Onchocerciasis control activities of the eleven participating countries of OCP - 1996

Onchocerciasis Control Programme in West Africa Programme de Lutte contre I'Onchocercose en Afrique de I'Ouest JOINT PROGRAMME COMMITTEE JPC . CCP COMITE CONJOTNT DU PROGRAMME Offrce of the Chairman Bureau du Pr6sident JOINT PROGRAMME COMMITTEE Seventeenth session Cotonou. 24 December 1996 Provisional asenda item 6 I. INTRODUCTION 2. NATIONAL DEVOLUTION COMMITTEES State of the official process of their setting up or modification Financial contributions of the States . Mobilisation of external resources JPCI7.6 ORIGINAL : FRENCH September 1996 ONCHOCERCIASIS CONTROL ACTIVMES OF THE ELEVEN PARTICIPATING COUNTRIES OF OCP - 1996 Contents 3 3 3 3 4 3. DEVOLUTION ACTIVITIES IN RELATION TO ONCHOCERCIASIS CONTROL AND BLACKFLY NUISANCE Original Area 2.t 2.2 2.3 3.1. 3.1.1. 3.1.2. 3.1.3. 4 4 5 5 5 5 5 5 5 5 5 6 6 7 7 Information, Education, Communication (IEC) . Knowledge, Attirude and Practice surveys (KAP) Awareness-raising activities Impact 3.2. Community mobilisation and control of blackfly nuisance 3.3. 3.3.1. 3.3.2. 3.3.3. 3.4. 3.4.1 3.4.2 3.4.3 Passive treatment Active treatment of detected cases Large-scale treatment by the mobile teams Epidemiological surveillance Active surveillance of the sentinel villages Passive surveillance Migration srudy JPCL7.6 Page 2 Extension Area 3.5. Epidemiological Evaluation . . . . 3.5. 1. Incidence studies 3.5.2. Other epidemiological evaluations 7 7 7 7 8 8 8 9 Ivermectin treatment Large-scale treatment by the mobile teams Community-based treatment 4. EVALUATION OF IVERMECTIN DISTRIBUTION PROGRAMMES 5. TRAINING AND REFRESHER COURSES 5.1. State of OCP fellowships 5.2. Field training in OCP epidemiological evaluation methods 5.3. National training seminars 5.4. Other training seminars 6. CONTROL ACTTVITIES RELATED TO THE OTHER ENDEMIC DISEASES INCLUDED IN THE DEVOLUTION PLAN 7. THE INTEGRATION OF DEVOLUTION ACTTVITIES 8. PROSPECTS: DRAFT SCHEDULE FOR THE TAKE-OVER OF RESIDUAL ACTIVITIES BY PARTICIPATING COUNTRIES THROUGH THE END OF 1998 9. FOLLOW-UP OF WORKSHOPS 10. DATA ANALYSIS AND INTERPRETATION, COMPUTER EQUIPMENT AND UTILISATION . . I1. CONCLUSION 3.6. 3.6.1 3.6.2 l0 10 10 10 l0 10 l1 t2 14 t4 15 JPC17.6 Page 3 1. INTRODUCTION The year 1995-1996 was marked by a) A greater awareness of the process of "Planning, evaluation and transfer" of the OCP Programme techniques and activities to Participating Countries over the period 1996-2N2, so as to enable these countries carry out timely onchocerciasis recrudescence detection and control. b) The running of workshops in all the Programme countries, aimed at setting up national Onchocerciasis surveillance and/or evaluation systems, and instirutionalizing the implementation of a community-based ivermectin distribution programme, with these strategies having to take into account the ongoing health sector reforms being undertaken in the countries. c) The detection during epidemiological surveillance in the Original Programme area, of the first case of recrudescence in the Bougouriba basin in Burkina Faso and for which vigorous action has already been taken by the concerned country and OCP. 2. NATTONAL DEVOLUTION COMMTTTEES (NDCO) 2.1. State of the official process of setting up or modification of the NDCO In countries such as Burkina Faso, Cdte d'Ivoire, Ghana, Mali, Niger and Togo national committees have been officially set up. The official documents instituting them are in the process of being adopted in the other Participating Countries. It is now evident that these committees are little or not at all operational This issue will be on the agenda of the next meeting of the National Coordinators in order to work out concrete proposals. It must be noted that if a driving force is indispensable in each country to follow up and animate onchocerciasis surveillance and control over the longer term, some flexibility must be left to the countries to decide on its structure and mode of operation. 2.2. Financial contributions of the States to devolution activities The financial contribution of the States are summarized in Table I for 1995 and 1996 JPCI7.6 Page 4 Table 1. Financial contribution of the Countries (1995-1990 Contribution Country 1995 1996 Benin 1,450,000 FCFA 2,910,000 FCFA Burkina Faso C6te d'Ivoire 61,000,000 FCFA 25,000,000 FCFA Ghana 72,000 us $ Guinea 13,764 US $ Guinea-Bissau Mali 14,000,000 FCFA 14,000,000 FCFA Niger Senegal Sierra Leone 25,000,000 Leones Togo 437,000 FCFA In addition to these contributed amounts, the salaries of all the staff are paid by the countries which also finance the participation of their respective delegations to the various JPC meetings, as well as the epidemiological evaluation of some of the sentinel villages. 2.3. Mobilisation of external resources for devolution The financing of devolution activities is taken into account in the national health development plans drawn up in connection with the reforms of the health sector undertaken by the countries and the World Bank (Cdte d'Ivoire, Ghana, Guinea, Senegal, Sierra Leone). OCP and WHO/AFRO have actively supported the countries in training and seminars; their contributions amounted to US $ 49,513.7 and US $ 76, 000 respectively. The first part of the national devolution plan of Niger which amounted to 123,000,000 FCFA was financed by the Netherlands as a grant aid. In Mali, NGOs (Sight Savers and OPC) contributed up to 10,M0,822 FCFA. The NGO HKI in Niger mobilized funds for IEC and a KAP study respectively in the amount of US $ 8,450. 3 DEVOLUTION ACTTVITIES IN RELATION TO ONCHOCERCIASIS CONTROL AND BLACKFLY NUISANCE Original Area In the original area of the Programme, transmission of onchocerciasis has definitively been interrupted, except in some trouble spots (Bougouriba in Burkina Faso, Oti-Penjari in Benin and Togo) where transmission continues. The devolution activities described below are being carried out in the onchocerciasis-freed zones of the Prograrnme. JPC17.6 Page 5 3.1. Information. Education. Communication (IEC) 3.1.1. KAP Surveys A KAP survey (Knowledge, Attitude and Practice) of onchocerciasis was carried out in Burkina Faso in those river basins eligible for large-scale ivermectin treatment in the context of the institution of community-based treatment with support from the Helen Keller International (HKI) NGO. 3.1.2. Awareness-raising activities In all of the countries, IEC activities are regularly carried out by the national teams supported by the OCP teams and the other actors using the various communication techniques and information media and available materials (debates, talk shows on radio and television, film shows on onchocerciasis). 3.1.3. Impaa The impact of IEC activities is perceptible at all levels. A greater mobilization of the community and of administrative authorities is observed during the various onchocerciasis control activities that are carried out in the countries. In C6te d'ivoire, fewer and fewer letters are received reporting blacldly invasion. In Burkina Faso, Offrce Nationd d'Amenagement des Territoires (ONAT) is more and more involved in onchocerciasis control activities. 3.2. Community mobilization and control of blackfly nuisance In most of the countries, the training of national and district teams, of technicians and villagers in ground larviciding is being actively continued, which helps in resolving the blackfly nuisance problem. 3.3. Ivermectin treatment 3.3. 1. Passive treatment During the period of June 1995 to May 1996, 98,&l individuals were treated through the passive method with 147,503 ivermectin tablets, which represents 3.8% of the total number of people treated using all available strategies. 3.3.2. Active treatment of detected positive cases A total of 1,601 individuals infected with microfilariae were detected during the epidemiological surveillance and treated with2,679 tablets of ivermectin. 3.3.3. Large-scale treatment by the mobile teams In the original area, the results of ivermectin treatment by the national mobile teams from June 1995 to May 1996 are shown in Table 2. It is worth noting that this large-scale treatment is carried out only in very limited areas where the entomo-epidemiological control results were unsatisfactory. JPC17.6 Page 6 Table 2. Large-scale ivermectin treabnent (mobile teams) in the Original Programme area, June 1995 to May 1996 * Basin with several distribution cycles per year. 3.4. Epidemiological surveillance 3.4.1. Active sumeillance (sentinel villages) The map provided in the annex indicates the regions currently eligible for active epidemiological surveillance in those parts of the Original Programme area which have been freed from onchocerciasis. Since 1992, about 260 villages in the onchocerciasis-freed zones have been maintained under periodic surveillance (every three years). They are the "sentinel villages" Iocated near former productive larval breeding sites and with high prevalence rates before the beginning of control activities. These sentinel villages constitute the minimum number of villages to be evaluated, to which can be added other neighbouring villages, ils wils done in Burkina Faso. Table 3. Epidemiological suryeillance results in sentinel villages Country (Original Area) Year 1995 Year 1996 Number of Villages Prevalence rates % Number of villages Prevalence rates 7o Burkina Faso 06 0.0-2s.9 03 0.0-0.0 Mali l5 0.0-5.9 Niger t2 0.0-0.5 C6te d'Ivoire 10 0.0-2.0 Ghana 09 0.0-6.3 02 0.0-2.8 Togo 05 0.5-10.8 Benin M 0.5-10.9 M 1.7-24.1 Total 56 t4 Country Number of villages Census Population Population treated Mean Coverage 7o Number of tablets distributed Benin* 63s 159,681 116,833 73.2 130,859 Burkina 28 9,750 6,699 68.5 9,984 C6te d'Ivoire 148 42,665 33,290 78.0 37,560 Ghana* 255 93,63t 70,328 75.r 162,L72 Mali 438 t95,470 148,553 76.0 163,907 Total 15M 501,I97 375,693 74.9 5M,482 Table 3 summarizes the results obtained in 70 villages evaluated in 1995-1996 JPC17.6 Page 7 These results are generally excellent however, evaluation carried out in some river basins have shown high prevalence rates. In the Bougouriba basin in Burkina Faso, special evaluations carried out in l9 villages around Zoulo village and in the Naimo river basin recorded high prevalence rates; varying between 0 and 53%, which indicates a recrudescence of the infection in that region. In order to understand better these results, the National team of Burkina Faso, in collaboration with OCP and other national partners, undertook complementary research in entomology, epidemiology and socio-demography. Treatment with ivermectin has been instituted in the area. The first treatment was given in June 1996. Complementary studies are planned in order to better understand the occurence of high prevalence rates (10-257o) noted in the Oti-Penjari basins in Benin and Togo. 3.4.2. Passive surveillance It is not yet fully effective in all of the countries due to insufficient retraining and training of health workers. However, the local communities themselves often inform health workers of suspected onchocerciasis cases (migrants or natives) so they can be taken care of. 3.4.3. Migratton investigatton In the event a positive case is detected during the epidemiological evaluations, a migration investigation is systematically carried out in order to determine the movement of the patients so as to identify the origin of the infection and take appropriate action. In this regard, with the exception of the special siruation observed in the villages around Zoulo in the Bougouriba basin in Burkina Faso, most of the other positive cases detected were migrants who had settled in the villages in question; in the case of Togo, the migrants had come from the Asukawkaw region in Ghana, and in the case of Burkina Faso, they had come from the border region with C6te d'Ivoire. Extension Area 3.5. Epidemiologicalevaluation 3.5.1. Incidence studies Evaluation in the Rio-Geba basin in Guinea-Bissau and the Koulountou-Kolibabasin in Guinea treated with ivermectin alone for five years showed no new infections in children five years of age. Prevalence rates had been brought down from 16-23% to 0.0-3.2% and from 48.2-62.7% to 8.6- 44.6% respectively. 3.5-2. Other evaluations A study on the effects of combined larviciding and ivermectin treatment was carried out in 121 sentinel villages in the extension zones. Evaluation in one of the basins of Guinea (Milo basin) showed no incidence of infection after eight years of combined treatment in a cohort of 235 individuals whose tests remained negative for four years and in children less than five years of age who were excluded from ivermectin treatment. The expected incidence without any intervention is over 27 cases per year. JPCL7.6 Page 8 3.6. Ivermectintreatment 3.6.1. Large-scale treatment by the mobile teams Large-scale treatment is carried out by the mobile tearns, with support from OCP. Table 4 shows the results of large-scale ivermectin distribution by the Participating Countries from June 1995 to May 1996. 1,27'7,W individuals were treated and I,687,039 ivermectin tablets were distributed in 7,588 villages. Table 4. Large.scale ivermectin treatment by the mobile teams (June 1995 May 1990 Country Number of villages visited Census Population Population treated Coverage % Tablets distributed Benin* 11 67 272,969 203,652 74.6 227,303 COte d'Ivoire 1369 385,054 289,904 75.3 394,954 Ghana* 200 83,379 u,693 77.6 80,342 Guinea 1337 236,463 173,868 74.0 206,610 Guinea-Bissau* 3t4 54,202 39 ,727 73.3 91,940 Mali 442 69,208 50,674 73.2 85 , 369 Senegal* r57 36,408 27,279 74.9 53,117 Sierra Leone 908 166,236 116,576 70.1 135,714 Togo 1694 400,446 3lo,67l 77.6 411,690 Total 7588 1,704,365 1,277,0U 74.9 1,687,039 *In some basins, two treatments were administered in the year 3.6.2. Communiry-based treatment In countries such as Guinea, Mali, Senegal, Sierra Leone, community-based ivermectin treatment is in operation and is supported by NGOs (Sight Savers, OPC). In countries such as Benin, Cdte d'Ivoire, Togo, the institution of community-based ivermectin treatment is implemented through the gradual training of community health workers (cH'M). Action plans to accelerate the institution of community-based ivermectin treatment in all the Participating Countries as from this year were developed during the national workshops (see section 7). In Senegal the training of community health workers was conducted in April 1996 in connection with the follow-up activities of the workshop. Table 5 shows the results of community-based treatments in four OCP countries from June 1995 to May 1996. A high coverage rate of 773% on average was achieved through this mode of treatment. Country Number of villages visited Census Population Population treated Coverage % Tablets distributed Guinea 455 211,488 165,197 78.t 225,408 Mali 1464 786,301 620,398 78.9 892,U3 Senegal 299 78,281 58,881 75.2 87,391 Sierra Leone 54 13,272 10,234 77.r 14,701 Total 2272 1,089$a 854,710 77.3 1,230,343 JPC17.6 Page 9 Table 5. Results of community-based treatment 4. EVALUATION OF TVERMECTIN DISTRIBUTION PROGRAMMES The evaluation of ivermectin distributionprogrammes carried out in 1995 in Guinea, Mali and Senegal was continued this year in four other countries: Benin, C6te d'Ivoire, Ghana and Togo. The participation of four Coordinators in this independent evaluation allowed them to better appreciate the activities carried out in those countries. Overall, the treatment coverage of individuals in the sample villages evaluated is good, varying from 61..8% in Togo to 74% in C6te d'Ivoire (Table 6). Table 6. Coverage of ivermectin treafment in a sample of villages Country Treated Totd Percentage Benin 625 974 &.2 Ghana 620 866 7t.6 C6te d'Ivoire 548 761 74.0 Togo 509 824 61.8 Total 2303 3425 67.2 This evaluation revealed a high rate of individuals who have never received the drug (26%) as against orty 3O% of the individuals who have been fully treated during all the treatrnent cycles conducted in the villages. The main reason for non-treatment was absenteeism (54.47o). Other reasons mentioned were the lack of information on treatment days, sickness or engagement in various occupations. Orny 2% of the individuals refused the treatment. [t is important that the national teams of the countries intensify information, education and communication (IEC) activities in order to reduce the number of individuals having never been treated or refusing treatment. Similarly, the setting up of community-based treatment committees in those countries should improve the deficiencies of large-scale mobile treatment (26% of individuals having never been treated and 44.5% of individuals having partially been treated). A special srudy will be carried out in the countries to better comprehend the true motives for refusing treatment. JPCL7.6 Page l0 5. TRAINING AND REFRESHER COURSES 5.1. State of OCP fellowshiE From 1974 to 1996, OCP granted 453 fellowships to the Participating Countries. The first results of the srudies undertaken to identiff the departments receiving trainees after their return from training in African institutions show that 87% of OCP fellows are within the health sector (ophthalmology, epidemiology, entomology, public health etc.) among whom only 30% work in the national devolution prograrnmes. 5.2. Field training in OCP epidemiological evaluation methods During the epidemiological evaluation missions, some countries such as Benin, Ghana, Guinea, Mali, Senegal and Togo started training their laboratory technicians in the districts in the techniques of skin snipping and in the counting of microfilariae through the microscope. The number of technicians trained in each country to carry out epidemiological surveillance evaluation in the OCp methods is shown below. It must be noted that the training and skill enhancement of a greater number of technicians are scheduled in the training plans developed during national workshops (see section 7). Countries Number of workers trained Benin Ghana Guinea Mali Senegal Togo 5.3. National trainine seminars Seminars and refresher courses on IEC, ivermectin treatment and epidemiological surveillance were organized in Burkina Faso, Benin, Niger and Togo. 5.4. Other training seminars Training seminars in medical entomology and ground larviciding conducted by OCP were organized in Burkina Faso, C6te d'Ivoire and Ghana. CONTROL ACTIVITIES RELATED TO THE OTHER ENDEMIC DISEASES INCLUDED IN THE DEVOLUTION PLAN African human trypanosomiasis, dracunculosis, schistosomiasis, malaria, leprosy, tuberculosis, and yaws are the endemic diseases included in the national devolution plans of the countries. With the exception of Burkina Faso, the satisfactory implementation of the passive and active surveillance of the above mentioned endemic diseases is confronted with the lack of funding for the devolution plans and especially the absence of an integrated programme for the control of these endemic diseases in the national health systems. With respect to trypanosomiasis, some activities were carried out (detection, vector control and training) in Burkina Faso. 24 t2 03 06 06 15 6 JPC17.6 Page 11 Even though dracunculosis is included in the devolution plan of some countries, it is specifically treated vertically with its eradication as the objective. Investigations aimed at determining the prevalence of schistosomiasis were initiated in some countries such as Senegal and Togo; furthermore, 10 villages in the endemic onchocerciasis zone in Niger were treated with praziquantel. In C6te d'Ivoire, systematic detection of dracunculosis, schistosomiasis and yaws is carried out during the ivermectin distribution campaigns. In Benin, the recording of all cases of blindness is done during the ivermectin distribution campaigns. 7. THE INTEGRATION OF DEVOLUTION ACTryITIES Detailed planning of the integration of devolution activities was begun this year, during the three day workshops organized in all the participating countries with the support of the OCP as shown in the timetable in table 7. Table 7. Schedule of workshops in Participating Countries Month Country Date January Burkina Faso 29-31 February Togo I 9-21 March Senegal Sierra Leone Guinea 18-20 23-25 27-29 April Mali C6te d'Ivoire I 1-13 t5-17 May Ghana Guinea-Bissau 15-16 2t-23 July Niger Benin r0-12 t8-20 These workshops were aimed at developing in each country a plan of action and budget for three years (1996-1998) for the short term, and to provide estirnates for the medium and longer terms. In addition, the workshops centred on the decentralization of the onchocerciasis surveillance and/or evaluation system in the countries, and on the installation and implementation of a community- based ivermectin distribution prograrrune. All the countries agreed that decentralization of onchocerciasis surveillance is necessary as it facilitates integration and is in line with the reform of the health sector currently under way in the countries. The targeted level of decentralization varies from one country to another (see Table 8). The choice of the target level of decentralization of the surveillance of onchocerciasis is related to the number of sentinel villages to be evaluated every year, and above all, to the cost of the equipment needed to implement such decentralized surveillance. JPCI7.6 Page 12 Table 8. Level for decentralization for epidemiological surveillance PROSPECTS: DRAFT SCHEDULE FOR THE TAKE-OVER OF RESIDUAL ACTIVITIES BY PARTICIPATING COUNTRIES THROUGH THE END OF 1998 The Participating Countries developed, during the country-specific workshops, initiatives for the take-over of OCP residual activities. As shown in Tables 9 and 10, the Participating Countries have identified periods and dates for the training of their personnel in order to prepare them for the take-over of activities from the Programme. 8 Country Region District Zone Benin I Burkina Faso C6te d'Ivoire Ghana I Guinea Guinea-Bissau I Mali I Niger Senegal I Sierra Leone I Togo t-'l JPCl7.6 Page 13 Table 9. hoposed plan of training in epidemiological evaluation/surveillance N.B. Figures in brackets indicate the number of workers to be trained Country Personnel (number) Type of training Period of training Financing Burkina Faso Doctors (3) Advanced course in epidemiology July.-Nov. 96 ocP + wHo/ AFRO Lab. Tech. (4) Theory + practice July.-Dec. 96 OCP + Gvt Burkina Faso * WHO/AFROPersonnel Distribution (to be determined) C6te d'lvoire Doctor (42) Theory * practice July 1996 November 97198 ocP + wHo/ AFRO Lab. Tech .(63) Theory * passive diagnosis November 96/97 July 1998 Health workers (117) July 1997 Guinea District Doctor (26) Theory * practice (48) December 1996 (5a) April 1997 (54) April 1998 ocP + wHo/ AFRO I-ab. Tech. (126) Mali DMO (40) Theory * practice July to September 1996 ocP + wHo/ AFRO * Gvt MaliLab. Tech. (35) Sierra lrone District health team (13) Theory * practice October/December 1996 ocP + wHo/ AFRO * Gvt Sierra I-eone Lab. Tech. (78) Peripheral health unit workers (500) Passive diagnosis training June - Dec. 96 Gvt Sierra kone Communiry health workers (2000) Senegal District Doctor (4) Advanced course in epidemiology July 1996 ocP + wHo/ AFRO Lab.Tech. (7) Theory * practice April 1996 OCP Head Doctor and supervisors (7) Data analysis November 1996 OCP District Doctor (24) Modulated course/AFRO December 1996 WHO/AFRO Togo Lab. Tech. (24) Theory * practice October 1996 OCP Data entry Personnel Data management tPct7.6 Page 14 Table 10. Proposed plan of training for community-based ivermectin distribution Country Personnel Number to be trained Period of training Source of financing Burkina Faso Village Distrib. District health teams to be determined End 96 to 97 OCP + Gvt Burkina C6te d'Ivoire Community health worker (CH\lf) 351 From May 1996 ocP Guinea Village Distrib. Health centre nurses District health teams Regional Doctor 2674 110 45 7 End 96 to 97198 End96197 End 96197 End 96 OCP + NGO Mali Doctors Village Distrib Village Distrib Village Distrib 20 320 3& 196 End 96 July.-Dec. 96 Jan.-Dec. 97 Jan.-Dec. 98 NGO + OCP Senegal cHw 3t4 April 96-Nov. 96 NGO + (OPC) Sierra Leone District health teams (trainers) Dist. health teams Distr. community workers 30 s00 (to be determined) End June End June End September Gvt Sierra Leone NGO + OCP Gvt Sierra Leone Togo Nurses District health teams Distributors 260 138 3092 96-97 96-97 96-97 ocP OCP is gradually proceeding with a reduction of its financial and logistic support to the Participating Countries. Consequently, the Participating Countries have developed plans of action and budget for 1996-1998 with a view to a gradual take-over of the residual activities. 9. FOLLOW-UP TO THE WORKSHOPS With respect to the follow-up to the workshops, some countries have started implementing the resolutions adopted during their workshops as planned. For example, Senegal has organized the training of its technicians scheduled to carry out epidemiological evaluations in their respective regions; Togo has organized the training of trainers in the Kara basin for the implementation of the community-based ivermectin treatment; C6te d'Ivoire has begun the training of doctors in the OCP original area for onchocerciasis surveillance and evaluation, in Ghana, the regions and districts have completed the preparation towards their plans to be implemented. 10. DATA ANALYSIS AND INTERPRETATION, COMPUTER EQUIPMENT AND UTILISATION Two countries, Sierra Leone and Guinea-Bissau, provided their national teams with computers during the period considered. This computer and its accesories will be managed by the national teams of these two countries, the members of which have received "on{he-job" training this year on the various aspects of the OCP information system. ncn.6 Page 15 Benin, Burkina Faso, Cdte d'Ivoire, Mali and Niger have computers with adequate capacity to handle the transfer and analysis of all OCP epidemiological data. All the National Coordinators have received appropriate training in the use of the equipment from OCP. Technicians from Burkina Faso, Cdte d'Ivoire, Sierra Leone and Niger have also participated in training courses for the processing and analysis of the data. I 1. CONCLUSION The will to integrate onchocerciasis control activities in the health systerns of the Participating Countries has now become a reality. The results of the workshops organized by all the Participating Countries and OCP have revealed the necessity, and above all, the feasibility of the decentralization of onchocerciasis epidemiological surveillance as it falls in line with the reforms of the health sector currently under way in the countries in connection with their national policy. In the Original area, where epidemiological surveillance was established after the cessation of vector control, the countries have demonstrated their ability to detect any recrudescence of onchocercal infection and to bring it under control by means of ivermectin distribution. A genuine partnership between OCP and the Participating Countries for the success of the planning, evaluation and transfer of the techniques and activities of the OCP Programme is more and more perceptible and augurs a promising future for the period 1996-2002 and beyond despite the economic difficulties currently being experienced by the Participating Countries. 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