Road map of epidemiological and entomological evaluation of onchocerciasis of biennium: 2014-2015

WORLD HEALTH ORGANIZATION AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (wHo/APoc) Road Map of Epidemiological and Entomological Evaluation of Onchocerciasis for biennium: 20L4-20L5 April 2OL4 Road Map for Epidemiological and Entomological Evaluation 2OL4-2OLS I. Introduction Following the shift from control to elimination goal, APOC has been working to determine when and where countries will stop treatment of onchocerciasis with ivermectin safely after confirming elimination of infection and interruption of transmission and ensuring recrudescence of infection and transmission will not come back. ln order to operationalize this objective a Conceptual and Operational Framework of Onchocerciasis Elimination with lvermectin Treatment in Africa has been developed to guide countries. Based on this framework epidemiological and entomological evaluation has been conducted in a number of countries. Between 2008 and 20L3, APOC has evaluated 55 sites/projects in 13 countries examining 233,760 individuals in more than L000 villages using epidemiological evaluation. See Table below. Table 1: Summary Results of epidemiological evaluations in 2008 - 2OL3 Country lutt"s" lrxamined. lMf nositive lerevalence Cameroon Equatorial Guinea Burundi Chad CAR Congo DRC Ethiopia Liberia Malawi Tanzania Uganda 3 7 L 1 2 4 5 t t 2 7t 81 28 762 33 55 40 38 19 60 294 L32 84 24,998 17,o28 7,656 48,339 4,928 11,653 7,080 3,550 3,554 11,893 5L,674 23,638 t7,769 7 3,145 4L 37 506 3,587 Ltt 19 244 42 2,84L 493 27L 0.03 L9.73 0.s0 0.07 L3.70 32.90 1.16 0.83 6.54 0.30 4.30 2.24 2.06 18 7 3 The evaluations are needed to address two sequential objectives: a. to assess the decline in infection levels towards breakpoints, and b. to confirm that the breakpoint has been reached and that treatment can be safely stopped. The two objectives constitute the phase 1a and phase 1b evaluations. ln the phase la evaluation as a fact finding assessment only epidemiological evaluation is conducted in few villages in a hyper to meso-endemic focus with a Grand Total 1,097 233,760 LL,344 5.33 Nigeria 55 number of years of good treatment history. lf the finding of the phase La evaluation shows promising result of the infection level reaching close to the breakpoint a phase 1b evaluation with two pronged approach of epidemiological as well as entomological assessment will be conducted in more villages and breeding sites in the focus to confirm the breakpoint of onchocerciasis elimination has been reached. Since 2008 we have conducted 55 phase La and L3 phase lb evaluations in 13 APOC countries. See Table 2 below. Table 2: Results of epidemiological evaluations in 2008 - 2013: Phase la and 1b evaluations Prdect 3 7 t L 2 4 5 1 1 2 18 7 3 55 Village 50 81 28 51 33 55 20 38 19 20 234 92 29 7fi Exam 19,550 L7,028 7,656 !7,145 4,928 11,653 4,094 3,550 3,554 4,335 41,182 76,443 4,337 155,49 mfpve 2 3L45 4t 5 s06 3587 ttt 19 244 0 2472 492 775 10,800 Prev 9.67 0.s0 0.04 19.38 33.33 3.87 0.83 6.54 2.53 4,63 Village 2L 101 3L,794 31 0.09 Exam 5,448 2,986 0 7,558 42 10,492 369 7,195 L 13,438 96 78,31t 54 mfpve Prev Proiect s 0.08 2 1 20 40 60 40 55 ??7 0.45 3.38 0.01 0.7L 0.81 t 4 2 3 13 Entomological evaluation of transmission assessment and delineation of transmission boundaries through identification of the black fly species is underway in: Nigeria, Malawi, Chad, etc See Table 3. II. Rationale During APOC Strategic Planning Meeting on Onchocerciasis and LF Elimination in Africa, Ouagadougou, Burkina Faso, L7 - 22 March,20L4; the results of the evaluations were reviewed and a tentative plan of action of evaluations for the year 2074 and 2015 were submitted by countries. This work was used as a basis to produce this road map for Epidemiological and Entomological Evaluation Road Map 2014-2015. This document is therefore prepared to streamline, prioritize and harmonize the different evaluation planned during the period to guide countries and partners on the way forward. This document will present the current status of evaluation in countries, planned activities by timeline and cost for the period 2OL4-2OL5, and potentia I partners su pporti ng cou ntries fina ncia lly a nd tech n ically. Burundi Cameroon CAR Chad Congo DRC Ethiopia Equatorial G Liberia Malawi Nigeria Tanzania Uganda Total Country Phase la Phase 1b III. Obiectives General Objective: to provide the scientific evidence required to make a decision of stopping of ivermectin treatment in countries Specific Objectives: to select countries and sites where phase la and phase 1b evaluations to be conducted in 2074 and 2015 to have a detailed plan of action with timeline and budget for the evaluations in 2014 and 2015 to collect the entomological and epidemiological information required to make a decision on stopping of ivermectin treatment in countries. IV. Country status The following countries where elimination is believed to be very close based on some of the evaluation undertaken by APOC and stopping of ivermectin treatment is a possibility are categorized under this group. 1. Bunuruot Since 2005, an annual mass distribution of lvermectin has been implemented using CDTI to fight against onchocerciasis in Burundi. Neglected Tropical Diseases and Blindness (PNIMTNC) coordinates the fight against onchocerciasis through 3 CDTI projects (Cibitoke, Bubanza, Bururi and Rutana) where L7o/o of the general population live. Since 2012 epidemiological assessments in the three foci and around them showed very good results. a a o Ia:-'.r, I:I, :-_ E1lt'Ja -,r.I*I..I,I..Ir. ffiE Efa Figure 1: showing epidemiological evaluation results of Burundi including evaluation done for the delination of treatment boundaries in hypoendemic areas. l4rhe. frrl8 Cd@ a ( lrria. L Ieodo a It"." n 15 30 :.'-.4 ": The next steps 1. conducting epidemiologial evaluation: a. phase 1b evaluation in 10 villages in Cibitoke Bubanza porovinces b. epidemiological evaluation in crossborder areas of DRC(Kivu), Tanzania and Rwand to check the disease sitaution across the board 2. conducting entomoilogical evaluation: a. for transmission assessment throughout Burundi 2. Cxao A number of epidemiological evaluations (phase 1a and phase 1b and modified phase 1a) have been conducted since 2009 in most part of the country with a very satisfactory result in all the evaluations. A couple of entomological evaluation was also started in some sites though not representative. Figure 2z showing epidemiological evaluation results of Chad including evaluation done for the delination of treatment boundaries in hypoendemic areas. t t-d o IE:-x..o lt-5r- {f,[> ' ,, The next steps conducting phase 1b epidemiological evaluations in: Logone Occidental, Bessao, L6r6 and Mayo Kebi Est Conducting entomological studies throughout the transmission zone o o % Cted o 0 gc.s o o a a a € a o oc -O1 o o Conduct phase 1b epidemiological evaluation in Cameroon side( North and Extreme north Provinces) 3. Mauwr The assessment of onchocerciasis has been conducted in 2011 and 20L2in 60 villages across all the transmission zones including the hypoendemic areas. The result showed very satisfactory result. The entomology transmission assessment and boundary delineation is underway. The transmission zone is also spill over to Mozambique where onchocerciasis treatment has never been conducted. As a next step we have to evaluate the current situation of onchocerciasis in adjacent areas of Mozambique. L.gmd o f rsr-rrro loetrrunra(, <v tUE' Figure 3: showing epidemiological evaluation results of Malawiincluding evaluation done for the delination of treatment boundaries in hypoendemic areas.t+ ---1 IIIIIII ln addition all the onchocerciasis transmission zones are co-endemic for lymphatic filariasis. LF program has been treating those areas for the last five years and pre-TAS evaluation is underway to see if LF transmission is interrupted in sentinel sites before conducting the full TAS this year. % 0- 30 60 a a o 4l::. "r'- )'--:- ,:.-a.r(:4 D C o o l l-'1 i:-1Y- -7 C tr) 4. Erxropra Figure 4: showing epidemiological evaluation results of North Gondar focus, Ethiopia. North Gondor CDTI project has been evaluated for onchocerciasis infection prevalence in 2011 and 2013 in 40 villages which showed no onchocerciasis infection. This year there is a plan to conduct entomological evaluation in the focus and epidemiological evaluation in the adjacent cross border area of Galabat in Sudan to ensure the whole area is clean. Another challenge before making a decision of stopping ivermectin treatment in this focus is assessing the status of LF. Onchocerciasis is prevalent in all States of Nigeria except Lagos, Katsina, Bayelsa and Rivers. lt is estimated that about 31 million persons in about 35,000 communities in 32 States are at risk in Nigeria. Since 2008 to 2013 extensive epidemiological and some entomological evaluation has been conducted. The resulted showed very good results in the most of the states but following States has showed very drastic reduction in infection levels: Adamawa, FCT, Kaduna, Kano,Kebbie, Kwara, Nassarawa Niger, Ousun, Plateau, and Zamfara. The result looks it has a pattern in which the North, North West and South West states performing faster than the southern and southern east counterparts. t rnd o I6r_r.aa ',. _ _ Bt-Itan loilrE d dll.Ut> =c-I2.Ie- I,IrI{I*I. I'1I., Iec 5. Nrcenla W .r\ C o 7a\\ V I( o I o -/ Oa o o C> a \ \ o \ I \t ! esr-urco - PST_U lUrn, logltruP.rad <l'ALUE> - -.:r'I:- l-- lto- t_-,-_J '. ' I:c- I3o- Ino- I:c- Ier- Iro- Isc- Iso- Figure 5: showing epidemiological evaluation results of Nigaria 2008-20013. ln some of the sites entomology evaluation for transmission assessment has already started (Kaduna) which needs additional support to include all the northern part of Nigeria to assess the whole transmission zones. The next step for the two years will be as follows: Conducting phase 1b evaluation in the following focus: Adamawa, FCT, Niger, Plateau, Nassarawa, Kebbie, Kwara, Osun, Oyo Zamfara Conducting LF assessment in the above area where indicated a o 62.5125 ##{ DFFAtrilARADl r$er21xpgp -t / .l r L! Borqou :Irc JTT 4 5. Taruzarura ln Tanzania three foci has shown very satisfactory epidemiological results: Tanga, Tukuyu and Tunduru. Tanga: is a relatively isolated focus in the north Eastern mountainous (Usambara mountains) part of the country where Simulium Niveo is the major vector. The evaluation has been done in 20010 and 2011 in 30 villages showing the prevalence of infection near zero. Tukuyu: This focus is located at the northern end of the Lake Malawi at the Rungwe Mountains. The site was one of the two vector elimination site that APOC has supported and achieved elimination of the vector S. thyolense & S. Kilibanum from the area. A study however showed that another non-human biting vector has reinvaded the area. Epidemiological evaluation conducted in 2010 and 2011 showed zero prevalence of onchocerciasis in the focus. Tunduru: This focus is found at the south eastern part of the country bordering in the south Mozambique. lt is an eastern extension of the vast transmission zone of Ruvuma Region bordered by Songea district in the West. Fortunately, the southern border of the focus in Mozambique is a national park which avoids potential cross border issues. The two countries are separated by the Ruvuma river. Epidemiological evaluation in 20 villages conducted in 2013 showed all the evaluated villages in the transmission zone has no onchocerciasis infection. Figure 5: showing epidemiological evaluation results of Tanga (left) and Tukuyu (right): 2010-2011 ) Arutha Ir. t- t- It-I--I{.Io. ot Io a 1,'4.. oaOO a attt- The Next step of activities in Tanzania is as follows: Entomological and TAS assessment will be conducted in the three foci. Additional assessment might be necessary to conduct around songea district to understand the infection level which is bordering Tunduru. o a a a -\, Y -\"\----l- t-{ (!; s-5 I t t a ,t 7. Ceruenooru The northern part of Cameroon which includes, Adamawa, North and Extreme North Regions are the ones who showed a promising result showing significant reduction of infection level of onchocerciasis in Cameroon. The other sites in the center, south and south west part of the country did not have significant change or some of them have unsatisfactory results due to high pre-control endemicity level or poor treatment coveraBe or inadequate frequency of treatment. ln such an area the reason has to be studied and possible alternative strategy or intensification of CDTI may warrants. Figure 7: showing epidemiological evaluation situation of Northern part of Cameroon, Chad, CAR and Nigeria The northern part of Cameroon is also bordering CAR, Chad and Adamawa Region of Nigeria. All of these areas have showed good progress towards elimination and understanding of the situation in Cameroon is very important. Therefore phase 1b evaluations will be done in North, Extreme north and Adamawa in 201.4 and 2015. Or..l [-** ^a Bctt. o a n aa a f a a lr a a a. 2550 1 a'o Gi# ao s a a 1, a o 0g,r a a o \ ZJ (atg 0 a a a a a \ a a aa a ueot' ' at a rl \ O3 ta 8. Ex-OCP Coururnrrs The ex-OCP countries are one of the group that in some of them elimination has probably achieved or are very close and needs only confirmation. Some of the countries are Senegal, Mali, Niger, Togo, and Benin. JAF 18 in Bujumbura has also instructed APOC to support countries conduct the assessment. To this effect APOC has supported some countries for epidemiological evaluations in addition to the usual support it has been providing for surveillance activities in the vector. Some of these countries are going to be also supported in 2014 and 2015 biennial period. ln 2014 we wanted to collaborate also with potential partners for funding while actively collaborating in providing technical assistance. o Senegal: Entomology evaluation in Kedougou, Tambacounda and Kolda o Mali: epidemiological and entomological evaluation in 9 districts including LF assessments o Niger: epidemiological and entomological evaluation in BOBOYE, GAYA, TERA, KOLLO, SAY including LF assessments o Togo: epidemiological and entomological evaluation in some of the districts o Benin: epidemiological and entomological evaluation in some of the districts V. Plan of action and Budget During the planning meeting that was held in Ouagadougou in March, countries have developed a draft plan of action of major activities for the elimination of onchocerciasis and lymphatic filariasis for the year 20L4 and 2015. One of the activities is regarding monitoring and evaluation which includes: Epidemiological and entomological evaluations and Transmission assessment Surveys. We have complied the draft PABs and annexed with this document below. It shows the countries, sites, phase and type of evaluations with timeline in quarters for the biennium. There is also an indicative draft budget and potential partner to support the activities. Table: Summary showing the number of Evaluation sites by phase of evaluation and estimated budget S. No. Countries Phase of Evaluation Total budget in USD 2 4 3 ! 5 1 t 1 1 1 1, 2 2 9 L 4 1 3 1 1 2 3 4 5 6 7 8 9 10 11 t2 13 t4 15 16 L7 18 19 20 2t 22 23 Benin Burundi CAMEROUN CAR CHAD Congo DRC EQUATORIALE G. Ethiopia Ghana Guinea Bissau Guin6e Conakry Malawi Mali Mozambique NIGER NIGERIA Senegal Sierra Leone SUDAN Tanzania Togo Uganda Total Phase 1a Phase 1b Total 1 TL 3 11 2 4 3 5 6 2 L 2 4 1 1, 2 2 9 1 L 1L 3 1 1 4 1 L 68 1 4 1 T 56 105,000 125,520 199,038 to7,510 483,340 117,000 LL6,3g4 80,000 181,855 30,000 50,000 55,500 130,000 495,651 1_00,000 40,000 720,O00 180,000 45,000 30,000 L38,900 35,000 70,000 3,636,709 1