checking of the accounts were conducted to verify the information forwarded to APOC Headquarters by the NOTFs for accuracy. a o JAF 7.4 Page 15 a 5.3.3 Timely disbursentent of instalments offunds to the projects In 2001, the Management of APOC has made encouraging progress in improving the delays in the disbursements of Trust funds to the projects. Tremendous efforts have been made in col- laboration with the Headquarters of WHO/Geneva, WHO Regional Office (AFRO) and the WHO country offices to minimize the delays in the disbursement of funds to the projects by APOC. In this reporting period, less than l\Yo of the 63 approved projects reported delays in the release of Trust Funds. APOC Management with technical and financial support from the Onchocerciasis Unit of the World Bank, established an integrated computerized financial management system. This was done to improve record keeping, communication on financial flows between the Management of APOC and the projects, financial planning and analysis for use by the management and pro-ject Coordinators. 5.3.4 Major achievements More than 40 participants including 5 accountants, 23 Districts Medical Officers(DMOs), l0 NOTF and NGDO members, and 3 community representatives were trained or retrained to understand the financial accounting requirements of wHo/Apoc. More than 80% of the on-going projects have submitted timely and satisfactory expendi- ture retums during the period under review. Less that l0o/o of on-going projects have complained during this reporting period of being obliged to postpone activities because of delay of funds from ApOC. 5.4 Inventory of Capital Equipment delivered to Projects in the Countries In response to the recommendations of the internal auditors, an inventory of capital equipment supplied to 14 countries was made. This inventory list was sent to the NOTFs and the WHO offices in the countries for verification. In appendix 2, some of the major equipment supplied to the countries are presented. 5.5 In-country Capacity Building In 2001, building the capacity of the national team was given priority by the Manage- ment of APOC. A total of 123,645 people were trained or retrained in different skills as in table below. This is an increase of 35Yo from last year. a a Table 4: Nationals trained in specific areas for project implementation JAF 7.4 Page 16 5.6 5.6.1 Country support visits Support visits by Management staff APOC management staff in joint missions with the World Bank and the NGDO Co- ordination Group, made a total of five (5) support visits to the National Onchocerciasis Task Forces (NOTFs) in 4 countries (table 5) for advocacy, training of project personnel and evaluation of management of Trust funds. The aims of these support visits included providing technical advising and assistance in CDTI project implementation and management; advo- cacy; providing training in financial accounting and WHO imprest accounting system; attend- ing Inter-Agency and NOTF Review meetings. Table 5: Country support visits by APOC Management (September 2000 to 3lst August 2001) 2000 2001 (as at Aug, 2001) Total 91,092 123,389 COUNTRY PURPOSE OF MISSION CAMEROON . Train APOC partners in financial accounts . Mission to advise NOTF on Management of Severe Adverse Reactions (SARs) CONGO BRAZZAVILLE a Discuss administrative and financial issues related to APOC TANZANIA Train APOC partners in financial accounts. Attend NOTF and NOCP Review Meetings Conduct field visit to assess community participation in CDTI Facilitate training on Community self-monitoring (CSM) UGANDA . Attend Inter-Agency and NOTF review meetings . Train APOC partners in financial accounting . Updating imprest account and training program managers on WHO administrative and financial management systems. .']- .., j JAF 7.4 Page 17 ,:rl 5.6.2 CDTI implementation in onchocerciasis and loasis co-endemic zones { Between 1999 and 2000 severe adverse reactions (SAR) occurred in four provinces ( Center 3, Littoral II, South West I and II) in Camerron . Following these events the TCC and the Mectizan Expert Committee (MEC) with input from APOC Management, developed comprehensive technical guidelines to improve the safety of ivermectin for CDTI areas where onchocerciasis and loaloa are co-endemic. In the reporting period, APOC Management and NOTF Cameroon instituted strict adherence to the TCC/MEC guidelines in the four Provinces mentioned above. Programme management facilitated additional rapid epidemiological assess ment (REA) in three (3) Provinces- West, North and Adamoua in Cameroon. This exercise provide additional data on the prevalence of onchocerciasis in suspected co-endemic areas. 5.6.3 Support visits by Temporary Advisors and Consultants In the reporting period, APOC Management organized technical support missions and travel of consultants and temporary advisors to eight (8) countries: Central African Republic, Cameroon, Democratic Republic of Congo, Equatorial Guinea, Nigeria, Uganda, Malawi and Mozambique (table 6 below). To develop capacity at country level APOC Management pur- posively instituted intensive search for experts in the 19 endemic countries to provide technical assistance to the Programme. To date, a core group of 24 advisors provide additional assistance to the NOTF in different aspects of the Programme. Technical assistance provided by tempo- rary advisors and consultants included Rapid Epidemiological Mapping of Onchocerciasis, Rapid Epidemiological Assessment using smaller grids, vector elimination activities and advo- cacy. ^^;#rt 'f ,. ifrrt +a t rl \ ,Jr iut,. rl, _li ,l I Ii I r. .ri iJli ')r .--.ra, :-l i I 0 t- t 11i I , l:' t: lii! i:; :t ir t.t JAF 7.4 Page 18 Table 6: Country support visits by Temporary Advisors and Consultants 5.7 Major Meetings and workshops A number of important meetings and workshops including Financial Management, NOTF Re- view meetings, workshops for front-line health care personnel on Community self-monitoring and Stakeholders meetings were successfully conducted in the period under reporting. Three of these de- serve special mention below. 5.7.1 NOTF Meeting in Ouagadougotr Following the recommendations of the sixth session of the Joint Action Forum, a meeting of representatives of the National Onchocerciasis Task Forces was held in Ouagadougou in February this year. The objective of the meeting was to providc a forum for the NOTFs to discuss the recommenda- tions of the External Mid-term Evaluation and contribute in the preparation of the Phase II and Phas- ing-out Programme document. The meeting achieved it's objectives as shown in the report produced by the participants (see document JAFT/INF/DOC.l). COUNTRY PURPOSE OF MISSION ADVISORS/CONSULTANTS Cameroon TCC mission to review and advise NOTF on prevention and management of severe adverse experiences. To study socio-anthropological issues related to community behaviour follow- ing severe adverse experiences Dr A. Hopkins Dr. S. Meredith Ms. L. Clemmons Dr. Nana Dr. Akogun Chad TCC mission for advocacy Dr P. Enyong Dr C. Godin Central African Republic Impact assessment (second round entomologi- cal baseline data collection) Rapid Epidemiological Assessment (REA) Dr. T. Soungalo Dr. Abel Nanssemo Democratic Rep. Congo Rapid Epidemiological Mapping of Onchocer- ciasis (REMO) National onchocerciasis task Force Equatorial Guinea To implement ground larviciding operations Dr. M. Wilson Mr. R. Meyer Dr. B. Cheke Mr B. Tele Nigeria Refinement of the REMO map Prof. B.E.B Nwoke Uganda Film mission Mr. A. Crump Dr. R. Ndyomugyenyi Dr. M. Katabarwa Mozambique Nation-wide REMO Prof. B.E.B Nwoke Dr. P. Enyong Mr. P. Tambala Malawi Support to NOTF : facilitate training on com- munity self-monitoring , conduct independent monitoring. Mr. Ukam Oyene JAF 7.4 Page 19 5.7.2 Inter-Agency Meeting in Uganda In less than half a decade, new campaigns on community based health interventions are be- ing launched against major endemic diseases, Lymphatic Filariasis, Malaria and Tuberculosis (TB). Disease control programmes and the National Programme on Immunization (NPI) are increasingly relying on community involvement in the execution of the programmes. In the period under report- ing, National Onchocerciasis Task Forces of 4 countries (Nigeria, Uganda, Tanzania, Cameroon ) have expressed strong concem with payment of large sums by programmes such as NPI to commu- nity members. To address this concern, the NOTF Uganda organized an Inter-Agency meeting of the major health providers in Uganda for standardization of communiry directed interventions (CDI) to ensure that different approaches and payment of monetary (cash) and non-monetary incen- tives do not compromise CDTI at community level. The meeting in Uganda recommended: (i) The Ministry of Health should work towards standardization of the process of imple- mentation of community-directed interventions to ensure that different approaches do not compromise each other at the community level. (ii) Community should collectively decide on the issue of support to implementers of Com- munity Directed programmes. (iii) Externally provided financial incentives are often ineffective and may have a negative impact on other community based programmes, and should therefore be discouraged 5.8 Special Programme Activities 5.8.1 First Programme Booklet To mark five years of the Programme (1996 -2000) the .-.. Management of APOC has produced a special booklet ' entitled: "Emporvering partnerships and communities: APOC and the fight to rid Africa of River Blind- ness..." Additional copies of the booklet willbe on dis- play and made available to participants at the Joint Ac- tion Forum in December, 2001. (See document JAFTI INF/DOC3). 5.8.2 Publication of APOC activities as Special Supplement in the Annals of Tropical Medicine and Parasitology. Between 1996 -2000 APOC Programme has been active in stimulating the formation of new drug delivery systems, reorienting and strengthening projects launched in the pre-APOC era in l4 of its Participating Countries. APOC's strategy of community directed treatment with ivermectin (CDTI) has been tried and tested for five years as an approach for attaining sustainable ivermectin distribution for the control of onchocerciasis. Communities have been deeply involved in their own health care on a massive scale and the strategy seems a potential entry point to the fight against other diseases of public health importancc. APOC in partnership with WHO/TDR and the NGDOs have developed new techniques and modcls such as I{EMO, indcpendent participatory n-ronitoring module, community self-monitoring and management of scrious adverse reactions guidelines for mass distribution programmes. in F.tz o':.ix :,I )}.sil .:a --'1 ".. ,.) JAF 7.4 Page20 What has been missing is systematic dissemination of the experiences of the APOC partners. In the year under review, APOC Management assisted by scientists, country representatives of the NGDO Coordination Group has organised the publication of seven (7) scientific articles. These will be published in the first quarter of 2002 as a special supplement on APOC activities. 5.8.3 Videofilm production in Cameroon The Management of APOC is pleased to announce that a video -"Seeing with the Heart", which production in Cameroon began last year with Technical Assistance from WHO/ Geneva Film Unit, is ready and will have its premier showing at the Joint Action Forum. The video is available in two languages, French and English. It highlights the psycho-social conse- quences of onchocerciasis as narrated by men and women who live with the disease. It docu- ments the inspiring achievements of affected communities and the partners in implementing the CDTI approach. 5.8.4 Special Filnt ntission to Uganda Management and the NOTF Uganda facilitated a special film mission to Uganda with technical assistance provided by WHO/TDR Communication Unit. The output of the mission will highlight ivermectin distribution in diffrcult-to-reach communities inhabited by pygmies; and programmatic challenges in communities where epilepsy and onchocerciasis co-exist. The new video will have its premier presentation at the Joint Action Forum in Washington, in De- cember 2001. In addition, still pictures from the mission will be usefu[ health education materials and these will be made available to all countries. 5.8 5 Meeting of lrupact Assessntent Teams I and II The teams mentioned above met in Ouagadougou and prepared manuscripts in Entomol- ogy, Dermatology, Ophthalmology and Socio- demography for publication in peer-review jour- nals. I I , r1+: A -. r:-+ t ! l1 t ll J, I li\rt I rl 7 I ! J, JAF 7,4 Page 2l 6. VECTOR ELIMINATION ACTIVITIES Table 7: Vector elimination projccts Projects Approval Objcctivc Total funds Provided US$ Itwara Focus (Uganda) 1996 Vector elimination 26,868 Mpamba-Nkusi (Uganda) 1999 Feasibility study for vec- tor elimina- tion 46,0s 1 Bioko Island (Eq. Guinea) 1998 Vector elimination I 32,1 50 Tukuyu Focus (Tanzania) 1997 Vector elimination r 18,860 Between 1996 and 2001 (APOC Phase I), three vector elimination projects and one feasibility study were approved ( table 7). The objective is to eliminate the vector from known isolated foci as part of au onchocerciasis control programme in conjunction rvith mass distribution of ivermectin (Mectizan@) by community-directed distributors (CDDs). i'= ! l i'1- h.ttt: '''': b t. 1* r-I \... Black fly JAF 7.4 Page22 6.1 ltwara Focus, Uganda In Uganda, the northem onchocerciasis focus of Kabarole district is mainly located around Itwara forest reserve. This main focus is not completely separated from two smaller foci located on the east: Siisa and Aswa river systems. In all foci, Simulium neavei is the only vector of Onchocerca volvulus. The first attempt to investigate the feasibility of vector control in Itwara was made in I994. The experimen- tal treatments to test the larvicide temephos (Abate@) were surprisingly efficient and ended up by virtually eliminat- ing the vector in 1995. In 1996, the NOTF's proposal to consolidate vec- tor eradication initiated by the Ministry of Health (MOH) and The German Technical Cooperation (GTZ) in 1995, was approved. Main Accomplishments Assessment studies conducted between 1997 and 2000 on a total of 4082 river crabs from different checkpoints of the Itwara focus revealed that all the crabs examined were negative for immature stages of S.neavei although treatments were suspended in January 1997.In the same period (1997-2000), pro- gress was recorded in the sub-foci of Siisa and Aswa where ground larviciding was pursued to prevent re- invasion on the main focus. In 200 l, an evaluation was carried out. Itwara focus remains vector free. Over nine hundred (993) crabs sampled were negative for immature stages of S. neavei and no single female vector was caught. This success recorded in the Itwara main focus was strengthened by the results obtained in the sub foci of Siisa and Aswa where all the 937 crabs examined in 2001 were also negative for immature stages of S. neavei. (see table 8) t :""I=., Main Challenges An early warning system should be set up in some key sites to enable peri- odic monitoring of the vector-free status of Itwara focus over several years. The MOH of Uganda and APOC need to provide entomological surveil- lance support for appropriate collection of data to confirm eradication. Monthly monitoring needs to be carried out in the sub foci of Siisa and Aswa to assess virtual elimination of the vector and the negative status of river crabs for immature stages of S. neavei. a a APOC Mid-Term Evaluation Tcam '...APOC is the only progrs,flnrc witlt the potenital to determine wltether focal eliminatiotr of ortchocerciasis vectors catt b e s u ccess uftt I l1t s s | 1 is1tsd... ttWrn TAF 7.4 Page23 Table 8 Examination of river crabs for immature stages of S. neavei in Itwara and sub foci, 1997- March 2001 Number of crebs Number of Itwere focus Ceught Positivc 7o positive Lervee Pupee Ceses t997 2285 0 0 0 0 0 I 998 638 0 0 0 0 0 t999 662 0 0 0 0 0 2000 497 0 0 0 0 0 200 I 993 0 0 0 0 0 All years 5075 0 0 0 0 0 Siisa river system 1997 1320 3 0.2 3 0 0 r 998 943 4 0.4 5 0 0 l 999 I 384 I 0.1 I 0 0 2000 1292 I 0.1 I 0 0 200 I 4t6 0 0.0 0 0 0 All years 5355 9 0.2 l0 0 0 Aswa river t997 t574 390 24.8 163 l 195 542 I 998 541 98 l8. r 136 74 94 t999 t2t2 34 2.8 30 I 5 2000 2624 98 3.7 5r8 40 122 200 I 521 0 0.0 0 0 0 All years 6472 620 9.6 23r5 310 763 6.2 Mpamba-Nkusi Focus, Uganda Mpamba-Nkusi focus is located in the northem part of Kibale district in Uganda. Ivermec- tin treatments was initiated by MOH and Sight Savers International (SSI) in 1992. Epidemiological studies (Ayele and Walsh, 1991; SSI, 1995) have shown that S.neavei is the vector of the disease in the focus; the palpable nodule rates ranged from 46 to 537o and 98% of the river crabs examined were positive for,S. neavei. Based on the results of the epidemiological studies a proposal was approved in 1996 as part of Itwara vector elimination project and later as a separate project, to determine the feasi- bility of vector elimination in the focus. Entomological base line data have since been col- lected and preparations are being made by the NOTF to undertake experimental ground lar- viciding before the end of 2001 . ,l $ JAF 7.4 Page24 6.3 Bioko Island, Equatorial Guinea The project was approved in 1998. Between 1999 and 2000, technical and administrative prepara- tion, collection of pre-control data, intensive river prospecting, insecticide susceptibility tests on local .S. damnosum, and environmental impact assessment were successfully carried out. Main Accomplkhments Main Challenges a Pre-control surveys of accessible rivers were conducted and very highly produc- tive breeding sites of S. damnoszz which were not previously detected were identi- fied. Teams responsible for treatments were trained on assessing river discharges, con- ducting ground spraying and monitoring the effects of control both in rivers on the larvae and by examination of adult female flies. A very positive attitude of popula- tion and local authorities towards the pro- ject was observed Experimental large-scale ground larvicid- ing with temephos was successfully con- ducted in February 2001 and 12 weekly ground treatment cycles have been adopted. Temephos (Abate 20EC) has shown good efficacy at a dosage of 0.4 litre product/m3 /s discharge. Inaccessibility of some rivers particularly in the south of the island Vector collections, monitoring of breed- ing sites and training of nationals should continue to ensure that adequate post- control information is obtained and the speed ofthe recovery of the vector popu- lation established. l.tticAICrl (SiIoco ) AlB221 Point 7o2 : lJiscltarqc o, [, m )r/5 I ;. .1. i(()()LO AC 711 l'orhl 120 a JAF 1.4 Page25 6.4 Tukuyu Focus, United Republic of Tanzania Although the project was approved in 1997, baseline data collection including practical feasibility studies, were only completed in 2000 as it took time for the NOTF and APOC Management to fulfill the administrative requirements preceding disbursement of funds. This delay was also partly due to poor qualification and commitment of the staff at the project level, particularly dur- ing the first two years of operations. Main A ccotttp lis h ments Main Cltallenges Re-evaluation of the entomological status was performed in 2000/2001 on all the river sys- tems in the focus. Susceptibility tests and experimental ground treatments with both temephos and Bacillus thurinetensis Btl4 were successfully con- ducted. The conclusion is that temephos is the most appropriate insecticide for the larvicid- ing operations in the focus. Continuation of surveys of larval habitats within and outside the vector elimination pro- ject area. Collection of transmission data has been on- going. Continuation of collection of climatic and river discharge data. Nationals were trained on how to implement ground larviciding and monitor the effects of control both in rivers (on the larvae) and by examination of adult female flies. Poor staffing of the project has led to postponement of large-scale ground lar- viciding scheduled to commence by the end of2001 or early 2002. Poor commitment of the coordination team to the project. Late Authorization for importation of 4000 litres of temephos for carrying ground treatments. Permission was granted by the national authorities only in July 2001. Ground larviciding in Tukul'u focus, Tanzania Forthcominq el'ent A review meeting on vector elimina- tion projects is scheduled for early 2002 to assess progress of on-going activities and to determine projects which should benefit from APOC funding in the Phase II. >*fi1'1=- -.*it:- ' :"L' r<,.:. !-* JAF 7.4 Page26 7 RAPID EPIDEMIOLOGICAL ASSESSMENT (REA), RAPID EPIDEMIOLOGICAL MAPPING OF ONCHOCERCIASIS (REMO) AND GEOGRAPHICAL INFORMATION SYSTEM (GIS) ACTIVITIES CARRIED in Sept 2000-August 2001 Table 9: Status of REMO/GIS in APOC countries as at 3l August 2001 ( t n ItI t :i Cameroon Rapid epidemiological assessment surveys were carried out in the Provinces of South West, West and Adamoua to identify and ex- clude from mass treatments, hypo endemic communities in CDTI priority areas co- endemic for onchocerciasis and loasis. Congo (Brazzaville) A country wide rapid epidemiological mapping of onchocerciasis was canied out. The data have been integrated into the geographical information system. The results of the GIS analysis confirmed previously defined CDTI areas based on the prevalence of depigmentation, skin snips and REMO surveys conducted before the civil unrest. Central African Republic Rapid epidemiological assessment (REA) was carried out the two regions (4 & 5) to enable the refinement of the REMO map of the country mainly on the borders of Democratic Democratic Republic of Congo Rapid Epidemiological mapping of onchocerciasis (REMO) was conducted in the Province of Band- undu. The meso and hyper endemic communities were delineated after integrating the data into the geographical information system (GIS). Ii I t aIil ') q I 1 ij Republic of Congo and Sudan. The results o the exercise are parlially satisfactory. Nigeria Nation-wide refinement of the country REMO map was carried out and the results of the exercise were integrated into GIS for up- dating the CDTI map. Discussions on of the updated CDTI map are ongoing between the NOTF and the Management of APOC. Mozambique From June to July 2001 a nation-wide REMO exercise was conducted in 8 of l0 provinces of the country. A total of 280 villages were selected and 7 210 persons examined for palpable nod- ules. Of this number examined only 0.6902 were carrying nodules. (See Figure 3). REMO status APOC countries Future activities NO REMO Angola and Burundi In Burundi, NOTF has been estab- lished. REMO survey will be con- ducted in October-November 2001. In Angola, nation-wide REMO will be planned as soon as the situation in the country improves. Partially Completed Democratic Republic of Congo - Sudan - Ethiopia - Kenya Additional REMO exercise will be carried out in Kenya in areas not in- cluded during previous exercise. REMO to be completed in Sudan and DRC u,hen leasible; REMO Complcted Nigeria - Cameroon - Uganda - Tanzania - Ma- lawi - CAR - Congo - Gabon - Mozambique - Chad - Liberia - Rwanda - Equatorial Guinea REMO/GIS results to be used for monitoring and evaluation of the pro- jects (See figure 4). JAF 1.4 Page 27 Figure 3: Rapid Epidemiological Mapping of Onchocerciasis, Mozambique b,oo LGg.nd ! Lakes/t-acs rt vcrs/Rrrreres Noduh3 l%) o0 o I-9 o t0- l9 o 20.19 o 10-t00 KM 0 100 200 Figure 4: CDTI Areas for large-scale ivermectin distribution in APOC countries Lca.nd /La9.ndc ffi *. *, ,,,,. r*, ,( ) tr(!, lnlorl rqil,{ !,.,r,.,.,,, rr"..,,,"nu.,,.. [.,r,,,,,"nr,,,* r",n,nu ! *,,,,,,, -.,,,u.,,,,* 7, *u*,,,.*u.*t,(\(il({n r!trh ) : j:: tr Mr.,e,,,,rllt uo.',-*^ !,.n.,,,,., KM r----------t 0 500 1000 EE@ t ,sia '-* c6 1.''1.:: q. o n -@ @ ''q " JAF 7.4 Page28 8. OVERVIEW OF APOC COLLABORATION WITH OTHER WHO GROUPS 8.f Collaboration with WHO/OCP . Administrative and Financial support in transfer of funds, payment of emoluments of APOC staff, purchase of capital equipment for APOC in Ouagadougou and in the countries. . Collaboration in sefting up an efficient and reliable communication system. . Allocation of office space to APOC Management. . Technical and/or logistic support for vector elimination activities in Tanzania , Equatorial Guinea and Uganda. . Development of strategies in carrying out CDTI activities. . DNA laboratory facilities available to APOC for analysis of entomological data. 8.2 Collaboration with WHO/AFRO . Advocacy for onchocerciasis control in the Africa region. . Monitoring CDTI and vector elimination projects. . Facilitation of entry and storage of insecticide for vector control. . Facilitation of Mectizan entry in endemic countries. . CDTI projects: transfer and replenishment of funds, procurement of capital equipment, audit of imprest returns. . Technical support to APOC particularly through the oflice of OTD. 8.3 Collaboration with WHOffiQ . Financial and administrative support in funds transfer, purchase of equipment. . Internal annual audit of APOC financial and technical management and administration. . Film missions for advocacy and production of health education materials. . Production of APOC booklet on activities of Phase I. 8.4 Collaboration with WHO/TDR: OPERATIONAL RESEARCH The Management of APOC maintain close links with WHO/TDR through the Task Force on Fi- lariasis Intervention Research to respond rapidly to the research needs of APOC field operations. This collaboration resulted in a number of achievements in the year under reporting. ,t The Task Force released the final report of a multi-country study on sustainability of CDTI at the health system and political level. The result of this study showed that inter- action between community members and health care personnel was generally poor, but improved following the introduction of CDTI. Further, the introduction of Stakeholders' meetings involving district and front-line health care workers had no significant effect on treatment coverage. However, it did reinforce the CDTI process and led to improved at- titude of health workers towards community participation in the delivery of care and partnership-building with communities. Several copies of the report have been distrib- uted to NOTFs and nationals in research institutions. JAF 7.4 Page29 / Furthermore, the Task Force supported studies on Rapid Assessment of Procedures (RAP) for monitoring treatment coverage. One such study conducted in Uganda showed promising results, suggesting that ivermectin treatment coverage in school chil- dren monitored by schoolteachers could give a good approximation of the population coverage. The Task Force and APOC Management plan to validate and upscale this novel method in other countries. Major achievement. Tool for Rapid Assessment of Loa loa (eye worm) infeclion at the community level EYE WORM ,l' Severe adverse neurological reactions, including deaths, have been reported in persons with a high intensity of Loa loa infection. This has affected ivermectin treatment pro- grammes in areas potentially co-endemic for Loa loa, in Cam- eroon. To better understand the distribution of Loa loa and identifo those communities where Loa loa is highly endemic, the Task Force on Filariasis Intervention, with additional US $59, 963 from APOC Trust Funds, launched a multi-site study on rapid assessment procedures (RAP) for mapping Loa loa endemiciry at the community level. The result of this im- portant study, a new reliable tool for mapping Loa loa, will be presented to TCC l3 and at the Joint Action Forum in Washington DC, in December 2001. ,t The success of community-driven drug distribution in onchocerciasis has drawn attention from other disease control programmes and there have been various attempts to use the CDTI system and the Community-Directed Distributors (CDDs) for other interventions. A preliminary assessment, facilitated by the Management of APOC has shown that more than 50% of CDDs are already involved in other health and development activities such as - distribution of vitamin A, malaria treatment, polio immunization, nutrition and water protection. However, the risks and benefits of this development for the sustainability of CDTI are unclear. Whilst integration of other community-based health interventions into CDTI is expected to enhance its sustainability, this may result in overloading of CDDs and/or eroding community directedness in the process. To address this concern, the TDR's Task Force on Filariasis Intervention Research has initiated a multi-site scientific evaluation of the current experiences to identifu what action needs to be taken to en- sure that integration of other health care activities in CDTI strengthens rather than weak- ens its sustainability. ,l- Based on the findings of Phase I, the second phase of a multi-country study will imple- ment and evaluate a framework for advocacy to ensure sustained demand, supply, dis- tribution and treatment coverage of ivermectin in CDTI for onchocerciasis control. The results of Phase II study will be available in 2002. ,l' With the new TDR strategy, the matrix management system, there will be expansion of activities in implementation research. In the context of APOC/TDR collaboration, there will be a focus on sustained control using available interventions and improved tools for treatment coverage, monitoring and evaluation. The APOC management and TCC are concerned that because of an avalanche of other priorities and urgencies that are the re- sult of the change to the new structure, there may be less flexibility, and TDR less capa- ble to respond rapidly to urgent research needs of APOC. These concerns are however receiving priority attention of WHO/TDR. 1 Ir. ! t:. Br ,J JAF 7,4 Page 30 MACROFIL . APOC's current control strategy is only based on a single, microfilaricidal drug- iv- ermectin. It is not known if ivermectin treatment alone can eliminate the parasite in the long term and under what conditions. Further, there is concern that repeated mass treatment with ivermectin could lead to the risk of resistance against ivermectin. The discovery and development of a macrofilaricidal drug that would result in permanent sterilization or killing of adult worm of Onchocerca volvulus, is therefore of primary importance to APOC. In the year under review, APOC investment in the search for a macrofilaricide is US$570,000. Clinical studies on Moxidectin, a registered animal health product; safety of ivermectin combinations for onchocerciasis; and pre-clinical research on ivermectin resistance detection tool undertaken by MACROFIL Re- search Group show promising results. Progress report on MACROFIL will be pre- sented during the joint session of the Joint Programme Committee/Joint Action Fo- rum in December,200l. th I lr\ t \ ? " The health worker must achieve a shift in paradigm, suspend belief in the "universal" epide- miological model, and understand and accept "local truths" as a necessary basis for partnership with the community to solve such problems as onchocerciasis. TDR/IDE/RP/CDT/00.1 t G L,ill {\- :' \ '.t' n a ..a,.'5D G\ JAF 7.4 Page 3 I I 9. CONTRIBUTION OF WHO/AFRO The WHO Africa Regional Office (AFRO) provided increased support to the Management and the NOTFs in the execution and monitoring of APOC operations in the region. The Budget and Finance Office (BFO) and the Division of Infectious Diseases Control (DDC) have played, as in previous years, significant roles in the implementation of the Programme activities. The Budget and Finance Office (BFO) provided support to the country offices to accelerate the transfer of funds to the projects and replenishments of the NOTFs' bank accounts. The Director of the Divi- sion of Infectious Diseases Control (DDC) who is one of the two representatives of WHO at the CSA, assisted the programme in this capacity. At the country level, the WHO offices continue to monitor the development of the na- tional plan for onchocerciasis control and the implementation of CDTI projects in the countries. The country offices also took an active part in the preparation and organization of this year's inde- pendent participatory monitoring of eight CDTI projects in Nigeria, intemal monitoring, and other activities which have been decentralized by APOC Management to the country level. Thanks to the support from WHO country offices, significant improvements have been made in the transfer of funds to the NOTFs following instructions of the Regional office and the APOC Management and delays in disbursements of funds have been reduced to two out of the fourteen countries. Country offices continue to play a pivotal role in the organization of various workshops and other activities of the Programme. WHO country offices in Nigeria, Tanzania, Uganda, Sudan, CAR, Chad and Cameroon are performing the internal auditing of the imprest retums before forwarding the imprest book to the APOC headquarters in Ouagadougou thereby facilitating speedy replenishment of the NOTFs' bank accounts for field operations. The country offices of Cameroon, Nigeria and Uganda coordinated the field work of the NGDO sponsored sfudy on Investigation into the administrative requirements of APOC in the pe- riod under review. r#l , -r-tsr 5 I f= {. a ! ::''\r-r - iiih, JAF 7.4 Page32 10. CONTIBUTION OF THE NON-GOVERNEMENTAL DEVELOPMENT ORGANIZATIONS (NGDOS) COORDINATION GROUP The Non-Governmental Development Organizations (NGDO) Coordination Group has been ac- tively expanding membership at international and country levels during this reporting period. This proactive membership drive has included visits to the United States and meetings with NGDOs from Europe to discuss potential collaboration with APOC. (See document JAF7.7). J The NGDO Coordinator conducted joint missions with APOC Management to three APOC countries (Ethiopia, Uganda, Tanzania ) during the period under review. In all three missions, the NGDO Coordinator provided invaluable assistance in promoting communication and col- laboration between the APOC partners in the country. J In most countries (table 10 below )a remarkably good relationship has been forged between the Ministry of Health and the NGDOs. J In the year under consideration, the Group funded a special investigation on the administrative requirements of APOC. Local NGOs ./ The Group has encouraged NOTFs to identify potential local NGOs who are to be trained and mentored by international NGDOs until they are ready to take on projects. ./ MITOSATH, a local NGO in Nigeria recently organized a seminar on the "Relevance of local NGOs in the sustainability of CDTI". ./ CBMA.{igeria mentoring MITOSATH, has provided the timeline for the handover of the remain- ing LGAs in Taraba State supported by CBM to MITOSATH. By 2003, additional eight (8) LGAs would have been devolved to MITOSATH. The transfer of responsibility from an intema- tional to a local NGO provide an excellent oppornrnity to assess the capability of local NGOs to support ivermectin distribution after the cessation of external support. Table 10: Countries where NGDO Group Members collaborate with APOC CAMEROON ' ts- ", r..*-:,1* CENTRAL AFRICAN REPUBLIC CHAD DEMOCRATi' *""'C OF CONGO EQUATORI,AL GUINEA ETHIOPIA LIBERI.A MALAWI NIGERIA SUDAN TANZANIA UGANDA CONGO BRAZZAVILLE GRBP, HKI,IEFI, SSI, BASED ] ' CBM Africare, OPC CBM,IMA University of Barcelona GRBP SSYCHAL, UNICEF IEF CBM, GRBP, HKI, SSI, IFESH, UNICEF, MITOSATH HKI, GRBP IMA/CSSC, SSI, HKI CBM, GRBP, SSI OPC COTJNTRY NGDO PARTNERS JAF 7.4 Page 33 1I. CONCLUSION In the year under consideration, encouraging progress has been made in the areas of rapid epidemiological mapping of onchocerciasis including in countries in conflict. Training and ca- pacity building at all levels, community participation, coverage and operational research at com- munity level have yielded positive results. Innovative strides have been taken by the NOTFs to enhance sustainability of the CDTI approach. There is considerable improvement also in financial accounting of projects, and delays in submission of financial reports now occur only in few pro- jects. The power and spirit of partnership was put to test in preparing the Programme Document and Memorandum for Phase II and Phasing-out Period. Although complex, the partnership is proving to be one that is flexible, dynamic and effective. Despite successes made in ground larviciding in Bioko Island in Equatorial Guinea and Itwara focus in Uganda, vector elimination activities remain a challenge to APOC and its partners. Other daunting challenges include, low treatment coverage in countries especially those torn by war and provision of financial incentives to community members by other programmes. However, CDTI projects have demonstrated that communities are capable of sustaining projects without financial rewards to CDDs from external sources. APOC partners continue to consolidate their unique ex- periences in building unorthodox alliances to support delivery of health care to the poorest popu- lations through Community Directed Treatment with Ivermectin (CDTI). These experiences will direct activities in the upcoming final phase of the Programme. a THANK YOU ,) JAF 7.4 Page 34 APPENDIX I (a) Annual treatment objective (ATO) and persons treated as at 3 I st August 200 I * (b) Communities treated in 42 projects as at 3 I st August 2001 * Country Cameroon Number of projects 6 Total population 2,133,143 ATO 2023446 Persons treated 491226 CAR I 1,415,264 1400000 1076292 Congo I 628,187 448779 191774 D.R. Congo 1,129,888 253000 597872 Malawi I 493,389 975740 346799 Nigeria 23 27,912,704 1 73B0B89 1 51 36783 Sudan I 600,000 209385 326290 Tanzania 4 788,014 724660 471087 Uganda 4 2,865,743 1454455 2045945 Total 42 37,966,332 24,870,354 20,684,068 Country Cameroon Number of projects 6 Total communities 431 B Treated communities 1719 CAR I 5014 5014 Congo I s93 232 D.R. Congo I 2279 1923 Malawi I 606 547 Nigeria 23 44933 30506 Sudan I 235 232 Tanzania 4 433 433 Uganda 4 3451 3451 Total 42 61862 44,057 * Trealment on-going in many sites t I a t JAF 1.4 Page 35 APPENDIX 2: MAJOR EQUIPMENT DISTRIBUTED TO PROJECTS (1997-2001) ITEM Country Vehicle Motorcy- clcs Bicycles Compu(ers Printers UPS P/copiers Fex Machines Overhead Projectors Crmeroon t2 135 7t l6 t3 9 ll 7 6 Congo Brazza I 5 0 2 2 I 0 Ethiopia 3 8 0 6 4 0 3 3 3 Gabon I 0 0 3 3 3 0 I Eq. Guinea 4 0 0 5 3 3 I I Liberia 2 20 0 I I 0 I I I Malawi 2 l3 0 6 6 5 I 0 I Nigeria 36 378 r 6l9 48 42 l5 3t ll 25 CAR 3 t7 0 4 I 2 I 0 0 DRC 3 I 0 4 3 0 2 0 2 Sudan 8 8 t26 6 4 2 I I 5 Tanzania 9 t7 0 t2 9 2 6 5 0 Chad 4 t6 I 7 6 5 3 2 3 Uganda 3 l9 77 3 3 2 2 I 0 Total 9l 637 1894 123 100 49 65 32 49 - I I JAF 7.4 Page 36 APPENDIX 3: FINANCIAL OVERVIEW - LETTERS OF AGREEMENT FINALIZED FOR THE 2OO1 BUDGET a I No Project Year of Project Amount requested US$ Amount approved US$ Difference in US$ I Centre I (Cameroon) I 262,t44 187,889 74,255 2 u6re @RC) I 149,685 131,035 18,650 3I 4 Kilosa (Tanzania) CDTI South West 2 (Cameroon) I 2 12s273 123,1 l5 109,805 ll7,t82 15,468 5,933 5 Ekiti State CDTI (Nigeria) 2 123,580 107,630 15,950 6 Ondo State (Nigeria) 2 145,860 135,860 t0,000 7 Kaffa Shekka (Ethiopia) 2 278,582 196,094 82,488 8 HQs Support (DRC) 2 143,794 104,670 39,124 9I t0 CDTI Kasai (DRC) Littoral II (Cameroon) 2I 3 l 18,338 48,17 | 104,238 48,171 14, l 00 0 ll Adamawa State (Nigeria) J 104,614 86,651 17,963 t2 Borno State (Nigeria) 3 108,919 95,750 r 3,1 69 l3 Edo/Delta State (Nigeria) 3 t30,259 132,933 -2,674 t4 Jigawa State (Nigeria) J 27,542 27,542 0 l5 Kwara State (Nigeria) 3 100,531 65,191 35,340 l6 Oyo State (Nigeria) 3 107,650 88,700 18,950 l7 Niger State (Nigeria) 3 85,398 81,658 3,740 l8 Kebbi State (Nigeria) 3 32,930 34,280 - I ,350 l9 Benue State (Nigeria) 3 I18,290 103,190 I 5,1 00 20 Bauchi State (Nigeria) J 98,640 82,640 16,000 2t Gombe State (Nigeria) 3 l13,960 97,960 16,000 22 Bioko Island CDTI (Eq. Guinea) 3 44,250 43,251 999 23 Phase 4 CDTI (Uganda) 3 68,278 ss327 12,95t 24 Phase 3 CDTI (Uganda) 3 62,062 63,360 - I,298 G JAF 7.4 Page 37 APPENDIX 3: FINANCIAL OVERVIBW - LETTERS OF AGREEMENT FINALIZED FOR THE 2OO1 BUDGET a - a .a I Project Year of Projcct Amount requested US$ Amount approved US$ Difference in US$ 25 HQs Support (Cameroon) 4 73,947 54,294 19,653 26 Adamaoua CDTI (Cameroon) 4 8 r,053 72,138 8,9r5 27 North Province CDTI (Cameroon) 4 fi6,366 107,627 8,739 28 Centre III CDTI (Cameroon) 4 t27,848 I18,983 8,865 29 South West I CDTI (Cameroon) 4 264,277 106J00 157,977 30 CDTI Project (Chad) 4 230,417 2l1,488 t8,929 3l CDTI Project (CAR) 4 t42,177 I 13,483 28,694 32 Tukuyu vector elim (Tanzania) 4 73,747 69,752 3,995 33 Ruwma CDTI (Tanzania) 4 33,872 32,537 1,335 34 HQs Support (Sudan) 4 175,050 13s590 39,460 35 Southem Sector CDTI (Sudan) 4 127,874 120,615 7,259 36 Northem Sector CDTI (Sudan) 4 107,715 94,278 t3,437 37 Cross River State (Nigeria) 4 87,400 79,950 7,450 38I 39 Enugu,/Anambra ..CDTI (Nigeria) Imo/Abia States CDTI (Nigeria) 4I 4 188,947 - 92,51r 175,854 96,238 13,093 3,727 40 Plateau/Nassarawa (Nigeria) 4 85,5 l9 91,449 -5,930 4l Kano State CDTI (Nigeria) 4 44,258 38,075 6,1 83 42 Osun State CDTI (Nigeria) 4 65,880 65,880 0 43 Zamfara State CDTI (Nigeria) 4 23,t60 23,160 0 44 Yobe State CDTI (Nigeria) 4 4t,755 29,620 t2,t35 45I 46 Federal Capital Territory (Nigeria) HQs Support (Nigeria) 4 5 33,893 180,780 32,732 102580 I,l6l 78,200 47 Taraba State CDTI (Nigeria) 5 5 5,255 49,288 5,967 48 Kogi State CDTI (Nigeria) 5 94,570 74,570 20,000 49 HQs Support (Tanzania) 5 6r,3l5 6lJls 0 50 Mahenge CDTI (Tnazania) 5 112,057 103573 8,484 5l Phase I CDTI (Uganda) 5 84,46r 56,287 28,174 52 CDTI Project (Malawi) 5 t6t,5t7 l6l5l7 0 53 HQs Support (Sudan) 5 73,700 55,200 r8,500 54 Northem Sector CDTI (Sudan) 5 96,320 86,6{5 9,67s TOTAL 5,859,506 4,922,025 937,481 l6%o reduction I ) 'l ,I I
Organisation mondiale de la santé (OMS) · Technical Documents
The World Health Organization year 2001 progress report : 1 September 2000 - 21 August 2001
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