Report of the thirteenth session of the Technical Consultative Committee (TCC): Paris, 10-14 September 2001

tAFRIGAN PROGRAMME FOR ON GHOCERCIASIS CONTROL (APoG)I.l At ':. I o REPORT OF THE THIRTEENTH SESSION OF THE TECHNTCAL CONSULTATTVE COMMTTTEE (TCC) Paris, 10-14 September 2001 't 2CONTENT A. OPENING (including agenda items l, 2, 3, 4, 9 and 12).. B. REVIEW, CONCLUSIONS AND RECOMMENDATIONS OF TCC13. REVIEW BY TCC OF ANNUAL TECHNICAL REPORTS OF THE FIRST, SECOND, THIRD AND FOURTH YEAR OF CDTI IMPLEMENTATION; OF SECOND YEAR PLANS AND BUDGETS; AND OF VECTOR ELIMINATION PROJECT REPORT (item 13) .... .. 8 Cameroon HQs Support Project technical report (3'd year technical report) ..........8 Haute SanagaiBelabo Diang CDTI Project (1" year technical report, 2'd year plan andbudget) . . ............9 West Province CDTI Project (1" year technical interim report and 2nd year plan and budget) . . ..... 9 5 8 B.1 Adamaoua CDTI Project (Znd year technical report).... South West II CDTI Project (Zil year technical report) Central African Republic CDTI Project (2"d year technical report)... Congo (Brazzaville) CDTI Project (1" year interint report and 2"d year plan and budget) . Democratic Republic of Congo Kasai CDTI Project (1" year technical report) Equatorial Guinea Bioko Island CDTI Project (Znd year technical report) Malawi CDTI Project (4'r'year technical report) Nigeria NOCP/HQS/NOTF (3'd year technical report) Adawama State CDTI Project (Znd year technical report).. Bauchi State CDTI Project (1" year technical reporQ ...... Benue State CDTI Project (1" year technical report)....... Borno State CDTI Project (Znd year technical report) ...... Cross River State CDTI Project (3'd year technical report) Edo/Delta States CDTI Project (2"d year technical report) Ekiti State CDTI Project (1" year technical report) Gombe State CDTI Project (1" year technical report) ..... ...... 10 ...... 10 11 .11 t2 t2 .. 13 t3 t4 t4 t4 15 15 15 t6 t6 JB2 TCC REVIEW OF NEW NATIONAL PLANS AND PROJECT PROPOSALS... 20 Democratic republic of Congo Bandundu CDTI Project Sankuru CDTI Project (re-submission) Niger State CDTI Project (1" year technical report) Ondo State CDTI Project (1" year technical report) Oyo State CDTI Project (2n year technical report). Plateau/Nassarawa States CDTI Project (3'd year technical report).. Sudan Southern Sudan CDTI Project (3'd year technical report)... Tanzania Tanga focus CDTI Project (1" year technical report) . Tukuyu focus CDTI Project (1" year technical report) Tukuyu Vector Eradication Project progress report ... Ethiopia Metema-Quarea Area CDTI Project (re-submission).... Bench-Maji CDTI Project Liberia South-Eastern Region CDTI Project Western Region CDTI Project........ Nigeria Akwa-Ibom State CDTI Project (re-submission) 83 TCC REVIEW OF RESEARCH PROPOSALS C ADDITIONAL SUBJECTS CONSIDERED BY TCC ... 16 ...17 ... t7 ... 18 18 .18 .19 .19 20 2t 20 20 Item 6 Item 7 Item 8 Item 10 Item 11 ltem 14 Item 15 Report on publication of the experience of APOC Monitoring of CDTI projects from 1988 to 2000: lessons for improvement .... Phase II and the Phasing-out Period of APOC: the Programme Document and the Memorandum... Report on TDR studies on Rapid Assessment Procedures for Loa-loa Report on the financial management of APoc-funded projects and the use of some Progralnme properties. Severe Adverse Events in Southern Sudan after treatment with ivermectin. Review of treatment of l,oa-loa risk areas in Cameroon with special reference to the additional REA exercises in the CDTI priority zones Other Matters 22 22 23 24 24 24 24 25 25 26 26 27 27Item 18 4Expenditures per treatment Indicators for operations and sustainability..... Cost Recovery ... TCC membership (2002) Lymphatic Filariasis Elimination and schistosomiasis Control in the Plateau Nassarawa States. Date and place of the fourteenth session of TCC...... Closure of the session 27 27 27 28 Item Item 19 2l 28 28 28 Annex 1:List of Participants .. Annex 2: Agenda Annex 3: NGDO Group priorities...... Annex 4: TCC recommended budgets. .29 .30 .3t .32 5THE APOC TECHNICAL CONSULTATIVE COMMITTEE Thirteenth session Paris, l0-14 September 2001 A. OPENING 1. Mr M Iguer, Vice-President of Merck, Sharp and Dohme, Inc., welcomed the participants in the thirteenth session of the TCC to the Paris Conference Centre of his company. He expressed his satisfaction that Merck & Co had been able to contribute to the success to APOC within the framework of the partnership of the Programme. 2. At the opening of the meeting the morning after the criminal terror attacks on sites in the United States the Chair and the Programme Director expressed, on behalf of the Committee, compassion with the American people. TCC participants observed a minute of silence. 3. Agenda item 1: rn opening the session, Professor Mamoun Homeida, Chair of TCC, re- iterated the welcome to Members of the Committee and otherparticipants. This sessionwas special insofar as it would be the last to be held during Phase I of APOC and more particularly discuss the Programme Document for Phase II and the Phasing out Period. Also, with its end, TCC would loose some of its Members who had all given strong support to the work of TCC and, thereby, to the success of the Programme. He finally referred to the changes that had taken place in the TDR structure, which would be reported to TCC as they would be of interest to APOC for its future collaboration with TDR as the research arm of the Programme (list ofparticipants attached as Annex 1). 4. Item 2: the provisional agenda (18.08.0i), attached as Annex 2, was adopted with the understanding that some of the time allocation to certain items in the provisional annotated agenda would need to be adjusted 5. Item 3: a brief summary of the items considered by CSA at its 93,d, 94't' ancl 95't' sessiorts, and of particular interest to TCC, was provided by Dr Ole Worm Christensen, Secretary to CSA. He referred to the CSA involvement in the preparation of the Programme Document for APOC Phase II and the Phasing-out Period and the corresponding Memorandum after which the Director of the Programme, Dr. Azodoga S6k6t61i, provided details of the procedures of the preparation of the documents. Dr Christensen then referred to the submission of the West African Freshwater Biodiversity Conservation & Ecosystem Management Project, destined to protect the rivers from environmental pollution, to the Global Environmental Facility (GEF) for funding. The GEF had requested further details concerning the prospect of sustainability of the project and its management structure and a revised proposal had been submitted. 6. In respect to support to socio-economic development in the oncho-freed zones in the OCP area, FAO had prepared a regional programme based on consultations with, and workshops held in, the Participating Countries which would be submitted to the forthcoming JPC calling also for donor supporl. Consideration had been given by CSA to the future onchocerciasis control activities in Siena Leone and the World Bank proposal for a grant for a countrywide ivermectin with vector 6control programme. CSA endorsed the recommendation of the EAC that control should be exclusively based on ivermectin treatment. The Programme Director informed the Committee ofthe findings of an entomological investigation undertaken in the border area with Guinea which concluded that transmission between the two countries could not be excluded. CSA had also examined the recommendation of EAC that aerial larviciding, together with ivermectin treatment, be continued for a few years after the closure of OCP in four circumscribed areas where the epidemiological and entomological situation remained unsatisfactory, and would support this recommendation at the JPC in Washington, recommending that part of the Trust Fund Reserve expected to be available at the closure of OCP be made available for support to this activity. No response had so far been received as to the request to the Gates Foundation for a grant to be shared between APOC Trust Fund and the NGDO Coordination Group. 7. The Committee was informed about the progress made in the arrangements underway for the closure of OCP and the establishment of the AFRO Multi-disease Surveillance and Control Centre and finally given details concerning the financing of the two Programmes. OCP would end with a surplus of US$ 7 million and APOC Phase I was fully financed with indications already now that more than half of the budgeted amount for Phase II and the Phasing-out Period might be forlhcoming. 8. Item 4: Miss Pamela Drameh, Coordinator of the NGDO Group for Support to Ivermectin Treatment, highlighted a few of the conclusions arrived at during the recent l8't' session of the NGDO meeting. TCC was informed that the Group had made a urgent request to the CSA for changes on the wording of paragraphs 6.1 .2 and 6.3 of the current draft of the APOC Programme Document for Phase II and the Phasing-out Period with regard to the Group's participation in the CSA and TCC (see section C. "Additional Subjects Considered by TCC", agenda item 8). 9. In relation to the report "An investigation into the administrative requirements ofAPOC" by Prozesky et aI, the NGDO Group agreed with the recommendation that certain core activities be given priority in APOC programmes. These core activities were presented to the TCC for its review for the possible application at country level in Phase II (see Annex 3). TCC however requested an executive summary of the report for review at TCC14. 10. Regarding the onchocerciasis control activities in Sierra Leone, the Group recommended "that consideration be given to enabling Sierra Leone to have access to technical and financial assistance from APOC." I l. TCC was informed about the Group's recommendation on the "necessity for flexibility when working in conflict areas and that a study be undertaken to review elements necessary to implement and maintain projects in conflict areas." 12. TCC was also informed that the name of the Group had now been changed to the "NGDO Coordination Group for Onchocerciasis Control". 13. Item 5: the Director of the Programme informed the Committee about thefollow-up to the recontmendations of the twelfth session of the TCC. A Mission to Chad had been fielded with representatives of OPC and Dr Peter Enyong representing the TCC and APOC Management. There seemed to be an unsatisfactory coordination between the National Coordinator and the two NGDOs, AFRICARE and OPC, due to an apparent lack of communication but the Mission observed with satisfaction that ivermectin distribution did take place. Problems concerning the receipt of ivenlectin consignments in the country and the distribution to the field were looked into and the 7Mission succeeded in facilitating the customs clearance for Mectizan entry into the country. The Minister of Health had signed a document allowing for direct delivery from the airport without levying duties or other taxes. Recommendations were made for a closer contact between the two NGDOs by more frequent meetings. 14. The recommendation of the Committee concerning the situation in Cameroon had been followed and there had been slow improvement in CDTI activities in the Loa-loa areas. A report had been prepared on the management of SAEs at the district level in the South West II Proiect (Cameroon) and a plan of action and training had been completed for resumption of CDTI activities in June. The REA exercise in Loa-loa suspected areas had intemrpted the treatment. Reporting from Ethiopia was highly unsatisfactory and APOC Management had informed the country that further funds would be withheld until receipt of a financial report. The CDTI programme had been launched in March. The CDTI manual had been translated into Amharic and APOC had provided funds for their printing. A report had been received from the Tukuw Vector Eradication Proiect in Tanzania; the question of continuation or closure of the project would be considered at ameeting early h2002 to review the situation regarding the progress of APOC funded vector elimination projects. In the meantime the embargo on the importation of temephos had been lifted. 15. Item 9: an explanation of the implementation of the new TDR strategy and the related changes in the organization of work was provided by Dr Hans Remme. The disease portfolio of TDR had become flexible with two new diseases added recently. TDR now operated under a matrix management structure in which disease specific planning and budgeting received greater emphasis. There would be expansion of activities in implementation research. The several current Task Forces, including the Task Force on Filariasis Intervention Research, would be replaced by two Steering Committees, one on proof-of-principle research and one on implementation research. The first nreeting of the new committees would be held in October 2001 when they would decide on their nrode of operation. 16. TDR's research strategy for onchocerciasis had been updated in consultation with APOC and OCP. The revised strategy focused on (i) sustained control using available interventions, and (ii) improved tools for treatment and surveillance. 17. TCC expressed concem that under these new alrangements, there would be less flexibility and that TDR would be less capable to respond rapidly and effectively to urgent research needs of APOC funded through the APOC Trust Fund. The Committee requested TDR to address these concerns, as TDR developes the modus operandi for Implementation Research. 18. Item 12: Mr Fortun6 Agboton, APOC Chief Administration and Finance, informed the Cornmittee that for the year 2001, the Joint Action Forum had approved US$ 11 030 000 for the funding of 78 projects in their first, second, third, fourth and fifth year implementation. At its 12tr' session, TCC had recommended for approval of 30 projects in their first, second, third, fourth and fifth year of implementation. 19. The Programme Director summarized the transitional procedures conceming the review by the APOC Management of proposals submitted by the NOTFs. He stressed that these procedures, for which guidelines had been developed and communicated to the NOTFs, were designed to alleviate the review burden of TCC so as to allow the Committee to concem itself more with technical, scientihc and programmatic issues. The Management was now reviewing from the 3'd year of project irnplementation all financial reports, budget proposals with their corresponding plans of action and interinr reports for the previous year and made decisions regarding approval with or 8without conditions which were subsequently transmitted to the NOTFs concemed who were encouraged to make their own reviews for transmission to the Management. The emphasis of the reviews was concentrated on financial reporting and the proposed budgets which should be in the order of those proposed in the original five year budgets previously submitted to the TCC. Letters of Agreement were subsequently prepared for signature without delay. Before the current session of TCC, APOC Management had reviewed 68 documents from 25 ongoing Projects. Only one Project had been requested to resubmit its proposal to the Management. The total budget of these 24 approved proposals as submitted by the concerned NOTFs was US$ 2,296,565. The total budget approved by the Management after revision was US$ 1,928,243 i. e. a 16% reduction. An additional six projects in their second, third and fourth year of implementation would be submitted to the Management for review and approval before the end of 2001. 20. The review of projects by TCC13 would therefore be confined to the examination of new project proposals, technical and financial reports as well as budget proposals for the first year of implementation of CDTI projects, annual technical reports on CDTI and Headquarters support projects and report for one vector eradication project. TCC expressed its satisfaction with these procedures, recognizing that they would increase the workload of the Management. B. REVIEW, CONCLUSIONS AND RECOMMENDATIONS OF TCC13 B1 REVIEW BY TCC OF ANNUAL TECHNICAL REPORTS OF THE FIRST, SECOND, THIRD AND FOURTH YEAR OF CDTI IMPLEMENTATION; OF SECOND YEAR PLANS AND BUDGETS; AND OF VECTOR ERADICATION PROJECT (Agenda item 13). Cameroon 21. HQs Support Proiect technical report (3'd year technical report) TCC reviewed this report that covered the period from May 2000 to June 2001 (13 months). The reporl contained many annexes making it rather weighty. TCC pointed out that it was however good to be able to refer to details of meetings as well as study the patient charts of those suffering SAEs altlrough the annexes were not well arranged. The financial report was rejected at TCC 12 bfi a revised report had been submitted to APOC Management and was satisfactory. The outline of the development of the National Plan for Cameroon was well described. TCC remarked that it was encouraging to see the NOTF playing a role in the reviewing projects and trying to mobilise the creation of new projects. Help from other International NGDOs was requested for these new projects. The NOTF had also been involved in problem solving in the Littoral 2 project where, due to the presence of Loa-loa, the NGDO partner was not performing well. These problems had been resolved and the partner is now working well to further ivermectin distribution. Loa-loa had also been a major problem in both the SW province projects. Some deaths had been reported and the NOTF had been active in studying them. Out of the four deaths in the SW2 project, TCC recognized that probably only one could be related to ivermectin intake. However, in the treatment charts in the Annex, it was difficult to see how some of these cases had evolved, and the completion of the Glasgow scale for unconscious patients was often inaccurately recorded, sqo the staff obviously required training. 9The NOTF had worked on the denominator for calculating coverage and this was now calculated at 44%. TCC noted that it was too low to have an effect on transmission of the infection. The government had added a budget line for onchocerciasis control, which is a very positive indicator for sustainability. Cost recovery has remained an issue, but "Onchocerciasis Funds" had been put into a frozen account for use at alater date except for the North Province. The TCC approved the report, and noted that it reflected an improvement in the activittes of the NOTF over the reporting period. TCC however requested that the next report be written in a clearer manner including a clear section on treatments countrywide. The NOTF needed to strengthen the training of health staff for the tllunagement of SAEs as well as reporting procedures. The NOTF also needed to resolve problems withfinancial accountability in the various projects in the country, and also address sustainability issues for the Programme when APOC fundtng was no longer available. 22. Haute Sanasa/Belabo Diang CDTI Prot ect (1't vear technical report. 2nd vear plan an{bqdssQ The Committee acknowledged that the project was moving along the lines that it had directed on approval ofthe projecl TCC reconmtended the approval of tlte report wttlt tlte following comments: i) The project should provide additional inforntation on SAEs and fears in the cotttttrunilies. iil Coyerage results should be provided on the previous 2 years treatnxent iii) REA should be completed in all the areas to deternine the hypo-endemic contrttuttities, and the TCC/MEC guidelines applied. TCC however noted the dfficulty of witltholding treatntent irt lrypo-endenic villages close to meso and Ityp er- endentic ar eas. TCC recontmended the 2"d year budgetfor approval and requested that it be scaled down by APOC Management, lookirtg in particular at the large amottnt requestedfor per dierus (62% of the budget). 23. West Province CDTI Project (1't year technical intertrnreport and 2"d year plan and budget) TCC noted that the project had not completed its 1" year activities and that this was a 6 months interirn report. The Committee therefore asked for a complete year 1 report which should include the following: i) More detailed information regarding the REA that was performed Clear description of the measures taken to implement the TCC/MEC recommendations. ii) 10 ii i) Clear indication of the numbers of activities in each district and ensure that data in all tables are reported consistently. iv) An update of any SAEs that occurred during treatment and an explanation of how they are managed. v) An explanation why laboratory technicians were trained for SAE management. The l't year interim report was accepted. The year 2 budget was recommended for approval and TCC requested that it be revised downward by APOC Management to more closely reflect the budget originally proposed for year 2. Tlte request for a computer, 5 motorbikes and $18 000 for T-shirts should be reviewed and scaled down by Management. Management should also review the needfor additional REA and tlte costs of undertaking it. 24. Adamaoua CDTI Proiect (2nd vear technical report) The committee reviewed the second year project report, dated December 2000, which should have been presented to the TCCI} but which was delayed. The report covered the period November 1999 to October 2000. TCC noted that the report was not well arranged and it was difficult to extract the information necessary for the report. However, TCC noted that that progress had been nrade although finding Loa Loa, particularly in the Bankim Health District, had complicated this. No treatment was carried out in Bankim. One other problem was the motivation of CDDs. This has become particularly acute due to the construction of the Chad-Cameroon pipeline. This project had been recruiting from the local population and there had been considerable attrition amongst the CDDs. The population was involved in the Project and one very positive result was the change of attitude between the CDDs and the govemment health staff who now work better as a team, and there had been a spin off into other health activities, e.g. vaccination programmes. There had been good integration into the PHC system. The TCC approved the report. TIte committee requested that tlte next report follow tlte APOC guidelines nxore accurately, and tltat non-essenttal information be omitted. 25. South West II CDTI Proi ect (2"d vear technical renort) This was a resubmission from SW2 Cameroon. The concems of TCC12 related to the failure to do REA prior to treatment, the failure to put a system to treat SAEs when they arise and the poor performance in coverage.TCCLZ had suspended ivermectin distribution in SW2 due to the 4 deaths (assumed to be relatedto Loa Loa). TCC13, taking into account the difficult terrain; poor infrastructure and almost non-existent health facilities noted that: i) REA was performed and treatment was withheld in areas where REA was not performed. 26. ii) 11 Reasonable facilities for treatment of SAE was put in place and awareness was high with regard to the occurrence of SAE. iii) The treatment coverage rate (372%),69 205 out of a total population of 185 874, was based on actual census. TCC accepted the report with the followirtg remarks: ,) Better training of CDD should be undertaken. ii) REA should be completed, and the exercise should follow the proper or agreed methodology. iiil Continuous supervision and care should be taken to observe and manage SAE. iv) Close collaboration between the NGDO (SSI) and MOH was encouraged. Central African Republic CDTI Prqiect (2''d vear te The TCC was pleased to note that the project was continuing to run smoothly, and following APOC principles. The effective integration of CDTI in the PHC activities in some areas, the commitment of some religious organizations in the mobilization activities, and above all, the excellent drug coverage (70% of the total population) were particularly noted. TCC encouraged the project to continue its efforts to improve the commitment of the population regarding support of the CDDs. 27. TCC approved the tecltnical report. Congo (Brazzaville) CDTI Project (1't year interim report and 2"d year plan and budget) Tlie TCC reviewed 6 monthly technical and financial reports of the Congo project and the proposed budget for the second year. This project had a major part of the treatment area in the city of Brazzavllle itself. Although the project got off to a slow start, most of the planned activities in Brazzavrlle itself had been accomplished. The project was waiting for the beginning of dry season to begin activities in the more rural part of the project. There had been involvement by Ministry of Health resulting in some good mobilization and the NGDO (OPC) had also been helpful in advancing funds to the project. There had been a good geographical coverage of Brazzaville altlrough only a therapeutic coverage of 55Yo. TCC noted that the financial report was adequate and the budget lines had been used appropriately. TCC approved the 1" year interim technical report. Tlrc year 2 budget was also reconrmended for approval on condition that APOC manoge,nent reduced excesstve budget lines e.g. per dierus for people to work in Bruzzaville ure not required. t2 Democrqtic Republic of Cottgo Kasai CDTI Proiect (1" year technical report) TCC noted that this was a relatively new CDTI project, but ivermectin distribution was implemented a long time ago. TCC encouraged the project to: 28. 29. i) Provide more information on how health education, mobilization and sensitization was done; ii) Do its best to move ivermectin to the health districts once it gets to the project area; iii) Clarify why only 1 889 villages were treated after 2 002 villages where mobilized and 1 991 villages had CDDs trained; v) Encourage more health education so that refusals and absenteism could be reduced; vi) Clarify why the number of health districts included in year 1 activities were split into 3 funded by APOC and 4 funded by CBM; vii) Give details on how the cost per person treated was calculated; v) Provide more information on the conditions under which the project is operating, given the political situation. The I't year technical report was accepted by the committee. Equatorial Guinea Bioko Island COft Proiect (Z'd ve TCC noted that the figures concerning the number of communities included in the project were confusing. It seemed that hypo-endemic communities in the town of Malabo were planned to be treated. A large discrepancy was noted between the population figures given in the introduction (90,000 in the Island, including 60,000 in the rural communities) and the number of persons recorded during the census activity (18 224 persons). Clarification was requested on these two issues. TCC also noted the very low therapeutic coverage (l2.6oh when one uses the figure of 60 000 persons living in the rural communities), and as a consequence, the very high cost per person treated ($S.S;. The 2"d year technical report was rejected. TCC recommended that anotlter report be produced after contpletiort of REA and accurate census (to be done simultaneously) in all the communities, and that APOC Management not forward any funds on tlte year 3 budget until cornpletiort of the activities ntentioned above. TCCfurther recornmended that APOC Managerflent sent a special nissiort to Bioko to assist in addressing the issues raised above. 13 Malawi 30. CDTI Project (4th vear technical report) TCC noted that this project was in its 4'l'year and needed to expand activities faster, ensuring that all the communities needing to be treated are treated. TCC also raised the following issues: i) The project needed to address the long list of weaknesses raised in the technical report quickly. ii) Total cost and not just APOC cost should be used for calculating cost per treatment. iii) Mass treatment in hypo-endemic communities outside the CDTI areas (red areas) should be stopped. iv) v) Involve districts more in planning and implementing activities and increased intemal capacity building at district level. 31. The MOH should work more closely with the NGDO partner and strengthen the partnership. Nonetheless, tlte tecltnical report was accepted but TCC recommended tltat the issues raised above be addressed before the lt' year's tnterim report, failirtg wlttch there will sltould be no releuse offunds by APOC Managementfor the 5tt' year. Nigeria NOCP/HQS TCC regretted that a national coverage figure was not provided based on the total number of treatments in 2000 (15 486 245) divided by an updated total (census) population. TCC was also concerned that the table on page 7 still showed incomplete data for the Year 2000 (last column). The Committee requested the following information: i) A detailed update on the process of revising the Nigeria REMO map following the REMO refinement exercise. TCC also requested that future maps of Nigeria provided in the NOTF HQ report show CDTI areas and project implementation areas (rather than the map provided in this report that was simply a map of the states of Nigeria); ii) A more detailed description of the structure and process of the national review of APOC reports and research projects prior to their submission to Ouagadougou; iii) Activities related to identification and development of local NGDOs to participate in APOC; iv) Subsequent reports should include operations research activities TCC accepted the Nigeria NOTF technical report witlt these clarificatiorts to befortuarded to APOC Management. t4 32. Adamawa State CDTI Proiect (2"d vear technical report) TCC noted the increase in treatment since APOC activities began, reaching 726 115 in 2000 (compared to 250 662 in 1998). TCC was still concerned that the report stated that only 9 LGAs were targeted for the APOC project while tables showed CDTI activities in all 17 onchocerciasis endemic LGAs in the State. The Committee noted that CDTI activities were being undertaken in 2504 communities (2515 in Table V), a considerable increase over numbers proposed in the original project proposal (1204), and requested an explanation. TCC would like to know if the project had now reached 100% geographic coverage (i.e. CDTI activities have reached all targeted communities). Satisfactory progress was reported in training activities, with 2068 (72%) CDDs trained of an annual objective of 2800. TCC noted that the required table for CDTI implementation was missing in the report and requested that this be forwarded to Management. The TCC again requested that the project give more information about the use of the Bamako Initiative Committees in the project. More detail should be provided about the committees' activities and orientation (e.g. will the committees request local cost recovery from ivermectin distribution that will effect coverage?). Enlistment of such committees may be an important area for operations research on integration of CDTI with local committees operating under the Bamako Initiative directives. TCC accepted the Adamawa State year 2 annual report with a requestfor subnission of items ruissirtg in the annual report to APOC Management. 33. Bauchi State CDTI Plqiect (1't vear technic4l report) TCC in reviewing this project noted the following: i) The NGDO or other partners involved in the project were not mentioned in the report. ii) The therapeutic coverage was very low for a project that had been in existence since 1991. TCC requested an explanation. iii) Cost per person treated should be calculated and reported. iv) Background on treatment coverage since 1991 should be provided. Nottyithstanding the above, the I't year technical report was accepted. TCC also reconrntended tlrut more State healtlt personnel be involved tn planning and intplementation of CDTI field activities. 34. Benue State CDTI Prqiect (1" vear technica TCC remarked that the project needed to make a concerted effort to attain the ATO set and that progress needed to be made in this 9 year old project. The NOTF was urged to address responsibilities devolved to NOCP by UNICEF. The Comntittee accepted tlrc technical report on clarification of issues andprovision of additional info rmatio n as follows : 15 il The conflicting information on the annual treatment objective. iil Complete information on Table 3 of the report. iiil Provision of a plan of acttonfor expansion. iv) NOCP to ensure adequate monitoring of CDTI implementation. v) Treatmentfigures should be providedfrom January to December 2000 and not only for Jan - September 2000. 35. Borno State CDTIJ TCC recognized this as a good report, noting satisfactory overall performance with the quality of training improved. The project itself identified weaknesses and options for addressing the weaknesses. Coverage of TlYo (therapeutic) and 98% (geographical) was impressive. TCC accepted the report but tlte project sltould: Intensifu comntunity sensitization and involve community based organizations (cBo9. ii) Organise stakeholders meetings itil Produce and distribute ntore IEC materials, particularly at conununity level iv) Select and train more CDDs, and retrain CDDs , I Address issues raised in TCCI2 ( state ATOs and current population at risk, and explain how the Bamako initiattve willfit in with CDTD. 36. Cross River State CDTI Proiect , ^rt]IJ VC ar technical reDort The Committee commended the project on very useful innovations that included community self- monitoring, stakeholders meetings and intersectoral collaboration, which were practical ways that could enhance the CDTI implementation process. TCC accepted the teclmical report but requested that proper figures be provided for CDTI intplementatiort irtdicators, training targets, mobiltzation and health educatiortfor one calendar yeur (i.e. 2000), instead of 2 sets of datafor 6 montlts eaclt (July - December 2000 and January - June 2001) as they ltave been provided in tlte curuent report. 37. Edo/Delta States CDTI Proiect ,andtz vear technical renort) TCC requested clarification for annual treatment objectives (ATOs) for the newly updated census data and additional information on what CDTI activity was done using LGA contributions received. Again TCC recommended that the cost per treatment be calculated using total funding and not just APOC funds. t6 Notwithstanding tlte above, tlte technical report was accepted by the TCC. 38. Ekiti State CDTI Proiect (1't year technical report) TCC asked the project to clarify ATOs for the upcoming years as the ATOs given in the original APOC proposal for years 3-5 exceeded total population given in this report. TCC also requested that the total population of the 416 endemic communities be clarified (is it 625 303 or is this figure the ATO for 2001). TCC noted that the cost per treatment was not estimated. TCC13 further reiterated the recommendation atTCCL2 that LGA staff needs more sensitization to ensure good reporting and involvement. Nonetheless, tlte tecltnical report was accepted by the Committee. 39. Gombe State CDTI Proiect (1't year technical report) TCC commended the project for reporting contributions by partners, but requested that additional information be provided on how funds from State and LGAs were used. The project was also requested to report cost per treatment based on total expenditures, and not only on APOC funds. TCC pointed out that the report needed to reconcile treatment figures (page 3 included clinic-based treatment and it was not clear if page 7 also included clinic-based treatment). The project was also asked to: i) Comment on integration of CDTI with PHC. ii) Provide additional information on the plan to increase CDDs. . The current ratio of CDD to person treated reported was 1:795. iii) Provide REMO data. Notwithstaruding the above, the Committee accepted the 7" year technical report. 40. Niser State CDTI Proiect 1rt vear technical renort)( This was the 1't year technical report covering the period Jan 2000 - December 2000 for an old project which has been treating onchocerciasis with ivermectin since 1991. The committee noted that: i) The progress of this project was very slow and a treatment coverage of 25.3% (240 620 out of a total population of 952 592) was unacceptable. There was contradicting figures for communities to be treated (608 and 1159 were given in different pages). iii) Some information was missing e.g. communities paying CDDs (table II). ii) i,r) Ways to improve mobilization of target communities were not addressed in a satisfactory manner (this was a concem in TCC12). The delay in release of funds was not accepted since the project received enough advance from both the LGA, UNICEF andGTZ. v) t7 vi) The number of CDDs trained is short of the expected number TCC rejected tlte report and requests APOC Management not to release funds ort year 3 budget unttl TCC concerns were addressed. TCC furtlrcr recommended tlrut three of its mentber visit Niger State to assr'sf in addressing the issues raised above. 41. Ondo State report) TCC noted the potential for success for this project. Communities were enthusiastic having been mobilized and sensitized, hteracy level was high and annual training objectives for all cadre of personnel had been met. The State Coordinator, SOCT, LOCT, and CDDs were committed and hardworking. However, performance was poor, and not much had been achieved since Jan 2001. Tlre project was still conducting first round of distribution one year after commencement of CDTI. There were conflicting figures on numbers treated and ivermectin tablets used. There were no figures on ATOs and no justification for training more CDDs when 7 700 CDDs had been trained against annual training objective of 1 500. As at March 2001 only about 50% of firstyear funds had been spent and the project was 5 months late in submitrting financial returns. TCC tlrcrefore rejected tlte report and recontmended that funding be suspended pending veriftcatiort by TCC members of intplementatiort of thefollowirtg: 42 , NOTF/HQ and State MOH to solve the problems of delay in the release of project funds to the SOCT.ii) Project should quickly concludefirst round of treatment. iii) Project should proyide accurate treatment data in the year 2 report. iv) Project should subnit all outstanding financial returns to APOC Managentent. Otro Slate CDTI Project (2"d year technical report) TCC noted that this was a well written report, showing progress made with room for improvement. The technicul report was accepted witlt tlte followirtg recontmendattons: ,) ii) i, iv) vi) vit) t,i) Increase nuntbers of CDDs and improve tlteir training. Improve training of trainers. Assure that sfficient quantities of iverntecttn are requestedforfuture cycles of treatment. Superttision and monitoring should be improved at all levels. Increase advocacy at State and LGA levels to encourage the release ofcounterpart funds. Confirnt nuntber of villages treated in CDTI area during reporting period and state such in all future projects. Revise ATOs from original APOC proposal (ATOs are likely to be higher than origi na I ly proj ect ed). The project should strive to increase trea.tment coverage.t,iii) 43 18 Plateau,/Nassarawa States CDTI Proiect (3'd year technical report) TCC acknowledged that the project had made good progress in implementation of CDTI. It however raised some concerns and requested additional information from the project as follows: i) The cost per treatment estimate; ii) Clarification was required on the nature of the 9 "new" meso-endemic LGAs, population figures for these LGAs requested, and clarification was sought on whether they are included in the LF programme; iiD The project was asked to provide a more complete explanation of "retreatments" given. iv) ATOs for the remaining years of APOC support should be revised, considering the total population of 894 013 and the 9 "new LGAs"; v) The project should explain how LF and schistosomiasis programmes have impacted and have been coordinated with CDTI; vi) Provide TCC with armual treatment data from commencement of programme to the present and information on census; vii) Funds for a special advocacy workshop were granted to the project, the activity of which should be reported; viii) The project should encourage advocacy visits that are necessary to help obtain State and LGA counterpart funds. Notwithstanding the above, the Committee accepted the technical report. Sudan 44. Southern Sudan CDTI Proiect (3'd vear technical reoort) TCC acknowledged the special circumstances of the situation in southem Sudan that justified the deviation from the usual CDTI strategy. The decrease in the number of NGDOs working in the project areas as well as the suspected cases of SAE, resulted in the significant reduction in the number of people treated (179 382). Nonetheless, the Soutlrcrn Sudon report was accepted. Tlte project wds asked to use tlte APOC technical report forntat as muclt as possible ltighliglilirtg treatment data in tlte report. Tanzania 45. Tanga focus CDTI Proieo TCC noted that the text was verbose but included more background information (life cycle of onchocerciasis, geographic and economic attributes of the three districts in the project area). CDTI as a strategy in communities was functioning well, with 100% of training objectives met, and 140 640 persons treated (7 5o/o of the total population). APOC funds had flowed well down to the project. TCC was pleased with the large portion of APOC funding used for training, and that the persons treated per CDD was 73:1. The cost per treatment was not calculated in the report, but TCC noted that APOC provided about $1.00 per treatment in Year 1 and hoped to observe a decrease in future reports. TCC was concerned that: D19 The report did not provide ATO objectives for 2001 (TCC noted that the original project document for Tanga proposed to treat 149,999 by the fifth year of the program). ii) Progress toward full geographic coverage was not established. In this regard, TCC noted that in 2000, 118 villages were treated and wished to be informed if that represented 100% geographic coverage (the original project document gave the total number of communities to be reached in the project area as 59). TCC was informed by Management that Tanga project was yet to submit its third year budget. Tlte annual tecltnical report was accepted. Tukuyu focus CDTI Proiect (1't year technical report)46. TCC noted that technical report was fairly well written. Good progress has been made in CDTI implementation. The project was requested to: i) Clarify conflicting information on when census was carried out ii) Address the issue of absentees and defaulters iii) Clarify conflicting information on training of staff and ATOs iu) Advocate for increased support of CDDs The technical report was accepted. 47. Tukuyu Vector Eradication Proiect report (January - July 2001) The project was still in the preparatory phase pending the arrival of the required amount of temephos to allow for large-scale ground larviciding. Permission for the importation of 4000 ltr. had been granted with a deadline for arrival in the country by October 2001. A detailed schedule for the implementation of larviciding had been prepared and preparatory activities continued. An order for 4000 ltr. of Abate will be channelled through OCP and APOC Management was urged to take action on this matter to avoid late arrival of the consignment in the country. In case the deadline was not observed, larviciding could not start in October as planned and would have to be postponed to a period between November 2001 and Mid-February 2002 i.e. before the rainy season. The technical report was noted by TCC with the recommendation that all efforts should be made to deliver the temephos consignment in the country by October this year to enable the start of large-scale ground larviciding before the next rainy season which may occur in March-April 2002. 20 B2 TCC REVIEW OF NEW PROJECT PROPOSALS (Agenda item 16) Democratic republic of Congo 48. Bandundu CDTI Project TCC recognizedthis as a well written proposal that addressed all the vital questions, with up to date information. Concern was however raised that the proposal did not address the fact that due to the political situation the necessary infrastructure might not be in place to allow the project to start witlrin 2002 inall the endemic areas. TCC therefore recommended that the project be implemented in a phased approached. TCC noted that the project might be in an area endemic for Loa Loa. TCC also highlighted the fact that the project area boarders Angola, and that there could be a potential refugee problem given the political situation Notwtthstanding the above, tlte Committee recommended approval of tlte project. TCC also recomrrrended approval of tlte proposed budget for the first year following review by APOC Management wtth particular reference to tlre vehicles requested and the budget calailatiorts. The need for capttal equipment tlrouglrout tlte five year period was questioned. 49. Sankuru CDTI Proiect submission ) This is a resubmission following the rejection of the proposal by TCC12 due to the lack of details regarding the implementation process. The total population of the 6 health districts included in the project was 917 000, and the treatment objective for year I is 412 000 persons (45% of the total population). TCC noted that the re-submitted proposal was clear, detailed, and gave evidence that those responsible for the project were strongly committed. The annual treatment objective (ATO) was considered to be realistic, taking into account the size of the target population and the political situation in the project area. TCC however noted that treatment should commence rn2002 and not 2001 as indicated in the proposal. TCC acknowledged the fact that the project would involve all levels, from the community to the central level, including those already involved in health activities at the community level (i.e. members of the village health committees). TCC recontmended tlte approval of the project. The buclget was also recommended for approval but details sltould be provided on ltotu KAP surveys will be funded. Ethiopia 50. Metema-Quarea TCC was of the opiniort that the re-submitted project proposal had not clrungedfrom tlrc origirtol sttbrttissiort and the resubmitted proposal htas rejected for the followirtg reasons: The resubmitted proposal did not have a partner NGDO letter of endorsement and therefore did not demonstrate the partnership spirit so important in the APOC projects. This letter must accompany the proposal together with the NOTF and Government letters of endorsement. i) 2l ii) The proposal did not incorporate REMO data from the Quara Woreda. Ifthe REMO exercise ha not been conducted in Quara, this activity must be undertaken and the results be used in the proposal before the document is resubmitted to a subsequent TCC session. iii) Sufficient background information on Quara Woreda, including community settlement patterns and accessibility relevant to project implementation must be provided. This should also be provided for Metema if treatment were also required in this area. iv) The budget estimates should reflect the APOC philosophy of reducing extemal support from a maximum in year 1 to a minimum in year 5. The maximum expenditure in Year 1 could be in the order of $2 per treatment ($1.5 from APOC) reduced to 20 cents by Year 5. The budget should be reduced from year 2. Due to the small size of the area proposed for ivermectin treatment, and the relatively small population size, the request for 2 vehicles and 6 motor bikes was not justif,rable. These vehicles further inflated the cost per treatment in the project. In addition, TCC noted that the duplication of vehicles and computers at Regional and Zonal administrative levels should be avoided. Budget lines should be justifiably presented with relation to the activity planned. 51. Bench-Maii CDTI Project Tlris is a CDTI proposal from the South West Region of Ethiopia. TCC rejected the project proposal wtth particular reference to tlte followirtg: i) The inadequate data on REMO. TCC noted that REMO was done in1997 in only 5 kebeles out of 185 kebeles to be treated, a small percentage of the whole area to be treated. ii) An unrealistic plan of action, proposing to treat all at risk population in 2001 (i.e. 3 months), when the endemicity of onchocerciasis is still unknown. iii) An excessive budget which reflected the lack of understanding of the CDTI strategy and APOC philosophy. This was reflected in the following requests: printing treatment cards for CDDs ($a 000); printing treatment registers for CDDs ($12 000); flip charts for CDDs ($20 000); and travel for CDDs ($4 680). The committee raised its concern that this project was submitted prematurely, and requested that due consultation with the NGDO partner be made, and REMO completed before resubmission to TCC. v) 22 Liberia 52. South-eastern CDTI Proiect TCC noted that the project proposal was not well written and appeared to have sections from another proposal (pages 40 - 43), with a number of annexes missing. TCC recommended that thts project be rejected for resubmissiort following responses to its concerns as follows: i) The proposal indicated that all 30 districts in 6 counties would be CDTI areas. Current REMO did not support this, and indicated that only a few districts were in the CDTI (red) areas. ii) The target population should match more closely with the REMO so that better budgeting could be provided. Particular attention should be paid to the request for motorcycles. iii) TCC noted that the budget reflected support for developing the primary health care in non-onchocerciasis areas. iv) An organizational chart was not available and should be included in the proposal to be resubmitted. v) A more detailed implementation plan should be provided. vi) The budget summary gave the total population for every year, used to calculate the cost per treatment over the 5 years. This should however be the annual treatment objective (the number to be treated per year). vii) The budget reflected an increase over 5 years in the NGDO budget contribution. This raised concem for the implication for sustainability. 53. Western Region CDTI Proiect TCC recontmended tltat the proposol be rejected and resubntitted to TCC witlt a 5 year budget. TCC's main concerns included thefollowirtg: i) TCC noted that there was no endorsement of the proposal by UNICEF and CHAL. The plan of action was not clear and the proposal should be 5 years and not just the residual 2 years of UNICEF current funding support. The plan of action was not clear and should cover 5 years and not 3 years. Activities were poorly planned, with distribution planned for in the rainy season instead of the dry season. TCC emphasized the need for the timing of distribution to be decided by the communities. ii) No details were provided on training in particular, annual training objective and the tirning related to ivermectin distribution. iii) The organizational chart should be reviewed in line with the APOC philosophy and partnership. iv) The flow of funds was unclear as was the flow of ivermectin. 23 v) The project did not clearly describe the monitoring process and the relationship with other PHC activities. vi) Some communities were very small with only 20 people. The definition of a community needed to be clarified in line with accepted norms. vii) Theprojectedtreatmentfrom 147 155 in2000to650051in2001 seemedunrealistic and should be revised. TCC concluded that the proposal reflected a lack of understanding of APOC philosophy. It therefore recommended thatAPOC Management provides assistance in the development of the proposal in view of the needs and particular situation in Liberia. Nigeria 54. Akwa-Ibom State CDTI Proiect (re-submission) TCC reviewed the resubmitted project proposal for two LGAs in Akwa Ibom State. The project proposal addressed several of the issues raised in the first proposal. The REMO had been completed and was reported leading to a change of LGAs to be treated although this was not explained in the proposal. The problem of Loa Loa had been raised and mentioned at some length in the text. However, the REA community by community required in accordance with MEC/TCC guidelines had not been planned. Although there was mention of management of Severe Adverse Events in specified health centres, only 500 US dollars has been allocated to this activity, which was totally inadequate for the training and possible treatment necessary. The Committee was equally concerned about the number of CDDs to be trained which was far from the 1 per 250 population required. Similarly the amount allocated for this important activity was totally inadequate. The Committee was concemed about an apparent lack ofunderstanding of some of the principles of CDTI, demonstrated by the phrase that the communities will be "made to" participate. The budget was considered to be way beyond the normal budget guidelines ofAPOC. Although the first year total was within normal limits the proportions allocated to each activity were not appropriate. Very little was requested for field activities, including the training of CDDs, whereas the general health staff for the project was excessive. The numbers of vehicles including motorbikes exceeded requirements to treat 2 LGAs. The second and subsequent year's budgets did not follow the usual reductions made within APOC programmes. TCC recontmended tlrut tltis proposal be resubntitted to APOC Management. TCC noted that it was imperative that the project complied with MEC/TCC guidelines, as this was an area of Loa Loa. REA had to be done in each community and a clear programme for management of SAEs put in place. It was also recommended that APOC Management help to carry out an experimental RAP LOA study together with the REA in order to estimate the risk of laa Loa provoked SAEs. B3 55. C. 24 TCC REVIEW OF RESEARCH PROPOSALS The Chair updated the situation regarding receipt and TCC Member review of research proposals ADDITIONAL SUBJECTS CONSIDERED BY TCC Agenda item 6: Report on publication of the experience of APOC 56. The Programme Director informed the TCC that seven (7) papers on the accomplishments of APOC since its inception were being prepared for publication in a supplement to the Annals of Tropical Medicine and Parasitology. The manuscripts had been prepared by researchers from APOC countries, APOC staff, NGDO representative, National Coordinators and the World Bank. Editing of the contributions was being carried out by Prof. Oladele Kale , former chairperson of the TCC. A formal agreement had been entered into with the publisher and the supplements would appear early rn2002. The articles are being prepared on: i) "Partnership and Promise: Evolution of the African Riverblindness Campaigns" "The Achievements and Challenges of the African Programme for Onchocerciasis Control (APOC" "REMO: Its application by APOC and Challenges" "The Challenges of Community-Directed Treatment with Ivermectin (CDTD of the African Programme for Onchocerciasis Control (APOC)" "The Gender Issues on Community-Directed Treatment with Ivermectin (CDTI) of the African Programme for Onchocerciasis Control (APOC)" "Monitoring Community-Directed Treatment Programmes for Sustainability: lessons from APOC Operations. "CDTI strategy of APOC and its potential for providing additional health services to the poorest populations". ii) iii) iv) v) vii) Agenda item 7: Monitoring of CDTI projects from 1988 to 2000: lessons for Improvement 57. APOC Management informed the Committee of the lessons learnt from the monitoring of CDTI projects. In 1998 a periodic assessment of CDTI projects through participatory partners' monitoring was initiated. The main focus was to assess treatment coverage, as well as the challenges and opportunities in the implementation process, for the presence of predictors of sustainability indicators (community involvement, partnership commitment, treatment coverage and integration into the Primary Health Care). This was done usually 12 months after the establishment of projects (or their reorientation to CDTI). 58. Recently, data from 15 109 household interviews inL 403 villages in27 ott of 39 CDTI projects monitored between 1998-2000 in five APOC countries had been analyzed. The data showed that community directed distributors (CDDs) treated 65.3% of the population; treatment coverage ranged from 55% to 77o/o. The lessons learned was that to improve treatment coverage and enhance sustainability of CDTI: vi) 25 59. Communities should decide the period of distributions; NOTFs should avoid late supply of drug and adhere to treatment period decided on by the communities in order to reduce the rate of absenteeism; 60. Severe Adverse Experiences (SAEs) by communities seemed an underlying factor of high refusal and low treatment rates in Cameroon; there was a need to improve communication strategies to address issues of community ownership; treatment of absentees and refusals; incentives; and irnproving the quality of supervision. CDTI participatory partners' monitoring provided opportunities for capacity building of health personnel at district and peripheral levels, cross- fertilization of experiences among program managers and lessons to contemplate changes. Agenda item 8: Phase II and the Phasing-out Period of APOC: the Programme Document and the Memorandum. 61. TCC in considering this agenda item, confined its attention to paragraphs 6.1.2 (Committee of Sponsoring Agencies) and 6.3 (Technical Consultative Committee (TCC)) in the Programme Document for Phase II (2002-2007) and the Phasing-out Period (2008-2010) dated 17.07.2001. During the previous week, the NGDO Coordination Group had reviewed the two paragraphs and agreed on modified texts. After a thorough examination of the two paragraphs, TCC endorsed the modifications proposed by the NGDO Group for the texts to read: Paragraph 6.1.2 (first sub-paragraph): "In Phase I, the membership of the Committee of Sponsoring Agencies (CSA) comprised representatives of UNDP, FAO, the World Bank and WHO who will continue as Co-sponsoring Members. The Director, APOC, will continue to attend ex-officio all session of the CSA. In addition, a representative of the NGDO Coordination Group and a representative of Donor(s) of ivermectin used by the Programme, will be invited to join the meetings of the CSA." Paragraph 6.3 (second sub-paragraph): "During Phase II and the Phasing-out Period, TCC rvill be expanded to 12 Members as follows: eight (8) scientists and experts recommended by APOC Management to CSA for its recommendation for appointment by the WHO Director- General; one (1) expert of the Mectizan Donation Programl and three (3) experts appointed by the NGDO Group for Onchocerciasis Control. Members will be appointed to a three-year term, renewable for a maximum of three years, on a staggered basis." 62. The Committee further endorsed the NGDO Group's recommendation that the TCC should " report to the CSA through the Programme Director". TCC therefore recommends that the last sentense of the first sub-paragraph under 6.3 be amended accordingly. Agenda item 10: Report on TDR studies on Rapid Assessment Procedures for Loa- loa 63. The results of a TDR study on Rapid Assessment Methods for Loa loa, co-funded by APOC, were presented to TCC by two of the principal investigators: Dr. I. Takougang of the Unversity of Yaounde and Dr. S. Wanji of the University of Buea. This was a multi-centre study undertaken in Cross-river State in Nigeria, and the South-West, North-West and Eastem Provinces of Cameroon. Tlre study involved a total of 102 villages covering a wide range of Loa loa endemicity from low in Cross-river State, high in Eastem Province and the full range of endemicity in West Cameroon. There was a clear relationship between the intensity and the prevalence of Loa loa infection at the community level, similar to that reported for Central Cameroon. 26 64. A total of 6 rapid assessment procedures (RAP) were tested for community diagnosis of communities where Loa loa endemicity exceeded defined risk thresholds were tested. The RAPs were based on the history of eye worrn and/or Calabar Swelling obtained using a simple questionnaire administered to a sample of 125 people per community. All 6 RAPs showed a statistically significant relationship with Loa loa endemicity. The sensitivity was betweeng4o/o and IU)yo,andthespecificityranged from48o/oto92o/o.ThebestRAPinvolvedarestricteddefinitionof eye worn, for which the sensitivity was 100% and the specificity greater than9}o/o. The researchers recommended the use of RAPLOA - the RAP based on the restricted definition of eye worm - for rapid assessment of the level of Loa loa endemicity and the corresponding risk of serious adverse reactions following CDTI. 65. TCC congratulated the researchers for a well executed and convincing study. TCC noted that RAPLOA appeared to be an effective rapid assessment method for Loa loa endemicity and it considered this an important breakthrough for onchocerciasis control. TCC recommended that appropriate action be undertaken by TDR and APOC to bring this new tool into operational use as soon as possible. This should include the development and field testing ofoperational guidelines for RAPLOA, validation of the tool in other major geographic zones, notably in DRC and Congo Brazzavillq and development of spatial sampling strategies. TCC also recommended that TDR and the research group at the University of Liverpool, that is developing the remote sensing risk map for Loa loa, discuss how the two methods could be used most effectively. Agenda item 11: Report on the financial management of APOC-funded projects and the use of some Programme properties 66. The Management of APOC has informed the Committee that most of the projects have improved their financial management through a better understanding of the WHO procedures and by reporting more accurately and more regularly on financial matters. However, certain projects are still very late in sending their imprest retums as requested by the Letters of Agreements. Steps are therefore being taken by APOC Management to improve the performance of these projects in that particular field. The attention of the Committee is also drawn on the problems encountered in Uganda, with the misappropriation by a MOH senior staff of an APOC vehicle designated for onchocerciasis activities. TCC expressed its concern and endorsed the steps being taken by Management to recover the vehicle for its intended use. Management also informed the Committee about the progress made on the investigations on vehicles stolen in Nigeria and Cameroon. Agenda item 14: Severe Adverse Events in Southern Sudan after treatment with ivermectin 67. TCC was informed of 5 cases (2 deaths) of SAEs from Southern Sudan that were reported to the NOTF, MDP/Merck, and APOC Management, in 2001. The TCC reviewed the cases and noted that only one (not a death) might have been associated with co-infection with Loa Loa and the consumption of ivermectin. 68. In areas of trypanosomiasis, normal guidelines for ivermectin treatment should be followed. Persons without symptoms should be treated with ivermectin if other exclusion criteria are not present. Patients with symptoms of chronic disease should not be treated. 69. Treatment with ivermectin have occurred for a number of years in Southern Sudan in areas sr-rspected as endemic for Loa Loa wrthott clear evidence that any reported SAEs could be attributed 27 to co-infection with Loa Loa. Thus, the TCC recommended that in stable communities where treatment has occurred regularly over the years, treatment should be continued as they have before. Prior to extending treatment into new areas (those with populations never treated), the project should consult the NOTF, APOC Management and the MEC for guidance. Agenda item 15: Review of treatment of Loa-loa risk areas in Cameroon with special reference to the additional REA exercises in the CDTI priority zones 70. TCC concluded that the current TCCATIEC guidelines in loa-loa high risk areas should continue to be applied in Cameroon. In cases where the additional REA exercises revealed small numbers of hypo-endemic communities surrounded by hyper/meso-endemic zones, decision could be taken after consultation with MEC, APOC Management, NOTF to put these hypo-endemic communities under mass treatment so as to simplify field operations. 71. In the light of the conclusions under items 10, 14 and 15 above, possible modifications to the TCCiMEC guidelines would be discussed with MEC during its forthcoming session. Agenda ttem 18: Other matters REMO in Mozambique 72. The Community noted the findings of the recent APOC supported REMO exercise in Mozambique which did not justify eligibility for CDTI in the country but recommended that a system be put in place for clinic-based treatment of cases of Onchocerciasis. Expenditure per treatment 73. TCC discussed the issue of financial contributions to APOC within the context of cost per treatment. TCC agreed that projects should report financial contributions from all sources including APOC, NGDOs and government in the annual technical report. 74. The Committee requested Dr Deborah McFarland to prepare or to assist in preparing a protocol (guidelines) for country studies on cost per treatment estimates. Indicators for oDerations and sustainability 75. TCC agreed to discuss indicators for operation and sustainability at TCC14 in order to improve reporting in the future. Cost Recovery 76. TCC was concemed about the possible negative impact on treatment coverage of cost recovery and agreed to commission a study. 28 TCC membership (2002) 77. The Director of APOC raised the issue of the need for continued institutional memory within the committee and would recommend to CSA the extension of the appointment of two to three current long standing Members. Lymphatic Filariasis Elimination and schistosomiasis control in the Plateau/ Nassarawa States 78. A progress report was presented by Dr Frank Richards illustrating the interaction between the APOC and LF programmes. TCC received the report with interest and noted how APOC structures could speed the implementation of LFE and schistosomiasis activities in co-endemic areas. Agenda item 19: Date and place of the fourteenth and fifteenth sessions of TCC 79 Agenda item 21: Closure of the session 80. The Chair, in closing the session, expressed his satisfaction with the transitional arrangelxents which had reduced the time spent by the Committee on project reviews, many of which were now undertaken by the APOC Management, thus allowing more time for TCC to deal with scientific and programmatic matters. He paid a particular tribute to Adrian Hopkins, whose mernbership of the Committee expired, for his outstanding contribution to the work of TCC and to the control of Onchocerciasis in general. 81. The Programme Director thanked all the participants in the session for their contributions with a particular reference to the NDGO Coordination Group for its input through the pertinent recommendations of its 18tl'meeting held in Paris. TCC14 TCC15 18-22 March 2002 in Ouagadougou 16-20 September 2002 in Ouagadougou 29 2 3 4 5 ANNEX 1 LIST OF PARTICIPANTS TCC Members Professor (Mrs) Adenike Abiose, Medical Director, The National Eye Center, P.M.B 2267,Kaduna, Nigeria, Tel: (234) 62 41 73 73, Fax: (234) 62 41 08 73 E-mail: abiose@infoweb.abs.net Professor Mamoun M.A. Homeida, Vice-Chancellor, University of Khartoum, P.O. Box 321, Khartoum, Sudan, Fax: (249) ll22 47 99; Tel: (249) ll22 47 62;E-ma11: amst33hotmail.com. Dr Adrian Dennis Hopkins, Medical Consultant of CBM, C.R.H.P., B.P. 406, Kinshasa I, Democratic Republic of Congo, Tel & Fax: (243) 88 03 940 - E-mail: Kincbm@maf.org Dr Frank O. Richards Jr. Deputy Director, Global 2000 River Blindness Program The Carter Center, One Copenhill, Atlanta, Georgia 30307, Fax: (770) 488 4521; T6l: (770) 488 451 1, E- mail: fxrl@cdc.gov Dr Bertha Maegga, Tukuyu Research Station, NIMR-HQ, P.O. Box 538, Tukuyu, Dar-es- Salaam, Tanzania, Fax: (255) 65 55 22 50; Tel: (255) 65 552250, E-mail: imatukuyu@maf.org 6. Dr Michel Boussinesq, Centre Pasteur du Cameroun, B.P. l274,Yaound6, Cameroun, Fax (237) 23 3s 84t23 ts 64, E-mail : orstorn.cpc(r?carnnet.cm Prof Eka Braide, Dept. Of Biological Sciences, Universrty of Calabar, P.O. Box 3679, Calabar, Nigeria, Tel: (234) 87 230 452,Fax: (234) 87 236 298 87 230 929, e-mail ek a (ri)unica 1. anpa. net. ng ; onchocal (rDskannet. com Dr Elizabeth Elhassan, Country Representative of Sight Savers International, 1 Golf Road, P.O.Box 55, Kaduna, Nigeria, Tel: (234) 62 24 83 60 or 62 24 89 73,Fax: (234) 62 24 89 73, email : ssing(rDinfbweb. abs.net OBSER\rERS 7 8 9 Dr Mary Alleman, Associate Director, Mectizan Donation Program, 750, Commerce Drive Suit 400, Decatur, GA 30030, Atlanta, USA, Fax: 14043711138;Tel: 14043711460; Email malleman@taskforce. org Dr Deborah McFarland, Associate Professor, Department of International Health, Rollins School of Public Health, Emory University, 15 18 Clifton Road, Atlanta, Gorgia 30312, Tel: 404 727 '7 849, F ax'. 40 4 7 27 45 90, e-mail : dmcfarl (rDsph. emor.rr. ed u Dr Peter Enyong, Tropical Medicine Research Station, P.O. Box 55, Kumba, Cameroon, Tel (231) 35 42 31, Fax: (237) 35 42 31, e-mail: penvollg(rrcamnet.crn APOC Secretariat: I 10 l1 Dr A. S6k6t6h, Director, APOC Dr U. Amazrgo, CSD a.i. Dr M. Noma, CEV Mr F. Agboton, CAF Mr A. Aholou, A./A Ms P. Mensah, Secretary 12 13 14 l5 t6 t7 30 ANNEX 2 TECHNICAL CONSULTATIVE COMMITTEE Thirteenth session Paris, 10 - 14 September 2001 PROVISIONAL AGENDA REV.1 1. Opening 2. Adoption of the Agenda 3. Matters arising from the g3'd,94't' and 95tr'sessions of the CSA 4. Matters arising from the l8'h NGDO meeting 5. Follow-up of the recommendations of the twelfth session of the TCC 6. Report on publication of the experiences of APOC 7. Monitoring of CDTI Projects from 1988 to 2000: lessons for improvement 8. Phase II and the Phasing out of APOC: The Programme Document and the Memorandum 9. Implementation of new TDR strategy 10. Report on studies on Rapid Assessment procedures for Loa Loa 1 1. Report on the financial management of APOC funded Projects 12. Report on the review by the APOC Management of 2"d,3'd and 4tl'year progress reports and subsequent year budgets (application of the new review process) 13. Reviewof l"yearprogressreports(technical&financial)and2"d,3'dand 4tt'yearannualtechnrcal reports from the following countries: Cameroon (5) (NOTF/HQ Support, Adamaoua, Western Province, Haute Sanaga, South West II) CAR CDTI Project (1) Congo CDTI Project (l) DRC (1) (Kasai CDTI Project) Equatorial Guinea (1) (Bioko Island CDTI Project) Malawi (1) (Thyolo,Mwanza & extension CDTI Project) Nigena (13) (NOTF/HQ Support, Adamawa, Bauchi, Benue, Borno, Cross River, Edo/Delta, Ekiti, Gombe, Niger, Ondo, Oyo and PlateauAlassarawa States CDTI Projects) Sudan (1) (GOS Southern Sudan CDTI Prolects) Tanzania (3) (Tukuyu Vector Elimination, Tanga and Tukuyu CDTI pro.lects) 14. Severe Adverse Events in Southem Sudan after treatment with Mectizan@ 15. Review of treatment of Loa loa nsk areas ln Cameroon with special reference to the additional REA exercises in the CDTI priority zones 16. Review of new National Plans and Projects Proposals 17. Review ofoperational research proposals 18. Other matters 19. Date and place of the fourteenth session of the TCC 20. Conclusions and recommendations 21. Closure of the session 3t ANNEX 3 t8r" MEETING oF NGDo cooRDINATIoN GRoup FoR IVERMECTIN DISTRIBUTION DISTRIBUTION: An investigation into the administrative requirements of APOC' by Prozesky et al. PRIORITISING PROGRAMME ACTIVITIES TOP PRIORITY Administrative tasks which sustainable CDTI support core tasks, essential to LONG TERM * Appropriate technical reporting to district and country management (NOTF). * Appropriate financial management and reporting within the country, at different levels. n Arranging training for field at different levels in-country. t' Arranging activities to sensitise communities, health workers and local authorities about CDTI. * Arranging the ordering of Mectizan, and its distribution according to normal channels within the country. * Integration of CDTI into the Primary Health Care System. * Arranging supervision and monitoring of CDTI at all levels. * Drawing up a yearly plan for CDTI. * Holding meetings to plan the actual distribution. .i. Planning for and handling serious side-effects. SHORT TERM (and principally related to tasks which support the APOC Programme, and NGDO Headquarters programmes) * Technical reporting to APOC, to NGDO headquarters * Financial reporting to APOC, to NGDO headquarters. * Drawing up proposals for project funding. * PR materials (such as making promotional movies) I LOW PRIORITY AND/OR UNNECESSARY Administrative activities * Ananging distribution of Mectizan outside the normal channels. * Arranging special events, related to the Programme but not directly to CDTI (e.g. the repear census) * Excessive, repetitious reporting, not used at any level for decision making. * Excessive training events (re-training without testing whether it is necessary). * Excessive, repetitious sensitisation events (in situations where coverage is already good). * Excessive supervision visits to projects. * Frequent meetings for their own sake - not for communication or decision making. * Presenting reports personally - spending days of travelling to do so. * Nice to have conferences and symposia: e.g. paftners' meetings. 'l Ananging extra events. n t I 32 ANNEX4 SUMMARY TABLE OF BUDGET PROPOSALS RECOMMENDED FOR APPROVAL OR APPROVED BY THE TCC AI\D THE MANAGEMENT OF'APOC APRIL 2OO1 _ SEPTEMBER 2OOI suB-TorAL (TCC 13) 893'551 893 551 * SUB - TOTAL of 2'296',565 l'928'243 368',322 GRAND TOTAL 3'190'116 2 821 794 * NO Project reviewed by TCC 13 Project reviewed by the Management of APOC Year of project Amount requested US$ Amount approved US$ Difference US$ 1 Bandundu (DRC) 1 110'170 1 10'170 2 Sankuru (DRC) I ll6'265 ll6'265 J Akwa-Ibom State (Nigeria) 1 152',913 t52',g13 4 Haute Sanaga (Cameroon) 2 69',519 69',519 5 West Province (Cameroon) 2 327',407 327',407 6 TIDC au Congo Brazza 2 l17'277 l17'277 2 278',582I Kaffa-Shekka (Ethiopia) 196'094 82',, Niger State CDTI project J 85'398 81'6582 3',740 J 32',9303 Kebbi State CDTI project 34',280 - 1'350 4 Benue State CDTI project 3 118'290 103'190 15'100 Bauchi State CDTI project J 98'6405 82'640 16'000 J6 Gombe State CDTI project 113'960 97',960 16'000 Bioko Island CDTI project J 44',250 43'251 9997 HQs Support (Cameroon) 4 73',947 54'294 l9'6538 4 8l'053 7z',138 8'9159 CDTI project Adamaoua 410 CDTI proj. North Province ll6'366 107,627 8',739 CDTI project Centre III 4 127',848 118'983 8'8651l 4 142',177t2 TrDC (CAR) 113'483 28',694 13 Ruvuma CDTI (Tanzania) 4 33',872 32',537 1'335 t4 Kano State CDTI project 4 44',258 38'075 6'1 83 4 65'88015 Osun State CDTI project 65'880 416 Zamfara State CDTI project 23',160 23'160 0 ( Yobe State CDTI project 4 4l'755 29'620 12'135t1 518 HQs Support (Nigeria) 180'780 102'580 78'200 r' t9 Taraba State CDTI 5 5s',255 49'288 5',967 Kogi State CDTI 5 94',570 74',570 20'00020 5 t12'057 103'573 8'4842l Mahenge CDTI (Tanzania) 522 Malawi CDTI project 161',517 16l'5t7 0 523 HQs support (Sudan) 73',700 55'200 l8'500 24 North. Sector CDTI (Sudan) 5 96',320 86'645 g',675 * Amount to be downscaled after review by the Management of APOC aI