Report of the twenty-first session of the Technical Consultative Committee (TCC): Ouagadougou, 12-17 September 2005

AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL (APOC) REPORT OF THE TWENTY-FIRST SESSION OF THE TECHNICAL CONSULTATIVE COMMITTEE (TCC) Ouagadougou, 12-17 September 2005 DIR/COORD/APOC/RAP/TCC21 30/12/2005 i TABLE OF CONTENTS OPENING: AGENDA ITEM 1 ...............................................................................................................1 FOLLOW-UP ON THE RECOMMENDATIONS OF TCC20: AGENDA ITEM 6:.........................4 REVIEW AND UPDATE OF THE REMO/GIS IN APOC COUNTRIES AND UTG IN APOC AREAS: AGENDA ITEM 7 .....................................................................................................................5 UPDATE ON RAPLOA AND REA ACTIVITIES IN APOC COUNTRIES AND ON THE MANAGEMENT OF SAES: AGENDA ITEM 8 ...................................................................................5 UPDATE ON OPERATIONAL RESEARCH: AGENDA ITEM 13....................................................5 UPDATE ON VECTOR ELIMINATION ACTIVITIES WITH SPECIAL EMPHASIS ON THE TUKUYU FOCUS: AGENDA ITEM 9..........................................................................................7 TUKUYU FOCUS.................................................................................................................................7 MPAMBA-NKUSI ................................................................................................................................8 ITWARA FOCUS..................................................................................................................................8 BIOKO FOCUS .....................................................................................................................................9 PHASE II OF THE LONG-TERM IMPACT OF APOC OPERATIONS - AVAILABLE RESULTS: AGENDA ITEM 10...............................................................................................................9 UPDATE ON SUSTAINABILITY OF CDTI PROJECTS AND MONITORING THE IMPLEMENTATION OF SUSTAINABILITY PLANS: AGENDA ITEM 11 .................................10 SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS OF A SPECIAL MEETING ON CDI AND INTEGRATION: AGENDA ITEM 12 .........................................................................11 CURRENT STATUS OF THE IMPLEMENTATION OF APOC PROJECTS AND ITS IMPLICATIONS ON THE DURATION OF APOC: AGENDA ITEM 20.......................................11 REPORT ON THE FINANCIAL MANAGEMENT OF APOC-FUNDED PROJECTS: AGENDA ITEM 16 .................................................................................................................................13 REPORT ON THE REVIEW BY THE APOC MANAGEMENT OF 1ST, 2ND, 3RD, 4TH AND 5TH YEAR PROGRESS REPORTS AND SUBSEQUENT YEAR BUDGETS: AGENDA ITEM 17 ...13 REVIEW OF NEW PROPOSALS: AGENDA ITEM 18 ....................................................................14 REVISION TO THE CDTI PROJECTS ANNUAL TECHNICAL REPORTING FORMAT.............14 GRADING OF ANNUAL TECHNICAL REPORTS .........................................................................14 REVIEW OF 1ST, 2ND, 3RD, 4TH AND 5TH YEAR ANNUAL TECHNICAL: AGENDA ITEM 19...15 ANGOLA.............................................................................................................................................15 NOTF Secretariat Support (1st year technical report).....................................................................15 BURUNDI ...........................................................................................................................................16 ii CAMEROON.......................................................................................................................................17 West Province CDTI Project (4th year technical report)................................................................17 North Province CDTI Project (6th year technical report) ...............................................................17 Littoral II CDTI Project (5th year technical report) ........................................................................18 South Province CDTI Project (1st year technical report)................................................................19 Adamaoua I CDTI Project (1st year technical report).....................................................................19 Adamaoua II CDTI Project (6th year technical report) ...................................................................20 East Province CDTI Project (1st year technical report)..................................................................21 CONGO ...............................................................................................................................................21 DEMOCRATIC REPUBLIC OF CONGO..........................................................................................22 NOTF/HQ Support (5th year report)................................................................................................24 Kasai CDTI Project (5th year report) ..............................................................................................24 Bas Congo CDTI Project (1st year report) ......................................................................................25 Uélés CDTI Project (3rd year report) ..............................................................................................25 ETHIOPIA ...........................................................................................................................................26 Issues common to Annual Technical Reports from the NOTF and CDTI projects in Ethiopia.......26 NOTF/HQ, 3rd year technical report ...............................................................................................27 Kafa-Shekka CDTI Project, 4th year report .....................................................................................27 Bench-Maji CDTI Project, 2nd year report ......................................................................................28 North Gondar CDTI Project, 2nd year report ..................................................................................28 East Wollega CDTI Project, 1st year report ....................................................................................29 West Wollega CDTI Project, 1st year report....................................................................................29 Metekel CDTI Project, 1st year report .............................................................................................30 Gambella CDTI Project, 1st year report..........................................................................................31 MALAWI.............................................................................................................................................31 Thyolo & Mwanza CDTI Project (7th year report) ..........................................................................31 Extension districts CDTI Project (4th year report) ..........................................................................32 NIGERIA .............................................................................................................................................33 NOTF/HQ Support (7th year report)................................................................................................33 Cross River CDTI Project (6th year report).....................................................................................33 Edo/Delta CDTI Project (5th year report) .......................................................................................34 Ogun State CDTI Project (3rd year report)......................................................................................35 Niger State CDTI Project (5th year report)......................................................................................36 Abia State CDTI Project (6th year report) .......................................................................................36 Imo State CDTI Project (6th year report) ........................................................................................37 Ebonyi State CDTI Project (6th year report) ...................................................................................37 Kaduna State CDTI Project (7th year report) ..................................................................................37 Yobe State CDTI Project (6th year report).......................................................................................38 Zamfara State CDTI Project (6th year report) .................................................................................38 Osun State CDTI Project (6th year report) ......................................................................................39 SUDAN................................................................................................................................................40 SSOTF Support Project (1st year report).........................................................................................40 East Bahr El Ghazal CDTI Project (1st year report).......................................................................41 West Equatoria CDTI Project (1st year report) ...............................................................................42 REPORT ON REVIEW OF COST PER TREATMENT...................................................................42 REPORT OF THE SUB COMMITTEE ON INCENTIVES .............................................................42 REVIEW OF OPERATIONAL RESEARCH PROPOSALS: AGENDA ITEM 21 .........................43 iii OTHER MATTERS: AGENDA ITEM 22...........................................................................................43 Reports on KAP studies on using CDTI to promote the integration of some components of reproductive health..........................................................................................................................43 Integration of Vitamin A Supplementation (VAS) into CDTI ..........................................................44 DATES AND PLACE OF THE TWENTY-SECOND AND TWENTY-THIRD SESSIONS OF TCC: AGENDA ITEM 23 ......................................................................................................................44 CONSIDERATION OF THE DRAFT REPORT OF TCC21: AGENDA ITEM 24 ........................44 CLOSURE OF THE SESSION: AGENDA ITEM 25..........................................................................44 ANNEX 1 : LIST OF PARTICIPANTS............................................................................................46 ANNEX 2: AGENDA ..........................................................................................................................49 ANNEX 3: CONCLUSIONS AND RECOMMENDATIONS OF THE TWENTY SIX MEETING OF NGDO COORDINATION GROUP FOR ONCHOCERCIASIS CONTROL.......................................................................................................................50 ANNEX 4 : IMPLEMENTATION OF TCC20 RECOMMENDATIONS.......................................54 1 OPENING: Agenda item 1 1. The Technical Consultative Committee (TCC) of the African Programme for Onchocerciasis Control (APOC) held its twenty-first session from 12 to 17 September 2005 at the APOC Headquarters in Ouagadougou, Burkina Faso, under the chairmanship of Prof. Ekanem Braide. With the exception of Professor Adenike Abiose and Dr. Michel Boussinesq who were absent, the meeting was attended by all TCC members, national onchocerciasis coordinators from Angola, Burundi, Congo, DRC and the Coordinator of South Sudan Onchocerciasis Task Force (SSOTF), APOC Management and the Multi-Disease Surveillance Centre (MDSC) staff. The list of participants is attached as Annex 1. 2. In his opening remarks, Dr. D.H. Djingary of the MDSC, speaking on behalf of Prof. Koumaré, acting Director of MDSC, welcomed participants to the session, underscored the importance of the outcome of the session to the MDSC and wished TCC a successful meeting. 3. Dr. Azodoga Sékétéli, Programme Director of APOC, warmly welcomed TCC members, the interpreters and particularly underscored the presence of the national onchocerciasis coordinators, all of whom are from conflict and post conflict countries. He informed the meeting that he was attending his last TCC meeting as Director of APOC before retiring at the end of September 2005 but still did not know who will be replacing him. In the meantime, to allow him enough time to prepare for his departure, he has requested Dr. Laurent Yameogo, Coordinator of the Office of Director of APOC to serve as acting Director during the current TCC and until his retirement. 4. Dr. Sékétéli also informed the Committee that the Programme will be requesting donors to authorize the extension of the APOC Trust Fund until 2015 in order to be able to complete the implementation of the delayed CDTI projects. 5. Dr. Sékétéli also expressed great concern for the future of APOC operations referring to a WHO policy which limits the use of short-term staff to a maximum of 4 consecutive years of 11-months contracts only (short-term time-limited - STTL). The consequences of this policy on APOC operations and particularly on SIZ activities are far-reaching. 6. Although 32 short-term general services staff posts have been converted to fixed-term posts, the Programme would require an additional US$2.5 million to be able to convert the current 10 STP posts to fixed-term positions until 2010. Unless an exception is made by WHO for APOC staff, all the current STP contracts in their 4th year would have to be interrupted for 12 months at least. APOC STP staff members concerned have been notified of the interruption of their contracts in accordance with this policy. So far attempts to obtain an exception from the WHO Administration have not been successful. 7. CSA110 discussed the issue at length and the chairman of CSA was asked to seek audience with the Director-General of WHO to request an exception of the application of the STTL policy for APOC STP staff. 8. In the meantime other alternative temporary measures are being explored to convert all or some of the current STP posts to fixed-term posts for a period of time and that would require a minimum of US$140 000. 2 9. The chairperson of TCC, Professor Ekanem Braide welcomed all to the meeting. She indicated that TCC now has to spend more time on technical issues such as mobilization of resources, advocacy, sustainability and integration, in addition to reviewing technical reports and proposals. She stressed the need to assess both the quality of technical reports and programme implementation using additional information from monitoring and evaluation reports. 10. Finally, she thanked Dr. Sékétéli, Director of APOC, for committed service to humanity and congratulated him on his well deserved retirement. 11. Agenda Item 2: The provisional agenda attached as Annex 2 as well as the draft annotated agenda were adopted with an additional item on the review of the revised reporting and grading formats for technical reports. 12. Agenda Item 3: In his report on matters arising from the 109th and 110th sessions of the Committee of Sponsoring Agencies (CSA) held in Geneva and London from 23-24 March and from 18-19 July 2005 respectively, Mr Abdulai Daribi, Secretary of CSA summarized the main conclusions of the meetings which focused on: 1) The APOC external evaluation and the Mid-Term Review of SIZ activities 2) Integration 3) Serious Adverse Events (SAEs) 4) Financial contributions from all partners - the need for APOC to develop a tool allowing for a more transparent way of reporting contributions, and the nature of the contributions. 13. CSA110 essentially focused on discussing several critical issues identified by the External Evaluation Team (EET) in its preliminary findings with highlights on: 1) Sustainable incentives 2) Operational research. 3) Management and staffing at APOC Headquarters 4) Integration 5) Sustainability 6) Partnership - future role of NOTFs. 14. The EET concluded that APOC is making progress towards meeting its 2010 objectives. But given the delay in implementation of some projects, it is clear that the objectives will not be achieved by 2010. 15. Other issues also discussed by CSA included: 1) The status of CDTI implementation: APOC is requesting donors to authorize the extension of the APOC Trust Fund until 2015 at no extra cost to donors in order to complete some projects whose implementation has been delayed. See also paragraph 4; 2) The APOC funding gap - reduced to $8.5 million if all expected pledges are honoured; 3) Peer review of the cost per treatment study; 3 4) Proposed technical and ministerial meetings of ex-OCP countries in Nov 2005 & March/April 2006 respectively; 5) Update on MDSC. 16. The next CSA session will be held in Amsterdam, The Netherlands, from 19-21 October 2005, preceded by a ceremony to unveil an "oncho statue" in Amsterdam on 18 October 2005 and a roundtable discussion. 17. Agenda Item 4: Dr. Tony Ukety, Coordinator of the NGDO Group, informed TCC that discussions of the 26th meeting of the NGDO Group which was held in Bensheim, Germany from 7-9 September 2005 focused mainly on: i. the proposed extension of the APOC Trust Fund until 2015 at no extra cost to the donors; ii. the integration of reproductive health into CDTI; iii. delay in the release of APOC Trust Funds to projects and some country-specific matters; iv. the forthcoming meeting of the National Coordinators of the SIZ and former OCP countries in November 2005; v. the need for further studies on the impact of Mectizan®; vi. admission of two new members to the Group and vii. change in the Vice Chairmanship of the Group. 18. A draft summary of the conclusions and recommendations of the 26th NGDO Group meeting is attached as Annex 3. 19. Three issues from the NGDO Group meeting generated considerable discussion, namely: a) expanding the geographic scope of APOC to cover onchocerciasis control in the whole of Africa and changing its name accordingly; b) expanding the mandate of APOC to include the control of other diseases in Africa; and c) the need for APOC to inform NGDOs on any new initiatives. 20. It was explained that "African Programme for Onchocerciasis Control (APOC)" remained the appropriate title even if its geographic scope was extended. However, any such extension or an expansion of the mandate was the sole decision of JAF. 21. With regard to the request to inform NGDOs on new initiatives, it was explained that some NGDOs have donors that restrict involvement in certain activities such as distribution of condoms or birth control pills and that integrating these activities into CDTI could create problems relating to NGDO support for CDTI. It was suggested that NGDOs should establish a list of diseases or health interventions which they may not be able to support for such reasons. 22. Agenda Item 5: Dr. Mary Alleman of the Mectizan® Donation Program (MDP) reported on the 34th Mectizan Expert Committee/Albendazole Coordination (MEC/AC) meeting held in Atlanta, Georgia, USA from 19-21 April 2005. The highlights of the discussions and recommendations related to onchocerciasis control are summarized as follows: 4 (i) A presentation of cumulative SAE data from 1988-2004 was made, and after the ensuing discussion, the MEC recommended that the following studies be undertaken: a) documentation of the clinical evolution of neurological sequelae seen in some patients with Loa loa-encephalopathy and b) a spatial analysis of the incidence and clinical outcome of neurological SAEs reported in 2005 in the context of the risk categories (> or < 40% RAPLOA) based on RAPLOA results. (ii) With regard to the optimal safety of clinic-based treatment in countries suspected, or known, to be endemic for Loa loa, the MEC recommended that a) national programs include all staff involved in clinic-based treatment of onchocerciasis in training opportunities provided in relation to the MEC/TCC guidelines, b) the total area of Loa loa endemicity be considered a “risk zone”, not only areas where mass treatment occurs, and c) the MEC/TCC guidelines should be routinely shipped with all Mectizan provided for clinic-based treatment. (iii) The MEC was informed that the NOTF of DRC had submitted a proposal to APOC requesting financial and technical support for a unit within the NOTF for SAE surveillance and management. During discussions, MDP offered to co-finance the unit with APOC. It is anticipated that a similar arrangement (including co- financing) may be needed in the future for Angola. (iv) A report was provided to the MEC describing the pathological findings from mandrills experimentally infected with Loa loa and then treated, or not, with ivermectin. Lesions seen in the brain, liver, lung, and kidney of treated animals were all consistent with an acute thromboembolic disorder subsequent to massive mortality of Loa loa microfilariae within the circulatory system (mechanical blockage leading to hypoxia). However, the “apparent” full recovery in some individuals suggests other (non-mechanical) mechanisms may be involved. Additional, similar studies will be conducted in baboons to look at pathogenesis at longer time points after treatment and to investigate the potential utility of steroids and aspirin in treatment of Loa loa associated encephalopathy. (v) The 35th MEC/AC meeting will be held from 10-12 January 2006 in London, UK. Examples of agenda items relevant to onchocerciasis control are: a) integrated mass treatment programs, b) long-term treatment scenarios, c) mathematical modelling of treatment frequencies, d) Loa loa advisers for Angola, and e) a Scientific Working Group on future scenarios for onchocerciasis control in Africa. 23. TCC urged that requests for ivermectin for clinic-based treatment of onchocerciasis from institutions outside of the Ministry of Health in Loa loa endemic areas be supplied through the NOTF and that these institutions be made aware of the risk of SAEs. Participants were assured by the representative of MDP that ivermectin being sent to such institutions in Loa loa endemic areas include the MEC/TCC guidelines for treatment in areas of Loa loa- onchocerciasis co-endemicity. FOLLOW-UP ON THE RECOMMENDATIONS OF TCC20: Agenda Item 6 24. Dr. Laurent Yameogo, Coordinator of the Office of the Director of APOC, updated the Committee on the status of implementation of the recommendations of TCC20 a list of which is attached as Annex 4. 5 REVIEW AND UPDATE OF THE REMO/GIS IN APOC COUNTRIES AND UTG IN APOC AREAS: Agenda item 7 25. Dr. Mounkaila Noma, Chief of the Epidemiology and Vector Elimination Unit presented an update on the latest REMO/GIS activities in APOC. 26. As at September 2005, the REMO exercise was conducted in Burundi and Congo. REMO results from Cameroon were also reviewed for a better refinement of CDTI areas in Littoral and South Provinces. These exercises allowed the estimation of the population at high risk at 89,233,299 persons as at September 2005 with an Ultimate Treatment Goal (UTG) of 74,955,126 persons. 27. There is still need to complete REMO in Angola, DRC, Liberia and Uganda, especially in areas where security had not been established yet. UPDATE ON RAPLOA AND REA ACTIVITIES IN APOC COUNTRIES AND ON THE MANAGEMENT OF SAEs: Agenda Item 8 28. Dr. Mounkaila Noma also provided an update on RAPLOA activities carried out in Cameroon, DRC and Sudan. 29. In Cameroon, the mean prevalence of Loa loa is lower in Littoral I (28.4%, [95% CI1: 28.1%-28.8%]) than East and South provinces where prevalence is above the threshold of 40% with respectively a mean prevalence of 59.1% (95% CI: 58.8-59.4%) and 58% (95% CI: 57.7%-58.2%). In DRC, RAPLOA was completed in 11 CDTI projects. The mean prevalence is below 1% in 4 projects (Equateur-Kiri (0.60%), Katanga Nord (0.42%), Katanga Sud (0.07%) and Lualaba (0.16%). The highest mean prevalence was observed in Ueles, 60.17% (95% CI: 59.96%-60.38%). In South Sudan, RAPLOA was conducted in East and West Equatoria. 30. There are still areas in DRC (Ituri, Sud Kivu Province) and Sudan (Upper Nile) where RAPLOA will be conducted as soon as possible. UPDATE ON OPERATIONAL RESEARCH: Agenda Item 13 31. Dr. Hans Remme of TDR. presented an update on operational research activities with focus on: RAPLOA, feasibility and cost-benefit of onchocerciasis elimination with ivermectin and the community-directed interventions (CDI) 32. Following completion of the validation of RAPLOA, a new spatial model combining the results of RAPLOA data and the Environmental Risk Model is being developed in close collaboration with Prof. Diggle. An interim report on the model was received in June 2005 and reviewed by a steering committee which was pleased with the progress. The model will now be refined and a software developed. The final report will be ready by January 2006. 33. The feasibility and transmission studies in 3 selected sites in Mali and Senegal were delayed due to late receipt of funds from the Bill & Melinda Gates Foundation. As a result, there has been a delay in the schedule of the study. A workshop of the investigators was held in January 2005 and approval has been obtained from the WHO ethical review board. A protocol 1 95% Confidence Interval 6 for the use of skin snipping within the community has been agreed. Discussions have also been held with the ethical review boards in Mali and Senegal. The study is ready to start in Mali but has been delayed in Senegal. 34. Dr. Remme summarized preliminary findings from the CDI multi-country studies on the major strengths of the CDI process for integrated delivery as follow: • There is strong community ownership; • The major priority for most communities is malaria; • There is strong buy-in by MOH and other partners; • Communities support integrated delivery of interventions; • CDI start-up and implementation is feasible but depends upon the presence of appropriate materials for respective interventions; • Preliminary data show encouraging results regarding the effectiveness of CDI; • There is no data yet available on the efficiency of CDI. 35. Agenda Item 14: An update on MACROFIL was provided by Dr. Janis Lazdins. MACROFIL activities are designed to specifically address the research questions that need to be answered to advance the onchocerciasis control activities. 36. The initiation of the first study of moxidectin in subjects infected with Onchocerca volvulus was put on hold after Wyeth recalled a formulation of moxidectin for dogs after the request of the US Food and Drug Administration Center for Veterinary Medicine (FDA-CVM). The recent approval by the FDA-CVM of a new drug containing moxidectin shows that FDA- CVM regards moxidectin as a safe compound. Following the TCC 20 recommendations, TDR. consulted external experts, including Professor M. Homeida, Professor A. Abiose, Dr. Boussinesq as well as representatives of the Ghana regulatory, ethical and pharmacovigilance bodies and Dr. Awadzi, the head of the Onchocerciasis Chemotherapy Research Centre (OCRC) and investigator for planned study. These experts came to the unanimous conclusion that there is no scientific reason not to conduct the study as soon as possible. TDR. communications with Wyeth resulted in Wyeth promising a final decision on re-initiation of the development by 10 October 2005. 37. The protocol for the clinical study of the efficacy of two different dosing regimens of albendazole on Loa loa microfilaremia has been written. Following Cameroon Ethics Committee approval, the protocol needs to be approved by the WHO Ethics Review Committee. The study is expected to be initiated around 2-3 months after this approval. 38. A ready-for-use DEC patch was developed and tested clinically at the OCRC. It was found not to deliver sufficient DEC amounts to the skin. A second version, designed to deliver more DEC to the skin is being developed and expected to enter clinical evaluation at the OCRC in November 2005. Once an efficacious DEC patch has been identified in clinical evaluation, the patch will undergo large scale field evaluation by the MDSC. 39. TDR. sponsored work has found a correlation between the frequency of certain genetic characteristics of Onchocerca volvulus and the number of ivermectin treatment rounds the people from whom the parasites were obtained underwent. A PCR hybridization assay will be developed that can detect mutant and wild-type alleles in a format suitable for surveillance. The 7 assay will be tested by MDSC to validate the hypothesis that there is a correlation between the genetic characteristics of Onchocerca volvulus and response to ivermectin. 40. The efficacy of emodepside, a compound from a new class of antihelmintics, on Onchocerca volvulus macrofilaria will be investigated. The protocol for this study has received approval by the Ghana Ethics Committee and is currently undergoing WHO Ethics Research Committee review. If approval is obtained, the study will start in the fourth quarter 2005. The results obtained will be reviewed in conjunction with the currently available data on the toxicity of emodepside in animals. Based on the results of this review discussions will be conducted with Bayer on the development of emodepside for onchocerciasis control. 41. TDR. and Pfizer have concluded an agreement that provides TDR. access to molecules that have shown activity against animal helminths and protozoa. These molecules will be tested against models for onchocerciasis and lymphatic filariasis as well as other TDR. diseases, as appropriate. 42. TDR. is starting the Parasitic Worm Initiative (PWi), whose core will be a network of laboratories to exploit genetic information to identify new molecules with potential for disease control. PWi is also designed to increase the discovery research capacity in disease-endemic countries (e.g. through workshops and scientific exchanges). 43. To provide the scientific basis for the safety of the combined administration of ivermectin, albendazole and praziquantel, TDR. conducted safety and pharmacokinetic study. The results show that co-administration does not expose subjects to an increased risk relative to the administration of each agent by itself and will be published in the Transaction of the Royal Society of Tropical Medicine and Hygiene. Discussions with the related control departments in WHO are ongoing on the development of suitable systems for pharmacovigilance of the combined administration of these drugs. 44. To increase knowledge on the pathogenesis of lymphatic filariasis, TDR. is sponsoring a study in India designed to define the clinical and pathological manifestations of Brugia malayi infection in children. The data available to date show that lymphatic changes occur in infected children as young as 5 years. The study also evaluates whether early administration of diethylcarbamazine + albendazole can arrest or reverse these lymphatic changes. 45. The TCC recommended that TDR initiate activities to evaluate whether the frequency of seizures in nodding disease changes with exposure to ivermectin. The TCC will recommend to TDR suitable experts to consult. UPDATE ON VECTOR ELIMINATION ACTIVITIES WITH SPECIAL EMPHASIS ON THE TUKUYU FOCUS: Agenda Item 9 TUKUYU FOCUS 46. TCC19 proposed that in 2005, a second and final larvicide spraying campaign to eliminate the vector be executed. The conduct of the said campaign was, nevertheless, subject to the conduct of some activities prior to TCC20. 47. TCC20 noted that the recommendation relating to the activities to be carried out, prior to the 2005 campaign, had been implemented. 8 48. Since funds have been made available, a larviciding campaign is currently in progress in the Tukuyu focus. On the average, 90 larviciding points are under treatment each week. The national team received some assistance from APOC advisers from 26 June to 29 August 2005 for the conduct of activities. 49. In the week preceding the campaign, 1640 blackflies were caught, while in the sixth week of larviciding, only 32 were caught. 50. The recommendation of TCC19 pertaining to a monthly detailed reporting on activities has not been not implemented. APOC Management is yet to receive any reports from October 2004 as noted in paragraph 52 ii, though the campaign started in July 2005. 51. TCC exhorts the national team to write up a first detailed progress report of the campaign. The report should contain information on the financial and technical components, and must be sent to APOC Management, through the national coordinator of the NOCP. 52. TCC19 suggested that APOC Management accept a second and last vector elimination campaign in the Tukuyu focus subject to the following conditions: i. Obtain a commitment from the State (MOH, National Coordinator) to assume responsibility for the project management (technical activities, follow-up of funds outlay, forwarding of financial returns to APOC Management); ii. The submission of monthly reports to the National Coordinator and APOC Management on the activities carried out during the month and those foreseen for the next month (from October 2004 through the end of the 2005 campaign). 53. In view of the above, TCC21 notes that none of the 11 reports expected have reached APOC Management. Consequently, TCC recommends that: i. APOC Management sends a letter to the Ministry of Health with a copy to the Director of the National Institute for Medical Research informing them of the present situation; ii. An external evaluation of the campaign is carried out after the larviciding campaign. MPAMBA-NKUSI 54. TCC 20 had indicated that larviciding should be continued in 2005 in the last S. neavei breeding site pockets (River Mutunguru and tributaries). Ground larviciding is, therefore, ongoing in the focus. It must be recalled that between January and December 2004, only 7 S. neavei adults were caught. The team is encouraged to provide a progress report in 2006. The later should contain information on the status of CDTI (therapeutic coverage in 2004 = 76%), which has been going on for the past 5 years. ITWARA FOCUS 55. The vector (S. neavei) has been absent from the focus for several years (1997). This situation was confirmed in 2004. TCC20 had recommended the continuation of entomological surveillance in 2005. This recommendation is being implemented. The team is encouraged to furnish a progress report in 2006. This report must contain details on the CDTI situation in the 9 districts of Kabarole (therapeutic coverage in 2004 = 77%) and of Kyenjojo (therapeutic coverage in 2004 = 74%). BIOKO FOCUS 56. To increase the value and maximize the achievements of the 2003 campaign, another campaign was planned for execution in the dry season of 2004. Unfortunately, the insecticide was not delivered on time, and the campaign was postponed to the dry season of 2005. 57. The activities executed in 2005 were centred on the prospection of breeding sites, the updating of insecticide application points, the conduct of larviciding and its evaluation. Some preparation towards the 2005 campaign was done in 2004, namely susceptibility tests and river trials of temephos phytagri. Aerial and ground larviciding were conducted from 31 January to 15 May 2005 in the Bioko focus, followed by entomological surveillance to continue with the evaluation of the campaign. It was to continue until the appearance of the first biting females. 58. During the period preceding the 2005 larviciding campaign, average blackfly densities were 202 bites/man/day (maximum = 510) in the north, and 595 bites/man/day as of the fourth week. While in February, females were caught at all the catching points, in March, no catches were made in the north (Sampaka, Barleycorn, Musola, Balacha) and in the south (Osa) of the island. This trend was more pronounced in April with zero catches at all the catching points. Data collected in May, June, July and August indicated that since the cessation of larviciding, no biting female of the S. damnosum s.l. has been caught on the permanent control points of the northern and southern parts of the island. However, catches made at the network of catching points were also nil. This means that, the combined action of aerial and ground larviciding brought about a drastic drop, followed by the extinction of blackfly densities at the control and network of catching points. 59. The main achievement of the 2005 campaign is that, for 5 months, no biting female of the S. demonism was caught in the Bioko focus. These results, although promising, are rather insufficient in terms of elimination. However, precautions have to be taken to consolidate this gain, and especially the continuation of entomological surveillance. PHASE II OF THE LONG-TERM IMPACT OF APOC OPERATIONS - AVAILABLE RESULTS: Agenda Item 10 60. Dr. Mounkaila Noma presented an update on the preliminary results of long-term impact assessment of APOC operations carried out in 13 sites in 8 countries. The results of the dermatological assessment showed a significant decrease in the prevalence of acute manifestations of the disease such as severe itching and Acute Papular Onchodermatitis (APOD) in most study sites. 61. A significant reduction in anterior segment lesions of the eye was observed in most of the sites except in CAR, DRC and Tanzania. The lesions of the posterior segment remain stable in the 5-year interval of the impact assessment studies. The final results of the study will be presented during the next session of TCC in March 2006. 10 UPDATE ON SUSTAINABILITY OF CDTI PROJECTS AND MONITORING THE IMPLEMENTATION OF SUSTAINABILITY PLANS: Agenda Item 11 62. Dr. Amazigo presented a summary of projects evaluated since 2002 to date. In all, 49 projects had been evaluated - 8 during 2002, 27 in 2003, 13 in 2004 and 1 in 2005. Of all projects evaluated, 75% were making progress towards sustainability. 63. Two projects of Bench Maji and North Gondar were expected to be evaluated in November 2005. She also mentioned the challenges of conflicts which hindered evaluation in Phase IV of Uganda, Bandundu and Uele CDTI projects of DRC. 64. Dr. Amazigo highlighted the difficulty of long-term financial commitment by some APOC countries which contributes to the slow submission of sustainability plans. As a result, out of the 521 district plans expected, 373 have been submitted to APOC management. 65. Projects have been monitored for the implementation of their sustainability plan in order to determine the extent to which partners were adhering to planned activities. Six CDTI projects were monitored in Nigeria, Tanzania and Cameroon in 2005. The indicators monitored include planning, Health education/Sensitisation/Advocacy/Mobilization (HSAM), training, finance, transport, Mectizan supply and distribution, monitoring and supervision, human resource, record keeping and coverage. 66. Dr. Amazigo presented the findings and overall conclusions of monitoring in the Plateau/Nassarawa, (Nigeria), Tanga (Tanzania) and North Province (Cameroon) together. In Nassarawa although CDTI activities had continued to be implemented they were largely financed by the Carter Centre. There were insufficient resources from government and their release was often delayed. For example, in 2004 and 2005 only 20% and 15% of approved government funds were disbursed respectively. However, there was integrated use of human resources, equipment, and training services. In Plateau State, integrations of programmes had enabled CDTI to continue despite no release of funds by the State and LGAs. However, integration at times delayed treatment in some LGAs because of late procurement of ivermectin for Lymphatic Filariasis. 67. In Tanga, the project was progressing well as it is integrated into the health system at all levels. All issues raised in the evaluation report had been addressed and budgeted funds had been released. The main weaknesses of this project were poor documentation, particularly at FLHF level, and inadequate staffing. 68. In North Province most of the activities planned had been achieved scoring mostly 2.5 and above except for training, financing and transport. Notably, at sub-district level training was weak focusing on the new health workers only while training of CDDs was very short. Finally, at community level all indicators were above average. 69. It was remarked that in some projects, communities were giving more incentives to their CDDs than projects were actually reporting. It was felt that for that reason, some CDDs in such communities do not want to share the task with other CDDs. 11 SUMMARY OF CONCLUSIONS AND RECOMMENDATIONS OF A SPECIAL MEETING ON CDI AND INTEGRATION: Agenda item 12 70. Dr. Uche Amazigo presented the summary of conclusions and recommendations of a Special meeting on Community-Directed-Interventions (CDI) and Integration of Community- Based Programmes. The meetings were held from 8-11 June in Tanzania and 27-30 June 2005 in Nigeria and attended by senior decision-making and policy-makers of the Ministries of Health, Finance and Local Government, WHO, UNICEF, a number of NGDOs, including EPI and APOC Management. 71. The purpose of the meeting was to provide a forum for senior decision and policy makers, national coordinators of community-based programmes, the NGDOs and donor agencies supporting or financing health programmes to dialogue on sustainable methods of control and integration of Community-based programmes (CBPs). 72. With regard to the recommendation of developing a module on CDI in the curriculum for MPH students, it was suggested that not only public health students but also medical and nursing schools be targeted, as it is nurses and medical doctors at the district level who are often directly involved in CDTI implementation. 73. Disparities in incentives were noted in countries, and several examples were cited about the implications on of the payment or the lack of payment of incentives project performance and coverage. It was agreed that, in the meantime, recruiting and training more CDDs was one way of tackling the issue of incentives. 74. There was need for a comprehensive assessment of the issue of incentives which should focus on coverage and CDD attrition. CURRENT STATUS OF THE IMPLEMENTATION OF APOC PROJECTS AND ITS IMPLICATIONS ON THE DURATION OF APOC: Agenda item 20 75. Dr. Sékétéli made a detailed presentation on the current status of the implementation of all APOC projects - 4 vector elimination projects, 7 HQ Support projects and 111 CDTI projects. 76. The implementation of the 4 vector elimination projects will be completed as planned and thus will have no impact on the duration of APOC. 77. Funding of HQs Support projects by APOC will last as long as CDTI projects continue to be co-financed through APOC Trust Fund, and thus will also have no direct impact on the duration of APOC. 78. With regard to CDTI however, out of a total of 111 CDTI projects to be implemented in 16 countries, it is estimated that only 62 projects would have received the maximum of 8 years funding from APOC Trust Fund by 2010 due to various reasons; the remaining 49 CDTI projects would therefore require the support of APOC Trust Fund beyond 2010 in order to complete the maximum 8 years funding. 79. The reasons for the delay in implementation of CDTI projects are: 12 i. the need to have Programme structures set up in Ouagadougou (APOC/HQs) and in the participating countries, and define key guidelines to be used by NOTFs; ii. the increase in the number of projects to be implemented as against the initial forecast in the Programme Document (from 85 to 111 projects) as a result of progress made in disease mapping; iii. project proposals and/or sustainability plans rejected due to their poor quality and late submission by NOTFs; iv. socio-political unrest (conflicts) in the project areas; v. need for tight risk management of funds from the APOC Trust Fund released or to be released to NOTFs/Projects especially in conflict zones; vi. non-compliance of projects with WHO financial accounting and management procedures; vii. absence of NGDO partners willing to support project implementation and the lack of pro-activeness on the part of countries to seek other means of starting implementation; viii. the relatively long and cumbersome WHO procedures for releasing funds and for procurement of equipment; ix. workload on APOC Management resulting in late response to the requirements of the countries; x. the need for rigorous management of SAEs in areas where onchocerciasis and Loa loa are co-endemic. 80. In view of the above reasons, and to enable APOC Management to complete the implementation of the delayed projects, APOC is requesting donors to authorize the extension of the APOC Trust Fund until 2015 at no extra cost to donors. 81. In this regard, Dr. Sékétéli presented a detailed breakdown of the programme's forecasted budget and actual expenditures since the inception of APOC: i. Phase I (1996-2001): US $56 million (fully funded); ii. Phase II and Phasing out period - current forecast: US$79 million (not yet fully funded); iii. Total APOC: US$135 million. 82. Of the US$56 million for Phase I, US$41.9 was spent during the 1996-2001 period and the remaining US$12.1 million earmarked was still being used to finance Phase I CDTI projects. Even by extending the APOC Trust Fund until 2015, it is still estimated that the total expenditure of APOC operations will amount to US$ 133 246 000, leaving a balance of US$1 754 000 at the end of the Programme in 2015. 83. APOC Management will therefore request donors to authorize the extension of the APOC Trust Fund for an additional five years until 2015 at no extra financial cost to them in order to ensure the completion of all CDTI projects in a sustainable manner with an estimated overall therapeutic coverage of 72%. 13 84. TCC unanimously endorsed the proposal of APOC Management to request donors to authorize the extension of the APOC Trust Fund for an additional five years until 2015 at no extra financial cost to them. 85. The World Bank, in a telephone discussion with Dr. Sékétéli, proposed other options for future APOC activities, namely, a) extend the geographic scope of APOC to include all onchocerciasis-endemic countries in Africa; b) expand the mandate of APOC to include the control of other neglected diseases. 86. It was remarked that, although, extending the geographic scope of APOC could be envisaged if JAF so requested, expanding the mandate of APOC to include the control of other neglected diseases would entail not only legal and cost implications but also jeopardize the achievement of APOC's current objective. REPORT ON THE FINANCIAL MANAGEMENT OF APOC-FUNDED PROJECTS: Agenda item 16 87. A total amount of US $ 6,961,634 had been budgeted for funding projects in 2005. As at 31 August 2005, US $ 2 868 395 had been committed for 6 CDTI in their first year, 2 vector elimination, 3 HQ support projects, 21 CDTI projects in their 2nd up to 7th years and other field activities leaving a balance of US $ 4 093 239 to finance 85 CDTI/vector control projects and 3 HQ support projects; i.e US $ 696 515 for CDTI projects in 1st year, $US 159 942 for one vector elimination project, $US 3 076 782 for CDTI projects in their 2nd up to 7th years and finally US $ 160 000 for 4 HQ support projects. TCC was informed that action was being taken to increase the rate of utilization of the funds allocated to country projects before the end of November 2005. 88. Out of the 1396 financial returns expected for the year 2005, 1168 (84%) were received as at 31st August 2005. Of these 1001 (86 %) were analysed: 334 by the projects at the country level and 667 by APOC Management. Some non-compliance with WHO/APOC financial and administrative procedures were raised, mainly, the late submission of returns and its impact on the release of funds for the activities. 89. Other financial issues were brought to the attention of TCC such as the absence of request or late request of the funds approved for the overheads of NGDOs under the letters of agreement covering year 1 activities. It was explained that funds approved for overheads and obligated cannot be carried over beyond 12 months. The frequent loss of APOC property (vehicles, other equipment) in the field was also discussed. NOTFs were urged to take the necessary measures to minimize such losses. REPORT ON THE REVIEW BY THE APOC MANAGEMENT OF 1ST, 2ND, 3RD, 4TH AND 5TH YEAR PROGRESS REPORTS AND SUBSEQUENT YEAR BUDGETS: Agenda item 17 90. As at 31st August 2005, a total of 118 projects had been approved by the APOC Management: 107 CDTI projects, 4 vector elimination projects and 7 NOTF Secretariat projects. Of these, financial support was required for 14 CDTI projects in their 1st year, 51 CDTI projects in their 2nd, 3rd, 4th , and 5th year, 46 CDTI projects which had received 5 years of APOC funding and now implementing their sustainability plans, 3 vector elimination projects and 7 NOTF Secretariat. 14 REVIEW OF NEW PROPOSALS: Agenda item 18 91. TCC20 had requested a revision and resubmission of three new project proposals from Tanzania for integrating Vitamin A supplementation (VAS) into CDTI projects. The total of the revised budgets of the proposals submitted amounted to US $ 129 958 of which US $42 629 was for the Kilosa CDTI project, US $49 868 for Mahenge CDTI project and US $39 920 for the Morogoro CDTI project. See also paragraphs 290 and 292. Revision to the CDTI Projects Annual Technical Reporting Format 92. Dr. Mary Alleman presented changes, proposed during TCC20, to the Annual Technical Reporting format. The changes were accepted and other minor changes were suggested. In addition, there was a lengthy discussion regarding the usefulness of the data reported in Tables 13 (financial contributions of partners) and 14 (expenditures by activity) and whether those tables should be maintained in the reporting format. A subcommittee was assigned the task of further discussing the issues surrounding Tables 13 and 14; the subcommittee met but felt it needed additional time and thus will report back during TCC22. Grading of Annual Technical Reports 93. At previous TCC meetings, concern was expressed regarding what is being evaluated during TCC reviews of Annual Technical Reports (NOTF and CDTI): The quality of the report or project progress? How should TCC grade when: The report is well written, but progress is poor or the report is poorly written, but progress is good? 94. A subcommittee was assigned, during TCC20, to further discuss the matter. The subcommittee made the following three-part scheme for how Annual Technical Reports could be graded: 1) Report itself (format, completeness, accuracy, etc.): - Accept - Reject - Request additional information as needed. 2) Overall project performance (execution of plan, outcomes, efficiency, etc.): - Good - Fair - Poor - Areas for improvement. 3) TCC’s suggested actions/sanctions. 95. TCC21 accepted these suggestions and agreed to adopt the proposed grading process. 96. As for what action should be taken with regard to projects that repeatedly have poor performance (even if reports are well-written and accepted), TCC agreed that a) a sensitization mission could be undertaken to the project; b) a letter of concern could be sent to policy makers; and c) project funds could be suspended. 15 97. TCC members requested that they be provided with the Executive Summary from sustainability evaluations for projects they review at TCC meetings. 98. As to whether to grade Year 6-8 Annual Technical Reports, especially if APOC did not provide funds, it was agreed that TCC would continue to receive and grade these reports as usual and that such reports should be submitted using the reporting format. REVIEW OF 1ST, 2ND, 3RD, 4TH AND 5TH YEAR ANNUAL TECHNICAL: Agenda item 19 ANGOLA 99. A progress report on the implementation of CDTI activities in Angola was presented by Dr. Antonio Pedro, the National Onchocerciasis Coordinator. 100. REMO and RAPLOA have been completed in Angola. Loa loa was found to be highly endemic in the Cabinda Province and the 3 other sites of the project area. Over one million people are at risk of onchocerciasis and a UTG of about 800,000 in 1,192 communities in these project areas. 101. CDTI activities were launched in January 2005 in Lunda Norte/Sul. The project covers 6 districts with a total population of 90,527 in 192 villages. A total of 168 health personnel and 405 out of 724 CDDs had been trained since the launching of this project. 102. The 5-year budget is estimated at US $ 333,294 of which US $ 138,992 is from APOC; US $ 126,012 from the Government and US $ 64,740 from World Vision International, the supporting NGDO. The Government of Angola is truly committed to onchocerciasis control and has, since 2003, released an amount of US $ 363,534 for CDTI activities. 103. A total of 41,646 people had been treated so far out a total population of 66,316, representing a therapeutic coverage of 63 %. 104. Major challenges included poor infrastructure and delays in launching CDTI projects (Cabinda, Bengo-Kubango- Uige, Moxico and Huila CDTI projects) for various reasons. 105. Delay in launching the other projects are mainly due to torrential rains and access to some project areas. In addition, counterpart funding from World Vision International was not received. APOC funds were also not released because the technical report had not been received by APOC Management. Dr. Pedro will ensure that technical reports are sent regularly and in a timely manner to APOC Management. 106. TCC commended Dr. Pedro on his efforts in the implementation of CDTI in Angola and advised that he discuss with APOC Management to sort out any administrative and communication problems. NOTF Secretariat Support (1st year technical report) 107. This was a first year HQ report. In 2004, most of the CDTI implementation was in Lunda Norte/Sul project only. 108. The following activities were carried out during the period under reporting: 16 i. Training of medical personnel at all levels (province, municipios and district); ii. Advocacy visits to the administrative authorities; iii. Community mobilization in view of sensitising them for ivermectin distribution; iv. Mectizan was ordered and received; v. Training of 60 CDDs; vi. Treatment was started but was suspended because of the rains. No results of the treatment given. 109. The Lunda Sul CDTI project was officially launched in January 2005. Training was also carried out in the Cabinda and Bengo projects. REMO was refined in Uige and Zaire; and RAPLOA was conducted in Uige, Zaire, Bengo and Kwanza Norte. 110. With regard to the report, a lot of information is missing, e.g.: a) There is insufficient data on training b) The outcomes of advocacy were not stated c) The treatment results are not provided d) The REMO and RAPLOA results including maps are not provided. 111. TCC rejected the report and requested a resubmission to TCC 22 addressing the following: i. information on all training data ii. the reasons for advocacy and the outcomes iii. treatment data for all the communities iv. all the results of REMO and RAPLOA and the maps generated from this data. BURUNDI 112. A progress report on the implementation of the Cibitoke-Bubanza CDTI project in Burundi was presented by Dr. L. Ndayisenga, the National Onchocerciasis Coordinator. The project is one of the three approved CDTI projects which was launched in January 2005. 113. The Cibitoke-Bubanza CDTI project covers two Provinces (Cibitoke and Bubanza) with a total population of 448,417 people scattered in 157 communities. The UTG had been estimated at 376,670 people. The project area includes 9 Communes of which 6 are found in Cibitoke and 3 in Bubanza. 114. Following the release of funds from the APOC Trust Fund on 10 January 2005, CDTI activities were launched on 14 January 2005 with the organization of a workshop for all the stakeholders. Social mobilization was then undertaken in all 9 Communes from January to May 2005. Cascade training was conducted in February to March 2005 and in May 2005. A total of 1,417 CDDs were trained. 115. Ivermectin distribution started in May 2005 and a total of 164,079 people were treated in all 157 communities, representing a 100 % geographic coverage and 36.59 % therapeutic coverage. Supervision was done in 3 Communes in May 2005 and in June 2005 in the remaining 6 Communes during the distribution. 17 116. A KAP study will be undertaken in the near future. The project faced three main challenges during this first round of treatment: a) lack of vehicle, b) strike of health staff during the distribution and c) risk of expiry of ivermectin tablets (2,000) in October 2005. 117. The two other projects (Bururi and Rutana) are due to be launched in November 2005. An amount of $40 000 has been received from APOC Management and other project capital equipment (2 vehicles, computers and accessories and generators) have been ordered. Ivermectin tablets have already been received. 118. TCC commended the project for the results achieved in very difficult circumstances. However, TCC requested that: • more CDDs be recruited and trained. APOC is willing to support such training; • a KAP study be undertaken in order to determine reasons of poor performance in some Communes, especially in Gihanga. CAMEROON West Province CDTI Project (4th year technical report) 119. This is a well-written report but it requires clarification or additional information on: • Number of absentees/refusals; • reasons for the high rate of attrition of CDDs; • Number of remaining tablets of Mectizan®; • Recommendations/results of the supervision undertaken; • information regarding the number and the maintenance of equipment.; • the definition of therapeutic coverage and the UTG seemed to be confused. With regard to project performance, TCC noted the need for motivating health personnel, leaders and advocacy staff. The financial contribution from the MOH was also inadequate 120. TCC accepted the report and recommended that project address the above issues. TCC also encouraged the project to continue to seek solutions to: • Resolve the problem of attrition of CDDs by using the kinship method; • Mobilize counterpart funding by pursuing advocacy of the administrative officials and ensuring a better coordination with other programmes with regard to the motivation of CDDs. North Province CDTI Project (6th year technical report) 121. The project submitted a comprehensive report indicating a successful year of CDTI activities. However, there were several issues in the report for which TCC requested clarification or further information: • The report only covers eight months of activities (January-August 2004). The project should explain why the report does not cover an entire year; • Some data provided in the Executive Summary (e.g. regarding training, CDDs chosen and trained) are not consistent with data in the body of the report; 18 • Outcomes of advocacy are not provided; • The project should explain how $30,555.97 was spent with only $25,663 cash released and why funds were released from APOC but none spent. 122. TCC accepted the report and requested that the project address the above issues relating to the report, and recommended that, to improve performance, the project: • be encouraged to continue its efforts to increase the number of CDDs in the project area and to provide them with training; • might consider operational research to find ways of encouraging participation of new (and old) CDDs in CDTI since the MOH is not paying the promised incentives and communities are not providing contributions; • While overall coverage is good, many communities have coverage of < 65%. The project explains that this could be due to unstable denominators caused by migration, bad census, poor delineation of treatment area, or poor record keeping. The matter should be investigated fully; • should work towards reducing absenteeism and refusals; • should review the table explaining training content to be sure that content is appropriate for each recipient group. Littoral II CDTI Project (5th year technical report) 123. In spite of delays in releasing APOC Trust Funds, project performed well during this fifth year of implementation of CDTI activities. TCC was pleased to note that the sustainability evaluation team concluded that the project was making real progress towards sustainability. 124. Additional information and more detail on the following in the report would allow a better assessment of the project: (i) minor SAEs and monitoring system used; (ii) sensitisation and advocacy activities; (iii) supervision and monitoring activities and (iv) description of the results. 125. In addition, the author of the report should have it proof-read and the calculations checked to avoid errors noted in the report and to ensure consistency in the figures. The project should also explain what happened to the remaining Mectizan® tablets at the end of the distribution campaign? Finally, the project should clarify the increase in numbers of communities from 2001 to 2003 while maintaining 100 % geographic coverage over three years. 126. The causes of delays in releasing APOC Trust Funds were explained and discussed. It was suggested that the NOTF should ensure better monitoring of the projects' financial returns and advocate for the release of counterpart funding for CDTI activities. 127. TCC accepted the report and requested that project: • Improve sensitisation; 19 • Train about 150 additional CDDs (as many female as possible); • Implement CSM in all villages with a strong introduction to the CDTI strategy in order to improve community ownership; • Advocate to health districts to include CDTI activities in their budgets. South Province CDTI Project (1st year technical report) 128. This is the first year technical report of the project which comprises 5 districts. CDTI activities were launched in 3 districts although ivermectin treatment had started in the area a long time ago through clinic based-treatment. The total population of the project is unknown since no census had been undertaken yet. However, according to the national census of 2004, the number of people in the three districts where CDTI had been launched was estimated at 223,710, scattered within 465 communities. 129. Onchocerciasis is co-endemic with Loa loa in the project area. Data of the last REMO and RAPLOA exercises from two districts where no ivermectin treatment has been undertaken are currently being analysed by APOC Management. 130. Training of health personnel at all levels has been done (33 at the referral hospitals; 88 at the health centres and 559 CDDs). The rate of CDDs/population is 1:258 persons. The geographic coverage was 100 % in the three concerned districts and the therapeutic coverage was not correctly calculated. However, a total of 86,043 people were treated during the first year. 131. In spite of 27 SAEs reported of which 12 had neurological complications (with coma), no deaths were reported. The representative of the MDP reported that MDP's records show that 25 of the 27 cases had fully recovered. MDP had no further information on the remaining two cases. 132. TCC commended the project team, the health personnel and especially the Minister of Health for their remarkable involvement in the management of these SAEs, particularly, for successfully handling the rumours created by an article published in the local newspaper. 133. TCC accepted the report and recommended that the revised oncho-Loa loa map be included in the next report along with a follow-up on the two SAE cases mentioned above. Adamaoua I CDTI Project (1st year technical report) 134. The project has submitted a report indicating a successful first year of CDTI activities with 100% geographic and 70% therapeutic coverage. However, there were several issues in the report for which TCC requested clarification or further information: 135. Report-related issues: i. No information was provided regarding how CSM affected project implementation or how it will be used in the future; ii. Use of media and specific methods for mobilization/sensitisation were not clearly described; 20 iii. Only $43,005 of NGDO/APOC funds was spent, yet $86,620 cash was released to the project; iv. In future technical reports, the Executive Summary should more comprehensively reflect the accomplishments during the reporting year; v. The project should explain why no health centre staff was trained; vi. The project should explain how the 45 bicycles provided by APOC were damaged beyond repair in one year of activities and how district carried out activities with no functional vehicles; vii. It is stated in Section 4.3.5 that some CDTI activities were financed by the districts and health areas using government funds. This was not indicated in the expenditures section. 136. Project-related issues: i. The timeline of activities was a bit unclear. For example, mobilization was planned for the entire year rather than focusing it within a number of months. It was unclear as to why the time frame for the census was undetermined; ii. The population to CDD ratio is 517:1. The project should strive to increase the number of CDDs; iii. Census should be conducted; iv. Release of funds from government. 137. TCC accepted the report and recommended that the project should send the requested clarification to APOC Management. Adamaoua II CDTI Project (6th year technical report) 138. This is a good report of a mature project in its 6th year of CDTI activities implementation although some deficiencies were noted in the manner it was written, namely: • the Executive Summary should be written in prose and include more details; • treatment figures and therapeutic coverage should be harmonized; • the role of HIPC staff should be described in details; • justification of lack of funds while there is a surplus of US $ 23,190 from the Lions' Club International Foundation (LCIF) contribution in 2004 - 2005. 139. Geographic and therapeutic coverage had progressed well since the project was launched in 1999, reaching the rates of 100 % and 75 % respectively in 2004. 140. TCC accepted the report and requested that the project address the above issues in its next report. 21 East Province CDTI Project (1st year technical report) 141. TCC commended the project for the first year report which is very well written and especially for successfully starting implementation of CDTI activities in this area where the risk of SAEs is high. All the 18 cases of SAEs were properly managed and the patients completely recovered. 142. However, the project is requested to address the following issues: • To increase advocacy in order to reduce the number of absentees and refusals; • To improve therapeutic coverage both in terms of increasing the number of treatments and in using the correct denominators for the determination of coverage rates; • To increase the number of female CDDs; • To improve the management of Mectizan® supply and distribution; • To treat minorities such as pygmies and nomads. 143. TCC accepted the report and requested that the project address the above recommendations. CONGO 144. Dr. François Missamou, National Onchocerciasis Coordinator for Congo reported on the progress on the two CDTI projects in his country: Congo and Congo-Extension CDTI projects. The projects were launched in 2001 and 2004 respectively. 145. The Congo CDTI project largely covers an urban population in Brazzaville which poses a problem for therapeutic coverage. Geographic coverage was 100% and therapeutic coverage was 67.18 % in 2004. Apart from Makélékélé health district, all the other districts were progressing well. 146. Communities participate in funding for incentives through a cost recovery scheme in the context of a national policy. Communities determine the amount themselves and this amount may vary from communities. Between 2001 and 2004, the communities' financial contributions ranged between US $ 5,000.00 (3 million F CFA) and US $ 8,000.00 (4 million F CFA) annually. 147. Efforts are being made to enhance advocacy, train/retrain health worker and CDDs in an attempt to reduce absentees and refusals. 148. Two operational research proposals (on cost recovery and therapeutic coverage in the Congo project) have been submitted to APOC Management for funding. 149. In the Congo-Extension CDTI project geographic and therapeutic coverage were 77 % and 61 % respectively for the same period. The project area is co-endemic with Loa loa and not easily accessible which explains the low geographic coverage. 150. TCC noted the progress report and commended the National Coordinator for a clear and concise presentation. 22 151. It was debated at length whether what was considered absentees or refusals in the urban areas was not rather due to inconvenient timing of the visits to the communities or households. TCC recommended that sensitisation be reinforced in the Makélékélé health district. DEMOCRATIC REPUBLIC OF CONGO 152. In light of the development of RAPLOA as a field tool for estimating the prevalence of high intensity infection with Loa loa, new knowledge regarding clinical management of Loa loa-associated SAEs following treatment with ivermectin, and cases of Loa loa-associated SAEs occurring after mass treatment with ivermectin in the Tshopo and Bas Congo CDTI project areas in 2003, TCC18 (in collaboration with the Mectizan Expert Committee) reviewed and revised the guidelines for treatment with ivermectin in areas of onchocerciasis-loiasis co- endemicity. (These guidelines were finalized and distributed to all program partners in June 2004.) Among several additions, these revised guidelines indicated that prior to mass treatment with ivermectin, the endemicity of Loa loa must be assessed in all areas where it is suspected to occur and that mass treatment with ivermectin can be instituted only where REMO has been completed and hyper-/meso-endemicity with onchocerciasis absolutely confirmed. 153. In addition to the revision of these guidelines, TCC18 recommended that prior to mass treatment with ivermectin, new CDTI projects that will operate in areas endemic of Loa loa should complete a checklist describing the following: a) Loa loa survey results; b) the elements of training carried out at the community, health centre, district and provincial levels to address the early identification, referral, and management of SAE cases; c) the personnel who were trained and their positions in the health care system in the project area; d) the equipment and materials that had been put in place at the health centre and referral centre levels for the appropriate management of cases of SAEs; e) the names and locations of referral centres/hospitals and their distances from the project area; f) training in the completion of SAE forms; g) the items of sensitisation carried out at the community level regarding treatment with ivermectin and the risk of ivermectin-related SAEs. 154. During TCC19, the findings of a joint MDP-APOC mission sent to Bas Congo to investigate the SAEs occurring there in 2003 were presented. As a result of the mission’s findings, TCC19 was informed that APOC had recommended the following to DRC’s NOTF regarding Bas Congo: 1) Reinforcement of the RAPLOA team with internal and external expertise; 2) REA to be combined with the RAPLOA exercise; 3) Decision on continuation of the CDTI campaign to be based on the RAPLOA/REA findings; 4) The strategy adopted for Bas Congo would be extended to all areas of DRC with high risk of SAEs. 23 155. TCC19 endorsed these recommendations which essentially halted the initiation of eight new CDTI projects approved by TCC16 (Equateur-Kiri, Katanga Nord, Katanga Sud, Lualaba, Mongala, Nord-Ubangi, Sud-Ubangi, and Tshuapa) and the continuation of ongoing CDTI in Tshopo, Bas Congo and some parts of Uele and Sankuru because of unknown loiasis endemicity. 156. In 2005, prior to TCC21, RAPLOA/REA exercises were conducted in the above- mentioned 12 CDTI project areas. During this TCC, DRC’s National Coordinator made a detailed presentation of the results of these exercises by project and by health zone therein, clearly indicating the REA/RAPLOA results and the risk of Loa loa associated SAEs. 157. In five of the 12 project areas (Sankuru, Equateur-Kiri, Katanga Nord, Katanga Sud, and Lualaba), the prevalence of Loa loa was found to be less than 24% in all communities surveyed. These five areas have therefore been deemed as “low risk” areas where strategy 2 of the MEC/TCC guidelines will be implemented. The remaining 7 project areas had Loa-loa results indicating a high risk for SAEs and therefore strategy 1 of the guidelines will be implemented. 158. Just prior to TCC21, a plan of action (with budget) for the resumption of CDTI activities in each CDTI project area deemed as “high risk” was submitted to APOC. These plans request funds for enhanced sensitisation, mobilization, training, and SAE surveillance as well as for clinical supplies for the management of the potential SAE cases (estimated at 3/10,000 treated). 159. TCC was requested to express its opinion on whether or not the 12 CDTI projects could now resume activities. 160. There was a lengthy discussion suggesting the manner in which CDTI activities should resume, namely: i. The National Coordinator was asked to pledge his personal commitment to follow up closely on the activities; ii. CDTI activities to resume in phases and not in all 12 projects at the same time iii. ensure availability of adequate resources (financial, human and material) for management of SAEs; iv. drugs and supplies for the management of SAEs should be available and accessible locally; v. ensure capacity building in supervision and adequate training of health workers in the management of SAEs (ensuring that newly transferred health workers are alerted to the risks of SAEs and trained accordingly); vi. the National Coordinator to review, in detail, with APOC Management the RAPLOA and REA data in order to determine exactly which communities should be excluded from mass treatment with ivermectin because of hypo-endemicity for onchocerciasis or because the risk of SAEs outweighs the benefits of treatment. 161. TCC recommends that the 12 CDTI projects in DRC, whose implementation had been interrupted, could resume in accordance with the plans of action outlined by the National Coordinator, provided all TCC/MEC guidelines and the suggestions of TCC stated above are adhered to. 24 NOTF/HQ Support (5th year report) 162. The recommendations of TCC20 had been addressed in the report which summarizes the entire CDTI activities conducted in DRC. A lot of critical information, including information on community self monitoring, stakeholders meetings, REMO and REA methodology, status of communication means, was just skimmed over. 163. TCC requested that the project: • complete baseline information that takes into account the “war/conflict” factor • ascertain and complete tables 5, 6, 8 and page 42; the ATO must be presented in tables • complete paragraphs 3.2 and 3.3 164. With regard to project performance, TCC requested the project to: • specify the level of implementation of the sustainability plan • intensify supervision in Health Zones that pose treatment problems. • avoid distributing IEC material before KAP survey • watch out for the expiration date on ivermectin tablets stored in the Health Zones, where CDTI has been suspended • ensure the supply of materials and drugs in every health zone. 165. TCC accepted the report, but the project must provide APOC Management with information relating to the above issues. Kasai CDTI Project (5th year report) 166. The report is well written and presented. TCC20 recommendations have been addressed, although very generalized. Geographic and therapeutic coverage were 95% and 70% respectively. 167. The project was requested to: • continue sensitisation with authorities for them to contribute to the financing of the project; • find solutions to incentives to be given to CDDs, and encourage health workers; • intensify supervision of the Kananga, Lulua, Tshilenge and Kabinda districts, so that results are at par with those of Kasai; • continue presentation of information by health zones in subsequent reports; • revisit the Mectizan® management system in order to avoid surplus orders, which give rise to the large number of leftover tablets; • indicate how the geographical variations in the rate of training and coverage between the health zones are analysed and interpreted; • specify the modalities of integrating CDTI at all levels in other programmes; • enhance sensitisation in order to increase the number of CDDs; • ensure that financial resources are available for ivermectin distribution. 25 168. TCC accepted the report with the understanding that the above issues will be fully addressed in the next report of the project. Bas Congo CDTI Project (1st year report) 169. This is the first year report since the suspension of the project in January 2004 following the occurrence of SAEs. The report was well written and the various sections are presented in a logical manner with detailed information on SAE-related issues. The project addressed all the recommendations made by TCC19. 170. However, to improve the quality of future technical reports, TCC has made the following observations: • the summary needed to be more concise with no repetitions; • background information is to be complemented with: number of health zones, health communities, HGR, population, project area, passable state of roads, state of communication equipment; • partnership component does not have any indication on the way the decision-makers are mobilized; • the “advocacy” and “supervision” components are a review of general information. The data have to be those of the project; • under mobilization/sensitisation, no solutions are proposed to address constraints; • under expenses, the item named “miscellaneous” has a high amount ($51772) and so must be split among bicycles, management of SAEs, office refurbishment and technical assistance; • integration was not mentioned, but is underway (p 46), and CDTI is part of the minimum package (PMA p. 40); • presence of a number of media outfits is presented both as a strong point (p 46), and as a weak point (p 21); there is a need for clarification and consistency. 171. TCC accepted this first year report and recommended the project to: • present future reports in accordance with TCC format, and fill in all columns; • include all data collected over the period, thus avoiding general information; • intensify sensitisation so as to increase the therapeutic coverage rate; • conduct operational research on SAE issues. Uélés CDTI Project (3rd year report) 172. The report was well written and addressed the recommendations of TCC20. Geographic and therapeutic coverage rates, although are markedly increasing, still need to be improved. 173. TCC commended the project for undertaking advocacy with authorities and successfully mobilizing the pigmy population. 174. However, the following observations were made by TCC, some of which require clarification: 26 • The rate of women CDDs is still low; • How CDDs are selected? • What has become of the 600000 tablets meant for the health zones of Pawa and Wamba? • Ministry of Health participation is still low ($2350); • The executive summary is brief. 175. TCC accepted the report and recommended that the project: • improve the executive summary, namely with the RAPLOA/REA component and the number of health zones and health centres; • give information on the presence or absence of HGR, especially with oncho/Loa loa co-existence; • continue sensitisation with authorities for government participation in the financing of project. ETHIOPIA Issues common to Annual Technical Reports from the NOTF and CDTI projects in Ethiopia 176. Ethiopia submitted eight Annual Technical Reports (NOTF/HQ, Kaffa-Sheka, Bench Maji, North Gondar, East Wollega, West Wollega, Metekel, and Gambella) for review by TCC21. In reviewing these reports, TCC identified issues that were common to all and asked that they be addressed by each project in their next annual reports. The common issues were: 1) The projects should explain what is being done to solve the problem of delays in the utilization and justification of funds; 2) TCC found sections of text that were identical from one report to the next. For example, the strengths, weaknesses, opportunities, and threats were exactly the same for several projects. TCC recommended that for future reports the different authors use their own words to describe project accomplishments and that the unique aspects of projects be highlighted; 3) In several reports, it was implied that CDTI occurs in “big towns” and “townships”. The projects are asked to explain why CDTI occurs in such areas since the endemicity of onchocerciasis is not typically high enough to justify mass treatment with ivermectin. Is there epidemiological evidence to the contrary in parts of Ethiopia? 4) The projects are asked to review the definitions of UTG, CSM, and SHM. It seems as though these concepts were not clearly understood since there is unclear/contradictory information about them in reports. For example in several reports, Table 6 indicates program partners were trained in CSM and SHM, yet these activities were not carried out (Table 11). 27 NOTF/HQ, 3rd year technical report 177. The report was fairly comprehensive and demonstrates that the NOTF is supporting its CDTI projects which, overall, are performing well. Moreover, CDTI activities in the whole of the country appear to be integrated into the PHC which should assist with long-term sustainability. 178. There were some deficiencies in the report for which clarification is requested. i. The Executive Summary lacked a presentation of project-level therapeutic and geographic coverage. These items should be mentioned in future reports; ii. Numbers of decision makers/officials mobilized by NOTF not provided. No information given on community participation, itself, and no comparisons among projects provided; iii. Explain which opinion leaders were trained by the national level and why they were trained in SAE management; iv. Financial contributions made to the NOTF were not reported but should be. More detail should be provided to explain the difficulty in utilizing and liquidating funds. v. 4 projects operated in the absence of a NGDO partner. The NOTF should continue the search for NGDOs to work in collaboration with these projects. 179. TCC also requested that the NOTF should: i. work with projects to find ways to reduce the number of refusals and absentees and increase coverage obtained thus far; ii. explain the need for 2-3 supervisory visits made by NOCP staff to each project area during the reporting period to assess overall activities of CDTI; iii. give reasons why there were significant quantities of ivermectin tablets remaining in some project areas. TCC accepted the report and requested that the above issues be addressed in future reports. Kafa-Shekka CDTI Project, 4th year report 180. TCC commended the project for good performance, namely achieving 100% geographic coverage and 78.3% therapeutic coverage (range: 72.9-83%) during the reporting period. Integration with health services, particularly at woreda level was good. 181. TCC accepted the report and requested the project should address the following issues in subsequent reports: i. respond to all questions in report; ii. Describe methods and assumptions made for calculating community and MOH financial contributions in Table 13. The table asks for cash contributions. The report indicates that the contributions of the community were monetized while the MOH contributions reflect indirect contributions. 28 Bench-Maji CDTI Project, 2nd year report 182. The performance of the project was good for a project in its second year. Geographic and therapeutic coverage were 92% and 62% respectively. The report was well written but with omissions and scanty information in some sections. 183. TCC accepted the report and recommended that, to complete the report, the project should provide APOC Management with information/clarification on: i. Table 14 and section 4.1; ii. number of tablets requested iii. activities undertaken throughout the reporting period; iv. attendance/participation of female members of communities at CDTI health education meetings/ village meetings; v. incentives for CDDs; vi. attrition of CDDs. To improve project performance, the project should: i. Intensify health education, target refusals and absentees; ii. Provide more detail on use of IEC materials; iii. Request communities to select and train more CDDs; iv. Implement CSM and SHM; v. Train community members to act as supervisors; vi. Educate community members on the need to fix drug distribution period outside farming period; vii. Address identified weaknesses and challenges i.e. delay in reporting, poor financial utilization and justification, and overburdening of health workers in FLHFs. North Gondar CDTI Project, 2nd year report 184. The project adequately addressed the recommendations of TCC18. However little effort was put into the report writing. Comments on tables, which should have enriched the report, were ignored. Some Tables (1, 13 and 14) were incomplete and there was a discrepancy in the number of CDDs trained. The NOTF needs to ensure it reviews and improves on subsequent reports. 185. Geographic and therapeutic coverage were high (100% and 76% respectively). However mop-up treatment could further improve therapeutic coverage. 186. TCC accepted the report but recommended that: i. the project complete Tables 1, 13 and 14. Sections of the report should be written up as they are undertaken so information is not lost; ii. the number of CDDs trained should be clarified; 29 iii. the project should ensure communities undertake CSM and SHM to reduce refusals and absentees; iv. operational research should be undertaken to identify and address the poor utilization and accounting for APOC funds, refusals and absentees. East Wollega CDTI Project, 1st year report 187. Performance of the project is fair for a project in its first year. Geographic and therapeutic coverage were 59% and 39% respectively. The report is well written but with some missing information. 188. TCC accepted the report and recommended that, to complete the report, the project should provide APOC Management with information/clarification on: i. activities undertaken throughout the reporting period ii. receipt of more tablets than requested for iii. attendance/participation of female members of communities at CDTI health education meetings/ village meetings iv. incentives for CDDs v. attrition of CDDs. For improvement of project performance: i. improve on coverage ii. intensify HSAM iii. select and train more CDDs iv. encourage communities to address problem of overlap of farming period with drug distribution v. address the problem of refusals and absentees vi. implement CSM and SHM vii. address identified weaknesses and challenges...late reporting and poor financial utilization and justification, and overburdening of health workers in FLHFs viii. involve local NGOs and CBOs in CDTI activities ix. ensure that all information missing in this report are included in subsequent reports. West Wollega CDTI Project, 1st year report 189. The project attained only 37% and 20% geographic and therapeutic coverage respectively even though it had technical support from the Carter Centre and received $82,460 from APOC. The endemicity of all 7 Woredas is meso – hyper endemic, however, no explanation was given for what happened in the other 5 Woredas. In its proposal to APOC for funding, it planned to treat 563,910 people in the first year. 190. Capacity building was provided for only 2 of the 7 Woredas with 43% of health staff in these Woredas involved in CDTI. 30 191. There was slow utilization and accounting of APOC funds. No information was provided on the reasons for under-utilization of funds. Tables 13 and 14 were not completed. 192. The project undertook training of communities in CSM and SHM but the communities did not implement these. 193. TCC accepted the report but recommended that the project: • state why treatment was undertaken only in 2 Woredas; • review work plan to include implementation of CDTI in all 7 Woredas; • improve the geographic and therapeutic coverage in the 7 Woredas; • review ATOs for training of health staff and CDDs in each Woreda to ensure adequate capacity building in the Woredas; • undertake HSAM in Woredas; • improve the utilization and accounting of APOC funds, as this would enable the project to access and utilize funds available to it to improve implementation of CDTI; • complete all tables (13 and 14) and provide comments on tables to improve quality of report; • provide information on the reasons for under-utilization of funds and address these to ensure this does not occur in subsequent years; • encourage communities to undertake CSM and SHM in the second year. Metekel CDTI Project, 1st year report 194. TCC commended the project for a good first year report and good performance. 195. For the next report to be submitted, TCC recommends that the project should: • Proofread the report: check all calculations and the entire report for consistency of data and information before sending it; • Describe the activities and results fully, particularly as concerns advocacy, sensitisation, supervision, monitoring and why treatment coverage was lower than expected; • Collect data on and report any minor side effects, if there were any. TCC accepted the report and recommended the following for improving project Implementation: i. The implementation plan was in a fairly logical order but rather long (9 months long). We suggest shortening the amount of time between key activities next year (Social mobilization was done 6 months before treatment and should be done much closer to distribution, training was done 3 months before treatment, which is too long. Supervision seems to have been done mostly after treatment, but 31 should be done throughout the entire CDTI implementation period, particularly during training and supervision; ii. To reduce absenteeism, the distribution period should be revised so that it is not done during the rainy season when some villages are inaccessible; iii. Increase and improve advocacy, and particularly sensitisation of communities to improve awareness and coverage; iv. Start using MOH funds for equipment / vehicle maintenance as soon as possible, at least by year 3; v. Set a more realistic ATO for year 2 (65% of total population is a realistic ATO, instead of 80%). Gambella CDTI Project, 1st year report 196. The project submitted a report indicating a successful first year of CDTI activities with high geographic and therapeutic coverage (91% and 72% respectively). However, there were several issues in the report on which TCC requested clarification or further information: 197. With regard to the report, it was noted that the project is using the total population of the treatment area as the UTG. This is incorrect as there are always a portion of individuals not eligible for treatment (e.g. children who do not meet the weight/height criteria, pregnant woman, etc.). Therefore, the UTG needs to be recalculated. 198. There are many places in the report where questions are not answered or were incompletely answered (e.g. Section 2.4 questions under Table 4, Section 2.5, Section 2.8 questions under Table 11). 199. In future technical reports, the Executive Summary should more comprehensively reflect the accomplishments during the reporting year. 200. In addition, TCC also requested the project to : i. provide more information regarding the $85,000 cash budgeted and released at the community level; ii. explain why only $25,720 was spent when $156,470 cash was released for the project; iii. explain how CSM was carried out in all 368 communities where there was treatment without conducting training of trainers; iv. work towards reducing absenteeism and refusals. 201. TCC accepted the report and recommended that the requested clarification be sent to APOC Management. MALAWI Thyolo & Mwanza CDTI Project (7th year report) 202. The report is well written and is an improvement over the last report, although there were some conflicting figures in Tables 2 & 7 on the number of communities in hyper and 32 meso-endemic areas. The overall performance of the project has improved significantly and acceptable coverage has finally been achieved (100% geographic coverage and 72% therapeutic coverage). 203. However, the project should : i. in future reports, provide information on follow up on TCC recommendations (page 1); ii. reconcile conflicting figures given for total number of communities in hyper and meso endemic arrears…660 in Table 2 and 672 in Table 7; iii. carry out studies on refusals and absentees and utilize the results in reducing refusals and absentees; iv. Select and train more CDDs; v. conduct CSM and SHM. 204. TCC accepted the report and requested that the project address the above recommendations. Extension districts CDTI Project (4th year report) 205. TCC commended the project for a very well written report and for the extraordinary improvement in project results - a huge increase in therapeutic coverage from 20% in 2003 to 66% in 2004 due to better planning; increased advocacy and sensitisation, training and supervision. Phalombe-Chikwawa should be commended for achieving over 70% therapeutic coverage with low numbers of absentees and refusals. 206. In its next report, TCC requested the project to: • Quantify the partner contributions as much as possible; • Give a more detailed description of advocacy and sensitisation activities undertaken; • Provide a description of the extent to which the sustainability plan has been implemented; • Explain why treatment in Blantyre HD was prolonged and training was completed after treatment ended. 207. With regard to project implementation, TCC suggested that the project undertake the following: • Although good effort has been made, continue to recruit and train more CDDs to cover all villages adequately, particularly in Blantyre (1 CDD/359 people and Mulanje with 1 CDD/229 people); • Include and/or assist representatives from the Tea Estates with planning at all level to reduce absenteeism; • Revise and adjust/simplify key messages given to communities from all sources in order to ensure consistency and accuracy; • Use radio or other mass media if possible to reinforce and strengthen messages in order to reduce the number of absentees and particularly refusals; 33 • Continue to update population figures every year; • Continue to undertake advocacy meetings (group and individual) at the highest levels, including the Finance Ministry (With high level MOH support); • Find out the reasons for the high number of refusals and absentees in Chiradzulu (20%) and Mulanje (30%) and make an effort to adjust the strategy in order to increase coverage. 208. TCC accepted the report and requested the project to address the above recommendations in its next report. NIGERIA NOTF/HQ Support (7th year report) 209. The NOTF has satisfactorily addressed previous TCC recommendations. 210. After a review of the report, TCC made the following observations: • Although the national therapeutic and geographic coverage is good there is need to look at each state critically; • Contribution by States and LGAs in cash and in kind can be misleading when dealing with sustainability of CDTI activities during the post APOC era. The NOCP should be emphasizing cash contributions; • The NOCP secretariat is still dependent on APOC. Government support is not adequate (US$ 5,000); • The Ratio of 1CDD per 456 persons is very low; • Women and youth involvement is still minimal; • Incentives for CDDs are generally a problem for sustainability of CDTI activities. 211. It was stated that coverage of Vitamin A increased when distribution was done by CDDs and not health workers. TCC suggested that the project may wish to consider this issue for operational research. 212. TCC accepted the report and recommended that the project: i. continue advocating for Federal government, state and LGA cash contribution; ii. encourage training of many CDDs in every community; iii. where women are accepted, should encourage their selection as CDDs; iv. where a project has more than one state, information for each state should be provided. Cross River CDTI Project (6th year report) 213. This is a very mature project that has been a showcase for CDTI. The project manager has thoroughly absorbed the CDTI principles and philosophy and is dedicated to extending the principles and strategies of CDTI to other organizations and other interventions of the MOH. 34 The report is very well written with consistent emphasis on data for decision- making. This report, submitted as an amended 6th year report, elucidates issues clearly and cogently. 214. The project, with a therapeutic coverage of 72% and UTG coverage of 88% in its last full year (2004), has attained consistent therapeutic coverage rates over 65% since 1999 although there was 1 LGA (Yala) that had therapeutic coverage of 58%. Has this low coverage rate been consistent in this LGA? Please address in the next annual technical report. 215. There is some confusion about numbers of communities and population totals in those areas that have had communal strife. The project notes the problems that this poses and notes the emigration of populations but never addresses whether immigration ever occurs over time. Please clarify in subsequent reports. 216. Project has innovative approaches to integration with activities of both international (SSI) and local NGOs, as well as other primary health care interventions. 217. This is a project that is an obvious candidate to monitor closely in the post-APOC scenario. 218. In future technical reports, the Executive Summary should more comprehensively reflect the accomplishments during the reporting year. 219. TCC accepted the report and requested that the project respond to comments and recommendations noted above in the next annual technical report. Edo/Delta CDTI Project (5th year report) 220. This is a mature project that has consistently achieved acceptable levels of geographic and therapeutic coverage since 1999. The level of integration with the PHC system appears weak although more effort is being made to improve this aspect of project implementation particularly with the introduction of schistosomiasis and LF interventions in the two states of the project. 221. The project uses fairly standard approaches to advocacy and mobilization of government decision-makers and while TCC has no objection to that, the approaches do not appear to produce the desired results in terms of pledged and released funds. The project should consider new strategies for committing government decision makers including new initiatives for poverty alleviation. 222. The fact that this project stretches across two states and uses the same facilities, TCC expressed concern about the ownership and sustainability of the project, particularly during the post APOC era as each of the states operate differently. There were suggestions that the project should be separated. 223. The report is well written and responds to all the questions listed on the reporting form. However, TCC requested that, in future reports: • The project should reconcile and explain the discrepancy in the UTG. Table 2 gives a UTG of 937,873 while Table 9 gives a UTG of 1,142,330. The report should reconcile the UTG for the entire project as well as for each state; 35 • each state should submit a separate report to the TCC. The report from each state should be prepared by the respective state onchocerciasis control officers. This is critical for future sustainability and advocacy; • each state should provide information and strategies to increase the number of CDDs and the number of female CDDs; • each state should ensure the accuracy of Table 10, on ivermectin utilization. It seems unlikely that there were no (zero) tablets, lost, wasted or expired. 224. TCC accepted the report and requested that the project address the issues raised above Ogun State CDTI Project (3rd year report) 225. Project is making progress regarding therapeutic and geographic coverage with the exception of two LGAs, Imeko-Afon (53%) and Obafemi-Owode (40%). The project should develop specific strategies to increase therapeutic coverage in these two LGAs to at least 65% while maintaining the high levels of therapeutic coverage in all other LGAs. 226. There is some indication that the CDTI philosophy and strategy is not fully accepted or understood at the LGA level and particularly at the FLHF level. 227. Only 22% of health workers in endemic LGAs are involved in CDTI. This is too low and specific strategies should be made to increase both the number and the percentage. 228. The level of targeted advocacy is impressive although the lack of response by LGAs is problematic. Project should identify specific reasons for the lack of responsiveness from the LGAs, identify one or two LGAs that have been responsive and engage the leaders of those LGAs to assist in advocacy with their counterparts. 229. The participation of churches in CDD selection and incentive structures is innovative. 230. The project should begin training for CSM and conduct of CSM in next year of project. 231. Although women participate enthusiastically in community meetings, this is not reflected in the number of female CDDs or the number of communities that have female CDDs. The project should explain this apparent paradox and give strategies for increasing the number of female CDDs. 232. Although the sustainability evaluation was conducted soon after the end of the current reporting period and thus the project did not report on recommendations in the sustainability evaluation, the project should immediately begin implementing the recommendations of the sustainability evaluation. These activities should appear in the Year 4 technical report. 233. The report is well written and responds to all the questions on the reporting form. 234. TCC accepted the report and requested the project to respond to all the comments and recommendations listed above. 36 Niger State CDTI Project (5th year report) 235. The report was well written, with a concise and comprehensive summary, which is consistent with data in the report. 236. The project has addressed to a large extent previous TCC recommendations although the ratio of the number of CDDs/population is still low. The project attained 80% therapeutic coverage and 100% geographic coverage. 237. TCC noted that State and LGAs financial contributions have been very low and irregular. It also seems that integration into the national health system is not well understood and certainly difficult to plan for. 238. There has been a remarkable level of mobilization of women with a potential for enhancing their involvement in CDTI activities although the skills for health personnel to handle the challenge are very limited. 239. This is a potential good CDTI project but needs technical mentoring support. 240. TCC accepted the report and recommended that the project: • Keep planning and monitoring state and LGA financial contributions; • Train more new CDDs in every village; • Find acceptable ways of enhancing women’s involvement as CDDs and community supervisors; • Advocate for Community-directed approach as a vehicle for health care integration. Abia State CDTI Project (6th year report) 241. The report lacked information on: partnership, training (ATO/staff and CDD trained), supervision, sustainability and integration issues, strengths, weakness and challenges 242. Executive summary was concise but not comprehensive; and the timelines of activities was not precise. The report reflects the poor performance of a project in its 6th year. 243. TCC also made the following observation relating to the project's performance: • Lack of funds from government at all levels despite several advocacy visits; • ATO for training not attained and inadequate number of knowledgeable staff with frequent transfer ; • CSM was not done; • High CDD attrition due to lack of motivation; • Geographic coverage and therapeutic coverage have been low since 1999, and only 83% and 58% respectively in year 6; • Poor supervision and no monitoring. 37 244. TCC expressed concern about the poor performance of this project with regard to sustainability of CDTI even if integration seems to be on the right way. 245. TCC accepted the report but urged the project to address the above issues. TCC also recommended the following actions: i. The NOTF and the Zonal Coordinator to hold advocacy meetings at all levels of the government to release funds in view of sustainability and to follow up on recommendations from CDI meeting; ii. The State Coordinator and the LGA Oncho staff to hold stakeholders and advocacy meetings at state and LGA levels to release funds in for CDTI; iii. The State Project Coordinator to exchange with better performing projects in their 6th year in order to reach ATO training, to improve treatment coverage and supervision; iv. Project to pursue the selection of CDD along kinship lines in order to increase their number. Imo State CDTI Project (6th year report) 246. The report was generally well written. However, TCC expressed concern about the considerable decline in geographic coverage from 100% last year to 78.6% and from 78.5% last year to 54.4% in therapeutic coverage respectively. It was noted that over 60% of the communities had female CDDs however, the ratio of CDD/population was still high (1:273). 247. TCC accepted the report and recommended that the project: i. improve geographic and therapeutic coverage. ii. increase number of CDDs iii. increase advocacy for the release of government funds iv. intensify mobilization for continuous support to CDTI. Ebonyi State CDTI Project (6th year report) 248. The project submitted a very good report. While 85.5% therapeutic coverage is good, it seems a bit two high. Therapeutic coverage should not be more than the UTG. Either the project was treating ineligible individuals or used an inaccurate denominator in the calculation of coverage. 249. TCC accepted the report and requested that the project: i. clarify the therapeutic coverage of 85.5% ii. start ensuring that ivermectin is ordered by MOH and not the NGDO iii. recruit and train more CDDs as the ratio of 1CDD:316 people is inadequate. Kaduna State CDTI Project (7th year report) 250. Previous TCC recommendations were fully addressed. The project performance was very good with geographic and therapeutic coverage of 100% and 88% respectively. Government financial support at state and LGA levels has been regular. 38 251. However, the following issues were noted in the report: • Inadequate funding • Inadequate supervision • Poor record keeping • Under-dosing, etc. TCC accepted the report and recommended that the project: • select and train community supervisors in all communities • Train more CDDs in every community • Improve on supervision of CDTI activities • Continue advocacy and monitoring of government financial support at State and LGA levels. Yobe State CDTI Project (6th year report) 252. TCC commended the project for a good report. Geographic and therapeutic coverage rates were high, 100% and 87% respectively, but only 61% of the health staff is involved in CDTI. The cost of drug delivery was high ($9,600). 253. It was noted that women are now involved in advocacy and mobilization. The CDD/population ratio is still low and supervision is poor. More communities were involved in CSM and SHM. 254. TCC also commended the project on the planned deduction of LGA contributions to CDTI at source and the persistent contribution and commitment of the state to CDTI. Integration and additional interventions – on are ongoing. 255. TCC accepted the report and recommended that the project: • Train all health staff on CDTI; • Integrate drug delivery into PHC to reduce cost and ensure sustainability; • Continue sensitisation, health education and mobilization of communities to improve awareness on community roles and responsibilities; • Review training objective for CDDs to attain a ratio of 2:250; select and train additional CDD; • Improve integrated supervision at all levels; • Update census in the 6 LGAs with therapeutic coverage rates over 84% to ensure a correct denominator; • Continue integration of CDTI into PHC. Zamfara State CDTI Project (6th year report) 256. The project did not use the current reporting format. The report is poorly written and full of inconsistencies and errors. The project should therefore review and edit this report and correct the errors. TCC also requested the project to clarify the following: 39 1) Why the number of health workers involved in CDTI went from 36/36 in 2003 to 62/96 in 2004; 2) UTG is 81%, i.e. 160,000 people treated by the project. What actually is the eligible population and what percentage of total population is UTG? 3) Level of integration into PHC was not well explained in report. Please elaborate; 4) Distribution was done during rainy season for 4 months (instead of 6 months last year); mop up 4 months later, explain the rationale; 5) supervision was done for 1 month only in 3rd month of distribution, explain? 6) Therapeutic coverage of 92% in Amka LGA is high. Was there a problem with the denominator or were ineligible people treated? 257. The project should, however, be commended for training Islamic scholars to reach more women in purdah with health education and for maintaining a high therapeutic coverage in the past few years and steadily improving therapeutic coverage from 71-83%, although coverage went down to 77.79% in 2004. 258. TCC rejected the report and requested that a revised report be resubmitted to APOC Management. To improve the project's performance, TCC recommended: 1. That the project integrate training of community supervisors into their strategy to increase community ownership, if funds are available; 2. There is only 1 CDD per 551 people in the project; however the range among LGAs is from 1 CDD/227 to 1 CDD/964 people. Project should try to train at least twice the number of CDDs overall, but preferably three to five times the number, depending on the LGA (along kinship lines) to reduce workload/CDD and better ensure sustainability; 3. Project should start ensuring that Mectizan ordering tasks are undertaken by government and not NGDO as soon as possible; 4. Project should try to shorten the period of distribution with a more intense social mobilization just before; 5. The local government should try to find funds for increased training and supervision activities. Osun State CDTI Project (6th year report) 259. The project did not use the new reporting format which rendered it difficult to assess. TCC made the following observations: i. there are inconsistencies in the LGA and community data ii. treatment period too long (Jan-May) iii. CDD/population ratio is still high (1 : 301) iv. too many absentees (20 920 people). 260. However, TCC noted that policy makers and communities released funds for CDTI. 261. TCC accepted the report and recommended that the project: 40 i. use the new reporting format in the next report ii. Harmonize the data iii. Reduce the treatment period iv. Select and train more CDDs v. Reduce the number of absentees and refusals. SUDAN 262. Dr. Samson Baba, Coordinator of the South Sudan Onchocerciasis Task Force made a presentation explaining the status of CDTI in Sudan. He stated that Sudan is a nation emerging from 2 decades of civil conflict that has devastated the social services and infrastructure in South Sudan. Most South Sudanese lack access to health care, education, clean water and sanitation. After the signing of the Comprehensive Peace Agreement on 09/01/2005, the Government of South Sudan (GOSS) embarked on short and long-term plans to improve coverage and access to the basic needs and health services especially diseases of public health concern in South Sudan (OV, sleeping sickness, kala azar and now the nodding disease). 263. The TCC was also informed that a good number of communities in South Sudan, Uganda and CAR frequently report on an unusual illness “nodding disease’ predominantly found in children and youths. Perceptions about the cause of nodding disease differ among communities. While some communities believe that ivermectin reduces the frequency of seizures in persons above 5 years who are eligible for treatment, there are communities who believe the contrary. 264. The committee also learned that there is to date no evidence-based research/information on the etiology and epidemiology of nodding disease, and in particular, there is no information on the effect of ivermectin (if any) on the disease condition. TCC was reminded that critically ill people should not be treated with ivermectin. 265. The concern of the national control programs is that people who refuse ivermectin treatment associate ivermectin with the nodding disease. Its relationship with onchocerciasis, if any, needs to be investigated to improve the health education and information provided to communities by onchocerciasis control programs. 266. Following the discussions, TCC requested TDR to convene a consultative meeting of experts to address the issue of nodding disease as it relates to the implementation of CDTI. SSOTF Support Project (1st year report) 267. There are 5 regions and 29 counties and a total population of 3,476,632 people in the entire area of the 5 CDTI projects. 2 out of 5 CDTI projects are operational. The population movement is very dynamic due to the civil unrest. Displaced persons are returning to their original communities. 268. The CDD/population ratio is 1:446 in the West Equatoria and 1:883 in the East Bahr El Ghazal CDTI project 269. The SSOTF secretariat located in Rumbek is fully functional. One weakness of the office is that a number of key secretariat staff lack special skills such as computing. The PHC structures are being established. 41 270. TCC accepted the report and recommended that the project: • Focus on training more CDDs and Community supervisors in every community; • Continue advocacy and supervision at all levels; • Continue polishing the population data; • Try to attain a good therapeutic and geographic coverage next year; • Train health workers and CDD in the management of SAEs; • Add Vitamin A supplementation to CDTI activities. East Bahr El Ghazal CDTI Project (1st year report) 271. This is a project in a post conflict area and the communities are in the process of resettlement and rehabilitation. Geographic and therapeutic coverage rates were 43% and 25% respectively, which are an improvement over the previous year's results. 272. The human resources available at the health service and community levels were inadequate. Only 35% of health staff in the area are involved in CDTI. The CDI process has a lot of potential for strengthening the PHC system, particularly for a post conflict area. 273. The problems identified by the project were low literacy of population and slow pace of reporting. 274. TCC accepted the report and recommended that, with regard to project implementation, the project should: • Continue advocacy with to policy makers to ensure onchocerciasis is one of 10 priority diseases, is included in state budgets and funds released for integration of CDTI into PHC; • Undertake sensitisation, health education and mobilization of communities to improve awareness; • Review ATOs on training at all levels (health service and CDDs) to meet need; • Select additional female CDDs whether literate or not; • Train additional health workers and CDDs; • CDDs to undertake census; • Train health staff on CSM and SHM and encourage communities to undertake CSM and SHM; • Request copies of pictorial recording and reporting monograph developed by WHO from APOC for adaptation by project; • Improve geographic and therapeutic coverage rates; • The project should review Table 6 to ensure that all project partners are trained on issues relevant to their roles. Moreover, training in management of SAEs should be appropriately given to all partners involved, especially, those working close to the communities (CDDs and health workers). 42 West Equatoria CDTI Project (1st year report) 275. The report is well written. The performance of the project is fair for a new project in a conflict area. TCC noted the efforts made in advocacy with high-level officials and mobilization of communities. 276. TCC accepted the report and recommended that the project: • Improve on coverage during next treatment cycle • Intensify mobilization, sensitisation and health education • Train project implementers on the management of SAEs • Select and train more CDDs and retrain CDDs on record keeping • Train supervisors on use of supervisory checklist • Conclude efforts to integrate CDTI into PHC. REPORT ON REVIEW OF COST PER TREATMENT 277. The final report of the cost per treatment study, incorporating the recommendations of the peer review undertaken by the World Bank at the request of the TCC, was distributed to the TCC. 278. The findings of the World Bank peer review were very positive. The reviewers deemed the cost per treatment study as an important piece of work, which was carried out in line with conventional and appropriate costing methodologies for health services. All questions and clarifications were responded to satisfactorily by the study review team. 279. A draft cost manual has been developed by the cost study team to assist CDTI projects to assess financial costs. The manual is based on the methods used in the cost per treatment study. The manual has not yet been field tested. 280. The TCC recommends that APOC management send a copy of the cost manual to each NOTF and request the assistance of the NOTF in identifying projects to field test the manual on a voluntary basis. TCC recommends that projects should be mature projects (in the 5th year and beyond) and projects that are not in conflict or post-conflict areas. REPORT OF THE SUB COMMITTEE ON INCENTIVES 281. Dr. Katabarwa presented the conclusions of a TCC sub committee whose objective was to: i. To develop terms of reference for specific research tasks for understanding incentives; ii. To obtain data-driven conclusions on how incentives are either beneficial or detrimental to project performance and sustainability; iii. To use the results for appropriate policy formulation for the betterment of program implementation in affected communities. 282. The subcommittee came up with the factors to consider in a research design. 283. TCC recommended that a research team be commissioned to develop and implement a protocol for studying incentives and their effect on performance and potential for sustainability of CDTI projects. 43 REVIEW OF OPERATIONAL RESEARCH PROPOSALS: Agenda item 21 Assessment of the impact of cost recovery on CDTI performance in Cameroon 284. TCC recommended the rejection of the proposal: The investigator should consult with a health economist in Cameroon to help design the new study and resubmit a scaled down study to the APOC Management for review by TCC. The new budget should reflect the smaller dimension of the study and should not include sensitisation of the population or mass media. This is not necessary to conduct the study. Study on the factors influencing therapeutic coverage by ivercmectin in targeted communities in Congo 285. The proposal should be resubmitted to the reviewers according to the observations made by TCC. Role of cost-recovery in the sustainability of CDTI in Congo 286. The proposal should be resubmitted to the reviewers in light of the observations made by TCC. Incidence of adverse events during the first mass distribution of ivermectin in a hyper- mesoendemic onchocercal population with high prevalence of Loa loa (RAPLOA > = 40 5). From the recommendations of the Mectizan Expert Committee 287. The objective, the justification and the results of the study are not clear and consistent. A lot of information about the methodology is lacking. 288. TCC recommended the rejection of the proposal as it is written and requested the researchers to consult with Dr. Kamgno, Technical Advisor for SAEs in Cameroon to help them revise the proposal for resubmission. OTHER MATTERS: Agenda item 22 Reports on KAP studies on using CDTI to promote the integration of some components of reproductive health 289. Reports of 4 KAP studies were submitted to TCC for review by the Adamaoua CDTI project in Cameroon, the Ebonyi, Enugu and Cross River CDTI projects in Nigeria. TCC accepted the reports and recommended that: i. before any distribution of the reports, detailed background information relevant to the objectives of the KAP study should be included in the introduction of the report; ii. each project should develop and submit to the next TCC a NEW proposal based on the findings of the KAP study; In developing the new proposals, the CDTI process should be highlighted in the design of the protocol, methodology and data collection. 44 Integration of Vitamin A Supplementation (VAS) into CDTI 290. Three proposals to pilot test integration of vitamin A supplementation (VAS) into CDTI were received from the Tanzania NOTF, namely 1. Mahenge Focus CDTI Project, 2. Kilosa Focus CDTI Project; and 3. Morogoro Region Office Support. 291. Two of the three proposals from Tanzania (Mahenge and Kilosa) aim to pilot integration of VAS into CDTI projects and the third proposal (Morogoro) provides the regional office with the means to support the two CDTI Projects. 292. TCC recommended that the proposals be revised to address the concerns of TCC as communicated to the NOTF and resubmitted to APOC Management as soon as possible. APOC Management should provide technical assistance to the NOTF and the projects in revising the proposals. DATES AND PLACE OF THE TWENTY-SECOND AND TWENTY-THIRD SESSIONS OF TCC: Agenda Item 23 293. TCC agreed to hold the twenty-second and twenty-third sessions of the Committee in Ouagadougou, Burkina Faso - TCC22 from 13-17 March 2006 and TCC23 from 11-15 September 2006. CONSIDERATION OF THE DRAFT REPORT OF TCC21: Agenda Item 24 294. A draft of the report of the session was discussed and adopted with the understanding that the proposed amendments will be reflected in the final report. CLOSURE OF THE SESSION: Agenda Item 25 295. In his closing remarks, Dr. Sékétéli thanked TCC members (including previous members since the beginning of APOC) for their invaluable contribution to the Programme and particularly for their support to the countries which, he hopes, will continue. There are challenges that TCC will be required to help the countries face: 1) the availability of ivermectin and the Onchocerca parasite: it is hoped that the parasite does not become resistant to ivermectin to warrant the need for Merck and other drug companies to start seeking alternative drugs. He stressed that the pledge of Merck and Co., Inc to provide ivermectin free of charge as long as needed for the treatment of onchocerciasis remains valid as long as Merck and Co. Inc remained in business. 2) commitment of countries: Governments need to fulfil their commitment. He urged the national coordinators to advocate for support of their governments to CDTI . 296. Dr. Sékétéli thanked the interpreters and all the colleagues who have been working for the success of the meetings and the Programme as a whole. He paid a special tribute to the chair, Professor Ekanem Braide, the first lady chair of TCC, for her outstanding chairmanship. 297. In her turn, Professor Braide congratulated all TCC members for the achievement at this session. She was pleased to note a lot of improvement in the performance of many projects. She was particularly pleased that projects in conflict areas are now being implemented. She acknowledged the invaluable contribution of the national coordinators to the meeting. 45 298. Prof. Braide reiterated her thanks to all participants including the support staff. On behalf of the "People at the end of the road", she thanked Dr. Sékétéli for his strong leadership and hope that his successors will continue the good work. She wished him the best for a well deserved retirement. 46 Annex 1 LIST OF PARTICIPANTS TCC MEMBERS Prof Ekanem Braide, Chair of TCC, Dept. of Biological Sciences, University of Calabar, P.O. Box 3679, Calabar, Nigeria, Tel: (234) 87 230 452, Fax: (234) 087 230 914/087 230 911, E-mail: ekanem_b@hotmail.com; onchocal@skannet.com Dr Elizabeth Elhassan, Country Representative of Sight Savers International, 1 Golf Road, P.O. Box 55, Kaduna, Nigeria, Tel: (234) 62 24 83 60 or 62 24 89 73, Fax: (234) 62 24 89 73, E-mail: ssing@infoweb.abs.net Dr Mary Alleman, Associate Director, Mectizan® Donation Program, 750, Commerce Drive, Suite 400, Decatur, GA 30030, Atlanta, USA, Tel: (1) 404 371 1460, Fax: (1) 404 371 1138, E- mail: malleman@taskforce.org Dr Peter Enyong, Tropical Medicine Research Station, P.O. Box 55, Kumba, Cameroon, Tel: (237) 35 42 31, Fax: (237) 35 42 31, E-mail: penyong@camnet.cm Dr Moses Katabarwa, The Carter Center, Global 2000, 2nd Floor, Kirbo Bldg, 1149 Ponce de Leon Av, Atlanta, GA 30306, USA, Tel: (1) 404 420 3830, direct: (1) 770 488 4511, E-mail: mkataba@emory.edu Prof Soungalo Traoré, c/o African Programme for Onchocerciasis Control (APOC), P.O. Box, 549 Ouagadougou 01, Burkina Faso, Tél: (226) 33 48 39, Cel: (226) 78 85 24 56, Fax: (226) 32 63 35, E-mail: pefoungo@yahoo.fr Dr Christine Godin-Benhaïm, 33 rue Brun Larochette, 26220 Dieulefit, France, Tel : (33) 6 08917193 ou (33) 4 75464059, Fax: (33) 4 75463934, E-mail : godin@wanadoo.fr Prof Deborah McFarland, Associate Professor, Department of International Health, Rollins School of Public Health, Emory University, 1518 Clifton Road, Atlanta, Georgia 30312, Tel: (1) 404 727 7849, Fax: (1) 404 727 4590, E-mail: dmcfarl@spj.emory.edu Ms Nancy Haselow, Director, Onchocerciasis Programs, Helen Keller Worldwide (HKW), P.O. Box 14227, Yaounde, Cameroon, Tel: (237) 220 9771 or (1) 212 532 0544, Fax: (237) 220 9771 or 1 212 532 6014, E-mail: nhaselow@hki.org OBSERVERS Dr Marcel Kupa Mukengeshayi, Coordonnateur National du Programme de lutte contre l=Onchocercose (PNLO), Boulevard du 30 Juin, Avenue Justice 36, n° 4310, c/o Kinshasa- Gombe, B.P. 3040, Kinshasa I, Tel : (243) 994 71 38; Fax : (243) 12 33247, s/c WR/Fax : 1 321 953 9097; Tél/Cellulaire : (243) 99 47 138, E-mail : pnlo_rdc@yahoo.fr et mukkupa@yahoo.fr 47 Dr François MISSAMOU, Coordonnateur National, Médecin-chef du Programme National de Lutte contre l’Onchocercose, Direction de la Lutte contre la Maladie, B.P. 236 ou 1066, Brazzaville, Congo, Tel : +242 668 05 63 – Fax : +242 81 04 81 – E-mail : opc_congo@yahoo.fr Dr Samson Paul Baba, Director Preventive & Promotive Services, National O.V. Co-ordinator, P.O. Box 10114-00100 G.P.O., Nairobi, Kenya, Tel/Office: (254) 20 578206, Mobile : (0722) 3644982, E-mail : samsonbaba@splmsoh.org; samson_baba@yahoo.co.uk Dr Antonio PEDRO JOSE, National Onchocerciasis Control Program Coordinator, Road Almilcar Cabral 121, 1/A, Luanda, Angola, Tel: 332398, 091510323/092306843 – Fax: 1 407 956 3882 Dr Libère NDAYISENGA, Coordonnateur National du Programme National de lutte contre l’Onchocercose, B.P. 1820, Bujumbura, Burundi, Tel: 257 24 93 33 – Fax: 257 22 91 96 – E- mail: ndalibere@yahoo.com WHO/GENEVA Dr Hans Remme, Coordinator, Intervention Development and Implementation Research (IDE), World Health Organization (WHO), 20, Avenue Appia, CH-1211 Geneva 27, Switzerland, Tel: (41-22) 791 3815, Fax: (41-22) 791 4774, E-mail: remmej@who.int. Dr Tony Ukety, NGDO Coordinator, Prevention of Blindness and Deafness, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland, Tel: (41-22) 791 1450/3416, Fax: (41-22) 791 4772, E-mail: uketyt@who.int Mr Abdulai Daribi, (co-rapporteur), AFRO/APOC Liaison Office, World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland, Tel: (41-22) 791 3883, Fax: (4122) 791 4190, E-mail: daribia@who.int Dr Janis Lazdins-Helds, Manager, Filariasis R & D (Macrofil), World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland, Tel: (41-22) 791 3818, Fax: (41-22) 791 4774, E-mail: lazdinsj@who.int. Dr Annette Kuesel, World Health Organization, 20, Avenue Appia, CH-1211 Geneva 27, Switzerland, Tel: (41-22) 791 3818, Fax: (41-22) 791 4774, E-mail: lazdinsj@who.int. WHO/AFRO/MDSC Dr M.H. Djingarey, Acting Director, MDSC, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: koumareb@oncho.oms.bf Dr Laurent Toé, Responsible, Molecular Biology Laboratory, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: toel@oncho.oms.bf Dr Yiriba Bissan, Entomologist, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: bissany@oncho.oms.bf 48 WHO/APOC Dr Azodoga Sékétéli, Director, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: seketelia@oncho.oms.bf Dr Laurent Yaméogo, COORD, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: yameogol@oncho.oms.bf Dr Uche Amazigo, CSD, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: amazigouv@oncho.oms.bf Dr Victoria Matovu, COP, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: matovuv@oncho.oms.bf Dr Lamissa Bangali, AHE, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: bangalil@oncho.oms.bf Mr Koffi Benoît Agblewonu, BFO, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: agblewonuk@oncho.oms.bf Miss Néné Keïta, FO, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: keitano@oncho.oms.bf Dr Mounkaïla Noma, CEV, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: nomam@oncho.oms.bf Mr Zouré Honorat, BIM, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: zoureh@oncho.oms.bf Mr Issaka Niandou, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: niandouy@oncho.oms.bf Mr Saïdou N’Gadjaga, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: ngadjagas@oncho.oms.bf Mr Yaovi Aholou, AO, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: aholouy@oncho.oms.bf Mr Samuel Odame-Banfo, TRAD, P.O. Box 549, Ouagadougou, Burkina Faso, Tel: (226) 50 34 29 53, Fax: (226) 50 34 28 75, E-mail: bamfos@oncho.oms.bf 49 Annex 2 TECHNICAL CONSULTATIVE COMMITTEE Twenty first session Ouagadougou, 12 - 17 September 2005 AGENDA Opening Adoption of the Agenda Matters arising from the 109th and 110th sessions of the CSA Matters arising from the 26th NGDO meeting 5. Update on the 34th meeting of the MEC 6. Follow-up of the recommendations of the twentieth session of the TCC 7. Review and update of the REMO/GIS in APOC countries and UTG in APOC area 8. Update on the RAPLOA and REA activities in APOC countries and on the management of SAEs 9. Update on vector elimination activities with special emphasis on Tukuyu Focus and Bioko 10. Phase II of the long-term impact assessment of APOC operations: available results 11. Update on sustainability of CDTI projects and monitoring the implementation of sustainability plans 12. Summary of the conclusions and recommendations of the special meetings on CDI and integration of community-based programmes 13. Update on Operational Research 14. Update on MACROFIL 15. Update on Phase I study on compliance to ivermectin treatment 16. Report on the financial management of APOC funded Projects 17. Report on the review by the APOC Management of 1st, 2nd, 3rd, 4th ,5th, 6th and 7th year progress reports and subsequent year budgets 18. Review of new Project Proposals 19. Review of 1st, 2nd, 3rd, 4th ,5th, 6th and 7th year annual technical reports 20. Current status of implementation of APOC projects (vector elimination, NOTF Secretariats, CDTI) and implications on the duration of the Programme 21. Review of operational research proposals 22. Other matters 23. Date and place of the twenty second session of the TCC 24. Conclusions and recommendations of TCC21 25. Closure of the session DIR/COORD/APOC/23.07.2005 50 Annex 3 CONCLUSIONS AND RECOMMENDATIONS OF THE TWENTY SIX MEETING OF NGDO COORDINATION GROUP FOR ONCHOCERCIASIS CONTROL TWENTY-SIXTH MEETING OF NGDO COORDINATION GROUP FOR ONCHOCERCIASIS CONTROL Bensheim (Germany), 7-9 September 2005 CONCLUSIONS AND RECOMMENDATIONS 1. The 26th session of the NGDO Group for Onchocerciasis Control was held in Bensheim, Germany, on 7 - 9 September 2005. It was attended by Group members, prospective members (Light for the World and United Front Against River blindness), representatives from APOC Management and the World Bank. Representatives from the West African Health Organization (WAHO), Medical Assistance Program International (MAP International) and Charitable Society for Social Welfare (CSSW) attended the meeting as observers. The Carter Center, OPC and Merck & Co. Inc., representatives were unable to attend the meeting. APOC COUNTRIES AND RELATED ISSUES 2. Regarding the proposed extension of APOC, the Group agreed that there was need to do so, but strongly recommended a revised programme document and a reformed management structure to address the following: • The title and mandate should be amended to reflect the need to integrate onchocerciasis programmes with other appropriate health interventions • It should expand its mandate to coordinate control activities throughout Africa. • More funding would be needed to enable the programme to fulfil its mandate. • There was a need to ensure that there was a more equitable partnership between all the stakeholders. 3. With regard to the integration of reproductive health with CDTI, the Group again expressed concern about the potential for negative impact on treatment. Some of the NGDOs do not have the mandate to support reproductive health programmes. It was recommended that the results of the KAP studies under way in Nigeria and Cameroon be shared with the Group before any proposals are considered. As for Guinea, the NGDO concerned had not seen the proposal, and the World Bank agreed to forward it to the Coordinator for transmission to the NGDO and to MDP. In future, the Group requested to be consulted before any new initiatives are considered for integration into CDTI. 4. Recognizing the importance of integrating onchocerciasis control into the national health care system and also the increasing difficulty of fundraising for disease-specific programmes, the Group discussed the various options of linking with other appropriate programmes such as the Neglected Diseases Initiative. The Group's concept paper had not 51 been updated for a year, and it was agreed to re-circulate it for comments and revise it in time for discussion and finalization at the Ad Hoc meeting in Paris, December 2005. 5. Delays to the release of APOC Trust Funds to the projects continued to cause disruption to treatment in a number of projects, such as Akwa-Ibom in Nigeria and in East Bahr-al- Ghazal and West Equatoria, Southern Sudan. The Group expressed willingness to work with APOC Management to identify blockages and find solutions. 6. Security restrictions on UN personnel had led to delays in post-war assessment missions in certain countries. The Group requested APOC Management to consider accepting reports from missions of partners, with agreed terms of reference, that the country in question was ready to re-start treatment as a basis for the release of APOC Trust Funds in order to facilitate this. 7. The Group was informed that UNICEF Nigeria was planning to wind down its support to onchocerciasis control in that country. At present UNICEF Nigeria supports nearly half of the UTG and there was considerable concern expressed that the high level of treatments would not be maintained. The Group therefore requested this important development be discussed as a matter of urgency in the appropriate for a including the TCC and CSA. 8. Concern was expressed about the current status of CDTI activities in Chad, and in view of recent economic developments, migration of people, and cross border issues with CAR and Cameroon. The Group was glad to hear of the proposed sustainability evaluation planned for January 2006. The view was also expressed that there is a need to investigate the current epidemiological status of onchocerciasis in Southern Chad. SIZ AND FORMER OCP COUNTRIES 9. The Group welcomed the inclusion of other countries and partners active in onchocerciasis control at the forthcoming meeting of the National Coordinators of the SIZ in November 2005, as a first step to achieving an overview of control activities throughout Africa. The Group continues to urge the creation of a permanent mechanism of coordination to ensure that the continent is guarded against recrudescence of the disease, and to address cross-border issues and those areas still in need of effective control measures. Members also saw an important role for the West Africa Health Organization in advocating for onchocerciasis control throughout West Africa. LF PROGRAMME 10. The report on the developments in the lymphatic filariasis programme was noted and the Group agreed to support the integration of LF with onchocerciasis control, where appropriate, and to work closely with LF NGDO Network. MECTIZAN® PROCUREMENT 11. It was agreed to review the allocation of the Mectizan® tablet donation, because of queries which had been raised by the auditors of some NGDOs, and those members with US registration to which this applies would begin to seek clarification in liaison with Merck. 12. The Group appreciated the initiative of MDP/MEC in putting in place guidelines for organizations who request Mectizan® on humanitarian basis, but urged those distributing 52 Mectizan® in Loa loa endemic areas systematically coordinate distribution with the NOTF to ensure that all staff are trained and SAEs are reported and properly managed. OPERATIONAL RESEARCH 13. With regard to the need of more studies on the impact of Mectizan, MITOSATH had already started a study on the evaluation of impact of 10 years of large-scale ivermectin distribution in onchocerciasis endemic communities of Taraba State in Nigeria (1992 - 2002). SSI is also planning to conduct a quality of life study in Nigeria and in Sierra Leone. The Group Members were informed about the availability of funds at MDP for research on the impact of ivermectin distribution on communities. It was also noted with interest that the World Bank was intending to study and demonstrate the link between onchocerciasis and poverty and to update the cost benefit analysis of OCP and APOC. MERCK GRANT 14. The sub-committee reviewing the Merck grant had received applications from six members agencies and approved all of them with a few minor modifications. Following clarification with Merck of the size of the first year's grant, the Coordinator would be writing to the agencies concerned. TERMS OF REFERENCE AND MEMBERSHIP 15. The terms of reference of the NGDO Group had been revised as requested by the 25th meeting and will be circulated for approval. 16. Two NGDOs, Light for the World and United Front Against Riverblindness (UFAR) had applied to join the Group. Since they had fulfilled membership requirements their applications were accepted and they were welcomed as members. 17. The Group welcomed Dr Abdullah Al-Kamel, representative of CSSW and appreciated the information given on the programme in Yemen. OTHER MATTERS 18. The NGDO Group brochure is out of date and it was agreed to review and update it. A subcommittee will produce a newsletter by December 2005 for circulation at the JAF. 19. Members were reminded to send their 2004 treatment costs data to the Coordinator as a matter of urgency. These were needed to complete the NGDO presentation to the JAF. 20. During the meeting, the Executive Director of MITOSATH presented a letter of appreciation and a plaque to the Executive Director of CBM in appreciation of CBM- MITOSATH partnership in Taraba State in Nigeria. 21. After discussion with the Vice-President of IAPB, it was agreed that he would raise the possibility of secondment of the Coordinator's post through IAPB at the Board of Trustees meeting in Hanoi in the week of 12th September 2005 and report back at the 27th NGDO meeting for consideration by the Group. 53 22. The Group thanked Catherine Cross for her work as Vice-Chair for the past 18 months and welcomed Nancy Haselow to the post. Members were asked to consider candidates as Vice-Chair with effect from March 2006 and send suggestions to the Chair. 23. The Group expressed its appreciation to the CBM Executive Director and staff for their excellent hospitality and efficient arrangements which have made this 26th session successful and enjoyable. 24. The 27th session of the NGDO Group will be held in Ouagadougou, Burkina Faso on 9- 11 March 2006. = = = 54 Annex 4 IMPLEMENTATION OF TCC20 RECOMMENDATIONS Recommendations Follow up action Recommendation 19: TCC recommended that the definition of UTG be discussed further at TCC 21 (para. 31). UTG is one of TCC21 agenda items. Recommendation 20: TCC recommended, and the World Bank agreed, to undertake a peer review, in concert with Prof. Deborah McFarland of the study data on cost per treatment and send feedback to TCC members through APOC Management (para. 70) Peer review has been done. Prof. McFarland could update the Committee on the outcome and the steps forward. Recommendation 21: TCC recommended that APOC Management should write to NOTFs to inform them about the availability of funds for training of CDDs and other community workers, where justified (para. 79) Letters were not sent out but APOC Management has initiated to adjust the training budgets in the Letters of Agreement to take care of the concern. In addition, special budgets for training submitted by projects are reviewed and approved by Management. Recommendation 22: TCC recommended that sustainability plans be submitted to APOC Management within two months of completion of a sustainability evaluation (para. 81) Reminders were sent to the projects concerned. APOC Management will keep reminding them any time an evaluation has to be conducted. Recommendation 23: In order to strengthen the capacity for planning at the district level, TCC recommended that more time be allotted, as part of the evaluation process, to the training of district health workers and provincial delegates in the development of sustainability plans (para. 82) Additional days have always been allocated when and where necessary. However, specific letters will be sent to the projects to be evaluated for them to be aware of this possibility. Recommendation 24: TCC recommended that Professor Abiose and Dr Sékétéli should attend the Executive Safety Review Committee meeting of Wyeth in May 2005 to present the perspective of onchocerciasis control in the context of the need for moxidectin development. Professor Abiose and Dr Michel Boussinesq also agreed to represent TCC at a meeting of clinical experts in Geneva on the same issue (para. 94) Dr Lazdins will report on the Executive Safety Review Committee meeting of Wyeth which was not attended by Professor Abiose and Dr Sékétéli. He will also inform the committee of the outcome of the the meeting of clinical experts in Accra on the same Moxidectin issue. Recommendation 25: TCC recommended that clinic-based treatment, in accordance with the TCC/MEC guidelines, be instituted in the medical services of the Kakuma camp to treat those persons infected with onchocerciasis (para. 120 i) The recommendation has been sent and discussed with the NOTF which was expecting the implementation of CDTI. Recommendation 27: TCC recommended that APOC Management should draw up a chart indicating the trend and current status of all the technical reports reviewed by TCC (para. 121) Tables and figures are being prepared but more time is needed to complete them. 55 Recommendations Follow up action Recommendation 28: TCC recommended that the NOTFs should have deadlines for receiving technical reports from projects and should return to the projects any reports sent late to the NOTF (para. 122) Many reports are still coming late to APOC Management, i.e. early September 2005, and the NOTFs concerned request that they are submitted to the present session. This is unacceptable and APOC Management will continue sensitizing the NOTFs on this recommendation. Recommendation 29: TCC recommended that APOC Management should send a high-level delegation to Oyo State to help the CDTI project address some fundamental operational problems (para. 209). Steps have been taken, in collaboration with the NOTF, to identify resource persons and elaborate the budget. The NOTF is waiting now for the project to communicate the period of availability of the State Governor to implement the recommendation. Recommendation 30: APOC Management and the NGDO partner should provide additional logistic support to the Mahenge project (para. 261 vii) Logistic support was given to the project by APOC for its 6th year. No additional request was made by the project for its 7th year.