Progress report of the World Health Organization for 1999 (1 October 1998 - 30 September 1999)

African Programme for Onchocerciasis Control (APOC) Programme africain de lutte contre I'onchocercose JAF-FAC I JOINT ACTION FORUM Office of the Chairman JOINT ACTION FORUM FIFTH session The Hague. 8-10 December 1999 Provisional agenda item 5 FORUM D'ACTION COMMUNE Bureau du Pr6sident JAF5.2 ORIGINAL: ENGLISH September 1999 ; I PROGRESS REPORT OF THE WORLD HEALTH ORGANIZATION FOR 1999 (1 October 1998 - 30 September 1999) t $ (i) TABLE OF CONTENT Page I. EXECUTIVE SUMMARY INTRODUCTION PROJECT DEVELOPMENT AND IMPLEMENTATION 3 3.1. ProjectDevelopment... 3 3. 1. 1 Country Visits . 3 3.1.2. Administrative and Financial systems preceding financing of APOC approved projects 4 3.1.3. Rapid Epidemiological Mapping of Onchocerciasis (REMO) and Geographical Information System (GIS) 4 3.1.4 Advocacy, IEC and Exchange Programme on CDTL . . . . . 6 3.1.5. Workshops and Meetings . . 7 3.2 Project Implementation . 9 3.2.1 Financing First, Second and Third Year Projects 9 3.2.2 Ivermectin (Mectizan@) Distribution and Treatment Coverage . . . . . . . 11 3.2.3 Technical Progress Reports on re-orientation/installation of CDTI method 12 3.2.4 Progress Reports on financial management of CDTI projects 14 3.2.5 Administrative, Financial and Technical Constraints of CDTI implementation 14 3.2.6 Sustainabiliy of CDTI projects 15 I J2 3 4 3.2.7 Vector Elimination Projects a) Itwara Focus Vector Elimination b) FeasibiliLv study in the Mpamba-Nkusi Focus in Uganda c) Tukuvu Focus Vector Elimination in Tanzania d) Bioko Vector Elimination MONITORING OF CDTI PROJECTS 4.1. Backgroundinformation 4.2. Summary of Findings of the monitoring teams 4.3. Internal monitoring activities of the NOTFs 4.4. Communityself-monitoring 4.5 Community indicators of success of CDTI . . TRAIMNG AND CAPACITY BTIILDING 5.1. Local capacity building 5.2. Training of Project accountants 5.3. Training of Health Staff and Community Directed Distributors (CDDs) 20 z0 20 20 2t 2t 2l 22 23 23 23 24 24 25 25 5 6( ii) LONG TERM IMPACT ASSESSMENT OF APOC OPERATIONS Background information Summary of Results . . 6.2.1 Sociology 6.2.2. Dermatology... 6.2.3 Ophtalmology . . 6.2.1. Entomology 6.3. Constraints 6.4. Summary OPERATIONAL RESEARCH AND COLLABORATION WITH TDR & HEALTHMAP COLLABORATION BETWEEN OCP AND APOC CONTRIBUTION OF AFRO CONTRIBUTION OF NON.GOVERNMENTAL DEVELOPMENT ORGANTSATIONS (NGDO) COLLABORATION BETWEEN THE NOTFS AND OTIIER SECTORS 12. CONCLUSION 6.1. 6.2 26 26 28 28 28 29 30 30 3l 31 32 32 JJ 33 33 34 35 35 36 36 37 7 8 9 10 11 Annexe 1 Annexe 2 Annexe 3 Annexe 4 Annexe 5 Annexe 6 Rapid Epidemiological Mapping of Onchocerciasis (REMO) in APOC Countries Rapid Epidemiological Mapping of Onchocerciasis in Liberia Rapid Epidemiological Mapping of Onchocerciasis in Rwanda Rapid Epidemiological Mapping of Onchocerciasis in Kenya Rapid Epidemiological Mapping of Onchocerciasis in Cameroon Rapid Epidemiological Mapping of Onchocerciasis in CAR JAF5.2 Page I I. EXECUTIVE ST]MMARY The APOC partners have achieved much over the last three years of operations. In the year under consideration, the following activities were undertaken: (i) Selection of communities for ivermectin (Mectizan @) distribution The Programme partners completed nation-wide Rapid Epidemiological Mapping of Oncliocerciasis (REMO) to prioritize liigh-risk communities in Rwanda and Liberia. The National Task Force of Cameroon also received financial and technical support to refine REMO in the Centre Province. (ii) Forrnulation of National Plans and Project proposals With the support of the Technical Consultative Committee (TCC) and the Non-Governmental Development Organisations ( NGDOs), the Management coordinated the preparation of one national plan and twelve new Community Directed Treatment with Ivermectin (CDTI) projects proposals, bringing the total of projects to be funded from the APOC Trust Funds to fifty seven (s7) (iii) Project Implementation Out of the fifty seven approved projecs, fifty (50) received money from the Trust Fund to implement activities. Over 13 million people received ivermectin through APOC supported programmes. The partners initiated APOC activities in Rwanda, Liberia, Ethiopia and in the Democratic Republic of Congo. Thirty-four (34) trtters of Agreement were signed with 11 countries for first, second and/or third year projects. On-going CDTI projects made remarkable progress in communiry involvement and participation in decision-making. Among 21 CDTI projects, 77% of the 19,288 communities treated selected ivermectin distributors (CDDs) from among their own ranks and one-third provided incentives to distributors. In these communities, previous delivery methods - mobile and community-based are being replaced by the APOC CDTI method. a Vector elimination activities are on-going in four foci in three countries: Uganda, Tanzania and Equatorial Guinea. (rv) Independent Monitoring of CDTI projects a Following a reassessment workshop for stakeholders in May 1999, the APOC CDTI rnonitoring instruments were finalized in two languages. Fourteen projects in five countries (Chad, CAR, Cameroon, Nigeria, Tanzania) were monitored by joint teams consisting of independent scientists, district project managers and representatives of the NGDOs. Also, the Programme initiated community self- rnonitoring in three countries. a a o a .lA Ir-5.2 Paec 2 (v) Training To improve the management of Trust Funds by the National Onchocerciasis Task Forces (NOTFs), the Programme's core activities centred on training and retraining of the Administrative and Financial Management staff of the Ministries of Health attached to the Onchocerciasis control activities of APOC. Fifty (50) people in seven countries received additional training on fund management and budget rnonitoring. a Significant achievements were also made in the area of training on CDTI lnethod. Seven thousand five hundred and seventy (7,570) health personnel (around 60% were peripheral health staff) and over 32,000 community-directed distributors (CDDs) were trained on the CDTI method. a Local capacity building has been supported by training all cadres of health personnel, scientists and technicians on CDTI, through the impact assessment and monitoring activities carried out in the year. Over 400 people in APOC countries were trained in bio-medical and social science rnethods and these are assisting the National Task Forces with internal monitoring of the projects. (vi) Baseline snrdies on the long-term Impact Assessment of APOC operations Another important achievement is the successful collection of baseline data for impact assessment of APOC operations. Work has been completed on the opthalmological, dermatological and socio-economic aspects of the study in eleven (11) sites in eight (8) countries. Entomological data were collected during two visits in each of the eleven sites. Data analysis workshop was held in Ouagadougou and a report will be available during the first quarter of next year. (vii) OnerationalResearclr Continuing the search for better and innovative method of installation of CDTI, the programme research arm, the TDR Task Force on Onchocerciasis and Lymphatic Filariasis pursued the intervention phase of the multi-country research on sustainability of CDTI. (viii) Partnership Links were strengthened with NGDO partners and their representatives in the countries (ix) Future plans o There are key areas to which the Programme will be directing special attention next year. The first is to improve the performance indicators with set targets on coverage, community participation, female participation in CDTI, supervision of activities at all levels and to re-train more peripheral health staff on CDTI. The second, timely disbursement of Trust Funds, will continue to receive adequate attention. The NOTF and Management of APOC will intensify advocacy visits and sensitization of participatrng governments to increase their financial contributions and political support to Onchocerciasis control. Tlie guiding principles of APOC to work in partnership and to set realistic priorities will be rnaintained. a o JAF5.2 Page 3 2. INTRODUCTION In spite of the difficulties of this complex programme, APOC partners are obtaining experiences, good practices and successful strategies for delivering drug to those at the end of the road and strengthening health care services through building partnership with the neglected population of the endemic countries. In two years of operation we have Iearned that transiting from vertical to conulunity-directed approach in drug delivery is feasible. 3. PROJECT DEVELOPMENT AND IMPLEMENTATION 3.1. PROJECT DEVELOPMENT 3.1.1 Country Visits The basic functions of the Management of APOC are to support the onchocerciasis control activities of the National Task Forces - a partnership between the Non-Governmental Development Organisations (NGDO) and the Ministries of Health, and to assist in insuring that these activities are carried out efficiently and at optimum cost. During the period under consideration joint rnissions by the Management of APOC, WHO/AFRO and NGDOs were undertaken to six (6) countries - Cameroon, Gabon, Tanzania, Malawi, Liberia and Ethiopia. The principal aims of the country visits were to: (i) ( ii) keep the national health authorities abreast of the evolution of the Programme; sensitize key national decision-makers, the partners and some recipient communities to lend support to the activities of the projects; initiate the elaboration of national plan and project proposals; negotiate with the national authorities the struchrres to be put in place and the procedures for transferring funds from the Trust Fund to the country for the execution of approved projects; follow up the implementation of approved projects and provide Technical assistance to the National Onchocerciasis Task Forces (NOTFs) on project management. (iii) (iv) (v) In Gabon the mission efforts centred around the establishment of the structure, administrative and financial functions of the NOTF, completion of the Rapid Epidemiological Mapping of Onchocerciasis (REMO), procurement of ivermectin and ownership of the programme by the health care services and affected communities. The mission and the parties agreed that as an interim arrangelnent the country office of the WHO will be responsible for iveremectin procurement and clearance. In Liberia, there is no onchocerciasis control programme because of the country's years of civil war. Over half a rnillion people are at high risk of onchocerciasis. As a result of the country visits, a national plan and a CDTI project proposal have been formulated and approved. Sequel to the visit to Ethiopia, drafts of a national plan and two CDTI project proposals have been completed and invitation has been extended to the NGDOs for collaboration with the National Task Force. .IAF5 2 Page 4 It is irnportant to note that during the mission in Cameroon, the delegation of APOC and the NOTF suspended urass treatlnent with ivermectin in the villages of Okola and Obala in the Centre Province (Centre 3 CDTI project) of Cameroon following reported cases of severe adverse reactions atier ivermectin treatment. A derailed documentation of the clinical history of the cases were prepared by the NOTF and was forwarded to the Mectizan Donation Program (MDP) and the Management of APOC. As a follou'up, the Management organised additional Rapid Epiderniological Mapping of Onchocerciasis (REMO) in Centre 3 Province. An important outcome of the mission to Malawi was the strengthening of the partnership, better understanding by the NOTF members of the roles and responsibilities of the partners and det-urition of training and treatment targets. During the joint visit to Tanzania, CDTI projects were reviewed. The rnission concluded that lack of accurate census data, insufficent communication among stakeholders and inappropriate response ro the programme duties were the major problems affecting the performance of the projects. The enonnous contribution of the NGDO partners to the programme is worthy of mention. The countrl'visits also provided unique opportunities to sensitize country representatives of rhe executing agenc)' on disbursement of funds and supervision of the activities of on-going projects. 3.1.2. Administiative and Financial systems preceding financing of APOC approved projects A prerequisite preceding the disbursement of APOC funds fbr the start of approved projects rs the setting up of a reliable adrninistrative and financial systern at the various NOTFs level- national and district. To set up efhcient financial systems at the NOTF levels, the APOC Management organised rnissions to Gabon, Malawi, Nigeria, Uganda and Sudan between October 1998 and August 1999. During the rnissions. accountants to the NOTFs' headquarter secretariat and from the projects were trained in the WHO imprest system. 3.1.3. Rapid Epidemiological Mapping of Onchocerciasis (REMO) and Geographical Information System (GIS) The results of the Rapid Epidemiological Mapping of Onchocerciasis (REMO) integrated into the Geographical Information System (GIS) enable the selection of hyper- and meso-endemic communities eligible for Community Directed Treatment with Ivermectin in APOC countries. The current status of the REMO in all APOC countries with approved projects is illustrated in Annex l. Based on the currenr estimates, 56.9 million people are eligible for treatment (table l). In 1999, a concerted effort to complete and/or refine the REMO had been rnade, and this had been achieved in Lrberia, Rwanda, Kenya, Cameroon, Nigeria, Tanzania and Central African Republic. In Liberia, a nation-wide REMO exercise was conducted. By integrating REMO data into the GIS it is estirnated that 990,000 persons are eligible for large scale ivermectin treatment (Annex 2). JAF5.2 Page 5 In Rwanda, the result showed that onchocerciasis is hypo-endemic throughout the country (Annex 3). In Kenya, the Rapid Epidemiological Mapping was conducted in the Western part of the country. The selection of the Western part was based on the previous knowledge of the distribution of the disease in the country. The results indicate that onchocerciasis is hypo-endernic(Annex 4). To obtain a complete picture of the disease pattern in the entire country, REMO will be extended to the other regions in the year 2000. In Cameroon, following reports of cases of severe adverse reactions observed in communities of co-endemicity of onchocerciais and loa loa, a REMO refinement exercise was carried out in the Province of Centre 3. This exercise was completed in July 1999 (Annex 5). The results showed that the cornrnunities where cases of severe adverse reactions (three of which were fatal) had occurred were hr,po-endemic and co-endemic for loasis. Further refinement of the REMO will be conducted in the other Provinces of Cameroon where additional information on severe adverse reactions is needed. Also, in the Central African Republic, the Rapid Epiderniological Mapping of Onchocerciasis has been completed in the South-Western part of the country which shares a common border with Carneroon. The results indicate that this region of the CAR is hypo-endemic for onchocerciasis (Annex 6) To detennine the extent of the cross-border issue between Nigeria ( APOC member country) and the Republic of Benin (within the OCP area) where control activities have been on-going for many years, a further refinement of REMO in Niger State, Nigeria, will be completed by the end of this year. In Tanzania, the proposal to conduct REMO in tlie Tanga and Tukuyu regions was approved arrd tield activities are scheduled to start in the dry season, frorr October 1999. .IAF5.2 Page (r Table I : Status of REMO/GIS and estimated number to be treated REMO estimates **: Estimated number of persons to be treated Pro-[rarnme Document*: Number of persons inf'ected by-1Q. volvulus 3.1.4 Advocacy, IEC and Exchange Programme on CDTI The Management continues to provide additional support to the NOTFs to mount aggressrve public awareness and population mobilization campaign on APOC activities. Eighty (80) video-tapes on dift'erent public service announcements for use in country and at the international levels were REMO/GIS NUMBER OF PERSON Counrtry No REMO Partially Largely Completed REMO/REA** Prog.doc. * Angola X 380 000 100 000 Burundi X 540 000 143 000 Cameroon x 3 670 000 l 300 000 CAR X 840 000 390 000 Chad x r 270 000 870 000 Congo x 190 000 50 000 DRC x 17 360 000 4 565 000 Eq. Guinea x 230 000 60 000 Ethiopia x 3 100000 929000 Gabon x 230000 60000 Kenva X Liberia X 990000 600000 Malawr x r400000 150000 Mozanrbique x Nigeria x 22260000 3302000 Rwanda x Uganda x 1530000 1200000 U.R.Tanzania x 1310000 6s0000 Sudan x 1690000 620000 Total 56990000 14998000 .IAF5.2 Page 7 distributed to the partners. Also, 500 copies of IEC leaflets (concise version of the manual) were made available to field staff in Malawi and Uganda. During the period under review, the APOC/CDTI Practical manual for training comrnunity- chosen distributors was translated into French and 5000 copies had been printed. Additional 3000 copiesoftheEnglishversionwereprinted. ByDecernberl999,atotalof2T50copiesofEnglishand French versions would have been distributed to I I countries. The Programme has also ltnanced the translation and printing of 2000 copies of tlie Arabic version . Intensive advocacy through the radios and television media, were undertaken in the current period by the NOTFs of Sudan, Tanzania, Nigeria, Cameroon and CAR. Newsletters, leaflets and radio jingles in local languages have been developed by the countries. The National Task Forces of Nigeria, Sudan, Cameroon and Tanzania organized activities to mark the "Onchocerciasis Control Week" in the countries. In Nigeria and Sudan, the activities included press-conferences and symposia organised by the NOTFs and attended by the Honourable Ministers of Healtli. To sharpen the skills of district/state level Onchocerciasis control coordinators in the irnplernentation of community-directed treatment method, the Management of APOC initiated an Exchange Programme for on-going projects. The aim is to provide opportunity for task managers to improve their skills in the process of entry into community, mobilization and sensitization of potential groups in the community. The Coordinators will exchange experiences with other projects within or outside their own countries. The beneficiary of the first Exchange Programme was the Coordinator of the CDTI project in Juba, Sudan. As a recognition of the impressive performance of the Cross River State Project in Nigeria, in community mobilization, the Coordinator of the Project in Juba, Sudan was sponsored by the Programme to work with the Cross River State Project for one month. This initiative will be an annual activity of APOC. 3.1.5. Workshops and Meetings During the period under consideration, the Programme financed 4 rneetings and l1 workshops (Table 2). Thirteen of these activities were hosted by member countries and two were held in Ouagadougou in Burkina Faso. .IAF.5 2 Pagc 8 Table 2: Workshops and Meetings sponsored by APOC in the year under review * Trarnrng workshop for prolect accountant for South Sudan was held rn Narrobi, Kenya Out of the 1l workshops organised in the period under consideration, nine (9) workshops were on rhe financial management of the Trust Funds. The workshops focus was on the regulations in the Lerrers of Agreement, WHO imprest cash book, disbursement and management of APOC funds and rnonitoring budget line items (table 2). In May this year a stakeholder workshop was hosted by the Government of Uganda in the district of Kabale. Sixty-six ( 66) participants from 4 countries - Uganda, Malawi, Sudan and Nigeria attended the workshop. Participants consisted of 53 districts onchocerciasis coordinators, represen[atives of the NGDO coalition, 3 APOC staff and 10 scientists who monitored CDTI projects in 1998. This workshop provided the stakeholders a participatory forum to review the findings of the 1998 rnonitoring, reassess the instrument and decide on corrective actions. Among others, they recommended increase in the participation of state/district managers and NGDOs partners in monitoring CDTI pro;ects and reviewed the instrument on community self - rnonitoring. Details on the objectives and outcorne of the rvorkshop are provided in the document JAF5/INF/DOC.2. According ro the ratings of district project implementers who attended this workshop, areas that need stakeholders corrective and collaborative action are: (i) (ii) (iii) (iv) (v) training/retraining of health staff and ivermectin distributors; identification and sensitization of local organized village groups to improve entry into communities; show of political support by the Ministries of Health; regular supervision and monitoring and, development of IEC materials. ACTIVITY Nrgena Uganda Cameroon Ethiopia Ouaga Tanzanra Sudan* DRC Gabon Malawr Morrrtorrng I nstrurlent + Rcvlew nrectrngs x x x x lnrplrct Asress nrenl Workshop x Der eloprren t ol Natronal * Pro.;ecr Proposal Worlshop x Trarnrng Workshop tirr Pro1ecr acc()u ntants x x x x x x x x x .IAF5.2 Pagc 9 3.2 PIIOJECT IMPLEMENTATION Fig.1: 57 Approved Projects (1996-1999) s 30 l0 CDTI Vecto r HQ 3.2.1 Financing First, Second and Third Year Projects In 1999 , the budgets of 34 projects were reviewed, downscaled and the preparation of Letters of Asreemerrt for the 34 projects was finalised. Of tliese 34 projects, 12 are in their first year (8 in Nigeria, I in Uganda, 2 in DRC and 1 in Gabon) of project irnplementation. 18 are in the second year (l in Equatorial Guinea. 3 in Carneroon, 1 in Chad, 8 in Nigeria, 1 in Central African Republic, I in Sudan, 2inTanzania artd I in Uganda) and 4 in the 3'd year (1 Malawi and 3 in Nigeria). The total corunitment in 1999 for these 34 projects to be paid from the APOC Trust Fund is US$ 4,459.895. It is worthy of note tliat the revision work undertaken by the Management of APOC on the budgets of these pro.iects resulted in the reduction of 34% on the initial budgets submitted by the NOTFs, hence enablirts the Management to make a considerable saving for the Programme. Details on the Letters of Agreements flnalized for the 1999 budget are presented in table 3. Of the 34 lrtters of Agreement,2l have been signed between APOC and the NOTFs at the time of the preparation of this report and part funding for implementation fbr the f-lrst or second year paid into the NOTFs account. It is expected that the rernaining i3 Letters of Agreernents will be signed by rnid-December 1999. Also, the first instahnent of funds had been released to nine (9) new projects in four countries. Secrtud instalment was rnade available to some projects while instructions have been given for the payment of'tlte first instalment of funds to the NOTF in the Democratic Republic of Congo (DRC). 48 54 .IAF5.2 Page l0 Table 3: Letters of agreernent finalized for the 1999 budget C()TiNTRY PROPOSALS No. BUDGET US$ Submitted Approved EG. (;TIINEA Bioko Vector Elimination Pro.lect Year 2 I 174,070 174,070 CAMEROON South West I CDTI Year 2 I 172,570 137,726 Centre III CDTI Year 2 I 666,338 143,863 National Secretariat Support Year 2 1 170,720 81,350 MALAWI Thyolo and Mwanza CDTI YEAR 3 1 161,538 t69,t37 NIGERIA Niger State CDTI I 327,830 200,240 Ondo State CDTI I 237,332 l7l,680 Benue State CDTI 1 245,120 157,160 Kebbi State CDTI I 108,555 93,525 Kwara State CDTI 1 103,495 99,972 Federal Capital Territory Year 2 I 48,170 5l,783 Plateau/Nassarawa State Year 2 I 178,758 101,669 Osun State Year 2 I 2t2,900 138,396 Enugu/Anambra/Ebonyi Y ear 2 I 479,429 249,532 Imo/Abia State CDTI Year 2 I 184,285 124,109 Kano State CDTI Year 2 I I I1,961 85,903 Yobe State CDTI Year 2 1 111,735 62,737 Zamfara State CDTI Year 2 I 36,325 32,546 NOTF/HQ support Year 3 1 249,tt0 L63,520 Cross-River State CDTI Year 3 1 131,861 99,855 Kaduna State CDTI Year 3 1 84,522 56,361 Edo/Delta State CDTI 1 589,313 305,655 Oyo State CDTI I 192,302 150,152 Jigawa State CDTI I 90,500 72,885 CAR CDTI project for CAR Year 2 1 172,376 122,189 SLiDAN Southern Sector CDTI Year 2 I 237,405 184,470 TANZANIA Ruvuma CDTI Year 2 I 85,528 87,451 Tukuyu Vector Elimination Year 2 I 158,247 130,041 TIGA\DA Itwara focus Vector elimination Year 2 1 23,009 23,009 Adj umani/Moyo/Apac/Gulu/Kibaale I I 48,160 t29,774 DRC HQ Support 1 100,730 82,130 Kasai CDTI I L95,874 124,721 GABO\ Gabon HQ + CDTI 1 137,500 108,182 CHAD CDTI pro.iectYear 2 1 471,731 344 t t02 TOTAL US $ 34 6, PERCENTAGE OF REDUCTION 34Vo 445989! .IAF5.2 Page 1 I 3.2.2 Ivermectin (Mectizan@) Distribution and Treatment Coverage a) Treatrnent of target communities ( geographic covera-qe) In 1999, APOC approved the commencement of l2 new CDTI projects in 5 countries including Liberia. Thus, between 1996 and 1999, a total of 48 CDTI projects have been approved (figure 2). The l]rethod of Community-Directed Treatment with Ivermectin has to a large extent replaced previous delivery stratesies (rnobile and Comrnunity Based Treatment) in seven (7) of the eleven (11) APOC countries wl-tich are currentlv receiving Trust Funds. During the period under review, 19,288 (71 .9Vo) of 23,071 target communities were treated in eight countries ( Chad, Cameroon, CAR, Malawi, Nigeria, Tanzania, Sudan, Uganda). In Tanzania, all the target conllunities received treatments and less than 5i% of the communities in Uganda and Malawi have received trearlnent. At the tirne of the preparation of this report (September), the rnean geographic coverage within tlre projects in terms of the percentage target communities which received treatment is 68.1Vo for the eight countries mentioned above for which complete information was available. Ivermectin distribution is on- going in a nurnber of communities in Malawi, Uganda, Nigeria, and in the Northern and Southern Sudan. It is worthy of note that despite the prevailing civil war, the APOC partners provided treatment to 198 comrnunities in Southern Sudan through the activities of a consortiurn of 26 NGOs coordinated by HealthNet International. Fisure 2: CDTI oroiects aooroved. imolemented and monitored in 1996-1999 a{) 45 40 $ :! 25 1) 1a lrl ,! oF No. of pro.iecls eproved No irrplerrEnted No. nDnitored 48 41 23 7 2 0 .rAF5.2 Page 12 b) Population (Treatment) Coverage During tlie period under consideration, more than 13 rnillion people were treated with iverrnectin. Tltis represents 51Vo of the annual treatment objective of APOC. 10.5 rnillion treatments were provided througli tlte CDTI method (by community members). With distribution still on-going in Uganda, Cameroon, Nigeria, CAR and Sudan at the time of the preparation of this report (Septernber), the number of treatments will exceed l5 rnillion people by December 1999. The mean coverage within the projects in terms of the percentage of individuals treated compared to the total population u'asJ7% for the highest mean coverage, and 22% for the lowest. After the first year of CDTI ilnplementation, coverage rates have improved in a number of sites. Tlie target of using the CDTI rnethod to distribute ivermectin to more than 65Vo of the target population was achieved in the current year by l6 of the 21 projects for which information was available. This includes the project in the South West Province of Cameroon. In spite of the prevailing situation in Sudan, over 85,000 people were treated in Southern Sudan and ivermectin distribution is still on-going at the time of the writing of this report. Similarly in the Northern Sudan, 77,591persons \\ere treated inJuba, Wau, Aweil and Alradoum areas and treatment is still on-going. In October 1998, the local NGDO (MITOSATH) announced that based on the advise on the strategic options for treatment from the APOC mission, it succeeded in treating communities in Takum and Ussa local Government -\reas in Nigeria where there was communal clash. This effort yielded the treatment of 45,428 people in Tak-um and21,694 people in Ussa. After obtaining a cease fire agreement from communiry leaders and providing treatment to high-risk communities the fighting did not continue. 3.2.3 Technical Progress Reports on re-orientation/installation of CDTI method In 1999, the Technical Consultative Committee (TCC) of APOC reviewed the Programme's activities, one National Plan, 19 new CDTI Project Proposals and 56 financial reports and project budgets. The corunittee also reviewed 42 technical reports on progress towards re-orientation of approved ivermectin delivery projects to communiry-directed treatrnent with ivermectin (see doc.JAF5.4, JAF5.5, JAF5.6 and table 4). At the time of the preparation of this report, complete information frorn 21 projects on CDTI process implementation was available. The projects are in Cameroon, CAR, Chad, Nigeria, Malawi and Tanzania. The reports showed that the national Task Forces mobilised 19,288 communities and these to a large extent sliowed willingness to share responsibilities in ivermectin delivery. As example , 14,899 ( 77 .ZVo) of tlie 19,288 communities selected their own ivermectin distributors (CDDs); 69% collected ivermectin from tlre lrealth centres and 357o provided incentives in cash or kind to distributors (table 6 Indicators on decision- rnaking by cornrnunity) In the Democratic Republic of Congo and in Southern Sudan, the installation of ivermectin distribution by CDTI method could not materialize because of the prevailing social unrest. The Programme will continue to explore alternative strategies that will enable ivermectin treatments to be provided to displaced populations and comrnunities in conflict and those in inaccessible areas such as communities in Kisoro District in Uganda. JAF5.2 Page 13 Judging by the performance indicators, there is progressive involvement of communities in four areas of pro-iect irnplementation. These are: (i) selection of their own distributors of ivermectin (CDDs); (ii) collection of drug from health centres/posts, (iii) decision-making on method of distribution, (iv) support and/or incentives to CDDs ( there is need for improvement) While more than 60Vo of the communities decided on the month of distribution, less than one-third received ivermectin at the point of collection on the agreed month. This is in part due to poor planning by the NOTFs on timely procurement and delivery of drug to the collection point agreed with the communities. Active parriciparion of rninority groups (women and youth) in decision making in CDTI activities was reported in few technical progress reports. Table 4 3 Vector Elirnination 2 Research Proposal 3 HQ Support and 34 First and Second Year CDTI Project Reports '' Technical reports consisted of: .rAF5.2 Page 14 3.2.4 Progress Reports on financial management of CDTI projects On the basis of the review of the TCC and the assessment of the Management, more than 70% of the pro.jects submitted accurate financial reports following the guidelines of the executing agency. It is worthy of note that there has been no misappropriation of funds in any of the 41 approved and on-going projects, of which financial returns reviews have been conducted. Feedback to the NOTF from APOC Management were occasionally delayed in part due to errors in the submissions by the Task Forces. In countries where APOC is supporting more than 10 projects (e.g. Nigeria), additional staff were hired by the WHO country office to support administrative and financial management of APOC projects. This has minimized the duration of delays in disbursement of funds and has irnproved the quality of the monthly financial statements. The payrnent of subsequent replenishment of funds to the projects are subject to regular transmissions at the end of each month of a copy of the bank statement reconciled with list of all clieques drawn from the Trust Funds. The rate of transmission of these monthly statements had not been optimum. The reasons included Delays in the expenditure returns from the district/state offices to the National Secretariat at the end of the month; Delays by the NOTF Secretariat in the compilation of the returns to the APOC Headquarters; In some instances, the WHO country offices were late with verification of the imprest returns and in communicating the findings to the Management. This is in part due to shortage of support staff in many WHO country offices. 3.2.5 Administrative, Financial and Technical Constraints of CDTI implementation a) Government commitment and Health Care systems While the communities have shown keen interest in CDTI irnplementation, the commitment of the Ministries of Health in sorne countries is not assured. Few Programmes have succeeded in controlling disease without strong political commitment at the highest level of government. Political and financial commitments were made by the Government of Sudan to the Northern Sudan project and 3 State Governments in Nigeria: Taraba, Federal Capital Territory and Kano States. Other national governments contributed funds for disease control as a whole from wliich funds for CDTI activities had been drawn. Details of these contributions by the participating countries will be presented to the Joint Action Forum by the National Coordinators. However, two-thirds of the technical reports itemised challenges facing the projects in the area of CDTI implementation as: Iack of strong commitment from the Ministries of Health; the need to strengthen the health care system for supervision of ivermectin distribution in difficult - to - access villages; insufficient IEC materials for sensitisation of communities and the public- JAF5.2 Page I 5 Because successful integration of the CDTI into the health system will depend also on the release of counterpart fund by the national/state/district level governlnents, demonstration of government comrnitment rueed to irnprove. b) Disbursement of funds to the projects Projects have reported delays in implementation due to late disbursement of funds by the executing agency, the governments or the NGDO partners. Following the TCC8 meeting which discussed problems surrounding disbursement of funds, APOC Mana_eelnent reviewed the causes of late disbursement of funds and identified the following as the main ones: Delays by the NOTF in responding to the queries and issues raised by the TCC and the CSA on technical and budgetary matters; Lack of details and clarity in budget justification; Late submission of financial reports and request for the release of subsequent funds; errors in project budget; Delays by the Management in the revision of budget and of WHO/AFRO (regional and country offices) in releasing subsequent instalments; Poor communication between the APOC Management and the NOTFs; Inadequate financial procedures of some participating governments and NGDO partners The Management of APOC, following the identification of these bottlenecks is taking concrete steps to rninimize delays in the disbursement of subsequent funds to the projects. 3.2.6 Sustainabiliy of CDTI projects a) Programme's indicators of sustainabilir.v Sustainability of the CDTI projects refers to the ability of governments and communities to sustain the achievements after the cessation of the Programme. A project is allowed 5 years to put in place viable infrastructure and organizational support to sustain the CDTI activities and to maintain high coverage rate that could eventually stop transmission. The key indicators of sustainability of APOC ivermectin delivery strategy include: Community involvement in decision-making in design and implementation of CDTI; Evidence of the commitment of Government; Integration of CDTI into the Health systems; Use of CDTI to establish PHC or as entry point to other health services; Adequate treatment coverage and cornpliance rate. i) Decision-making by community As shown in the Table 5, the strength of Communiry-directed treatment with ivermectin rnethod lies in the very strong commitment of participating communities. There is evidence from the reports of 21 on-going projects that communities are willing to participate in distribution and be responsible for the ownership of the programme (see section 3.2.3, table 5). The challenges are: (i)how to improve knowledge of comrnunity .tAIr5.2 Page I 6 rureurbers on what role is expected of them (ii) to improve community support and incentives to CDDs in order to reduce tatigue and attrition rares among them. As mentioned in section 3.2.3, only 35% of the almost 20.000 comrnunities paid incentir-es to CDDs. ii) Evidence of Government commitment A number of districts/ states and national level governments have demonstrated commitments to onchocerciasis control. In Uganda and Tanzania, onchocerciasis control is inctuded in the "Minimum Health package,' and in Cameroon it is part of the Minimum Package for Health Centers. Allocation of 5% cost recovery funds to treatment of side effects has also been approved in Cameroon. In May 1999. follorving a request from the Management of APOC, the Ministry of Health, Uganda updated the guidelines for "pHC Conditional Grant" to include onchocerciasis, thereby empowering district aurlioriries ro commit funds to support CDTI activities. In Chad, Nigeria, Tanzania, Cameroon and Uganda budget lrne item for onchocerciasis control has been established at the national and district levels while CDTI is included as a sub-component of the PHC in few districts/states. Through the advocacy activities of the Taraba State (Nigeria) Onchocerciasis Control Team, the State Government financed the construction of a vocational Rehabilitation Centre for blind victims in the State, a project which has cost 10 million Naira ($125'000). However, for a number of projects, the difficulty is with actual release of funds budgeted. iiD Integration into the Health systems It is important to mention that in seven of the eleven countries receiving Trust funds, ivermectin is now in the ,,Essential Drug list". To date integration of ivermectin procurement into the national drug system ald delivery from port to community is taking place in 9 APOC countries, however, the experiences of these countries vary. ln Tanzania and Malawi, procurement of ivermectin is being undertaken by the national medical stores; in Cameroon, Chad and DRC the NOTFs are assisted by the WHO country offices to procure ivermectin. In Uganda, CAR and Nigeria the NGDOs assist with the procurement of drug. Based on a study undertaken in 199g by the WHO Action programrne on Essential Drugs (DAP) there is a case to be made for involving other parries (the office of the WHO representatives, NGDOs) at least for the time being in the procurement of ivermectin. The onchocerciasis control activities in Adamaoua II Province in Cameroon is integrated into the pHC(JAF5/INF/DOC.5l. InKisorodistrict(Uganda)andosunState(Nigeria)therecordsofthecDDsare now used for other pHC programmes (see 1998 monitors report on Kisoro; Osun State Technical report, 1998- ee) Integration is also measured by the proportion of treated villages in which the ivermectin distributors are supervised by the pHC system. This responsibility has been taken over by the health care system in CAR' Carneroon and in some states in Nigeria. To illustrate with few examples, in Cross River, FCT, Osun and Ebonyi States in Nigeria. in Kabale district in Uganda and in Ruvuma district in Tanzania PHC facilities are being used as collection points for ivermectin. In Cross River and Osun states, the MOH vehicles for Monitoring and Evaluation units are also used for CDTI mobilization and supervision activities. This year in the CAR, 253 ivermectin distributions were supervised by the health system- iv) Use of CDTI to establish PHC or as entry point to other health services Because the CDTI method is refatively uncomplicated and feasible, it is a good entry point tbr- the initiation of other health services, to influence or establish the PHC system where it does not exist. .tAF5.2 Page l7 In the Central African Republic, the CDTI method had led to the introduction of a wider primary care services in the Bocaranga district in the north-western region. In this district, community selected distributors (CDDs) received additional training and subsequently became involved in other health care activities. Some becarne health workers in charge of a health posts. Other areas in the region were then sensitized to begin silnilar activities and this has led to an increase in the number of health posts in Bocaranga district. In Sudan, other forms of health services are made available to communities under civil unrest through CDTI activities. For exarnple, with the discovery of a large number of blind cases not due to onchocerciasis but could be surgically treated, in Raja, following the hnpact Assessment srudies, a team composed of ophthahnic surgeons, rnedical and technical assistants from the Ministry of Health was organized by NOTF/Sudan to provide other health services to communities. A total of 1409 persons were screened and provided with rnedical care. One hundred and thirty one (131) operations were performed. In Cameroon, the CDTI project of the South West Province has initiated special training for literate CDDs to assist the Health care services with the identification of cases of leprosy in target communities. v) Adequate treatlnent coverage and colnpliance rate. The performance of projects on treatment coverage rates is provided in sections 3.2.2 & 3.2.3 of this document. Because compliance of target communities to ivermectin treatment is important to reduce transmission, in time, the monitoring exercises ( e.g household surveys) will provide reliable information on whether good compliance rate has been achieved. In addition, it will also provide information on coverage rate. b) Findings of study on sustainability Three years into the operations of the Programrne, a consultant reviewed the irnplementation of CDTI projects. The airn is to identify critical factors for long-term sustainability before cessation of external support and to make recommendations to enhance sustainability of projects. The consultant made an extensive review and analysis of programme activities and relevant documents, made reference to the reports by independent monitors, interviewed members of the NGDO ad hoc comrnittee on sustainabiliry, held briefing sessions with APOC Management staff and made field visits to three CDTI projects in Cross River and Taraba States in Nigeria and in the Central African Republic. The APOC operations were examined under three interrelated dimensions of sustainability - narnely: (i) cornrnunitv participation in CDTI; (ii) performance of treatment activities and (iii) strategic and contextual issues. The study concluded that in the CDTI method community participation is being carried out successfully. In his fietd visits the consultant noted the involvement of the local infrastructure including traditional midwives, traditional healers, farmers cooperatives and youth clubs in CDTI. 'Involventent of these ittstitutiorrs is likely to increase occeptotrce of iverntectin treatnrcnt and nnke it part of culture ortd practice in tlrc cotttttturtiN ". However, the consultant noted that the CDTI lacked structural mechanism to feedback to cornrnunities and their leaders the outcorne of treatments. 'The lvenneclin treatnrcnt progrannte was appreciated itt tttost t'ilLuges. However, cotntnutttN leaders and sometinrcs even distributors were not aware of results of the evulrttttiott of tlrc prograntnte ". This observation was made by JAF4 and at the stakeholders workshop in Uganda rrr May 1999, prior to the study on sustarnabiliry, project managers recommended the institution of "conunwtiry feedback .forrun" as a component of CDTI. .IAF5.2 Pagc I 8 The study highlighted that community support to distributors, motivation of health workers and the participation of women in decision- rnaking process (selection of CDDs) needed more attention. The key challenge is how to improve the participation of wolnen. By estirnation, less than 15% of ivermectin distributors are fernales and the proportion of the trainers of CDDs who are females is low. To address this problern clifferent mechanisms are being explored by the Management of APOC to make CDTI activities gender sensitive with defined performance indicators and targets on women's participation. Consultations with inter-agency units (TDR Task Force on Gender) is planned for next year to discuss how the Task Force "tvoftrctt Listening Sroups" programlne in some ApOC countries can be used to improve the participation of worren in CDTI. The Managerlent of APOC has encouraged project managers during workshops to nurture dialogue between com,ru,rties and project management to increase the participation of worren as ivermectin distributors in order to reach and treat wolnen in seclusion. .rAI.-5.2 Pagc I 9 -fable -5. Indicators of decision-rnaking by community I rc,rtrrrcrrt on-torng at the tlrne of preparatron of thts report Ntrnrber of target communities is 23,071 Country end Proj+ct Numbgr tf.Corn- n{Unltles,::i: trinteflt tt: _ ji]1 \.1 ...: Humb+r and Percentage qf Cffilmuniti+^e thetr ileeidef,+n nrothod nf tre*ffierrt frnllsctsd drqg fiverme+tffi:':: CAMEROON t Adarnaoua ? $putlr West 1* 3 North Frovince* 4 Cenre 3 5 CAR 6 MALAWI* TAI{ZAI{IA 7 Mahengc Focus,t I Ruvurna Focus * CHAE 9 Chad CDTI NIGERIA t0 Cross River* t I Taraba* I2 Kogi* I3 Osun 14 PlateaulN. 15 Federal Capital Territory 16 Hn*gul Anambr#Ebnnyi I? Kano 18 Imo/Abia 19 Yobe TOZaw{ara 2l Kaduua I l3 777 43r 565 2.166 725 9l r32 2,0r7 860 l,095 525 559 r,465 420 1 553 100 2.210 r88 99 t.t91 80 751 JJ s65 2,072 405 9r 128 480 666 1,080 525 317 960 4r6 2,754 65 1,998 157 99 1,197 71% 97% 8% t00% 96Vo 56% r00% 97% 24% 17% 99% r00% 67% 66% 99% 78% 6s% 90% 84% r00% t00% 60 0 JJ NA t,645 221 9t t32 NA 538 1.086 43'7 327 0 4t6 2,582 65 r,998 185 99 878 53uL, 0% 87o 16% 31% t00% 100% 63% 99% 83% s8% 0% 99% 73% 65% 90% 98%' l00Vo 13% 91 615 JJ 565 2,t55 163 91 t32 NA 666 123 49r 327 960 4t6 2,754 65 1,998 r85 99 622 8t% 87% 8% 100% 99% 23% l00Vo 100% 77% 66% 94% s8% 66% 99% 78% 65% 90% 98% too% 5t% 80 NA 33% NA 362 0 23 NA NA 580 575 525 58 860 393 1,616 I 407 I 13 99 923 7t% NA 8% 11% 0% 25% 67% 67% r00% t0% 59% 94% 47% r% 18% 60% r00% 77% TOTAL , retss 1489q TT.2% 1tr799 58.*To 13211 6t^5%, f708' '.34,8%. .IAF5.2 Pzrge 20 3.2.7 Vector Elimination Projects Three tector elimination projects and one project for feasibility study have been approved since the start of APOC operations. These are: Itwara Vector Elimination Project in Uganda (approved in December 1996). Mparnba-Nkusi Focus Project in Uganda (feasibility study approved in 1996). Tukuyu Vector Elimination Project in Tanzania (approved in September 1997) Bioko Vector Elimination Project in Equatorial Guinea (approved in April 1998) The marn straregy to be used in all the foci is ground-larviciding. For a short interval, aerial spraying using OCP helicopters may be combined with ground-larviciding in the Eastern part of Bioko Island. a) ltwara Focus Vector Elimination in Uganda During rhe period under consideration, the NOTF vector elirnination team has succeeded in rnaintaining the Invara main focus still free of S. neavei. Intensive monitoring and supervision had been maintained to ensure that the vector collection is being done appropriately. The activities also involved prospections in key checkpoint in Itwara main Focus and river treatments at four weekly interval in the sub-foci of Siisa and Aswa. Monitoring of vector dynamics through adult catches in six establishing catching sites indicate that the ltwara main focus is still free from S.neavi but the same cannot be said of the Aswa sub-focus. During the period (May-July 1999), prospections were conducted in the Asrva sub-focus and a total 354 crabs were caught of which 12 (3.47o) were positive with S.necvi immature stages. Two dosing sites had positive crabs with infestation rates of 13.9% and 14% indicating possible breeding sites in a stream joining the main river Aswa. Ground larviciding will continue especially in Siisa sub-focus. River treatments will continue especially in Siisa sub-focus since it is within the fly flight range. b) Feasibility study in the Mpamba-Nkusi Focus in Uganda In December 1996, the project of Mpamba-Nkusi was approved as part of the vector elimination project of Itwara focus. On the recommendation of the Technical Consultative Committee of APOC, Mpamba-Nkusi project which will cover an isolated focus of 100krn2, was redefined and separated in 1998 from the Itwara focus one. The Project was then approved as a vector elimination feasibilify study since the vectors and the transmission dynamics were unknown. In i999 field activities enabled to identify the vector as S.neavi'.98Vo of the 45 crabs caught were positive for S.neavi with a tnean crab infestation of 14 larvae per crab. Comprehensive prospection started in June 1999 will establish the breeding limits as well as the vector density and infection rates. c) Tukuyu Focus Vector Elimination in Tanzania This projecr was approved in September 1997 but the conditions preceding the disbursementofTrustFundsweremetbytheNOTFonlyduringthesecondhalfof 1998. InOctober I998, the NOTF began with the collection of entomological, ecological and climatological baseline data. a iAFs.2 Page 2l Adult fly capture and fly dissection for vector abundance, cytogenetic, infection rates to estinrate transmission indices and insecticide susceptibiliry have been completed. Survey datafron225 flres dissected, adult fly (biting) captures in four points and pre-adult sampling of 34 sites showed 44% palous rate and infection rate similar to previous studies. All pre-treatment surveys will be completed in early year 2000 and treatment with temephos is scheduled to begin next year. Field activities including field larvicide testing, larvae susceptibility tesring, chromosomal analysis and aquatic and transmission baseline rnonitoring have been intensified. Also, hydro-biological sampling for non target fauna for baseline of the aquatic species co-endemic with the S.damnosum immature stages have began. Following the recommendation of the TCC for pre-treatment surveys to be satisfactorily corrrpleted, a technical expert from the OCP is currently (September 1999) in Tanzania to assist with field trials on insecticide efficacy and effective carry of ternephos and train local staff on the lnanagelnent of activities and data. d) Bioko Vector Elimination in Equatorial Guinea In 1999, all requisite data for a proper elimination attempt in Bioko Island in Equatorial Guinea was undertaken. The project was initiated in January 1999 and the objectives set for the first year were: i) to train local sraff to collect pre-control baseline entomology data, ii) to determine the susceptibility to Temephos (Abate'") of Simulium damnosum s.1. larval populations found on the island of Bioko, and iii) to conduct environmental impact assessment studies. In January 1999, a team of external scientists visited Bioko and trained four technicians for fleld collection and dissection of flies. Two scientists of Spanish Cooperation (the NGDO partner of the NOTF) were trained in the OCP to supervise the entornology data collection. Two full insecticide susceptibility tests were carried out in 1999 and the results showed that $. darnnosum larvae on Bioko are highly susceptible to temephos 20 EC. Environment Impact Assessments (EtA) were carried out in April 1999 by scientists from Narural History Museum, London and Water Resources Institute, Accra. The aim is to obtain baseline infonnation of aquatic fauna and to assess the impact of temephos on the invertebrates and fish fauna of rivers in Bioko. Estimates of condition (K) of fishes were made to provide baseline data and also to use as reference for monitoring once larviciding begins. The impact of temephos on the densities varied between 61Vo-27% and between rivers. However, the effect of temephos EC20 on the non tarset fauna in the rivers on Bioko was considered not different from the effects observed in the OCP. 4 MONITORING OF CDTI PROJECTS 4.1 Background information APOC objective rs to expand, onent and accelerate all rvermectrn treatment actrvities tosards sustarnable systems,reduce dependence on external frnancial support and enhance geographic and treatment coverage rates. The CDTI method was thought to offer the best prospects for achieving thrs oblectrve. Because CDTI rs a multi-faceted process, the drfferent steps ln the delivery process need to bc ntonrtored to: .rAF5.2 Page 22 identify implementatron problems that may impede or delay the prospects or prevent projects from having the intended effect. assess for dynamrc change and promote regular interactions between the health care services, the affected communrties and the NGDOs. Following the finalization of monitoring instruments (JAF5/INF/DOC.1 in French and Enghsh ), 14 CDTI projects in the second year of implementation were monttored this year. This represents 29o/o ofthe 48 CDTI approved projects. Therefore, in 1998 and 1999, 23 projects have been r.nonrtored and all are being sponsored by the NGDO coalition ( figure 6). The estimated cost of monitoring the l4 projects in 1999 is US$ 165,000 (estimate average cost of US$ 11,8OO/project). 4.2. Summary of Findings of the monitoring teams At the time of the preparation of this report, the monitoring of eight of the fourteen projects mentioned above had been completed. Using a multi-stage sampling method, each monitoring team selected and assessed CDTI implementation in 30 communities in each project area (sampling method in JAF/INF/DOC.1). From the findings, treatment coverage rates were good and transition from mobile and community-based approaches to CDTI methods was evident in six of the eight projects. While the CDTI decision-making process was largely followed in the selection of ivermectin distributors (CDDs), the degree of community involvement varied across sites. In all eight projects, monitors reported inadequate community education on their roles and responsibilities. Further, the search for and sensitization of potential local groups on their roles and responsibilities had not been adequately carried out. Therefore, monitoring teams concluded that the general approach to the communities (entry into cornrnunity) for ownership of CDTI need further improvement in all eight sites. In Tanzania and Cameroon the CDTI seems well integrated into the Health care system (JAF5/INF/DOC.4 page19; JAF5/INF/DOC.5 page 9). In Nigeria, only the projects in Osun and Federal Capital Terrority are integrated into the Health system (JAF/INF/DOC.3, page 24). On the contrary, the monitors of Enugu State project in Nigeria observed that there is 'IVo deliberate attentpt to strengthen the capacity of health staff for longterm implementation of CDTI by NGDO partner" (see monitors report on Enugu State page 2). Summarizing the findings on indicators of sustainability, on South West 1 Province Project in Cameroon, the monitors observed 'the prospect of sustainability are quite good, especially as nnst lrcalth personnel interviewed identified the problems currently being faced as teethin7 problems ". Sirnilar observation was made by monitors for the projects in Adamaoua II Province in Cameroon; the Osun Srate, Federal Capital Territory and Ebonyi State projects in Nigeria and the Ruvuma project in Tanzania. A resume of the hndings on the eight projects is presented by country in JAF5/INF/DOC.3 (Nigeria), JAF5/INF/DOC.5 (Cameroon), JAF5/INF/DOC.4 (Tanzania). Also, a detailed report on each project is available. .TAF5.2 Page 23 Figure 6: Number of NGDO supported projects monitored in 1998 and 1999 12 10 SSI IEF GRBP CBM UNICEF IMA BASED AFRIC,ARE Orc 4.3 Internal monitoring activities of the NOTFs In 1999, internal monitoring of CDTI projects was conducted by flre National Task Forces in five States in Nigeria, four project areas in Sudan and will begin in October in four districts in Uganda. It is expected that the instruments for independent and internal monitoring will allow for quanritative assessment of treatment coverage but also qualitative holistic appraisal of CDTI projects. 4.4. Community self-monitoring The aim of community self-monitoring is for community members to develop indicators and assess conununity participation, commitment and contribution in CDTI. In the year under review, following the recommendation of JAF4, community self- monitoring has been initiated in Malawi, Nigeria and Uganda. By the time of preparing this report (September), the data collection for this exercise was not yet completed. 4.5 Community indicators of success of CDTI In 1998, the Programme documented community members' perception of indicators of success of CDTI method. It is important to observe that the indicators of success as determined by focus groups in 140 villages in eleven projects are similar to those set out in the monitoring insrruments. According to community members, the indicators of success of CDTI are: Sustained increase in coverage until 100% treatrnent coverage is achieved (everyone is getting treated); 14 I 6 4 2 trNo. d NGDO supported Prciect trNo. of proiect monitored t 'l 1 1 1 2 8 9 1 1 6 2 1 10 0 1 .rAF5.2 Page 24 Steady reduction in the nurnber of persons with the disease and with side eff'ects: skin rashes have disappeared; improved eye sight; reduction in body and joint pains; Ability to distribute themselves and regular supply of iverrnectin; Treatment of other diseases like malaria; other diseases have been reduced; people are in good health. 5 TRAIMNG AND CAPACITY BTITLDING 5.1. Local capacity building The various activities of the Programme such as monitoring and Impact Assessment of APOC operations have demonstrated that there is considerable capacity in the APOC countries. For instance this year, 85 persons ( 29 District Project Managers, 8 representative of the NGDOs and National Coordinators and l7 Independent Researcher) were members of the teams which monitored APOC CDTI projects. Also, the Impact Assessment studies provided opportunity for local scientists in tlie countries of study to be trained on various professional techniques. A total of 403 persons participated in five activities of the Programme and 259 were trained in various disciplines (table 6). Table:6 Local Caoacitv-buildins throush APOC activities 28 25 89.3Completion and refinement of REMO 80Workshop on Monitoring (Francophe/Anglophone teams) 25 20 8s.6IMPACT Assessment L67 143 85 68 80lndependent Monitoring of CDTI projects 98 33 33.7Vector Eliminallon Projects .IAF's 2 Page 25 5.2. Training of Project accountants One of the responsibilities of the Management tearn is to oversee and ensure tirnely transfer of tirnds to tlle NOTF, submission of financial reports and judicious use of the Trust Funds by the Pro.fect Managers. In the course of the implernentation of the approved projects, there were inaccuracies in irnprest returns sent by the countries. These inaccuracies led to delays in tlie disbursement of Trust Funds. To address them and furtlier strengthen the capacity of the NOTFs. the Management organised training and retraining sessions on the irnprest system for the NOTFs of Malawi, Nigeria, Uganda, Tanzania, Northern and Soutliern CDTI Projects in Sudan. A total of 50 participants including accounlants, Representatives of NGDOs and National Coordinators were trained in 1999. In each country, ernphasis was on the WHO irnprest account bookkeeping and on budget ntonitoring . The core staff at the headquarters of the NOTFs were trained to serve as trainers of district accountants. 5.3. Trailing of Health Staff and Community Directed Distributors (CDDs) A total of 7570 health staff were trained during the period under consideration. These staff traiued and supervised the activities of the CDDs. The reports showed a four-fold increase in the number of health personnel trained and involved in the CDTI method of ivermectin delivery from 1998-1999. This dramatic increase was made possible by the enormous contributions to local capaciry building by Prograrrune partners, in particular, the NGDOs in the current year and the acceptance of the CDTI by the field staff. The training and retraining of different cadre of health staff were carried out by members of the NOTF. In Uganda and Malawi, Management staff assisted the NOTF with training district liealth personnel. Also, 32,489 communiry-distributors of ivermectin (CDDs) were trained by 7570 health statTtbr 21 projects (table 7) in 7 countries for which cornplete information on training was available at the tinre of the preparation of this report. An average of 2 CDDs were chosen per community. In Uganda, to address attrition and fatigue among ivermectin distributors in communities where access to disperse households is difficult because of the terrain, the NOTF encouraged communities to select more than 3 CDDs in large size communities for training. The exceptions were Plateau/Nassarawa State project in Nigeria, Mahenge Project in Tanzania where no colrrrnunity chosen distributor was trained and North and Littoral II provinces in Carneroon which trained less than 50 CDDs in the period under review. IAF.5.2 Pagc 2(r 'f:rble 7: Number of Cornmunity Directed Distributors (CDDs) trained fiom October 1998 to July 1999 6 LONG TERM IMPACT ASSESSMENT OF APOC OPERATIONS 6.1 Background information To document the long-term impact of APOC control operations on the burden of drsease and fbllowing rhe approval of the time-line of activities by the Joint Action Forum (JAF) in December 1998, the TCC and Management embarked upon evaluation studies in early 1999. The working hypothesis for the impact assessrrent studies is that regular treatment with ivennectin will: reduce severe itching, prevent the development of onchocercal skin lesions and regress early skin lesions; prevent the development or delay progression of onchocercal eye lesions and blindness and regress early stages of ocular lesions; significantly reduce vector infectivity and transmission of O. volvulus improve economic status of benefitting community. Eleven (11) out of 14 sites selected were covered by August 1999 by four teams. The selection trf tlre sites was based on availability of "virgin" villages i.e. areas with (25% ivernectin treatlnent and the ecological zones. Sites were therefore selected frorn the forest, savanna and savanna fbrest rnosaic ecological zones. Figure 7 shows the sites in Nigeria, Catneroon, Central African Republic, Gabon, Democratic republic of Congo, Uganda, Tanzania and Sudan. Thirty-four (34) scientists - biomedical, social science and entomologists using standardized ntethodology have collected baseline data to test the hypothesis after repeating the studies at 3-5 years intervals. CAMEROON 354 93 538 3628 CAIt 20 27 224 1977 N{AI,A\\'I 20 t1 441 1275 590.I'ANZA\IA 94 337 r38 991 2r95 19100NIGERIA 851 68 621 608StIT)A\ 78 10 339 53r lT;(;ANDA tt7 .IAF5.2 Page 27 Work has been completed on the ophthalmological, dermatological and socio-economic aspects of the study. Entornological studies will run for one year in the sites. Sites covered are: Cat.neroon (2), Gabon (l), CAR (l), Dernocratic Republic of Congo (l), Sudan (l), Nigeria (2), Uganda(l)andTanzania(1). PoliticalproblemshavepreventedcommencernentofstudiesinDRC (rernaining one site) and CAR (remaining one site) and clearance issues delayed the commencement in Ethiopia. However, plans are advanced to carry out baseline studies in these sites early next year. Data analysis workshop was held in Ouagadougou (Septernber 6-16, 1999) and a report will be available during the first-quarter of next year. The cost of the collection of the baseline data is estiurated at US$ 566,041 (average cost by sites is US $ 40,432) including the cost of the equiprnent purchased specifically for the study. Figure 7: Study sites rd\t TF C:meroon a Site of studies A Sudan CAR T:nra l. ORC l. .IAF5.2 Page 28 6.2 Summary of Results Sociologr6.2.1 Across sites, knowledge about the cause of onchocerciasis is still very poor and local names reflect the degree oi stigma attached to the disease. Reduced productivity resulting from unrelenting itching and family disintegration were often mentioned. 6.2.2. Dermatology Onchocercal reactive skin lesions were identified in all the sites. Troublesome itching was lrighest in the age -sroup 25-34 and 3544 (figure 8). The highest rate of Acute Papular Dermatitis(APOD) was obsen'ed in Kumba, Cameroon (15.23%). While ttre highest prevalence rate of Chronic Papular Dermatitis (CPOD) was observed in Raja, Sudan (28.09%). Lichenicfied onchocercal derrnatitis (LOD) uas low in all the sites; the prevalence ranged from0.90% (Taraba) to 7 .73Vo (Cross River). Depigmenration was detected in all sites and the highest prevalence rate was observed in Ngarnbe (22%) and Kumba (36Vo) in Cameroon. Figure: 8 Itching and troublesome itching by age groups 30 20 't5 l0 5 0 5- 14ye-: 15-24years 25-34years 3t,{4y€rs 4tilyears 55-64years >'65years 14.5 '10 6 I 104 247 29.8 28.4 26S 24.9 13 0.4 E ll,:-,ng I Tr r,clegme il ching ! JAF5.2 Page 29 6.2.3 Ophtalmology Blindness rate are comparable among all the countries except Sudan where the highest rate in Raja is 6.77o (figure 9). The prevalence of dead microfilariae was high in Morogoro, Tanzania (6.1%) and in Lusambo in DRC, (4.0%). Punctuate keratitis, inflammation in the cornea secondary to dead or presence of microfilariae in the cornea were more prevalent in Kumba (Cameroun), Lusambo (DRC), Taraba and Cross River States (Nigeria). The highest prevalence of microfilariae in the anterior clramber was observed in Sudan (Raja 49.27o) and Cameroon (Kumba 41.77o\. Figure: 9 c 18 00 16 00 14 00 12 00 10.00 800 6.C0 4.00 2.00 000 Kumb. Nge& L.stouvill. Lob.y. 8utuy Mo.ogo Raja Kqi Lusmb N E Visual impaircnt .IAF5.2 Page 30 Oncho chorioretinetis, an early sign of the risk of blindness from onchocerciasis had its higlrest prevalence in Cross River State, Nigeria (35.8%); in Kumba (Cameroon), (15.8%) and in Lusambo in CAR (19.8%; figure 10). Figure: l0 Oncho chorio retinitis in all the sites ,9 o 70 60 50 40 30 20 10 E5-14 y6 I 15-24 yrs o25-34 yrs r 35-44 yrs tr45-54 yrs r55-64 yrs o 65 yrs & above .C """ d."C ""-- ""."' "J "" ^C $"q' €\6 """"t A total of 7203 persons were examined using the computer video-perimetry (Wu-Jones Test or Motion Sensitivity Screening Test). Severe vtsual field defect was recorded in 11.7% of the population and 9.7 % of the study population presented mild visual field defect. The highest visual field defects was recorded in Cross River and Kogi States in Nigeria. The lowest prevalence rates were recorded in Lusambo, Democratic Republic of Congo (5.6% severe visual field defect) and in Raja, (6.7%). 6.2.4. Entomology The results of the analysis of the data collected in two-subsequent visits in each of the 11 selected sites showed mean parous rate of between 20-40% except in Raja (et%). The monthly biting rates (MBR) are low at Lusambo (570) and Cross River (780). The highest biting rates were recorded in Ngambe (10,200), Kumba (12,450) and Lastrouville (7380). Annual transmission potential (ATP: critical value : 100 L3lmanltlear) varies from 26 L3lmanlyear (Lastrouville) to 218 L3lmanlyear (Kumba). It is observed that high biting rate does not correlate positively with high transmission rate. Constraints6.3 The constraints encountered during the srudies included: remoteness of study sites which i#iliJil "il, rt 7.IAF5.2 Page 31 translated into accessibility problems; difficulty in finding sites where treatrnent with ivermectin has not taken place and difficulty in obtaining some equipment and supplies. 6.4. Summary In summary, across board, Raja in Sudan had the highest prevalence rates of blindness and of rnicrofilaria in the anterior chamber whilst the highest prevalence of oncho chorioretinitis is registered in Cross River State. Reactive skin lesions were common in all sites with troublesome itching and was predominant in the economic active age group, 25-34 years old. OPERATIONAL RESEARCH AND COLLABORATION WITH TDR & IIEALTHMAP The Programme has had three years of consistently positive relationship with the TDR Task Force on Onchocerciasis responsible for consolidating the scientific basis of APOC. In 1999, the TDR/Task Force on Community-Directed Treatment with Ivermectin in collaboration with APOC continued with the intervention phase of seven-site study on the implementation and integration of CDTI into the Health System. Due to delays in the release of funds and in receipt of ivermectin from the national programmes, the final resultof the study will be available in the first quarter of year 2000. A study on advocacy for sustained ivermectin treatment in onchocerciasis control began in October 1998. The overall aim is to develop strategies to ensure sustained demand by high risk comrnunities as well as supply and distribution of ivermectin for the control of disease. Research teams include members of the National Onchocerciasis Task Forces to ensure the use of the results and new rnaterials to be developed to enhance the activities of the NOTFs. Following the recommendations of JAF4 that TDR should provide direct assistance to APOC countries to find solutions to country-specific problems to the implementation of onchocerciasis control, the Task Force for Onchocerciasis and Lymphatic Filariasis and the Management of APOC sponsored a lunch-time meeting with country representatives of WHO in APOC countries in Geneva, in April 1999. Subsequently, other consultations have been on-going between the Task Force and other parties. A progress report will be presented by the Task Force. Reports from projects field staff continue to draw attention to difficulties with reporting by non-literate ivermectin distributors and the Pictorial Reporting Form designed and pretested by the Task Force. To address this need, a new multi-site study has been initiated to revise the Pictorial Reporting Form and pretest its usability in APOC supported countries. In collaboration with the Healthmap (Geneva) and the School of Public Health in Liverpool, using the remote sensing method, prevelance data on Onchocerciasis and Loa loa had been overlayed to forecast areas where adverse reactions can occur following the administration of ivermectin. .IAF5.2 Page 32 8. COLLABORATION BETWEEN OCP AND APOC As in the past years, APOC received support from the following units of OCP (i) Vecror Control Unit (VCU): provided expert advice and training of the local technician in the vector control activities in Equatorial Guinea and Tanzania: assisted APOC in supplying insecticide and entomological equipment to Uganda, Tanzania and Equatorial Guinea; (ii) Personel Service: for the recruitment of Programme's personnel and temporary assistants; (iii) Budget and Finance Offrce: assisted with budgetary and financial matters (salaries of personnel, payment of travel claims and bills, instalment of funds to NOTFs); (iv) Bio-statistics and lnformation Service: for computer equipment maintenance and servicing; (v) Supplies Service: the supply of stationery, establishment of purchase orders for . ,"hi.l"r and equipment for the countries, maintenance of the Programme offices; (vi) Transport Service: facilitated the transportation of participants during conferences, provision of transport to Programme's personnel, advised on vehicles for purchase for the countries; (vii) Communication, Conferences, Translation and Documentation units: for assisting from time to time in the supervision of meetings and the translation of documents from French to English and vice versa; (viii) The office of the Administrative and Finance Officer: assisted when needed in the coordination and monitoring of the activities mentioned above. 9. CONTRIBUTION OF AFRO During ttre period covered by this report, AFRO has played an important role at the regional level. The country officis provided support to the Management and the NOTF in the implementation and monitoring of APOC operations. At the country level, the WHO offices had been pivotal in initiating the development of the national plans for onchocerciasis control and the project proposals for ivermectin treatment in Liberia and Ethiopia. The officers for disease control and prevention (DPCs) took very active part in the elaboration of the CDTI project proposals. In spite of the constraint of their imprest account ceiling most of tlie country-offices transferred funds to the NOTFs following instructions of the Regional office or the APOC Management. Some of the country offices (e.g Nigeria, CAR) also performed the internal auditing of the imprest returns before forwarding the imprest book to the APOC Headquarters in Ouagadougou, and facilitated the replenishment of the NOTFs' bank accounts as appropriate. t .IAF5.2 Page 33 It is also worthy to mention that the transportation of the consultants and field staff for independent monitoring of CDTI projects and the collection of baseline data for impact assessment of APOC operations were assured with the assistance of the WHO country offices. Furthermore, they were instrumental in the organization of various workshops and other important activities of the Programlne. Atthe levelof the regional office, the Budgetand Finance Office (BFO) and the Division of lntegrated Disease Control (DDC) played important roles in the implementation of the Prograrrrrre activities. The former provided support to the country offices for the transfer of funds to the projects and replenishments of the NOTFs' bank accounts. The latter contributed to the Progralnrle not only througli the DPCs at the country level as mentioned earlier but also through the regional adviser on other tropical diseases (OTD) who is based in Ouagadougou and is working very closely with tlie Management of the Programme. 10 CONTRIBUTTON OF NON.GOVERNMENTAL DEYELOPMENT ORGANTSATTONS (NGDO) Members of the NGDO Group for the Distribution of Ivermectin played an important role as a source of technical expertise and funding, at the regional and the country levels in the irnplernentation of APOC operations. The Coordinator of the Group also contributed during the period covered by the report to the realisation of various important activities of the programme. The document JAF5.7 highlights the important role played by the NGDO group in the implementation of APOC activities. 11. COLLABORATTON BETWEEN THE NOTFS AND OTHER SECTORS 12. CONCLUSION It should be said that much of these could not have been achieved without the additional hurnan and financial resources frorn the NGDOs, the participating governments, the WHO /AFRO country Representatives, the OCP and guidance of the TCC and the Comrnittee of Sponsoring Agencies (CSA). Though impressive achievements were made in the period under consideration, there is need to irnprove the perfonnance of the Communiry Directed Treatments with Ivermectin projects especially in the areas of : involvement of health personnel, supervision, financial commitrnent and involvement of the MOH in planning and execution of the activities. Timely disbursement of Trust Funds and strengthening of the partnership will receive special attention. Three innovative and successful collaborations between the NOTFs, other service providers and the private sector deserve mention. In Cross River State in Nigeria, collaboration between the State Onchocerciasis Task Force and the South East Nigeria Eye Care Out-Reach Services made possible the provision of free cataract surgery through CDTI structures in the communities. Also, Joint Monitoring of all Prirnary Health Care (PHC) components including CDTI activities was initiated by the State Task Force. In Cameroon, the production of IEC campaign leaflets, posters, brochures and T-shirts for ivermectin distributors to launch CDTI activities in South West Province was financed by the private sector - Guinness Cameroon. .IAF5.2 Page 34 Annexe l: Rapid Epidemiological Mapping of Onchocerciasis in APOC countries Rapid Epidemiological Mapping of Onchocerciasis in APOC countries (August 1999) Commun(y Dtrected T,eatmenl wdh Urgenl lo .€lne. CDTI lrk€ly rn parl ol lhe zone To r€lne - Probablv no CDTI iirji; No CDTI '[+ REMC onqornq / delated q JAF5.2 Page 35 a Annex 2: Rapid Epidemiological Mapping of Onchocerciasis in Liberia Rapid Epidemiological Mapping of Onchocerciasis, Liberia Legend I Dfidr.lo%EFdbiEs ! onttarmrnuu" t ::"*** Nodules O0 g l-9 o 10-19 o 20-39 9 40-100 KM o 50 100 Annex 3: Rapid Epidemiological Mapping of Onchocerciasis in Rwanda Rapid Epidemiological Mapping of Onchocerciasis Rwrnda. August 1999 I l*vuro NODULES (%) lmr.ll.l.trd,UA'@!B Legend/L69ende - Rjvid6/.iv6 90 o l-9 O 10-19 O 20-39 9 40-100 _- t: .9, t: ?: '9) rll itlrl t: t: t: ti le: 9)t) t: .q KM r--------'l o2040 JAF5.2 Page 36 Annex 4: Rapid Epidemiological Mapping of Onchocerciasis in Kenya Rapid Epidemiologica! Mapping of Onchocerciasis Kenya Legend I National Boundarics ! ures - rivcrs Nodules (%) o0 o l-e o 10-19 o 20-39 o 40-100 r--------'l0 100 200 Ae@# Annex. 5: Detailed REMO of Centre3 in Cameroon Refinement of Nodules (%) O0 g l-9 o lcl9 o 20-39 o rlGloo KM I a JAF5.2 Page 37 Annex 6: Rapid Epidemiological Mapping of Onchocerciasis in CAR CARTOGR-APHIE EPIDEMIOLOGIQI'E RAPIDE DE L' R6publique Centrafricainc 0 o0 o o Pr6valence nodulalrs (%) 0i0.t 0.t t t0 10120 20440 40. 100 Hrs mcore @ ffiuf zmc de TIDC t lU:'r:*i*f mli'.8',ff"1',fl ",,* . o 0,,.o* It^d..rlDS.66 rnhrDrt6 ffi FCIB&, n &b&* TmryAP@. F- l* -"aW Km 't a I