The World Health Organization year 2006 progress report: 1st September 2005 - 31 August 2006

JOINT ACTION FORUM Office of the Chairman JAF-FAC: TWELFTH SESSION Dar-es-Salaam, 5-8 December, 2006 FORUM D'ACTION COMMUNE Bureau du Pr6sident African Programme for Onchocerciasis Control Programme africain de lutte contre I'onchocercose I -l i The World Health Organrzation Year 2006 Progress Report: l't September 2005 - 31 August 2006 JAF 12.5 ORIGINAL: ENGLISH August 2006 t ::- G 0 p .J i ,1 * JAF I2.5 Page a PflosfftoNwqAPoa i ; This year, the stakeholders joined hands to reposition APOC. For the achievements. We thank the Working Group on the Future of APOC and Onchocerciasis Control in Africa and all who contributed in the preparation of APOC's Exit Strategic Action Plan and budget of 2007-2015. We are proud of the Yaounde Declaration of African Ministers of Health on onchocerciasis control - a truly historical milestone in the commitment of the African member states. And celebrate the 2006 EMMY Award to onchocerciasis control partners and the PBSAilGBH film producers for outstanding Informational Programrning. We are grateful to, and count on, the unparalleled support of our traditional and new donors, Merck Co. Inc and NGDOs to maintain the Programme's pro-poor focus and goal to impact on human health and development; build the capacity of communities and govemments to guard the significant investments and achievements of the former OCP and APOC. - APOC 2006. I ) I JAF I2.5 Page i TABLE OF CONTENTS 1. NEW FOCUS: REPOSITIONING APOC .................2 Womnqc GRoUP oN THE FuruRE oF APOC AND oNCHocERCIASTS coNTRoL IN AFRTCA . PARTNERS, MEETTNG oN THE FUTURE oF ONCHoCERCIASIS CoNTRoL IN AFRICA Exn SrnerpGIC ACTIoN PLAN AND BUDGET oF APOC 2OO7 -2015 CoMMUNITy DATA coLLECTIoN AND MANAGEMENT................... 2.I , FNg-ysan IMPACT ASSESSMENT: COMPARING PHASE I AND PHASE II STUDIES .... 2.2. LoNG-TERM HEALTH IMPACT ASSESSMENT (HIA) or APOC opERArroNS .......... ...,.,......4 ............5 6 3.2.1 Training of Health Workers...... .,,6 3.2.2 Improving community human resources for control activities; training of Community-Directed 3.2.3 Training on operational research protocol development in Cameroon 3.2.4 Other technical support to countries.. 3.2 CRoss BoRDER MEETINGS ........... 3 .2 . 1 Tripartie cross border meeting of National Onchocerciasis Task Forces of Sierra Leone, Guinea 3.2.2 Cross border meeting of National Onchocerciasis Task Forces of Nigeria and Benin Republic .... 4. OPERATIONAL RESEARCH........... ........................8 4.I . STUOY ON THE FEASIBILITY OF MEASURING INDIVIDUAL AND CoMMUNITY CoMPLIANCE To IVERMECTIN TREATMENT 4,2. STUDY ON EXTERNAL MONETARY INCENTIVES oN CoMMI.INITY BASED PRoGRAMMES 4.3. OpeRerroNal. RESEARCH By WHO/TDR................ T t 1.1 1.2 1.3 1.4 5.1. 5.2. 5.3. 2 3 J 4 3.I. CAPACITYBUILDING..... 6 6 6 7 ..7 ..8 Reyised Environmental Risk Model Map Feasibility of the elimination of transmission of O. volvulus in Mali, Senegal and Guinea-Bissau... Multi- c ountry study on the C ommunity- D ire c te d Intery enti on (C D D ...........4.4. MACROFIL 4.4.1. Discovery Research...... 1.4.2. Development of diagnosticsfor O. volvulus infection....... 4.4.3. Development of macrofilaricide/macrofilaria sterilizing dgent......... 5. COMMUNITY-DIRECTEDTREATMENTWITHIVERMECTIN MAPPING oF oNCHoCERCIASIS AND LoIASIS ........ IVERMECTIN TREATMENT IN APOC CoUNTRIES TN 2005......... MaNacsNasNr oF SEVERE ADVERSE EVENTS (SAEs)........ 6. EVALUATION AND MONITORING OF SUSTAINABILITY OF CDTI 6.1. EvaLuauoN oF THE susrArNABrlrry oF CDTI pRoJECTS.....6.2. MoNrroRrNG TMpLEMENTATToNoF susrArNABrlrrypLANs..... 7. ADVOCACY ANDRESOURCE MOBILIZATION MISSIONS........... 7,1. MISSION TO DEMOCRATIC REPUBLIC OF CONGO 7.2. CONFERENCE OF THE AFRICAN FINANCE MINISTERS ..FTNANCING FoR DEVELoPMENT: FRoM CourranupNT To AcrIoN." NIGERIA.... 4.3.1 4.3.2 4.3.3 8 8 9 9 9 9 9 9 I t0 t0 t2 l3 JAF 12.5 Page ii 7.3 7.4 JOTNT MISSION WITH THE WONTO BANK TO BRUSSELS MISSION TO PREPARE FOR APOC PARTNERS, MEETING IN CAMEROON....... ........,.,.. l4 .,.,.,.....,.14 8. 9. TECHNICAL CONSULTATIVE COMMITTEE (TCC) t4 9.1. 9.2. VECTOR ELIMINATION CoMMTINITY-DR.ECTED TREATMENT WITH IVERMECTIN ............. t4 l5 11. COUNTRY SUPPORT MISSIONS BY APOC MANAGEMENT AND TEMPORARY ADVISERS t6 l, 12. DOCUMENTATION AND PUBLICATIONS. ........................17 12.1. APOC'S CoNTRIBUTIoNS rO rHE MILLENNIUM DEVEL0PMENT GOALS (MDGs) ..............17 12.2. PUBLICATIoNS IN PEER REVIEW JOURNALS .................. .............17 L ANNEXES ON ROUTINE ACTIVITIES.............. ............18 ANNEX I : CouNrnv PRoFILES IN YEAR 2005............. ........ 18 ANNEX 2: Survlvany oF THE GEoGRApHTc AND THERApEUTIC covERAGES ATTAINED BY CDTI PRoJECTS nt 2005 t JAF I2.5 Page iii LIST OF TABLES Table 1 Table2 Table 3 Table 4 Table 5 Status of CDTI Community DataatNOTF and APOC HQ levels 4 7 7 1l 12 Number of CDDs and Health workers trained/retrained in 2005 . Technical and Support missions to APOC Countries . Number of persons and communities treated in73 CDTI projects in 2005 Summary results of sustainability evaluations of CDTI projects from September 2005 to August 2006 . Number of projects monitored and status of implementation of the sustainability Plans .. Overview of support visits to the NOTFs APOC Key Publications 2005 -2006 Table 6 Table 7 Table 8 l3 16 t7 LIST OF FIGURES Figure 1 : Community-directed treatment with ivermectin (CDTI) areas in APOC countries, as at July 2006 . 10 Figure 2 : Number of persons and communities treated between 1999 and 2005 in APOC countries 11 t JAF 12.5 Page iv ACRONYMS ACIAMS APOC APOD ATP BFO CAR CBM CBO CDD CDI CDTI CHAL CPOD CRS CSA DEC DPM DRC FLHF GCP GIS GPN GTZ HIA HKI HSAM IEF IFESH IMA IPSAS IRC ITN JAF LGA LOD MDG MDP MITOSATH MoH NAFDAC NGDO NGO NID Computerized Imprest Account Management System African Programme for Onchocerciasis Control Acute Papular Oncho Dermatitis Annual Transmission Potential Budget and Finance Officer Central African Republic Christoffel-B lindenmission (German NGO) Community-B ased Organ ization Community-Directed Distributor Community-Directed Intervention Community-Directed Treatment with Ivermectin Christian Health Association of Liberia Chronic Papular Oncho Dermatitis Catholic Relief Services Committee of Sponsoring Agencies (and APOC sponsors which include representatives of UNDP, FAO, The World Bank, WHO, the NGDO Group and Merck & Co. Inc.) Diethylcarbamazine Depigmentation Democratic Republic of Congo Front Line Health Facility Good Clinical Research Practice Geographic Information System Global Private Network German Technical Cooperation (German research support agency) Health Impact Assessment Helen Keller International (US NGO) Health education /Sensitization /Advocacy /Mobilization International Eye Foundation (US NGO) International Foundation for Education and Self-Help Interchurch Medical Assistance (US NGO) International Public Sector Accounting Standards International Rescue Committee Insecticide Treated Net Joint Action Forum (APOC participant body) Local Government Area Lichenifi ed Oncho Dermatitis Millennium Development Goals MectizanrM Donation Program Mission To Save The Hopeless Ministry of Health National Agency for Food, Drug Administration and Control of Nigeria Non-Governmental Development Organization (see NGO) Non-Governmental Organization (see NGDO) National Immunization Day a a NOTF NTD OCP OPC RAPLOA REA REMO SAE SANRU SIZ SNEL SPSS SSI TCC TDR JAF 12.5 Page v National Onchocerciasis Task Force Neglected Tropical Disease Onchocerciasis Control Programme in West Africa Organisation pour la Prdvention de la Cdcit6 (French NGO) Rapid Assessment Procedure of Loa loa Rapid Epidemiological Assessment Rapid Epidemiological Mapping of Onchocerciasis Severe Adverse Event Projet de Soins de Santd Primaires en Milieu Rural Special Intervention Zones Soci6t6 National d'Electricit6 (Democratic Republic of Congo) Statistical Package for Social Sciences Sight Savers International (British NGO) Technical Consultative Committee (APOC scientific advisory group) Special Programme for Research and Training in Tropical Diseases (part of CRD, a department of CDS, WHO) Vitamin A Supplementation World Health Or ganization see OCP see TDR VAS wHo WHO/OCP WHO/TDR JAF 12.5 Page vi SUMMARY In the period (September 2005 - August 2006) under review, the accomplishments of the Programme and partners are summarized below. The decisions of the 11th session of the Joint Action Forum (JAF) were implemented. The Programme produced a report on the Future of APOC and Onchocerciasis Control in Africa for consideration by the 12ft session of the JAF. A meeting of the Partners was held in an African country. Over 87,249 communities in 14 countries benelited from ivermectin treatmen$ 208'611 out of 261,000 Community-Directed Distributors (CDDr) and 17,263 health workers were trained and or retrained in the CDTI strategy. Almost 40 million (39,832,844) persons were treated in meso and hyper communities in 73 Community-Directed Treatment with Ivermectin (CDTI) projects. For all projects, the mean geographic and therapeutic coverage rates of90% and 690/o respectively, were recorded. 349 health and Non-Governmental Development Organization (NGDO) project staff in l0 countries received training on community-directed treatment with ivermectin(CDTl) philosophy and financial management. A good number of them were additionally trained on computer acquisition skills, operational research, evaluation of CDTI sustainability, management of Severe Adverse Events (SAEs), Rapid Epidemiological Mapping of Onchocerciasis (REMO), Rapid Assessment of loa /oa (RAPLOA), Geographic Information System (GIS), CDTI data collection and management. The onchocerciasis control partners in Sierra Leone, Liberia and Guinea held cross border meetings to review treatment activities in border areas. The partners resolved to harmonize treatment periods and strengthen communication among member countries. The partners in Nigeria and Benin also held similar meetings and agreed to institute cross border surveillance, mobilize resources and scale up monitoring and supervision. Comparative results of phases 1 and 2 impact assessment studies showed significant impact of the APOC operations on skin and ocular onchocercal disease and vector control. Across sfudy sites, the prevalence of reactive skin lesions (RSL) showed a significant decrease in six sites out of 10, ranging from 3 l.3Yo to 9lYo. In one site, the prevalence remained stable with 24.33% in phase I and 24.13 in phase 2. An increase was recorded in three sites. In one of these sites, the increase in the prevalence, from 7.63% to 7.96%o, was not significant. Bilateral blindness decreased in all the 10 study sites with a reduction rate ranging between 44%o and 72%o. This decrease was significant in two sites (61% reduction rate). For sclerosing keratitis, a decrease in the prevalence was recorded in 8 of the l0 sites with a reduction rate ranging between \oh and 85%; with the decrease being significant in four sites. The prevalence remained stable in two others. The prevalence of iridocyclitis between phase 1 and phase 2 was reduced in five sites, with the reduction rate ranging from 39o/o to 89%.It the remaining five sites, the prevalence of this lesion in phase 1 was either nil or low. Considering all stages of the optic nerve disease, a reduction in the prevalence of this lesion, ranging between l2o/o and 52o/o was recorded in five sites. The number of infective /ties and larvae decreased in 63%o of the sites while 3 8% of the sites had a significant reduction in annual transmission potential (ATP). A study to assess the direct and indirect health impact of APOC operations was initiated by APOC in collaboration with Erasmus University, The Netherlands is underway. The phase 1 multi-country study on the feasibility of determining individual and community compliance to ivermectin treatment in 17 projects with at least 7 annual ivermectin treatment rounds confirmed the availability of reliable data from which accurate rate of eligible individual and community compliance to ivermectin can be made. The phase 2 main study in progress will also evaluate the correlation between the number of consecutive treatments taken and perception of benefits. Another multi-country study to document the policies on external monetary incentives for community volunteers by dffirent health programmes, in Cameroon, Ethiopia, Nigeria and Uganda, is under way' JAF 12.5 Page vii Analysis of theJirst year data of the Community-Directed lntervention (CDI) study revealed that CDI start-up and implementation is feasible but depends on the availability of appropriate materials for respective interventions. There is a strong community ownership and buy-in by Ministry of Health and other partners. Malaria is the major priority of most communities. Screening of nearly 1,000 compounds yielded several new compounds in Macrofil research. On development of diagnostics for O. volvulus infection, preliminary analysis of the data showed that the DEC patch patch is safe and produces readily recognizable local reactions. Further work is required to move this forward. Development of moxidectin as a macrofilaricide was re-initiated in Ghana. Progress was made in the mapping ayf onchocerciasis in Angola, Burundi, Cameroon, Central African Republic, Democratic Republic of Congo and Tanzania. Mapping is yet to be finalized in Liberia, Sudan and Uganda. Loa loa mapping in 4 CDTI project areas of DRC identified high risk areas for the occurrence of SAEs. APOC in partnership with Mectizan Donation Programme (MDPTM) provided support to improve the management of SAEs in DRC and Cameroon. Of the 155 suspected cases reported from DRC, 76 were confirmed SAEs. Seventeen people were hospitalizedwith coma andALL recovered. Continuously excellent results were reportedin 2 foci (ltwara and Bioko) of the 4 foci in the Vector Elimination Project. The vector has also been absent in these foci and elimination seem to be achieved. The implementation of eight sustainability plans in 4 countries was monitored. Five of these plans were satisfuctorily implemented by governments, 1 was moderately implemented and 2 were poorly implemented. The Technical Consultative Committee QCC) now focuses on Programme strategic and technical issues. The committee reviewed 67 annual technical reports, 8 research proposals, 3 progress reports on vector elimination and supported capacity building workshops, country missions and vector elimination activities. Advocacy and resource mobilization missions were undertaken by APOC to support the Programme. APOC Management addressed the meeting of the African Ministers of Finance on the need to maintain over US$ 1.5 billion investments of the OCP and APOC partners and avoid a recrudescence ofonchocerciasis in freed zones. To accelerate the implementation of field activities and reduce administrative burden of project managers, the period of execution of Letters of Agreement have been harmonized not to exceed one calendar year (January to December). 100 letters of Agreement were harmonized during the period under review. X'ive scientific publications on various aspects of onchocerciasis control and CDTI were published in peer review journals/or in press. Contributions of the Programme to the Millenium Development Goals (MDGs) have been documented. JAF I2.5 Page 1 INTRODUCTION Ten years ago (December 1995), in a historic gathering, four United Nation's Sponsoring Agencies, Ministers of Health of 19 onchocerciasis endemic countries, donor community and non- governmental development organizations convened to extend the unprecedented success of the Onchocerciasis Control Programme (OCP) in West Africa to free the remaining endemic countries in Africa from the scourge of onchocerciasis - a major cause of poverty and impediment to economic development of hundreds of communities. Recognizing the opportunity provided by the free donation of an efficacious drug, ivermectin (Mectizan@), the partners established the African Programme for Onchocerciasis Control (APOC) to function for a time limited period. Ten years later, the control strategy of APOC, community-directed treatment with ivermectin (CDTI), has proven to be a highly successful method for delivering medical care on a large scale to remote communities from the reach of the formal health systems and an important vehicle for other pro-poor community-based health and non-health interventions. This report is a summary of the efforts of stakeholders to reposition APOC within the rapidly changing landscape in global health to maintain its leadership as a pro-poor initiative and plan for exit in 2010 or 2015 if an extension of the Programme is approved by JAFI2. The first section of the report entitled New Focus outlines recent activities of APOC parbrers to reposition APOC to attain its primary objective and goal, advance its contribution to the MDGs and maintain the investments and success of the OCP. Far reaching recommendations made on the future of APOC and onchocerciasis control in Africa are presented. The second section Scaling up Activities, summarizes the work of communities, MoH and NGDOs in the year under review. The third section describes the S-year impact assessment of APOC and the long-term direct and indirect health benefits of APOC operations. We end the report with section four on Success stories in vector elimination and ivermectin distribution and contributions of APOC to the MDGs. "APOC has achieved many significant successes in onchocerciasis control, and premature closure of the programme would lead to the loss of many of the benefits derived from the activities of the last several years which provide an effective platftrm for the delivery of other health interventions which are needed by millions of unserved people in Africa and which address the MDGs". - Working Group on the Future of APOC and Onchocerciasis Contol in Africa. JAF 12.5 Page 2 1. NEW FOCUS: REPOSITIONING APOC This section covers what was undertaken during the year in three major areas in line with the vision to reposition APOC with a clearly defined exit shategy. Three main activities presented in this section are: (i) Future of APOC and Onchocerciasis Control in Africa; (ii) The Partners' Meeting in Yaounde, Cameroon and (iii) Exit Strategic Action Plan and budget of APOC 2007-2015. The fourth subject is on Community data collection and management. 1.1. Working Group on the Future of APOC and onchocerciasis control in Africa Following the decision of the Joint Action Forum (JAF), in response to the recommendations of the 2005 External Evaluation and the 2005 Mid-Term Evaluation of the Special lntervention Zones (SIZ), the Committee of Sponsoring Agencies (CSA) commissioned a Working Group on the future of APOC and onchocerciasis control in Africa. The primary goal of the Group was to reflect on: a) the future of APOC until 2010 including the modalities of an eventual extension; b) modalities of continuing control activities in the countries (transfer, integration, funding and advocacy); c) geographical extension of APOC activities to SZ areas (after 2007) and some ex-OCP countries; d) eventual financing before and after 20 1 0. The Working Group concluded that APOC has achieved many significant successes in onchocerciasis control, and premature closure of the programme would lead to the loss of many of the benefits derived from the activities of the last several years which provide an effective platform for the delivery of other health interventions which are needed by millions of unserved people in Africa and which address the MDGs. The challenges and the need for on-going activities does not imply an onchocerciasis control programme with an indefinite end point; however, continued success will require long-term ioordinated support, continuity of that support and a careful definition of the roles and responsibilities of different actors. Control efforts will require the development of a flexible approach in which countries can call on different levels of support from APOC according to their capacity and the level of progress accomplished to date. The Group consider the future challenges for onchocerciasis control as follows: (i) to establish and sustain adequite treatment with ivermectin in all endemic areas in Africa, (ii) to determine where and when treatment can be stopped and (iii) to ensure effective surveillance in areas where active control has come to an end. The Group sees the future vision of APOC is one of an effective organization that lacks strict geographical boundaries and can address the need for advocacy, technical assistance and continued support for onchocerciasis control throughout the entire region. It also continues to promote innovation at thi community level to help promote the sustainability of onchocerciasis programmes using its core operational philosophy of CDTI to harness additional resources and assist countries in co-implementation where appropriate. The Group recommended that: a) APOC's main objective of establishing sustainable national onchocerciasis programmes in all countries where needed should be maintained and endorsed. b) APOC operations should be extended to 2015 to enable it to fulfill its original objectives. c) APOC should take on the additional objective of developing the evidence base to determine when and where ivermectin treatment can be stopped, and provide guidance to countries on how to prepare for and evaluate cessation of treatment. e) APOC should promote integration and co-implementation of interventions with CDTI to effectively provide multiple health benefits to large populations. JAF I2.5 Page 3 0 APOC's mandate should be extended to include all onchocerciasis endemic countries in Africa where the epidemiological situation requires sustainable CDTI. g) Financial planning and fundraising for onchocerciasis control should build on existing mechanisms and traditional donors but should also explore new funding opportunities particularly those offered in the context of Neglected Tropical Diseases (NTDs). The Report of the Working Group is included as document JAF12.8 for detailed reference. The Group will present this report to the Joint Action Forum in Dar-es -Salaam in December 2006. 1.2. Partners' Meeting on the future of Onchocerciasis Control in Africa Following the decision of the I lth session of Joint Action Forum (JAF1 1), a Special Meeting of the Parbrers of the former ex-OCP and APOC countries was planned to be held in Yaound6, Cameroon, 26-27 September 2006. The goal of the Meeting would be to discuss the findings and recommendations of the Working Group on the Future of Onchocerciasis Control in Africa and make recommendations to the l2th session of the Joint Action Forum (JAF). The Report of the Yaounde meeting is submitted to the JAF as Working document IAFL2.9. The proceedings and outcome of the Partners meeting will be presented to the Joint Action Forum. 1.3. Exit Strategic Action Plan and budget of APOC 2007 -201.5 The environment of onchocerciasis control is changing rapidly and there is consensus on the challenges and opportunities over the next decade. The major challenges are - 22 million more people in Africa are at risk of onchocerciasis than had been expected in 1995 when the control progra,mme was launched. Conflict - recent, continuing and new, as well as problems with co-endemicity of onchocerciasis and loiasis have delayed or interrupted 43 APOC projects by an average of 7 years. As a result of these factors beyond the control of APOC, 43 CDTI projects will not be sustainable by the original APOC closure date of 2010. The Working Group concluded that these projects cannot be abandoned: "cessation of support to countfies that have made a late sturt wilh CDTI would be detrimental and an unethical public health decision." Therefore, using the recommendations of the Working Group, the 2005 external evaluation of APOC and mid-term Review of the Special Intervention Zones, an exit strategic Action Plan and budget has been developed for the period 2007-2015. The focus of APOC during this period as shown in the draft strategic action matrix includes: i. Upscaling treatment with ivermectin in all endemic areas in Africa and reach its target of treatment to 90 million people by 2015 ii. Securing increased govemment ownership and sustained financing of onchocerciasis control to safeguard the huge investments of the ex-OCP countries and donors; iii. Re-establishing control activities in the few ex-OCP fragile states where conflict has caused the epidemiological indicators to revert to pre-control levels; iv. Building the capacity of nationals of member countries by empowering them with skills and tools to determine where and when to stop ivermectin treatment; v. Gradual decentralization of technical and financial management of control activities to the Ministries of Health, WHO country offices and some regional organizations. vi. Positioning APOC to complement the new initiatives of the neglected tropical diseases; using its human and material resources to advance the objectives of the NTDs. This document JAF12.11 is submitted to the Joint Action Forum (JAF) in December of 2006 for consideration. JAF I2.5 Page 4 1.4. Community data collection and management Table I: Status of CDTI Community Data at NOTF and APOC headquarters levels Community data available at NOTF and APOC HQ In preparation of the exit of APOC, the Management and the NOTFs have designed a database on CDTI community data. The ultimate goal of APOC is to improve CDDs census and treatment registers and in so doing provide reliable information to the health systems and the new global initiatives such as the Health Metrics Network, NTDs and the UN Millennium Village projects at community level. Every year, community-directed distributors (CDDs) of ivermectin record and update household treatment census and treatment registers. To date there are over 200,000 CDD Country CDTI Projects Burundi Congo Malawi Cameroon l5 DRC Nigeria Tartzania Uganda 7 4 Total 80 24 treatment registers available in 16 countries in Africa. This initiative will enable APOC keep comprehensive data at community level for all onchocerciasis endemic areas, prior to its exit. To further this project, a workshop to harmonize and standardize CDTI community data collection was organized in early 2006 in Ouagadougou. Eighteen (18) participants from 6 countries (Burundi, Cameroon, Democratic Republic of Congo [DRC], Nigeria, Tanzania and Uganda) were in attendance. A list of indicators for CDTI project annual technical reports, country plans of action for data collection and the sharing of data among partners were agreed. This activity has been completed in Congo Brazzavllle and Malawi and Trust Fund released to the NOTFs of Nigeria and Uganda for implementation. Technical and financial support in setting up an integrated management information system and production of 5500 community treatment registers was provided to the Chad National Onchocerciasis Task Froce (NOTF). Table I shows countries with community/village CDTI data and others needing attention. APOC Management expects that the new initiative in reporting detailed community CDTI data will improve the quality of data reported by projects. Other programmes will have access to the database. 2. TMPACT ASSESSMENT OF APOC 2.1. Five-year impact assessment: comparing phase I and phase II studies Between 1998 and 2005, APOC Management carried out two cross-sectional studies at a five- year interval to evaluate the long-term clinical, entomological and social-demographic impact of its operations. The comparisons of the clinical findings of the baseline studies (phase 1, 1998-2000) and the subsequent impact assessment studies (phase 2,2004-2005) revealed: ' Asignificantdecreaseintheprevalence of severeitchingin60% of the l0studysites.The reduction rate ranges between 61Yo (kaja, Sudan) and 86%o (Bushenyi, Uganda). ' The prevalence of nodules was reduced in all sites except two: Inga (DRC) and Morogoro (Tanzania). The reduction rate, which ranged between 5oh (Olamaboro, Nigeria) to 84Yo (Ikom, Nigeria), was significant in 5 of the study sites: Kumba. Lusambo, Raja, Ikom and Bushenyi. ' Reqctive skin lesions (RSL), deriving from three skin lesion types (acute papular onchodermatitis (APOD), chronic popular onchodermatitis (CPOD) and lichenified onchodermatitis (LOD), are the most important risk factor of pruritus. Across study sites, their prevalence showed a significant decrease in six sites ranging from 31.3o% (Lusambo, DRC) to 9lYo (Ikom, Nigeria). In one site, Bushenyi (Uganda), the prevalence of RSL remained stable between the two phases of the impact assessment studies with 24.33%o in phase I and 24.13 in phase 2. An increase in the prevalence of RSL was recorded in three sites. In one of these sites, Inga (DRC), the increase inthe prevalence, from 7.63%to7.960/o, I 2 J 2 2 2 8 20 27 0 8 J 0 JAF I2.5 Page 5 was not significant. The increase in the prevalence of RSL from 5.31o/o to 8.51% in Olamaboro (Nigeria) may be due to the sampling scheme with the selection of new communities in the phase 2 study. The prevalences recorded in phase I (18.23%) and phase 2 (46.64%) in Morogoro (Tanzania) should be investigated. . Bilateral blindness decreased in all of the 10 study sites with a reduction rate ranging between 44%o (Lwantbo, DRC) and 72%o (Morogoro, Tanzania). This decrease was significant in two sites: Morogoro and Raja (61% reduction rate). Considering all bilateral yisual impairments (blindness, moderate and severe visual impairment), a significant decrease between phases I and 2 was recorded in four sites (Lusambo, Ikom, Raja, and Olamaboro). . Except two sites, a decrease in the prevalence of sclerosing keratitis was recorded in all the sites with a reduction rate ranging between 8% (Gashaka, Nigeria) and 85% Qllgambe, Cameroon). This decrease was significant in four sites: Kumba and Ngambe (Cameroon), Ikom (Nigeria), Bushenyi (Uganda). In two other sites (Raja, Sudan and Gashaka, Nigeria) the prevalence was stable between phase I and phase 2. ' The prevalence of iridocycllfl's between phase I and phase 2 was reduced in five sites, with the reduction rate ranging from 39%o (Inga, DRC) to 89% (Kumba, Cameroon). ln the remaining five sites, the prevalence of this lesion in phase 1 was either nil or low: Ikom, Gashaka and Olamaboro (Nigeria), Ngambe (Cameroon) and Bushenyi (Uganda). ' Considering all stages of the optic nerve disease, a reduction in the prevalence of this lesion, ranging between l2o/o (Ikom, Nigeria) and 52Yo (Lusambo, DRC) was recorded in five sites. The early optic nerve disease remained stable between the two phases of the studies in all the sites, except in Lusambo, Olamaboro and Raja where a marked decrease was noted. The prevalence of the advanced optic nerve disease increased in six sites and decreased in the remaining four sites; but this trend (increase or decrease) was not significant in all sites. ' The number of infective females per 1,000 parous flies, and the number of infective larvae per 1,000 parous flies decreased in 630/o of the sites, while a significant reduction in annual transmission potential (ATP) was recorded in only 38% of the sites. In summary, the impact assessment studies revealed that when ivermectin treatment is consistent, eye and skin lesions, due to onchocercal infection, regress. In addition, the development of early lesions is prevented. On the other hand, the studies suggest that ivermectin treatment should be long enough to have an impact on the transmission of the onchocercal disease. Detailed information on the impact assessment of APOC operations have been submitted for publication in peer review journals. The impact assessment of APOC will be presented to the JAF under the agenda item 6. 2.2. Long-term Health Impact Assessment (HIA) of APOC operations This study aims to estimate the direct and indirect health effects of APOC operations using the ONCHOSIM-model. The Erasmus University Medical Center, Rotterdam, The Netherlands is car.ying out the study in collaboration with APOC. Analytical approach An assessment of the health situation in1995,2005 and 2010 (expected) will be compared to a hypothetical situation in which there was no APOC Programme. The differences in the health outcomes would be the health impact of APOC. The assessment will distinguish direct health effects, effects on the health system and the socio-economic impact of the programme. Besides the effects on onchocerciasis infection and its clinical manifestations, the direct health effects include any effects on other infections and side effects of ivermectin. Priority will be given to the analysis of direct health effects. Direct health effects An assessment will be made of the burden of disease due to onchocerciasis at the start of APOC in 1995 based on data from REMO, population data and publications on the clinical consequences of onchocerciasis infection. Subsequently, an estimate will be made of the situation in 2005, using data on the duration and coverage from APOC, combined with literature on the effects of treatment with ivermectin and JAF 12.5 Page 6 mathematical modelling. The target population will be divided up by level of infection and duration of treatment received and for each of these subpopulations the ONCHOSIM-model will be used to estimate the health consequences. The total effects will be added and presented by country. For the forecast of 2010, the analysis will be based on the expected treatment coverage for the years 2005-2010. The burden of disease in the period 2005 - 2010 will be estimated in a similar manner under different scenarios. In addition, a brief assessment will be made of the side effects of ivermectin treatment during the programme, and of the effects on lymphatic filariasis, loiasis, and other relevant diseases. Where possible, effects will be quantified. Health semices and socio-economic consequences APOC aims to establish a sustainable network that can deliver treatment to underserved, remote communities in the participating countries. A quantitative assessment will be made of the population this network can reach, as well as a qualitative assessment of its potential uses. The effects on productivity and household income of relieving the symptoms of onchocerciasis will be addressed. A presentation of preliminary findings will be made to the Joint Action Forum under Agenda item 6. 3. SCALING.UP ACTIVITIES APOC needs now to plan its exit from countries. During the year under reporting, APOC Management intensified specific activities and began new ones in preparation of the cessation of APOC Trust fund to endemic countries. The routine activities are summarized in this section. 3.1. Capacity building 3.2.1 Training of Health Workers APOC staff and resource persons facilitated training workshops on APOC philosophy and CDTI strategy in five (5) post-conflict countries; Angola, Liberia, Burundi, South Sudan and Central African Republic where ivermectin distribution had been slowed down or halted. The Programme invested in capacity building of nationals on community ownership, integration of CDTI activities into national health systems, sustainability, monitoring and evaluation to strengthen and boost CDTI. Partners from the health service, local and international NGDOs of these countries affended the workshops (Table 3). 3.2.2 Improving community human resources for control activities: training of Community-Directed Distributors (CDDs) In 2005, 73 CDTI projects in 14 countries trained/retrained atotal of 208,611 out of 26I,000 CDDs and 17,263 health workers in CDTI implementation under the coordination of the NOTFs (Table 2). 3.2.3 Training on operational research protocol development in Cameroon APOC Management organized a workshop to train nationals of Cameroon in operational research protocol development. 3.2.4 Other technical support to countries APOC Management, Technical Consultative Committee (TCC) members, Non Governmental Development Organizations (NGDOs), Mectizan Donation Program and other external experts supported 349 nationals from 14 APOC and I ex-OCP countries in advocacy to policy makers, training in financial accounting, computer skills, sustainability evaluation, development and monitoring of post-APOC sustainability plans, management of SAEs, impact assessment studies of APOC operations, vector elimination, Rapid Assessment of Loa /oa (RAPLOA) and Rapid Epidemiological Mapping of Onchocerciasis (REMO). Details of the capacity building missions are shown in Table 3. Table 2: Number of CDDs and Health workers trained/retrained in 2005 JAF I2.5 PageT Number of people trained/retrained aaJJ Angola 515 25 Burundi 1,417 0Cameroon 9,477 13,017 cAR 1,594 3,219Chad 422 0Congo 546 1,436 DRC 8,447 14,t70Ethiopia 18,096 25,728 Liberia NA NAMalawi 1,500 2,237 Nigeria 13,483 46,136Sudan 1,673 1,283 Tanzania 1,900 5,801Uganda NA NA TOTAL 59,070 113,052 NA: Not available 42 45 87 56056 728 1,323 2,A53 32528 42 19 6l 56 156 2t2 801 1,643 2,444 444 688 t,132 NA NA NA 213 298 5ll 2,295 6,705 9,000 140 91 231 98 255 355 NA NA NA 4,918 1t2,48 17263 Total 540 1417 22,494 4,813 422 1,982 22,617 43,824 1,126 3,737 59,619 2,956 7706 3 5,358 208,611 Table 3: Technical and Support missions to APOC Countries Area of capacity building Countries Financial Management Refresher courses on financial management of APOC Trust Fund, monitoring of approved budgets and timely reporting of expenditure. Training of nationals including oncho coordinators on computer skill and Operational Research Sustainability evaluation of CDTI and monitoring of sustainability plans Training on the management of SAEs in areas co- endemic for onchocerciasis and loiasis Vector Elimination REMO/REA, RAPLOA Training oncho coordinators on GIS and data management. Total Angola and Burundi Cameroon DRC, Ethiopia, Cameroon, Uganda, Nigeria, Liberia Angola, DRC, Sudan Equatorial Guinea Angola, CAR, DRC, Burundi, Tanazania Burundi, Chad, Congo and Togo l1 64 IJ 8 90 70 349 3.2. Cross border meetings 3,2.1 Tripartie cross border meeting of National Onchocerciasis Task Forces of Sierra Leone, Guinea Conakry and Liberia The objective of the meeting was to improve onchocerciasis control in border areas of Sierra Leone, Guinea and Liberia by synchronization of CDTI activities. Representatives of Ministries of Health of the 3 countries and partners from SSI and HKI attended the meeting in Siena Leone. As an outcome of the cross border meeting, Guinea Conakry, Sierra Leone and Liberia agreed to harmonize ivermectin treatment to ensure that communities on either side of the borders receive ivermectin annually, to hold tripartite meetings bi-annually and to strengthen communication among member countries. JAF I2.5 Page 8 3.2.2 Cross border meeting of National Onchocerciasis Task Forces of Nigeria and Benin Republic Representatives of the Republic of Benin and Federal Republic of Nigerian held a cross-border meeting to discuss improvement of treatment coverage in border communities, population movement, inadequate CDD/population ratio and CDD incentives. APOC and Special Intervention Zone (SIZ) co- financed both meetings held in the countries. The meetings were attended by programme and policy makers at national, state/district levels of Ministries of Health, APOC ManagemenVSlZ and Sightsavers International (SSD. Strategies proffered to address issues were the creation of joint monitoring teams, synchronization of plans of action, documentation of communities in border LGAs/Commune and resource mobilization. In addition, the group agreed on a strategic plan for epidemiological and entomological surveillance of the Nigeria border and scaling up monitoring and supervision. 4. OPERATIONAL RESEARCH 4.1. Study on the feasibility of measuring individual and community compliance to ivermectin treatment The CDTI has been shown to be effective in reaching hundreds of previously neglected communities or those with limited access to health services. However the rate of compliance of individuals to treatment with ivermectin since the inception of APOC CDTI programmes is unknown. As a preliminary step to determine compliance of individuals and communities to treatment with ivermectin, a phase I study was designed to determine if adequate and reliable data exist in the field from which accurate assessments of individual and community rates of compliance can be made. The study was conducted in 17 projects with at least 7 annual ivermectin treatment rounds selected from Cameroon, Chad, Nigeria, T anzania and Uganda. Treatment data from dishict level registers, community summary forms and CDD registers and recall of treatment by individuals were collected from 984 communities and 121 districts andanalyzed during the study. CDDs' record of having received ivermectin five times was chosen as the standard for compliance. The rate of individuals' compliance to ivermectin treatment varied from 42.3%o in Cross River, Nigeria to 88.0% in Uganda phase I. The overall average among sites was 62.3%. The study confirmed the feasibility of a large scale compliance study, while recognizing difficulties in conducting such a study in poorly managed projects with inadequate record keeping and documentation. The findings further suggested a possible link between sex and age to compliance as males (64.6%o) were more likely to have taken ivermectin five times than females (60.6%) and older adults had better compliance (65.54%) than those aged l2-I9o/o (59%). The need to include ethnic and minority groups in such a study was also underscored. The phase II study is underway to evaluate the correlation between the number of consecutive treatments taken and the subjective perception of benefits. 4.2. Study on external monetary incentives on community based programmes APOC continuously receives reports from projects drawing attention to high attrition rates of community directed distributors (CDDs) because of huge monetary incentives provided by other programmes. A study in Mali last year on different incentive policies for community distributors highlighted the need for a harmonized national policy on this issue. At the moment it is uncertain what incentive policies are implemented and who funds what. There appears to be confusion at the community level in countries with different incentive policies. The effects oi incentives will be more severe when donor funding is withdrawn. The National Programme on Immunization Plus in Nigeria, a programme that provides incentives at all operational levels has shown interest in the study. A protocol development workshop held in July 2006 in APOC headquarters was attended by 8 participants from Cameroon, Ethiopia, Nigeria and Uganda. The study will be implemented in 2 phases. JAF I2.5 Page9 The first phase study modelled after the study in Mali will document the policies on external monetary incentives for community volunteers by different health programmes, the determinants of these policies and to what extent they overlap at the implementation level. The outcome of the phase I study, would determine the scope of the phase II study. The findings will be presented to the JAF under agenda item 10. 4.3. Operational research by WHO/TDR 4.3.1. Revised Environmental Risk Model Map A revised spatial model combining the results of RAPLOA data and the Environmental Risk Model has been developed. A version suitable for local use that identifies zones with high risk of SAEs has now been generated. It has been adapted to identiff areas where ivermectin treatment can be instituted safely. 4.3.2. Feasibility of the elimination of transmission of O. volvulus in Mali, Senegal and Guinea-Bissau Preliminary data on vector infectivity from the study on the feasibility of elimination of transmission in Mali, Senegal and Guinea-Bissau show zero O. volvulus L3h larvae among 1,000 parous flies and thus consistent with the requirement for interruption of transmission (1 L3h larvae among 1,000 flies). Epidemiological surveys also show that in most of the villages, the situation is consistent with the entomological data. Detailed findings will be presented to the JAF under Agenda item 11. 4.3.3. Multi-country study on the Community-Directed Intervention (CDI) Analysis of the first year data revealed that: i. There is a strong community ownership of CDI ii. Vitamin A delivery can in principle be integrated, but in practice was difficult because of the integration of its delivery with NlD/polio (National Immunization Day ) campaign; iii. Case finding and referral to DOTS (Direct Observed Treatment, Short-course) were successfully integrated into CDTI, but the specific role of CDDs needs further definition; iv. The major priority for most communities is malaria. Integration of Home Management of Malaria is in principle possible. For instance, the percentage of children receiving appropriate treatment of fever within 24 hours of onset increased by more than 50% from baseline through integration with CDTI in Uganda; v. CDI start-up and implementation is feasible but depends on the health systems making appropriate materials available for the respective interventions. For instance, integration of Insecticide Treated Nets (ITN) distribution did not happen since essentially ITNs were unavailable for distribution. Meetings have been held with the principal investigators and the Ministries of Health of Cameroon and Nigeria where intervention materials were unavailable to review the implications of the preliminary findings. Progress made will be presented in December 2006 under agenda item 9. 4.4. MACROFIL 4.4.1. DiscoveryResearch Screening of nearly 1,000 compounds has resulted in several new hits. Evaluation of emodepside (a new anthelmintic compound with exceptionally good activity against adult worms of Onchocerca gutturosa and microfilariae of O. lienalis) activity against O. volvulus (obtained from human subjects) in Ghana has been initiated. Data are expected for fourth quarter of 2006. TDR is now in possession of thousands of additional compounds for screening through a new drug discovery partnership with Pfizer and Chemtura as well as other collaborations. The increased partnership and network JAF 12.5 Page 10 activities in drug discovery provide a framework for the Helminth Initiative that TDR is promoting. This initiative will further facilitate the discovery and development of new compounds. 4.4.2. Development of diagnostics for O. volvulus infection Based on the results of clinical testing of a first prototype of a diethylcarbamazine citrate (DEC) patch that utilizes transdermal drug delivery technology, a new prototype of the DEC patch was developed and tested clinically. The preliminary analysis of the data shows that this patch is safe and produces readily recognizable local reactions. Skin snip biopsies will determine if the reactions are due to the death of the microfilariae (localMazzotti reactions), which is the requirement for the use of the patch for diagnosis of infections with O. volvulus. 4.4.3. Development of macrofilaricide/macrofilaria sterilizing agent The development of moxidectin was re-initiated in the study site in Ghana. Equipment required to conduct the proof-of-concept efficacy and safety study and procedures for Good Clinical Research Practice (GCP) to ensure support for registration if moxidectin meets its target product profile were provided and put in place. An expert group, and data management and reporting procedures were set up for independent adverse event evaluation and advice on dose progression. With the approval by Ghana Food and Drugs Board, the study commenced in August 2006. 5. COMMUNITY.DIRECTEDTREATMENTWITHIVERMECTIN 5.1. Mapping of onchocerciasis and loiasis Progress in onchocerciasis mapping was made in Angola, Burundi, Cameroon, Central African Republic, Democratic Republic of Congo and Tanzania. The validation of the REMO data of Cabinda Province, Angola revealed that onchocerciasis is hypo endemic. REMO is yet to be finalized in other parts of Angola, CAR, DRC, Liberia, Sudan and Uganda. Figure 1 shows the updated CDTI areas in APOC countries as at July 2006. Figure 1: Community-directed treatment with ivermectin (CDTI) areas in APOC countries as at July 2006 flNettonal bourdertm (DTI prlorltv rces Eq t(il 0 Leoend Netrel prrlrr Lrkcs Esclndcd No CIlil rles .&res to bc re{foiod WlrO/APOcroJrrym l JAF I2.5 Page 1 1 NOTFs and APOC Management rely on the Rapid Assessment procedure for Loa loa (RAPLOA) to assess the prevalence of Loa loa and to delineate areas of high risk of occurrence of SAEs due to coendemicity of onchocerciasis and Loa loa. When the prevalence of eye worm is equal to or above 40%o, there is a high risk of occurrence of SAEs. RAPLOA was conducted in 4 CDTI projects' of DRC: Lubutu and Kasongo (Maniema province), Beni-Butembo and Massi-Walikale (Nord Kivu province). Two health districts of Lubu and Punia (Lubutu CDTI project) and Beni (Beni-Butembo CDTI project) were identified as high risk areas. Isolated villages in Massi-Walikale and Kasongo CDTI projects had prevalence of 40%o. RAPLOA in Cabinda Province in Angola revealed a high prevalence of loa loa. 5.2. Ivermectin treatment in APOC countries in 2005 In 2005, 73 CDTI projects treated 39,832,844 persons in 87,249 meso and hyper endemic communities (Table 4 and Figure 2).Treatment data by country in 2005 is summarized in annex l. Treatment coverage by project is shown in annex 2. Table 4: Number of persons and communities treated in 73 CDTI projects in 2005 Angola Burundi Cameroon CAR Chad Congo DRC Eq. Guinea Ethiopia Gabon Liberia Malawi Nigeria Sudan Tanzania Uganda Total 49,645 164,794 3,613,842 537,388 1,065,249 406,031 4,953,959 NA 3,164,007 NA 352,584 1,299,7 55 20,848,986 768,1 1 I 1,252,793 1,355,700 39,832,844 119 157 8,698 3,986 3,250 770 11,041 NA 16,3 88 NA 294 2,186 31,744 1,058 4,593 2,965 87,249 335,664 569,952 4,943,553 1,320,304 1,607,131 607,486 9,324,004 NA 4,013,466 NA 2,308,932 1,629,540 28,589,915 1,767,882 1,677,994 I ,685,41 I 59,381,134 738 l8l 8,800 5,014 3,250 ,70 13,473 NA 16,388 NA 2,598 2,186 36,367 2,029 4,593 3,013 99,400 I I t4 1 1 2 4 0 6 0 I 2 )1 J 6 4 73 1 I 15 I I 2 t4 I 9 I 2 2 27 6 7 4 94 ND :Not available Figure 2: Number of persons and communities treated between 1999 and 2005 in APOC countries **T _ T'* ."m.mt ffi _ffiI::ffi+ N NI*gil:NNNNlu E r,={N 19€ 2000 3001 20e !ocK, 3fi!4 206 Number of projects meso/hyperTreatedCountry JAF 12.5 Page 12 5.3. Management of Severe Adverse Events (SAEs) During the period under review the following actions were taken to prevent and/or ensure proper management of SAEs: a) Mapping of Loa loa in DRC in all areas suspected to be coendemic for onchocerciasis and loiasis (refer to disease mapping). b) Training first line and reference hospital personnel on early diagnosis and management of SAEs in Angola, DRC and Sudan. c) 331 642 US$ was released for drugs, equipment, vehicles and motorcycles for frontline health facilities and referral hospitals for management of SAEs in DRC and Angola by APOC and Mectizan Donation Program. Of this, 283 135 US $ was from APOC Management while 48 507 US $ was from MDP. d) Advocacy materials (films) for sensitization in conflict areas with co-endemicity of onchocerciasis and Loa loa and follow up of SAE patients were produced for Cameroon and DRC by APOC and MDP. The impact of all these actions and support is yielding good results. As at July 2006 in DRC, of the 155 suspected SAEs cases reported in Nord Ubangui, Sud Ubangui and Tshopo CDTI projects, 76 cases were confirmed. Of the 76 cases, 17 persons were hospitalized with coma and ALL recovered. 6. EVALUATION AND MONITORING OF SUSTAINABILITY OF CDTI 6.1. Evaluation of the sustainabilify of CDTI proiects CDTI projects are evaluated for sustainability in the 3rd year and if a project were experiencing problems it is re-evaluated during its 5ft year. A project is found to be sustainable if *CDTI activities in the area continue to function effectivety for the foreseeable fature, with high treatment and geographical coverage, integrated into the available health care system with strong community ownership, using resources mobilized by the community and their respective government". The main indicators of evaluating sustainability are: Planning, Health education /Sensitization lAdvocacyl Mobilization (HSAM), Training, Finance, Transport, Mectizan Procurement, Delivery and Distribution, Monitoring and supervision, Human Resources, Record Keeping, data collection and maintenance of therapeutic and geographical Coverage. Table 5: Summary results of sustainability evaluations of CDTI projects from September 2005 to August 2006 Country Project Making progress Number of Number of towards health communities sustainability Yes Yes Yes Six projects in 4 countries were planned for sustainability evaluation. Three projects in DRC and Ethiopia have so far been evaluated during the reporting period. All 3 projects were judged as making progress towards sustainability (Table 5). The remaining three will be evaluated by December 2006. districts D.R. Congo Bandundu Ethiopia Bench Maji North Gondar Total J J 2 8 t2 t2 T2 36 Of the 18 sustainability plans expected from 5 countries during the reporting period, only Ethiopia and Nigeria submitted 16 plans. Nine of these plans have been reviewed. The other seven plans are being revised. 6.2. Monitoring implementation of sustainabitity plans In 2004, a mechanism for monitoring the progress on implementation of sustainability plans of projects evaluated in the third or fifth year of CDTI implementation, at the end of the 4th or 6th year respectively, with or without receipt of APOC funds was put in place. The main objective of monitoring the sustainability plans was to determine the extent to which participating governments, particularly at the district, first line health facility (FLHF) and community levels were implementing their sustainability plans. The focus of the monitoring was on JAF 12.5 Page 13 Table 6: Number of projects monitored and status of implementation of the sustainability plans Country Cameroon Ethiopia Nigeria Uganda Total Implementation of sustainability planj::f:i, satisfactory rair Poormonrtored J 1 2 2 8 I 3 I 1 1 2 5 2 I planning and funds allocation at National, Regional, District/LGA and FHLF levels. Eight CDTI projects in 4 countries were monitored for implementation of CDTI sustainability plans. Five were judged satisfactory, one fair and 3 poor (Table 6). Feedback on the outcome of the monitoring was given to all the levels especially the higher levels of policy and decision-making for follow up and action. The main findings of the monitoring were: 1. Ivermectin was available to communities and activities continued with adequate geographical and therapeutic coverages at project level in most countries. 2. Crucial activities such as sensitization and mobilization, monitoring and supervision are highly dependant on NGDO funding once APOC funding is reduced or withdrawn. 3. The FLHF level was still the weakest level even after the evaluations recommended that they be strengthened. 4. CDD/population ratio was still low and hence the increased work load and demand for incentives by CDDs. 5. Poor advocacy to policy and decision-makers resulted in poor commitment and release of funds even though the sustainability plans had been endorsed. Some countries released only 1/8 of the allocated funds. 6. Integration of sustainability plans into the general heath plan and government commitment at all levels could ensure sustainability of CDTI without external funding. 7. ADVOCACY AND RESOURCE MOBILIZATTON MISSIONS Four missions were undertaken to DRC, Nigeria, Belgium and Cameroon to advocate for resources from partners and donors. 7.1. Mission to Democratic Republic of Congo The Director of APOC as a follow up to the initiative of her predecessor visited the Inga River Basin in Bas Congo, DRC to solicit government financial support for vector elimination activities in the Inga. Annual black fly biting rate is known to be over 10,000 per person per day. The Ministry of Enerry approved the release of US$800,000 for larviciding in the first year. A committee made up of representatives of MoH, Ministry of Energy, NOTF, SNEL (Soctdtd Nationale d'Electricitd), APOC/SZ and Office of the President would meet to develop an action plan for vector control. 7.2. Conference of the African Finance Ministers 66Financing for Development: From Commitment to Action." Nigeria The invitation of Finance Minister of Nigeria provided a unique opportunity for the Director and Team Leader of the Special Intervention Zones to bring to the attention of the African Ministers of JAF 12.5 Page 14 Finance on the challenges of ex-OCP and APOC control programmes as a result of recurring conflict in the sub-region. They highlighted the risk of recrudescence in previously cleaned OCP countries and the danger of losing over US$1.5 billion investments of countries and the development partners in 32 years of onchocerciasis control. They solicited for a renewed commitment from the Ministers of Finance. 7.3. Joint mission with The World Bank to Brussels The Coordinator of the Onchocerciasis Unit of The World Bank and Director, APOC visited senior officials of Ministry of Foreign Affairs and Development Cooperation for multilateral cooperation to solicit for continued support of the Government of Belgium. The mission was assured of the commitment of the government of Belgium up to 2007. 7.4. Mission to prepare for APOC partners' meeting in Cameroon The APOC Director paid an official visit to Government of the Republic of Cameroon to follow up on preparations for APOC Partners' meeting in September. A report of the Partners' meeting is submitted as JAF12.10. 8. TECHNICAL CONSULTATIVE COMMITTEB (TCC) TCC members continued to play a vital role in the achievement of the Programme objectives. They were involved in workshops organized by APOC, country missions and vector elimination. The committee now focuses on technical and scientific issues leaving implementation issues to APOC Management. During its 21st and22nd sessions, the Committee reviewed 67 annualtechnical reports and revised the annual technical reporting and grading formats with a view to improving reporting by projects. Eight (8) operational research proposals were appraised. Other research activities and studies namely MACROFIL, cost per treatment, review on incentives, RAPLOA and environmental risk mapping as it affects CDTI implementation and Impact Assessment of APOC Operations were discussed. Three (3) progress reports on vector elimination received attention as well as sustainability evaluation of CDTI projects reports, sustainability plans, independent monitoring, add-on interventions, strengthening of health systems, Community Directed lntervention study, integration and financial management of projects. 9, SUCCESS STORIES 9.1. Vector elimination From the four (4) foci selected in three countries for vector elimination activities fltwara and Mpamba-Nkusi in Uganda (S. neavei foci), Bioko in Equatorial Guinea (S. yahense form Bioko focus) and Tukuyu inTanzania (S. thyolense focus)], excellent results have been achieved in Itwara and Bioko foci. Since 1997 when ground larviciding ceased, regular entomological evaluation revealed no larva andlor adult of the Simulium neavei in the main Itwara focus. In the sub-foci of Siisa and Aswa, the vector has been absent for at least two years after the cessation ofground larviciding. ln Bioko where combined aerial and ground larviciding has been conducted for two years and ceased in May 2005, no larvae and/or adults of the S. yahense Bioko form have been found on the island, despite intensive entomological surveillance. This is an exceptional result with respect to the S. damnosum complex. Ground larviciding in the Tukuyu focus was conducted from 2003 to 2005. Although the identity of biting blackflies is yet to be determined, partial cytogenetic and molecular identification results suggest that the S. thyolense might have been replaced in the main focus by non-anthropophilic species. In which case, one could talk of achieving vector elimination, at least in this main focus. A workshop was convened by the Management to review the vector elimination activities and recommend the way forward. Procedures for certification of vector elimination by the Programme were recommended since some sites had fulfilled the phase I and II and phasing out requirement of a JAF I2.5 Page 15 maximum of three years larviciding followed by two to three years monitoring to evaluate entomological status. The workshop key recommendations were: General recommendations i. For foci in which vectors are no longer found, APOC Management should give adequate logistic and financial assistance for a three year enhanced entomological surveillance programme; ii. APOC to undertake a modelling study by a mathematician and a medical entomologist with specialization on blackfly to refine the observation period and isolation status ofthe focus. Tukuyufocus iii. APOC Management to fund a complete blackfly (larvae and adults) collection by NOTF Tanzania focus with morphologic, cytogenetic andlor molecular identification of the samples. Biokofocus iv. APOC needs to maintain, until the end of 2008, its assistance to the current surveillance network, and enhance the supervision of catches by specialised external teams. v. Investigate the possible sources and modes of re-infestation by blackfly populations in the focus; Itwarafocus vi. Stop surveillance in the main focus. Carry out an additional round of catches and crab trapping in the sub-foci of Siisa and Aswa. Undertake immediate localized larviciding if larvae of the,S. neayei are caught. Mpamba Nkusifocus vii. Special efforts need to be made to identif,z and treat any source of persistence of the vector in the focus. Entomological surveillance (Simulium larvae and biting blackflies) must be maintained and the situation reassessed at the end of 2006. Enhancing data value viii.APOC Management to notiff relevant authorities in countries once certification is accomplished, publicize and publish the results in peer review journals. 9.2. Community-Directed Treatmentwith Ivermectin The National Agency for Food, Drug Administration and Controt (NAFDAC) of Nigeria organized awrtreness and sensitization workshops on free Mectizan@ and vitamin A, in Nigeria. Co-implementation of CDTI and VAS. This year, the CDTI project in Taraba State, Nigeria trained 1,349 members of 14 local community based organizations (>15% are females). The Community- Based Organization (CBO) members resident in communities now supervise and monitor integrated delivery of ivermectin and vitamin supplementation. There is improved treatment coverage in eligible communities. 10. MANAGEMENT OF APOC TRUST FUND BY PROJECTS Harmonization of Letters of Agreement To comply with the new World Health Organization (WHO) financial regulation which became effective in January 1st, 2006, which states that activities financed must be completed within a period not exceeding one calendar year, APOC Management has harmonized the Letters of Agreement for different projects by calendar year. For these projects, new Letters of Agreement were prepared covering the period from January to December 2006. Fifty five (55) Leffers of Agreement were prepared. Also, Implementation Letters were prepared to extend the period covered by the Letters of Agreement to December 2006. Thirty seven (37) Implementation Letters were prepared. Eight (8) Implementation Letters are being prepared to bring the number to 45. To date, all Letters of Agreement JAF I2.5 Page 16 have been harmonized as required. It is expected that this exercise will reduce delays regarding the transfer of funds on condition that projects account for expenditure of APOC Trust Fund. 11. COUNTRY SUPPORT MISSTONS BY APOC MANAGEMENT AND TEMPORARY ADVISERS Technical support to countries The APOC Management staff in joint mission with the TCC members, Non Governmental Development Organizations (NGDOs) Coordination Group, Mectizan Donation Program and other external experts made support visits to the National Onchocerciasis Task Forces (NOTFs) in 13 countries during this reporting year. The objectives of these visits included facilitating CDTI implementation and vector elimination activities, advocating for stronger partnership, collaboration and political commitment to CDTI activities, training in financial accounting and in data management and analysis, providing technical advice and assistance in implementation and management of projects, monitoring and evaluation of projects. The overview of these visits is presented intable 7 . Table 7: Overview of support visits to the NOTFs Country Mission/purpose Angola ' Training on WHO/APOC financial and administrative procedures . Training on SAEs management . Epidemiological assessment of onchocerciasis (REMO) Burundi ' Training of health workers on CDTI activities . Training on WHO/APOC financial and administrative procedures ' Training on data management and geographical information system (GIS) Cameroon . Review of REMO data and validation of REMO map ' Monitoring the implementation of CDTI sustainability plans (Adamaoua2, Centre 3 and Southwest I CDTI projects) CAR r Assess the implementaion of CDTI in CAR ' Assist the National Programme in formulating its needs for the pursuit of the activities in the framework of integration and sustainability of CDTI. Chad . Implementation of a computerized data management system. , Training on geographical information system (GIS) Congo ' Training on data management, geographical information system (GIS) and statistical analysis (SPSS) . Implementation of a computerized data management system. . Collection of CDTI data detailed by community. DRC ' Epidemiological assessment of onchocerciasis and loiasis (REMO/RAPLOA) . Training on SAEs management . Evaluation of the sustainability of CDTI (Bandundu CDTI project) Equatorial . Development of CDTI plan work plans for 2006 and2007Guinea . Entomological surveillance ' . Monitoring of CDTI . Census in one CDTI community (Ureca village) Ethiopia ' Evaluation of the sustainability of CDTI (Bench Maji and North Gondar CDTI projects) ' Monitoring the implementation of CDTI sustainability plans (Kaffa-Shekka CDTI project) Nigeria ' Monitoring the implementation of CDTI sustainability plans (Imo and Cross River States)Sudan . Training on SAEs management Togo ' Implementation of a computerized data management system for the Special Intervention Zones countries. ' Training on geographical information system (GIS)Uganda ' Monitoring the implementation of CDTI sustainability plans (Phase 2 and Phase 3 CDTI projects) The APOC Budget and Finance Officer (BFO) participated in a meeting of WHO Budget and Finance Officers in Philippines. Highlights of issues discussed were adoption of the computerized JAF I2.5 Page 17 Imprest account management system (ACIAMS) for standardization of the Imprest system in regions and implementation of the new policy in relation to income and expenses of the Organization versus international public sector accounting standards (IPSAS). 12. 12.1. DOCUMENTATION AND PUBLICATIONS APOC's contributions to the Millennium Development Goals (MDGs) Onchocerciasis control is a unique global endeavor, encompassing disease control, hunger reduction and poverly alleviation. In many respects onchocerciasis control is inextricably linked with the origins, formulation, objectives and spirit of the Millennium Development Goals (Crump 2006). The highly successful stratery of onchocerciasis control operations currently under way is not only contributing significantly towards achieving the MDGs - the goals themselves mirror the spirit which helped define onchocerciasis control, namely concerted action to lift hundreds of millions of people out of extreme poverty. APOC and onchocerciasis control direct impact on MDG 6, target 8 and indirect impacts on the other MDGs are documented in JAF12/INF /DOC.4. 12.2. Publications in peer review journals APOC Management with the contribution of resource persons from countries made scientific contributions to increase knowledge on onchocerciasis and community-directed treatment with ivermectin stratery. The list of the publications either published or in press is presented in Table 8. Table 8: APOC Key Publications 2005 -2006 Published articles and book The rapid monitoring of ivermectin treatment: will school-based surveys provide the answer? Okeibunor et al. Annah of Tropical Medicine & Parasitologlt. 2005 Dec;99(8):771-9. Programme africain de lutte contre l'onchocercose (APOC) : importance du vecteur Simulium damnosum s./., taux d'infectivit6 en larves d'onchocerque infectantes et pathogenicit6 de la maladie dans deux r6gions de la R6publique Centrafricaine. Enyong P.et al Parasite, 2006, I3,35-44. Disease and mortality in Sub-Saharan Africa.. U. Amazigo et al. Disease and mortality in Sub-Saharan Africa. 2'd Edition. The World Bank, pp.215-222.2006 Journal ( Manuscripts in Press) Programme africain de lutte contre l'onchocercose (APOC) dans la r6gion de Lastourville, Gabon. Aspects cliniques et entomologiques. G. Fobi et al. Bull Soc Pathol Exot,2006 Programme africain de lutte contre l'onchocercose (APOC) : intensit6 de la transmission d'Onchocerca volvulus par Simulium squamosum dans deux rdgions de la R6publique du Cameroun. P. Enyong et al. Bull,Sac Pathol Exot, 2006 Transmission d'Onchocerca volvulus par Simulium damnosum s.l ir Inga (R6publique d6mocratique du Congo). S.Traord et a. Cahiers Santd vol. 16, no 2, avril-mai-juin 2006 African Programme for Onchocerciasis Control (APOC): Evaluation of the diethlycarbamazine-patch test as a tool to evaluate levels of endemicity for onchocerciasis in Central Africa. G. Ozoh et al. Tropical Medicine and International Health JAF I2.5 Page l8 ANNEXES ON ROUTINE ACTIVITIES Annex 1: Country profiles in year 2005 ANGOLA Year CDTI was first launched 2004 Number of CDTI projects - approved to date 6 - being implemented I - to be launched 5 -which distributed ivermectin in 2005 0 - to be elaborated I Number of CDDs - newly trained 525 - retrained 25 - trained/retrained 540 Number of Health workers - newly trained 42 - retrained 45 - trainediretrained 87 NGDO partners : World Vision, Africare, GOAL, Malters, MLAL Challenges: Establishing sustainable CDTI in all meso and hyper endemic communities. ! g E oq 60,000 50,000 40,000 30,0(x, 20,000 1g000 0 140 120 100 80 6{' /o m 0 BURUNDI E p o e q 1 80,000 1 60,000 140,m0 120,0(x) I 00,000 80,000 60,000 40,000 20,0m 180 160 '140 120 100 80 60 4 20 0 CAMEROON 4,000,000 3,500,000 3,000,000 2,500,000 2,000,000 ,,500,000 1,000,000 500,000 0 10,000 9,000 8,000 7,000 6,000 5,000 4000 3,000 2,000 1,000 0 ! c g 'e E E Conflict 1999 zx)0 N1 2002 2003 2004 2005 tsPeFns 49,645 <-Oommunities 119 Year CDTI was first launched 2005 Number of CDTI proiects - approved to date 3 - being implemented I - to be launched 2 - which distributed ivermectin in 2005 1 Number of CDDs - newlv trained t4t7 - retrained 0 - trained/retrained 1417 Number of Health workers - newly trained 56 - retrained 0 - trained/retrained 56 Nq!.O partner : CBM Challenges: Establishing sustainable CDTI in all meso and hyper endemic communities Burundi: Peens and communities keated Conflict 1999 2000 2001 2002 2003 200.. 2005 NPepns 164,794 .+Communities 197 Year CDTI was first launched 1998 Number of CDTI proiects - approved to date 15 - being implemented 15 - distributed ivermectin in 2005 t4 Number of CDDs - newly trained 9477 - retrained 13,017 - trained/retrained 22,494 Number of Health workers - newly trained 728 - retrained 1323 - trained/retrained 2051 NGDO partners : Perspectives,lHealth for Humanity, The Carter Center, HKI, IEF. SSI Challenges : Maintain high treatment coverage and Government's contribution to CDTI 1999 2000 2001 2002 2003 2004 2005 2,395,05N Petgns 529,967 727,921 1,0't 8,1't 1,550,38 3,'t 80,7G 3,613,84 +Communilies 2,013 3,r 07 4,069 5,07'l 5,843 7,489 8,59i1 Angola: Pemns and communi6es teated T p o .E a E o JAF 12.5 Page 19 CENTRAL AFRICAN REPUBLIC e ?. I 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 6,000 5,000 4,000 3,000 2,000 1,000 0 E E { I - retrained CHAD 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 Chad: PeBns and communities trcated 3500 3000 2500 2000 1500 I 000 500 0 E A NNNN 1999 2000 2001 2002 2003 2004 2005 NPeBns 591,251 565,819 999,546 992,542 993,698 1,032,27 1,055,24 ..4-communities 2309 2539 3250 3250 3250 3250 3250 ! E 'E E E o CONGO ! o 4 450,000 400,000 350,000 300,000 250,000 200,000 150,000 r00,000 50,000 0 900 800 700 600 500 ilo0 300 200 100 0 !o .E E o Year CDTI was first launched 1998 Number of CDTI projects 1- approved to date - being implemented 1 - distributed ivermectin in 2005 1 Number of CDDs - newly trained t594 - retrained 3219 - trained/retrained 48 l3 Number of Health workers - newly trained J 25 - trained/retrained 28 NGDO CBM Challenges : Establishing sustainable CDTI in all meso and endemic communities cAR: Pepns and communities lEated 1999 2000 2001 2002 2003 2004 2005 't,076,29NPepns 934,158 778,989 7t4,365 E90,747 9t3,491 537,388 +Communilies 4,584 4,995 4,594 4,682 4,69't 4,835 3,086 Year CDTI was first launched 1998 Number of CDTI proiects - approved to date - being implemented I I - distributed ivermectin in 2005 I Number of CDDs - newly trained 422 - retrained I 0 - trained/retrained 422 Number of Health workers - newly trained 45 - retrained 20 - trained/retrained 65 NGDO partners : OPC Challenses : Guidance and funding for developing sustainable CDTI Year CDTI was first launched 2001 Number of CDTI projects - approved to date 2 - being implemented 2 - distributed ivermectin in 2005 2 Number ofCDDs I - newly trained 546 - retrained 1436 - trained/retrained 1982 - newly trained 56 - retrained 156 - trained/retrained 212 NGDO partner : OPC Challenges : Maintaining high treatment coverage as long as Onchocerciasis is a public health problem 1999 2000 2001 2002 2003 2004 2005 NPeBns 22E,220 195,950 353,281 386,302 i106,031 -.rFCommunities 42s 468 719 765 770 Number of Health workers JAF 12.5 Page 20 DEMOCRATIC REPUBLIC OF CONGO 6,000,000 5,000,000 4,000,000 3,000,000 2,000,000 1,000,000 0 DRC: Peens and communities tEated 't4,000 1 2,000 ,0,000 8,000 6,000 4,000 2,000 n 14 - to be launched 6 - distributed ivermectin in 2005 4 - to be elaborated E .E E Number of CDDs o e o trained trained 801 I- retrained - trained/retrained Challenges: Guidance and funding for developing sustainable CDTI in conflict, post conflict zones and Loa loa and Oncho co endemic areas TORIAL GUINEA 1998 Peens and communities treated 140 120 't00 80 60 il0 20 - distributed ivermectin in 2005 0 60000 50000 40000 30000 20000 10000 0 trained 0 E - retrained - trained/retrained Challenges: Establishing sustainable CDTI in all meso and hyper endemic communities and avoid ivermectin distribution as in 2003 and 2005. ETHIOPIA 2000 Number ofCDTI ects 3,500,000 3,000,000 2,500,000 2,000,000 1,500,000 1,000,000 500,000 0 PeHns and communities trcated 18,000 l6,tx)o 14,000 12,000 10,000 8,OOO 6,000 4,000 2,OOO 0 - distributed ivermectin in 2005 6 Number of CDDs trained o retrained 43 mber of Health workers trained 444 - retrained - trained/retrained NGDO The Carter Center Year CDTI was first launched 2000 Number of CDTI projects 20- approved to date 8447 1 t70- retrained trained/retrained t7 Number of Health workers 1643 2444 SANRU NGDO partners : CBM, CRS, IMA, IRC, Lions 't999 2000 2001 2002 2003 2004 2005 606,420 4,403,83NPeens 1,968 4,949 11,966 't't,9't 6 11,04',1+Communities Year CDTI was lirst launched Number of CDTI proiects 1- approved to date 1 Number of CDDs 0- newly trained 0- retrained - trained/retrained 0 0 Number of Health workers 0 NGDO partner : University of Barcelona 1999 2000 2001 2002 2003 2004 2005 N Per$ns 1236 7882 't0797 1047 4 48551 -+communities 15 68 67 95 't28 18.096 25,728 trained/retrained 688 Challenges: Maintaining high treatment coverage as 1132 as Onchocerciasis is a health Year CDTI was first launched prol 9- approved to date 9- being implemented 1999 2000 2001 2002 2003 2004 2005 '1,025,84 2,960,6S233,309 5,t8,2'17 3,164,00N Perohs 494 2,088 4,250 1 6,364 16,388+cohhunities r l l ! E .E E E _.f_- l JAF 12.5 Page2l GABON LIBERIA c. e 19S9 2oo0 20D1 2002 2003 2004 2005 sPeEns 35t9 4228 5359 5935 6425 6242 +Communities 18 18 18 19 't9 t9 7000 5000 s000 4000 3000 2000 1000 19 19 19 '19 '18 't8 18 18 18 17 I t 1999 228,014 2000 293,320 2001 310,056 2002 473,505 2003 477,103 2004 2005 +Communities 342 553 596 861 759 2,186 2,186 1000000 9o00oo 800000 700000 6o{x}00 s0{x}00 4qD00 300000 200000 1 00000 0 2,500 2,00o 1,500 't,000 500 o '1,400,000 '1,200,000 1,000,000 800,000 500,000 400,000 200,000 0 2,500 2,000 1,500 I,mo 500 0 E E E E e 4 Year CDTI was first launched 1999 Number of proiects - approved proiect prior to REMO 1 - being implemented 1 - distributed ivermectin in 2005 0 - newly CDDs trained Not applicable - CDDs retrained Not applicable - CDDs trained/retrained Not applicable Qg!!gIS: Maintaining Govemment funding to ivermectin distribution in 19 communities by peripheral health workers. Year CDTI was first launched 2000 Number of proiects - approved to date J - being implemented 2 - to be launched 1 - distributed ivermectin in 2005 1 Number of CDDs - newly trained - retrained - trained"/retrained tt26 Number of Health workers - newly trained - retrained - trained/retrained Govt contribution (US$) in 2005 2000 NGDO partners: SSI, CHAL Challenges: Developing sustainable CDTI in a post conflict country Conflict+- 1999 2000 200'l 2002 2003 200,4 2005 sPeens 177523 497662 900000 900000 21 6550 352584 +Communities 281 1,988 1,628 23 2U Year CDTI was first launched 1997 Number of proiects - approved to date 2 - being implemented 2 - distributed ivermectin in 2005 2 Number of CDDs - newly trained I 500 - retrained 2237 - trained/retrained 3737 Number of Health workers - newly trained 2t3 - retrained 298 - trained,/retrained 511 NGDO partner: IEF Challenges: Maintaining sustainable CDTI in all Onchocerciasis meso and hyper endemic zones. ! E E Liberia: PeBns and communities tEabd MALAWI JAF 12.5 Page22 NIGERIA trained 2295 - retrained 6705 NGDO partners : SSI, The Carter Center, CBM, MITO TINICEF Challenges: Sustaining high treatment coverage and funding of Government as long as Onchocerciasis is a health ,blem SUDAN trained 1673 Challenses: Guidance for developing sustainable CDTI in post conflict zones and Loa loa and Oncho co endemic areas. TANZANIA Govt contribution in 2005 20,000,000 15,000,000 10,000,000 5,000,000 1 999 2000 2001 2002 2003 2004 2005 Es Persns 15,137,3 16,520,2 ,8,390,1 +Communiti.s 7,782 23.533 28,514 3r,801 32,137 3'1,480 31,744 E Ec G I A g E e 35,000 30,000 25,000 20,000 15,000 10,000 5,000 00 l 800,000 700,000 600,000 500,000 400,000 300,000 200,000 100,000 0 1,400,000 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 't,2oo 1,000 800 600 400 200 0 7 5,000 4,500 4,000 3,500 3,000 2,500 2,U,0 1,500 1,000 500 0 t Year CDTI was first launched 1997 Number of projects 27- approved to date 27- being implemented - distributed ivermectin in 2005 27 Number of CDDs - newly trained 13,483 - retrained 46,136 - trained/retrained 59,619 Number of Health workers - trained/retrained 9000 Year CDTI was first launched 1997 Number of projects 6- approved to date J- being implemented - to be launched 3I J- distributed ivermectin in 2005 Number of CDDs - retrained 1283 2956- trained/retrained Number of Health workers 140- newly trained - retrained 91I - trained/retrained 231l NGDO partners : CBM, The Carter Center 1 999 2000 2001 2002 2003 2004 2005 248,180 372,615 768,111Nl Perons 431,329 123,821 789,935 495,970 +Communili.s 219 47A 890 349 234 618 1,058 Year CDTI was first launched r998 Number of to date 7 - distributed ivermectin in 2005 6 Number of CDDs - newly trained I 900 - retrained 580 I - trained/retrained 7701 Number of Health workers - newly trained 98 - retrained 255 - trained/retrained 353 USU 466,101 NGDO partners: IMA, HKI, SSI and Lions Club Challenges: Ensuring contributions of some districts to CDTI proiects for sustainability. 2000 2001 2002 2003 2001 20051999 730931 1082665 1271453 1252793S Pepns 30'1709 283823 645232 +Communilies 303 250 1,279 '1,389 1,7G7 '1,931 4,593 l Year CDTI was first launched 1997 Number of proiects 4 - to be elaborated to date - distributed ivermectin in 2005 Number of CDDs - newly trained - retrained l 093 JAF 12.5 Page23 UGANDA 4 1,8oo,o0o 1,600,000 'l,ioo,ooo 1,200,000 1,000,000 800,000 600,000 400,000 200,000 0 4 - trained/retrained 35 58 ! r Number of Health t ; a - new trained - retrained - trained/retrained NGDO partners : CBM, The Carter Center, GTZ, SSI Challenges: Sustaining high treatment coverage and funding of Government as long as Onchocerciasis is a public health problem Community-directed treatment with ivermectin (CDTI) areas in APOC countries as at July 2006 q Partial Oata 1999 2000 2001 2002 2003 2004 2005 NPe@ns '1226494 1402018 1543926 16329E7 1756416 1761700 'l 355700 +Communitias 3,422 3,613 3,966 3,956 4,186 4,745 2,965 Leoend Nrtudpds Lrktl Erdudcd CDfi prioriqr- ercer No CDTI tcer Arcrs to bc rcfucd Nrtlonrl borudslcr Eq n KT 05m1m WllO/AP0C20.luly2ffi - beins implemented 1 6,000 5,000 4,rD0 3,000 2,000 1,000 0 E h.nyrl n//t JAF 12.5 Page24 Annex 2: Summary of the geographic and therapeutic coverages attained by CDTI projects in 2005 in 16 APOC countries Country Angola Burundi Cameroon CAR Chad Congo DRC Eq. Guinea Ethiopia Gabon Liberia No I 2 3 4 5 6 7 8 9 l0 ll t2 t3 t4 l5 l6 l7 l8 r9 20 2t)) 23 24 25 26 27 28 29 30 3l 32 33 34 35 36 37 38 39 40 4t 42 43 44 45 46 47 48 Projcct Lunda Cibitoke-Bubanza Adamaoua I Adamaoua 2 Centre I Centre 2 Centre 3 Est Far North Province Littoral I Littoral II Northern Province Northwest Province South Province South West I South West II Westem Province CAR Chad Congo Congo Extension Bandundu Bas - Congo Equateur-Kiri Kasai Katanga Nord Katanga Sud Lualaba Mongala Sankuru Tshopo Tshuapa Ubangi Nord Ubangi Sud Ueles EQ.Guinea CDTI Bench Maji East Wollega Gambella Illubator Jimma Kafa-Shekka CDTI Metekel North Gondar West Wollega Gabon Lofa, Bong, Nimba Southeastern Coverage r*e(o/o) Geographic Therapeutic 16.1 14.8 86.7 28.9 100.0 72.8 100.0 74.4 100.0 71.4 100.0 76.3 100.0 71.8 68.9 39.7 100.0 73.6 Trt delayed 100.0 68.2 100.0 75.9 98.3 68.6 100.0 59.7 100.0 75.6 99.8 72.9 100.0 78.1 79.5 40.7 100.0 66.3 100.0 66.9 100.0 62.5 80.0 62.8 Trt. Delayed- Trt. Delayed" 99.6 71.2 49.5 35.8 Trt. Delayed- Trt. Delayed- Trt. Delayed' 44.t 24.5 Trt. Delayed- Trt. Delayed' Trt. Delayed' Trt. Delayed- Trt. Delayed- NA-- 100.0 83.3 Trt delayed Trt delayed 100.0 74.9 100.0 83.1 100.0 77.2 Trt delayed 100.0 78.6 100.0 76.9 NA-" 11.3 15.3 Trt. Delayed No ProJect 49 Malawi Extensiorr 50 Thyolo, Mwanza 5l Adamawa 52 Akwa Ibom 53 Bauchi 54 Benue 55 Bomo 56 Cross River 57 Edo, Delta 58 Ekiti 59 Enugu, Anambra, Ebony 60 FCT 6l Gombe 62 Imo, Abia 63 Jigawa 64 Kaduna 65 l(ano 66 Kebbi 67 Kogi 68 Kwara 69 Niger 70 Ogun State 7l Ondo 72 Osun 73 Oyo 74 Plateau Nassarawa 75 Taruba 76 Yobe 77 Zarnfara 78 EastBahrElGazal 79 East Equatoria 80 Northem Sector 81 UpperNil 82 West Bahr El Gazal 83 West Equatoria 84 Kilosa Focus CDTI 85 Mahenge Focus 86 Morogoro 87 Ruvuma 88 Tanga 89 Tukuyu Focus CDTI 90 Tunduru 91 Phase I 92 Phase II 93 Phase III 94 Phase IV Coverage rute (o/o) G&grephic Therapeutic 100.0 78.5 100.0 81.s 92.8 '.79.2 92.3 44.0 100.0 66.3 47.1 45.5 100.0 86.6 100.0 81. I 100.0 73.1 100.0 76.1 96.2 85.0 100.0 88.0 99.9 65.3 54.6 36.1 100.0 82.4 98.8 87.t 100.0 88.1 72.1 65.5 100.0 7t.7 8r.r 88.9 88.1 76.8 100.0 81 2 100.0 82.2 100.0 95.2 76.5 56.9 96.8 87.7 100.0 84.6 100.0 82.3 73.1 61.8 Trt. Delayed' Trt. Delayed' 70.1 47.7 Trt. Delayed- 43.3 35.5 46.8 52.4 100.0 75.5 100.0 71.8 NA-. 100.0 71.8 100.0 80.4 100.0 80.1 100.0 70.0 100.0 82.4 95.2 80.7 100.0 82.3 100.0 78.7 Malawi Nigeria Sudan Tanzanfu. Uganda I ! ; * Trt delayed: Treatment delayed due to risk of SAEs or conflict ** NA: Data not available .!' i t .t tt r