Proposal for the plan of operations for the fourth financial phase, 1992-1997

Onchocerciasis Control Programme in West Africa Prognamrne de Lutte contre l'Ondrocencose en Afriqu€r de IOuesL JOINT PROGRAMME COMMITTEE Office of the Chainnan JPC.CCP COMITE CONJOINT DU PROGRAII'IME Bureau du Pr€sident .t JOIM PROGRAMME COMMITTEE Twelfth session Rivadh 1-4 1991 JPC12.g ORIGINAL: ENGLISH October 1!t1 il l. It Provisional Agenda. iten 10 Propos a1 for the PIan of Operat ions for the fourth Financial phase ( 19q2-1q97) The attached proposal for the Plan of Operations for the fourth FinancialPhase (L992-1997) is submitted to the Joint F"og"*'r" Comnittee for itsconsideration and eventual approval A draft which was before the Connittee at its eleventh session in Decenber1tt0 was subsequently adjusted to reflect the comnents and suggestions made bynembers of JPC as well as the reconmendations of the External ieview Groupapproved by the Committee at the sarne session. Since then, the Expert Advisory Committee during its June 1991 sessionexamined the draft in some detail and recommended a number of modificationswhich arq contained in the proposal now before the Joint progranme Committee. A doc'ument entitled rrcontext for the fourth Financial phase (1992-L997):bringing the Programme to a successful conclusion" is issued'rrrri""reference JPC12.10. Note: IWORLD HEALIH ORGAI{IZATION ONCHOCERCIASIS CONTBOL PROGRAUME IN WEST AFRICA PLAN OF OPERATIONS FOR TIIE FOT'RTH FINANCIAL PHASE (L992.I997) Tab1e of contents A. D\ECUTIVE ST]It{MARY 1 L.L-L.2L PART I(the past) B. BACKGROTJND 4 Onchocerciasis, its transnission and control The inportance of onchocerciasis. the origin of theOnchocerciasis control progranne and charicteristics of the Progranme area . Page 1 4 10 L7 18 2L 22 25 29 2 3 4 5 5 7 Organization, financing and nanegenent of the progranrne .. OCP operations and achievenents until the end of ine 5 7 third Financial phase (1985-1991) c PART II 1992-1997 PLAN OF OPEBATIONS FOR TI{E FOI.IRTTI FINANCIAL PHASE (L9g2-L9g7) .. Introduction 20 Objective and targets General considerations Vector control Epideniological evaluation and surveillanceIvernectin distribution .Biostatistics and information systens ... 33 34Support to socioecononic development Managenent, adninistration and support services ..Suunary of total estinated costs for the fourthFinancial Phase 35 35 36 38 4r 4z D. BET.IEFIIS, RISKS AND SAFEGUARDS .. Long-tern Strategy, Plan of Operations for the thirdFinancial Phase (1985-1991) and their inplenentation .....Milestones in the developnent of the progrnmme and its cost until the end of the third Financial phase Development of a nacrofilaricide Research. Devolution ....... 8. 9. 10. 11. t2. 13. 14. t5. 15. 77. 18. 19. 20. 31 Training 21. Benefits 22. Risks and safeguards . October 1991 44 q4 46 Annex 1 Annex 2 Annex 3 Annex 4a Annex 4b Annex E Annex 5 Annex 7 Annex 8 Annex Qa Annex Qb Annex Qc Annex qd fuinex 10 -ii- : Life cycle of a vo1vulus Original Programne area and Extension areas - VCU operational areas List of Donors to the Onchocerciasis contror progranne Progranne structure OCP organizational chart Reinvaded zones in the 0riginal progranne area (19g3) Effect of vector control (predicted and observed) Ivernectin control of recrudescence OCP fellowships by country and by field of study Ma:<inum larviciding (1990) Ma:<inun larvlcldlng (1992) Ma:<inun lanriciding (1994) Ma:<inun larvicidins (1997) River basins selected for active connunity treatnentwith iver.uectin Annex 11 : Predicted lnpact of vector contror in the E:<tension areas Annex 12 Proportional distribution of expenditures/budgetary forecastsduring the third and fourth Financial phases,-by the originarProgranne area and the Extension areas as well as by calendar year. L ONCHOCERCIASIS CONTROL PROGRAII{IIIE IN hIEST AFRICA Plan of 0pera tions for the fourth Financial Phase (1 -79971 A. . DGCI,ITIVE ST'II{MARY 1-1 The nain features of ocp operati.ons during the 1992-1997 period asreflected in the present PIan of Operations "r"i continuation of larviciding tocontrol transnission ; connunity-wide application of ivermectin for thepurpose of control of nanifestations of the disease including prevention ofocular nanifestations; and preparation for, and inplenentati;nTconsolidation of,the devolution process. Vector control t L'2 It is expected that what little is left of larviciding in the non-reinvaded part of the original progranne area will cease by 1994. ocpo'erations will then be withdrawn from the Original area, ana wnat remeins oflrrrviciding in the fornerry reinvaded zones wilt become part of vector :ontrolactivitiesintheE:<tensionareas(para8raph1o.16) 1'3 Larviciding in the Southern and western Extension areas will continue tobe conducted according to seasonal variations in transnission and on a sel-ectivebasis' The ain wilr remain virtual interruption of transmission wherever thereexist significant hunan reservoirs of onchotercal parasites with a potential forcausing the blinding forn of the disease (paragraph 10.1). 1'4 Fina1 decisions regarding cessation of larviciding in any given area willbe taken on the basis of such criteria as the duration of vector contror, theconnunity nicrofilarial load (CMFL) and the prevalence having reached anepideniologicalry insignificant level conforning with nodel predictions. Arso,there should have been no significant incidence of infection- (paragraph 10.6).Entonological surveillance wirr continue j.n the area two years after larvicidinghas cone to an end (paragraph 10.8). L-5 Monitoring of the possible effect of larviciding on the aquaticenvironnent will be focussed on the Southern and Western Extensi6n areas(paragraph 10.10). The Progranne will encourage national investigations of theinpact of hunan resettlenent on the riveratn nilteu and of the broaderenvironnental aspects in onchocerciasis controlled areas (paragraph 10.11).AIso' oCP will nonitor eco-environmental changes in the onchocerciasis-controlled zones in -respect of any potential inpact which tray exacerbate thepotential for recrudescence. page 2 Ivernec tin treatnent 7.6 oCP will continue its large-scale ivernectin distribution progra.nne invillages where populations were at risk of onchocercal blindness, ,rra this with an increasing national participation (paragraph t2.4). The collaboration withNon-governnental and Private Voluntary Organizations will be further strengthened (paragraph 72.72). It is expected that oCp-conducted ivermectindistribution will cone to an end before 1997 (paragraph 12.il. Devolution 1.7 Insofar as the ultinate success of the Progranne will depend on the extentto which the Participating Countries will eventually detect and control recrudescence once OCP ceases operations, particular attention will be given tothe preparation for devolution and support to its inplenentation (paragraph18.2). 1.8 Special efforts will be nade to ensure that devolution-connectedactivities in the Participating Countries are developed on the basis ofcontinuity and sustainability (paragraphs 9.3 and 18.1). Ttre availability ofa nacrofilaricide would greatly facilitate the control of recrudescence and thushelp to sustain the devolution process (paragraph 1g.10). L'9 Ttre Devolution Unit of the Progremnre will provide active support tothe-Participating Countries concerned in such rilras as trainirrs (p"r.graphs75'2-3), preparation of devolution plans and their inplenentation. The last ofthe Participating Countries to conplete preparations for devolution should havedone so early during the phase (paragraptr fg.fg). 1'10 oCP will also lnstitute an inter-country infornation exchange which willhelp to ensure act,ive collaboration a^Eong the Partlcipating Countiies in thefield of devolutl.on before and after the progremme ceases operations(paragraph 18.23). Ttre fourth Financial Phaie should be seen as a period of "learning by doing" leading in the end to effective devolution throughout thewhole Progranme area (paragraph 18.20). 0ther tivities 1.11 Epideniological evaluation witl continue to assess the inpact of vectorcontrol in pre-selected indicator villages, with enphasis on th; Extension areas(paragraph 11.1). and to provide the infornation necessary for decision-na]<ingIn respect to cessation of vector control (paragraph 11.5). L.Lz The unit concerned, OCP/EPI, will also give support to epidemiologicalsurveillance and recrudescence control as carried out by national health adninistrations in the context of devorution (paragraph 11.11). 1.13 In the field of biostatistics and information systetrs, the competent unit,OCP/BIS, will play a key rote in final decisions concerning cessation of vectorcontrol in areas where larviciding has lasted 14 years (or more) (paragraph13.1), a decision-naking process for which the epideniological noalt will beof particular use (paragraph 13.5). 1.14 oCP/BIS will continue to inprove upon the nodel with a view to makingj.t increasingly comprehensive so as to be able to deal with such issues as recrudescence contror (paragraph 13.8) and the eventual inpact of a nacrofilaricide in addition to allowing for decisions related to cost- effectiveness control (paragraph 13.7). pase 3 L'15 The role of OCP as regards socioeconomic development will renain Linitedto an assessnent of the effect of onchocerciasis control in this field and toliaison functions with the Committee of Sponsoring Agencies, entrusted with theactual support to socioecononic developnent, and with the participatingCountries (paragraph 14.4) . 1'15 oCP-conducted research will continue to be guided by reconmendations ofthe E:(pert Advisory Conmittee. Ttre priorities will relatL to the followingissues: vector control, biononics, Onchocerca volvulus identification,imnunodia8nostictesting,chenotheraffirir'"i"iae),node11ing and operational research (paragraph 17.1) l.t7 The Programme will nake all possible efforts to attain the nostsatisfactorv cost/effectiveness ratio (paragraph 19.1) and thouint will be givento how the oCP infrastructure could erentuaily help to strengthEn the healthsystens of the Participatlng Countries (paragraph fg.4l Benefits and risks 1'18 The benefits expected to accrue from inplenenting the present pran ofOperations can be sunmarized as follows: the Progrrrre objective wi]l bereached before 1997 in the original ocP area, whiitr will remain protected fronreinvasion; populations in endenic regions within the Extension areas wirl nolonger be at risk of acquiring onchocercal brindness; the hunan Onchocercavg1vq1usreservo1rintheB<tensionareaEiwi11bew.ir"i-il"*.,ffir eliuinationi there will be considerable reduction of norbidity lrra or risk ofblindness anong originally infected persons after at reast six years ofivernectin treatnent; riverain land wilr be nade availabre for resettlenent;and devolution will be fully operational in the Original progre,,rne area withpreparations conpleted ln the E:<tension areas (paragraph zL.T. t'79 rt is thus estinated that ocP operations until 1997 will have resurted ina total of 2 nilrion persons having b-en spared onchocercal disease and 150 0oocases of onchocercal blindness having been averted. Furthernore, controloperations during the 1992-1))J peciod are expected to al1ow G to 7 millionnewborn to grow up without risk of onchoc.r"ri brindness, thus bringing thetotal since the start of operations to 14 to r5-nirrion, and to nake about10 nillion hectares of tilIable riverain land lvailable for cultivation (tota1 ,o? 2J million hectares since t974), pot"nti.irv-s"rricient to feed 17 millionpeople using traditionar technologies and agrilultural practices (paragraph2L.4) . 1'20 The risks that nay be attached to or inpede the inprenentation of the planof operations (and their safeguards) couia ;;;--;gg"avarion of rarvicideresistance (search for new tarviciaes and inprovei-fornulations); lowerednlcrofilariae susceptibility to ivermectin (routine testing for resistance;search for a nacrofilaricide); geographical extension of vectors carrying thebrinding forn of.O. vgrvulus due to nodification of the environment(deforestation) (;ei"f;ced ;ntonorogical surveilrance and control); reinvasionof infective blackflies fron foci outside the progrAmme area (entonologicalsurveillance and pronpt control); derayed detectiin of, and failure to contror,recrudescence (full support to devolution, eventual availabifity-of aninnunodiagnostic test and a nacrofilariciiei; -rigr"tion (epideniologicalsurvei'llance) and conplacency (continuing involvient of all parties) (paragraphs22.7-22.9). t'?1 The budgetary requirenents for the fourth Financial phase will be in theorder of us $175 nillion including price contingencies to neet projected costincreases (paragraph 20.1) B2 page 4 PART I(the past) BACKGROIJND The parasite 2.1 Onchocerciasis is caused by a parasitic, filarial worm, onchocerca vol-v-ulus, of which the adurt fenale (macrofilaria, 40-45 cn io in nodules under the skin and produces nillions of nicroscopic enbryos(nicrofilariae) during its lifespan which rarely exceeds ra v"*1,-a finding ofinportance in designing the vector control st"ategy. Ttre microfilariae, whichlive about th,o years, give rise to intensely itching rashes, to wrinkling,thickening arld depigaentation of the skin, to lymphadenitis resulting in hanginggroins and erephantiasis of the genitals, to loss of weight and generaldebilitation' and, eventually, to severe eye lesions inciuding btinaness. Thelife expectancy of the brind is reduced by 10 to 1! years. tti" crinicalplcture is conmonly fotrnd in savanna areas while the infection only rarely givesrise to blindness in forest zones. The vector 2'2 The vectors in l{est Africa ane blackflies of the Sinuliun dannosun speciesconp1ex.Ttrefema1e1aysitseg-gsat,orbe1ow,waterffitowing rivers where they hatch after 35 to 48 hours. Ttre lanral stage lasts five toten days (depending on the water tenperature) and is forrowed by pupati.on.Adult brackfries energe after further two to four days and rive up to four weeksduring which tine they can cover up to several hundred kiloneters in flight. Ttre transnission 2'3 When a fenale brackfly takes a bloodneal (necessary for the naturation ofits eggs) fron a person with an onchocercal infection, it ingests nicrofilariaewhich are transforned within the brackfly to infective larvae (L3) andtransEitted to other persons during subsequent bloodneals. fne f"i larvaedevelop in the hunan host into adult nale and fenate lrorns, and the rife cycleof the parasite is conpleted (fuinex 1). Note: PART I of this docunent is first and forenost intended for readers whoare unfarniliar with the hlstory, operations and achievements of the prograrutre,the knowledge of which will facilitate the understanding of the plan ofoperations contained ln PART II. Readers faniliar with Ocp night confinethemselves to a scrutiny of pART rr with occasional references toPART I. Onchocerciasis, its transnisslon and control 2'4 The incubation period, i.e. the tine between the entry of larvae (L3) andthe appearance of onchocercar synptons, varies between one and three years. Theseverity of the disease, and the probability of ocurar nanifestations occurring,correlate with the intensity and frequerrcy Lf infection, the risks being thehlghest in areas with a high prevalence of onchocerciasis (h54perendenicity) anda dense blackfly population. Transnisslon control 2-'5 Larvicidinq of the breeding sites of the blackfly larvae is, presently,the only neans of interrupting transnission to the extent that the huEanreservoir of 0- volvulus will eventually die out, and will renain so unti.l_such tine as ffiGaEi of the adult reorn can be achieved by comnunity-wideapplication of, as yet unknown, chemotherapeutic agents. page 5 Morbidi control the 1 Contand terlstics of lhe Programne area tude of the as wor, The oricin the ce Con 1 wuo E:<pert connittee on onchocerciasis, Technical Report series (TRS) 752. 3'r onchocerciasis is found along rivers (therefore its colloquial na.me,river blindness') il tropical zones in Africa, the Middle East and LatinAnerica' Globa1ly,^81.1-nrttion peopre are exposed to the risk of the disease, th3 ::lli3t.3"irte[;:*u and 340 0o-0 have uee', ui:,,ded by onchocercj.asis 2'5 Until recently, only two anti-onchocerciasis coppounds were available:diethvlcarbanazine (DEc) which kilIs microfilariae (nicrofilaricide), andsura^min, a nacrofilaricide (kills the adurt worn). However, both have seriousside-effects and are therefore unsuitable for connunity-wide application. 2'7 Since 1987 iveruectin, a microfilarlcide, has becone available forlarge-scaIe distribution in hunan populations and has proved itself to be avaluable therapeutic agent, easily dispensed under field conditions, but withoutthe originally hoped for, decisive inpact on transnission. 1S3 3'z rn addition to being a serious pubric health problen, onchocerciasis isan inpedinent to socioecononic developnent insofar as the widespread disabilitycaused by the disease leads to 1owered productivity, and the affllctedpopulations Eove away fron riverine, fertile land in fear of contractingonchocerciasis. fa paSe 5 3.3 Therefore, when a Joint USAID1/OCa6B27wHO Technical Meeting on theFeasibility of Onchocerciasis Control concluded in Tunis, Tunisii, i.n 1!58 thatlarge-scale Sinullun control through aerial larviciding h,as feasible, seven lgestAfrican countries-3ftogether with bilateral and nultilateral donor agencies, established the Onchocerciasis Control Progranme j.n the Volta River Basin area(since 1985: the onchocerciasis control progrr.re in west Africa - ocp). The area of OCP operati.ons and its population 3.4 The boundaries of the original seven-country progremme area (nap inAnnex 2) were determined in 1973 by the PAG Mission4 on the basis of theprevalence of the blinding ("savanna") for.n of the disease and excluded areas where the non-blinding ("forest") forn prevailed as the mandate of oCp waslinited to the control of savanna onchocerciasis. 3.5 Vector control operations, launched in L974/75, expanded over the Tgllotlg two years to cover arr of the original seven-counrry area(654 000 knz) which was extended trL 1978/79 inro the south of C6te d'Ivoire(Annex 2) thereby increasing the Original area to 754 Ooo kn2 with nore than18 000 kn of river under vector control. 3.5 The total population of the Original Progranne area exceeded 1O nillion and it rdas estinated that more than one nillion people were infected by onchocerciasis with 100 000 suffering fron serious ocular nanifestationsincluding 35 000 blinded by the disease. Since then, the level of lnfectionin that Original area has cone close to zero as a result of L2 to t4 years orvector control. 3.7 Ttre expansion of OCP operations into the Southern and Western Er<tension areas as fron 1995_ (iee paragraph 5.1 below and Annex 2) increased the progra.mroe area to I 235 000 knz, the total population to 30 nillion and the length ofrivers under control to about 50 OOO kn. Ttre nunber of particlpating Countri-es reached eleven by the addition of Guinea, Guinea Bissau. Senegal and SierraLeone. 1 Agency for International Developnent of the United States of America. 2 Organisation de Coordination et de Cooperation pour la lutte contre lesGrandes End6nles 3 Benin (then Dahoney), Burkina FasoMaIi, Niger and Togo. (then Upper Vo1ta), C6te d'Ivoire, Ghana, 4 The Preparatory Assistance Mission to the Governnents of the participatingCountries (fielded by trlHO in association with FAO and funded bV lrNDpj. page 7 3.8 In the present eleven-country Progranne area (essentially in the Extension areasl., 2,4 nillion people are currently infected by onchocerciasis with closeto 100 000 blinded by the disease. 3.9 Within theyears as conpared nunber of infants born) varies fron countries. Population statistics Progranne area, life expectancy at birth ranges fron 43 to 50to 70 plus in nost of Europe. Ttre infant nortality rate (the who fail to survive the first year of rife out of 1 o0o live 100 to 200 as against 7 or 8 in a nunber of European.. ins and Eanagenent of the Pro 3.10 -children aged less than 1! years nalce up 451 ot the total popuratioD, ofwhon 50 to 90 per cent live in rural areas. Bnrolment in primary school rangesfron 20 to 70 per cent of chitdren at school age. Econonic conditions 3'11 The econony of the Participating Countries is first and forenostagricultural and pastoral, accounting for the enplo5ment of 70 to 80 per centof the labour force. Ttre majority oi the countries fall into the low-incomebracket with an average per capita GNp at the lever of uS $ 2oo to l!0 perannun; only one or two countries reach the niddle-incone bracket (annual percapira GNP above US $410) Clinate 3'L2 The greater part of the Progranne area is situated in the dry and hunidsavanna belt. The wet seasoni when blackfly breeding and OCp larvicldlng areat their Ea:<inu.m' extends fron May to September with the highest rainfall inAugust. the annual ralnfall variei rron 5oO nn in the North to 1 300 nn in theSouth. The persistent drought since 1974 when the progranne started,acconpanied by deforestation, has led to a southward eitension of savannaconditions necessitating an expansion of the area covered by oCp vectorcontrol. 4 tion. Structure 4'f The overall authority for policy-naking and the planning, progranming,inplenentation and financing of OCP operatiorrs is vested in the Joint progranoecontrittee (JPC) composed of representatj.ves of the Participating countrj.es, ofthe Donors and of the Sponsoring Agencies (LNDP, lllHo, FAo and the world Bank).JPC nornally neets once a year to consider the annual progress reportr toaPprove next year's Plan of Action and Budget, and to deai with oiher importantProgra.mne Eatters. 4'z Ttre Expert Advisory Connittee (EAC) with a nenbership of not more than12 scientists carries out annual, ind$ndent evaluati.ons of OCp operations andgives technical and scientific advice to JPC, through CSA (see followingparagraph), and to the Progra.une Director. Ttre five-menber Ecological Group,a sub-connittee of EAC, nonitors the effect of vector control on the aquaticenvironnent. page 8 4.9 Representatives of LNDP, t.lHO, FAO and the World Bank neet several- timesa year as the Connittee of Sponsoring Agencies (CSA) to nonitor progranne operations, consj.der nanagenent issues and revieilocunentation for JpC. CSAcan provisionally authorize supplenentary budgets and approve budget transferbetween budget lines. Ttre connittee also supports socioecononic developnent ofthe oncho-controlled zones. 4'4 National onchocerciasis Connittees (NOCs) in the participating countriespronote OCP sponsored activities, such as derolution. Representatives neet asrequired, usuarry once a year. Nocs are non-statutory bodies. (Annex 4a .sunnarizes the Progranme structure). Planni.ng, and evaluation 4.9 Ttre basic strategf,/ for oCP's activities, centered on larviciding for thecontrol of transnission, was laid dorrm by the PAG Mission which also went intosone details regarding Programe stnrcture, methodologies, tine tables andresource requirenents. Ttris was developed further by a uNDp-furded interinproJect during t973. Financing 4.5 OCP is financed by donor countries. international developnent banks,nultilateral institutions and uN agencies (list of Donors in Annex 3), as weIIas by the Participating Countries which contribute L.4l of the Uuag"t, nakestaff available to the Progra.mne, provide office space and offer operationalfacilitles. Ttre World Banlc has statutory responsibility for deterntning theIeve1 of funding required to finance OCP operltior,s and for solicitingcontributions fron individual Donors. All contributions are deposited in theOnchocerciasis Fund which is adninistered by the l{orld Bank and audited by itsexternal auditors. Ttre annual PIan of Action and Budget is approved by theJoint Progra.une connittee followed by pledging of Donor corrt"ilutions. 4.5 Since OcP beca.me operationar, a systen of ,,Financial phases,, hasfacilitated nediuT-tern planning and budget forecasting. Each six-year ,phase,is covered by an Onchocerclasis Fund Agreenent, signed by the "ContributingParties". which constitutes the legaI basis for the funding and operations ofthe ProgrFmne. A Menorandun of Agreenent, describi.ng the institutional andoperational arrangeEents of oCP and signed by l{Ho and each of the participatingCountries, forms part of the onchocerciasis Fund Agreenent. In addition,individuar protocors are estabrished by ocp with each governnent of theParticipating Countries. Managenent 4.1 rtre Progrrrmme, executed by the world Hearth organization, is nanagedaccording to WHO procedures and ls technically and adrirristratively assisted bythat organization. 4.8 The Director of OCp is supported at progranne Hes in Ouagadougour BurkinaFaso, by five technical. and adninistrative ,rrrlts (vector control, epidemiolo-gical evaluatlon, biostatistical analysis and infornation systems support,support to devolution' and aduinistration and support servites) each headed by achief assisted by operational/scientlflc and cenlral Serwices staff(organigra''ne in Annex 4u). A Liaison Office is situated at wHo/He in Geneva. psge 9 4-10 More specificalry, the preparatory Mission insisted on a 20 years,tinespan for PrograEllle operations in the original seven-country oCp area as itwas considered at that tine that "the cunulaii,re lifespan of adult g.volvulusfilariae and of the last nicrofilariae produced by these adults t".ffiiregion of 15 to 18 vears"l. Donors and Participating Countries arike subscribedin principle to the pAG requirenents. 4'rr In 1978, WHO, at the request of the Joint coordinating connittee (theprecursor to the Joint progranme Connittee), subnitted an eialuation report asthe basis for preparing for the second Financial phase trgSo-ii85l. lrl "epo"tconcluded that control activities had developed satisfactorirv, lnat re.searchhad been camied out according to operational requirenents, rrra that thetraining conponent net the needs of the programmg. 4.L2 A trHo rndependent comnission on the Long-Tern prospects of theonchocerciasis control Progranne, set up in t97g, reconnended inter al-ia in its1t81 report that ocP operaiior," be sraduarry exienil-;;;;;Ilaffin. sourhwardextension had already been approved in pr:.nt:.ple); that funds be provided topharnaceutical conpanies to search ror L ,.""Lrii.ricide; that atransnission/control nathenatical nodel be elaborated; that devolution start asfron 1tt1; 8nd that the Programne be eventually transforned into an inter-country disease surveilrance training and advilory centre. 4:13 rn 1985 the usArD undertook an inpact assessnent of the progranne with aview arso to exa.oining the extent to which OCp experlence night be of use 1nplanning future ArD-supported progremtes. Ttre Agency concruded thet ,, . . . theocP, to date, Eust be consid."Ld orre of the nore successfur nurti.-donorprogra,[es ln the short history of devel0pnent assi.st,nce." 4'14 The ArD Mission suggested that rower-cost vector control nethodologies,Eore amenable to devolution, should be looked for; that nationar invorrmentshourd be increased with a view to futr integration of the ocp verticaloperations within the natlonal hearth deliveiy "y"t"r"; that corlaboration withprivate pharnaceuticar conpanies ln the sea"ci, fir chenotherapeutic agents becontinued; that a conprehenslve training progrrrra be instituted; that aninnuno-diagnostic test be developed; ane tn.I. eventualry, there wourd be a needfor an OCP successor body, an "Inter-country Facilityr,, to assune qualitycontrol, coordination and training function!, as required, once theParticipating countries had becone responsible for ,,naintenance', activities. 4'1f rn 1990 an exterrral review of the Progra-nme was carried out j.n order totake stock of oCP's progress to date. examine the reasons for the programmsr5achievenents and draw lessons applicabre to other progrannes; to assess theprogress nade towards devolution; to assess progress towards pronoting futuresocioecononic deveropnent in onchocerciasis-controtted areas; to highlightrelevant issues for ocP's future and nake reconnendations for the attainment ofthe Prog?anne objective; and to exarnine ocP's potential contribution to healthsystens developnent in the participating Cor:ntries. 4'15 Ttre findings concerning lessons of potentiar interest to otherprogramnes 8re sunmarized in paragraph 4.t7-uetow, while the findings andreconmendations regarding devolution, pronotion oi socioeconomic deveropnent,issues relevsnt to ocP's future and its contribution to health systemsdevelopnent are reflected in the corresponding sections of part rr of thepresent docunent. 1 pec report, page 4l page 10 4.77 The External Review Tean concluded that the success and achievenents ofthe Programne could be ascribed to a clear objective and defined operationaltargets; a realistic tine frane; a technology geared to what can effectivelybe done and afforded; the contracting-out of-lervices whenever cost/effectivl;a strong build-in operational research element; a pronognced autonony inprogramming and operations; a systen of checks and balances; and a clear andtransparent accountabili ty. 4.f8 Apart fron ad hoc reviews and evaluations, the Expert Advisory connittee(EAC) undertal<es 4""""1 audits of operational, scientific and researchactivities of the Progranne. EAC reconmendations, based on such audits,constitute one of the nain elenents in the pranning, progpammjpg grtflinplenentation of OCP operations. 1.tg A Long-Tern Strategy for the Prograrue was adopted by the Joint progranneConnittee (JPC) in 1!84 and a Plan of Operations for the third FinanciaL phase(1985-1991) was approved by JPC in 1985 (both docunents are reviewed in section5 below). \:?9. Annual progranme proposals contained in the Plan of Action and Budget(PAB) translate nediurn-tern progrannes into detailed activities and corresponding budgets. The consideration of the hlllO Progress Reports and thePAB's by the Joint Progranne Connittee affords yet another opportunity to assessthe achievenents of the Programme and to deternine its future direction. 5. ocP until end of Phase Profranne ob.iective 5'L AIl ocP activlties are oriented towards the attai.nuent of the progra.nneobjective as defined by the PAG Mission, and clarified by the Expert AdvisoryCoEtrittee in 1983: "to elininate onchocerciasis as a di.sease of public healthand socioecononic inportance throughout the OCP area and to ensure that thereI's no recrudescence of the disease thereafterr' (within thaa ;;;;):1 Vector control: ope tions 5'2 Aerial operations are carried out by a fleet of up to 11 helicopters and2 fixed-wing alrcraft, available on coulltercial contract. Weekly flight plans and dosagle schedules for larvicides are worked out on the basis of entomologicaland hydrological data collected by the Progranne-wide entonological surveillancenetwork. and connunicated to the operational bases and OCp HQs by Eeans of theOCP radio systen. 5'3 The surveillance network consists of sectors and subsectors nanned byentonologists. laboratory technicians, vector collectors, radio operators anddrivers. Hydrological conditions (water level and discharge rate") .""nonitored by autonatic devices in rlvers and teretransnitted via saterrlteto the operational centres. 1 See also paragraphs 8.1 and 8.2 below paSie 11 5,4 Untll the end of the third Financial Phase (1985-1991) rhe sector andsubsector staff in the orrginal and Southern Extension areas was enployed by theProgra'nne, while the sectors and operational bases (equivalent to subsectors) inthe Western Extension area were nanned by governnent-enployed personnel receiving allowances for added responsibility and travef pL" aie, from OCp (seeparagraph 9.4 Uelow). 5'5 Since 1t8/ when larviciding became a pernanent feature in the Extensionareas, the Progra-one area has, for the purpose of vector control, been dividedinto the Eastern 0perational Area (EOA) with operational headquarters in Kara,Togo, and the Western Operational Area (wOa) witn headquart"r"- in Ba.nako, Mali(nap in Annex 2). The aerial bases are rocated in Kara and 0dienn6,COte d'rvoire. The ocP centre for testing of larvicides is located in Bouak6,C6te d'Ivoire. Routine monitoring of larval susceptibirity to larvicides incuEent use is carried out with the aid of field teams located in Kara, Bouak6,odienne, Banako and Bobo Dioulasso, Burkina Faso. New compounds andforuulations are tested at a fierd station in Soubre on the Sassandra river inCOte d'Ivoire. 5'5 Ttre nunber of river kiloneters under vector control in the originalProgra'nne arear at a na:<imun of 18 ooo during ite "ainy season in 1!g2, u,as tnorethan harved by L9?o. correspondingly, the ninber of flying hours in the0riginal ocP areal has decllned fron- a no<inun of 7 500 in 1982 to 1 500 in 1990while it increased from 1 4OO in 19g7 to G gOO i" fggO in the Extension areas. 5'7 The annual consunption of larwicides in the original area reduced fron250 000 to Lz5 000 litres2 between 19si-;; 1t90, whire the consunptionincreased in rhe E:<tension areas from 5! ooo ii;;;s rn rggi-;-roo 000 rirresdurlng 1990. 5'8 conconnitentry with the changes in intensity of operations, the nunber ofsectors and subsectors ln the original ocP area hls dininlshed from 7 and 1!,respecrively, in.!!g g."rv eighties to 4 and L2 at the end of the thirdFinancial Phase (1991). rtre network in the southern Extension area remai.nedstabre (1 sector and 5 subsectors since t97g) while it has grown to I sectorsand 12 0perational bases in the l{estern E:<tension area. 5'9 since its inception, Ocp has had the benefit of the advi.ce of theEcological Group and the support of a prog.*r.-*iae network of aquaticnonltoring stations in its efforts to ensure that the effect of rirviciding onthe non-tarset fauna renains insignificant. Presentry, the ocp hydrobiologicalservice monitors invertebrates at 8 points wnire-nationar teams survey fishpopulations at 9 stations. 1 rn order to allow for comparison with resource requirenents during the fourthF;'nanclal Phase (1992-L997), the 1990 flsures for ftying hours and con,.rmptionof rarvicides in the original area exclude those pertaining to the 19? 79extension into the south of C6te d'Ivoire (para. 3.5 .bo.r.i ",ni"n .r" .rcludedin the figures given for the l,lestern Extension area. See also footnote toparagraph 10.13 below. 'Igr ease of presentation, rarvicide consunption is gj.ven in global litrefigures. rather than specified by indiviaual products. paSe 12 Vector control : results 5.10 As early as 1978, the Annual Transuission potentiar (ATp)1 naa droppedfron 800 to below the acceptable leve1 of 1OO2 in two thirds of the area underlarviciding. Rapidly, a sinilar sltuation extended to the entire Original area, except the reinvaded zones in the West and in the South-east and in a few circunscribed zones where vector control had net with operational difficulties(see nap in Annex !). 5.11 Tttus. in 1985 the last year of larviciding in the whole of the Original OCP area, nore than 9Ol of the insect capture points reported ATp's less than100 and in nany cases zero. Since then, Iarviciding has practically ceased inthat Original area with the exception of the reinvaded zones and the areas where operational probrens tenporarily inpeded effective control. 5.L2 The situation in the reinvaded zones in the Origlnal Progranne area hasgreatly inproved since larviciding extended to sources of reinvasion beyond itsboundaries. For exa.op1e, after treatnent of the Upper Sassandra Basin in south- eastern Guinea, biting rates and transnission potentials in northern C6ted'rvoire and south-westerrr Burkina Faso were reduced by over !01. Ttrereinvasion of MaIi ls now finally under control but this entailed treatment of sources up to 500 kn upwind in Guinea and Sierra Leone. 5.13 Another inportant achievenent has been the handling of loweredsusceptibility of the Simuliun larvae to tenephosr an organophosphorousinsecticide which rurtiIJ9'86787, when resistance appeared on a nasslve scalefollowing circunscribed lnstances since 1978, had been the universally appliedlarvicide within OCP. Since then lowered susceptibility to organopnopnorouslarvicides has spread throughout the Progranmg L"ea. However, this tenporarilylnpeding effect on control operations was overcone by rotation of the sixlarvicidesr,arlallable to the prograrme, i.e., tenephoi, chlorpho*in3 ana-pyraclofosa (all organophosphorous conpounds), Bacillus thuringiensis, H-14(a biological control agent). pernethrin (a pyr-throid) and carbosulfan (a carbanate). 5.14 In spite of extensive larviciding by OCP there has been little effect onthe aquatic environnent artd the record of the Progranme in this respect can besaid to be unblenished. No disappearance of fish and invertebrate species hasbeen recorded and the observed nodifications have been of minor importance, and anyhow reversible. It can therefore be safely concluded that a "yste, of strictnonitoring and surveillance of vector control conducted by the prograome duringnore than 15 years has shoum no adverse inpact of rarviciaing. 1 The theoretical nu^nber of onchocercal larwae (L]) received by a person statloned at an insect capture point during one year. 2 Ttte upper tolerable limit for occupying the river valleys without risk of contracting serious onchocercal. ocular leslons. 3 Pnased out in 1990 4 Introduced operationally in 1990. paSe 13 5'L5 Until 1988, the actj.vj.ties of the Epideniological Evaluation Unit (EpI)were essentially ori.ented to an agsessnent of the inpact of vector control byDeans of repeated exanination of indicator villages consisting of ,,sinp1eevaluations" (search for nicrofilariae in skin-siips and visuat testing) and "detaired evaluations" (ophthalnological exanination added). Much of this workhas since 1989 been camied out by ocP-trained national teams, supervi.sed by EpIand supported materially and financiarly by the programne. 5'L5 Ttre data obtained fron the evaluations in indlcator virrages arlow for theconputation of the incidence, prevalence and connunity load of infection. Theseindices which constitute the elements for trend analysis have talcen on addedinportance in the Original Progranne area where they are used to deternine whereand when onchocerciasis has reached the 1evel below which larviciding cancease. 5'17 rtre Prograone also carries out dissection of onchocercal nodures in orderto ascertain the proportion of dead fenale worns in communities under vectorcontrol. 5'18 ocP/EPr. with substantiar help fron national epideniologlcar tea.ms, hassince 1990 conpreted a conprehensive progranne oi epideniologicar napplng in theE:<tension sreas with a vlew to establishlng uaserines for future assessnent ofcontror operations' estinating the nunber or peopte lnfected and brinded byonchocerciasis, 91d identifyitg corrur,ities rn nlea of large-sca1e ivernectintreatnent' rn addition to skin-snip exa.nination, Epr has indertaken speciarophthalDological surveys to deteruine the seriousness of the infectlonstransEitt€d. and to eventually evaluate the effet of ivernectin treatEent. 5't9 Fina11y, ocP/EPr supports connunity-wide ivernectin distributionprograEnes in villages with populations at risk of onchocercal Ulinaness (Cttlpllabove 10) ' carried out uy naliinal teams with the assistance of Non-governnentarorganizations' other approaches to ivernectin distribution in affected vilragesare under study by ocp together with national heaith authorities. 1 co'ntunity }licrofirarial Load: the geonetric nean of nicrofilariae per skin-snip anong persons aged 20 years arrd nore, including those with zero count. page 14 evaluat ion: findines and results 5.2O As a result of the interruption of transmission during up to 14 years ofvector control, the CMFL has cone close to zero in all of the Original programmeareai excepting the reinvaded zones and a few cj.rcunscribed areas wherelarviciding Eet with operational problens. 5.2t Once the CMFL approaches the zero level in a given area it can no longerbe used for trend analysis and is replaced-by other indicators. The prevalenceln the naJor part of the original OCP areal is now insignificant and tarvicidinghas been discontinued in nore than 8Ol of that area. 5.22 Another success of vector contror, confirmed by epidemiological evaluation' is the fact that no onchocercal infections occurred in the original area Frnong children born since the start of vector control, except in the relnvaded zones and in the few areas where transnission tempor""ity relapsed.In these areas, only 10 to 20 per cent of the infections expected in the absenceof larwiciding were recorded. 5.23 It is estimated that by 1!!1 approxinately nine nillion children bornafter ocP operations started have been spared the risk of contracting onchocercal btindness, that l0 nillion people (including the population of theExtension areas) are protected fron onchocercal disease, tn.t t.Z5 nittioninitially seriously infected are no longer so and that over 1OO OOO have beenprevented fron going blind. 5.24 The progress nade in OCP-conducted large-scale ivernectin distributionwithin the Programne area is sunnarized in the below table (see also rnap inAnnex 10): Table 1 Number of persons in OCP-conduc ted i distribution 1q87/88 1988/89 1q8q/o0 1q90/q1 0riginal area I'lestern D( t. area Southern Ext. area 28 \82 8 rz3 L4 32t1 23 5L5 28 977 7L t57 25 299 177 335 75 768 29 787 183 391 45 059 Total 50 929 53 543 218 403 259 247 No!e: coverage of total popuration in average around Gol (see paragraph 5.33below for exclusion criteria). 1 See footnotes under 5.5 above and 10.11 below page 15 5'25 Ttre unit concerned with biostatistical and infornation systems (BIS)supports other units in the analysis of operational data and in tne ptanningand evaruation of fierd studies; provides technical backstopping for the gCpcomputerized infornation systen; and trains progranme staff in its use. Theconputer network covers OCp Hes and aIl operational stations. 5'26 The Sraph in Annex 5 lllustrates the epidenlological effect of larvicidingin the original OCP area, predicted and observed. Ttre prediction emanates froma transnission nodel developed by ocP/BrS. Ttris nodel is capable of producingepideniological forecasts under varying control scenarios, including the risk ofrecrudescence of infection and disease after cessation of vector contror. 5'27 Ttre nain conclusion of nodel sinulations is that 14 years of larvicidingis required to virtually elininate the hunan reservoir of the onchocercar worn,and thus to practl'cally preclude any rlsk of recrudescence e,anatlng fron insidethe area under control. 5'28 Furthernore, sinurations and field observations have denonstrated thatcomnunity-wide application of ivernectin does not reduce transnissionsufficiently to elininate the hunan parasite reservoir, even if continuedregularly at a high 1eveI of coverage for a prolonged period as repopuration ofnicrofilariae comnences fairly soon after trlatnent. At the sa.ne tineprerininary nodel predictions are that effective iveruectin distribution cancope with recrudescence' provided such dlstrtbuiion is instituted soon after theappearance of recrudescent infection (Annex Z). 5'29 Progranne actlvities in this field have been linited to the corlection ofdata required for assessing the inpact of ocp operations on socioecononicdeveropnent' The ocP officer concerned also lilises with the participatingcountries and facllitates studies undertaken by the connittee of sponsoringAgencies (CSA). 5'30 As a first-step, cSA sponsored a regionar study to identify, within areasunder ocP control, the zones with promising developnent potential, and toprepare forlow-up action. The second step was a study of resettlenent designedto provide guiderines for pronoting settrenent-rerated deveropnent inoncho-controlled zones. ltre third activity consi"t"a of an in-depth analysis atthe nationar revel to serve as the basis flr the iormulation of deveropnentplans for each countryrs onchocerci.asis area. 5'3L so far, 15 million hectares of riverain, tillable rand have been nadeavailable for resettrenent and curtivation, i" p"ra as a result of ocpoperations' Ttris has provided foodstuff" ""ous[-io feea 10 nirlion peopre perannum' rt is expected that the land available Ior resettlenent wil.l come cl0seto 2J nillion hectares before the end of this century. 5'32 A speciar ocP research endeavour is the onhocerciasis chemotherapy project(ocr) which since 7982, i" "oii.uoration with the Special progra.mne of Researchand Training in Tropical Diseases (trHOiu$p/il";il Bank) and the pharmaceuticalindustry, has been engaged in the search for anti-onchocercal drugs with thefocus on macrofilaricides. page 16 5.33 As a result of these collaborative efforts, ivermectin becane availablefor hunan use in t987. Ivernectin is adninistered oral1y, it gives rise to few, and only nild, adverse reactions and its clinical effect is pr-nounced. Thedisconforts, such as itching, disappear rapidly, and the risk of ocurarnanlfestations, including blindness is signifitantly reduced. Ttre drug shouldnot be dispensed to pregnant wonen, mothers during the first week of lactation,children less than five years old, and patients suffering fron severe diseases. 5.34 Being a nicrofilaricide, ivernectln needs to be given regularly, once ortwice annualry, during several years. As already neniioned (parasrlph 5.zg)the reduction in transnission following large-scate applicatio. oF the drug, isinsufficient to bring the hunan parasite reservoir to an epidemiologicallyinsignificant leveI. It should be stressed in this connection that ivernectinhas no effect on the infective larvae (L3) after entering the hunan skin and cantherefore not be used as a neans of prevention. Research 5'35 The OCP research protra$re Is entirely operations-orlented and followsclosely the reconmendations nade by the E:<plrt Advisory Connittee. Recently,t'he research priorities fall lnto slx naJor groups: vector control (Sinuliun'biononics and larvicides), identification of-parktte strains , imnuno-diagnostic testing. chenotherapy (search for L nacrofilaricide (see precedingsection), effect of ivernectLn on transnission - alone or in conbination),nodelllng and health systems research (epideniological surveillance andrecrrrdescence control) . 5'35 Appried research rerated to operationar inperatlves Ls undertaken as aninteglal part of ongoing Prog?omrns activlties, including the continuing searchfor Lnproved cost/efflclency of operatlons. In additlon, OCp relies on a nunberof institutions and consultants for carrylng out studies in more specificareas' Ttre ability of the Progranne to respond rapidly to resear.i, firrairrgs hasin large part been the reason for its success. 5'37 The results of OCP conducted/supported research have helped to enhance thequality of Progremme activities and allowed OCP to cope with operationalobstacles. E:<anples are the increased availability and inprorld fo.nurations oflarvicides to overcone resistance, the steadily inproved understanding of thebiononics and vectoriar behaviour of the blackiry as related to patterns ofblindness, the progress nade in developing . t."i to detect earty infection,and, not the least, naking ivernectin available for large-scale ireatnent of thedisease. TraininF 5 ' 38 Ttre training prograrnrng fgllded by OCP awards fellowships to nationals ofthe Participating Cor:ntries in disciplines of direct relevance to onchocerciasiscontrol' The progranme has over the last few years become increasingry orientedtowards training in subjects related to devorution. Ocp also arrangesin-service training for its own staff. 1'39 Between 1974 and December 1990, 338 ocP fellows have been trained in suchdisciplines as entonolory, hydrorogy, tryarouiology, epideniology, parasitorogy, ophthalmology and public health, practicalry all in African institutions (seeAnnex 8). paSe u tion 5.40 After a period of doubt and uncertainly concerning devoluti-on, the concept, nature and inplications of this process, essential for attaining theProgra.nne objective, have been clarified following the advent of ivernectin.Conceptually, devolution should be seen as national maintenance of oCp achievenents through active epidemiological surveillance aiming at earlydetection of foci of recrudescent infection/disease, and the control of such recrudescence by ivernectin treatnent. 5.47 So far, the seven Participating Countries which together nake up the0riginal Programne area. have prepared devolution plans wtrictr have been subnitted to, and endorsed by, the Joint Progranne Connittee (JPC). In all ofthen, surveillance of onchocerciasis has been conbined with that of otherdiseases of public health inportance and provision has been made for coping with recrudescence of the disease. Recently a Devolution Unit has been set up atOCP HQs. Managenent 5.42 The overall direction of 0CP, including inplenentation of general policy and ProgralrEe nanagenent, is entnrsted in the Director's office which alsohandles external relations, coordlnation of research, support to devolutioninforuation of the public, train-.ng, neetings and the Geneva Liaison office.Chief, Adninistratlon and Support Services, is on his side responsible forbudget and finance Datters, personnel. equipnent and supplies, transport andbuildings. 5'43 To obtain th,' hest possible cost/efficiency ratio of progra.ne operations,a close watch is kept on alr activities at arl rlvers to ensurE the greatestbenefit at the rowest cost. rn thLs connection, annual Staff Senlnars serrre asoccaslons to inbue operational and adninistrative staff with a high degree ofcost-consciousness. 5'44 More specifically, -good Eanagenent practice has allowed for a reduction ofstaff bv 3o I between 1987 and 1990 to sone extent conpensated for by the use ofnationally enployed personnel. AIso, the Progra.ume direction has succeeded,through negociations with industry, in lowering the price of larrricides, in onecase by as nuch as 501. 5'45 In the field of institution building, OCP has created a highly efficient,regional adnlnistration and connunications network in support of all progranneactivities' based on a conplenent of well-trained, conpetent and notivatedstaff' by far the najority recruited fron the Participating Countries, andsupported by a region-wide radio syste, and conputer link-up. for Phase 1 and of6 5.1 The nain thrust of the Long-Tero Stratery (LTS) and of the plan ofoperations for the 1985-1991 period was the eGansion of OCp operations into theSouthern and t{estern E:<tension areas (see nap in Annex 2) intended both toprotect the populations in those areas and to prevent reinvasion into the0rlginal are8. vector contror was planned to "t."t in 198G ;; ; expected tocotre to an end in 1997 as' at the tine of preparing the LTS, the lifespan of thefemale ttorn was believed to be on the a.r.""ge- 11 years, so that eleven years oflarviciding would suffice to elininate the turan ieservoir of 0.volrnrrus. page 18 6.2 The Long-Ter:n Strategy further predicted that oCp would cease itsactlvities in the origlnal seven-country area bv t993/94 after which thePartlcipatl'ng Countries would assune responslbillty for naintenance operations as they would ln the E:<tension areas starting tn t997. What was referred to as "naintenance" at the tine of preparing the LIS and the Plan of Operations in1984 and 1985 has since been clarified in operational terns as the process ofdevolution. 5.3 The success of the Progra.mne in the original area has been conplete. Thehunan parasite reservoir was virtually elininited throughout the area already by1990 (and even before) with the exception of the previously reinvaded zones and one or two circunscribed areas where vector control had net with teuporaryproblens. Ttris result was obtained in less than the 20 years originally igreed upon as the tinefrane for OCP operations in the Original progr""! area. 5.4 As regards the E:<tension areas OCP control should be seen as a successorprogranne to that in the 0riginal area, distinct fron it in operations and inits tinefrAm€, but necessary to protect the achlevenents in that 0riginal areaas well as the concerned populations. 6.5 The start of vector control operation in the E:<tension areas has suffereda delay of up to three years due to serious reslstance problens with which theProgranne has been faced since the first harf (1985-198-8) of the tti"a FinancialPhase. 6'5 Furthernore, epideniological lnvestigations in areas where larviciding hasbeen conducted since L974, supported Uy preaictions of the epideniorogicaluodeI. have now establlshed that up to 14 years of larviciding is required toelininate the hurnan reservoir of the onchotercal parasite, i.e for the longestliving adult worns and the last batch of nicrofillriae to die out. This is incontrast to the 11 years estinated when the Lls was prepared. 5'7 As a result of the delay in connencing larviclding and the underestinateof the duration of vector control necessary to ellninata the parasite, ocp willneed to continue larviciding beyond 1997 rn parts of the E:<tension areas,although on a gradually dininishing scale. 7 MiIes in the of the Progranne and its cost until the endof the third F'lnanciaI 7.L During the first Financial phase (Lg7q.L9lg) vector contror, basedexclusively on tenephos' expanded gradually throughout the Original progranme area with the result that transnission was controiled in two thirds of thatarea. The second Financial Phase (1980-1985) was characterized by continuingsuccessful larvlciding with sone operational problens created by reinvasion andclrcunscribed instances of resistance to organophosphorous conp6unds. Theseproblens h,ere accentuated at the beglnnlng or tte third Financial phase (1gg5-1991) but successfully overcone by the exiension of vector control to the3ources of reinvasion in the South-east and in the trlest and by instituting arotational schene for the appllcation of the five larvicides then avallable.AIso. the end of that Phase saw the advent of ivermectin as an effective neansof control of onchocercal nanifestations. p88e 19 7 '2 Ttre total cost of ocP operations during the first Financial phase amountedto uS I 56.2 nillion and ca.ne to uS $ 104.1 iiiii"" for rhe second phase. Ttreexpendltures for the thlrd Phase totalled us SrZ9.6 nrrlron.-iaii-"rounrs aregiven in nominal $ values). 7'3 Ttre proportion_of the budget spent on vector control has renained fairlystable at the 55 to 75 per cent level, while epidemiological evaluation hasaccounted for 3 to I per cent and Eanagenent, including the Directorrs 0ffice,for 11 to 1l per cent of the total exp-nditures. page 20 PART II 1qo2-taa, C. PLAN OF OPERATIONS FOR THE FOURTH FINANCIAL PHASE (7g92-Lgg7) Introduction a' The following Plan of Operatlons has been developed withln the fra.meworkof, and in confornity with, the OCP Long-Term Strategy whose main featureswere: continuation of transmission control by larvi-iding, expansion of vectorcontrol lnto the E:<tension areas and an inteniiried search for auacrofilaricide which, if and when available, could alter the controL strategy.Already, the availability as fron 1987 of the nicrofilaricide, ivermectin,has enlarged the scope of progra.nne operations by naking an inportantcontribution to norbidity control, including reduction in ocular pathology. b' The onchocerciasis control Progranne has consistentry ad.hered to a nunberof operationar policies and nanagerial principles which have been instrumentalin naking the Progranne progress in a cost/effective Eanner. The futureoperations under the PIan of Operations should be viewed in the context of theseporicies and principres sone of which are mentioned in the folrowing. c' ocP is pre-eminently a fierd operation. It has succeeded in naintainingits nomentun and overconing technical and other obstacles essentially becausein-built scientific and operatlonal research has anticipated such obstacles andprovided sorutlons. Exanpres ar€ the phenor"r. oi reinvasion and resistance toorganophosphorus larvicides. In the first case, the progro,,r" "*p*ded itsoperations to cover the aources of r.einvasion whire in the second, thesuccessfur search for new insecticides allowed for the rotationar use of severalenvironmentally acceptabre rarvicides to overcone resistance. d' Also, as a resurt of research the lncreased knowledge of the vectors andinproved understanding of their behaviour and inportance for transmission havecontributed largely to steadily inproving vector control operations and theirefficiency. Another inportant developmerrt h." been the advent of ivernectin asa neans of onchocercal norbidity control in hunans, to a rarge extent due tofield studies camied out by the Progranrre. rt shourd be stressed in thisconnection that OcP collaborates cloiely with other research entities within andoutside lilHo. so as to achieve the best possible cost/effectiveness arso in thisfie1d. e' Although the Progra.nne adheres to the overall strategy raid down in theP"s:I91, strategy there has always been anple roon for edaptation andflexibllity in its application. Itris is denonstrated by the occasionalnodification of the boundaries of OCP operations originally deter.uined onentonological grounds' but nore recently nodified so as to conforn withepideniological crlteria (see paragraph 10.29 below) f' Cost/effectiveness and optinization of the use of resources are of najorconcern in the Eanagenent of the Progra.nne. Deternined and continued search forinprovenent in control operations at a lower cost has thus resulted in theapplication of contlnuous saterlite transnission of hydrological data arrowingfor rarwicides to be sprayed in the right quantity according to precise readingsof the water flow, thereby econonizing on insectilioes. Also, thecoEputerization of helicopter circuiti has gone a long way towards optinizationof flying hours. page 2t s' The Progranne nanagenent is constantly on the outlook for savings and hason several occasions succeeded in lowering the cost of comnodities throughnegot:: ions with industry. OCP has thus benefited fron substantlal reductionsln th< cice of larwicldes, in one case up to 5Ol. a" ".i"ra"lr""r""tj.n, itwas ai r extensive discussions with the Progra.nne Director that thenanufacturer decided to nake the drug avaitaute free of cost. h' Whenever activities are better and nore cost/effectively perforned by otherentities than oCP itself such serwices are contracted out. This goes for aerialoperations where the Progra.nne enters into contract with the conpany naking thenost advantageous bid' a procedure repeated every three years. i\gtheruore,trucking of insecticldes and other connoditles, previously done by progra.nnevehicles, is now in the hands of private firus-on a contractual basis as aresecurity arrangements at ocp headquarters and operationar centres. i' --The Progra.une has been fortunate in attracting highly quallfied and devotedstaff' Ttre overriding consideration in selection has always been high technicaland nanagerial skllls and OCP's record of staff retalnnent is indeed inpressiveconsidering also that conditions in the field are often very ta:<ing. i' An inportant, fairly recent developnent has been the construction of anepideniological model which is now an instrrrnent of significance-in thedevelopnent and continuing adaptation of operationar prans. k' It is by the apprication of the operational policies and nanageriarprinciples exenprified above, that the Progta.nne has succeeded in folrowing itschartered course and thereby gone a long wly towards the attainnent of itsobjective' The operationar approach of OcP has stood the test of tine and it isconfidently predicted that the continued adherence to this approach during thefourth Financial Phase will produce the expected results so that operations wilrcoEe to an en 'rithin the tine fra.ue predicted on currentry available technicalinforuation. 1' rt is appreciated that the developnent of a nacrofilaricidal dILg couldradically alter the approach to control and prove an invaluabre toor ininstances of recrudescence during and after devorution. D' Progress will be constantly nonitored by the Comnittee of SponsoringAgencies' the Expert Advisory clmnittee ana ine Joint progranme connittee, andthe course of action will be adjusted according to the guidance andreconmendations received fron these bodies. Furtheruo"e, it is suggested thatan external review be camied out at nid-teru during the fourth Financiar phase.Ttre findings and reconnendations of the review nission wourd assist the ocpEanagenent to naintain its effective adaptation to the Eost recent knowredge ofrerevance to Progromme operations and this tn partlcurar in respect to theinpact and futr .e role of iver.oectin. 8. Obj."ai*r" rrrd a""".a" fo" oo.".arorr" d,r"rrr* an. 1oo2-1oq7 o."aod 8'1 The obJer ilve of the PrograrEe as deflned in 1g83 by the Expert AdvisorycoEEittee reads rs forlows: "to erininate onchocerciasis as a disease of publichealth and socroecononic inportance throughout the ocp area and to ensure thatthere ls no recrudescence of the disease Ihereafter,. 8'z since then' epideniological nodel predictions indicate thatrecrudescence, should it occur, could Ue effectively dealt with throughapprication of ivernectin, a drug that was not availabre for hunan consumpti.onat the tine of definition of the obJective. consequently, EAC at its 1!!osession reconmended-the following nodiflcation to the objective slightryadjustes by csA: : 'to elininate onchocerciasis as a disease of public health page 22 inportance and as an obstacle to socioecononic developnent throughout theProgra.nne area and for the participating countries to Ealntain this achlevenent. tt 8.3 Progra-mne operations during the 7))2-L997 period will ain at attainingthe following targets: Tarse t date plans for devolution prepared and its implementation underrray in the maJor part of the 0riginal OCp area excepting the reinvaded zones (para. 18.19) preparatlon for devolution conpleted in the Extension areas (para. 18.19) discontinuation of entonological surveillance and reduction of the network in the najor part of theOriginal Progranne area (para. 10.18) cessation of what litt1e is left of lanriciding in the non-r'elnvaded ortginal Ocp area (paras 10.14 and 10.15) withdrawal of the renainlng entonologlcal eurveillance network fron the non-reinvaded Orlginal OCp area(para. 10.18) Lgg2 1992/93 1992/94 1994195 L995 9. General considerations 9'1 The present Plan of Operations falls within the franework of theLgns-T9r'm Stratery (LTS) and the activities enunerated are a continuation ofthose described 1l-!h" LTS as appropriate for reaching the progremns gljsctive.During the 1p!2-1!!/ period the enphasis of contror operations wilr shlft fronthe original OCP area (where the objective will have been fully net before theend of that period) to the Extension areas where vector control will safeguardthe achievenents in the Original Progra.une sreai protect the populations in theExtension areas, and nove OCP towardi attaining iis objective throughout theeleven-country area (see also paragraph 9.g Uelowy. 9'2 with vector control practicalry completed in the original progranme areaand well undervay in the Extension areas, a doninant feature of the fourthFinancial Phase wlll be the consolidation of devolution in the forner areaand its preparation and gradual inplenentation in the latter areas. The ultinateauccess of the Progremns will depend on the extent to which the participatingCountries will aBive at early detection of recrudescence and at its effectivecontrol by neans of ivermectin distribution. 9.3 The strengthening of the natlonal epidenlologlcal sunreillance andcontrol capabillty will therefore r"enaln a naJor concern of oCp throughout theperiod with particular enphasis on the sustainability of this capacity in theParticipating Countries and on its nanifestations in operational ter,s. Giventhe overriding inportance of the Progranme's support to the national efforts inthis respect, an ocP Devorutlon Unit was establi;hed ln Ouagadougou by the endof the third Financial Phase. The activities of this unit will be furtherEtrengthened during the Fourth phase. page 23 9.4 It is planned that General Service staff in the original and SouthernExtension areas will becone nationally enployed under siniiar conditions asthose already prevailing in the Western Extension area, this harmonization beingin line with the Progra.nne's nove towards a steady increase in nationalinvolvnent within the context of devolution. Negotiations witl be undertakenwith the Participating Countries in this respeci and the agreenents reflectedin the country protocols (see paragraph 4.G above) 9.5 More than 1! years of OCP-conducted vector control, supported by modelpredictions, has denonstrated that successful larviciding can Lchieveinterruption of transnission and, if continued uninterrulteaty during 14 years,result in virtual elinination of the hunan reservoir of ine plrasite in the absence of renewed infection, within the area under control. Arthough,initially, Iarge-scale field trials seened to indicate that ivernectin mighthave a similar effect if applied for a sufficiently long period, suchexpectations were soon discouraged by subsequent field investigations andepidemiological nodel sinulations. 9'6 The E:<pert Advisory Connittee therefore reconnended, at its June 19g9sessi'on. that OCP should continue to rely on larviciding for the controt oftransnission and that ivernectin should be used widely ior the treatnent ofinfected cases with a view to controlling norbidity and preventing ocurarnani'festations leading to blindness. Vector control brings the piogra.ume to itsobjective within a finite perlod while ivernectin control of onchocercalnanifestations will need to be continued indefinitely as without vectorcontrol,transnission will continue in areas where ivirnectin is given alone. 9'7 EAC further reconr':nded that whenever ivermecti.n was applied on aconnunity-wlde basis together with,lanriclding, the drug couta-be given duringfive to seven yeals to ensure rapid ma:<inum clin:.car effect after which vectorcontrol alone would bring about virtual elinination of the hunan parasltereservoir. 9'8 The findings and reconnendations of the Expert Advlsory connittee wereincorporated in a strategy docunent (Jpclo.g) which was considered, andendorsed' by the Joint Prograrnne Connittee in Decenber 1989. it-*"" underlinedthat ocP wourd furly attain its objective in the original seven-country area,and this within the twenty year period assigned to it. operations in theE:<tension areas should therefore be seen as a successor control progra,1,,e,independent in activities and tinefra.ne and intended to protect the popul-ationsin these areas and to safeguard the achievenents in the briginal area. 9'9 At the sane tine it was stressed that ocP, as a result of an under-estinate of the duration of infectivity of the parasite in nan (14 years insteadof 11) and a delay of up to I years in the start of larviciding'in the Extensionareas due to resistance problens. would need to continue vector contror beyond1997 when the Prograrune was inltially predicted to cone to an end. operationsduring the renaining years wouId, however. be conducted on a graduarry reducingscale. 9'10 The overall strategy for the fourth Financial phase will thus continue tobe based on larviciding as the Deans of transnission control. Chenotherapy byivernectin will constitute an inportant conplenent aining at preventing severeocular nanifestations of the disease as was already th" crs" iuri.ng the thirdFinancial Phase (1985-1991). page 24 9'11 In deternining the target areas for, and the extent of, larviciding, theoverriding consideration will remain the need for interruption of transni.ssionwhenever considered indispensable for attaining the progrr.me objecti.ve.origlnally the overall strategy ained at, and iucceeded in, vector controlthroughout the Original ocP area. since then, clarification of the d5manics ofthe onchocercal epideniology and the advent of i.vermectin have allowed theProgranme to institute larviciding in the E:<tension areas on a tlore selectiveand seasonal basis or leave out vector control fron certain areas whereepidemiologicar investigations and other consi.derations have estabtished thativerrnectin distribution alone will aIlow the Progranne to Eeet its objective(see for example paragraph 10.28 below) 9'72 More specificarly, areas designated for ivernectin distribution arone arethose where: - the serious hyperendenic foci are linited to a few circunscribed zones; - population is sparse; - a substantial proportion of onchocercal larvae in blackfLies areaninal filariae; - the endenic foci do not constitute sources of reinvasioni and - the cost of aerial operations would constitute an inordinatedrain on linited resources. 9'L3 ^In preparing the Long-Terrn Strategy (LTS) and the plan of Operations forthe 1985-1991 period, the ttotiot or graduation of vector contror according tointensity of operations (attack, consolidation, naintenance) was introduced.Tttis concept has not been applied in the pranning for the fourth F.inancialPhase. insofar as rarwiciding in the Brtension "i".. developed naturally intoserective and seasonar operations which can no longer be graded according to theLTS system. 9'14 The operational plans and budgetary forecasts contained in the renainderof the present document have been worked out on the basis of nore than 15 yearsof fleld experience. The Llkellhood is therefore that inplenentation will matchpredictions. However, given the dependence of OCp operations on a series ofunpredictable biological and climatic variables, it is inportant that theProgrnmme nanagetrent continue to be granted the frexibirity necessary to neetunforeseable circunstances and events and to adjust the use of resourcesaccordingry' ocP will thus enhance its proven cipabirity to respond and adapt tochanges in the operational environnent. 9'L5 High priority will continue to be given to the developnent of a field-applicable nacrofilaricidal drug, the introducti.on of which tould radicallyalter the control strategy. 9.L5 OcP has over the years developed and refined a unique regionalinfrastructure, both as regards connunications and avairability ofinterconnected operationar centres where Progrorre staff have accumurated anintinate knowledge and understanding not onty in the field of onchocerciasiscontrol but also in respect to local, social and econonic conditi.ons. rt wouldtherefore seen legitiEate to explore ways to put OCP-related personner andstructures to the use of further developnent or health care systens,coordinated care of natural resources and the strenghtening oi'researchcapabilities within the t{est African region. page 25 9'77 Ttre Progroye wilr operate over an area of r 235 ooo kn2 (incrudingthe Original area), and close to 50 ooo kE of river will be under controL:surveillance and larviciding or surveillance alone (original area: nore than18 000 kn). rn all, 30 nitfion peopre wirl be protected fron onchocercarinfection. 10. Vector control Vector control: Eeneral 19'1 Ttre operational ain will renain virtual interruption of transnissionwherever there exist significant hunan reservoj.rs of onchocercar parasites witha potentiar for causing the brinding forn of the aisease.--rt"-.pp"oach toattaining this ain will continue to be seasonal and selective ta.yiciarng whichis finetuned to Prevent transmission of the brinding strain of 0. volvolu: byefficient. usually migratory, savanna cytoforns, ".In"i-tiL'iri.r."t treaLnentthroughout the year. 7o.2 Ttre Progra.mne has over the years acquired a unique knowredge andunderstanding of the blononics, vector efficiency and nigratory practices of thevarious cytoforns of the blackfly throughout th;-ocp area. Arso, the seasonalchanges in the dynarnics of vector popuritions are beconing increasingly known. 10'3 By reacting to the results of applied research when drawing up mediun-tern and short-tern progrannes, ocP h;'br;;dt-Iuo.rt a consiae".lr" inprovenentin the cost/effectiveness of vector contror ip"".tiorrs and wilr continue itsefforts in that direction. 10'4 Also' the now generarized use of saterlite-transnitted data concerningrlver discharge, captured from beacons posltioned at key points, arrows for aprecise insecticide treatnent as regards deternination of appricatlon points,aircraft circuit, choice of rarvicides and d;";;;. The conputer storage andanalysis of hydrologicar and larvicide applrcaiiop data wirl continue to beof essence in this respect. 10'5 The use of different larvlcides in rotatlon wirl renain the strategy forcoping with resistance to tenephos which wilr continue to be used in any givenarea until larval susceptibility reaches a point at which the five repracementrarvicides: Bacillus-thuri$eienlis (B.t. i-i4)l-o".r"ahrin, phoxin, carbosulfanand pyracror6Gne inroJil 10'5 The vector controt unit wirl rely on the results of epideniologicarsurveys when deciding finally on the cessation oi rarviciding withi.n theoriginal ocP area' -iarviciding wiu be discontinued after 14 years if thedecrine ln CMFLI and preval"t"E or skin nicroiii.ii." in indiclror virlages havebeen in accordance with nodel preafctions. zu"ite".or€, there should have beenno significant incidence of infection (incruai;;-;" incidence in chlrdren bornsince the start of vector control) a"ri"i-it"-"3"1"or period and the results ofcross-sectional surveys in surrounding vltt.s""-"hourd be consistent with thosefor the indicator viIlages. rn case these criteria are not net, detairedinvestigations will be undertaken to d.t"rmine the risk of recrudescence ofinfection and to estinate the required additionar-period of larwiciding. 1 connunity Microfilarial Load: the geonetric Eean of nicrofilariae per skinsnip among persons aged 20 years and nore, incruJing those with a zero count. page 26 LO'7 At the tine of cessation of larviciding in a circunscribed area, thenational health authorities concerned will be notlfied accordingly with a view +ntef alia to nake the final arrangenents for the devolution aclivities requiredln that area. 10.8 As a general principle, the entonological surveillance netrdork wil1 bekept in place for two years of significant blackfly presence after larvicldlnghas been discontinued in a given area in order to produce tangible evidence thattransnission has reached an insignificant 1evel (post control evaluation). 10.9 Similarly. the Expert Advisory Connittee reconnended at its June 1989session that nonitoring of fish and invertebrates be continued for at, Ieast oneyear in sone river basins in the 0riginal OCP area where 1arviciding ceased in1990. 10.10 Surveillance of the aquatic environment is expected to focus lncreasinglyon the effect, or lack of effect, of vector control in the F,xtension areas asand when larviciding ceases in the 0riginal OCP area. Ihe nonitoring ofinvertebrates will renaln the responstbitity of ocP and the surveillance of fishthat of national hydrobiologists. 10'11 During the fourth Financial Phase, the Programmg sl]] continuelnvestigations of the inpact of larviciding on thi riverine nirieu and encouragenational authorities to nonitor the broader environnental effects that hunanresettlenent and socioecononic developnent nay brlng to onchocerciasiscontrolled areas. ocP will arso nonitor eco-environnental changes in the oncho-controlled zones in respect of any potential inpact which ..y "i.".rbate thepotential for recrudescence. lo'L2 As vector control cones to an end, the blackfly will return. This could,apart fron the nuisance of bites, give rise to fear of blindness, a fear to bealleviated by raised conmunity awareness of the node of transnission and thenanlfestations of onchocerciasis. Reassurance that the return of the blackfrycamies no risk of reappearance of the disease nust therefore be given to thepopulations concerned. Vector control: operations 10:13 OrigiEal. Progfa+ne-area:1 larviciding which ceased during 1990 in thenaJor part of the original seven-country area, w111 during the first two yearsof the fourth Financial phase renain confined to a few ,oi.", where thereduction in the nicrofilarial load was derayed due to tenporary vector controlproblens. 10'14 These zones wilr be kept under intenslve epideniorogical evaluation inorder to deteruine shen larviciding can be discontinued without risk ofnesuEption of transnission. rt is expected that vector contror wilr no rongerbe needed there as fron L994, except that entonologlcal surveirrance naycontinue for two years nore (see paragraph 10.g ablve). 1^t:l the purpose of the following. the Original Progra.une area excLudes the1978/79 extension into the south of c6te d'ivoire (see para. l.! above) wherelarviciding started with a 4 to ! years' delay and where particular operational condltions were encountered. Plans for vector control in thatextension are included under those for the l'lestern Er<tension area (paragraphsLO.25 to 10.32 below). page 27 10'15 Vector control will also continue in the south-eastern and rdesternperiphery of the Original area where the reduction in the CMFL lagged behind asa result of persistent transnission naintained by reinvasion until the end ofthe eighties when the sources in the Extension areas h,ere brought under contror(see nap in Annex 5). 10'16 Bv 1994 larviciding will cone to an end throughout the original programmearea. with the exception of the previously reinvaded peripheral zones wherevector control will be continued as an integral part of oCp operations in theExtension areas. 10'17 Ttre nunber of flying hours required annually for larviciding in theoriginal OcP area will remiin at an average lever ir r t+oo- il;; untir L994.The consumption of insecticides will cone-to 55-ooo-rit".It ,Ii-;.." through1994. 10'18 The strength of the entonologicar surveillance network in the griginalPrograone area wirr be reducea rn rigz llggi f;;;-4 ;; l-;;;;r; and fron 12 to 8subsectors, all to be disestablished bV tggO. 10'19 The estinated requirenents for larviciding and entonologicar surveillancein the reinvaded zones of the 0riginal area beyoia fgglt are included in theestinates for the E:<tension areas as given below. 10'20 Aquatic nonitoring will continue at least one year after cessation oflarviciding in a few representative observatior,-po"t". 10'21 southern Extension a-rga: as fron 1988 larviciding attained fu1l coverageof the a"ea after a geogpaphically linltea start in Ghana during 1!gG followedby an expansion through soutte"r, Benin and Tojo in 19g7. Lo'22 selective and seasonal larvlciding will renain the guiding principle forvector control ln the southern Extension area and certain regions w1rl continueto be left out entirery as' for instance, tne Soia Basin in the North of Beninwhere rarviciding was discontinued during the iti"a Financlal phase as its costwas prohibitive. due to excessive distance from airbase coupled with perennialbreeding' Furthernore the basin does not constiiute a source of onwardtransnission' For these reasons, vector control has been replaced by large-scale ivernectin treatnent which will be continued through the fourth FinancialPhase. 70'23 simirarly, larviciding wirl be linited in the south-western region of thesouthern E:<tension area' in the uprand rainforest zone on the border betweenTogo and Ghana, where the rough nountaineous terralD, dense vegetation andfrequent adverse-conditions nlnper aerj.al operations. This is further warrantedby the conflr'oation that the original vector, the ,,DjodJi* forn of sinuliunsanctipauli seens to have been replaced in that ione uy s. squa-mosunffiS. yahense vectors of non-blinding onchocerciasis. 10.24 It ls estinated that ae.ial 1anriciding in the Southern Extenslon areawill require 1 oo0 frvlng hour- p9" year untir rgg4 art"r-rii"t1il *.r"rrequirenent will increase to 1 5bo hours "= " ".iirt of larviciding in thereinvaded zones of.the original ocP area u""oriii-part of operations in theE:<tension areas' Around go ooo litres of larvicides wirr be required each yearduring the t992-1997 period. ' Ig" ease of presentation larwicide requirenents are given in globar lltrefigures rather than specified by indiviauat proaucts. PaSe 28 LO.25 The entonologlcal surveillance network in the Southern Extension areawill remain at the 1991 leveI (1 sector and 5 subsectors) until 1!!4 when itwill lncrease to 2 sectors and 5 subsectors following the "absorpiion, of thenetwork in the south-eastern reinvaded zones in the Original prolranne area. LO.25 Western rytenslg!-gEeg: as in the Southern E:<tension area, larvicldingwittcoffiandseasona1innature.TtreextentofIarviciding will be deternined on the basis of up-to-date ento-epideniological andhydrologlcal data. tO-27 In Guinea, larviciding aining at the control of the "savanna" vector S..sirb.anun, whether or not associated with forns of S. soubrense, will continuethroughout the year. In Sierra Leone, Iarviciding inTfiffiffi]iocusing onS.sirbanun capable of transnitting into the sarranna belt, will be conductedregularly while the control of S. soubrense B (relatively non-nigratory) in thesouth will be conducted on a tasty-ffie and seasonal basis. 10.28 Ttre exclusion fron larviciding of the northern part of the WesternExtension area (see Annex 9) is in accordance with the overall control strategy and in confor'nity with the criteria listed in paragraph 9.12 above. Lo,29 contror in that area wirr continue to be based on large-scaleivermectin distribution and the Progranne will spare no efforts to ensure thehighest possible coverage of the target populations. FuII use will be nade forthis purpose of the existing ento-epideniotogical network established by oCp.The population groups concerned will thus see onchocerciasis renoved as adisease of public health and socioecononic inportance. 10.30 Concurrently with, and in support of, the lntensive Lvernectlntreatnent progranne, opportunity will be taken of field operations toinvestigate such questions as the possible additional benefits of increasing thefrequency of treatnent and the cost/effectlveness of different strategies forconEunity-wide and centre-based ivernectin distribution. -10.St It is expected that aerial operations in the l{estern Extension area willbe conducted at the 1990 level through lggtl. i.e at the rate of 5 400 flyinghours annually. During the renainder of the fourth Financial phase, the nunberof hours per year will increase to 5 8OO as a result of the inclusion in799\/1995 of vector control in the westerly reinvaded zones of the griginal areawithin the Extension operations. The consumption of larvicides is estj.mated tooscillate around 370 000 litres annually. LO.32 The entouological surveillance netlrork will renain at its 1!!1 level(l sectors and 12 operational bases) until 1994 when 2 subsectors from thepreviously reinvaded zones of the 0riginat OCP area will be operationallyincorporated ln the ttlestern E:<tension area. No further changls are expectedbefore the end of the fourth Financial phase. page 29 1O'Eg : Ttre anticipated naxinun extent ofrarviciding throughout theFrocrame area in (1990), 7992, 1994 and 1997 isdeplcted in naps shown in Annex 9. 10.34 The trend in resource requirenents can be sumnarized as follows:in 1990 the total nunber of flying hours and litres of larvicides for the entireProgra-ume area came to I 3oo and 625 000 respectively ; these requirements wilrdecrease until 1994 and further reduce to 7 3oo arra 450 ooo therJafter;likewise, there wirr be a reduction in the nwber of sectors andsubsectors/operational bases fron 8 and 2! respectively (planned for 1991) to5 and 20 by 7997. 10.35 Monitoring of the aquatic environment in the two Extension areas wirlcontinue as an integral part of vector control operations. As nentioned above,(paragraph 10.9) ecological surveillance will extend one year beyond thecessation of larviciding in any given zone. T?re national teans wiu continue tononitor the effects of larviciding on fish and the oCp tea.n will renainresponsible for surveying invertebrates. 10.35 VCU staff requirenents at OCp HQs and in the headquarters of the Easternand western operational Areas will renain stable throughout the tggz-tggl periodwith littre variation fron the 1!!1 situation. Ttre toial VCU stai.f conplenenton ocP/wHo contract-wilI, lyrins the fourth Financial phase. dininish from 1g to1! Professionars and fron 351 to 58 oenerJ a;;i". posts in offices withintercountry responslbilities, the renaining General Servlce staff beingnationally enployed. 10'37 operationgl and other expenses for vcu are estimated to decrease fronus $4.3 million in Lgg2 ro us sj.g-ririi;"'i; 7:g61, i.e. us $1oo ooo per year. 11. EpidenioloFical evaluation 11,'1 The epideniological Evaruation unit (EPr) will continue its traditionalrole as the focar point for assessing the inpaci of vector controi, essentiarlyin the Extension areas where the-epideniologicar naps prepared in tggg/go willserve as benchnark. The search for nicrofilariae in skinsnips, whenever carriedout' will continue to adhere to wHO instructions designed to preventtransni.ssion of such viral diseases as hepatitis and ArDS. t7'2 However, given that comnunity-wide ivernectin distribution, undertaken ona rarge scale throughout the progra.nne area, reads to a rapid and steepreduction in the nicrofilariar Ioad, the CMFL ceases to be a valid index for theepideniological trend analysis in villages previously selected for skin-snipexa.oination. 11.3 rnsofar as ivermectin treatnent wilr continue for an average ofsix years (see para. 9.7 above), evaluation of the effect of vector control 0ntransnission will be rinited to entouological surveirrance during that periodas the teEporary disappearance of nicrofilariae nakes exaninatioi of skin-snipsworthless' After a further three years without ivernecti.n treatpent, skin-snipexami'nation will again becone a valid Deans of evaluating the inpact oftransmission contror. rn the DeantiEe efforts will be ,.d. to alverop otherdiagnostic procedures allowing for rapid connunity assessnent, independent ofivernectin application and devoid of rist of diselse transnission. page 30 11.4 Also' inpact analysis in ter-Es of neasuring incidence will to sone extentrely on skin-snip examination of non-treated, previously skin-snip negativepersons and of children excluded fron ivermectin treatnent, although such tests are of linited sensitivity initially. Obviously, the eventual araitabitity of an inmunodiagnostic test would drastically alter the situation and the prograrrewill continue end reinforce its support to the developnent of a field-applicabletest (see also paragraph 1/.8 below). 11.5 Apart fron nonitoring the impact of vector control in the Extension areas' epideniological evaluation will provide the data necessary for OCp/VCU todecide on cessation of larviciding (see para. 10.5 above). 11.5 OCP/EPI will therefore direct a good deal of the evaluation efforts toindicator villages situated in the circumscribed zones within the griginalProgranne area where larviciding had previously uet with operationaldifflculties and therefore had to be continued beyond 1990 (see paragraph 10.1J above) when it ceased in all other parts of the non-reinvaded zones of that area. It.7 Epideuiological evaluation reinvaded zones ln the peripheral expectation that the results will these zones before the end of the will also pay particular attention to the regions of the 0riginal area wlth the allow for cessation of larviciding in parts offourth Financial Phase (see naps in Annex !). 11.8 The naJor part of the fieldwork will contlnue to be carried out bynational epideniological teams noh, operating, with OCp financial and logisticsaupport. in all the Participating Countries. OCP/EPI will renain responsiblefor progranning, coordinatlon, supervision and for ensurlng conparability offindings as well as for analysis of data and training. 11'9 In all, eleven national teans are enployed for periods ranging fron I toJ nonths a year in epideniological evaluation and ivernectin dtstriUution (seeparagraph 12.5 below). Each team is conposed of a ninlnun of 6 technicians andone driver. EpidemioloRical survei llance 11'10 with larwiciding coning to an end in nost of the originar progrannte area,vigilance is called for to ensure that any recrudescence of onchocerciasis, thatnay occur' is detected sufficiently early to ensure its control by focaltreattrent. 11.11 Although such naintenance activities faIl under the operationalresponsibility of the Participating Countries, OCP/EPI will continue to providetechnical arrd logistic support to national teams, including training, ensu"ing'uniforaity ln surveillance techniques and iveruectin distribution nethoaolosy,identification of high-risk foci, reporting, and inter-country connunication.In addition, the Progra.me will act as a coordinating body and a "clearinghouse" for infornation regarding national devolution activities and participatein investigations and control of recrudescence (see also "Devolutionr, section18 below). OCP involvenent in i vernectin dis tion tL.t2 OcP/EPr wirl pursue its progranne of comnunity-wide ivernectinapplication in areas where populations are at risk of onchocercal blindness, asinitiated during the third Financial Phase (for details: see folrowing section and the nap in Annex 10). page 31 11.13 Ttre nediun-tern and long-ter.n inpact of large-scare ivernectindistribution will be assessed by longitudinal ophthalnological surveys carriedout in a network of conmunities in the Extension areas where ocular examinationshave established the pre-treatnent base-line situation. Such surveys wil1 useobjective neasurenents, including eye photography, in order to ensureconparability between the findings of differ"rrl ir,.r."tigators. 11.14 The staffing of the ocP/EPI unit is expected to renain stabre at.theleveI of two Professionars throughout the tggr-L997 period with 2l GeneralService posts, reducing to 20 bV 1997 11.15 Operational and other expendltures are expected to be aroundUS$ 825 000 per year. t2. Ivernectin distribution L2'7 ocP has, since ivermectin becane available for large-scale apprication inhunan popurations, taken the lead in carryirrg ori field studies and inorganizing arld conducting connunity-wide aislrruution of the drug to alleviatethe often debititating synptons of the diseasie and prevent lts seri.ous ocularnani.festations, including blindness. L2.2 rver"mectin wilr continue to be suppried free of charge by thenanufacturer to all hearth adninistrations "rrJ ois"rrlzations upon the subnissionof distrlbution prograrunes, endorsed by_the indeplndent nMectizan E:<pertcomnlttee"' Ttle Progra.nne acts on uenarr of the .1.r.r, ocp countries as theprocurenent agency for the entire area. L2'3 Insofar as lvernectin has proved itself to be devoid of serious side-effects' it is now dispensed on a conmunity-wide basis with nonitoring ofadverse reactions. t2'4 rn co'nmunitles at risk of onchocercar brindness, which were broughtunder ivernectin treatnent by ocP/EPr aurrni-ttr"-i"tt., harf of the thirdFinancial Phase, ocP wirl "ontirrr" annual, rarge-scale distribution to arlpersons infee.-ed with the onchocercal parasit.l "u"p."ted of being infected,or nerely llv-ng in the villages concerned. Ttris wilt be done w:.Ih increasingnational part :.cipation. t2'5 The treatnent will last for an average of six years (to achieve na:<inunbenefits of lvernectin in the control and ai"""t of otular nanj.festations) afterwhich vector control will ensure vlrtual elinin. tion of the hunan reservoi.r ofthe parasite (see paragraph 9.7 above). rnsofar as ocp-directed ivermectintreatEent has been appried to these coonunities since rgg7, starting with allnited nunber in the original progranue area and rapldry increasing toconounltles throughout the OcP area. distribution will gradually cease between1992 and the end of the fourth Financial phase. L2.5 Most of the actual fierd work will be carried out by nationalepideniorogical evaluation tears supplenented by the staff of rocal healthcentres' while ocp/Epr wilr be prinarily concerired with drawing up thedistribution schedules, supervislng the treatnent, evaruating the resurts andproviding technlcal and logistics support. page 32 L2,7 FulI use will be nade of such ,outreach" activities as innunization canpaigns to enhance large-scale distribution of ivernectln, a field in whichTDR-supported operational research, designed to improve the coverage andefficacy of connunity-wide drug application, would be welconed. L2-8 Estinates of OCP/EPl-conducted treatnent during the t992-19g7 period aregiven below: Table 2 Estima nunber of OCP/ ivernectin treatEents during the 1qo2-19a7 period, by calendar year(oool 10q2 400 1qg3 400 1aq4 350 7995 350 10q5 100 1aq7 5o The gradual decrease in the annual totals is explained by the fact thatan increasing nunber of persons will have received fivl to sevei years oftreatnent after which they are no longer included in the distribuiionprogranne. rn addition' an estlnated popuratlon of 4! o0O will be included in theiver"nectin distribution progra.E,e in the northern part of the trrestern Extensionsrea-(see paragraph LO.29 above). Ttris figure will renain unaltered fron 1!!2to 7997. 12'9 In areas with low endenicity only persons diagnosed as harbourlng theparasite will be treated. Iveroectin wirr ue dispensed in fixed hea1th centresto which patients sufferlng fron slrnptons of onchocercat infection presentthenselves. t2.LO The staff of health centres wiII undertake this ,passive,, case_findingby neans of presunptive or laboratory diagnosis in persons showing s5mptoms ofonchocerciasis, and institute treatnent of the disease. oCp will nalce fieldnanuals available to the national authorlties. Special enphasis wiII be givento record keeplng and to the nonitorlng of side-effects. L2'LL In all prograrEes of ivernectin treatment, be they comrnunlty-wide orcentre-based, the exclusion criteria existlng at any given tine wiII be adheredto. L2'L2 Ttre Programms piff continue, and strengthen. its collaboration withNon-governmental organlzations (NGOs) and Private Voluntary organizations (pvOs)ln the distribution of ivernectln. rnterested NGOs and pvbs oferating in the oCP area do so under agreenent with the Participating countriel and in thefra.uework of national progranne activities. Ttrerefore. ocp-Nco/pvocollaboration falls naturalty within the Prog?emmg's collaborative agreenentrith the national health authorities concerotd. pase 33 L2'L3 In supporting the ivermectin distribution progranne, NGos and pVos willcontinue to follow the guidelines prepared by the Pr-grarre, adhere to the OCprecord systen and nonitor adverse reactions i.n line with the currentdirections. L2.74 Although the probability that nicrofilariae becone resistant toivernectin is renote, a process of nonitoring of susceptibility to the drug willbe instituted in order for the Programme to be assured of the conti.nuingefficacy of ivernectin. 13. Biostatistlcs and infornation systens 13'f The unit responsible for biostatistical analysis and support toinfornation systeEs developnent, OCP/BIS, will continue to *rork- closely with thevector contror unit (vcu) and the Epideniological Evaluation unit (EpI) in thepranning and collection of the data nece"s."! to deternine cessation oflarviciding in a given area, in the interpreiation of such data, and in arrivingat the final decision. 73.2 OCP/BIS will, in this connection, assist VCU in developing progrannes forthe two years'entomological surveillance to be continued after thediscontinuatlon of larviciding (cf. paragrapn fO.g "U"".1-"ii-r,"i, in theensuing data analysis. 13'3 The unit will contj.nue to be concerned with the interpretatj.on of thefindings of epideniological evaluation in indicator villages as werl as with theanalysis of entonological surveillance data. However, a great dear of theroutine analysis, foT which conputer progremrnes have been developed. wirr becomethe responsibility of the units concerned, and the rore of 0cp/BIS will belinited to integrated analysis and technical backstopping. 13'4 continuing nodel sinulations, based on constantly updated operationar andappried research data, wirr renain an essential .l.r.rrt in the adaptation of theoverarr control strategy to variations in the entomo-epideniological situationwithin the Progranre area. 13'5 A particularly inportant use of the epideniological nodel will be itscontribution to the finar decision regarding cessation of larviciding in areaswhere vector control has been underway ror I pe.ioa which in principle shouldsuffice to elininate the hunan reserrroir of the parasite (see alsoparagraph 10.5 above). L3'6 Also, the nodel will continue to be utilized for trend analysis resultingin epidenioroglcar forecasts of direct relevance to pLanning and operationardecision-naking' rt is thus estinated that, with the exception of a few foci,the CMFL and overarr onchocercal prevalence wirr be virtuarly zero bv 1994throughout the non-reinvaded zones of the original ocp area. rn the initialryrhyperendenic' virrages in the E:<tension a"eas under vector controL since theend-of the.eightieg !t is expected that the oMFL and the prevalence will havefallen to 401 and 801 of their respective pre-control values by 7gg4, and to 101and 501 in 1997 (see graph in Annex 11). 73'7 Furthernore' special attention will be paid to the use of modelpredictions of onchocercal nanifestations in the eye in order, inter aria, toanticipate rhe rong-rern erfect of ivermectin trea;;.;;.-;i;;: tiJ noaer wilr beused to rook into the wora-age dependent effectiveness of iver.oectin, and toinvestigate the potential 0perational value of a nacrofilaricide. rn addition,enphasls w111 be given to nodel-supported decision-naking to enhance cost-effectiveness in control operations. page 34 13.8 In connection with preparations for devolution, the epidemiological nodel1111 help to clarlfy such issues as the na;<lnun adnissible tine between thereturn of infection and lts control, the epldeniological lnterpretation ofsurveillance data based on skin snips or innunodiagnosis (when available), andthe operational aspects of recrudescence control by ivernectin (threshold values, population coverage, frequency and duration of treatnent, etc.). Ttre use of the nodel will facilitate technical discussions between epideniologists and aid the decision-naking process on recrudescence control under devolution. 13.9 The Progranme-wide conputer network will continue to be utilized. extensively for operational, nanagenent and adninistratlve purposes (aerlal operations, budget end finance, personnel, supplies and equiprent, transport, 9tc.). OCP/BIS will ensure the best possible use of the network by training theProfessional and General Service staff involved, and by helping in nakingavailable the most suitable hardware and software to the staff concerned. 13.10 The OcP/BrS staff requlrenent for the fourth Financial phase is estinatedat 1 Professional and 2 Generar Serwice posts throughout the period. 13.11 Annual operational and other expenditures are expected to renain stableat the leve1 of US$ 120 000. 14. Support to socioecononic developnent 14'1 Assistance to socioecononic development in the onchocerciasis controlledzones falls outside the Programmers teros of reference which are linited to thecontror of the disease. Support to the Participating countries in this field was therefore entrusted to the coEEittee of the Sponsoring Agencles (CSA) actingas a collegiate body or individually through its nenber o"gar,irations withintheLr fields of conpetence. L4 '2 Since then cSA has conpleted a series of regional and country developnentstudies in the Partlcipating countries to ldentify in oncho liberated zones theDost proEising geographic areas for agro-pastoral production and to bringattention to the land settlenent lssues and policy options which are nostfavourable to cost-effective, envLronnentally susiainable production systens.cSA is in a favourabre position to facilitatl bringing togLther theParticipating Countries and the Donor connunity, collectj.vely and individuallyto build on these studies in efforts to define and pronote altion to addressdeveropnent opportunities, reguirenents and constraints. 14'3 More specifically. the connittee wirr be instrunentar, to the extentrequlred by the Participatlng Countries and in concert with potentlar donors, inI'nitiatlng on a country and intercountry basis, the preparation of straterydocuBents and plan of actions for such regiorrai p"ogranmes as river systenEanageDent talclng account of enhanced productlvity in relation to the protectionof the environnent. 14.4 The contribution- of_OCP per se will essentially be one of providingliaison services with the partrcfpatrng Countries and the CSA in its support tosocioecononic developnent. The Progrnmmg wilf also assist, whenever required,in any studies that nay be called for to assess the progress nade in this fieldbased on the pre-control data collected by the Progranne in the Extension areasas well as on the reconnendations enanating fron the above regional studies.The oCP responsible officer for socioeconomic developnent wili work closely withthe Devolution unit to which he wirr be adninistratively attached. pase 35 14.5 The OCP socioecononic support staff will renain at its 1gg1 staffing1eveI, namely 1 Professional post. 14.5 0perational and other expenditures are expected to be in the order ofUS$ 50 000 per year unrit L995. 15. Training t5't The OCP-funded training prograrme will center on the preparation. for, andreinforcenent of, the devolution process. Fellowships wi1l Le Lwarded tonationals of the Participating Countries to study nanagement of health services,epideniology, epideniological surveillance, treatln statistics, organization andimplementation of large-scale public health activities, health edication andinpact assessnent. !5'2 As a general principle, oCP fellows wiII be trained in institutionslocated in Africn. Given the inportance of a strong epideniologicalsurweillance in the context of devorution (see paraErapn r8.4 uEro"l, specialefforts are undervay to strengthen institutions in Banako (francophone) andAccra (anglophone) ln order that they nay provide courses in epideniologr at thelever of nasters degree. Ttre nodarities-dlteroined by the needs andrequirenents, will be worked out at an early date and considered by EAC at its1992 session. L5'3 It is expected that OCP-funded training for devolution will becoordinated with, and supported by, the award of ferlowships uv wno/eFno. TtreRegional'office has reconmended to lts l{est African Menber Staies that theyreserve a fixed percentage of the wHO regurar budget arrocations toonchocerciasis control. Part of these anounts "oira usefully be spent ontraining for devolution. 15'1- The Progremms retff continue its in-service tralning prog?anne for its ownstaff' both on the technical and adninistrative side. Given that nore than95 per cent of the totar number of staff positions - in alr 550 (1990) - arefilIed by nationals fron the Participatin! countries, ocp can be said to nake asignificant contributlon to Danpower deveiopnent within the region it serves. L5'5 During the fourth Financiar Phase, particular attention wilr be paid tothe evaluation of the enplo5rnent of forner oCp fellows, and the nationaladninistratlons concerned will be encouraged to direct the expertj.se of thesefellows to devolution-connected activities. L5.5 It is expected that the cost US$ 250 000 annually throughout the of OCP fellowships will be in the order ofL992-7997 period inctuded in the budgetestinates for devolution. 15. t6'7 rn the field of-chPnotherapv, the search for a nacrofilaricide wirlrenain the obiective of Ehe-offided 0nchocerciasis chemotherapy project(ocr) ' ^-The etrergence of an effective, field appricable drug without seriousside-effects wourd ease the contror of the aislase and radically alter thestrategy of the Progra.une. A nacrofilaricide would also greatly sinptify thecontrol of recrudescence. paSe 35 15.2 As regards the institutional arrangenents for OCT, a joint OCp/TDRproJect has been established for the development of a nacrofilaricidal drug andto bring such a drug(s) to the point of registration. The project ("MACROFII,,)ls funded jointly by OCP and TDR, each contribution nanaged separately by theProject Manager who renains an Ocp staff nember. Ttris sireanrines nacrofilaricide activities for both onchocerciasis and lynphatic filariasis in one group to the benefit of both progrannes. 16.3 Ttre nunber of posts will renain at the 1!!1 IeveI, i.e. one professional and one General Service staff through the fourth Financial phase. Trhe totalbudgetary requirenents for the 1992-1!!J period are estinated at us $ 14ni11ion, it being understood that, given the nature of research and developnent, a certain flexibility will be pernitted in deternining annual expenditureswithin the overall ceiling. 77. Research 77.L Ttre OCP-sponsored research activities will continue to be planned andinplenented to neet the priorities set by the Expert Advisory connittee (EAc).They have over the last few years faIlen into thl following iatn groups withvarlatlons as to the inportance attached to each group: vector contror,bionomics,-0. volvulus characteristics, innunodialnostic testing, nodelling andoperational research. Ttre Programmg rdlf naintain its support io the searchfor a nacrofilaricide as a priority concern through the funaing of theOnchocerciasis chemotherapy ProJect (OCT), referrEd to in the preceding section. L7 '2 It ls expected that the priority g?oups will renain wLthout naJor changesduring the fourth Financial phase. although lhe retatlve inporlance given tolndividual reseerch subjects sithin each group Eay alter as new knowredge isacqulred or other operational questions cone to the fore. EAC guidance willcontinue to be of cruclal inportance j.n this regard. 77.3 Most of the Programms'!s research activities wirr, as hitherto. be conducted ln connection with ocp field operations and wilr, as such, contain astrong elenent of operational research oriented towards a steady inprovenent ofthe Progremmgrs day-to-day perfornaJrce in terns of cost/effectiieness ofoperations. 77.4 An indication is given in the following of what is expected to be thenain enphasis of research activities within each of the aforlnentioned groupsduring the 1992-1!!J period. 17.5 As regards vector-control. ocp wilr, routinery, ascertain thegeographical and sGnir aistri;ution as well as the vectorial role of thevarious forns and species of the blackfly in the Extension areas and correlatethe findings with the epideniology of onchocerciasis. Cytotaxononic studieswill be naintained as will susceptibility tests on non-target organisns whereverlarviciding takes place. Also, fly-feeding and transnission experinents willcontinue until the relationship between different IeveIs of the microfilarialload in infected persons and the risk of transnission has been clarified, usingboth savanna and forest vectors. Further studies will be undertaken on theorganization of an entonological surveillance network to be kept in place twoyears after cessation of rarwiciding in any given area, and on theinterpretation of the data thus provided. pase 37 17.5 Screening and evaluation of new larvicides and of potentially inprovedfornulations of existing ones will renain a najor preoccupation of the VectorControl Unit. L7.7 Studies will continue to ascertain the blinding potential of 0. volvulustransnittedundervaryingeco1ogica1conditionsandbydifferent,,ecI6ffio inprove the identification of the characteristics of the parasite at theinfective rarvae (L 3) stage; the latter in particular in respect to theseparation of different hunan strains of the parasite and the distinctionbetween hunan and aninal strains transnitted by the blackfly. Recent testing ofDNA probes camied out on nodules collected fron persons belonging toconnunities with onchocerciasis in its blinding and in its less ".r"". form, asascertained by ophthalnological surveys, have shown this nethodology to becapable of a high degree of differentiation. This line of investigation will bepursued to eventually extend its use to the identification of Ll larvae.collaboration with rDR wilr be naintained in these respects. t7 '8 The availability of an inngnodiagnostic test of high specificity andsensitivityandeasi1yapptieaffis,o,,idauo",forear1y diagnosis and, in particular, facllitate the detection of recrudescence of thedisease in the context of the devolution process. ocp wilr therefore continueits collaboration, in particular with TDR, in the search for a biogenetlc testthat meets the above criteria and undertake its epideniological testing. L-7 '9 Ttre Progrt'mne will continue its studies on the 1ong-tern effect ofivernectin on the clinical, in particular ocular, nanifestations of the diseaseand on transnission when given alone, at increased frequency or in conbinationwith other drugs. The optinal frequency of application will be another subjectfor continuing operational research as ,irr tirl organlzation of derivery ofivernectin' connunity-wide or through fixed centres, and the contribution ofNGOs and PVOs. 77 'to Ttre need for an in vitro test for deternining the revel of nicrofilarialsusceptibility to ivernffilEs arready been refemed to in paragraph 12.14above. L7 'tt The epidemiological nodel w111 be further developed with a view toenhancing its predictive vailrand contribution to the programnsrs pranningprocess. Particular enphasis will be given to the risks arra ayrr"rics ofrecrudescence and its detectlon and control under devolution, including thedeternination of the incidence level above which contror by ivernectin nust beinstituted' Ttre noder will also be strengthened with a view to enhancing itscontribution to operational decision_naking. 77 '12 rn connection with the lncreasing involvenent of the participatingCountries in epideniological surveirlance of onchocerciasis and control ofrecrudescencer OCP wiII increase its involvenent in operational research toidentify the requirenents for devolution to succeed on a sustainabre basis, toinvestigate operational aspects of devolution activities, to assess the extentto whlch the necessary infrastructure and resources exist in the countriesconcerned, and to help in closing the gap between what is requirea ana what isavailable. 17'-13 other subjects to be investigated through operational research are theeffect of nigration on recrudescence during deiolution and the promotion ofconnunity awareness regarding the proble, ,rra dyna.uics of onchocerciasis. pase 38 L7.L4 Fina11y, the OCP units directly concerned will fo1low closely theprogress nade in Participating Countries and pronote national operational research in aid of the devolution process. 18. Devolution 18.1 rn general terns, devorution is seen as the naintenance by theParticipating Countries of OCP's achievenents after the cessation of progranne operatlons. Devolution-connected actlvities wlII be integrated into the national health systems in order that recrudescence of onchocerciasis nay bedetected and managed at an early stage. L8.2 OCP has atrply demonstrated its ability to elininate onchocerciasis as aproblen of public health and socloecononic inportance. However, the ultimatetest of the success of the progremme will be the extent to which theParticipating Countries will detect and control recrudescence of the diseaseafter OCP operations have come to an end. Strengthening of the devolutionprocess wirl therefore continue to be of crucial inportance. -18.3 Although the risk of reappearance of the disease in ,,oncho-freed, areashas been reduced to a nininun, the Participating Cor.rntries will need to naintaina state of vigilance to ensure early detection of rene",ed transnission, shouldlt nevertheless occur, and to deal with it rapidly and effectively. 18.4 Operationally, the two tools of devolution will renain epideniologicalsurveillance to detect recrudescent cases and the control of such cases. It isof the utnost inportance that the Participating Countries will have strongcentral epideniological services capable of ptanning and directing fieldsurveillance and of analyzing conpetently the data collected so as to institutepronpt control whenever and where required. 18.5 Onchocercal surveillance will continue to be part of nobile polyvalent epideniological investigations conducted regularly in selected indicatorvillages in high-risk areas with the exaninition Letng linited to first-lineconnunities. only if new cases are detected will the investigation be extendedthroughout the area concerned. 18'5 The control of recrudescence will (in the absence of a nacrofilaricide)consist of connunlty-wide application of ivernectin organized by the nobileepideniological surveillance teans, or by the heaLth centre st"ir. 18.7 As already mentioned, the capability to detect and control recrudescencenust be firmly lnplanted in the public health systens of the participatingCountries as a continuing and sustalnable activity. 18.8 In addition to active surveillance. static health centres in oncho- endeuic areas wtII be equlpPed to carry out passive surveLllance and thus caterfor patients who report on their own with synptons that should alert the staffto the possibility of onchocercal infectlon. 18.9 Entonological surveillance will not play a rore in recrudescencedetection, but linlted vector contror on th; ground nay in geographicarly clrcunscribed zones, under particular circunsiances, help to afreviate nuisanceduring the periods of the year when biting rates are excessive. page 39 18'10 The availabillty of an imnunodiagnostic test wourd greatly facilitatesurveillance and this, in particular, in regions where skin-snip exa4ination isof little use because of large-scaIe distribution of ivernectin. Likewise, theenergence of a field-applicable nacrofilaricide would 1argely contribute to thesuccess of devolution. 18'11 Although the principles of devolution have now been firnly established,there renains a need for research designed to facilitate decision-naking,including the search for an inmunodiagnostic test and the deternination of theincidence level which signals recrudescence as well as further clarification ofoperational and nanagerial aspects of surveillance and the control byivermectin. L8'L2 rnsofar as devorution, once fuIly operational, is by its very nature anational undertaking, the role of the Prograrre will be one of surweillance{initiallY), support and coordination. For that purposei OCp has established aDevolution unit by re-assignnent of existing staff and will seek expertice insuch fields as epideniolo5r, nanagenent. social sciences and training on an ,,asand when required' basis. Ttre unit incrudes the officer responsibre for supportto socioecononic developnent, transferred fron the Directorrs office, as well asstaff deallng with infornation. Budgetary allowance wi1l be nade for theenploSrnent of consultants whenever necessary. Ttre unit has a conplenent of fourprofessional posts' one secretary and an annual budget in the order ofus $1 100 000. 18'11 Ttre Progrenrng s{ff thus continue to assist national health authorities indrawing uP their devolution prans, to provide technicar guidance (incrudingnanuals) as regards epideniological surveillance and coniror of recrudescence,and to train national staff in disciplines related to devolution, includingmulti-disease sun/eilIance' drug disiribution "rra ,"rr"s"nent. Assistance wirlbe given to the preparation of nunan resource deveropment prans, to thesensitization of govenrEents and connunities in respect to the inportance ofonchocerciasis contror naintenance and to operational research connected withdntg delivery systens, the epideniological irp."t of iver.nectin in differentreglnes. its long-tern safety and coniunitv p'."ii"ipation. 18'14 The Participating countries wirr be encouraged to enhance the role oftheir National Onchoceriiasis Comnittees; and to nalce then ,,focal points,, fordevolution with which OcP could establish direct and crose working relations. 18'15 lilith the steadiry increasing involvenent of nationars in progranneoperations. the Partlcipating countries will have at their disposal a core ofexperienced staff ready to be enployed in the devolution process. Arso, ocpwllr continue to put lts experience, infrastructure and services at the disposalof the ParticipatinS count"i"" ln Joint efforts to nake their health servicescapabre of dearing effectlvely with devolution (see paragraph 1!.4 below). 18'15 As already nentr'oned' the sucess of devolution wlrr depend on thecapabllity of the national health systens to cope effectively with onchocercalcase-detections and with the control of renewed transnissions. Hence the needfor strengthening the pubric hearth systens in the participating countries ofshlch devolution activlties forn an tntegrar part, and for instituting orenhanclng continuing training of hearttr iorkers io erraule them to participateeffectivery in the devolutioi process. rt is in this connection that theprovision of direct technicar and naterial support by ocp and the l{Ho RegionalOffice for Africa becomes of crucial inportanll. page 40 L8.L7 By continiously pursuing its constitutional role to help Menber Stateslnprove their health delivery systens, HHO/AFBO contributes to laying thefoundation for a successful devolution process within, and anong, theParticipating Countries. More specifically, an intercountry coordinator fordevolution, stationed in the office of the WHO Representative in 0uagadougou,has been appointed by the Regional Director. AIst, WHo representatives in theParticipatlng Countries are encouraged to give priority attention to devolutionactivities and regular neetings are held between WHO/AFRO and OCp staff. It isexpected that the direct involrment of the Regional Office and its field staffin the devolution process will be further strengthened durLng the fourthFinancial Phase. 18.18 In additlon to suPport fron WHO/AFRo at the country revel, Ocp and theworld Bank wiIl, in consultation with the participating cLuntries, seek thesupport of devolution fron other nultilateral organizations as well as fronbilateral agencies, NGOs and PVOs. Likewlse, th; Progra.une will continue itsendeavour to enhance the collaboration wlth the OCP Oonor Connunity in thisinportant fieId. 18.19 rt is preparations Phase, white begun in the expected that the last of the participating countries to cotrpletefor devolution will have done so earry in itre fourth Financialplans for devolution wirl have been prepared and its lnplenentationoriginal seven-country area already by 1992. 18'20 Given that vector contror has already stopped in parts of the originalocP area and will cease throughout that a"ea au"ing the fourth Financiar phase,the years 7992 to 1997 will be a period for field-testing of devolutionactivities by the Participating Countries with OCP helpins to ensure thatoperational experience ls properly analyzed and effectively comnunicated anongthem. 18'21 Solidarity aDong the Particlpatlng Countries has been the leituotivenabling oCP to reach its targets and objective. wlthout nutual understandingand the will to collaborate in the connon interest, vector control courd nothave interrupted transnission over such a vast area and over such a rong tine. L8'22 But if solidarity has been a conditio siqe-gua non for the success ofProgranne operations per se it becone-"en nore;ssentiaL in the post-Ogpdevolution era' when an undetected or ignored resurgence of new infections courdresult in an unnanageable situation not only within the afflicted areabut also' via trans-border transnission, in neighbouring countries. L8.23 Inter-country conEunication and collaboration, which have been spearheaded and supported by OCP, nust therefore continue unabated afterthe end of the Progranne. More specifically. OCP will during the fourthFinancial Phase, in close collaboration with the Participating Countries,institute a systeE of exchange of infornation regarding ipideEiologicalsurvelllance in indlvidual corrntries and its findingsi as wel1 as possiblelnstances of recrudescence and lts control. Such eichange shoufd Le institutedat an early date and extended gradually to becone fully 6perational before thecessation of Progranne operations. page 41 18'24 During the fourth Financial Phase, discussion will be held anong allinterested parties on the arrangenents to be nade at the end of OCp operationsfor naintaining coordination beiween the Participating Countries in devolution-certtered fields and for ensuring the infornation flow necessary for an effectivesurveillance and control on a regionar basis, so as to safeguard theachievenents of the Progrr're and avoid the occurence of ,rrrrarrageable instancesof recrudescence of the disease. Ttris would include nonitoring epidemiologicaltrends throughout the Prograrnne area, coordinating onchocerciasis researchcarried out in the Partj.cipating Countries, assisling in data processing andstorBge, helping countries to determine thei.r needs and priorities, makingarrangenents for training and reviewing research. By the end of the phase,a brueprint of a suitable arrangenent should be avairable. 19. ManaRenent, adninistration and suoport services 19.r As in the past. the centrar nanagenent of Ocp, supported at theoperational leve1, wirr ain at the best possible cost/efflctiveness ratio ininprementing the annual Plans of Action. senior Staff seninars wirl continue toprovlde an opportunity for ensuring that cost-consciousness renains apreoccupation throughout the Progranne and for soliciting ideas and suggestionsfor lnprovenent. L9'z Although !h9re will be a gradual decrease in vector control operationsduring the fourth Financial Phase, no substantial reduction is anticipated inthe core estabrishDent at ocP HQs in ouagadougo., and at the operational AreaHeadquarters in Kara and Banal<o, tn Bouaf6 1rilui and in the VCU research andhydrobiorogical estabrishnents. These central activities and services arerequired at a level and in quantities which cannot be reduced further if theProgra.nne's snooth ,arragerent process is to be naintained. 19'3 Even if immense progness has been nade in recruiting nationals from theocP region for posts at all Progranne levels. efforts will continue to fillfuture vacancies with staff orilinating fron the ereven participating countries.r?tis should be seen as a najor iontribution of ocp to the strengthening ofnational aduinistrations and, urtinately, to ensuri.ng the success ofdevolutlon. 19'4 Also' the Progra-mne-wlde operations and communication network (sectors,subsectors. radio, co,puters, vehicles, etc.) "o"ia eventuarry herp tobuttress hearth services in the Participatirri corrrtries, once ocp activities ina given area cotre to an end. Ttris courd even be the case in nost of theOriginal Progranne area before the end of the fourth Financial phase. 79'5 A particular problem connected with devolution courd be the reintegrationof OcP staff seconded by the national adninistrations concerned. At the sanetiEe it wourd seeE essential to retain such staff capabre (after a period ofreorientation) of naking a substantial contribution to the strengthening of thenationar hearth services which is an j.ssue of najor concern to the participatingCountries and the Donor Connunity. L9'5 The nunber of posts (including the Director,s office) will reduce duringthe 1992-1ttJ period fron 9 to 8 Proiessionats and fron !1 to 40 GeneraL servicestaff. 79.7 operating costs and capitar expenditure (vehicles, equipnent, etc. ) areestlnated ro reduce rron uS $1 ooo oob in r99i io-us $Gio ooo-ii-iigz. page 42 19.8 The following table sunmarizes the planned reduction in OCp/WHo posts between 7992 and 79972 20. Sunnarv of total est costs for fourth Phase ?o.t Ttre budgetary forecasts for the L99z-L997 period alle sunmarized inTable 3 below. These estinates are based: (a) on "osts used for the 1991 planof Action and Budget, applying a US dollar/CFA exchange rate of 285 and- iu) onassunptions nade for prlce contingencies for arurual cost increases in thevarious categories of expenditures as follows: - an annual cost increase of 7.51 for Professionals and 7l toc GeneralService staff - lncrease of zLl in aerlar contract over the period 1993 to L997; - annual increase of 5l in cost of fuel (including Jet A1) (takes account of cost increase as well as of overall consunption); - air fares increase during renainder of 5l; of 1Ol of the annually in 7992 and 1993, 5l each yearFinancial Phase; annual per dien increase - annuar increase of 3.51 Ln cost of vehicles from 1p!2 to 1994(thereafter few. if any, purchases), - 5l increase in cost of equipnent fcon 7992 to 1994 (thereafter costlncrease to be set off by decrease in quantities purchased); - 8l annuar increase in services throughout the Financial phase; - no increase for larwicides. Unit: Prof. Categpry 1992 LqgT Gen.Senr.Category 10q2 19q7 Vector control Epideniological evaluationBiostatistics and infornation systens Devolution Onchocerciasis Chenotherapy Project (OCT) Managenent and adninistration 18 2 1 4 1 9 L5 2 1 4 1 8 351 23 2 1 1 91 68 20 2 1 1 4o Total: 35 31 479 132 paSe 43 Table 3 Esti.na costs of opera.tions by Progranne activit-y and by calendar(us$ 000) year Activity tgg2 L993 L994 t995 1996 1997 Tota1 Vector control Biostatistics andinfornation systens Management and adrninistration Geneva Statutory neetinFs evaluation 2 Adninistrative t costs caIEpi 1S tsc tal deniol erci y1Project (ocr Devolution 22 365 1 803 288 964 2 195 3 285 907 340 305 19 860 1 857 1 010 2 385 3 Lo7 907 255 350 323 79 777 7 57O 7 057 2 77t 2 899 907 255 360 323 18 690 7 564 1 110 2 57O 2 872 510 265 350 323 18 541 L 535 1 154 2 295 2 83e 313 265 350 323 tB 5oz t 528 7 222 L 785 2 817 255 350 323 777 895 13 943 L7 8L6 3 544 9 957 7 673 5 527 2 740 7 g2O 30 085 30 O2g 28 304 27 732 26 862 L75 465 Total, of which - budgeted for theOriginal OCp areas: - budgeted for Extension areas: 21 100 32 453 11 400 8 7oo 21 400 23 400 6 600 2 200 25 700 1 9oo 25 8oo 1 400 25 4OO 32 2OO 143 2OO Note: Annex 12 provides a graphic presentati.on of trends in the proportionaldistribution of expenditu.esTb,rdget.rv-ioi""asts during the third andfourth Financial Phases, by the Original e"og"",nr. area and the Extensionareas as we1l as by calendar year. cost-estiDates for other research included within budgetary forecasts forindividual activities. This budget line includes provision for expenditures in respect to theDirectorrs office, Adninistration & suppori services conprising personner,Budget and Finance, Supplies & services, and rransportation a.oounting toaround LOI of the total expenditures. 1 2 page 44 2O.2 Ttre planned 1992-t997 Ievel of budget estinates reflects a situation where operations in the Original Prograrnne area have ceased and been transferred tothe equally inportant Extension areas as a successor progremme designed to safeguard the achievenents in the former area and to protect the populations inthe latter. Ttris nove of centres of gravity was initiated already during thethird Phase and will allow for a gradual decrease in control activities throughout the fourth Phase resulting in a L7l reduction in the budget from1992 to L997. 2O.3 The total cost of operations during the third Financial phase (1985-1991) will cone to US $180 nillion and that of inplenenting the Plan of Operations forthe fourth Financial Phase (1992-L997), expressed in 1!!1 prices including contingency allowance will be in the order of US $U5 niIIion. In real terms,that is in constant 1991 US dollars, the cost of the fourth phase will be appreciabry lower - 251 less - than the cost of the third phase. 2o.4 The main concerrl in drawing up the present Plan of Operations has been topresent the nininun of control operations, and the comesponding resource requirenents, which will a1low the Progranme to eventually "each its objectiveand this at the least cost. It is therefore obvious that any reduction in theplanned operations, any substantial nodification to the control strategT or anyfurther cuts in the oCP establishnent would seriously Jeopardize the eventualattainnent of the Progranne obJective. 2O.5 On the other hand, thought could be given to the substitution of cheaperfor nore expensive larvicides, €.g. use pernethrin nore extensively thanforeseen in the Plan of Operations. It should be stressed, however, that therotatlon schene of the various lanricides takes account of, and adheres strictlyto' the reconnendations of the Ecological Group so as to ensure that there benor or nininal, danage to the non-target fauna specificarly and to the environment in general. Any excesslve use for rLasons of Lconony of, forlnstance, pernethrln causlng damage to the environment would not only run counter to the recommendations of the Ecological Group but seriously taint theinage of the Progranme aDong the Participating Countries and within the Donor connunity. D. 2L. BENEFITS, RISKS AND SAFEGUARDS Benefits zL,L Ttre lnpleEentation of the above Plan of Operations wiII take theProgramrng a long way towards neeting its objective. By tgg7, and even before, onchocerciasis wlII no longer be a problem of public trlaftn inportance or animpedinent to socioecononic developnent within the Original OCF area, nor wiIIthere be any risk of rmcontrolled recrudescence insofar as devolution wiII havebeen flrnly anchored in the nationar health services of that area. 2L.2 what will be left for the progranne to carry out beyond 1997, wirl belinited to vector control and epideniological evaluation and surweillance in theExtension areas, activities which will gradually decrease in inportance before coning to an end a few years later. Ttre support services, such as conputer support' training and research, will equally dininish as control operations cease. page 45 2L.3 In nore speciflc terns, the benefits will be: the hunan reservoir of theonchocercal worn will be virtually elininated throughout the Original progranne area fron where OCP will have withdrawn; people living in endeni- reglons withinthe E:<tension area will no longer be exposed to infeciion; the Original areawill be protected fron reinvasion; the hunan reservoir of O. vohnrlus in theExtenslon area will be well on its way to virtual etintnatfoiJffiie""or" -originally suffering fron onchocercal infection will be treated by ivernectinfor at least six years with a considerable reduction of norbidity and risk ofbllndness; riverain land will be nade available for resettlement-; and devolutionwill be fully operational in the Original OCP area with preparations conpletedin the Extension areas 2t.4 Expressed in figures, the estinates are that as a result of ocp operations fron 1974 up to the end of the fourth Financial phase, l0 nillionpeople will continue to be protected fron onchocercal infection, 2 nillionpersons will have lost their infection and 150 OOO cases of onchocercalblindness will have been averted; 5 million children born during the Lg92-lgg7perlod will grow up without risk of blindness due to onchocerciisls fup-to ii'nilIlon since the beginning of OCP); and around 10 nillion hectares of fertile,riverain land in the E:<tension areas will becone available for cultlvationduring the fourth Financial phase (a total of 2J nirlion since L974),- --potentially sufficient to feed nore than U nillion people if free fron othermaJor constraints to agricultural developnent and if cultivated usingtraditlonal technologles and agricurtural practices. 1 2t'5 A nunber of equally inportant. but less tangibre, achievenents wirlcontinue to accrue as a result of the various activitles of the programme.Although direct natlonal participation in OCP operations was linited in scopeuntil the beginning of the eighties, Participating Countries have since thenbecone increasingly involved in ocP activitils. tti" trend wirl be intensifiedduring the 1992-1997 period to the benefit of the health services of thecountries concerned. 27'6 AIso. the direct I'nvolvenent of African staff in progra.mne operations(971 of arl posts Ln 1992) will provide the Participatint countries with a bodyof health workers who have had a-sorid experience in nanagement, once ocp conesto an end in any given area. 2t.7 In thls connection, devolution shoutd be seen as a neans to pronotehealth delivery systens in the Participating Countries. Developnents duringthe fourth Financial Phase courd very well orre. a unlque demonstration of howa trvertical', nono-disease control progrorrs like OCp can Dove towards a "horizontal", integrated public health-activity and provide the know-how andoperational experi.ence necessary for overarl hlalth systens developnent. 2t'8 0f particular inportance will be the direct and indirect contribution ofthe PrograEEe to the strengthenlng of the epideniological surweirlance systensin the Participating Countries asr an essential conponent of devolution. 2L'9 ltre all inportant collabor.'tion anong the participating countries as werlas between then and the Donor cou.:unity - a perfect exa.upre of a successfulNorth-south diarogue - constitutes the basis on which the success of theProgrammg has been built and on which its future will depend. Although thiscollaboration has so far been essentially linited to ocp operations as such,no doubt, the inpreEentation of devolution will give rise to a widening of Donorsupport to the benefit of hearth care in the pariicipating countries. 1 Io* 9r, analysls of the benefits deriving fron ocp operatlons: see ,cost-benefits of onchocerciasis control" by Eruce Benton and Elizabeth D. skinner,Acra Leidensia (1990) 59, No. 1 and Z, 4Oi_a11:---- page 45 2. Risks and safernrards 22't Since 1985' OCP has learned to live with resistance to 1arvicides as aproblen for which operational solutions have been refined. Given the extensive experlence Ln rotatlon of the available conpounds and the llkelihood thatadditional larvicides becone available, there is little risk that an unnanageable situation could arise in the future. However, the search for newlarvicides and inproved fornulations of existing ones will continue not only forthe purpose of providing additional safeguards but also with a view to improvingthe cost-effectiveness of environnentally acceptable vector control. 22.2 Although the probabtlity of 0. volvolus developing lowered susceptibilityto ivernectln is remote, the Progre'ms is supporting research ln order toeventually institute testing for nonitoring resistance in 1arge-scale treatnentprograules. 2?.3 _Followlng the experience of vector control in the t{estern E:<tension areawhere larwiciding had to be extended west and south-ward due to a change inecology resultlng in vectors of the blinding forn of 0. volrnrlus novin! beyondthe originally deteroined Progran'mg boundaries, enton6 rveillance willrenaln alert to the possibility of sinilar situations arising in other parts ofthe Progranne area. 22'4 Ttre risk of epideniologically significant, nassive invasion of blackfliesfrom countries outside the OCP area is nininal. In Liberia the nain vector, S. vahense' is non-migratory and probabry refractory to the savarn. "ii"i"-.i-it;parasite. To the east of the Progranne lies the savanna country of Nigeriafronwhere large-scare, long-distance novenents or s. aannosun sll. do not occurI'n a westward direction. Ttrerre is, however, signiFicant short-ranselnflltration of the border rivers (Sota and-Oueie) of ttre Republic of Benin. Inthe North' the sota vauey, whlch has been controired since i978. now presents asltuation where the disease has disappeared and infection reveis are very 1ow.Further south the Ouene basin, part of the Southern Er<tension area, is subjectto unsatlsfactory transmission levels at present, but epideniologicar surveyssuggest there is llttle btindness owing to onchocerciasis. Ttre f,otent:.ar1yexposed zones will continue to be kept under surveillance and appropriatecontrol Eteasures instituted should "danger situations" unexpecteify arise. 22'5 Delayed detection of recrudescence could result in difficulties inachieving its effective control. OCP will therefore spare no efforts inbringing the devolutlon process in the Participating Countries concerned toa fully operational level, and in pursuing the search for a field-applicablelmnunodiagnostic test, and for a fierd-aplticabte nacrofiraride. 22'5 Previous OCP epidenlological studles have indicated that hunal nigrationdoes not pose a threat to the onchocerciasis controlled zones of the orlginalProgranne. However. the risk of infected Bigrants giving rise to recrudescencecannot be entlrely discarded. in particular in view of an increasing South-Northpopulation DoveEent Fesulting fron socl.oecononlc developnents in the reglon.Again, the inportance of national vigitance and epideniological control nust beenphasized. page 47 22.7 A series of unforeseeable biological, climatic and hunan developnents could influence OCP operations, including deforestation, water nanagenent andmodiflcations in rainfall patterns. Ttre Progranme will continue to keep alert to such developnents and whenever needed, adjust lts strategy and tactics accordingly, so as to ensure that it reaches its objectivl as pranned. 22,8 In undertakings which have been going on reasonably successfully for agood nunber of years, there is always a certain risk of conplacency setting in,i.€. ' the contractlng parties becone accustoned to a snooth-runnint operation tothe extent that their interest and support start waning. This has never beenthe case as far as OCP is concerned and it is inportant that the progra.nne can continue to count on the full support, involvnent and vigirance of theParticipating Countries as well as of the Donor Comrnunity until the end of oCpoperatlons.

Annex I LIFE CYCLE OF ONCHOCERCA VOLVULUS Onchocerco volvulus { o Adults in subcutenlous titsue Microf ilariac Subcutanrous trr3ur Sk rn \ Enters skrn througn lly brre wound HOMO SAPIENS lntccrrvc stage Mrcrotrtarra rn skrn Mrgretes to h?ad and proborcri # II nge3reo Nr'd 5r.e! rar,. -\ SIMULIUM Penetraleg rtomach wall ThOracrc musctes Larva (sausage lorml €Bf .tr air r6i A / Annex/annexe 2 I .\ GtrJ ,(,t-\za I t I -t I I 'l I I I I t I I I t (t t\= I G-- lrJ(9 z at a o(9 a a a o I o aj rl al ol Z9YctES =qct I I o Uc J a 9 F c c o zo tr( G2 GU tso E U z o ^T r.i ,o a I ,t - _t-rr , It t I t t I f = t t z -0 t 1o ld o L) I o (3 U ctr o (J }J c o, tr o tr d LJ 0,, cJ I a :., a t , I o @ J I t I t , t I I , t I I t I I t I , , I I , t I I I = = I I + I G o I FoU3 o 'J U o U J ts2 zo E EI c o u z o a U G z 9 ts C,UA o I cE aU , lrJ z = (, Z (9 I .a a ,( I I I I I I , t I I ) 2G,I , , I J (9 lrJ z lrJo+ U(t .Jao=!o c5 tr C.d 'nE cJ!!xxe, =l. c!oocrJo =N a I c ,o a o c o an c c.)U x -o .o o o N OJ !(i o .H o o IJ x trl ! 0) t) o U) Ij E A. o: :g .:i: ; i33 :- :T 5; 6-ra;i!;a:i i.i;: :E4.!5:3:; i g6' ' ; o i 3.. -:'-E 3:!!:gE€t:! 3 t::24ao<ooo O O{< a . I + z o - + U c!2 ts oU J o zU C, I o ! ocroI at cC 2oo + f& &r lrJ <Z att =at I lrJ ft< z.n =o66 ll, aD E(9 o\|.\ @F\ o\ 0) o c! o 'F{oi>OFr (,)E OJ qJ !! x(o rr1 (J oo .n! g).iltroo>T'Hx- oJ! O\O t\ lJ\. (Oco() r.-orC I J a d.tr a z N I .J) o H a ! X .J) J I :r z, 3 H J -J) '= J z H3 ll o I .t) z -{azA :ix ,d '2, 'J) d ,J o& J z (J H! t I Annex/annexe 3 List of Donors to the 0ncho cerciasis Con trol ProgremneListe s Donateurs au de Lutte contre 1' Onchocercose Belgiun/BeIgique Canada Finland/Finlande France Gernany/Allemagne Grand Duchy of Luxenbourg/Le grand-Duch6 de Luxenbourg Italy/Iralie Japan/Japon Kuwait/Koweit Netherlands/pays-Bas Norway/Norv6ge Portugal Republic of Korea/R6publique de Cor6e Saudi Arabia/Arabie saoudite Switzerland/Suisse united Kingdon of Great Britain and Northern rrerand/Royaume-uniGrande-Bretagne et d'Irlande du Nord United States of Anerica/Etats-Unis d,Am6rique **t African Developnent Bank/Banque africaine de D6veloppenent conmission of European connunities/commission des conmunaut6s europ6ennes calouste Gurbenkian Foundation/La Fondation calouste Gurbenkian 0PEC Fund for rnternationar Deveropment/Fonds opEF pour 1eD6veloppenent international United Nations Deveropnent programne /progranne des Nations Uniespour le D6veloppenent The World Bank/La Banque nondiale world Hearth 0rganization/organisat,ion mondiale de ra sant6 January/janvier 1991 Annex 4a Structure Joint Programme Committee(ry1 THE STRUCTURE OF'OCP Conoos i tion /suoport Ro1e,/ resoons i.bl L::.,. Representatj.ves of: - The Parti.cipating CounEries - The Donors - The Sponsoring Agencies Commi t, tee of Sponsoring Agencies (CSA) ja"o""="r,.arives of UNDp. iFAO, t{orld Bank and t.tHO l{r""ts several tines la year) I I - 0vera11 polic;... operatj.onal a:C budgetary auchorl::,. - Approves Plan ci .{ct,:cr and Budget (aee:s once a year) Revier,r of nanage=enc/ budget trat,ters a,c c:- .I?Cdocs: can provisic::aii;,. aut,horize supp).e=encas]. budgets: supporcs soc:o- econonic develcp=enc Proqraooe Direccor HQ in Ouagadougou Supported by Units of: - Vector Control - Epideoiological Evaluation - BiostaEist,i.cs andInforoation Systeos - DevoluEion - Aduinistration & I'tanagemenc 12 menbers; Ecoloqical Group (! nembers) i- a subgroup of EAC in each of the art,icipating Countnies. gh-1eveI representat,ives neec once a year Responsible to JpC for all OCP acrivit:es - Planning anci prc3:--::.3 - Operatj.ons - Budget and Fi.::g:ce - Reporting - Technical audir of CCp - Advise to Direc:cr anci JPC rhrough CS.l (oeers once a year) - Facilitate liaison betrgeen OCp and national author: t,:.es - Promote OCp activit,ies l.IorId Bank: Fund mobilizarion and Trusc Fund admi- nistracion Ecological Grou Expert Adviso ttee (EAC) National 0nchocerciasis Coaoit,tees (NOC) Annex 4b Fo ufFUOEo6 = o 9 GoAoz EF c, utI o0 oF o 3? = lrt T6lOoI z Uo t! o UJJ Et( c!o l! 5 o =t'iiEoig F0 UJ ro3 EEo -o Gl{(, ,.F _u6 o6 tr = Jo<<zd.Eo<UIF- .E !.tE o o lrl o9g!>J4G lrtGc, =.2 oIu >zut<02 3Ea ul = =E(5r o?r tr=JOOr F<-F-q lE-6e ;k9= H$ u6 o - 4ozo c, oJoEo (, 0zc9 9k>fOJF<z> lrJ lrl lrlzz o0cl{A 9 EFO = Ct J o 1{zl{ a, .FJO <trl =! <=lr, <Z0 =oG,a 6 o -Uis2Efigldqo<oo Fo l! 0 lrl(JtEu0 GocGt6 o oo <l!U'FEX < lrl J2 <EziEI tE=oo0 ut .E .E u, o lrl 9 z lrl E ,(, oo o o ? utu E .E x I o *= =9<Y - 6i HTE fi I6oD<EO3E ao E oFo=r!O *s;o =6rE5 8oE o. 9o U F x ut El!F o lr, B J' =uI 0 o 9 - 4, olr = IF oIo oI =o ut(,E<L>og a8 = a, G, trl Ear =*urO -aE(,A d -(, zo o, 9c,otr ds Ef; lll fo(, , oo 0 f o lrtG z Glrt o lrJ 3 ul c, g c o o .EF oo .Co(, IT Annex/annexe 5 @ o\ L'o& o. a ld HF z U' z a U) ?J1 lrl oN ,, ri.(vl @ o\ ld& lrl E d(, o& -f (2 &o ET F zH t7 tdzoN olda 2 ]ll{& It$. ,\ ,e .\,45rr'ke=-\I,\9i _( .) ( L', o )-r _ (r I lJ ( i i I t \-) . --t ,: (1 r .-l t. t -1 -!_ ( I a \ I t /i\ :\ '!' i.iiii. \ I .l I I Annex 6 o$t E o o l- o o o o o o 0, @ (D I N o o o .u(L(J o (u o(, o o o o) G (, E oT'tr o I o o c o o o o o C'c o .u oL. Ct E ic,E oLF ui 'lil ...i a..-4...". ..:.r. . '--'.,..:':'. ql (o tt ot t: g ,i i o N o$o@oo o o(o (a6Eluacjad sE) sllnpe lo uorloc u! lru lo acuale^aJd otoog?r IllJJ =ll.ll.!::E;;(,Elt cLl I t o o o .Et o tr i i tr o a ".'1.)i Annex 7 40 PREDICTED IMPACT OF CONTROL and e:<amples of Dremature cessation of vector control (a).lmpact of 14 years of vector control 100 80 60 20 o (b). Recrudescencs after premature cessatlon ol vector control 100 80 60 40 o E oL o(, I o EL o o ED o o oL o o. 20 o (c). Recrudesconce control wlth lvermecttn 100 80 60 40 20 o --- CMFL - ?aav.ml/a vacto, conltol a yaars ol t 2 ,..r. ct vacta? contral L 12 r..?..t vaclai conlrol 1O y..?.., lY.?ln.ctla lraalhanl ',1970 1990 2010 2030 2050 a a. r .t' '. a il Annex/annexe 8 lirbra de blnEficiaircs d,,une bo,:,rse oFfs:a par I'OGP{ PGfs eE E:r disciplf--(arr&E :r.r 31 zt5nehre jggO) OCP fellowships, by eount ry and by field of srud D!-ri.pE= ?:.ys E---l- 81e F;Crcbtr logre Ep!d+''r lcgie S--{ grbJ:que Paresice logre r}L-^1+- loge EcancciE &Ia &n:E I.r-r-.-.- lt=ci"o ec f Y'r-t'-.o I;-ngr-res Ic:.'l 10 5 t I o 2 L> }.=:ci= S:-sr 12 3 5 ?D 6 2 3 l_ 52 C3:e d'ir,oi-r l5 3 2 I 22 Gr.=:3 lo 4 3 z 2 3 I I C-uia:r- !ic_r 3 3 3 9 ar. 6 3 3 I ::l VrI r' 43 5 9 5 4 ., 59 l:i6er 5 5 I u si;*_r 9 L 4 I 15 Sie- i.ccre I] 4 1 3 22 ToF t5 z I 2 4 ArE6 peys I 9 1 3 1 2 ]B Tocd 190 32 32 42 30 1') 0 t, ?ao 1 Other countries kt?\:\L(i Annex annexe 9a / \ (._ \a$ LL. I I t t II I a a I( a' , o o)I i\. 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