aC World Health Organization AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) REPORT OF THE THTRTY.NINTH SESSION OF THE TECHNICAL CoNSULTATTVE COMMTTTEE (TCC) Ouagadougou,08 - 12 SEPTEMBER 2014 D I R/ P T,,T/A POC/REP/TCC 39, I 7 / I I /20 I 4 I TABLE OF CONTENTS ABBREVIATONS/ACRON YMS I OPENING: Agenda Item I 2 ADOPTION OF THE AGENDA: AGENDA ltem 2 INFORMATION 4 MATTERS ARISING FROM CSA l45rH 146'h AND 1476 SESSIONS : Agenda ltems 3 5 REPORE ON THE LAST MECTIZAN EXPERT COMMITTEE MEETING: Agenda item 4 6 REPORT OF THE TRANSITION TASK FORCE: agenda item 5 7 FOLLOW UP OF KEY RECOMMENDATIONS OF THE THIRTY EIGHTH SESSION: Agenda item 6 STRATEGIC AND TECHNICAL ISSUES 8 APOC ACTIVITIES REVIEW AND PLANNING MEETING: Agenda item 7 9 ELIMTNATION OF ONCHOCERCIASIS TNFECTION AND NTERRUPTION OF TRANSMISSION: Agenda item 8 9.1 Elimination of Onchocerciasis with ivermectin in Africa: 9.1.1 Update on epidemiological evaluation results: Comprehensive analysis of Epidemiological evaluation conducted between 2008'201 4 9.1.2 Update on transmission assessment 9.1.3 Update on delineation of transmission zones 9.1.4 Update on the delineation of treatment boundaries for the elimination of Onchocerciasis. 9.1.5 Evidence and rationale for the current APOC monitoring and evaluation framework for elimination 9.1.6 Update on black flies trapping and other studies related to Onchocerciasis 9.1.7 Predictive S. damnosum habitat modeling in Burkina Faso and Northern Uganda 9.1.8 Elimination of O. Volvulns infection: New diagnostics of PATH 9.1.9 New Diagnostic technology to tropical diseases, specifically for detection of loa loa infection 9.1.10 Results of the OV-I6 studies in Africa 9.1.1 I LF and Oncho co-evaluation study vl a , I I 3 4 7 7 7 8 8 8 9 l0 l0 ll t2 l3 l3 t { t4 l5 l6 L9.1.12 Research on genetic markers for sub-optimal response to ivermectin and definition of transmission zones 17 9.1.13 WHO Guidelines on verification of elimination of human Onchocerciasis l8 9.1.14 Roadmap for alternative treatment strategies for the acceleration of the elimination of Onchocerciasis: 2014-2015 18 9.1.15 Proposed algorithm for deciding on areas to refine loa loa map 2l 9.1.16 Perspectives for LF and Oncho elimination: Results of test and treat study in Cameroon 2l 9.1.17 Review of Uganda dossier for the four sites that have intemrpted transmission of Onchocerciasis 22 9.1.18 Contribution of TCC to the preparatory activities for the launching of the new entity, specifically the LF/Oncho programmes scale up 23 IO RESEARCH ON NEW CONTROL AND SURVEILLANCE TOOLS BY COLLABORATING INSTITUTIONS: Agenda item 9 23 l0.l Update on moxidectin 23 10.2 Research on the vulnerability of Onchocerciasis and LF to emergence of resistance 24 10.3 Update on DEC patch agreement 25 10.4 Assessment of the impact of community directed treatment with ivermectin on the parasitological indicators of Loa loa in areas of co-endemicity with Onchocerciasis in Cameroon 25 I I REMARK BY TECHNICAL ADVISORS TO APOC MANACEMENT: Agenda item l0 26 l2 REMARKS BY THE FORMER DIRECTORS TO APOC MANAGEMENT: Agenda item I I 26 MANAGEMENT OF THE APOC TRUST FUND 26 13 REPORT ON THE FTNANCIAL MANAGEMENT OF APOC FUNDED PROJECTS: Agenda ltem 12 26 14 REPORT ON THE REVIEW BY APOC MANAGEMENT OF THE FTNANCIAL CoNTENT oF lsr,2*o,3*,4t', 5t', 6",?",8t',9t', lorH, llfr, l2rH, l3t'a,d 14ft YEAR PROGRESS REPORTS AS AN INTRODUCTION TO THE REVIEW EXERCISE: Agenda Item 13 27 REVIEWS 28 15 REVIEWoF lsr,2*o,3*,4t*,5t', 6",7",8t',9t', lorH, llrH, l2rH, l31r{ l4rH AND lsrH YEAR ANNUAL TECHNICAL REPORTS: Agenda ltem 14 28 I5.I NEW PROECT PROPOSALS 28 l5.l.l ETHIOPIA 28 I ll I l5.l.l.l Awi Zone CDTI Project Proposal 15.1.1.2 Dawuro Zone CDTI Project Proposal 15.1.1.3 Konta Zone CDTI Project Proposal I5.2 ANNUAL TECHNICAL REPORTS I5.2.I ANGOLA 15.2.1.1 KwanzaNorte CDTI Project}nd year annual technical report 15.2.1.2 Moxico CDTI Project 5n year annual technical report t5.2.2 COTE D'MIRE 15.2.2.1 Cote d'lvoire CDTI Project (Comoe, Bandamq Sassandr4 Cavally and their tributaries) 66 year annual technical report 15.2.3 DEMOCRATIC REPUBLIC OF CONCO 15.2.3.1 lturi Sud CDTI Project 2"d year annual technicat report 15.2.4 CUINEA BISSAU 15.2.4.1 Cuinea Bissau CDTI Project 5n year annual technical report 15.2.4.2 Guinea Bissau CDTI Project 6n year annual technical report I5.2.5 SOUTH SUDAN 15.2.6 TANZANIA 15.2.6.1 NTD/HQ Project 4ft year annual technical report 15.2.7 UCANDA 15.2.7.1 Phase 5 (Kitgum & Pader) 3'd year annual technical report I5.3 ONLINE REVIEWS 15.3.1 CHAD I 5.3.1.1 Chad CDTI Projectl4th year annual technical report 15.3.2 CONGO 15.3.2.1 Congo CDTI l3.h year annual technical report 15.3.2.2 Congo Extension CDTI Project lOn year annual technical report 15.3.3 DEMOCRATIC REPUBLIC OF CONCO 15.3.3.1 Bandundu CDTI Project I ln year annual technical report. 15.3.3.2 Bas Congo CDTI Project 9n year annual technical report 15.3.3.3 Equateur Kiri CDTI Project th year annual technical report 15.3.3.4 Kasai CDTI Project l3n year annual technical report 15.3.3.5 Butembo-Beni CDTI Project 76 year annual technical report 15.3.3.6 Mongala CDTI Project 9'h year annual technical report 15.3.3.7 Rutsuru-Goma CDTI Project 8h year annual technical report iii 28 29 30 3l 3l 3l 3l 3l 3l 32 32 33 33 33 33 33 33 34 34 35 35 35 36 36 37 37 37 38 39 39 40 40 4l a 15.3.4 r 5.3.5 15.3.3.8 15.3.3.9 15.3.3.10 15.3.3.1 l 15.3.3. r 2 15.3.3.13 ETHIOPIA 15.3.4.1 15.3.4.2 15.3.4.3 15.3.4.4 15.3.4.5 15.3.4.6 15.3.4.7 15.3.4.8 15.3.4.9 15.3.4.10 LIBERIA 15.3.5.1 15.3.5.2 Sankuru CDTI Project 10ft year annual technical report Tshuapa CDTI Project 9ft year annual technical report Tshopo CDTI Project lOh year annual technical report Ubangi-Nord CDTI Project 9ft year annual technical report Ubangi-Sud CDTI Project 9ft year technical report Uele CDTI Project I l'h year technical report Bench Maji CDTI Project I lh year annual technical report East Wollega CDTI Project 9ft year annual technical report Gambetla CDTI Project 9ft year annual technical report Iltubabor CDTI Project 106 year annual technical report Jimma CDTI Project 10ft year annual technical report Kafa CDTI Project 13ft year annual technical report Shekka CDTI Project 13tr year annual technical report Metekel CDTI Project 9ft year annual technicat report North Gondar CDTI Project I lth year annual technicat report West Wollega CDTI Project 9th year annual technical report 4l 4t 42 42 43 44 45 45 45 46 46 47 47 48 48 49 49 50 50South East CDTI Project 8h year annual technical report North West CDTI Project l2e year annual technical report (Resubmission) 15.3.5.3 South West CDTI Project 8ft year annual technical report I5.3.6 SIERRA LEONE 15.3.6.1 Sierra Leone CDTI Project 8tr year annual technical report 15.3.7 TANZANIA 15.3.7.1 Kilosa CDTI Project I 16 year annual technical report 15.3.7.2 Morogoro CDTI Project 9ft year annual technicat report 15.3.7.3 Ruvuma CDTI Project 12ft year annual technical report (res- submission) 15.3.7.4 Ruvuma CDTI Project 14ft year annual technical report 15.3.7.5 Tunduru CDTI Project 9ft year annual technical report 15.4 TECHNICAL REVIEW COMMITTEES REPORTS: Agenda item 15 15.4.1 CAMEROON 15.4.2 MALAWI iv 5l 5l 5t 5l 52 52 52 53 53 54 54 54 55 15.4.3 NIGERIA 56 15.4.4 UGANDA 56 16 DATE AND VENUE OF THE FORTIETH AND FORTY FIRST SESSIONS OF THE TCC: Agenda ltem 16 57 l7 CLOSURE OF THE SESSION: Agenda item 18 57 ANNEXES 58 v a ABBREVTATONS/AC RONYMS AfDB African Development Bank AFRO WHO Regional Office for Africa AFRO/NTD Neglected Tropical Disease Programme of AFRO APOC African Programme for Onchocerciasis Control ATO Annual Treatment Objective ATS Alternative Treatment Strategy AWOL Anti-Wolbachia CBO Community-Based Organization CDD Community-Directed Distributor CDI Community-Directed lnteruention CDTI Community-Directed Treatment with lvermectin CMFL Community Microfilarial Load CSM Community Self-Monitoring DOLF Death to Onchocerciasis and Lymphatic Filariasis HKI Helen Keller lnternational DEC Diethylcarbamazine FLHF Front Line Health Facility GAELF Global Alliance for Elimination of Lymphatic Filariasis GPELF Clobal Programme for Elimination of Lymphatic Filariasis HR Human Resources HSAM HealthEducationSensitizationAdvocacyMobilization HQ Headquarters HW Health worker IEC lnformation, Education, Communication IPM lndependent Participatory Monitoring JAF Joint Action Forum LF Lymphatic Filariasis LGA Local Government Area (in Nigeria) LTS Lohmann Therapy Systems MDA Mass Drug Administration MDM Distribution of Medicine MDP Mectizan@ Donation Program MF Microfilaria vl MOH MOHSW NCDO NOCP NOTF NTD PAB PCT PHC RAPLOA RPRG SAE SCI SHM SS TAS TCC UTG VAS wHo Ministry of Health Ministry of Health and Social Welfare Non-Governmental Development Organization National Onchocerciasis Control Programme National Onchocerciasis Task-Force Neglected Tropical Diseases Plan of Action and Budget Preventive Chemotherapy Treatment Primary Health Care Rapid assessment procedure of Loa loa Regional Programme Reporting Group (LF) Severe Adverse Events Special Country Initiative Stake Holder Meeting Sightsavers Transmission Assessment Survey (LF) Technical Consultative Committee (of APOC) Ultimate Treatment Goal Vitamin A Supplementation World Health Organization vll !f OPENING: Agenda Item I l. The 39'h session of the Technical Consultative Committee (TCC) of APOC took place in Ouagadougou from 08 to 12 September 2014.ln opening the session, the Chair of the Committee, Prof Mamoun Homeida welcomed all participants and acknowledged the presence of the former directors of ex-OCP and APOC, Drs Kofi Yankum Dadzie, Azodoga Seketeli and Uche Veronica Amazigo. He observed that the Programme is at a junction for transit to PENDA. 2. The Director of APOC also welcomed all participants to the meeting, particularly the former directors of OCP and APOC who accepted the invitation of the management, sparing time from their busy schedules to join them for the session. He also welcomed the advisors to the management and Dr Christian Bailly from France who at some time followed the development of the Programme, having being a representative of a donor country to the Joint Action Forums. He thanked all of them for their valued knowledge, expertise and experiences which will enrich scientific discussions during the session. 3. lntroduction of participants following the opening remarks, the list of who is appended as annex l. 2 ADOPTION OF TIm AGENDA: AGENDA Item 2 4. The provisional agenda was adopted with slight modification, removing item 4 concerning the NGDOAITD network meeting which has not yet taken place. A copy is appended as annex 2. INFORMATION 3 MATTERS ARISING FROM CSA 145TH l46th AI\ID I4TtI.SESSIONS: AgENdA ITEMS 3 5. Continuing from the opening speech, Director of APOC, Dr Roungou presented a summary of matters arising from CSA I 4 5, 146 and 147 . Six main points were highlighted in his briefing. 6. The governance structure of PENDA: Following the approval of the Concept Note and the Strategic Plan2016-2025 by JAFI9, the JAF requested that more information be provided on the roles of the various organs proposed for the new entity, and that the revised MoU and the Trust Fund document be prepared to serve the need of PENDA. A working group on governance was therefore set up by CSAI43 for that purpose. The group was working through teleconferences and held their first meeting and presented the first draft of the governance structure to CSA146 which advised the group to finalize the document and present it to CSAI48 in October and the JAF in December 2014. 7. The review of APOC management: APOC management review was requested during the donors Dialogue meeting as there were some concerns raised by partners on the staffrng at APOC management, some believing that APOC structure was overstaffed and some even questioning managerial practices. A review conducted by independent experts reassured members of the partnership that there is value for money and funds given to APOC are well used. The report also noted that the staff employed is appropriately qualified/skilled and the number of support staff is appropriate to the requirement of the activities. (i) The transition Task Force (TTF): the TTF was created by the CSA at is l+On session in Paris in October 2013 to guide in the transition from APOC to a new entity. The TTF had its first face to face meeting in Ouagadougou on 24 June 2014, before the CSA 146 to which it reported. Among the TTF recommendations were (i) the management structure of PENDA to focus less on operational and financial management of projects and more on supporting countries to take their Page I a own approach to NTD control and elimination; (ii) PENDA should be a hybrid support model with the bulk of financial support moving directly to the countries and have funding to provide central technical support and resources to countries with less developed programmes; (iii) counhies should be divided into three categories: countries with effective integrated programmes, countries with some integration, but technical and/or financial challenges, and counhies with poorly functioning programmes and needing much central support. The Director indicated that on the third recommendation there were some reactions with different views from country representatives in CSA. (ii) The expanded CSA: The Director informed TCC that since the decision to have a new entity from 2016 to address elimination of Oncho and LF and support efforts to other PC-NTDs it was decided to expand the membership of the CSA in order to have all partners as part of the transition from APOC to PENDA and the decisions and recommended delivered to the governing body, the JAF. He indicated that four expanded CSA meetings were organized, bringing together, a part from the statutory members (WHO, World Bank, African Development Bank, NGDOs, Merck and MDP), representatives of the LF community, donors, NGDOs, other drug donation companies and endemic countries. (iii) The reduction of the 2014 budget:_The Director indicated that because there is little new income flow despite efforts in resource mobilization, the l46th session of the CSA directed APOC management to prioritize activities and implement a 19 million budget instead of 25 million for 2014, advising specifically to curtaildown on routine epidemiological and entomological evaluation activities and prioritize upscaling treatment. He informed that the management is doing its best to maintain a reasonable level of funding for treatment but still confronted with some difficulties to respond to countries' requests and needs. (iv) The refinement of PENDA: The Director informed TCC that in the Strategic Plan of action and indicative budget presented and approved by JAFI9, a preliminary estimate of US$800 million was indicated but CSA realized that this amount is inclusive of funding going through different channels, hence the necessity for refinement which will serve as the basis for advocacy and resource mobilization, including organization of a pledging conference in 2015. He indicated that the group will start work on 29 September 2014 and their preliminary report presented to CSA 148 in October in Geneva. (v) The transitional management structure: Dr Roungou informed TCC that it is expected that the PENDA management structure will be a hybrid taking into consideration primarily OOncho and LF needs but also the needs for support to some PC-NTDs. He indicated that discussions are underway to find the best approach to come up with such a structure hence the setting up of a committee to agree, not only on a structure, but also look at the implications of the closure of APOC. The transfer of some staff to PENDA is one of the options being considered. (vi) JAF20: The Director informed that committee that the JAF20 will be jointly held with the Global Alliance to Eliminate Lymphatic Filariasis and the stakeholders of Page2 a a IUniting to Combat NTDs. The Joint JAF will be held in Addis Ababa from 8 to 12 December 2014. He also informed that committee that the CSA session scheduled to take place in Abidjan ftom 22 to 24 October 2014 has been relocated to Geneva on the same dates. 8. TCC thanked the Director of APOC for the update and observed that the transition period is a critical one which needs thinking out of the box. Therefore, the expertise of both LF and Oncho should be used of the nvo constituencies. 4 R.EPORT ON TIIE LAST MECTIZAI\I E)PERT COMIVIITTEE MEETING: Agenda item 4 9. Dr Yao Sodahlon of MDP updated TCC on the 51" MEC meeting which took place in Seaffle on 20ft and 2l't March 2014. The main recommendations of the meeting are: D Mectizan treatment in co-endemic areas: The committee endorsed the recommendations of the Loa loa scientific working group (191031201\ as follows (a) The Test and Treat project together with the Atlanta NTD Support Centre to use current data to model communities with Loa loa prevalence of <40Yo (RAPLOA) to see what proportion of the population are heavily infected so that a risk benefit analysis before starting treatment with Mectizan can be done. Projects requesting Mectizan will be asked to wait for these results before beginning new treatments. Where LF is endemic in these communities, projects can follow WHO guidelines using Albendazole alone semi-annually and vector control. (b) In areas where loa loa prevalence is >40oA the Test and Treat strategy will be available in the near future and projects should wait. The committee will need to decide on the best strategy for those patients above the threshold of 30,000 mflml. Modelling will indicate whether they will contribute significantly to transmission of disease and whether treatment will need to be curative or symptomatic. ii) On Administrative issues: The MEC reviewed and enclosed the Annual Report of MDP and noted progress in line with year 2 of the Strategic Plan i.e.: (a) Data management was progressing and being aligned with WHO and other partners; (b) Special support had been given to DRC and Nigeria; (c) tt was noted that the role of the research subcommittee needed refining; (d) The structure and administration of CRFiIMT was reviewed and the committee awaits a report concerning the site of the new centre; (e) The MEC approved the invitation to Dr Mary Nyamongo (a social scientist) to join the MEC; (f) The MEC structure will be reviewed when APOC becomes PENDA in 2016. iii) Regarding countries' specific issues, on the request from Togo for 2 times/year treatment in some poor performing foci, MDP will wait for an analysis of the current situation from APOC before deciding on treatment strategy in Togo. For Burkina Faso, on the epidemiological situation of Onchocerciasis in Bougouriba focus, it was noted that analysis was going on to determine the reason for ongoing transmission. Once completed, it would be clear if the project in Bougouriba needs twice yearly treatment, increased efforts to improve treatment coverage or special treatment of systematic non-compliance. Page 3 l TCC comments and recommendations: 10. TCC thanked Dr Sodahlon for the presentation. On the issue of guidelines for countries to decide, it was noted that the TCCiMEC guidelines is still in force, even though there is plan to revise it. It was also noted that there is 6 to 8 million tablets of drugs not distributed in South Sudan because of the current situation. On the issue of countries where there is plan to stop treatment and have drugs in clinics, it was advised that countries ready to stop treatment should implement the last heatment and if clinic base is can be ordered separately 5 REPORT OF TIIE TRANSITION TASK FORCE: agenda itent-S- I I l. Dr Tom Unnasch, Chair of the TTF, presented the report of the first meeting of the TTF which took place in Ouagadougou on 24s June 2014. As background information he said the TTF was established in April 2013 to provide strategic guidance to the CSA on upscaling interventions. He presented the composition of the TTF and its tasks which are to: a (i) Provide guidance to APOC to ensure smooth transition involving both Onchocerciasis and LF communities;(ii) Provide technical advice on new Onchocerciasis and LF elimination targets and program implementation;(iii) Provide input on strategies for upscaling interventions;(iv) Promote rapid mapping of diseases including hypoendemic Onchocerciasis areas;(v) Rationalize overlap on implementation and evaluation units for both diseases;(vi) Advise in scale up in areas where access to medications remains limited and measures to ensure a smooth transition towards launch of PENDA in 2016. 12. He indicated that the TTF reports will go to the CSA and GAELF EG. The TTF will liaise with TCC and RPRG, and will sunset in June 2016 (six months following end of APOC statutory committees), as its role is (a) to serve as a bridge from existing efforts of APOC and GAELF in Onchocerciasis and LF to integrated approach of PENDA; (b) to serve as an "institutional memory" after I January 2016, helping the new PENDA advisory structure to get on its feet; (c) to focus on integration of Onchocerciasis and LF for now and no other NTDs; (d) to identif, areas of poor fit between programs and recommend ways of improving fit of the puzzle pieces. He also presented the following recommendations from the TTF meeting: Reoort on Manaeement Structure of APOC: Recommendations: - "PENDA should focus less on operational and financial management of projects, providing more focus on supporting countries to take their own approach to NTD control and elimination"; - Provide technical support both in country and as a regional centre; - *PENDA'S research should be a collaborative model reflecting needs and capacities of countries" General recommendations - PENDA structure: - Hybrid support model with bulk of financial support moving directly to the countries. - Funding to the central office targeted to providing central technical support and limited resources to countries with less developed programs; - Needs of countries and role of PENDA will vary from country to country. Three broad classifications: o Countries with effective integrated programs already (little central technical support needed); o Countries with some integration but technical and/or financial challenges (some central technical support needed); o Countries with poorly functioning programs (much central support needed). Page 4 Centralized activities of PENDA: - Technical support and training in data analysis to national program staff; - Assistance in identiffing diverse and bilateral funding mechanisms for country programs; - Support of meetings within or between country programs to share experiences, accomplishments and to develop common strategies and metrics for data standardization; - Promote country ownership, analysis and publication of data. Program integration: - Agreement with APOC's decision to adopt districts as implementation unit; - Migration effects (people and vectors) are not likely to be significant impediments during control and elimination phase; - When it is thought that elimination is achieved sensitive assays to ensure that transmission has been intemrpted (entomological assessments by PCR pool screen and Ovl6 ELISA in children and skin snip PCR) necessary to ensure migration is not supporting residual transmission. Operational integration - LF and Onchocerciasis programs are already effectively collaborating at local (country) level in many cases; - APOC and ELF Africa should consult with local programs that have successfully integrated to identifu pathways to success and pitfalls experienced. Operational Research needs - Epidemiological status - Collect and analyse epidemiological data of LF, Oncho and Loa loa from all sources; - Use data to classifr disease status and programmatic situation at district level: o ldenti0 gaps in knowledge; o Current treatment status; o Present in tabular format; o Operational Research needs - M & E; - Ground truthing studies to validate 5% nodule rate as transmission breakpoint; - Entomologicalandepidemiological; - Relationship of nodule rates (with appropriate statistical prediction of error) to other more sensitive indicators necessary to validate transmission intemrption; - Pool screen PCR of flies; - Ovl6 antibodies in children. Recommendations on scale up: - Acknowledge that scale up to fult treatment in LF by 2016 is not possible, pushing PENDA's timetable backward (if using current strategies); - Concentrate on low hanging fruit for scale up now (e.g. districts not yet treated for LF with CDTI) to most efficiently increase numbers under treatment; - [n areas close to Onchocerciasis elimination push to get them over the finish line and confirm elimination in places where it is thought that success has been achieved (e.g. Senegal). Areas for further discussion and research: - How long and at what frequency should treatment occur in Oncho hypoendemic areas? - Can we use data from hypo-endemic LF co-endemic areas to look at this? - Evaluate results from NTD resource centre on TAS-like surveys to evaluate transmission in areas where ICT positivity is still >l7o but where no evidence for circulating mf exists (possibly shrinking the map for LF). - Can night bloods be restricted only to those people who are ICT positive? - Areas with hypo-endemic Oncho and hyper-endemic Loa need to be identified and treatment regimens need to be developed. Page 5 13. Future activities of the TFF are to prepare final report to be submitted to CSA in June-July, 2014. The final report will then be presented to EG, RPRG, TCC in September 2014 and the JAF in December 2014. TCC comments and recommendations 14. The TCC members appreciate having received the report of the first meeting of the Transition Task Force (Ouagadougou, June 23,2014) before the meeting, which allowed them time to read through and make detailed inputs. The members acknowledged the presentation made by the Chair of TTF, Dr. T. Unnasch, and look fonvard to further collaboration with the team in this transition period. Having considered the report and participating in the discussions, the committee was concemed with the report in its cunent form and made the following observations: (l) Membership of the TTF: The membership of the TTF was discussed by TCC38, and reiterated in this meeting, as not being representative on various counts: i. Composition: The TTF is overwhelmingly Anglophone with no representation of Francophone countries; ii. Country representation: There is only one programme manager in the team - there is a need to increase the presence of country managers or persons with country experience; iii. Discipline: there is a need to balance the disciplinary representation in the team (for instance, there is no social scientist on the current team, etc.); and iv. Gender: Only two of the 10 members are women (20%); consider increasing the representation of women on the team. (2) Acknowledgement of the role of APOC in disease control: There is a need to recognize the role played by APOC in control efforts and acknowledge the potential to build on the experiences and structures, both at the regional and country levels. The members noted an apparent effort in the document to downplay the major strides made in the region in Onchocerciasis control. This was seen to be reflective in the language used in the document (the specific areas of concern have been highlighted in the document in tracked changes that will be handed over to the APOC management for consideration). For . instance, Section 38 minimizes the work of co-implementation, which was initiated by APOC in several countries in collaboration with national and local health authorities, over the last 7 years without any additional mandate, budget or staffreinforcement. It is notable that a number of the recommendations for PENDA made in the TTF report refer to activities that have been widely developed or at least initiated in countries, even though they may need adjustments and adaptations to the new context. These include the recommendation of in-country or inter-country meetings for PENDA, a process that has already been initiated by APOC (as presented during this TCC). (3) Implementation unit: the report indicates that the district will function as the implementation unit. Although this seems to have been agreed, the TCC notes that Oncho control has not historically functioned along transmission zones as implementation units - this is only the case for mapping delineation of treatment zones and epi-ento evaluation surveys. Ivermectin delivery and coverage measurements have always been at the district (administrative) while the basic implementation unit for treatment has been the community. The concern is that using the district as a treatment unit will lead to the treatment of innumerable villages, which may not need treatment, and in some cases the whole country. The TCC proposes that the report should include a statement that Oncho controUelimination results have to be evaluated through a transmission zone, which is not incompatible with a district approach. Page 6 0(4) Target audience: The TTF report seems to focus and target the donors and international community with limited promotion of country ownership, which is critical to the success of PENDA. (5) Nexr sbps: The TTF has identified key technical and operations research issues to be undertaken in preparation for the launch of PENDA. We commend this while recommending that more emphasis should be placed on capacity building and preparation of field guidelines in preparation for the new roles of govemment and PENDA management. 15. The committee therefore made the following recommendations: i) Review the membership of the TTF and consider including the members in consideration of the gaps highlighted above; ii) The TTF should revise the report and ensure that it is reflective and appreciative of the achievements of APOC, which remains the basis upon which PENDA is being developed; iii) The TCC recommends that the Director of APOC presents these observations and next ( FoLLow up oF KEy REcoMMENDATIoNS oF TIIE THTRTY EIGHTH SESSION: Agenda item 6 16. Dr Fobi presented a summary of the status of implementation of the TCC38 recommendations. The full text is appended as annex 4. TCC comments and recommendations 17. TCC commends APOC Management for a thorough presentation and for the actions taken. The committee however made the following recommendations : i) A summary should be made of recommendations implemented and those not implemented. Where the implementation is ongoing in countries, the number of countries should also be known; ii) Some of the recommendations addressed to the management should not be sent to the countries; iii) The operational research should not be undervalued, especially that there is transition from Onchocerciasis contol to Onchocerciasis and LF elimination and the PENDA. The committee further stressed on the importance of research and advised the management to publish operational research results and how these researches were used to better implement activities. STRATEGIC AI\[D TECHNICAL ISST]ES 7 APOC ACTryITIES REVIEW AND PLAI\NING MEETING: Agenda item 7 18. Dr Sobela presented the outcome of the APOC activities review and planning meeting that took place in Ouagadougou from 17 to 2l March 2014. In attendance were 95 participants: Onchocerciasis and LF National Programme Coordinators from 25 endemic countries, partners, research organizations, APOC and WHO staff. The objectives of the meeting were to: i) Delineate treatment and transmission zones, ii) Set treatment targets for Onchocerciasis and LF for years 2014 and 2015, iii) Evaluate the epidemiological trends towards elimination, iv) Prepare the stopping of ivermectin treaunent as part of Onchocerciasis elimination, v) Strengthen health system at the peripheral levels, vi) Strengthen partnership in the elimination of these diseases and vii) Strengthen operational research. Page 7 ) 0 19. During this meeting, the presentations focused on the situational analysis, mapping of both diseases, update of the concept note on Onchocerciasis elimination and the foundations of the LF surveillance, entomological and epidemiological evaluations, activities towards stopping ivermectin treatment as part of Onchocerciasis control; proposals of approaches for co- implementation of interventions, the proposals of alternative approaches for problematic areas, and the submission of technical and financial reports by projects funded by APOC. Partners aftending this meeting were allotted a session to brief participants on their interventions in the countries and to talk about their planning for years 2014 and 2015. 20. Other areas dealt within groups included, identification of activities related to delineation of treatment boundaries; setting specific dates for epidemiological and entomological evaluation and LF transmission assessment activities in countries; prioritizing requirements necessary for strengthening health systems, particularly at peripheral level; identification of operational research areas and naining needs; and finally planning of activities related to cross-border collaboration. 21. Discussions after the presentations mainly focused on some clarification questions, on additional information and on how to address the gap noted in funding, how mapping, PCT interventions, health systems perspectives, operational research and cross-border issues could be dealt with together, for the achievement of elimination of both diseases in Africa. 22. Based on these discussions/observations and given the situation, various statements and recommendations were made for each of the following 8 key areas: Mapping for both Onchocerciasis and Lymphatic Filariasis, Health systems strengthening in countries, Surveillance, Coordination of NTDs in countries, Funding of NTD activities, Operational research, Cross-border collaboration, Administrative and financialmanagement of the APOC Programme. TCC comments and recommendations 23. TCC commended APOC management for organizing this meeting as it is a sign of good collaboration between LF and Oncho programmes. The committee was impressed by the number of recommendations and wished the TTF could use some of them, and advised that they be classified by category and that some of them can be transformed into activities plan. TCC encouraged APOC to continue to work in collaboration with other partners and to increase advocacy support in direction of endemic countries and partners to mobilize resources for the implementation of these key recommendations. The committee also observed that through these meetings confidence will be built in the countries and suggested that follow-up process be built in the countries themselves. 24. Reflecting on some of the recommendations, the WAHO representative indicated that WAHO can be implicated in the implementation of some of the recommendations. 25. The commiftee also advised that the report be largely distributed. The next review and planning meeting is scheduled for 24 to 28 November 2014. TCC advised that the period of the meeting be largely communicated to partners. 8 ELIMINATION OF ONCHOCERCIASIS INFECTION AND INTERRT]PTION OF TRANSMISSION: Agenda item 8 8.1 Elimination of Onchocerciasis with ivermectin in Africa: 8.1.1 Update on epidemiological evaluation results: Comprehensive analysis of Epidemiological evaluation conducted between 200&2014 26. The results of comprehensive analysis of epidemiological evaluation that were conducted between 2008 and 2014 were presented by Dr Afework Tekle. Pre-and post-control burden of Page 8 Onchocerciasis in Africa was presented, including the results of phase la and phase lb epidemiological evaluations. Some of the sites presented showed impressive reduction in microfilaria prevalence rate for a number of countries and also unsatisfactory results for some countries. Based on the findings of the evaluation, sites were categorized into four categories, namely: sites close to elimination, sites on track but need to treat for some time, sites on track but need intensification of intervention to meet the 2025 target, and sites with unsatisfactory results. 27. The majority of areas close to elimination were reported to be Burundi, Chad-CAR (partially)-Cameroon (North), Congo (Pool), Ethiopia (North Gondar), Equatorial Guinea (Bioko), Malawi, Nigeria (Kaduna, Zamfara, Niger, Kano, Kebbi, Oyo, Osun, Kwara, Adamawa, Plateau- Nassarawa etc.); Tanzania (Tanga, Tukuyu, Tunduru) and most of ex-OCP Countries (Senegal, Mali, Niger, Togo, Benin, Guinea Conakry, Burkina Faso). 28. Unsatisfactory results were cited in some sites in Nigeria (Ondo-Edo, Kogi and Cross River etc.), Cameroon (Centre, Littoral, West and South West), DRC (Uele, Bas-Congo, Sankuru, etc.) and Congo (Pouenza). Sites which are on track based on ONCHOSIM prediction but that need to intensifu treatment to get to the end date of 2025 are the following: Mahenge and Morogoro in Tanzania and Taraba and Enugu, states in Nigeria. The analysis also showed that post-treatment prevalence of 15 sites (27o/o) was as predicted by ONCHOSIM; while 34 sites (62%) showed prevalence lower than predicted and the rest 6 (l l%) higher than predicted. 29. Challenges encountered are unavailability of entomological information to stop treatment, co-infection of LF in some sites, difficulty of pinpointing the real cause of poor performing sites, financial constraint to implement some of the planned 2014 epidemiological and entomological evaluations and poor cross-border collaboration. TCC comment: 30. TCC thanked Dr Afework Tekle for the presentation and congratulated APOC Management and the countries for the excellent job. The committee observed that in looking at the epidemiological evaluation in general, the results are much better than predicted by the models, based on pre-control Onchocerciasis prevalence. The committee also noted that some countries such as Burundi, Chad and Malawi are showing very good nationwide epidemiological evaluation results. 31. The committee recommended complementing in 2014-2015, the epidemiological results with entomological transmission assessment survey to know the situation in the vectors, despite the financial challenges APOC is facing. TCC agreed to send a special letter requesting the CSA to look for funding for these important activities to be implemented. 32. The Committee requested APOC Management to conduct studies on the reasons or determinant factors of poor performance in some projects based on previous epidemiological evaluation results. 33. The committee also encouraged APOC management to publish results of epidemiological evaluations before PENDA is launched, advising the Management to adopt strategies for mobilizing resources, targeting specific countries who may be willing to co-finance research studies, especially during this period of budget constraints. 8.1.2 Update on transmission assessment 34. Prof Boakye presented an update on entomological activities undertaken since TCC38 by first reiterating the JAF20 recommendation and the APOC Conceptual Framework on elimination about the need for transmission assessment in deciding when to stop ivermectin treatment by countries. The results of the transmission assessment for Malawi were reported. The results indicated that although 12 vector collection sites were selected for evaluation only 6 of them Page 9 actually had members of the S. damnosum collected. The samples for the 6 sites with.S. damnosum s./. were received for processing at the APOC Yankum Dadzie Laboratory, Ouagadougou for the presence or absence of infection. At the reporting time samples from 4 sites have been processed with no infection detected. The samples from the remaining two sites are being processed. This initial result appears to be confirming those of the epidemiological surveys. However, Year 2 assessments are necessary to confirm the absence of transmission and therefore proceed to stop treatments. It was indicated that Year 2 assessment will require intensive supervision. 35. [t was reported that although transmission assessments plans were made and reported to the TCC38 for some l0 countries only Senegal and Niger are on-going and that the one for Burundi would start in September, 2014. This was due to budgetary constraints. Other challenges not related to funds, were indicated as the initial decision to stop treatment for ffansmission assessments, and the lack of understanding that entomological evaluations depend on the availability of vectors. 36. Pool screening results were presented for a few sites from three countries (C6te d'lvoire (2), Guinea (l) and DRC (l)) but these were not related to the decision to stop treatment. 8. 1.3 Update on delineation of transmission zones 37. The presentation reported on the plans made at the beginning of the year and to TCC38. It was highlighted that collection of samples was planned to take place during the selection of breeding sites as a cost effective strategy for sampling. However, due to the inability to undertake the transmission assessment because of lack of funds, samples have not been obtained for analysis. The only activity undertaken after the last TCC is the training of participants from Ethiopia (5), Sudan (6) and South Sudan (2) in cytotaxonomy. This training was undertaken in May-July,2014 in Ethiopia at the Ethiopian Public Health Institute. Microscopes and dissecting instruments as well as reagents were provided to the countries as part of APOC's capacity building. E.1.4 Update on the delineation of treatment boundaries for the elimination of Onchocerciasis. 38. An update on the delineation of treatment boundaries was presented by Mr Zoure. [t is worth noting that mapping of Onchocerciasis was done using Rapid Epidemiological Mapping of Onchocerciasis (REMO) method, and that results of REMO precontrol surueys were used to delineate high risk areas (nodule prevalence Z 20%) where ivermectin is to be distributed for Onchocerciasis control. With the objective of elimination, the REMO data was re-analysed and a map of estimated nodule prevalence was drawn. The ivermectin treatment map was overlaid on this map, and in line with APOC guidelines for delineation of treatment boundaries, areas previously classified as hypo-endemic were surveyed to collect additional microfilariae prevalence data. 39. Fourteen countries were identified for the conduct of the surveys (Angol4 Burundi, C4meroon, CA& Chad, Congo, C6te d'Ivoire, DRC, Equatorial Guinea, Ethiopi4 Gabon, Mozambique, Tanzania and Nigeria). Started in 2013, the activity is fully implemented in Burundi and Cameroon. It is partially completed in DRC, Chad, Equatorial Guinea (mainland) and Gabon. These surveys are ongoing in Congo, DRC (provinces of Sud-Kivu, Maniema and Bandundu) and C6te d'Ivoire. For 2014, survey results have been completed in DRC (Bas-Congo province), Chad and Gabon. 40. In Bas-Congo province of DRC, out of 14 villages surveyed, 3 had individuals carrying mf with prevalences of l.lTyo,l.28o/o,1.54o/o and8.54Yo; the highest prevalence village is located in an area where the pre-conffol prevalence is estimated to almost 30%. Surveys will be conducted in the bordering province of Bandundu for suffrcient data to decide on the need to extend treatment in some health zones in Bas-Congo province. 41. tn Chad the mf prevalence was zero in all the 12 villages stirveyed in Benoye, Lai and Moundou health districts. There is no need for extension of treatment. Page l0 042. [n Gabon, REMO has shown that 18 villages had individuals carrying palpable Oncho nodule. The Ministry of Health of Gabon conducted ivermectin treatment in 19 villages using mobile team from 1999 to 2004 and achieved therapeutic coverages of 54.3Yo, 53.5o/o, 62.60/o, 62.9yo, 66.4% and 63.8%o. In 2014,27 villages were selected for epidemiological assessment. The results revealed that 9 of the 27 villages have mf prevalence ranging benveen l2%o and 50%. In particular, the known Oncho focus of Lastourville has been confirmed and it appears that Mass Distribution of Medicine (MDM) should be introduced in Gabon. The exact area of the target MDM will be delineated if additional surveys are completed, pending the mobilization of an amount of USD 132,000. TCC comments and recommendations 43. TCC commended APOC management for activities carried out. The committee advised management to not take the risk of missing some areas during the transition period to PENDA. The committee was mainly concerned with the reduction of the Programme budget leading to stopping critical activities needed to be undertaken for smooth launching of PENDA. 44. TCC therefore appeal to the CSA, especially the fiscal agent to endeavour mobilizing resources for critical activities such as epidemiological and entomological evaluations to be carried, paving the way for a smooth launching of PENDA. The committee finally agreed to send a letter with a budget to the CSA through APOC management. 8.f.5 Evidence and rationale for the current APOC monitoring and evaluation framework for elimination 45. The rationale and evidence for the current monitoring and evaluation framework for Onchocerciasis elimination in Africa was summarised in a presentation by Dr Remme. The cunent methodology is based on over 30 years of experience with elimination in Africa. The experience of the OCP showed the importance of having both entomological data on transmission and epidemiological data on residual infection levels, especially in adults (data for children were less valuable as young children are at low risk). OCP introduced epidemiological modelling into the evaluation to provide benchmarks for indicators and guide decision-making on stopping control. When vector control was stopped after 14 years of larviciding in the original OCP are4 the prevalence of mf and vector infectivity levels were not yet zero but had fallen below model- predicted thresholds. Two years post-control entomological evaluation showed that vector infectivity levels remained below the model-predicted threshold of I infective fly per 1000 parous flies. Subsequent epidemiological surveillance confirmed elimination of infection and this evidence supported the validity of the indicators and thresholds used. There was one exception. The construction of a small dam along an affluent of the River Bougouriba created a new breeding site that had escaped vector control and maintained a small pocket of local transmission which spread to surrounding areas when larviciding was stopped. This was not detected by the post-control entomological evaluation but only later by skin snip surveys during routine epidemiological surveillance. This experience raises questions about the optimal evaluation network density during the control and post-control period. 46. The impact of mass treatment with ivermectin is fundamentally different: microfilarial loads fall rapidly, transmission is not interrupted but progressively declines and the fertility of the adult wonn population is reduced. Models predict and large-scale field data have confirmed, that repeated mass treatments can bring infection levels below elimination breakpoints when treatment can be safely stopped. During the intervention phase (lA) the aim of the evaluation is to assess the decline in infection levels towards elimination breakpoints. The ONCHOSM model predicts that the number of years required to achieve elimination ranges from 8 to more than 20 years depending on initial endemicity level. The results for the first 38 evaluated CDTi projects are consistent with these predictions and significant tests have now been introduced for routine comparison of observed and predicted prevalence of skin microfilariae for each surveyed village. This evaluation Page I 1 methodology for phase lA appears to be performing well. The aim of evaluation in phase lB is to confirm that the breakpoint has been reached and heatment can be safely stopped. This involves entomological evaluation of transmission levels using pool screening and a threshold of 0.5 infective flies per 1000 flies (based on the OCP criterion and assuming a parous rate of 50%) and skin snip surveys to assess residual infection levels. Survey villages are selected every20 to 30 km along the main rivers/affluents and at lower density in the remaining area. The corresponding threshold for stopping treafinent is defined as a prevalence of slin microfilaiae <5%o in all villages and <lo/o in 90Yo of villages. This threshold is based on the experience with stopping control in the OCP and ONCHOSTM simulations, and was successfully tested in the proof-of-principle study of elimination in Mali and Senegal. However, the computer simulations indicate that the prevalence threshold for stopping freatment depends on the precontrol endemicity level, and that the current thresholds are only applicable if the maximum precontrol CMFL in a focus does not exceed 50 mf/snip. This is the case for first 60 CDTi projects where treatment will be stopped and for which the above stopping thresholds are therefore applicable. But based on the experience in these first projecs, the thresholds should be revised in four years' time before making decisions to stop treatment in projects with higher precontrol endemicity levels. The evaluation objective in phase 2 and phase 3 is to detect possible recrudescence of transmission and infection. Currently recommended indicators are the vector infectivity rate and the prevalence of microfrlariae. For phase 2 the vector infectivity rate is expected to be the most effective indicator for rapidly detecting recrudescence, but in phase 3 it may become operationally and financially prohibitive to use entomological evaluation at the required scale. For the detection of new infections the skin snip method has been used effectively by the OCP (e.g. R.Bougouriba) and for surueillance by the OCP countries themselves. It is anticipated that more sensitive and easier to use diagnostics will become available by the time the first project enters the surveillance phase and APOC has been collaborating with PATH in the development of an Ovl6 based test for this purpose. Operational research will be needed to assess the performance of new tests under relevant operational conditions. TCC comments and recommendations 47. TCC thanked Dr Remme for the presentation on the evidence and rationale for the current APOC monitoring and evaluation framework for elimination, recalling the experience of the ex- OCP. The committee wished him a speedy recovery. 8.1.6 Update on black flies trapping and other studies related to Onchocerciasis 48. To respond to the criticism about the ethical aspects of the use of human fly-catchers and the need of collecting enough fly for control and surveillance activities, research are being undertaken by a consortium of institutes and institutions in the USA, Mexico and Africa (APOC) led by Prof Unnasch from University of South Florida at Tampa through a grant from the Bill & Melinda Gate Foundation. Dr Toe updated the TCC on this study, noting the progress made towards its use in the freld, some of which are as follows: Comprehensive evaluations of trap platforms were conducted for their ability to collect Simulium damnosum in Banfora (Burkina Faso). The design of the trap is now adapted for Africa. The Esperanza window trap has shown its effrcacy in collecting flies in savannah and in the forest and savannah transition areas, with captures at least equal to the performance of the vector collector. Studies have demonstrated that human olfactory attractants, when used in conjunction with CO2, have proven extremely effective for collection of O. volvulus in S. damnosum. The research team plans to develop methods to relate the collections obtained from the traps to the human landing rate, permitting data collected from these traps to be utilized in current models to predict transmission intensity. Page 12 G 049. The study group will determine if the traps collect a fly population with the same age structure as that collected using human landing collections. Extensive studies comparing parity rates in the trap and in parallel human landing collections performed over different times of the year will be necessary to determine if similar segments of the population are being sampled. 50. The team is interested in determining the general utility of this trap for surveillance of O. volvulus in the vector population; it would be advantageous to evaluate the optimized model in additional locations, where other species and cytospecies of O. volvulus vectors are found. 51. Development of improved chemical lures and readily obtainable sources of CO2 is also warranted. A trap that collecs host-seeking vectors of O. volvulus in large numbers would provide the basis for replacing humans as bait in the monitoring and surveillance of Onchocerciasis vectors. Such traps will be useful in both aiding in the verification of elimination of O. volvulus transmission and in the post-treatment surveillance era. 52. Training on the use of traps was carried out for members of the national entomological team of Ethiopia. The objective is to transfer the methodology of the trapping, to train the field teams' members to collect flies for the surveillance and monitoring of Onchocerciasis elimination in the endemic communities. In Ethiopia" seven trainees received a theoretical and practical training. 8.f.7 Predictive S. damnosum habitat modelling in Burkina Faso and Northern Uganda 53. Dr Toe updated the TCC on the latest finding of the study. The primary model predicting Simulium damnosum breeding sites was based on images extracted of Quickbird with a resolution of 0.61 meter. A move has been done using images of Rapid Eye which are less precise (5m). 5m Rapid Eye modelreduces the cost by 100 fold. Rapid Eye model is78Yo sensitive vs. the sensitivity of 100% for Quickbird model. 54. The study group, in collaboration with Sighsavers and the National Onchocerciasis control team of Niger is running an application of existing models to identifr breeding sites in Niger. TCC comments and recommendations 55. TCC thanked Dr Toe for the presentations and the research team for the wonderful job being carried out. The committee observed that it will be a very great achievement to have fiaps instead of human fly catchers. The committee noted the progress made in developing the trap and recognized its usefulness and the potential for using the trap as a control methodf,The committee therefore recommended the activity to continue despite financial constraints. The committee also advised the team to collaborate with institutes and universities in the countries of implementation in order to avoid tumover of trained personnel. J( 8.1.8 Elimination of O. volvulus infection: New diagnostics of PATH 56. Ms Faulx presented the current status of the PATH Ovl6 rapid test, which is a field- rapid test for detecting IgG4 antibodies against the O. volvulus antigen. The primary use case for the rapid test is in post-treatment surveillance activities to screen children for possible exposure and by inference detecting recent reinfection of the area. Other possible uses to consider are mapping to delineate transmission zones and possibly using the test as a tool to help in the decision to stop treatment. The project began in 2010 and since that time PATH has developed an Ovl6 rapid test and transferred it to Standard Diagnostics, Inc. in Seoul, South Korea. [n the fourth quarter of 2014, the product will be launched under the name "SD BIOLINE Onchocerciasis [gC4". Following product launch, PATH will be starting demonstration studies in priority sites. Demonstration studies should be sfuctured to generate objective evidence about the performance and implementation of the SD BIOLINE Onchocerciasis tgG4 test in post-elimination settings. PATH strongly believes that additional demonstrations must be done by partners to build a robust evidence base. PATH is seeking to reach a non-binding memorandum of understanding with APOC Page 13 qin order to conduct demonstration studies with respective National Onchocerciasis Task Forces. PATH is developing a quality assurance plan to ensure that the SD BIOLINE Onchocerciasis IgG4 test is within product specifications. Currently, PATH is developing the plan structure and understanding partner needs for this quality assurance plan. The plan will be transferred to APOC within one year after the test has been launched. Additionally, PATH is proceeding with development of a biplex test that will detect IgG4 antibodies against O. volvulus antigen Ovl6 and W. bancrofir antigen Wbl23. Current timelines indicate that this test will be launched in the fourth quarter of 2015. TCC comments 57. TCC members were encouraged by the progress of the test but sought clarification on the following: - On whether the test has been evaluated for cross reactivity with other filarial diseases, especially in relation to Loa loa infections, the reply was that laboratory studies have been conducted with endemic negative samples and cross reactivity appears to be limited with other species, but further evaluation in field settings is important. Additional field evaluations should be completed, specifically in areas with high co- morbidity with other filarial diseases. - On the question of cost, the test cost has been negotiated to be similar to other rapid diagnostic tests. PATH and SD are committed to providing a low cost test. The impoftance of making the test affordable and available was reiterated and there is the potential for looking at previous experience with other diagnostic tests for lessons leamed. - On the question of where the test should be used, the original priority use case has been post-treatment surveillance (PTS). However, it is believed that the test may be useful in other seftings such as for determining when to stop MDA with ivermectin and for mapping hlpo-endemic areas. 58. On the issue of FDA and other regulatory approvals, Standard Diagnostics has filed for Korean FDA (KFDA) approval and will receive approval in the next few months. Additional country registration and regulatory requirements will be filled on a country-specific basis. 59. TCC noted the study and encouraged the new diagnostics to continue 8.1.9 New Diagnostic technology to tropical diseases, specifically for detection of Loa loa infection 60. Dr. Biamonte presented initial results towards a lateral flow assay for the detection of loiasis. The device is intended to be quantitative and to predict the number of L. loa microfilariae. The project is a collaboration between NanoComposix and Drug Discovery for Tropical Diseases; both companies are based in San Diego, CA. The assay features two innovations. First the assay is configured to detect proteins (antigens) recently discovered in the blood and urine of infected patients. The antigens were discovered by the group of Dr. Nutman at the National Institutes of Health (NIH). Second, the assay employs NanoComposix' novel ultra-high contrast Nanoparticles to enhance the sensitivity of the assay. The ultra-high contrast nanoparticles were shown to enhance the sensitivity of a lateral flow assay by up to 30-fold in a model system. The assay was then configured to detect one of the novel Z. /oa antigens, with an initial detection limit of 3-10 ng of protein. The most critical next step is to determine which of 13 available antigens will best predict the number of microfilariae. TCC comments and recommendations 61. TCC thanked Dr Biamonte for the presentation and the development of this new tool. Noting the development of the tool, the committee advised to look at the population to be treated for feasibility of the test. TCC also advised to look at the possibility of using urine for the test. Page 14 8.1.10 Results of the OVf6 studies in Africa 62. Dr. Paul Cantey of the Center for Disease Control and Prevention, USA, presented the results of OVt6 studies in Africa. As background and methods, he said as African Onchocerciasis control programs move from control to elimination, the available diagnostic tools need to be evaluated to determine in which phase of the conceptua[ framework of elimination they are useful, either alone or in combination. The available tools were evaluated in the study presented in two hyper-endemic foci, one in Uganda and one in Ethiopia, where there had been limited exposure to ivermectin. A convenience sample of 1000 individuals was enrolled, 500 in each country. A questionnaire was administered, eye and skin examinations were performed, and blood and two skin snips were taken. In the country the skin snips were examined after incubation in normal saline for 24 hours. ICT card tests and blood smears were done. Dried blood spots were made and the plasma and serum were saved for further analysis at CDC. DEC patch test was not available. The performance of OVl6 IgG4 ELISA and skin snip microscopy was compared to real-time PCR melting curve analysis (qPCR). The sensitivity and specificity of OVl6, OV17, and OV33 were determined using a panel of specimens form individuals with known parasitic infections. 63. Key resuls include the following: l) Skin snip microscopy had a sensitivity of 615% compared to qPCR for the detection of patent infections; this decreased to 39.6yo when analysis was restricted to individuals with 2 or fewer microfilariae. [The same analysis was performed in individuals who had not used ivermectin in the last year and the sensitivity was the same. When the analysis was performed in individuals who had never used ivermectin, the sensitivity was found to be 80% and 55Yo respectively.]t Sensitivity of microscopy decreased even more when the analysis was done in Ethiopia alone, which had a much lower prevalence of microfiladermia. Skin snip microscopy was highly specific for patent infection. 2) OVl6 IgG4 ELISA had an excellent sensitivity for the detection of patent infections compared to microscopy and qPCR in all the settings mentioned in #1. Sensitivity was 93-95%. Specificity was low, [though it improved in the individuals who had not received ivermectin in the last year and who had never received ivermectinl'. 3) OV16 IgGa ELISA had excellent sensitivity and specificity for the detection of active or prior infection as analysed using the collection of specimens from individuals who had positive skin snip microscopy and qPCR and a bank of specimens with known filarial infections. Sensitivity was 88.2% and specificity is 99.3o/o using the current cut off. 4) Performance of OV16 IgG4 was compared to OVl7 and OV33 using a multiplex bead assay. OV16 performed better than the other two antigen tests (96.3% sensitivity and 99.7% specificity), though OV33 had a high specificity (98.5o/o as well). 64. Key conclusions: [n the presence of ivermectin use, the sensitivity of skin snip microscopy for the detection of patent infections declines. Its sensitivity is quite low in individuals with 2 of fewer microfilariae per skin snip. The sensitivity of OVl6 does not decrease in the presence of ivermectin use, but its specificity for patent infection is low. Evaluation of the sensitivity and specificity of OVl6 tgG4 ELISA for the diagnosis of active or prior infection with Onchocerca volvulus is excellent. A better understanding of the age distribution and longevity of the antibody response in multiple epidemiologic contexts would help inform how the test can best be used to evaluate elimination programs. OV33 may be an antigen that could be used in the evaluations of individuals who may have false positive OVl6 results. Final analyses of the specificity and sensitivity of the va.ious tests wilt occur when the 3'd study site is completed, so the figures given in this reports should be considered as preliminary. A brief discussion of which diagnostic tools might be most meaningful at different key program time points if the conceptual framework for elimination took place. Finally, next steps in the studies were described. Plans include examining 'Analyses included in the brackets were not discussed in the presentation but were shared with some TCC attendees at the request of Dr. Michel Boussinesq. As this is a subgroup analysis it should be kept in mind that the sample size is smaller and the estimates are less robust. Page 15 bthe age distribution and longevity of the OVl6 antibody response and evaluating the available diagnostic tools in hypo-endemic areas (both hypo-endemic by baseline mapping and those whose transmission has been suppressed by many years of successful CDTD. Vector collection will be included to see how markers in the vectors correlate with markers in humans. TCC comments and recommendations 65. TCC thanked Dr Cantey for the presentation and observed that there is no ideal tool as both OVl6 and the skin snip have their limit and both tools can be used at phase l, and OVl6 is appropriate for post-surveillance activities. Further research is needed to understand the significance of the tool. 8.1.11 LF and Oncho co-evaluation study 66. Dr Christine Dubray from the Center for Disease Control and Prevention, CDC, Atlanta presented the results of the Co-evaluation of Lymphatic Filariasis and Onchocerciasis in three districts treated for Onchocerciasis with lvermectin in Senegal. She observed that the current efforts to eliminate lymphatic filariasis (LF) and Onchocerciasis (Oncho) are through mass drug administration (MDA) using ivermectin for Oncho and ivermectin and Albendazole for LF. It is possible that years of ivermectin distribution for Oncho have decreased or intemrpted LF transmission in certain areas not yet treated for LF. The objectives of this study were to evaluate the status of LF in communities treated with ivermectin for OOncho for > l0 years, and to determine the value of integrated Oncho and LF assessments for LF and Oncho elimination programs. 67. [n Senegal, LF mapping was carried out in 2003. Mapping results were above treatment threshold (Z lo/o positive tCT) in two of the three districts (Salemata, Kedougou, Saraya) of the Kedougou region. No villages were mapped in the Salemata district. [n February 2014, these districts had not received LF treatment (Albendazole and ivermectin) yet but they had beneficiated from annual or bi-annual Oncho treatment (ivermectin) since 1988. The study added LF screening (ICT) to a lb Oncho epidemiological evaluation (skin snip) to assess intemrption of Oncho transmission in three river basins (Gambia, Faleme and Koilakabe) located in the Kedougou region. Additionally, dried blood spots were collected on filter papers to test for antibodies to the Wbl23 (LF) and Ovl6 (Oncho) antigens. The Oncho Program in Senegal used the methodology described in the Conceptual and Operational Framework of Onchocerciasis Elimination with [vermectin Treatment (APOC, 2010) to select villages and participants. 68. The study took place in February 2014. Two of the sixteen villages selected by the Oncho Program refused to participate to the evaluation and at the end 14 villages were included in the study. All village residents > Syears old willing to participate were eligible for the study. A total of I192 villagers signed the study consent, which represented 5l%o of the eligible population (2328). Of those, 9 (l%) refused to give blood and 162 (14%) refused to provide skin snip. The proportion of positive lCTs (61174, 3.4%) was above treatment threshold in the district of Salemata. No participants were ICT positive in the districts of Kedougou and Saraya. Of the I145 participants with Wbl23 results, 7 (0.6%) had a level of antibodies above the positive cut-off. Only one participant (11992,0.102, male, 79 year old) living in the Gambia basin had a positive skin snip. Of the I 13l participants with Ovl6 results, TS (6.9%) had a level of antibodies above the positive cut- off. Positive Oncho serology(Ovl6) was found in2.5%o(71279) of the 5-9 yearolds included in the study, 2.7% (31109) in the Gambia basin and 3.5% (4/l l5) in the Fal6m6 basin. 69. This integrated evaluation provided important programmatic information to the LF and Oncho elimination programs in Senegal. The evaluation showed that the Kedougou and Saraya districs might not need LF treatment despite mapping results found to be above heatment threshold in 2003. lvermectin distribution should continue in these districts until interruption of LF transmission has been established by population-based survey (TAS). Albendazole should be added to ivermectin in the district of Salemata where the proportion of positive ICTs was still above Page 16 0treatment threshold. Wbt23 results suggested very low or absent LF transmission among the population tested. Ovl6 results suggested that Oncho tansmission had occurred in the last l0 years. TCC comments and recommendations 70. TCC thanked Dr Dubray for the presentation and observed that the study is in right track with PENDA. The committee also observed that there is lack of correlation between ICT and Wbl23, hence the need for an operational research. TCC hoped that entomological results of the area would be presented to its next session to confirm or not the existence of residual transmission. 8.1.12 Research on genetic markers for sub-optimal response to ivermectin and delinition of transmission zones ?1. Dr. Grant presented results from different research projects to investigate the phenomenon of suboptimal response to ivermectin, primarily in Ghana and in Cameroon, funded since the mid 1990s by OCP, APOC and TDR. Phenotypically, suboptimal response is defined via the faster than expected re-population of the skin with microfilariae and earlier than expected female macrofilariae with active embryogrammes. 72. Analysis of population genetic data from adult worms from former OCP areas with between 0-17 rounds of ivermectin treatment which had been genotlped at 23 loci shows that the proportion of parasites that are reproductively active in the total parasite population decreases over the first 9 - l0 rounds of treatment as expected but that this trend is reversed from l0 rounds of treatment when the proportion of the parasite population that is reproductively active begins to increase. 73. There are two important points to note with respect to this result: (l) the sample of parasites was biased towards parasites sampled from people in communities in Ghana in which suboptimal responses had been documented and does not represent a random sample of parasites from across the former OCP, (2) an increase in the proportion of the population that is reproductively active at day 90 post-CDTI does not necessarily mean that the absolute number of reproductively active parasites is increasing. The result is, however, consistent with an increase in the incidence of suboptimal response. It may, therefore, be an early step along the road towards recrudescence. These data also illustrate the general utility of genetic analysis as a means to monitor the contraction/expansion of a parasite population. 74. The 'Ivermectin Response Marker' project was initiated several years ago with APOC funding to take advantage of new developments in genome sequencing. Two analyses were presented. The conclusion from the first was that the genetic analysis of suboptimal response still has some way to go, and that more work is required to determine the feasibility of developing a genetic test that can detect suboptimal response and/or predict the ivermectin response phenotype of the parasites (see presentation from Dr Kuesel about TDR funding for such research). The second analysis showed that the genetic analyses undertaken can discriminate between parasites according to geographical origin, so that parasites from Ghana and Cameroon could be distinguished readily, and that the spatial scale of discrimination may be as small as one river basin to another (in Ghana) over distances of <200km. TCC comments 75. TCC thanked Dr Grant for the presentation and was pleased to note that the research work has advanced with very good results. The committee noted the importance of a tool that can help in delineation of transmission zones. The committee therefore encouraged continuation of this research and potential development of a tool to complement currently available methods for determining transmission zones and to determine whether parasites that are found post elimination are the result of re-invasion (immigrants) or are the last few resident parasites that may have escaped elimination. Page 17 /7\ o 8.1.13 WHO Guidelines on verilication of elimination of human Onchocerciasis 76. Prof Unnasch made a presentation on the WHO Guidelines on verification of elimination of human Onchocerciasis. The presentation described the process of elimination in three phases, the criteria for certihcation of intemrption of transmission which was set up in 2001, the WHO Guidelines operationalized by APOC, the guidelines operationalized by OEPA. He indicated that the work of the committee was to update the 2001 guidelines. He observed that the remaining questions are operationalizing ATP values for Africa, new tools and what value will they play, and integration with LF. TCC comments and recommendations 77. TCC thanked Prof Unnasch for the presentation and observed that the guideline presented has been improved from the first version which was shared earlier. The committee also observed that there was no African representation in the certification committee while 90% of the disease is in Africa. The Director of APOC informed the committee that he sent a letter to WHO/HQ pointing out the oversight, and that it is likely the guidelines will be improved taking into consideration his complains. The APOC Director also reminded the TCC on the process set up by WHO to review guidelines. Two colleagues were proposed by APOC to be members of the guidelines verification committee. 8.1.14 Roadmap for alternative treatment strategies for the acceleration of the elimination of Onchocerciasis: 201+2015 78. The objective of the consultative workshop was to discuss with experts how to operationalize Alternative Treatment Strategies (ATS) during the period 2014-2015 in areas requiring intensified Onchocerciasis and/or LF control to achieve elimination objectivesOncho, specifically: - OnchoCriteria for Onchocerciasis and/or LF endemic areas requiring intensified control; - Strengths and weaknesses/limitations of different ATS for addressing specific challenges to Onchocerciasis and/or LF control, including: o Strengthening of annual M treatment strategy; o Bi-annual IVM treatment (presentation of country experience); o Other drugs and the type of heatment strategy (MDA, diagnosis based/test and treat) they are suitable for (Anti-Wolbachia drugs, moxidectin, flubendazole); o Test and treat: development of algorithms for decision-making; o Related operational research; - OnchoOnchoOnchoAlgorithms for choice of ATS. OnchoOncho; - Areas for piloting ATS in 2014-2015; - Build consensus amongst a small group of experts to support APOC Management and countries with problem areas on how to implement ATS during the period 2014-2015 for Oncho/LF. 79. The methodology of the workshop was roundtable discussions and presentations. The first outcome of the meeting was a categorization and sub-categorization of areas requiring intensification of control efforts. Three main categories were defined: (i) projects which started late; (ii) projects with very high pre-control endemicity level and/or where Onchocerciasis is transmitted by black fly species with particularly high vector competence (projects where Onchocerciasis elimination cannot be reached by annual IVM treatment only); (iii) projects with unsatisfactory results, as assessed during the evaluation surveys conducted after many years of MDA. The latter category includes two sub-categories, namely presence of a suboptimal response of the parasites to the drugs, and poor therapeutic coverage, and the latter subcategory includes various situations (programmatic issues, Page 18 specific situations such as conflicts or poor accessibility, or reluctance to take ivermectin because offear ofserious adverse events). 80. The experts determined that in any case, before implementing ATS, the existing annual IVM treatment should be reinforced, e.g.: - Solve first the managerial issues (weak health system, poor management, poor monitoring, poor partnership, poor training, human resource issues, CDD motivation and attrition, poor community mobilization and ownership, CDD overload, CDD low number); - Possibly increase the duration of the treatment campaign - Possibly treat just before the transmission peak period (if it is not already the case). 81. They proposed various ATS for each of the project categories defined above. These ATS included mass treatments (including biannual treatments for some cases), vector control, and three Test and heat approaches, for which algorithms were developed; - One for areas hyperendemic for Onchocerciasis, and coendemic for LF and Loa loa, - One for Onchocerciasis hypoendemic areas with Loa /oa microfilaremia prevalence > 20Yo and non-endemic for LF - One for Onchocerciasis hypoendemic areas with Loa /oa microfilaremia prevalence > 20Yo and co-endemic for LF Oncho 82. In each algorithm, the treatment is determined based on the results of 2 or 3 successive diagnostic tests. 83. The meeting also pointed out challenges for the implementation of these ATS, including (i) the availabitity of DEC patch test for testing large populations for patent Onchocerciasis infection; (ii) the cost and operational constraints for large scale use of doxycycline; (iii) limited operational research information on ATS; and (iv) Lack of large scale field experience on Test and Treat. 84. Availability of moxidectin would address the operational challenges and feasibility of biannual treatment with ivermectin and lower than optimal impact of CDTI when it is not optimally timed in areas with transmission seasons. Availability of Flubendazole, which is not expected to have a microfilaricidal effect, could be beneficial in particular for addressing the challenges in Lo iasis co-endem ic areas. 85. The Consultative workshop made the following recommendations: General: - In areas of unsatisfactory epidemiological results, APOC Management should support the country to conduct a thorough situation analysis and come out with a roadmap to address persistent infection. - There is need to define pre-control prevalence threshold above which elimination of Onchocerciasis with annual treatment with lvermectin cannot in any case be achieved. On Biannual treatment: To ensure effective implementation of bi-annual treatment, there is need for clear guidelines and indicators for programme managers and health workers. To guide decision on bi-annual ivermectin treatment as ATS, there is need to provide data on cost of biannual treatment vs. that of annual treatment and ensure availability of the necessary resources. In areas where treatment has been conducted for 15-20 years with persistent high prevalence, the group recommended that managerial issues should be addressed first. Then, depending on the local situation, use of mobile teams, biannual treatment with Page 19 0ivermectin, annual treafinent with moxidectin and/or vector control should be implemented. On Test and Treat: ln order to address the issue of high infection levels in Loa loa co-endemic areas, there is need for operational research to understand the negative impact of Loa loa on the control of Onchocerciasis in order to suggest relevant possible ATS. In order to ensure the safety of doxycycline where Onchocerciasis is co-endemic with Loa loa, the proposed algorithms have to be field tested to determine which one is the most suitable and cost-effective. To scale up implementation of ATS with LF, there is need to identifr problematic areas where standard strategy for LF, ATS for LF and [VM can be implemented. 86. The following next steps were identified: - Categorization of all APOC projects into the three categories and various sub-categories identified by the expert group; - Discussions with modellers to define the thresholds of late CDTI start and high pre- control endemicity that would qualift an area for ATS; - Develop appropriate field guides and indicators; - Develop protocols for evaluating the cost effectiveness of the different ATS; - Evaluate feasibility of vector control by ground larviciding in areas requiring ATS; - Finalization of APOC roadmap document. TCC comments 87. TCC commended the Expert Group on ATS for the impressive work carried out and strongly endorsed the roadmap on ATS. 88. TCC recommended to: incorporate the outcome of expert consultation and the discussions in TCC39 in the roadmap on ATS; Make DEC patch and moxidectin available quickly to accelerate upscaling of ATS; lncorporate in the modelling issues raised by the situational analysis from poorly performing projects in order to understand the impact of determinants for poor performance which could include political reasons, decentralization, data flow from the periphery to centre; Differentiate project areas which started CDTI late but achieved good coverage from those which started CDTI late and implemented it with bad coverage; Reconsider the algorithm for categorization of projects and pool projects with late start and projects with poor performance; Create a high level advocacy group to visit countries with areas requiring intensified control efforts to sensitize the authorities on the subject; Use a mobile team s approach in some areas; Introduce treatment cards to provide more reliable data on treatments received; Conduct ALB monotherapy in conjunction with integrated vector control; Not delay mapping for LF, with appropriate tools, in Loa loa arcas; Advocate for treatment to be intensified during a given short period in the community to avoid inducing atypical responses to [VM; Pay attention to the fact that doxycycline is contraindicated in children under Tyears and pregnant women. Clear guidelines for pregnancy tests have to be provided given the fact that women in Africa do not usually declare they are pregnant until relatively late into the pregnancy; Address the issue of how to identif, atypical responses and put those in the document; Page 20 ^h Address the issue of pharmacovigilance when including new drugs in addition to the other NTD drugs already in the community and in the LF impact assessment guidelines; Consider the possibility to revert back to annual CDTI when entomological and epidemiological indicators become satisfactory; Present the document at the Programme managers meeting in November for their inputs before sending it to countries involved. 8.1.15 Proposed algorithm for deciding on areas to reline Loo loa map 89. Professor Wanji presented the Roadmap for the finalization of the Loa loa map in support of the Elimination of Lymphatic filariasis and of Onchocerciasis in Onchocerciasis hypoendemic areas. This roadmap is the outcome of discussion of a committee mandated by the management of APOC that worked in collaboration with WHO/AFRO. The group reviewed the RAPLOA map that was published in 201I by APOC to identi$ areas that require further mapping using the following considerations: ( I ) Areas where the probability that Loa mf prevalence exceeds 20Yo is either above 5%o or below 95%o. ln areas where the probability that Loa mf prevalence exceeds 20o/o is below 5%o, there is almost a certainty that Z. /oa does not exist. In areas where the probability that Loa mf prevalence exceed 20o/o is above 95yo, it is almost certain that L. /oa is highly endemic. In areas where the probability that Loa mf prevalence exceed 20%o, is between 5 and 95%o, there may be a gradient of endemicity of Loiasis. (2) Areas that were not sampled during the initial L. loa mapping, were so either because the ecological conditions are not suitable for the existence of Chrysops, vectors of L. loa, or because the level of insecurity in those areas are too high for the safety of field workers. An algorithm for the selection of communities to be surveyed was presented. The algorithm took into consideration the outcome of previous RAPLOA surveys, the endemicity of LF, the status of the health district in term of ivermectin MDA. Members of TCC made suggestions for the improvement of the selection of areas to be surveyed and communities within those areas. The exercise of L. loa map refinement will also take into consideration the cross reactivity of tCT test for high Loa mf carriers demonstrated recently in Cameroon and DRC. Oncho TCC comments and recommendations 90. TCC thanked Dr Wanji for the presentation of the algorithm. 91. The committee noted thag in spite of the dramatic impact of long term CDTI on the prevalence and intensity of loiasis in hyper-endemic areas (Loa loa mf prevalence >-30yo), it will not be justified at this time to abolish the test and treat approach. 92. Members of TCC made suggestions for the improvement of the selection of areas to be surveyed and communities within those areas. The exercise of L. loa map refinement will also take into consideration the cross reactivity of tCT test for high Loa mf carriers demonstrated recently in Cameroon and DRC. TCC encouraged the management of APOC to continue this important activity of the refinement of the L. loa map that will accelerate the elimination of Lymphatic filariasis and Onchocerciasis in areas where loiasis is hyperdemic. 8.f.16 Perspectives for LF and Oncho elimination: Results of test and treat study in Cameroon 93. Dr Boussinesq presented the results of the Test and treat project carried out in Cameroon. The objective of the study is the development and evaluation (performance and applicability) of a simple method enabling to identift subjects with a high Loa microfilaremia (> 30,000 mf/ml) associated with a possible risk of post-IVM SAEs. Such a tool would permit to launch IVM distributions against LF and/or hypo-endemic Onchocerciasis in areas where loiasis is co-endemic (by enabling to exclude from MDA those few individuals at risk for SAEs). As part of this project, a survey was conducted in South Cameroon to evaluate the association between Loa loa and W. bancrofti. Page2l 94. The conclusions of the study revealed that: ICT test can turn positive for individuals with a very hi$r Loa mf density; Similar results have been reported from other areas in Cameroon and DRC; The false positivity would be worse with the new Test Strip, which is more sensitive than ICT to detect antigenemia; The figure suggests that an ICT prevalence of l%o can be reached when the Loa mf prevalence is as low as l5%; ICT alone cannot be used to map LF in loiasis areas; ICT should be completed by nocturnal sampling (to seek ll/. banuofti mf on blood smears or to detect ll/. bancroft DNA in the blood); or ICT could be replaced by other tests (Wbl23 antibody detection tests) once the performances of the latter will have been evaluated on a larger scale. TCC comments and recommendations 95. TCC thanked Dr Boussinesq for an excellent work which will have impact in the field and observed that it is an opportunity of having a tool for large scale test. The commiftee observed that it is very important adding these essays to Prof Wanji's plan of mapping Loa loa as all these have to be assessed. The committee reiterated that the ICT test should be used even if there is cross- reactivity. E.f.17 Review of Uganda dossier for the four sites that have interrupted transmission of Onchocerciasis 96. Dr Tukahebua presented the dossier of the four sites of Uganda that have intemtpted transmission of Onchocerciasis. tt is to be recalled that TCC at its 38h session in March 2014, recommended that all projects that may intend to halt intervention after reaching elimination break point to provide a dossier for review by the TCC. It was in line with that recommendation that the Uganda Onchocerciasis Elimination Experts Advisory Committee (UOEEAC) presented the dossier. 97. tn Uganda, Onchocerciasis is endemic in 17 foci (35 districts). Control started in 1993 with annual ffeatment and vector control in 2 foci. !n2007, the shategy was changed to elimination and bi-annualtreatment coupled with vector elimination in isolated foci. 98. Nine foci have been recommended by the UOEEAC and certified by the Ministry of Health to have intemrpted transmission. Eight of them halted ffeatment while one is still treating with ivermectin for LF. A dossier for one of the foci, Obongi located in Moyo district - North Westem Uganda was prepared and presented. The rest will be presented during the TCC40. 99. The UTG in Obongi focus has been fluctuating with the lowest (17%) in 1993 while from 2012 to April 2014 it has been > 95yo. From epidemiological assessment, all the examined children were OVl6 negative and had no microfiladermia. Entomological assessments revealed no vectors since 2012. It was concluded that there is no transmission in the focus. Recommendations by UOEEAC - Open another catching site in the northern part and continue with entomological assessments. - Continue treating for LF until TAS is conducted and a decision made accordingly. TCC comments and recommendations 100. TCC acknowledged the steps taken by the UOEEAC by responding to their recommendation. The committee however reiterated its recommendation to countries to submit to Page22 0 a0 TCC projects they think to be eligible for intemrption of treatments instead of stopping treatment before informing TCC. The committee further encouraged the UOEEAC to submit a complete dossier at its next session. TCC also made the fotlowing recommendations: In the table for epidemiological assessmen! a column of total population per surveyed village should be included to show the proportion of people that were examined; Noted that for epidemiological assessment, few children were examined and this may not be a good representation ofchildren in the surveyed villages. 8.1.18 Contribution of TCC to the preparatory activities for the launching of PEI\IDA, specilically the LF/Oncho programmes scale up l0l. As contribution of the TCC to the preparatory activities for the launching of the new entity, specifically the LF/Oncho programmes scale up, the committee gave the following views: i) tn fund raising, contacts should be widen in the search, targeting African Countries; ii) The fiscal agent, the World Bank should help tapping African philanthropists.; iii) African countries should know what are the problems and their responsibilities. They should be in the Centre of PENDA and be involved in it; iv) Emphasis should be put on the importance of not letting communities down; v) The new programme should learn from the success of both the LF and Oncho programmes to Strengthen PENDA; vi) Upscaling of LFiOncho programmes will very much depend on the new stnrcture of PENDA which should be though; vii) A solution should be found for taxes imposed by some countries on drug consignments before the launching of PENDA; viii) Countries should be implicated in the thinking for launching PENDA; ix) Capacity should be strengthened at the country level as performance of some programme managers at country level may refrain implementation of activities; x) The CDI model at the community level should not be loosed as it is a strong tool for the success of elimination. 9 RESEARCH ON NEW CONTROL AI\TD SURVEILLAhTCE TOOLS BY COLLABORATING INSTITUTIONS: Agenda item 9 102. Dr. Kuesel reported on the research co-funded by APOC and TDR. 9.f Update on moxidectin 103. The efficacy data from the Phase 2 (Awadzi et al. 2014) and Phase 3 study (previously presented to TCC) are being used to model time and in-country cost to reaching the provisional operational thresholds for stopping treatment (pOTTIS) with annual community directed treatment with moxidectin (CDTM), annual CDTI (aCDTI) and biannual CDTI (bCDTD. 104. The results of EpiOncho modelling of the Phase 2 data" conducted by H. Turner, M. Walker and M-G Basanez were presented. The modelling assumed that eligible population, the cumulative effect of repeated doses on adult worm reproduction and in-country costs for community directed treatment are identical for moxidectin and ivermectin, and that moxidectin is provided to countries free. Costing data were based on those from Ghana (Tumer et al. 2013). 105. Across a variety of assumptions on pre-treatment endemicity, treatment history and treatment coverages, the number of years to reach pOTTIS with aCDTM were comparable to those with bCDTI. Since bCDTI costs per year around 1600/o of aCDTI, the shorter time to stopping treatment with bCDTI than aCDTI results in higher in-country costs, while the shorter time with aCDTM results in lower in-country costs. Publication of the data is in preparation. Page23 106. Modelling was also conducted for two different patterns of seasonal transmission and different timing of aCDTI or aCDTM relative to peak transmission season. aCDTI not at a time that results in minimal skin microfilariae levels at time of peak transmission results in an up to around 40 Yo increase in the number of years to reach pOTTIS relative to aCDTI conducted at the optimal time point. [n contras! timing of aCDTM relative to peak transmission season does not significantly impact the time to pOTTIS. 107. The results suggest that moxidectin could be a cost-effective alternative to bCDTI in a variety of circumstances: endemicity/biting rates are high, transmission is highly seasonal and optimal timing of treatment cannot be guaranteed, treatment coverage is insufficient and achieving sufficient coverage 2x I year is not more feasible than achieving it lx I year, in-country funds don't allow implementation of bCDTI, and/or bCDTI implementation reduces in-country funds for other MoH and NGO activities. 108. WHO has recently concluded an agreement with the Not-for-Profit Australian organization Medicines Development for Global Health (MDL) for hansfer of all data on moxidectin. MDL is currently trying to raise funds to be able to pursue registration of moxidectin for Onchocerciasis, and to develop moxidectin for lymphatic filariasis and scabies. TCC comments and recommendations 109. TCC welcomed the information that moxidectin registration is again being pursued since the data on moxidectin's effect available to date and the modelling of the impact of annual treatment with moxidectin on O. volvulu transmission suggests that it will be an important complement to currently available tools for control and elimination of Onchocerciasis. I10. The committee therefore endorses further development of the drug and free donation to the counhies so that it can be used as an alternative treatment strategy. 9.2 Research on the vulnerability of Onchocerciasis and LF to emergence of resistance lll. TDR is expanding its support for research addressing the vulnerability of Onchocerciasis control to emergence of resistance (see Report from W. Grant) and plans to include LF, schistosomiasis and soil transmitted helminth in this research. ll2. Projects to be funded include (a) continuation of the search for genetic markers of suboptimal response of O. volvulus to ivermectin and potential development of a genetic marker based tool for use by control programmes for surveillance of the frequency of such genotypes, (b) research for markers of O. volvulzs populations to complement currently available methods for defining transmission zones, (c) literature review on determinants of parasite response to drugs and transmission (parasite, vector, host, environmental, social and control programme factors affecting parasite response and/or progeny transmission of parasites exposed to drug(s)), (d) modelling the spread of parasites with low drug susceptibility within and between parasite and human populations. I 13. Motivated by the inter-individual variability in the effect of ivermectin on skin microfilariae levels at different times post-treatment in participants from four CDTI naive areas in the moxidectin Phase 3 study, TDR has published a call for interest in collaboration, asking researchers and conhol programmes to join a project aimed at characterizing the range of variability of response early on during mass treatment as a reference for the frequency of different levels of response after long term MDA. After the close of the call on 30 November 2014, the calls will be reviewed to determine for which parasite/drug combination there are enough data to justif, identification of an investigator to conduct the analyses. Page24 nv TCC comments I14. TCC welcomed the fact that TDR is continuing research in this area and is looking forward in particular to the results of the research on genetic markers that could complement available methods for defining transmission zones. 9.3 Update on DEC patch agreement l15. The DEC patch agreement has been signed by the company and originals are being sent to Ouagadougou for signature by WHO (Director APOC). TCC comments and recommendations 116. TCC noted the arrival of DEC patch test which is welcome as a tool for evaluation and acceleration of Oncho and LF elimination. The committee thanked Dr Kuesel for the three presentations and TDR for pursuing these different research agendas. 9.4 Assessment of the impact of community directed treatment with ivermectin on the parasitological indicators of Loo loa in areas of co-endemicity with Onchocerciasis in Cameroon ll7. Professor Wanji presented the outcomes of an operational research study that was recommended by TCC to be carried out in areas of co-endemicity Onchocerciasis/loiasis to find out if long-term treatment with IVM in such area might have led to a marked reduction in the parasitological and entomological indices of loiasis as this could constitute an added value to the primary goal of APOC which is the control of Onchocerciasis. The study was carried out in four CDTI projects in Cameroon where pre-conffol information on the endemicity of loiasis existed (CDTI South West I & 2, CDTI North West, CDTI East). The research team used combined social science and parasitological methods to assess the parasitic indicators and compliance to ivermectin treatment from the study participans. The study came out with the following conclusions and recommendations: I 18. In the East and North West CDTI projects that have been distributing ivermectin for 7-8 years, and where the pre-conhol endemicity was very high (29-30%), the prevalence of L. loa mirofilaremia was reduced by 600/o, the prevalence of high microfilareamia (>8000Mf/ml) was reduced by 70o/o and the prevalence of very high Loa mf density (>30,000 mflml) was reduced by 50o/o. It was also noticed that those individuals who took ivermectin more regularly were in majority amicrofilaremic and that even if they were still microfilaremic, they were carrying very low mf densities. This contrasted with those who refused systematically to take ivermectin or were poor compliers as these categories of individuals were more frequently microfilaremic and also carrying higher Zoa mf densities. I19. It was concluded that repeated treatment with ivermectin in areas of co-endemicity OnchocerciasiVloiasis is making impact in reducing the parasitological indicators of loiasis and by doing so reducing the risk of people developing SAEs following ivermectin treafinent. But the fact that a fraction of the population in areas of co-endemicity were non-compliers or poor compliers constituted a threat for the elimination of Onchocerciasis in these areas as those people are likely to be reservoir for both O. volvulus and Z. /oa. Strategies to detect those people and treat them with alternative tools should be envisaged. TCC comments and recommendations 120. TCC commended Prof Wanji and his team for these important findings and encouraged them to explore the possibilities of developing a mathematical model with data collected that will make the finding of this study more operational. For that, more data on L. loa infection from@ Page25 children 5 to ten years will be needed. The committee observed that the study confirmed the knowledge of the field and reassure project implementers in the field. 10 REMARK BY TECHNICAL ADVISORS TO APOC MANAGEMENT: Agenda item 10 l2l. After listening and participating in discussions on technical and strategic issues, the technical advisors concem was mainly on the current budget constraints at this critical period of the Programme. The advisors regretted that the problem occurs at the time the Programme is about to reap the fruits of its hard labours. They therefore advised the Programme management to adopt a resource mobilization strategy quickly in order not to jeopardize many years effort. This strategy should target mainly African countries. Advocacy and sensitization should be made toward African Ministers of Finance through ambassadors of goodwill. 122. They observed that since 2000 western countries' attention was focalized on the three major diseases, Malaria" Aids and tuberculosis, losing sight of NTDs. They were also more concemed about emerging diseases. All this coupled with the emergence of many foundations and NGDOs competing in the health sector, impoverishing neglected diseases. They therefore advised for a good communication tool and strategy to approach those countries. ll REMARIG BY TIIE FORMER DIRDCTORS TO APOC MANAGEMENT: Agenda item ll 123. The former directors of OCP and APOC, Drs Yakum K. Dadzie, Azodoga Seketeli and Uche V. Amazigo, also shared the concerns of the technical advisors on the budget constraints at this critical hansition period of the Programme. They however advised the management to do everything possible not to delay the launching of PENDA, despite these ftnancial constraints, because delaying would be detrimental to the new Programme and the poorest of the poor in Africa who earnestly need this new Programme. They recalled the financial problems ex-OCP and APOC went through some times ago and advised the management to seriously take into consideration technical advisors advices but leave to each partner what he knows doing better. They also advised to seek for the advices of those at the fiscal agent who used to mobilize funds for OCP and APOC in the past and who know better how to approach potential donors. They observed that global health policy is changing and becoming more competitive, and the management need to think deeply on how to reposition the programme. They advised APOC management and partners to invest in research and publication. The Management can invite scientists for collaboration in that area as they should go to JAF with publications. 124. The former directors seized the opportunity to thank APOC management and the Director for inviting them and pledged their availability to support the management. MANAGEMENT OF TITE APOC TRUST FTINI) 12 R.EPORT ON TIIE FINAI\CIAL MANAGEMENT OF APOC FT]I\IDED PROJECTS: Agenda Item 12 125. This presentation was outlined in four major points: i) Progress made in returns submission from March to September 2014 ii) Status of Financial returns for 2014 and previous years iii) Ageing report for financial returns iv) Status of FACE returns from2012-2014. It was recalled that the TCC session in March has recommended to the APOC Management to engage with countries having long outstanding returns in order to improve the situation. It was further recommended to the management to suspend further instalments to those projects red carded. 126. The APOC management indicated that following TCC recommendations, field missions have been conducted in some countries and written reminders sent. This resulted in substantial reductions in the number of outstanding reports from 701 in March to 283 in September. However, Page26 red carded projects have not been denied funding since the APOC management opted for field mission to assist projecs in preparing retums. This was also motivated by the fact that the JAF had given a clear list of milestones and deliverables to achieve in 2014 as a preparation for the new entity. This could not be achieved if APOC had not disbursed funds as planned. 127. The current status of financial returns shows that, out of the 2272 reports due as at September 2014, a total of 1493 reports have been received and 774 are still outstanding. This is reflected in a submission rate of 660/o. 128. Out of the 774 outstanding reports, Tl are due for less than six months; 6l I due for 6 to 12 months and92 due for more than 12 months. The total of 703 outstanding reports for more than six months is owed by 80 projects located in 14 countries. 129. In terms of FACE submission, the report showed that outstanding reports for 2012,201 3 and 2014 are respectively 19,78 and 97. These reports have to be submitted latest by DEC 2015 and DFCs closed. 130. After the discussions, it was recommended that (i) reasons for delay continue to be identified (ii) TRCs should not review proposals from projects with outstanding financial and technical reports. 13 REPORT ON TIIE REVIEW BY APOC MANAGEMEI.IT OF TIIE FINANCIAL CoNTENT oF lsr, 2no, 3*, 4t', 5t', 6t', 7t*, 8*, 9*, lorH, llrH ,12", l3t' ard 146 YEAR PROGRESS REPORTS AS AI\T INTRODUCTION TO TIIE REVIEW EI(ERCISE: Agenda Item 13 l3l. This presentation was outlined in three main chapters: i) the background that lead to the budget downscale ii) the high level budget overview iii) CDTI projects implementation in year 2014. 132. Following the discussions started during the 144ft CSA session held in Geneva, a mid-term review was conducted during the l46h CSA session held in Ouagadougou, and it was decided that the budget approved for 2014 be scaled down from USD 25,014, to USD 19,000,000. This decision was reached after considering the inflow of funds and the projected resources flow for 2014- 15. 133. The orientation from the CSA in revising the budget was to curtail the routine epidemiological and entomological activities to upscale treatment. The orientation was implemented by APOC management and following budget appropriation lines have been revised downward: i) Evaluations activities within the EVE unit; ii) Staff salaries iii) Administration and management costs. 134. After the budget review, the allocation per major area of work is as follow: Results areas Budget allocation Percentage Administration, Management, leadership and partnership 7,731,758 4l%o2 Advocacy and transition to the new entity 1.348.514 7o/o Co-lmplementation 1,077,315 60/o lmplementation of CDTIs 6,217,748 33% Mon itori ng/Evaluation/S urve i I lance 2,624,748 l4o/o Grand Total 19,000,000 l00o/o 135. It includes llYo for field equipment that should be accounted for CDTI implementation activities. As at September 10, 2014 the overall budget implementation rate is 80% and all results areas have an implementation rate ranging between 56Yo and l0l%. The lowest rate being for co- implementation and the highest rate for CDTI implementation. Page2? A136. During the 2014 year, APOC has implemented a total of I 17 projects, strenghened six NOTF secretariats and supported 4 country programmes for regular activities and seven country programmes for post surveillance. The total amount planned for field activities was USD 7,144,161 and as at September 2014 this amount was committed at9lYo 137. TCC thanked Mr Bizimana for the presentation and observed that the delay in submitting outstanding financial reports by the countries is becoming critical. The commiftee suggested that countries that have TRCs could help in recovering those financial reports and that country expertise could also be used in that regard. The committee advised APOC management to be firm with the project and that those at the hierarchy could be informed as they are mostly not aware of the problem. 138. TCC also recommended that APOC management i) presents the amount for field equipment in the CDTI implementation budget line ii) ensures that staff salaries from January onward are available before end of December. REVIEWS 14 REvIEw oF lsrr 2n'r 3*r 4t*r 5t'r 6*1 7or 8or 9t', lorH, llrH, 12t', l3m 14rH AND 15TH YEAR AIYI\ruAL TECHNICAL REPORTS: AgENdA IIEM 14 I4.I NEW PROECT PROPOSALS 14.1.1 ETITIOPIA 14.1.1.1 Awi Zone CDTI Project Proposal l. General overview of the proposal 139. This is one of the three proposals from Ethiopia being considered for support by the TCC. Awi zone is one of the I I administrative zones in Amhara regional state situated in the western part of the region. The total area of the zone is 8,588.8 km2 with a population density of 130/km2 inhabitants (based on the census conducted in 2007). The zone has a total population of 1,200,761 people (but there is a table presenting the total population as I ,3 82,06 I l, 85 .60A of which is located in rural areas. The total population for the CDTI project is 889,679 people distributed in 1,759 villages. The zone is bordered by North Gondar zone to the north & northwest, West Gojam zone to the East & Southeast and Metekel zone of B/Gumiz region to the West. The zone is divided into I I districts, 8 of which are endemic of Onchocerciasis and three are endemic for LF - Chagni town, Jawi and Zigem which are endemic for both diseases. There are 4l health centres and 185 health posts in the zone. 140. Service delivery, including the provision of health services, is decentralized in the country providing structures through which the new project will be implemented. Epidemiological data exist to confirm prevalence of the disease. There is also a potential of learning from the experience of existing CDTI projecs in the region. 141. Ethiopia's health system is highly decentralized, with functional coordinating and oversight bodies at the central, regional, zonal and Kebele levels. There are 412 (budgeted for 354) rural and 49 urban Health Extension Workers in the zone. And recently the Health Development Army (HDA) is in place with 6,278 HDAs in the zone. 142. TCC was concerned with the following: - Need to use consistent data on population size. In the background section it is indicated that the estimated population is 1.2 million but there is also an indication that the total population is 1.3 million people. Page 28 q_p - The team proposes to undertake a KAP survey towards the development of health information materials. The key question is why not adapting the materials being currently used by the neighbouring zones which will expedite the start-up of the project. Adaptation would require reviewing and updating the existing materials rather than starting from scratch. - The outline of the implementation of the activities indicates that the team will require 42 weeks to undertake the preliminary activities. This implies that treatment will only be initiated towards the end of 2016. However the table on timeframe shows that this will be done during the l't quarter of the year. - tn the text, a KAP survey is planned to inform the design of health information materials but in the timeframe does not include the same. - The narrative states that: the most appropriate timeline to conduct Mectizan distribution and carrying other program activities including supervision is during the months of November for the first round and May for the second round of MDA, but the timeframe does not include twice yearly treatment. - The budget calculations have errors with a difference of about USD 150,000 for year one. - There is a need to rationalize the budget and provide justifications that are more informative. - The project team is silent on the fact of basket funding and how it plans to work within this context. 143. TCC recommends more interaction between the zones around Awi to mentor the new project implementers in order to learn from each other and accelerate the implementation. Sharing of health information materials witl facilitate earlier implementation of the treatment activities as opposed to the proposed preparatory period of 42 weeks. The committee also made the following specific recommendations: Security is identified as one of the key risks for the project but the proposal does not provide any mitigation measures. It is critical for the team to outline the measures to be put in place to ensure timely implementation of the project activities. Ensure that the timing of drug distribution is undertaken during periods when the people are available in their communities (in the minimum ensure consistency between the background information and the timeframe). The team needs to show clearly when the nvice-yearly treatment will be done and reflect this in the timeframe. The budget needs to be revised and rationalized appropriately. 144. TCC recommended the approval of the proposal with the understanding that the above obsemations and recommendations would befully addressed. 14.1.1.2 l)awuro Zone CDTI Project Proposal 145. A summary of the review of the project proposal submitted to APOC management was presented as follows: 146. Dawuro zone is divided into 6 woredas (districts) and l7? Kebeles (villages). The projected population of the zone in 2014 is 619,359,87o/o of whom live in rural areas. The health service structure is organized and well distributed with a structured community based health system - Zonal health office, Woreda health office, one general hospital located in the zonal town, 23 health cenhes, 177 health posts, 2,133 health development armies consisting of 20-30 households organized in I to 5 networks. 147. REMO undertaken in2012 and earlier established that the area is meso-endemic with a total population of 519,354 in meso-endemic areas and 199,019 in hypo-endemic areas. Mf prevalence survey was not carried out. Page29 148. LF endemicity undertaken established one district (Essera) 80,317 population is LF endemic with ICT results revealing LF prevalence of l%o (2 cases detected in 2 villages/200 people examined). 149. There is a strong leadership structures which is a favourable condition for CDTI establishment, e.g. zonal, district and village adminishative councils; Village Administrator, a paid civil servant responsible for facilitating social mobilization at community level. The health development army has strengthened leadership and implementation capacity of health extension programmes at community level. CDD's selection should align with this community structure. 150. There are a number of opportunities the project present for CDTI such as (i) experience of implementing CDTI in the region and in the country; (ii) willingness of one of the NGDO partners (The Carter Centre) to expand its support to the zone; (iii) Strong partnership already exist with international as well as with local partners including communities; (iv) The health development army and the I to 5 network concept offers opportunity for community mobilization and promotion of women participation; (v) The recently launched MoH NTD programme offers opportunity to integrate with other NTD PC diseases; (vi) the zone does not share an international boundary. l5l. The budget of year one which is $433,684 with $263,735 for APOC seems to be very high and needs to be revised. 152. TCC recommends the following: - Revise proposal after receiving comments from Ethiopia MOH; - Update proposal to include LF - endemicity and elimination strateg]; - Further budget review to align with resources available; - Confirm the financial commitment of The Carter Centre (currently working on own proposal). 153. TCC recommended the approval of the proposal subject to budget review by APOC management. 14.1.1.3 Konta Zone CDTI Project Proposal 154. A summary of the review of the project proposal submitted to APOC management was presented as follows: 155. Konta is previously (Ela) one of 4 special Woredas in SNNP& and not part of any zone per se. The projected population is l12, 068 with over 90% living in rural areas. Communities are living in scattered settlements, and some are inaccessible. The REMO undertaken in 2012 established that the entire woreda (46 villages /Kebeles) are mesoendemic for Onchocerciasis. 156. The health and leadership structures are similar to that of Duwaro zone There are however some foreseen challenges such as weak community compliance at the initial stages due to misconception and misinformation regarding the use of ivermectin, poor accessibility of some villages/Kebeles by road which will have implications for achieving optimal coverage required for elimination. The project is relying on three main sources of funding (MOHS, NGDOs and APOC). Delays in the release of funds by any paftner will have implications on the quality and timeliness of implementation. 157. The total budget for 2015-2019 is 405,08IUS$. The project should redo the year 4 budget which is not clear. 158. TCC recommended the approval of the project to be funded from APOC Trust Fund, after reviewing the comprehensive cost.@ Page 30 I4.2 ANI\IUAL TECHNICAL REPORTS I4,2.I AI\IGOLA 14.2,1.1 Kwanza Norte CDTI Project 2od year annual technical report 159. This seems to be a pretty good start for the frrst year. The condition of two-year old vehicle and lack of integration are some of concerns for long term success of the project. Recommended solutions to step up coverage rates: - Enhance competence in preparation of timely orders of Mectizan@; - Timely submission of financial reports (copies by e-mail and originals by post); - APOC to provide project funds on time using a safe mechanism (through WHO); - Start treatment in dry season, May - August each year; - Make available a vehicle onsite: Preferably a Land Cruiser 4X4 to best match the ground conditions of Kwanza-Norte province; - Expand the geographic coverage in 2013 and beyond. Ensure communities in Banga municipal ity receive treatment; - lncrease the involvement of health facility staff in CDTI. ,1 t, 160. TCC accepted the repoa and commended the projectfor the good performance. 14.2.1.2 Moxico CDTI Project 5t year annual technical report 16l. The 2011 campaign scheduled forOctoberdid not happen for late arrival of the medicines though the application was approved on June 27 for the following raisons: Time consuming tax exemption process (almost 4 months); Application of 2.5% of CIF tax on the donation which held the consignment for I month at the port of the entry for lack of payment. 162. The TCC recommends APOC/WR to assist the programme management in: identifoing a smoother way of processing the paperwork for the NTD donated medicines; a high level advocacy in order for the Government to waiver/pay in a timely manner the taxes of any kind on the importation of the donated medicines. 163 I s). The coordination to submit the application a year ahead as recommended by WHO (August tL< 164. TCC accepted the report 14.2.2 COTE D'TVOIRE 14.2.2.1 Cote d'Ivoire CDTI Project (Comoe, Bandama, Sassandra, Cavally and their tributaries) 6th year annual technical report TCC comments ond recommendations 165. As usual, a well written, clear and comprehensive report. ltems dealt with are generally well analysed. The text is well illustrated with several maps and graphics. It is unfortunate, however, that this report dated end of July did not take into consideration in its analyses and way forward the partners' meeting held in Abidjan in early April 2014. This year again, this is another quality report A Page 3 I regarding its form but the results are those of a national programme that has not made progress the last two years after its promising re-launch six years ago. 166. The 2013 activities and results showed failures similar to those of the previous years: 33 districts out of 59 (those treated without intemrption over the preceding 4 or 5 years) were treated; which led to unsatisfactory coverages of 560/o (GC) and 45o/o (TC\ i. The regions at the Ghanaian border located in the North-East of the counbry are not treated as recommended and epidemiological surveys show active transmission foci related to the absence or irregular treatments. 167. The reason for the geographic reduction of treatments is thought to be inadequate credits. However, intemal and external advocacy seems to be a routine and the involvemeng sensitization and participation of the health staff and the populations as well as integration are obviously not optimum. The NOCP-SS should be commended for carrying out annual epidemiological and entomological surveys. The results of the latter surveys are awaited while the extremely useful results of the former survey should be detailed in the same way they were in previous years and more adequately linked to the programme evaluation needs. The intention to relaunch applied research is commendable but it is recommended that projects be defined according to the needs of the programme and that its scientific quality be ensured in consultation between APOC and TCC. TCC Conclusions: 168. It was recommended that the 2014 work plan incorporate the recommendations from the April meeting in Abidjan, particularly at the level of reorganizing operational structures (division into four operational zones for better management), fund raising policy and mostly integration of the elimination of LF and that of Onchocerciasis. 169. TCC accepted the report, and requested APOC managemcnt to do all possible to submit project proposals to TCC taking into conside?ation the dimension of the country, The committee also recommcnded that, in view of the importance of Cote d'Ivoire in LF and Oncho endemiciE, the country needs to be made vkible to donors and NGDOs. An international conference of donors and NGDOs should he organized in this regard. 14.2.3 DEMOCRATIC REPUBLIC OF' CONGO 14.2.3.1 Ituri Sud CDTI Project 2od year annual technical report 170. The report does not clearly lay emphasis on the work done under circumstances not often easy. There are many contradictions in the figures. Some are due to partial treatment of the project; the calculation of coverages in relation to total populations should be respected, even in such circumstances. Key figures are to be reviewed (number of community directed distributors, total population, treatment indicators) and avoid information discrepancies between chapters, texts, and tables in the next reports. TCC recommends that the national coordination carefully review the presentation of figures prior to the transmission of the reports to APOC. l7l. The project implementers should continue efforts to increase the rates of geographic and therapeutic coverages. Recommendations: - Include a map of hydrographic network in the section called, presentation of the project. - Review key frgures: calculation of TC in the summary, the number of CDDs (summary, table 4, and table 5), total population (summary, page 9). 172. This report shows the desire to improve the project performance after a thorough identification of the current weaknesses and the suggestions of well-defined palliative measures according to the CDTI components and the roles expected from the stakeholders. Page32 ,c lk 173. TCC accepted the report. 14.2.4 GT,IINEA BISSAU L4.2.4.1 Guinea Bissau CDTI Project 5fr year annual technical report TCC comments ond ?ecommendations 174. This report is that of a disaster for year 2012. But compared with its initial version, it was significantly improved. [t is now more important to know how the NOCP was able to recover in 2013 from 2012 after an indispensable audit. x? 175. TCC accepted the report in its cunent form, to be filed, and look forward to the fuure?athq than to a past that has been utemely disappointing. 14.2.4.2 Guinea Bissau CDTI Project 66 year annual technical report 176. There has been significant improvement in the programme compared to the situation in 2012. Both the DLMTNT and the APOC/TA are to be commended. The report is complete, carefufly written and well-illustrated; efforts were made for careful analysis, thoroughness and transparency. However, it would be useful to specift co- endemicity situations and clarifo the figures of the results related to each disease or joint results in the tables. Progress in coverage was significant after the 2012 collapse but the entire CDTI is to be upgraded and improvement efforts are to be continued in all domains. l??. Sensitization, education and advocacy actions are to be undertaken urgently. The selection and training of peripheral health workers is another priority. The seasonal treatment calendar should be rehabilitated. Sanitation, financial management, and the management of medicines are a prerequisite. Programme managers should be invited to propose rapidly a series of steps to be taken towards rehabilitation. 178. Facing an apparently incurable lack of government support and also of sound NOCP management, it is indispensable to provide foreign support to the DLMTNT: the announced return of Sightsavers as a donor is indispensable and APOC should maintain technical support in addition to its financial contribution. $ 179. TCC occepted the reporl because it shows willingness to improve. 14.2.5 SOUTH SI'DAN 180. TCC observed that CDTI activities are not effectively implemented in South Sudan because of the current crisis in the area. Communities have been restructured and prerequisite management structure and logistics for successful CDTI implementation do not exist. TCC therefore recommends suspension of review of South Sudan projects until full relaunch of the projects is concluded. fr 14.2.6 TANZAI\IIA 14.2.6.1 NTD/HQ Project46 year annual technical report l8l. The report is a summary of coordination activities carried out in Tanzania by the NTD team. The repon highlighted coordinated NTD activities of the NTD team like annual stakeholders meeting, annual joint NTD planning meeting, epidemiological evaluation, and finalization of the Page 33 master plan, M & E meeting in Harare among others. A workbook that was included in the report reflecting treatment target, populations and achievement was helpful and it is commended. 182. However the TCC 38 recommendations on approving the use of new format, which is to ensure that critical, project indicators that will demonstrate that the HQ is supervising the CDTI projects is lacking. These include reporting on advocacy activities its outline issues and outcomes, monitoring and supervisory visits and its outcome as well as Partner financial contributions details. Recommendations to improve on the report - This report was indicated as the Tavania NTD activities 4n year annual technical report. However it seems that this is the second NTD team report that has been submitted to APOC since TCC agreed to receive the NOTF report in the new NTD reporting format. Kindly clarifr; - Include information on HQ supervisory and monitoring visit and its outcome. Recommendations to improve on the project performance - There is need for closer monitoring of the projects to ensure good coverage, early commencement and reporting; - A project like the Kilosa project and some others needs support to achieve 100% geographic coverage and at leastS2o/o therapeutic coverage; - Some projects have need (capital equipment, capacity building, and reporting) that require follow up with APOC and other partners in a coordinated manner and need to be addressed. xf 83. TCC accepted the report. 14.2.7 UGANDA 14.2.7.1 Phase 5 (Kitgum & Pader) 3'd year annual technical report 184. This is the 3'd year of CDTI implementation with APOC support, for phase 5 districts in Uganda. The project is implemented in 1,155 communities with a total population of 428,003 people. Two treatment rounds were carried out in 2013, Therapeutic coverage werc 59%o and 66%o, respectively. The geographical coverage during both treatment rounds were 100%. First round coverage figures were consistent for 2012 and 2013 (58% versus 59oA), but improved for the 2nd round treatment. 185. Overall, this project is making steady progress, although coverage rates are below 80% threshold since the project inception. Suggestions for improving project implementation: - Take advantage of the availability of community supervisors to improve on coverage. All I155 communities have community members as supervisors. Empower community supervisors further to support CDD; - Improve on community compliance; - Address the reported reasons for low coverage (untimely delivery of drugs, weak sensitization at all levels, weaknesses with CDD training, limited involvement of politicians in the sensitization process); - Explain the reason for high Trainer CDD ratio - Number of trainers to CDD is roughly I trainer to 2 CDD. The ratio is extremely high. Explain the rationale; - Undertake comparative analysis to demonstrate value of CSM - 190 (16%) of ll55 communities carried out community self-monitoring (CSM). It will be of interest to compare coverage achieved by these communities against other communities which did not implement CSM. Page 34 )\'ru' TCC accepted the report. 14.3 ONLINE REVIEWS 187. Regarding online reviews, TCC decided that if there is no critical issue to be brought to the aftention of members at plenary, once the two reviewers accept the report, there is no need to review it again at plenary. 14.3.1 CHAn l43.f .l Chad CDTI Projectl4* year annual technical report 188. This is a l3-year project that covers 7 districts and3,250 villages. The report is well written and largely reflects the quality of the work done in the field by all the players in order to achieve integration and control of NTDs. Because of an epidemiological evaluation taking place, treatment was not implemented in all districts. That is the reason why therapeutic coverage (73o/o\ and geographic coverage (94%) have declined, as indicated in table 9. The project strongly mobilizes national stafi NGDOs, religious communities and beneficiary communities. The permanent presence of APOC technical advisor is recognized as a key force. 189. Beyond the figures, the following should be highlighted: - Advocacy at several levels: political (mayors, MPs, governors...), confessional authorities (pastors, imams, priests), traditional authorities and opinion leaders. A certificate dubbed CDTI "Community Relays" is given to each participant. Several communication channels are also used: radios, public meetings, town criers, artists. The Management of APOC (namely APOC Director) was also on advocacy mission to this country. - No Community Directed Distributor (CDD) attrition. CDDs are receiving support by communities (farming, gifu in kind). I1,497 CDDs (among which 34olo women) were mobilized in 2013. The ratio is ICDD/140 people. - Training provided to players as part of capacity building (health workers, administrative and politicalauthorities, CDDs, community leaders...) on several topics. - Technical training sessions on epidemiological and entomological evaluations (46 health workers and24 village fly catchers). - The results of the 2009,2012 and 2013 epidemiological evaluations in 64 villages are satisfactory. As part of entomological evaluations: 3 catching points in the Nyan river basin -Bebedja Health District) with 15,000 flies sent to APOC (samples dissected on the spot were negative). - Activities regarding integrated mapping of loiasis: suruey in 23 villages (samplings were sent to Yaound6/Cameroun). 190. As far as integration is concerned, the (CDT[) structure has been used for a long time by other programmes (malaria, Schisto, soil transmitted helminthiases, sanitation...). CDTI activities are included in the plans of health regional delegations. It is worth noting the efforts of the financial contribution made by the government of Chad. These efforts are part of the phasing out plan of APOC. l9l. The unique weakness noted is the discrepancy between some of the figures compared to 2010. 2010 report < Among the 7 delegations involved, there were 19 health districts, 246 Responsibility Zones or health areas that cover 3,250 villages. The total population living in the project area is 1,905,121 people according to the general population census carried out in 2009 and also according to census taken by community directed distributors". 2013 report < [n the 7 delegations involved, there are 20 health districts, 393 Responsibility Zones or health areas that cover 3,250 villages. The total population living in the project area is 2,377,178 people according Page 35 to the general population census carried out in 2009 and also according to census taken by commun ity directed distributors". 192. TCC commends the national team for the work done. It encourages the authorities in Chad to maintain and strengthen the country financial contribution. TCC also welcomes the support provided by the technical advisor and the Management of APOC. Recommendations to national coordination of the project: - Review the discrepancy existing between figures contained in the 2010 and 2013 reports; - Review the population figures (2,377,178 in the summary and 2,211,354 in section l.l). - Review the figures of the ATO (NOTF): 1,901,738 (summary); ATO (NOCP): 1,769,083 (section l. I ); - Paginate the document; - lnclude a geographic map of the country that indicates the CDTI area location. 1 93. TCC occepted the report. 14.3.2 CONGO 14.3.2.1 Congo CDTI 13th year annual technical report 194. The report covers the period from January to December 2013. It is well written; the executive summary is concise and comprehensible and the data are consistent with those of the report. 195. The previous report submitted to TCC36 was accepted with recommendations and suggestions to be taken care by the team. The most important recommendations and suggestions were efforts to increase the number of health workers involved in CDTI activities in the health zone and train a greater number of CDDs to reduce their workload. According to the coordination, these recommendations are facing funding problems, the retirement of health workers and the lack of incentives for CDDs. The government made an effort by granting a 25%o increase of the NOCP budget but the mobilization rate is less than 75%. 196. This a l3th year project that covers a population of 880,606 people, 748 communities (133 in hyper endemic zone, 615 in meso-endemic zone) and 5 departments all located in the southern part of the country. [n 2013, the geographic coverage was 100%. The UTG was to treat739,728 people. 705,479 were treated, i.e., a rate of therapeutic coverage of 80.1%. 197. The project is facing an inadequate number of human resources. [n total, 631 CDDs were newly trained and 1,248 were retrained; i.e., a total of 1,879 CDDS trained among which 582 female (31% CDDs) distributed in 382 communities (51% communities).Women's participation decreased from 843 female CDDs in2012 to 582 in 2013. 198. The ratio CDD/population treated is still very high: 1CDD|376 people treated (l CDD|672 people treated in urban setting and I CDD/213 people in rural setting). The CDD attrition rate has also increased from 10.3% in20l2 to 32.3%o in 2013. The refusal (2%) and absenteeism (3%) rates are still high, particularly in urban setting of Brazzaville (Makel6k6l6 and Mfilou). The involvement of the sous-pr6fets and some local NGDO in community mobilization is significant. 199. A national integrated NTD control plan was adopted and the Oncho-LF joint control in co- endemicity zones already under CDTI has started. Page 36 9' @Q) rot. TCC accepred the report. 2OO. TCC, once again, expresses concerns regarding the sustainability of this project due to the low level of disbursement of the budget allocated by the govemment (less than 75%). Current activities depend essentially on APOC and OPC financial support. Bes@s: - Continue efforts to reduce the CDD attrition rate; - Continue efforts to conduct CSM and SHM to solve concrete problems; - Analyse the reason for low therapeutic coverages in the 7 districts that have coverages between 66%o and79o/o; - Continue efforts to improve women's involvement in CDTI; - Finalize operational research to use their results. 201. TCC accepted the report. 14.3.2.2 Congo Extension CDTI Project 10tr year annual technical report 202. A well written repor! pleasant to read. Appropriate responses were provided to the different recommendations of TCC. The executive summary is clear and full with information. This project covers a population of 5,977 inhabitants distributed into 22 communities (13 meso-endemic and 9 hyper endemic). Key partners are MoPH, MDP, WHO/APOC and OPC (NGDO). 203. In 2013,43 CDDs were mobilized for the treatment of 4,977 persons, i.e., lCDD/ll6 persons. The geographic coverage is 100% and the therapeutic coverage is 83.3% (in progress compared to 2012). [t is worth noting the existence of co-endemicity Onchocerciasis-loiasis in this project; however, no SAE case was reported. Advocacy conducted at departmental level fosters the involvement of decision-makers. SHM sessions were conducted inthe22 communities. 204. Regarding integration as part of NTD control, a national plan was adopted in May 2013; the CDTI structure is therefore used by other programmes. Within this cope, a joint Oncho-loiasis activity started in the 2l communities where the two diseases co-exist. [n short, the performance of this project is quite enjoyable. TCC commends the national team for the quality of the report and the technical work done. 14.3.3 DEMOCRATIC REPTJBLIC OF CONGO 14.3.3.1 Bandundu CDTI Project 1l'h year annual technical report. 206. The report covers the period from January to December 2013. This report is fairly well written but has key information for the evaluation of the project performance. The executive summary is concise and comprehensible but did not include important data related to human resources, namely, the CDDs. 20?. The previous repoft submitted to TTC37 was accepted with some recommendations and suggestions to improve the following reports and the performance of the project. The key ones were related to women's participation in CDTI activities, CDDs training sessions for the reduction of their workload, sensitization in order to reduce the number of communities where the therapeutic coverage is < 80% and the increase of the government financial contribution. Some of these recommendations are being implemented but with very timid results. 208. This is a project in its I lth year implementation activities and 9 years of Mectizan distribution. [t covers a population of 1,513,004 inhabitants, distributed into 3,606 communities. The rate of geographic coverage was 100% and that of therapeutic coverage was 79%o. 33Yo Page 37 ,/) U villages had a therapeutic coverage rate less than 80%. The refusal (0.5%) and absenteeism (0.8%) rates are not significant. 209. tn 2013, 1,398 CDDs were trained or retrained. The CDD/population ratio is lCDDl278 inhabitants;36.4% CDDs are female and only 2.7o/ocommunities have female CDDs. The 2,E41 health staff members working in the zone are involved in CDTI activities. CSM and SHM were conducted in 203 communities (5.6%). The CDD attrition rate is considered high but the figures are not included for its justification. No integration or operational activity was conducted. 210. TCC expresses concerns relating to the sustainability of the project achievements, considering the inadequacy of the therapeutic coverage, the lack of financial support from the government and the lack of initiative regarding co-implementation and the integration of CDTI activities. ztt. TCC recommends that the team make some efforts to: - lmprove women's participation in CDTI, - Improve CDD/Population ratios, - lmprove the rates of disbursement of the government budget, - Intensifu the process of CSM and sustainability, - Multiply the initiatives for co-implementation and CDTI integration in PHC, - Sensitize the populations to provide incentives to CDDs. 212. TCC accepted the report. 14.9.3.2 Bas Congo CDTI Project 9th year annual technical report 213. A 9s year project with globally, a well written report. 3,061 communities grouping together almost I million inhabitans. 33.6% (52111,548) health workers are involved in CDTI. In 2013, 5,859 CDDs treated 682,142 persons. The geographic coverage is 89% and the therapeutic coverage of 69Yo. These values are decreasing compared to those reported the last 2 yearc. Data on sustainability are inadequate. 214. It should be recalled that this project covers 2 provinces: the Bas Congo and Kinshasa (i.e., a part of the Kinshasa Megalopolis). During previous discussions on DRC, it was strongly recommended to separate the two zones, inasmuch as from a chronological point of view, the gap between some communities was up to 3 years. In fact, out of the 15 health zones, only 3 are at the 9n round (5 are the 8s round, 6 at the 7n round and I at the 6s round). In addition, some specific groups are not taken into account, or their treatment at least does not occur as such; they are vegetable growers and stone "breakers" (for construction work) namely in the Kinshasa zone; members from these two groups come from different suburbs of Kinshasa and are permanently exposed to the biting of the flies at the banks of the river. 215. No operational research was conducted despite the promises and commitments made during the 20 12 advocacy meeting. Recommendation to the national team: - Describe better the mechanisms of CDTI integration in the national system; - Make explicit how the groups of vegetable growers and stone breakers are heated; - Initiate and relaunch an effective collaboration with the Brazz,aville team, taking into account the specificity of this project (extension to urban area on the 2 banks of the Congo River); - lnitiate evaluation or entomological surveillance activities. 16. TCC accepted the repon. Page 38 @' 14.3.3.3 Equateur Kiri CDTI Project 9n year annual technical report 217. Effons made to maintain geographic and therapeutic coverages at an appropriate level since 2009 in the project area are recognized and we encourage the coordination to maintain this performance level. 218. However, a special attention should be paid to the following points: i) Improve the quality of the drafting of the report by: - being consistent in the use of thousand delimiters (comma if it is in English and period if it is in French) for figures. All the figures in tables l3a-13c, table 0, table 2 are to be harmonized; - Checking the accuracy of the calculations: some calculations of tables 4 and 10 corrected of the 2012 report are stillerroneous as well as some calculations in tables 0 and I of the 2013 report. This should be corrected; - Adding a map to the section called <geographical location> for easy visualization; - The summary is concise. But it is good to specifr in it the implementation year, the key funding source, the occurrence or not of adverse effects, given the fact that loiasis is co- endemic; - Specifu the reasons for advocacy and its outcomes. $? Ue. TCC accepredrhe report 14.3.3.4 Kasai CDTI Project l3th year annual technical report 220. The report covers the period going from January to December 2013 221. It is fairly better written compared to the previous one and has key information for the project performance evaluation. The executive summary is concise and comprehensible and data are more consistent that those contained in the previous report. 222. TCC37 after consideration of the report had made some recommendations among which the most significant were: report on loiasis and the map of the hydrographic network, explain the procedures of management of the important stock of Mectizan left, and initiate cross border meetings with Angola. Apart from the last recommendation, all others were taken into consideration. 223. This is a project in is 136 year of activity implementation but 3l%o of the health zones went through 7 rounds of treatment and 69%o implemented benveen 8 and 13 rounds of treatment. The project cover a population of 10,714,454 inhabitants distributed between 9,91I meso and hyper endemic villages. This is the biggest and largest project in the country. It overlaps two provinces in 68 health areas. The rate of geographic coverage was 100% and that of the therapeutic coverage was 80%. 6,171 villages, i.e., 62Yo,had a therapeutic coverage more than 807o. 224. In 2013, 21,403 CDDs were trained/retrained, i.e., 55.4% of ATO achieved. The CDD/Population ratio is CDD/501 inhabitants with77%o of health workers of the area involved in CDTI activities which is encouraging. Only 20% CDDS are female and 34o/o of communities have female CDDS. The refusal (0.1%) and absenteeism (l%) rates are not very high. CSM and SHM were conducted in 21.6% villages. No integration or operational research activity was conducted. 225. TCC recommends to the coordination team to continue efforts to: - lmprove CDD/Population ratios, - lmprove the rate of disbursement of government budget, - Extend the CSM and SHM implementation to all the areas, - Intensiff the initiatives for co -implementation and integration of CDTI in PHC, Page 39 \x hq Sensitize populations to contribute to CDDs incentives, lnitiate a cross border meeting with Angola. 226. TCC accepted the report. 14.3.3.5 Butembo-Beni CDTI Project 7'h year annual technical report 227. The report covers the period from January to December 2013. This report is fairly well written and has key information for the evaluation of the project performance. The executive summary is concise and comprehensible and data are consistent with those included in the report. 228. The previous report submitted to TCC 36 was accepted with recommendations made to the team to make efforts in order to improve the CDD/population ratio, the financial contribution and the disbursement of the government budget; reinforce the process of CSM and sustainability; initiate co- implementation activities and the integration of CDTI activities in PHC as well as operational research proposals. Most of these recommendations have not been implemented. 229. This project is in its 7h year implementation with 6 years of ivermectin distribution. tt covers a population of 1,265,159 people reported in 2013, distributed into 1,613 villages/neighbourhoods. [n 2013, the rate of geographic coverage was93o/o versus 95.5%in2012 and the therapeutic coverage of 74.8o/o versus 73.1% in 2012. 29.6% villages only have a rate of therapeutic coverage higher or equal to 80%. 230. According to the team, insecurity was at its worst in the northern part of the project in 2013. This could be the reason for the low coverage rates and difficulties faced in getting reliable population data. 231. In 2013, 3.470 CDDS, out of which 2.047 were male and 1.423 female, were trained or retrained. However, the CDD/population ratio is still far away from the standard, ICDD/369 people; 4l% CDDs are female. The CDD arnition rate is very high; 4lo/o active CDDs in 2013 were newly recruited. The refusal (3o/o) and absenteeism (5%) rates are also very high. 30 villages only conducted CSM; no SHM was initiated. No integration or operational research activity was conducted. 232. TCC expresses concerns regarding the project performance improvement, particularly in the insecurity zone, taking into consideration the lack of government funding. 233. TCC recommends that efforts be continued to: - Improve the CDD/population ratio, - Improve the government financial contribution and budget disbursement, - Reinforce the process of CSM and sustainability, - Initiate co-implementation activities and the integration of CDTI activities in PHC, - Initiate proposals of operationalresearch. 234. TCC accepted the report. 14.3.3.6 Mongala CDTI Project 9tb year annual technical report 235. The report is faithful, well, clearly and explicitly written, even though explanations were not equally shared from one chapter to another. The problem with this project is that, although CDTI activities were implemented, therapeutic coverages have stayed at75o/o for a couple of years. The increase in staffing, training and health workers' involvement in advocacy, population sensitization, census taking, management, distribution timing, CDD management for keeping village registers and results, and medicine stocking activities should be considered. Page 40 236. The coordinator has accurately identified his programme's weaknesses at all levels and has even made proposals for improving the sectors. These are to be reconsidered in a more coherent format. It is imponant that APOC Management and the existing NGO examine the extent to which a budget increase and an alignment of disbursements over the operational calendars would contribute to improving the situation. What is mostly important for APOC and CBM is to get the government finally make significant financial contributions in the future to this project. 4O 237. TCC accepted the report. 14.3.3.7 Rutsuru-Goma CDTI Project 8th year annual technical report 238. This is a project having diffrculties to maintain high level coverages due to the instable situation that prevented the organization of CDTI in 2013 in one of the three health zones. The difficult situations and the situation of shess in which the health staff work should be recognized and all necessary support should be provided to them to improve coverage in all communities covered by the project. The project coordination supported by its partners should work on the following: i) Programme funding: - While awaiting the setting up of a sustainable funding mechanism, APOC should maintain a minimum level of funding for the project; - The project coordination should request technical support from the national coordination in its advocacy activities for the mobilization of internal resources. ii) lmprove the DC/population ratio: - Recruit and train new CDDs in order to get the ratio back about 100 people treated by I CDDs in the three zones. ( ( n9. TCC accepted the report. 14.3.3.8 Sankuru CDTI Project 10th year annual technical report 240. Since 2009, the programme has maintained good geographic and therapeutic coverages. A key concern, however, is about the precarious level of funding of the project, namely the government and local authorities' contributions. To this end, efforts in current advocacy and CDTI integration activities should be continued. The nationalcoordination should conhibute to replacing obsolete equipment; Make sure that CDTI campaigns are not organized during the rainy season. 241. Congratulations to the team responsible for the drafting of the report which is well written. tlu zqz. TCC accepted rhe reporl 14.3.3.9 Tshuapa CDTI Project 9tr year annual technical report 243. The report is generally well written. The summary included the key data; explanations relating to treatment rounds show a big discrepancy, depending on zones; but these explanations are not included in the body of the report. Responses were provided to TCC recommendations; it is good now to make sure that implementation is carried out. 244. The Tshuapa District covers an area of 132,648 km2 with a population 1,308,009 people distributed in 1,950 communities. There is loiasis-Onchocerciasis co-endemicity but no case of SAE reported. The main partners of this project that began in 2004 are MDP, APOC and CBM (NGDO); the govemment direct financial contribution is still too low. Page 4l 245. 27.5% (77612,814 health staff are involved in CDTI.). 1,098,728 people were eligible for treatment in 2013 among whom 785,643 were treated, i.e., a geographic coverage of 73o/o and a therapeutic coverage of 600/o; these figures are declining compared to 201I and2012.2,l l7 CDDs were mobilized, i.e., ICDD/371 persons; this ratio is still too high. No CSM or SHM was conducted. For the sustainability of this project, it good to: - Continue the efforts in the field in order to raise the levels of geographic and therapeutic coverages; - Continue advocacy towards national authorities to get more significant financial contribution; - Initiate actions for operational research, namely by liaising with universities. - Conduct CSM and SHM exercises. q,l 246. TCC accepted the report. 14.3.3.10Tshopo CDTI Project 10th year annual technical report 247. The report is well wriffen and all the sections well informed. Responses were provided to the different recommendations of TCC. The total population is 1,503,158 inhabitants in 2,629 communities. 51.4o/o (146412847) health workers participate in CDTI. 10, 697 CDDs (of which 1,127 women). Key partners of this project are MoPH, WHO/APOC, MDP, CBM, Belgian cooperation, religious communities. 248. However, different levels of implementation are noted; in facL out of the 19 health zones concerned, 4 are at the 9ft round of treatment, I I at the 8th round, 2 at the 3'd round and 2 at the l " round. In 2013, 1,156,680 persons were treated, i.e., a geographic coverage of 93.7%o and a therapeutic coverage of 76.90/o; these figures are increasing constantly. 3 SAE cases were reported and well documented. To reinforce ownership and sustainability, sessions of CSM and SHM were conducted in 1,344 out of 2,629. As far as integration is concerned, CDTI is used by other programmes. Key challenges are mostly incentives for CDDs and the financial contribution of the government. Recommendation to the national team: - Continue efforts to maintain the quality of the work done; - Continue advocacy at all levels to increase and sustain the financial contribution of other NGDOs and the Government. 44 Zqg. TCC commended the team of this project and accepted the repon. 14.3.3.11Ubangi-Nord CDTI Project 9s year annual technical report 250. The implementation of a CDTI project in Ubangi Nord is particularly difficult and costly due to co-endemicity with loiasis with risks of SAEs occurence. The teams involved in the implementation of the project should be commended for achieving the best coverage rates in 2013 and for maintaining a zero death rate related to SAEs. The report is well written with figures and graphics that help have a good understanding of the results. Maps indicating the levels of coverage by zone are good tools for sensitization in the field. However, the following recommendations should be taken into account by the project coordination: Review the numbering of the tables; Comment of the table on page 29: Explain why there is a difference between the total population at risk in the table (871,558) and the one indicated in the comment (856,489) on page 30; Page 42 t4 I Activity schedule: o Explain why community mobilization and supervision are carried out all the year round. Is that realistic? [n a context of high risk of SAEs, it would be more cost- effective to keep resources to scale up these mobilization and supervision activities around CDTI; o [s it not possible to harmonize the period of CDTI implementation in all Health zones ofthe project area? Community participation. 251. [n this context of community low compliance with CDTI due to high risk of SAEs occurrence, it is important de take steps to: Set up groups of community supervisors; Recruit and train new CDDs in order to reduce the ratio between the number of persons to be ffeated perCDD which should be less than 100 persons, if possible, while paying a particular attention to the Wasolo and Wapinda health zones where the ratio is particutarly high; Increase female participation in the CDTI: Male/Female CDD ratio is still very high (average llItI/lF); Refusals and absenteeism: The rates are mostly high in the project area. A better involvement of the community, as suggested earlier, in addition to the continuing involvement of community leaders, could conhibute to the reduction of this rate. 252. TCC accepted the reporl l4.3,3.l2Ubangi-Sud CDTI Project 9th year technical report 253. The report covers the period from January to December 2013.It is better written compared to the previous one and contains key information for the evaluation of project performance. The executive summary is concise and comprehensible and data are consistent with those of the previous report. 254. The previous report submitted to TCC was accepted with recommendations to improve the performance of the project. It consisted for the team in making efforts to improve women's participation in CDT[, the CDD/Population ratio and the rate of disbursement of the government budget. The team was also to start the CSM and sustainability process and multiply co- implementation and CDTI integration in PHC initiatives. Finally, TCC recommended that the team initiate proposals of operational research and sensitize the populations for providing incentives to CDDs. But most recommendations were not implemented. 255. This is a project in its 8ft year activity implementation with 7 years of ivermectin distribution. [t covers a population of 1,480,912 inhabitants distributed into l0 zones, 1,282 communities or villages. [t is an Oncho and loiasis co-endemicity zone that recorded 8 cases of SAEs in 2013 out of which 4 comas but no death. 256. The rate of geographic coverage was 100% but that of the therapeutic coverage remains stationary at75%o and 603 villages have a therapeutic coverage less than 80%. In 2013,7,031 CDDs were trained/retrained, i.e., SlYo of ATO achieved but the ratio CDD/population has remained stationary at I CDD/278 inhabitants. Only l0% of CDDs are female and 7.7Yo communities have CDDs. The refusal (2.4%) and absenteeism (5.3%) rates are also very high. CDDS attrition rate is also reported as being high, but figures are not included to justifr it. No mention of whether the Independent Participatory Monitoring or sustainability evaluation has been conducted. No integration or operational research activity was conducted. Page 43 257. TCC expresses its concern regarding the performance of the project that has been stationary. The challenges for the team are still to improve the rate of therapeutic coverage, and in the context of co endemicity with loiasis, manage SAEs accurately. 258. TCC recommends for better improvement of the performance that efforts be made to: lmprove women's involvement in CDTI, lmprove the CDDiPopulation ratios, Improve the rate of disbursement of government budget Start the process of CSM and sustainability, Multiply co-implementation and CDTI integration in PHC initiative, Sensitize the population to provide incentives to CDDs. \b, TCC acceprcd.the report. 14.3.3.13 Uele CDTI Project 116 year technical report 259. The report covers the period from January to December 2013.It is well written and has key information for the evaluation of project performance. The executive summary is concise and comprehensible and data are consistent with those included in the report. 260. The previous report submitted to TCC37 was accepted with recommendations in order to reduce the rate of refusals and absenteeism, CDDs workload and increase the financial contribution of the government. Some of the recommendations are being implemented but the insecurity that prevails in the Dungo and Ango zones is considered as a major constraint for the improvement of the geographic and therapeutic coverage rates. 261. This is a project in its llft year implementation that covers a population of 1,92t,483 inhabitants, distributed into 3,606 communities. The rate of geographic coverage was 100% and that of therapeutic coverage was79%o.33o/o villages have a therapeutic coverage less than 80%. The lowest therapeutic coverages are from areas co-endemic for loiasis. Eight SAE cases were reponed with no case of death. 262. The refusal (0.5%) and absenteeism (0.80%) rates are not very high. The CDD/population ratio is one CDD/278 inhabitants; 36.40/o CDDs are female and only 2.1%o communities have female CDDs. 789 health workers working in the zones out of 1,078 (73.2%0) are involved in CDTI activities. CSM and SHM were conducted in 203 communities (5.6%). 263. The CDDs attrition rate is considered high but no figures are included for its justification. No integration or operational research activity was conducted. The lymphatic filariasis mapping was conducted by the NOCPAITDs. Thirteen out of 2l health zones are endemic for LF. TCC expresses its concern regarding safeguarding the achievements of the project, considering the inadequacy of the therapeutic coverage, the lack of financial support from the government and the lack of initiative for co-implementation and the integration of CDTI activities. 264. TCC recommends that the team make some efforts to: - Improve women's participation in CDTI activities, - Improve the CDD/Population ratios, - Improve the disbursement rate of the government budget, - Intensiff the process of CSM and sustainability, - Multiply co-implementation and the integration of CDTI in PHC initiatives, - Sensitize the population to provide incentives to CDDs. Uft 265. TCC acceptedthe report Page 44 q4 18 14.3.4 ETItrOPIA 14.3.4.1 Bench Maji CDTI Project 1l'h year annual technical report TCC comments and conclusions: 266. This project is in its eleventh year of implementation. The report is well written. The project covers a population of 758,634 people in 1354 communities. Thirty percent (30%) of the communities are hyper-endemic for onchocerciasis. There has been a steady increase in coverage rates over the years. Biannual I treatment was done in 2013. In both rounds maximum geographic coverage was achieved, while therapeutic coverage was above the 80% threshold (80.4o/o (Rl) and 82%(R2). Recommendations to improve on the report: - Justiff biannual treatment: Provide an explanation for the shift given the project already had a good coverage record; - Explain the reason for the dramatic drop in the number of health workers involved in CDTI: The proportion of health workers involved in CDTI dropped from 66Yo in 2012 to 39%o in 20 I 3. Provide an explanation for the decrease; - Rationalize the reason for the substantial increase in CDDs: The number of CDDs more than doubled between 2012 and 2013 from 5892 CDDs in 2012 to 9722 ( l't round) and 13758 ( 2nd Round). What was behind the drive to double the number of CDDs? - Account for the fact that all activities for the second round were accomplished in one month: What were the implications for the quality of implementation? - Update table 5: The data on Mectizan inventory suggest results for one round of treatment only; - Clariff the data in Table 1l- The total number of communities in the project area is 1363. In table tl, it is reported that2762 communities implemented community self- monitoring (CSM). Did communities carry out CSM after each round of treatment? Recommendations to improve project implementation: - Address the issues uncovered during supervision visits, especially the updating of village registers. 267. TCC accepted the report. 14.3.4.2 East Wollega CDTI Project 9tr year annual technical report 268. The project is in its 9tr year of implementation. Atthough it was planned to start semi- annual treatment in seven new districts, this was not done reportedly due to lack of funds. However, advocacy and training of health extension workers were conducted as part of preparatory activities to inhoduce CDTI in the new districts. The project is maintaining a good geographic and therapeutic coverage. Advocacy, HSAM, Mectizan ordering and delivery activities are all well planned and implemented. CSM & SHM was however not conducted due to lack of funds. The male: female ratio is 3: I but is reportedly improving. 269. The major constraint is insufficient funding which has led to new health staff not being trained and a number of CDTI activities not being carried out. Funds from APOC are reportedly being received late and the second instalment was not disbursed. Financial contribution by the NGDO (LTfW) partner is not reported; it would appear that this is not adequate and with the project expanding to new districts, additional NGO support may be required. The project, which covers four zones, appears to be large and with the inclusion of new districts, it will even become larger. The sharing of budgets across four zones is a challenge; the project team has proposed spitting the project. Page 45 'q5 P Recommendations: - Semi-annual treatment should commence in the new districts as planned. Constraints, including inadequate and late disbursement of funds, should be addressed; - New health workers in the CDTI area should be trained in CDTI; - CSM and HHM needs to be conducted; - Report on NGO finance contribution and if none, please indicate as zero; - APOC management to advice on the merits or demerits of diving the project as proposed by the country team; - APOC management to consider carrying out cmf prevalence surveys to establish baselines. 270. TCC accepted the repon. 14.3.4.3 Gambella CDTI Project 9th year annual technical report 271. Overall this project is seems to be doing well. The therapeutic coverage over the last 4 years ranged from 8l% to97%o. The reported rate for 2012 is84%. 272. This appears to be a model program with NGDO and government support and full integration into the health care system. The program is meeting or exceeding its treatment goals as a result. 2?3. TCC accepted the report 14.3,4.4 Illubabor CDTI Project l0th year annual technical report 274. The geographic scope of this CDTI project expanded from 12 districts/LGA to 20 districts in 2012. ln 2013, treatment was carried out in phases. The first set of 12 districs received treatment in the first phase and the 8 new "districts" received heatment in the second phase. The project has maintained high and stable coverage rates since 2007 . ln 2013, the project reached all communities in the 20 districts (100% geographic coverage), and achieved therapeutic coverage rates of8l7o and 80% for phase I and phase 2 districts respectively. 275. For 2013 the report was presented as a twice yearly treatment intervention but it seems it was more like a phased treatment that happened July 2013 for the older districts and Aug 2013 to Dec 2013 for the new projects. Suggestions to Improve on the Oualiiv of the Report: - Correct Table 5 - The data on the number of CDDs trained are inaccurate. The totals don't add up at all; - Correct Table 13- The calculation of total funds available in 2012 and 2013 based on the data provided are grossly inaccurate. The funding level for 2013 is 244,253usd and not l56,2I4USD; - Reach consensus with APOC on the use of the terms, "l't and 2nd Treatment rounds" - The project treats two sets of communities at different times in the year, and refers to the phased treatment approach as 1" and 2nd treatment rounds. Typically, the use of l't and 2nd treatment rounds implies that all communities receive treatment twice in one year, which is not the case in this instance. The project might consider using the terms phase I and 2 to describe each phase of treatment rather treatment round I and 2. Suggestions to improve on the Project Performance: - Improve the level of involvement of health staff in CDTI in selected districts. Overall, the level of involvement of health staff in CDTI is reasonable at 50o/o. However the level of involvement of health staff is relatively low for Darimu (38%) and Bure (27%) respectively; Page 46 APOC to work with the project to validate the quality of CSM implemented. The reported coverage for the implementation of CSM is 100% - all 6415 communities implemented CSM and SHM. This is an extraordinary achievement. APOC is encouraged to work with the project to validate the quality of CSM done, so that other projects can benefit from the lessons learned; Separate the new districts report from the older it can be titled ILLBABOR 1 and 2.This is important because it will help highlight performance and how the project is managing to overcome the initial teething problem of new CDTI project. 276. [t is also easier to extend support where necessary and not assume that the existing project can take on all the demands of the new project. (t zll. TCC accepted the report, f43.4.5 Jimma CDTI Project lOm year annual technical report 278. The project is in its 10ft year of implementation. tn 2013, semi-annual treafinent was initiated in nine new endemic districts and this has increased the target population in the project area from 1,383,803 to 2,266,066. Good GCRs and TCRs have been maintained even in the new CDTI districs. Female participation in the project has significantly improved with the M:F ratio being almost at l:1. The CDD: Pop ratio of l:66 achieved exceeds the recommended ratio. All communities conducted CSM and SHMs. Equipment is adequate and in good condition. APOC replaced a vehicle and motorcycles. 279. However, the constraint in Mectizan shipping, which has to do with customs clearance, has remained unresolved. The number of drug refusals (30,975) is fairly significant and is explained by religious misconceptions on Mectizan in the new target communities. Although the number of absentees (38,746) is similarly high, it has not affected the coverage rates. Out of 9.6 million drugs requested, a large number i.e. 1.2 million (12.5o/o) remained after treatment, which is significant. tt is not mentioned if baseline cmf prevalence rates were established in the new districs before initiation of treatment. Recommendations: - Improve on the estimation of drug requirement and ordering to reduce on the numbers remaining after treatment; - Continue to address misconceptions on Mectizan in the new communities through advocacy, community mob ilization and sens itization ; - Partners to meet and work out how to resolve the persistent issue of the constraints to Mectizan shipment; - APOC management to consider cmf prevalence survey if this has not been carried out. ( a ZtO. TCC accepted rhe reporr 14.3.4.6 Kafa CDTI Project 13fr year annual technical report 281. A fairly well written report but not in current format. A number of indicators and ables are missing. The executive summary is also not comprehensive. The project has performed well particularly in community participation, coverage and funding. Twice yearly treatment poses a problem because there are two sets of data for most indicators. There is need to sort out the problem of data presentation in twice yearly treatment. Suggestions for improving the report: - The Executive Summary should be comprehensive; - Harmonizp datafor alt indicators for l" round and}nd round; - Provide missing information in sections 2.2 and2.3; Page 4? Provide information on community response and suggestion for improvement in sensitization and mobilization co-implementation and other programmes using CDI strategy. Suggestions for improving project implementation: - Sustain effective partnership with communities; - Train all CDDs,health workers and project officers on record keeping and data analysis for twice yearly treatment; - Reduce number of absentees and refusals; - Train more health staff and involve them in CDTI. If possible, train all health staff in the region to take care of attrition; - Plan early and properly for Mectizan procurement to avoid late arrival. 282. TCC accepted the report. 14.3.4.7 Shekka CDTI Project 13'h year annual technical report 283. A fairly well written report. The project has performed commendably particularly in achieving good community involvement, training achievement and coverage. There is however a challenge in reporting data for twice yearly treatment. There are two different sets of data for the two rounds of treatment for the same 5 districts for population, community involvement, training and treatment. For instance, is the therapeutic coverage reported average coverage of the same persons (who received treatment twice). Suggestions for improving the report: - The Executive Summary should be written in a proper format excluding tables; - Harmonize treatment figures (ln round and 2nd round) into one for actual treatment for reporting period; - Provide missing information on reason for mobilization, problems encountered, and suggestion for improvement and on use of media/other local systems to disseminate information in sections 2.2 and2.3; - Show timeline of activities for all districts (Table 3) in next report; - Provide information on community response and suggestion for improvement in sensitization and mobilization. S u g gestions for im provin g project imp lementation : - Sustain the good community involvement and support so far achieved; - Select (in consultation with communities) suitable timing for treatment to reduce absentees; - Conduct training on CDTI for all heath workers in the area to take care of knowledge gap which is associated with high health staffturns over; - Improve plan for Mectizan procurement to avoid late arrival. 284. TCC accepted the report. 14.3.4.8 Metekel CDTI Project 9th year annual technical report 285. This project has registered its highest therapeutic coverage rate (82Yo) since its inception in 2004, while maintaining maximum geographic coverage (100%). Performance at the operational level was equally good: The level of engagement of health staff in CDTI was high (70o/o), and all those earmarked to be involved in CDTI activities received the necessary training. Suggestions to Improve on the Quality of the Report: - Shorten the executive summary - The executive summary is too long. Keep the content to one page as per the reporting guidelines; Page 48 Clarifu population data source - Was a census actually done? [f so who organized for the census? Suggestions to improve on the Project Performance - Take steps to minimize CDD attrition - Even though the project performed well, the loss of aboutSs% of CDDs in 2013 is a cause for concern; - Adjust CDTI activity timelines to avoid undertaking treatment during unfavourable periods. Absentees and refusals account for 7Yo of the annual treatment objective (ATO). Many more people could benefit from the treatment and therapeutic coverage increased, if distribution is done during the dry season and outside the farming season. - Plan in advance to address treatment needs for migrant community; - APOC and Carter Centre to support Metekel Project team, address treatment needs for an anticipated influx of labourers (15-20,000), moving in to the project area, to work on an infrastructure development project. TCC accepted the report. 14.3.4.9 North Gondar CDTI Project 116 year annual technical report 286. Although the project team has improved treatment coverage to 82.7%o during the reporting period from 80% in 2012, there are still major gaps in reporting. The team is currently implementing twice yearly treatment in Chilga and Tegede but it is not clear from the report how it computes the annual coverage. Recommendation to improve the report: - Use the current reporting format to report on project activities; - Complete all tables including the TCC recommendation table and follow the format provided by APOC. [n addition, provide information on the number of communities and people in meso and hyper-endemic areas (Table 3 indicates N/A); - Ensure that reporting on treatment coverage for Chilga and Tegede reflect the coverage for each round of treatment. It is not clear when the two drug distribution exercises are conducted. Recommendations to improve programme implementation: - Enhance CSM in the project sites; the current coverage at l5%o is too low. Attention should be paid to Chilga and Tegede where twice-yearly treatment is currently being undertaken; - Address the high number of absentees in Chilga (reported at about 20,000); - Ensure that ordering of the tablets is informed by need. The number of remaining tablets is too high. It is not clear whether the project exhausts tablets in stock before supplying the new stock. Recommendation to APOC: - Follow-up with Carter Centre regarding the results of a monitoring study undertaken in 2012. The team indicates that it is still awaiting the report. 287. TCC occepted the repon. f43.4.10 West Wollega CDTI Project 96 year annual technical report 288. The project is in its 9ft year of implementation. Although it was planned to start semi- annual treatment in seven new districts, this was not done reportedly due to lack of funds. However, advocacy and training of health extension as part of preparatory activities to introduce CDTI in the new districts was conducted. The project has maintained good GCR and TCR. Advocacy, HSAM, Mectizan ordering and delivery activities are all well planned and implemented. Page 49 CSM & SHM was however not conducted due to lack of funds. The M: F ratio is 3:l but is reportedly improving. 289. The major constrain to project implementation is insufficient funding which has led to new health staff not being trained and a number of CDTI activities not being carried out. Funds from APOC are reportedly being received late and the second instalment was not disbursed. Financial contribution by the NGDO (LTfW) partner is not reported; it would appear that this is not adequate and with the project expanding to new districts, additional NGO support may be required. The project, which covers four zones, appears to be large and complex to manage, a situation which may be complicated further with the addition of new districts. The sharing of budgets across four zones is a challenge; the project team has proposed spitting the project. TCC recommendations: - Semi-annual treatment should commence in the new districs as planned. Constraints, including inadequate and late disbursement of funds, should be addressed; - New health workers in the CDTI area should be trained in CDTI; - CSM and SHM should be conducted when funds allow; - The project should report on financial conhibutions by all partners including the NGDO and where there was no contribution, this should be recorded as zero; - APOC management to advice on the proposal to divide the project into two; - APOC management to consider carrying out a cmf prevalence survey in the new districts to establish baselines. 290. TCC accepted the report. 14.3.5 LIBERIA 14.3.5.1 South East CDTI Project 8th year annual technical report 291. The Liberia South East Project report documents activities and results for the eighth year of CDTI implementation. The project is implemented in five counties and targets 997 communities. Although the project did not achieve maximum geographic coverage for 2013 (89%\, therapeutic coverage (82%) was above the 80% threshold. The results suggest that communities which were not reached were relatively smaller communities. Suggestions for improving report: i) Address data gaps and data inconsistencies: - Table 2- insert data for ultimate treatment goal (UTG); - Table 4- The calculation of %o of communities with female CDDs for 4 of the 5 communities is inaccurate. The correct overall % is 52.2% and not?lo/o; - Table 7- The data for total population is exactly the same as for Annual treatment objective. This implies intent to treat even those members of the population who are not eligible for treatment; - Section 4 - lnformation regarding sustainability of CDTI was left blank. ii) Undertake comparative analysis to demonstrate value of CSM - CSM was piloted in 15 communities in River Gee. It would be worthwhile to undertake comparative analysis to show coverage results obtained by CDD versus coverage results obtained by monitors. Suggestions for improving project implementation: i) Take steps to raise the geographic coverage to 100%. The project should work towards undertaking treatment during the dry season; ii) lncrease the level of involvement of frontline health workers in CDTI- The proportion of health workers involved with CDTI is rather low ( I lo/o- 176 of 1655); Page 50 iii) Encourage more joint partnerships to implement CDTI activities - The reported activities undertaken by partners (section 1.1.2) in 2013, were exactly the same activities reported in every annual report since 201 l; iv) APOC Adviser to continue paying close attention to this project to improve on the integrity of the data. 292. TCC accepted the report. 14.3.5.2 North West CDTI Project 126 year annual technical report (Resubmission) 293. This seems to be a well-run program that was meeting its goals. However, it is at the centre of the current Ebola outbreak. This is likely to have a significant impact on the program's activities in the future. 14.3.5.3 South West CDTI Project 8th year annual technical report 294. This report is acceptable although it is notable that the same challenges identified in the initial reports still persis! including incomplete tables and conflicting figures. It is important for the project team to pay attention to the project and the reports in order to be reflective ofthe situation in the project sites. Recommendation to improve the report: - Calculate the UTG to reflect the right treatment coverage figures, - Correct Tables 4, 5 and 7 to reflect the correct figures, - Ensure all sections of the report are completed. Recommendations to improve proEamme implementation: - Ensure all communities are reached and for communities not reaching 100% geographic coverage, there is a need to assess and address the causes before the next round of treatment. Pay specific attention to Grand Bassa, which has the lowest treatment coverage; - lncrease the proportion of health staff involved in CDTI from the current l5oZ; - Intensiff efforts towards undertaking CSM and SHM; - Although the 2012 report indicated that the project was planning to conduct a geographical coverage survey and GPS mapping in 2013 to validate the coverage reported and target communities, there is no evidence that this was done. [t is important for the project team to share the status of this study with the TCC. Recommendations to APOC: - There is need to confirm the status of the equipment in the Project site. There is a huge discrepancy between the2012 repoft and the current report. 295. TCC accepted the report. 14.3.6 SIERRA LEONE f43.6.1 Sierra f,eone CDTI Project 86 year annual technical report 296. The project is in the 8th year of CDTI implementation and in the 6h year of integrated NTD activities. Its target population of 3,298,502 is almost a half of the population of the country. Since April 2013, the country has adopted an integrated NTD control approach based on a broad partnership that brings donors supporting the NTD programme together. The report is comprehensive with great attention to detail and shows good progress for most CDTI indicators: GCR of 100% and TCR of over 80oZ has been achieved consecutively for the past three years; HSAM activities increased community participation with CSM groups formed; all ATOs were Page 5 I achieved; CSM and SHM was carried out in 2 of the 12 districts; good drug ordering and utilization is demonstrated and integration into PHC is being achieved. A few areas to watch include: the high M:F CDD ratio of 6:l; not to record minor adverse effects as SAEs and to discuss with APOC management the decision not to treat in urban areas. 29?. The programme has definitely pulled up and its management should be congratulated. Recommendations - Target females in selecting CDDs to improve on the M:F CDD ratio; - Report only SAEs in Table 7 as required and do not include people minor adverse effects (the figure of 420 reported as SAEs would be alarming); - Discuss further with APOC management/Tcc on the decision not to treat the population in urban areas. 298. TCC accepted the report. 14.3.7 TANZAI\IIA 14.3.7.1 Kilosa CDTI Project 1lth year annual technical report 2gg. The report which is an I ls year project report of 2013 activities was a copy and paste version of Year 2012 report with very minimal changes in the figures. In the reporting period, Kilosa CDTI now comprises of two districts after the government divided Kilosa district into two districs namely Kilosa and Gairo. The Gairo district has only one zone, namely Gairo zone while the Kilosa district remained with four zones. 300. In the 2012 report the project highlighted about 8 challenges and none was resolved in 2013. Rather,2 additional ones were included which were non-compliance in town centres and difficulties with treatment data retrieval in some areas especially the new Gairo district. Recommendations on the repoft: - Ensure that the repoft is endorsed; - Address TCC 37 concerns; - Explain why project have not carried out health workers training since the past 2 years. If training was carried out in an integrated manner, the number trained should be reflected in table 5. Recommendations for the project: - Achieve and sustain 100% geographic coverage and 84% therapeutic coverage; - There is the need for close supervision and monitoring of ivermectin distribution and ensure that ivermectin distribution is effective; - Ensure that ivermectin fieatment commences early enough in the year to avoid treatment spill over into another year. Recommendation for APOC management: - Clarifr whether Year 5 sustainability plan was conducted and whether the report has been shared with the project team; - APOC to consider replacing some of the capital equipment that has been written off. 301. TCC accepted the report. 14.3.7.2 Morogoro CDTI Project 9th year annual technical report 302. The project is in the 9th year of implementation and in the 6th year of integrated NTD activities in the two project districts. The project achieved a GCR of 100% and a TCR of 77%. Page 52 The trend shows that TCRs have been between 75%-80% for most of the project duration; advocacy activities targeted new district leadership with an important outcome of CDTI being included in the Comprehensive Council Health Plans; male:female CDD ratio is at I to I with good pamicipation of females and a low CDD amrition rate; all ATOs are well achieved; CSM and SHM was conducted in half of the communities; good Mectizan inventory control and integration of CDTI activities into PHC. However, a number of equipment including the vehicle, motorcycles and offrce equipment are non-functional but the project has requested replacement from APOC management. 303. [n November 2013, epidemiological evaluation was carried out by APOC which showdd an mf prevalence rate of 5%o and a nodule prevalence rate of 0.8% showing significant progress towards achieving intemrption of transmission has been made. TCC recommendations: - To increase community mobilization to improve on TCR to the recommended coverage rate of at least; - To address gaps in equipment availability with APOC management and/or NGDO partners; - To conduct epidemiological re-evaluation after three years to further determine if intemrption of transmission has been achieved. 304. TCC accepted the report. 14.3.7.3 Ruvuma CDTI Project l2th year annual technical report (res-submission) 305. The project team has responded to most of the issues raised in the 2012 report It has addressed the inconsistencies between the summary and the main report. [n addition, there is a better sense of what the project achieved during the reporting period. Recommendations on the report: - Correct information in Table 4; - Report on reasons for and outcomes of advocacy and monitoring and evaluation activities as required. Recommendations on the project: - Pay attention to Ludewa, which has low coverage, a high number of absentees, and poor reporting; - The programme team should bring a closure on the lost laptop issue. 306. TCC accepted the report. 14.3.7.4 Ruvuma CDTI Project l4'h year annual technical report 307. This is an acceptable report although the performance of Ludewa continues to be a cause of concern especially in a context where the project should be working towards elimination. Recommendations on the report: - Correct information in Table 2; - Report on reasons for and outcomes of advocacy and monitoring and evaluation activities. Recommendations on the project: - Pay attention to Ludewa, which has low coverage, a high number of absentees, and poor reporting. The treatment duration in the site also too long (October - December). The project team should explore and address the factors influencing the poor performance in this area; - The project team should bring a closure on the lost laptop issue; Page 53 The number of tablets reported as to have been in stock in 2013 was less than that reported as remainingin2012 (402,168 - 543,968) - it is important for the team to pay aftention to the tablets and how they are managed. Recommendations for APOC: - Follow-up with the project team to understand how the evaluation results are being used to strengthen the project implementation. 308. TCC accepted the report. 14.3.7.3 Tunduru CDTI Project 9s year annual technical report 309. Project has performed well particularly in training, treatment coverage, community participation, supervision. There is need for improvement in implementation of recommendations from monitoring and evaluation as well as advocacy for increased funding by government. Suggestions for improving the Report: - Provide missing information on the use of media for sensitization and expenditure per treatment. Suggestions for improving Project Implementation: - Map out strategies for reducing absentees; - Replace/repair non-functional equipment; - Conduct CSM and SHM; - Select (in consultation with communities) more CDDs; - Commend communities for providing effective non-monetary incentives for CDDs; - Implement suggestions (made by project in section 2.3) for improvement of mobilization and sensitization of target communities; - Sustainco-implementation. 310. TCC acceptedthe reporl 14.4 TECHNICAL REVIEW COMI{ITTEES REPORTS: Agenda item 15 t4.4.1 CAMEROON 3 I l. Dr Biholong, National Coordinator of the NOCP/Cameroon presented the report of the I l'h session of the Technical Review Committee (TRC), on behalf of the Chair of the TRC/Cameroon. A total of three technical reports from the Centre CDTI Projects (Centre I, II and III) were reviewed. TRC observed that the CSM was planned in the Centre II and III projects and that the supervision of Mectizan and Albendazole distribution activities in the Centre II project were canied out in cascade from the regional to the peripheral level. 312. TRC noted that all the previous recommendations of the TRC concerning the three projects were fully addressed by the three CDTI projects and that all the three reports were acceptable. However, TRC recommended the following for the Centre III project: Strengthen the community participation (community supervisor, motivation of CDDs) Implement CSM; Reduce the number of refusals; Find ways for alternative motivation of CDDs by the communities. 313. TRC/Cameroon accepted the three reports of Centre I, II and III. Page 54 314. TCC thanked Dr Biholong for the presentation and commended TRC/Cameroon for the efle c t iv e p e rfo t mt n c e. 14.4.2 MALAWI 315. Dr Damson Kathyola, Chairperson of the Technical Review Committee (TRC) of Malawi, presented the report of the second meeting of the TRC/Malawi which took place in Liwonde, from 5-9 May, 2014, to review 2013 annual technical reports for the Thyolo/Mwanza and Extension CDTI Projects as well as Operational Research Proposals. 316. The TRC observed that both CDTI projects were performing well. TRC therefore accepted the two reports with the following recommendations: Train more Health Surveillance Assistants; Upscale Community SelGMonitoring; Select and train more CDDs to reduce workload; Intensiff sensitization in communities including more involvement and engagement of local leaders to reduce absentees and refusals; Continue to monitor the status of implementation of the recommendations of the study on "Factors contributing to increased absenteeism and refusals during Mectizan distribution in Malawi" by NOTF; Efforts should be made to organize a planning meeting on the study of prevalence of Onchocerciasis in Mozambique. 317. With regards to the operational research, two proposals were reviewed by the TRC which judged that they were poorly written and recommended that they should be rewritten before submission to APOC. 318. TRC also received report from the NOCP Coordinator on the entomological assessment being conducted, following positive results of the epidemiological evaluations conducted in 20ll and2012. The resuls of the assessment are awaited from APOC laboratory in Ouagadougou where the flies are being analysed for infections with the parasites. 319. The TRC/Malawi made the following final recommendations to the NOCP and the Minis0ry of Health as wellto APOC: For the Ministry and NOCP: - To enhance the confidence and understanding of CDTI activities of TRC Members, the members are proposing for a one day field visit to some sites to be undertaken before TRC Meeting days; - Noting that the Deputy Coordinator has not been appointed, the committee recommended that the Director of Preventive Health Services (DPHS) should appoint a Deputy Coordinator to strengthen national level capacity; - The project should develop a communication strategy to ensure that all stakeholders are reached with the messages and emerging issues are taken care of in the course of the project. For APOC: - In order to further reduce workload of TCC and APOC Management, TRC Malawi is offering itself to be reviewing reports from other countries without TRC; - [n order to improve quality of research proposals, APOC is requested to fund research proposal development training for technical staff in CDTI Districts. Technical capacity is available at counfiy level. Page 55 320. The third meeting of the TRC will be held in Blantyre in April/May,2015. The committee agreed that it will be targeting for September TCC meetings when holding its meetings. 321. TCC thanked Dr Kuhyola for the presentation and commended lhe TRC Malowi for organizing a successful TRC session. 14.4.3 NIGERIA 322. Professor Eka Braide, Chairman of Technical Review Committee (TRC), Nigeri4 presented the report of l3n meeting of the Committee. A total of l8 technical reports were reviewed. Updates on advocacy and monitoring activities conducted by NOCP and the Zones were received. Extent of implementation of recommendations from TRC 12 was appraised. TRC observed that most of the projects performed satisfactorily in HSAM, coverage and integration but poorly in training, monitoring, supervision and resource mobilization. In addition to project specific recommendations which will be communicated to project offrcials, TRC recommended that: APOC should provide support to projects for scale up of CSM and SHM; NOCP should facilitate joint planning of CDTI activities in Edo/Ondo border areas to improve project implementation, assist Benue in addressing challenges currently being faced, commend Yobe State Government for consistently providing financial support for programme implementation and ensure that all missing technical reports are submitted for review at TRC 14; NGDOs should identif,/ assist in bridging funding gaps in implementation of CDTI by the projects they support, ensure that funds for project activities are well utilized/accounted for timely; Projects should update census before every round of distribution, strategize to complete treatment within a short period of time as possible, intensiff advocacy to LGAs for provision of incentives for CDDs and plan strategically for programme implementation in the States with security challenges. 323. Prof Braide reported that TRC has commenced a comprehensive profile/performance audit of all CDTI projects using indicators in technical review format. On completion of the exercise, information on profile/performance of all CDTI projects in Nigeria will be available and will thereafter be used for identifoing/appraising challenges faced by each CDTI project as TRC/CDTI moves into the NTD family and TRC merges with NTD Steering Committee. She also gave an update on the APOC- supported situation analysis being conducted in seven projects (Cross River, Edo, Ondo, Kogi, Ogun, Oyo, Taraba) with poor epidemiological assessment results. She indicated that a planning meeting has been held, desk review is ongoing and visits to the projects will soon be conducted. Collation of findings, preparation of intervention plan and submission of report will be concluded in November 2014. 324. TCC thanked Prof Braide for the presentation of a concise and clear repoa and commended TRC Nigeriafor effectively achieving the objectivesfor which TRCs were set up and advisedthe TRC to continue the move to metge with NTD Steering Committee. 14.4.4 UGAI{DA 325. Dr Tukahebua, Chair of TRCAJganda, presented the report of the TRC. She informed the committee that the reports for this period were reviewed by the integrated NTD Technical Commiftee. These were January 2013 - December 2013 reports for six projects namely: phases I- lV and vector elimination projects of Mpamba-Nkusi and ltwara. 326. Phase I project, in its l7s year of implementation, is comprised of 15 districts. Phase II project has 12 districts and this was the l3u year report. Transmission has been intem-rpted in 9 all Page 56 of which have stopped MDA and are undergoing post treatment surveillance (PTS). The other 3 are hampered by cross-border issues but had good heatment coverage >80%. Phase tII project comprised oi 8 districts is in its l4n year of implementation. Phase IV project is comprised of 7 districts and is in its l5th year of implementation. The vector elimination projects of Mpamba- Nkusi and ltwara foci are undergoing (PTS). No new proposal was reviewed but the research that was approved by TCC37 has now commenced and a report will be presented during TCC40. TRC noted that there was general improvement in report writing and accepted all the reports with some revisions. 327. TRC recommended the NTD programme to: strengthen pharmaco-vigilance, PTS and operational research and also improve data quality. The recommendations made to APOC were: reviewing the technical report format; clarifo on UTG percentage coverage in Table 9 and supporting implementation of cross-border action plan. 328. TCC thanked Dr Tukahebua for the presentation and commended the TRC of Uganda for the repoil. The committee noted that the recommendation to APOC of supporting cross border action plan needed to be revised because the APOC is already supporting this agenda The committee also noted that the NTD Technical Commiaee did not absorb Oncho TRC but build on it, and requested the NTD Technical Committee to review the reponing format and incorporate it in LF and other NTDs. 15 DATE AI{D VENUE OF THE FORTIETH AI\[D FORTY FIRST SESSIONS OF THE TCC: Agenda Item 16 329. The 40'h session of the Technical Consultative Committee (TCCa0) is scheduled for 09 to 13 March 2015 and the 4['t session from 07 to I I September 2015, both in Ouagadougou, Burkina Faso. 16 CLOSIIRE OF TIIE SESSION: Agenda item l8 330. In closing the session, the Chair thanked all TCC members, advisers and other participants for their contributions and dedicated work which led to a very successful session. He particularly thanked the Director of the Programme and his staff for the excellent preparation and organization of meeting. He obserued that TCC39 was an exceptional one, very rich in science with real progress. 331. He thanked the former directors of ex-OCP and APOC for their impressive contributions and was pleased to note that all of them have endorsed the way forward for PENDA. He reassured CSA that they are all looking forward to a new structured programme which will serve Oncho and LF, preserving the success Oncho and getting the LF and other NTDs together, making one Programme for the benefit of the poorest of the poor at the end of the road suffering from these scourge of NTDs. He believed that only an integrated approach and one programme can move things forward. 332. He finally thanked the interpreters who have been extremely patience throughout the five- day meeting, staying beyond the accepted hours. 333. On this the Chair declared the 39h session of the Technical Consultative Committee of APOC closed. Page 57 I2. 3 4. 5 6. 7 Annex l. List of participants 39th SESSION OF TIIE TECHNICAL CONSULTATTVE COMMITTEE Ouagado ugou, 08- I 2 September 20 I 4 LIST OF PARTICIPAI{TS TCC MEMBERS Prof Mamoun HOMEIDA, President, University of Medical Sciences & Technology (UMST), P O Box 12810, Khartoum, Sudan - Fax: (249 183)224799 - Tel: (249 183)227599 - E-mail: amst33@hotmail.com Prof Mamadou Souncalo TRAORE, Directeur G6ndral de I'Institut National de Recherche en Sant6 Publique (INRSP), BP : 1771, Bamako, Mali, Mobile: (223) 66 75 9051, Tel. Home : (223) 20 20 6868 - Fax(223)20 21 43 20 - E-mail: traorem@afribonemali.net Dr Yao SODAHLON, Senior Associate Director, Onchocerciasis, Mectizan Donation Program, 325 Swanton Way, 30030 Decatur, GA, USA, E-mail: ysodahlon@taskforce.ors Dr Mary AMUYUNZU-NYAMONGO, African Institute for Health and Development, P.O. Box 45259, Nairobi 00100, Kenya, TeUFax: (254) 20 3873385; Cell: (254) 722850401; E-mails: Mnyamon go@aihd int.org and Manyamongo@yahoo.com Dr Francisca Onyekachi OLAMIru, Executive Director, MITOSATH, 42046, Mun-Gyel, Behind WAEC Office, P.O. Box 205, Jos, Plateau State, Nigeria, Mobile: (234) 80333 18085 - Fax: (234) 7 3 46 47 92, Email : m itosath@hotmai l.corn ; franciscauk@hotrnail.com Dr Johnson NGOROK, Country Director, Sightsavers Uganda, East African Development Bank Building - Ground Floor, 4 Nile Avenue, P.O. Box 21249, Kampala, Uganda - Mobile : 256 787 92 42 l0 - Fax: 256 414 230338 - Email : ingorok@sightsavers.org Dr Bernard PHILIPPON, 35 Avenue Jean Moulin 75014, Paris, France - Tel : (00331) 40 44 94 04 - Fax : (00331) 44 12 23 0l- E-mail: abphilippon@yahoo.fr OBSERVERS Prof Thomas R. t NNASCH, Distinguished USF Health Professor, Chair, Department of Global Health, Global Health Infectious Disease Research, 3720 Spectrum Blvd, Suite 304, Tampa, FL 33612, Florida - USA - Fax: 813-974-0992 - Tel. 813-974-7807 (office) - 813-974-0507 (laboratory) - Email : tunnasch@health.usf.edu Dr Maria REBOLLO POLO, Program Director, Neglected Tropical Diseases Support Center (NTD- SC), the Task Force for Global Health, Atlanta, USA + 1404 247 l? 57- E-mail: m rebol lo@taskforce.orel mariazyl@hotmai l.com TECHNICAL ADVISERS Dr Tshinko B. ILUNGA, Public Health Specialist, 25 B.P. 229, Abidjan 25, C6te d'Ivoire, Tel: (+225) 57970438 - E-mail: tbimbuta@yahoo.com 8 9 l0 Page 58 11. Dr Michel BOUSSINESQ, Institut de Recherche pour le D6veloppement (tRD), UMI-233, 9l I avenue Agropolis, BP 64501, 34394 Montpellier Cedex 5, France, Tel: +33 675139151'E-mail: michel.boussinesq@ ird.fr TRC 12. Prof. Ekanem BRAIDE, Chairperson of the Nigeria Technical Review Committee, Federal University, Lafia, Nasarawa State, Nigeria - Tel. (234) 80 3341 6842 - E-mail: ekanem braide@hotmai l.com 13. Dr Benjamin Didier BIHOLONG, Coordonnateur National du Programme de lutte contre l'Onchocercose (PNLO), Secr6taire Ex6cutif du GTNO, Ministdre de la Sant6 Publique, B.P. 155, Yaound6, Cameroun - Tel/Fax: (237) 2222 6910 -Cellulaire: (237) 99612800, (237) 79758660 - E- mai I : biholongld i@.vahoo. fr 14. Dr Edridah Muheki TUKAHEBWA, Assistant Commissioner Health Services-Vector Control & NTD Coordinator, Ministry of Health and TRC chair, Vector Control Division, Ministry of Health, Kampala, Uganda, Tel.: +256-772443659; +256-414-251927 - E-mail: edmuheki@gmail.com 15. Dr Damson KATHYOLA, Chairperson of the Malawi Technical Review Committee, Ministry of Health, Lilongwe, Malawi - Tel: +265 888344443 - Email: dkathyola@gmail.com AGENCE REGIONALE DE SANTE DE ZONE OUEST, REI\INES 16. Dr Christian BAILLY, Conseiller sanitaire de zone, Agence rdgionale de sant6 de zone Ouest, Service zonal de d6fense et de s6curit6, 6, place des Colombes, CS 14253, 35 042 RENNES Cedex - T6l secrdtariat 02.90.01.25.22 - Fax 02.99.65.76.78 - Tdl direct 02.90.01.25.24 - Email: bai I lyj abot@oran ge. fr ; Christian. BA I LLY@ars. sante. fr cDc t7 Dr Paul CANTEY, Medical Epidemiologist, Parasitic Diseases Branch, DPDTU/CGFVCDC, 1600 CliftonRoad, MS A-06, Atlanta, GA 30333 Tel. + 404718 4735 - Fax: 404-718-4816 - Email: gdn9@cdc.gov 18. Dr Christine DUBRAY, Medical Epidemiologisg Parasitic Diseases Branch, DPDM/CGFUCDC, 1600 CliftonRoad, MS 4-06, Atlanta, GA 30333 - Tel. + 404718 4769- Fax: 404-718-4816 - Email: ffg5@cdc.gov DDTI) l9 Dr Marco A. BIAMONTE, CEO, Drug Discovery for Tropical Diseases, 10835 Road to the Cure, Suite 230, San Diego, CA 92121- Tel. Office: (858) 999-2360 - Mobile: (858) 405-1277 - Email: marco. biamonte@ddtd.org LA TROBE UNTVERSITY Dr Warwick GRANT, Associate Professor Warwick Grant, Reader, Genetics Department, La Trobe University, Bundoora 3086 - Australia - T: +61 3 9479 5067 ' F: + 61 3 9479 2480 Email: w. grant@ latrobe.edu.au Page 59 20 22. PATH 21. Ms Dunia FAULX, PATH, PO Box 900922, Seattle, WA 98109, USA, 2201 Westlake Avenue, Suite 200, Seatrle, WA 98121 - Tel. + | 206.285.3500 - Fax: I 206.285.6619 - Email: dfaulx@path.org UNIVERSITY OF BUEA Prof Samuel WANJI, Head of Department of Microbiology and Parasitology Faculty of Science University of Buea, P.O. Box 63, Buea - Cameroon - E-mail: samwandji@gmail.com WAHO Dr William BOSU, Professional Officer for Non-communicable Diseases, West Africa Health Organization (WAHO), 175 Av. Ouezzin Coulibaly, 0l B.P. 153, Bobo-Dioulasso 01, Burkina Faso - Tel : (226) 20 97 57 75 - Fax : (226) 20 97 57 72 E-mail: wbosu@wahooas.orq EX-OCP and APOC ex DIRECTORS 24. Dr K. Yankum DAZDIE, Nuamah-Donkor Avenue, Kitase-Peduase, Residential Area (near Peduase Lodge), P.O. Box 0S-1905, Accra, Ghana - Email: yankumdadzie@iname.com Dr Azodoga SEKETELI, Ing6nieur Agronome, Entomologiste m6dical, 224, Rue des Morelles, Tokoin Wuiti, B.P. 3841, Lom6, Togo - Tel: (228) 226 83 85 ou (228) 900 94 05 - E-mail: azodoea.seketeli@emai l.com ; azodo ga@.seketel i.org Dr Uche Veronica AMAZIGO, Scientist, P.O. Box 3397, Main Post Office, Okpara Avenue, Enugu State, Nigeria - E-mail: amazigo4@yahoo.com; ucamazigo@gmail.com LF.RPRG/AFRO Dr Ricardo THOMPSON, Senior Researcher Scientist, National Institute of Health, Av. Eduardo Mondlane, 1008, Maputo, P.O. Box264, Maputo, Republic of Mozambique - Tel: +258 823 060 036 - E-mail: rthompsonmz@ gmail.com 28. Professor Moses J. BOCKARIE, Director, Centre for Neglected Tropical Diseases, Professor of Tropical, Health Sciences, Liverpool School of Tropical Medicine, Pembroke Place, Liverpool L3 5QA, UK Phone: +44 (0) l5l 705 3343, Fax: +44 (0) l5l 705 3370, Mobile: +44 07595020694, Email: rnoses.bockarie@ I iv.ac. uk: 29 Dr Alexandre TIENDREBEOGO, NTD Monitoring & Evaluation Officer, World Health Organization, Regional Office for Africa (WHO/AFRO), Citd du Djou6, BP 06, Bruzzaville, Congo - Email: tiendrebeogoa@who. int NOCPruGAI\IDA Mr Tom Luroni LAKWO, Senior Entomologist, National Coordinator, National Onchocerciasis Control Programme (NOCP) Secretariat, Ministry of Health, P.O. Box 72?2,Kampala, Uganda - Tel: +256-414-348332 - Fax: +256-414-348339 - Email: tlakwo@grnail.com 23 25. 26. 27 30 Page 60 wHo/HQ 31. Dr Jonathan KING, Scientis! WHONTD/PCT, World Health Organization (WHO),20 Avenue Appia, 12l I Geneva2T,Switzeiland - Tel: +41-22791 1423, E-mail: kingi@who.int 32. Dr Tony UKETY, Medical Offrcer, WHO/NTD/PCT, World Health Organization, 20 Avenue Appia" l2ll Geneva 27, Switzerland, Tel: + 41 22 791 1456, pn1; + 41 22 791 4869, E-mail: ukelvt@who.int 33. Dr Annette KUESEL, Scientist, TDR/CBR, World Health Organization (WHO), 20 Avenue Appia CH-l2ll, Geneva 27, Switzerland - Tel: +41 22791-1541 - Fax: +41 22791 4774 - E-mail: kuesela@who.int APOC TEMPORARY ADVISERS Dr Laurent TOE, Responsible Officer, Molecular Biology Laboratory, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53,Fax: (226) 50 34 28 75, E-mail: ltoe@hotmail.com 35 Dr Aim6 G. ADJAMI, Molecular Biology Laboratory, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: adjamiga@who.int: adjamiTS@hotmail.corn wHo/APOC 36 Dr Jean-Baptiste ROUNGOU, Director/APOC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 3 4 29 53, F ax: (226) 50 3 4 28 75, E-mail : roungoui@who. int 37 Dr Chris Ngenda MWIKISA, CSI\,I/APOC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 503429 53, Fax: (226)50342875, E-mail: mwikisac@who.int 38 Dr Grace FOB[, CSD/APOC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 3428 75, E-mail: fobig@who.int Dr Frangois SOBELA, Chief a.i., Epidemiology and Vector Elimination Unit (CEV a.i./APOC), P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: sobelaf@who.int Mr Honorat ZOURE, BIN{/APOC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: zoureh@who.int Dr Afework Hailemariam TEKLE, EPII/APOC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53,Fax: (226) 50 3428 75, E-mai[: teklea@who.int Prof. Daniel BOAKYE, Technical Officer/Entomology, P.O. Box 549, Ouagadougou, Burkina Faso, Tel (226)503429 53, Fax: (226)50342875 -E-mail: boakyed@who.int; yawbadjei@yahoo.co.uk Mr Asmani BZIMANA, BFO/APOC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53,Fax: (226) 50 34 28 75, E-mail: bizimanaa@who.int Ms Thdrdse GUISSOU, FO/APOC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: guissout@who.int Mr Tendainashe SIWOMBE, ITO/APOC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226\ 50 34 28 75, E-mail: siwombet@who.int 34 39 40 4t 42 43 44 45 Page 6l 46. Mr Issaka Niandou YACOUBA, ISO/APOC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: niandouy@who.int 47. Dr Raogo Augustin KIMA, TRAD/APOC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53,Fax: (226) 50 34 28 75, E-mail: kimar@Oncho.afro.who.int 48. Mr Ibrahim TOURE, AO/APOC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 3429 53, Fax: (226) 50 34 28 75, E-mail: tourei@Oncho.afro.who.int 49 Mrs Bintou SAVADOGO, AHR/APOC, Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: savadogob@who.int 50. Mr Yaovi AHOLOU, Programme Officer, Meetings/APOC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53,Fax: (226) 50 34 28 75, E-mail: aholouy@who.int INTERPRETERS 51. Mrs Safi6tou BARRY,09 BP 526 Ouagadougou 09, Burkina Faso, Tel: (226)7021 4l 14l (226)78 03 64 55 - E-mail: barrvsafietou@smail.com; safia-barry@yahoo.fr 52. Mr Andrd NIKIEMA, 0l BP 922, Ouagadougou 01, Burkina Faso, Tel : (226) 70 67 5l l0 /78 80 90 53, E-mail: nikiemaandre@gmail.com: andrenikiemaS I @yahoo.fr 53. Mr Oumarou NAGABILA, 03 BP 7038, Ouagadougou 03, Burkina Faso, Tel: (226) 70 26 33 32 I (226) 75 76 16 16,E-mail : onagabila@hotmail.com 54. Mr Nobila Jean Christophe SORGHO, 03 BP 7183, Ouagadougou 03, Burkina Faso, Tel +226 70 62 86 7 8/ 50 36 57 7 5 - E-mail: njcsorgho@ gmail.com Page 62 I 2 Annex 2: TCC39 Agenda Opening Adoption of the Agenda Information CSA: matters arising from the l45th, l46th and 147ft sessions Report on the last Mectizan Expert Committee Meeting Report of the Transition Task Force TCC: follow-up of the key recommendations of the thirty-eighth session Strategic and technical issues 7. APOC activities Review and planning meeting 8. Elimination of Onchocerciasis infection and intemrption of transmission:(i) Elimination of Onchocerciasis with ivermectin in Africa a) Update on Entomological/Epidemiological evaluations b) Delineation of treatment boundaries c) Update on the delineation of transmission zones d) The evidence and rationale for the current APOC monitoring and evaluation framework for elimination e) Update on black flies trapping and other studies related to Onchocerciasis(ii) Elimination of O. volvulus infection: New diagnostics of PATH(iii) New diagnostic technology to tropical diseases, specifically for detection of loa loa infection(iv) Resuls of the OV-16 studies in Africa(v) LF and Oncho co-evaluation study(vi) Sub-optimal responses to ivermectin(vii) WHO Cuidelines on verification of elimination of human Onchocerciasis(viii) Roadmap for alternative treatment strategies for the acceleration of the elimination of Onchocerciasis: 20 I 4-20 I 5(ix) Proposed algorithm for deciding on areas to refine loa loa map(x) Perspectives for LF and Oncho elimination: Resuls of test and treat study in Cameroon(xi) Review of Uganda Dossier for the four sites that have interrupted transmission of Onchocerciasis(xii) Contribution of TCC to the preparatory activities for the launching of the new entity, specifically the LF/Oncho programmes scale up 9. Research on new control and surveillance tools by collaborating institutions:(i) Update on Moxidectin and research on the vulnerability of Onchocerciasis and LF to emergence of resistance(ii) Update on the DEC patch test and Lohmann(iii) Assessment of the impact of community directed treatment with ivermectin on the Parasitological indicators of Loa loa in areas of co-endemicity with Onchocerciasis in Cameroon a 3. 4. 5. 6. 10. I l. Remarks by Technical Advisors Remarks former Directors to APOC Management Manaeement of APOC Trust Fund 12. Report on the financial management of APOC funded Projects Page 63 Reviews 13. 14. Reoort on the review bv the APOC Management of the financial content of ltt, 2nd, 3'd, 4h, 5th' 6fi and 7th,8*,9th, lbth, llth, l2th l3tr, l4h, l5th years projects progress reports as an introduction to their technical review Review of New project proposals and l't, 2*,3'o,4tn,5tn'6th and 7tn,8to,9'h, loth, llth, l2th, l3th, l4th, l5s years annual technical reports of projects Technical review Committee: Cameroon, Malawi, Nigeria and Uganda Review of operational research proposals Date and place of the fortieth session of the TCC Conclusions and recommendations of TCC39 Closure of the session 15. 16. 17. 18. 19. a Page 64 aAnnex 3: Follow-up of TCC38 Recommendations SubjecdTopic Action to be'taken Status of implementation Matters arising from CSA l42nd and l43rd sessions and JAFI9 (i) TOR of the Transition Task Force (TTF) be shared with TCC members para 19 ii) Prepare a draft of the governance structure that would be reviewed by JAF in December 2014 for the final document to be signed by partners at the JAF of 2015. Para 21. Implemented On-going Matters arising from NGDOAI\IN meeting Provide a copy to TCC Guidelines on when and where to stop treatment for Onchocerciasis and verification para 25. Implemented Follow up of key TCC recommendations (i) Link follow-up actions to the recommendations made by the TCC in future presentations. (ii) Angola: Management to brief the committee on steps taken regarding that country and the outcome of such approaches. (iii) Recommendations to be implemented in 2014 should not be identified as on- going. (iv) Recommendations of TCC on when and where to stop treatment should be taken as general recommendations to be addressed to all countries. Para 28 Implemented. On-going. Two NPO being recruited to strengthen human resources capacity Noted Noted Update on E ntomologicaUE pidemiologic al evaluations (i) To complement the good epidemiological results with entomological transmission assessment survey to know the situation in the vectors. Para 40. (ii) APOC Management to conduct studies on the reason or determinant factors of poor performance in someprojects from previous epidemiological evaluation results. Para 4l (iii)Stopping treatment in projects that reached the breakpoint a social study Entomological assessments have started in Senegal and Niger with Burundi starting this month. The processes are in place -fo, assessments in Ethiopia and Sudan next month. The number of entomological assessments initially planned have been drastically reduced due to budgetary cons traints fol low ing C SA I 4 6 Implemented. A situation analysis of some projects with poor epidemiological results will be done in September 2014 in Nigeria and Cameroon Not implemented. Page 65 SubjecUTopic Action to be teken Stetus of implementation should be carried out on how to persuade those communities to stop treatment. Para 42 (iv) The APOC Management should urgently initiate a process of developing a toolkit for community preparedness to stop treatment. Para 44. Not implemented. Transmission assessment para 54. (i) Support the techniques being currently used in APOC; Accelerate the capacity being built within the countries. (ii) Strengthen collaboration with institutions both within and external to endemic countries to provide complementary support for entomological activities and also the development of newer tools (iii)Base the selection of countries for entomological assessments on epidemiological considerations and evaluations towards the elimination goal. (iv) Channel requests for candidates to be trained for entomological activities through the links that APOC has established with Universities in Africa (v) Continue the cytotaxonomic training and studies to delineate transmission zones and encourage collection of material that may be used for molecular studies to complement the ongoing cytotaxonomic work. Implemented. Capacity building is now a component of all entomological assessments. In addition to on-labour training done during epidemiological evaluations, a worlahop has been organized in DRC and 8 program oficers from DRC, Chad and Burundi were trained Implemented. Collaboration with institution such as USF continues with a training component. Implemented. All countries selected for entomological assessments are based on the reported good phase I b epidemiological evaluation results prevalence data from the ep ide mio logical surveys. Not implemented. This is to be done in the countries when new activities are planned Ongoing. Training was done for Ethiopia, Sudan and South Sudan. However, sampling for delineation are coupled with transmission assessments to be cost effective Delineation of treatment boundaries (i) APOC to find ways of equipping countries with the appropriate diagnostics tools, in view of its contribution to building national capacity on the implementation of epidemiological assessment. P ara 65. Ongoing. Sclerocorneal punches hqve been ordered to equip countries -for conducting epi evaluations a Page 66 aSubjecUToplc Action to betaken Strtus of implementation (ii) For ethical purposes, survey teams should find ways to heat individuals that will appear to be infected following the skin snip examination. Para 67. (iii)Future presentations of the assessment results should show rate of refusal and absentees. Para 68 Implemented Ongoing Concept Note on Elimination of Onchocerciasis in all hypo- endemic areas by 2020 (i) Consider lymphatic filariasis elimination implementation activities during the delineation of ivermectin treatment boundaries. para 73. (ii) Finalize the comparative study on skin snip mf to Onchocerciasis nodule association which started recently at APOC level. para 74 Not implemented Ongoing. Data collection is completed and analysis is ongoing to be Jinalized within a week Alternative Treatment Strategy Selection (i) Further trim down the indicator list by selecting critical and minimum indicators required to establish alternative treatment strategies. (ii) -Following the selection of critical indicators, develop a grading system, which will take into account indicators by assigned weight, for a more objective process to guide the decision making processes regarding which projects are eligible for alternative treatment. Para 76 (iii)-APOC to consider applying modelling principles to improve on the grading system decision making process. (iv)Consider the final list of indicators to improve the existing APOC management decision making scheme. Para 76. Ongoing. Experts consultation meeting is looking into the issue. Ongoing. Presentation from the group will made to TCC39 Not implemented. P resentat ion from Experts consultations on ARS will address these issues Ongoing. Black fly trapping and other studies related to Onchocerciasis (i) There is need to have a new and more efficient tool to collect flies for entomological monitoring and surveillance. (ii) Accelerate the transfer of the trap to national teams. Para 79. Ongoing. The research on blaclcfly trapping continues and will be reported Ongoing. Plan for transfer of the trap rs being implemented in countries. Page 67 SubjecdTopic Action to be tsken Satus of implementation (iii) APOC Management to continue the support given to the research team for optimizing and implementing the use ofthetraps. Para80. (iv) Carry out studies to optimize the bait formulation for the current trap design. The trap should be evaluated on the forest dwelling species of S. damnosum and other vector species, and optimized if necessary. Para 81. Ongoing. APOC provides support to the research team Ongoing. Studies are ongoing to make a lure specific to ,S. damnosum; Evaluation of trap for forest dwelling species will be done in Ghana (4 Q) Predictive S. damnosum habitat modelling in Burkina Faso and Northern Uganda Use breeding site modelling to assist the entomology and epidemiology teams in mapping areas of Onchocerciasis and for the identification of capture points and communities for epidemiological surveys. Para 84 Ongoing. Presently in use in transmission assessment in Niger The use of skin snips for estimating prevalence of infection in hypoendemic areas (i) Evaluate the sensitivity of the skin scratch PCR to determine if it might be used to replace the conventional skin snip. (ii) The use of other assays as a primary screening tool followed by skin snip confirmation should be evaluated as an operational tool. Para 87. Also see para 69 on perceptions towards diagnostic tools. Not implemented Not implemented. LF and Oncho elimination Programmes collaboration There is need to have standardized reporting with narratives. Not implemented. Perspectives of Lymphatic Filariasis (LF) and Onchocerciasis elimination (DOLF Disseminate guidelines provided by WHO to countries for use in the field. Para 98. Implemented. Recommendations of UOEEAC (Uganda) on stopping treatment in some foci of Uganda The Ugandan Programme to prepare a dossier for projects where transmission of Onchocerciasis has been interrupted and submit these to TCC for their review. Para 103. Also see para 44. Not implemented. Format for the dossier was sent by APOC to Uganda Dossier will be prepared and submittedfor TCC40 Relaunching of activities in CAR CDTI (i) APOC Management to continue providing all necessary assistance to CAR" given the efforts already made at national level. Para I 13. (ii) National authorities and APOC Management can rely on international or national NGOs, accustomed to interventions in times of crisis, for the distribution of ivermectin. Para I14. Ongoing. Planning workshop to launching of Oncho and LF activities organized in CAR in July Ongoing. Meeting Sector Cluster to distibute IVM with Health see how to a Page 68 aSubjecUTopic Actlon to be taken Status of implementation Rolling Out New Tools to Support the Elimination of Lymphatic Filariasis and Onchocerciasis (i) To liaise with the task force and share research priorities, consulting earlier topics indicated to the TCC but not funded. Identiff mapping /OR needs at country level that APOC could not sponsor due to budgetary constraints. Para 149 Not implemented Review of operational Research proposals a) Determinants of refusol and absentees to CDTI in the Western Region of Cameroon in 2014 b) Strategies for Community ownership and sustainability of CDTI in Rural areas of Cameroon (i) Continue efforts to provide support in operational research, as opportunities exist. APOC should encourage partners to find opportunities, ways to continue supporting countries while minimizing/reducing " the back and forth " that causes delays. (ii) Update the list of operational research that has been published. (iii)Take the two programmes (Oncho and LF) into account from now on in the submission of operational research proposals. Para 153 (iv) Strengthen collaboration with partners in supporting countries' capacity for operational research, with researchers and expertise available in the countries. (v) Develop a roadmap, taking into account all the points raised by TCC for the new Technical Offrcer in charge of operational research. Para r53 (vr,) Proposal approved and funds to be put at disposal ofresearcher. Para 155 (vii) Approval of the research proposal for funding. Para 157. (viii) Translate the two proposals into English and send to the two social science specialists of the committee for their inputs. Para 158. Not implemented due to financial constraints. Not implemented Not implemented. Not implemented Ongoing. Roadmap developed Implemented. To be sent to PI after review of TCC members. Finalization pending review of TCC 2nd social scientist Implemented. Funding pending Jinalization of review by TCC members Project linancial reports due (i) Train project accountants during APOC Management field visits. Para 166. Ongoing. Training project accountants has been delivered during the field missions caruied outin the last six months. This has resulted in significant reduction of outstanding reports as outlined in - Page 69 SubjecUTopic Action to be taken Status of implementation (ii) Work with projects to restore the situation whereby "the amount of financial reports due by projecs is alarming". Para 166. the presentation on Financial reporting Ongoing. Close follow up has been made with projects having long outstanding and large amount of reports due Poor submission rate of financial and FACE reports Measures suggested:(i) Suspension of further instalments (ii) Check if projects do not have excess money as they receive funding from three partners and there is no joint planning at field level. (iii)Review the way funds are channelled to the projects in order to prompt them to implement planned activities and report accordingly. Para l7l Not implemented. The need to increase the implementation rate prevailed over the new policy considering that it is the first year of introducing the change Ongoing. Through FACE reports, APOC staff can review the budget and utilization of funds, certify expenditure and conJirm balance available -fro* APOC funds Utilization of funds from other partners is not reported to APOC. Ongoing. APOC has been trying to address the issue on a case by case basis for countries where there are intermediary accounts in the channels, so cts to ensure funds are directly channelled to the impl e ment ing proj e c t ac c ount. Ghana CDTI Project 4th year annual technical report (i) The Ghana project is due for Participatory Independent Monitoring, (ii) Mid+erm evaluation and 5 year sustainability evaluation. What are APOC plans for conducting these evaluation activities? Para 182. Implemented. Independent Participatory Monitoring had been done Not implemented. In the context of elimination T33 had advised that we s top developing sustainab ility plans. Midterm evaluation for this project has not been done Rutana CDTI Project 8th year annual technical report Take necessary actions to set up national autonomous systems for epidemiological and entomological evaluation/ surveillance. Para I 97. Not implemented. Bioko CDTI project Equatorial Guinea (i) Continue to assist the national team to maintain the good results of vector control and consider Onchocerciasis elimination in Bioko in the future.Para226. (ii) APOC Management to continue contacting national officials to Ongoing. Ongoing. a - Page 70 aSubjecUTopic Ac'tion to be teken Stetus of implementation mobilize more financial resources for Onchocerciasis and other NTDs control. Para227. Sudan CDTI Project APOC to consider visiting this project to clariff issues that will guide to plan for further collaboration and support. Para 2it Not implemented. Roadmap for re- launching CDTI developed in 2013 and activities started in 201i but civil unrest situation is jeopardising implementation Tanzania Mahenge CDTI Project lSth year annual technical report APOC to consider replacing the project vehicle and motorcycles. Para 234. Noted. a Page 7l Annex 4: TCC Observations on the TTF report A: Observations 334. Below is a summary of the key observations made by the TCC. (2) Membership of the TTF: The membership of the TTF was discussed by TCC38, and reiterated in this meeting, as not being representative on various counts: i. Composition: The TTF is ovenvhelmingly Anglophone with no representation of Francophone countries; ii. Country representation: There is only one programme manager in the team - there is a need to increase the presence of country managers or persons with country experience; iii. Discipline: there is a need to balance the disciplinary representation in the team (for instance, there is no social scientist on the current team, etc.); and iv. Gender: Only two of the l0 members are women (20%); consider increasing the representation of women on the team. (6) Acknowledgement of the role of APOC in disease contol: There is a need to recognize the role played by APOC in control efforts and acknowledge the potential to build on the experiences and structures, both at the regional and country levels. The members noted an apparent effort in the document to downplay the major strides made in the region in Onchocerciasis control. This was seen to be reflective in the language used in the document (the specific areas of concern have been highlighted in the document in tracked changes that will be handed over to the APOC management for consideration). For instance, Section 38 minimizes the work of co-implementation, which was initiated by APOC in several countries in collaboration with national and local health authorities, over the last 7 years without any additional mandate, budget or staffreinforcement. It is notable that a number of the recommendations for PENDA made in the TTF report refer to activities that have been widely developed or at least initiated in counhies, even though they may need adjustments and adaptations to the new context. These include the recommendation of in-country or inter-country meetings for PENDA, a process that has already been initiated by APOC (as presented during this TCC). (7) Implementation unit: the report indicates that the district will function as the implementation unit. Although this seems to have been agreed, the TCC notes that Oncho control has not historically functioned along transmission zones as implementation units - this is only the case for mapping, delineation of treafinent zones and epi-ento evaluation surveys. Ivermectin delivery and coverage measurements have always been at the district (administrative) while the basic implementation unit for treatment has been the community. The concern is that using the district as a treatment unit will lead to the treatment of innumerable villages, which may not need treatment, and in some cases the whole country. The TCC proposes that the report should include a statement that Oncho controUelimination results have to be evaluated through a transmission zone, which is not incompatible with a district approach. a - I Page72 a(8) Target audience: The TTF report seems to focus and target the donors and international community with limited promotion of country ownership, which is critical to the success of PENDA. (9) Next steps: The TTF has identified key technical and operations research issues to be undertaken in preparation for the launch of PENDA. We commend this while recommending that more emphasis should be placed on capacity buitding and preparation of field guidelines in preparation for the new roles of government and PENDA management.a Page 73
Organisation mondiale de la santé (OMS) · Technical Documents
Report of the thirty-ninth session of the Technical Consultative Committee (TCC): Ouagadougou, 08-12 September 2014
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