1995-2010: 15 years of working with communities to eliminate river blindness

AFRICAN PROGRAMME FOR ONCHOCERC!ASIS CONTROL tip' 15 YEARS OF WORKING WITH CO]U]VIUNITIES TO ELI]VTINATE RIVER BLINDNESS "Putting science into practice, helping c ommunitie s help themselve s" - t"i ,*\ t t/ /,,", World Health 0rganization I{r :€,-y .\!': ) l J .& ,f, {4. \ www.who.int/apoc @ -+7s- APOC Partners MEMBER STATES DONORS . Angola . Burundi . Cameroon . Central African Republic . Chad . Congo . Democratic Republic ofthe Congo . Equatorial Gulnea . Ethiopia . Gabon . Kenya . Liberia . IVlalawi . IVlozambique . Nigeria . Rwanda . Sudan . Uganda . United Republic of Tanzanla . African Development Bank . Beigium . Calouste Gulbenkian Foundation . Canada . France . Germany . Kuwait Fund 'Luxembourg . iVlerck & Co.,lnc. . The Netherlands . Norway . OPEC Fund . Poland . Saudi Arabia . Slovenia . UNDP . United Kingdom of Great gritain '' and Northern lreland . United States of America . World Bank (Fiscal agency) . World Health Organization !:"t" (Executing agency) NGDO Partners Ex-OCP . Cote d'lvoire . Ghana . Guinea Bissau . Sierra Leone . Charitable Soclety for Social Welfare . Christoffel-Blindenmission . Helen Keller International . Interchurch A/ledical Assistance World Health . International Eye Foundation . Llght for the World . Lions Club International Foundation . IVlectizan Donation Program . IVIission to Save the Helpless . Organisation pour 1a Prevention de ia Cecite . Schistosomiasis Control Initlative . Sightsavers . The Carter Center . United Front Against Rlver Bllndness . US Fund for UNICEF Research Partner UNICEF/UNDP/World Bank/WHO Special Programme for Research and Tralning in Tropical Diseases (TDR) oN -.iUU a.{ o -rr 3 o oU rd 0U o U o o U d o! o o. 6U o Community Partners The entlre populations - men, women and children - of 746 000 communities in sub-Saharan Africa l L L Forewotd 8 It is wldely accepted that the global campaign o to combat Onchocerciasis (River Blindness)has been one of the most successful public health interventions ever implemented. The Afrlcan Programme for Onchocerciasis Control (APOC) has played a crucial role in accomplishing some major milestones. Indeed, APOC has been a pioneering and unique partnership that has, through its policies, successes and products, become a role model for others to follow. APOC has been and continues to be an extraordinary venture in public health. Operating solely in Africa, it has truly been unprecedented, not least in its innovatory methods and practices, but also for its scale. The APOC programme has been made possible by support from donors from outside and within Africa, but that too has been ground- breaking and truly exceptional. The APOC partnership is unprecedented for several reasons, including: 1. Development of a unique, safe, highly effective and multipurpose drug, ivermectin, which can be glven without direct medical supervision and for which, despite over 25 years of use, no drug resistance has appeared when used in humans. 2. A pioneering, first-of-its-kind drug donation venture (a model for all subsequent programmes) that makes the single controL tool drug available free of charge for as long as it is needed in the quantities that are required. 3. An unwavering prolonged commitment from a core group of donors that has enabled Onchocerciasis control to succeed - and whrch may well see the disease eliminated globally as a public health problem in the not too distant future. 4. Resolute and altrulstic undertaking of support and i.ntersectoral action from African governments at regional, national, district and local levels. B $ H r$,i u"l x$ (J 4 fiu ,6 ils s m s d,l Fa M o oFI I (n o 3 t APOC Director, Dr Uche Amazigo 5. A coalition of non-governmental organizations (NGDOs) committed to support Ministries of Health to eliminate Onchocerciasis, providing both fi.nancial and technical asslstance. 6. Development of a singular and remarkable Community-driven drug delivery mechanism, custom-made, appropriate and acceptable to Africans - and one that holds lnfinite promise for improving Primary Health Care among Africa's most disadvantaged and needy rural populations. Ownership reinforces commitment. And commitment increases the probabllity of positive results, maxlmizes impact and assures long-term sustainabiiity. Around 120 mlllion people, from a1l walks of iife, are active in the APOC partnership, all contributing in their own small way to a common goal. As you will see from the contents of this booklet, we have made great strides forward in combating River Blindness, as well as putting in place infrastructure, practices and products that augur well for widespread and sustainable improvements in public health throughout sub-Saharan Africa. APOC has proved that preventive chemotherapy is a viable strategy for treating Neglected Tropical Diseases (NTDs). Further, it has proved to be an optimai means of combinlng resources, innovation, expertise and advocacy as well as multl-sector engagement. All of us involved in the campaign are rightly proud of our achlevements - but we stil1 have much to accomplish and cannot rest on our laurels. We must not 1et up in our effort to overcome one of the world's most debilitating and disfiguring diseases. To do so would be to fal1 those who have gone before - as well as future generatlons who deserve a life free from the threats of River Blindness. And we will continue to encourage others to join our unique APOC extended-family enterprise and help us leave a fltting legacy - better health and quality of llfe throughout sub-Saharan Africa. Dr Uche Amazigo (APOC Director) (., & ko & rS k o s DO ,t( 3 o (t(, Pr o o Fa I (rio 4 APOC: Genesis The origins The Afrlcan Programme for Onchocerciasis Control (APOC) was established in 1995 as a multidisciplinary inclusive, science- based partnership with a participatory programme of action ranging across 19 countries of sub-Saharan Africa. From the outset, APOC's focus has been, is, and always will be the poorest of the poor - those individuals most in need of support to help them solve their own specific health problems. Originally a single-dlsease intervention, APOC's success has seen its activities broaden and expand to encompass a multi- disease, more holistic approach that is reaping even greater dlvidends. Yet any successful enterprise has to be bullt on solid foundations, and APOC is no exception. Onchocerciasis, a devastating disease of massive medical and socioeconomic importance, is caused by chronic and Iong-term infection with a parasitic filarial worm. It was one of the four main causes of blindness in sub-saharan Africa. It used to be a widespread disease affecting 30 countries and ruining the quality of life and causing severe deprivation for tens of millions of people. Most of the world outside Africa used to be blind to River Blindness. It was of little signiflcance, indisputably one of the world's most neglected troplcal diseases. Its epldemiology was elucidated in1926,but no means of controlling it were developed as affected populations lived in remote, inaccessible areas, out of sight of politicians and administrators and beyond the reach of fl edgling, post-independence, over- stretched and under-resourced national health services. In7974,foilowing a visit of the then- President of the World Bank, Robert IVlcNamara, to Burkina Faso, the plight of the affected people in West Africa came to global public attention and the Onchocerciasis Control Programme (OCP)was established to control the disease, initially and predominantly by killing the insects that transmit the disease to humans. The vector, females of a small blackfly, Iays eggs in fast- flowing rivers and streams (see Box 1). "\ BOX 1. life-cycle of the blackfly vector The blackfly is a Dipteran (two- winged) fly of the genus Simulium. Only adult females feed on blood and transmit River Blindness. The genus is found worldwide and breeds in fast-flowing, well- oxygenated streams and rivers. Females deposit their eggs in the riverine breeding sites. Larvae hatch from the eggs and attach themselves to submerged rocks, grass, twigs or other plants, subsequently pupating and developing into adults. Adults live for an average of around 6 days but may live up to 20 days. The larval stage is vulnerable to attack with appropriate insecticides. s{, Or {d rq UF & .q( t o o m U x f; tr o 3 bo( JIH o F ri o 6 .!$ h o oAt Ittgr(,i LJ o P-, rs g '- o r- B FF*5 B 5 The greatest burden of infection and disease therefore occurs in communlties Iivlng close to the breeding sites, hence the disease's common name "Rlver Blindness". Control of the fly by aerial spraying of chemicals to kill fly larvae, using helicopters to reach the riverine breeding sltes, proved hlghly successful and helped control the disease in 10 of the 11 OCP target countries. States, Onchocerciasis is not endemic. However, vector flies easily transmit the disease across borders, so all nations must be vigilant and work together cohesively to conquer it. The advent of APOC The flrst crucial innovation was a new drug, ivermectin, discovered from a soil- dwelling microorganism, which was registered ln 1987. Ivermectin ki11s larvae of the Onchocerca worm, but not the adult female worms, which continue to deposit millions of microscopic larvae in the skin of the human host throughout their long, 15 year or more,life-span (see Figure 1 for details of the transmission cycle).lmmature larvae are the cause of the skin disease (severe itching and skin discolouration) and eventual blindness, as they migrate through the skin and, in some cases, enter the eye causing inflammatory reactions when they die. Registration and The creation of APOC was the result of a marriage of two revolutionarY components, within the sPlrit encapsulated in an old Swahili saying, "giving is a matter of the heart, it is not a matter of wealth." The "All for one. One for all" spirit pervades every aspect of the APOC partnership, as evidenced by the fact that in three of the Member o Larvae develop into adultswhich lodge in lymphatics Adults Droduce sheathed @ microfilariae that migrate intod ? lymph and blood channels a blood meal meal skin) Human host o (ingests o s Simulium sheaths, and migrate Ors F ig ure 1 : Onclrocerciasfs tr ansmi ssion cycle, @ L, L"-ae o muscles 6 m a) Hsg trt lro & o 6 at a) o o(U ttc E oUt 3 00 E 5H o 3 o UIH .! o 6 o oAI I Or or U o tr-, rd tr '- o .C P B B 3 6 o (13 immediate free donation of ivermectin by the manufacturer, the US-based pharmaceutical giant NIerck & Co.,Inc., was an astonishing breakthrough. It led to a change in strategy of the OCB which immediately integrated ivermectin distribution into its operations up until the programme's closure in 2002. Secondly, in the late-l980s, global decision-makers increasingly began to recognise that Community-based Development (CBD)was the optimal method to channel development aid and pubiic goods. Above all, CBD can easily be targeted on the poor, is more responsive to their real needs and gives them voice and agency in the process. The World Bank, the Carter Center and NGDOs were all engaged in raising funds to establish APOC, former US President Jimmy Carter and Nlr Bruce Benton, the Bank's longest- serving Onchocerciasis expert, being especiaily active. In 1995, APOC was set up to expand Onchocerciasis control to 19 additional African nations, as well as to maintain control, by surveillance or continued treatment, in the OCP countries. Aerial Iarviciding could not work in APOC nations, so the chalienge was to find a way of delivering ivermectin to the 120 million people at risk of the disease in tulember States. The remote living locatlons of those at risk, coupled with health services that lacked the human resources, infrastructure and logistic support necessary to achieve the task, made everything even more demanding and seemingly impossible. Fortunately, the timely development of a unique, appropriate and effective intervention mechanism provided an ideal soiution. BOX 2- APOC Governance APOC has as its executive agency the World Health Organization (WHO). The World Bank (housing an Onchocerciasis Control unit) is responsible for fiscal management, administering the APOC Trust Fund. 20 donors contribute to the APOC Trust Fund. The strategy, objectives and policies of APOC are set and overseen by its governing body; the Joint Action Forum (JAF), comprised of Ministers of Health of 19 participating Member States and representatives of 15 non-governmental development organizations (NGDOs), multilateral and bilateral agencies, research institutions and donors, and which meets annually. The Committee of Sponsoring Agencies (CSA)acts on behalf of JAF when it is not in session (all decisions are subject to JAF's ratification). Non-Governmental Development Organizations (NGDOs). 15 members, working with the Ministries of Health, are involved in the management, financing and training aspects of ivermectin distribution projects. APOC also has a Technical Consultative Committee (TCC), comprised of nominated experts in the fields of onchocerciasis control, health systems and epidemiology, together with partner NGDOs. The TCC is also attended by observers from other scientific organisations, donors and people involved in control of other neglected tropical diseases (NTDs). The TCC reviews technical aspects of APOC's activities, including ivermectin delivery project proposals, and monitors ongoing operations. APOC Management acts as the executive secretariat of the Programme. u ho d Fq a) & il .6I t (U o 0 tU t g H o 3 h0I J1 o 3 o fi It ,o )h h C) oN I 1 or Or U(J 9-, r$ tr .-.1 o(- B B B B 7 Agnes'story As a young girl from Etteh village in Enugu State, south-east Nigeria, Agnes used to enjoy playing with her friends by the river near her home, although they would often be bitten by the small black flies that bred in the fast-flowing water. As she grew older, Agnes's skin started to itch intensely, so much so that she found it hard to concentrate in school or to sleep at night. Her skin, which had been smooth and brown, became rough, and disfigured by nodules. This scared hel be- cause there were many people in her village with skin like this, but worse, several of those so afflicted had later become blind. Some of the young women who had the condition were left unmarried because of their unsightly skin. They were also excluded from many activities of the community.. After some time Agnes left school because of her inability to concentrate, which made her teacher impatient. She was happy a few years later when her u parents announced that they had arranged t a marriage for her; this meant she wouldn't end up like the unmarried women who were sometimes laughed at and ridiculed by the community. The following years held bitter disap- pointment for Agnes though, as after her marriage, she found that her husband was disturbed, even angry, to find the condition of his wife's skin, especially as it worsened. Eventually, he sent her back to her father. Not long after, however, some people from the Ministry of Health came to the village and held meetings with all the community, in which they explained that there was a drug to cure the disease that was carried by the small black flies breeding in the river. lf the community was willing, the drug would be freely provided but they should organise themselves so that selected members of the villages could be responsible for distributing the drug, which had to be taken once a year for a long period. Agnes's attention was gripped by this information and she vowed to be one of the first people to take the drug. The scheme was accepted by the community, the majority of whom happily took the drug each year. Agnes found that her itching stopped and her skin was becoming smooth again. Her former husband later negotiated with her father to have her back. Agnes decided to become a drug distributor for her community and found that this brought her new respect as, not only did she provide the drug for River Blindness but she also provided vitamin A supplements and could teach people about prevention of malaria through the use of insecticide-impregnated bed-nets, thereby enabling them to protect their children from a life-threatening disease. oh a) €fi trl Ho ts & (u (t t (u o so tr t E o .c 3 o0 fr o 3 o oH td U tsr o oA' I (n or LJ o fl}.fd CI B 3 B I APOC's initial objective : To establish, within a period of 12 to 15 years, effective and self- sustainable community-directed ivermectin treatment (CDTI) throughout the endemic areas within the geographic scope of the Programme and, if possible, in selected and isolated foci, to eradicate the vector using environmentally safe methods. Of note, APOC's original mandate and workload has been extended by the need to respond to the disease situation in four ex-OCP countrles, where the epidemiological situation and conflict- related failures have necessitated the introduction of CDTi activlties. Currently, APOC is active in a1l four ex-OCP countrj.es that require support in this respect, maintaining coverage of 88% (geographic) and 7 8% (therapeutic) of the designated target levels. f Phase I-1974 OCP countries I PhaseII-1995 APOC Member states Figure 2: Countries of OCP and APOC. The scale map oJ Afrtca and other land masses illustrates the true geographic size of the APOC pragramme. India \ United States Europe o d m (u & o4 a( u o (u fi E oU 3 b0 &k o 3 () utrd o h o o r\' Ih Or Or LJ0 O. 16 '- o A+ 3 B 3 9 "The African Programme for On cho cer cias is C o ntr ol ha s helped tens of millions of people fight river blindness by enabling delivery of lWectizan@ (ivermectin) in Africa. The programme's focus in buildlng human resouTce capacity is creating a sustainable, healthy future." (Richard T. Clark, Chairman & CEO, Merck & Co., lnc.) The breakthrough solution: Community- Directed Treatment with lvermectin tcDrr) "Before this drug, some people had skin infection. Others abandoned their wives but now everything is okay." (Village leader, Tanzania) Any solution to the challenge of delivering ivermectin clearly needed to invoive the communities affected by the disease, and to do so from the beglnning. It was unreallstic to expect financial resources to be found to strengthen national health systems sufficiently to do the task alone. Given the donation of ivermectin and a Community-Based Development driving force, involvement of the communities not only seemed the optimal approach but also applied the concepts for Primary Health Care expressed at the AIma-Ata Conference (1978). The CDTI system is very effective and extremely adaptable, so that other interventions, such as the Home Management of Malarta (shown here), can easily be undertaken by CDDs. o0 o, trE GI o & OJ .! tr tr (u o o a) H tr og ,q 3 oog & o 3 o 0H6o >' o o6t I (rr(h U a P. cd H '- o # f" 3 3 3 10 Initially, in the mid-1990s, NGDOs involved in River Blindness control distributed ivermectin on a relatively small scale. A novel strategy was devised by the UNICEF/UNDP/World Bank/WHO Special Programme for Research & Training in Tropical Diseases (TDR) Task Force on Onchocerciasis, of which the current APOC Director, Dr Uche Amazigo was a member. Research had proved ivermectin to be an exceptionally safe drug that could be administered by non-medical personnel. Dosages are determined simply by an individual's height using iow-cost, unsophisticated equipment (a dose pole) readily available in rural settings. The goal was then to empower communities to take over responsibility for distribution of the drug using selected community members, known as Community Drug Distributors (or CDDs). The communities themselves meet all costs involved in collection and mass drug administration. This innovative strategy was adopted by APOC in 1997 and is termed Community-Directed Treatment wlth Ivermectin (CDTI). It enabled communities to decide when, where and how to distribute ivermectin tablets, with assistance from Nlinistries of Health and NGDOs, and with generous financial support from donors provided through the APOC Trust Fund, forming what has become one of the world's biggest and most successful Public-Private heaith partnerships. What is special about the CDTI strategy? The CDTI strategy depends upon engaging communities and empowering them to make decisions, allowing them to be decisively involved in their own health care. It is a person-centred system that brings out people's willlngness to voluntarily help themselves, relatives and peers, rather than depending upon financial motivation or material galn. This is also the reason for its sustainabllity compared to programmes that depend upon relatively short-lived external funding or flnancial rewards to motivate individuals. The spirit of 'self-help' and serving fellow community members, many of whom are relatives, creates a 'feel-good'factor that many CDDs value, as it boosts their self-esteem as well as earning them respect within their society. APOC's major comparative advantage is being able to harness the African altruistic spirit into participatory focused health improvement projects which create effective community infrastructure and improved health outcomes, as well as secondary beneflts well above and beyond the primary objective. 0 u qs pq (u H tu .d tu o(u H 0 3 uo o 3 o o (d c,l >' h o o a\ Ih or or U o R. 16 Jr tr '- o r-!.-r B 3 3 B 11 o c, t 6 frt Ho * 6J#(d d o o o o # tr tr o .q B @ .l( o 3 o o d 11) o o 1\I I ol ol U() 9-{ rs #g 'n o& E B B 3 a i I .' l, u ; I I Rapid Epidemiological MaPPing of Onchocerciasis (REMO) has suweyed over 13 000 villages and generated one of the most detailed and comprehensive disease distribution maPs ever produced. r Villages covered Mappingof Onchocerciasis 12 APOC: from small beginnings... The Partnership As referred to in the Foreword, APOC is above all else a partnership, and this is a critical factor behind the Programme's success. APOC is a multifaceted partnershlp of disease endemlc communities (comprising the beneflciaries as well as those who undertake drug delivery), Niinistry of Health staff (who provide funding and train, supervise and monitor at country level), NGDOs (which supply flnancial, logistic and technical support, at both community and national level), donors (who have generously provided funds for many years), IVIerck & Co., Inc., (providing both the drug and funds), the World Bank and WHO (being the fiscal and implementlng agencies respectively), and dedicated APOC staff. Altogether, we like to think that there are well over 100 million individuals in the partnership, all contributing in their own way to ensure that APOC accomplishes its goals and leaves a lasting continent-wide legacy. Who we are APOC headquarters is located in Burkina Faso's capital, Ouagadougou. The secretariat is small, but it manages an extensive global partnership, coordinating and facilitating activities throughout the member countries. This coordination includes providing access to, and the services ol a network of scientists, health system experts and specialists in Onchocerciasis, biomedical and social sciences, as well as CDTI, which exists throughout Africa and beyond, forming an lmmensely valuable resource that provldes a backbone to the Programme. APOC is actively operating via a large corps of individuals throughout tropical Africa. Everyone involved is committed to our aim of preventlng and eventually removing the unrelenting and soul-destroying symptoms of River Blindness for the over 120 milllon Africans estimated to be at risk. What we have achieved so far would not have been possible without the remarkable commitment of a veritable army of devoted lndividuals, frequently working without remuneration, at all levels of lv1ember State health systems, and including hundreds of thousands of dedicated individual volunteers in rural viliages, NGDOs and donors. What we do APOC was established with one key goal: to find an effective, acceptable and sustainable way to deliver free ivermectin treatment to the communitles who need it. We understand that the success of CDTI is critically influenced by local cultural and social systems and that wholesale application of best practlces may not necessarily work, so we ensure the necessary steps are taken to overcome this potential diffl culty. Consequently, in achieving our aim, we have had o \r lq H{u ts & o 6d o o q lU h o 3 bo A J(! o 3 o s (s o 6 o oN I (n(h Uo O* r$ tr '- o rs--{ B B B 3 13 to branch out lnto new science, new Ioglstical techniques, and even new philosophies of health care delivery, to guarantee that the benefits we are able to offer reach the right people - and continue to do so for the long term. crises, all facing a daily struggle for survival. Despite Africa's rapid urbanisation, within our Nlember States, at least 63% of the population still lives in rural areas. Over 162 million people living in our target areas are undernourished, with concomitant high rates of stunting, infant mortality, hunger and compromised immune systems. We know that River Biindness affects most severely subsistence farming communlties in remote areas, so we have supported front- Iine health staff in f,nding ways to contact these communities and provide the annual doses of ivermectin for distrlbution, no matter what the physical, environmental or politlcal barriers. We have provided bicycles to those who have no transport; we have loaded vehicles onto rafts to cross rivers to reach villages that seemed inaccessible; and we have negotiated Where we work APOC operations extend over an area of 13.45 million km2 of inhospitable, difficult terrain encompassing a population of 567 million people, rzo million of whom have been at risk of River Blindness infection. NIost of our end-user men, women and children are far from being ordinary healthy lndividuals. The majority are poly- parasltized, suffering from a variety of infections and conditions of ill- health, living in countries undergoing prolonged food deflcits and insecurity A CDD co-administering ivermectin, albendazole and vitamin A capsules in a rcmote, mountainous community in Uganda. 6ootEt Fq (u & o .Si t o o 6 o I5 trt og E 3 bot J( o F tt o uH .t o o oN I Oi or ,{ ::l j te ffiq '7, i. ff H ,iU o P. rs '- o P4 B B 3 14 .f. safe passage and drug delivery with warring factions where conflict has prevented many health programmes from operating. Community-rooted driving foice A large part of APOC's uniqueness lies in the way we put community views, cuitures and social factors first when communally designlng strategies for drug delivery. Communities receive training on the disease and its treatment, but after that, they determine everything else themselves: they tell us when they want the drug; they collect and distribute the drug among themselves; they record who has taken it; and they report any incidents of side effects. Knowing that the treatment keeps themselves and their famllies healthy gives them the motivation for sustaining the programme. Without this intense and highly-personal commitment, nothing would be posslble. NGDOs When ivermectin was flrst introduced to treat Onchocerciasis, a key group of international NGDOs were responsible for distributing it to rural communities, mainly through their existing Iocal connections and channels. As the CDTI process was introduced and refined, the same NGDOs became instrumental in improving the training and distribution systems and extending the geographic range of the mechanism to reach the most remote outposts in the countries in which they were operating. The association between the NGDOs and APOC has been a long-standing and highly productive one. NGDOs play a key and balancing role in APOC's statutory bodres, as well as working closely with A/Iinistries of Health to promote Onchocerciasis control and to help set up the necessary bodies and mechanisms to effect training and management of CDTI systems. "I"he success af APOC in up scaling treatments in its 15 years of existence is apparent for all to see....What is not sa apparent is the successful partnership that is enshrined in the set-up of APOC, which includes the NGDO Group for OnchocerciasIs Control. This Group is represented at all levels of APCC decision making....I know no other partnership for global heatth that inclu d e s q ov e rnme nts, the UN agencies, the private sector, donors and the l/GDOs in the same fara: €ach with a voice and each able to initiate partnership in everything they do." (Simon Bush, Chair, NGDO Coalition) 0 {u HB !q o H 7) .6 tu u o E t f, oq ,q F uo o 3 o{,H6(u h o oFI I gr Ch U o A* r$ Pt' '- o .l-{ B 3 T> 3 15 Donors A core group of 20 donors have invested funds in OCP (7974-2002) and APOC (1995 to date) totalling well in excess of US$ 1.1 billion over a 36-year period, the major- ity of which has been spent in Africa. In 2007, the commitment to rid the world of the disease was re-emphasized by a decision to extend the APOC Programme to 2015, made possible by a pledge to con- tinue funding for this period. This was done to ensure that action could be taken to solve problems and delays caused by civil unrest and hostilities in seven Nlem- ber States and so that problematic areas within ex-OCP countries could be dealt with successfully. Future activities will enable us to reach our goals and ensure that the massive lnvestment of funds, time and commitment of everyone will not have been wasted. In fact, there ls now indisputable evidence that elimina- tion of O. volvulus infection and interrup- tion of transmission has been achleved, so the return on donor's investment may soon be measured in terms of disease elimination rather than control. tion to resource mobilizatlon, the Bank has made a fundamentally significant contribution of funds to, as well as maintenance and operation of, the APOC Trust Fund. WHO The existence of APOC owes a great deal to the World Health Organizatlon, which has, from the outset, been the formative and steadfast executing and technical agency governing the programme's operations. Since the early- 1990s, the WHO and TDR have provided the technical and scientiflc evidence and background upon which APOC has been soundly grounded. Successive WHO Directors-General have provlded staunch support for APOC. In addition, Dr Ebrahim Samba, a renowned leader in the early years of the campaign to control Onchocerciasis, and who was instrumental in setting up APOC, extended his unwavering support and guidance, during his subsequent tenure as WHO's Regional Director for Africa, further contributing to his major role World Bank The World Bank is widely recognised as providing the original seed of Onchocer- ciasis control ln Africa, which has been carefully nurtured and blossomed so well over the past 3 5 years. Through suc- cessive administrations, including those operating during APOC's existence, the Bank's Ieadership has provided strong political backing and substantial flnan- cial guidance, especially with regard to socioeconomic cost-effectiveness, to guide both policy and practice.ln addi- WHO / AP OC he adquarters, Ouag adaug ou, Burkina Faso. oo(u fi rd tr lq 0, > N o .( s t o o 0 OJ tt E o ,E 3 00 H o 3 tt o 6 IJ o ol\t I C'T or U() i).{t g '- od F.> ft 3 3h 16 in helping rid his natlve continent of Onchocerciasis. The WHO Regional Office for Africa (AFRO) has continued to provide significant leadership, support and resources to help with financial and administrative work, as well as advising on matters of policy. This support has been more prominent in recent years under the Ieadershlp ofthe current Regional Director, Dr Luis Gomes Sambo. Recently, as circumstances have been undergoing rapid change, the extensive advocacy efforts of Dr Sambo in countries and at regional committees have become invaluable. His personal participatlon in all meetings of the APOC governing board, the loint Action Forum, underscores his appreciation of this unique partnership in his sub-region. WHO's Country Offices, and individual Country Representatives (WR) have also made a pivotal contribution to APOC over the past 15 years. They have assisted with the clearing of Nlectizan@ tablets at the ports of entry in Member states, as well as facilitating drug storage and sometimes covering demurrage costs. Country offices also assist with monitoring the management of APOC Trust Fund use by the national Nlinistry of Health, whilst also supervising al1 in- country missions, as well as monitoring specialised visits of TCC member visits and the like. They facilitate and support all APOC missions financially and logistically, as well as working diligently with regard to advocacy and communications. Indeed, but for the support received from the WRs, APOC would not have achieved so much. Political will and the contributions of participating governments During the planning and all operational stages, APOC has been fortunate to be supported by constant and positlve political backing from every source, especially from all Member States, as well as from the executive-level multilateral, international and regional agencies associated wlth the programme. This is exemplifled by the 2006 Yaounde Declaration that reaffirmed the commitment of a1l partlclpating governments to work together to accelerate the elimination of River Blindness as a pubhc health and socloeconomic development problem in all nations. The following year, all African governments endorsed a resolution that countries should consider the control of Onchocerciasis as a development issue and should give priority to funding control activities from thelr national budgets. Country ownership, sustainability and devolution of activities to lower Ievels were identifled as pillars of successful and effective control. The focus was on the primary health care approach and strong community participation, with the strengthenlng of peripheral Ievel health system facilities, including human resources, being seen as crucial if the elimination goal is to be accomplished. Collective African polltical will has been clearly demonstrated in such fora as the World Health Assembly, the African o H € trl (U > p1 (L, .!t ts o o 6 o d$ trtH oU + 3 a0 &x o B o dx .t o h o or{ I Or c,t [J o tr-..(6 L-{ ..1 o +-r '-J B d 17 Union and in specialised meetings, such as the 2006 African lvlinisters of Health gathering. The international community, through several World Health Assembly resolutions, are also irrevocably committed to eliminate onchocercal blindness by the end of the decade as a pivotal eiement within the GIobal Initiatlve for the Elimination of Avoidable Blindness, known as Vision 2020 - the Right to Sight. Governments of APOC Niember States, as well as several non-members, long ago recognised the potential beneflts of controlling Onchocerciasis and have provided soiid backing to APOC throughout the programme's exlstence. The participation of Ministers of Health and their delegations in Governing Board meetings and in special APOC partners'meetings, and the fact that they meet all such related costs, represents a huge flnancial contribution as well as evidence of forthright and sustained politicai wi1l. Since APOC began field control operations in 1997, Member State governments have defrayed all costs related to the delivery of Nlectizan@ to locations close to endemic communities. Collective efforts by member States resulted in a significant annual increase in flnance for core Onchocerciasis control field activities released to al1 countries. With the move from control to elimination where feasible and launching of programmes for the controi of the Neglected Troplcal Diseases (NTDs), participating governments have relied on, and encouraged the use of the CDTI process as a vehicle to bring to very remote Onchocerciasis-endemic areas additlonai drugs for the control of other NTDs. APOC Management Since APOC was set up in 1995, several dlrectors have been at the helm of the programme, ali having helped enthusiastically drive the programme successfuliy forward durlng changing and difficult times. As bef,ts a programme purely focusing on Africa, all APOC Directors are native Africans. They were able to benefit from a wonderful Iegacy inherited from the trail-blazing forerunner, the OCP. Nevertheless, their work has not been easy, having to deal with major civll unrest and conflicts, natural disasters, global economic downturns, donor fatigue, cultural and language difficulties, the spectre of ivermectin resistance, fluctuating international focus on differing target diseases and other difficulties, both big and small. The contributions of the initial APOC Director, Ghanaian Dr Yankum Dadzie and his successor, Togo's Dr Azodoga Seket6li, cannot be overestimated and the programme owes them both a huge debt of gratitude. The contributions of the current Director, Nlgerian Dr Uche Amazigo, to the adoption of the strategy of Community-Directed Treatment and empowerment of affected communities, together with her visionary spirit, has been instrumental in achieving and documenting the impact of APOC operations - which can now aim for disease elimlnation rather than control. Pharmaceutical pledge What we do has been made possible by one remarkable promlse:the 1987 60o trE trl (, > & o df E (u o AJ I) E E oI 3 00 &H o 3 o 6 .! IU >t o oN I CD or U o A-. rd q tr .-.: o .l-.t E l.- 3 18 donation of ivermectln (produced as Ntectizan@), by Nlerck and Co., Inc., for the treatment of Onchocerciasis for as long as it is required. In 1998, that commitment was extended to cover the donation of ivermectin for treatment of Lymphatlc Filariasis ln areas where the two diseases co-exist. The unprecedented and ground- breaklng decision by Ivlerck & Co., Inc. to donate ivermectin prompted several other multinational pharmaceutical companies to subsequently donate their products to combat tropical diseases among the poor and disadvantaged, particularly in Africa. These include Pfizer, which is donating azithromycin to help elimrnate Trachoma, and GlaxoSmithKline (GSK), which is donating albendazole to help eliminate Lymphatic Filariasis. This corporate philanthropy is being harnessed and optimised by APOC via its seminal Community-Directed Distribution process. This is being expanded to encompass free, integrated preventive chemotherapeutic delivery of a variety of donated drugs, together with a variety of other free and appropriate health technologies and interventions. Evidence-guided policy APOC's activities are based on sound evidence and proven science. There are at Ieast four key implementation/ operational research elements that determlne APOC's policies and control activities. These are: (i) the rapid epidemiological mapping of Onchocerciasis (RENIO); (ii) multi- country studies on community-directed BOX 3. The Mectizan Donation Program Mectiza n" (ivermectin), developed and produced by Merck & Co., lnc., is a safe and highly efficacious drug approved for mass treatment of two of the world's most disfiguring and disabling tropical diseases: Oncho- cerciasis and Lymphatic Filariasis (LF). ln 1982 the company committed it- self to donating the drug for as long as necessary for the control ofOn- chocerciasis, creating the Mectizan Donation Program (MDP)which has become the world's longest ongoing drug donation programme. The do- nation and distribution of Mectizan@ involves a large, global public-private partnership of UN agencies, bilateral donors, multilateral development agencies, governmental and non- governmental organisations, local communities, and the private sector. Today, with more than 700 million people treated since the MDP's in- ception and 80 million people being treated annually in Africa, Latin Ame- rica and Yemen, blindness caused by Onchocerciasis is increasingly rare and there are regions of Latin Ame- rica and Africa that have eliminated the disease or infection altogether. Merck & Co. lnc. remains steadfast in its commitment to donate "as much Mectizan as necessary, for as long as necessary" to treat River Blindness. il {, c pq k o E .( o o a{u H ts oU 3 uo( }( o ts o 6 6 OJ h o oAI I gigr Uog' rs g "t o l- kI 3 B B 19 # r treatment with ivermectin (CDTI), based upon which APOC adopted the community-driven strategy as its principal control method; (ili) use of the community directed approach for co-implementation of other health interventions, (iv) evidence that elimination of Onchocerciasis transmission with ivermectin treatment in Africa is possible, which has recently changed the orientation of the Programme from control to elimlnation. The UNICEF/UNDP/ World Bank/WHO Special Programme for Research & Training in Troplcal Diseases (TDR), played a key role in all these studies under the expert guidance of Dr Hans Remme. TDR's contribution has been both essential and diverse, both before and during APOC's existence.lt has enabled APOC to engage, enlighten and empower afflicted communities. TDR was responsible for initial large- scale fleld trials that confirmed the safety and effectiveness of ivermectin. The programme was instrumentai in lobbying for the drug to be made available at the lowest possible cost. The TDR Task Force on Onchocerciasis was also a driving force behind the development of the critical CDTI system for drug dellvery. In addition, TDR has made, and continues to make, invaluable contributions, through applicatlon and innovative exploitation of biomedical and social science expertise, such contributions including the creation and refinement of sophisticated mapplng techniques, the search for a macrofilaricidal drug and specialised training and advocacy products and processes. Sustainability prioritised Sustainability is defined as "the ability of a project to continue to function effectively, for the foreseeable future, with high treatment coverage, integrated lnto available health care services, with strong community ownership using resources mobillsed by the community and government." One of the primary objectives of APOC was to establish an ivermectin delivery system that would be sustainable in the long term. Annual treatments with ivermectin are necessary for the decade or more lifespan of adult female worms, after which the source of microfilariae will end, thereby eliminating the reservoir of infection for vector blackflies. A requirement for this sustainability was that any fi.nancial or other incentives given to CDDs should come from the communities themselves. As external funding could not be relied upon for more than the decade necessary for complete treatment. Naturally, other expenses would be incurred by APOC partners in maintaining the strategy, such as costs to transport the drug to remote communities, training community members involved in drug distribution, and maintaining the necessary recording system essential for tracking and evaluatlng progress. Thus sustainability will depend upon Nlember State governments assuming full responsibiiity for funding aspects of the strategy - taking over in a phased mannerfrom APOC. 6 otdg cq o N(J (t c E (u o o IU a t oI 3 bo o B o oHdq, o oN I gr Or U LJ P. rs P )-{ '- o rs{ B 3 B 20 Gender matters Yet, in Africa's patriarchal societies women are less frequently selected to be CDDs. There are a variety offactors responsible for this, some not well clarified or understood, which the CDTI process has identifled and which require further study and elucidation. We are, however, pleased that there is no under- representation of females among the eiigible population treated; over 50% of those who receive ivermectin being women. APOC is a pro-poor programme of action working cohesively with other international efforts to help achieve the Nlillennium Development Goals and other specific targets for human and socioeconomic development. This includes goals to improve gender equity and, in particular, to raise the status and role of women in society, where required. in most African societi.es women are the care-givers in the family, they are not seen as the'breadwinners' (so can more easily undertake voluntary work) and are less prone to migration in search of work to support their familles. Consequently, for sustainable ivermectin distribution, women, particularly elder women who no Ionger have young children to look after, would appear to be better prospects to become CDDs than men. APOC is strivirrg to ensure that women are equitably included in all aspects of the CDTI process. t I *j k .+# 'ii* *€ .d 6 o tt rq (u F nc (lJ .B c o o 6 o k ts tr oU B bo x o ts o oxIt o Fr 6 o oN I oo U o tr rs g '- o:S.{ =B 3 21 ,ft._fti,4+ '*o J Over 1.3 billion Mectizan@ tablets distrtbuted E t Over 440 million cumu- lat iv e tr e atme nts g iv en between 1997 and 2009 \ , { I !!li ! a - 6 o, H\, EA oF & (U d .d * E (,, o 6o # 5 tr oU 3 @t o 3 o 6H .! o >r H o ot\I I C'tgr LJ og* 16 #g ,.1 $(' ,5{ E F B 3 nt : 22 Achievements and impact APOC aims to protect an estimated 120 million people, freeing them from the ravages of Onchocerciasis and helping to improve their overall health and quality of life. Building on past successes and thanks to a widespread and diverse popular participatory movement, APOC's accomplishments are widely recognised as being very lmpressive, especially given the difficulties of working beyond the reach of the health systems. The flrst 10 years witnessed difficult but steady progress as APOC built up its core competencies. However, since 2005, there has been a tremendous surge towards reaching our goals, expedited by the cessation of hostilities and civil unrest across several large geographic areas. By the end of 2010, after 15 years of operations, it is fu11y expected that l million CDDs will have been trained and mobiiised, well over 74 000 health workers familiarized with and engaged ln CDTI projects, and some 500 mlllion ivermectin treatments will have been administered. APOC is now firmly "on track" and continuous efforts from all our stakeholders over the next flve years should result in our goals belng realized by the time APOC activitles wind down and eventually cease. 70 60 50 People treated annually 40 (millions) 30 20 10 0 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Figure 3: Progression oftreatment coverage (1997-2009). By 1999 the CDTI strategy was in place resulting in a marked increase in the numbers of people treated. TJ o eL. r$ Lr '- o rl-r 3 B 23 At the launch of APOC: . 41.9 million people were estimated to be infected with River Bh.ndness . 29.7 million had severe itching and skin disease . 385 000 people had already been blinded . 944 000 had impaired vision s(U e (u P N $ .(t H {u o q o v t ov '( 3 uo xH o 3 o oH a!(u 6 o oN I o(h Results Since 1997 APOC has achieved: Communlty delivery of over 1.3 billion tablets of ivermectin Administratlon of 440 million doses of lvermectin CDTI projects already operating = 96% of target (protecting 94 mi11lon people) Geographic coverage = 91% of APOC area Therapeutic coverage (overall) = 89% of 2015 target 146 000 communities engaged CDD treatment of 68.4 mlllion people in 2009 (well on the way to the treatment target of 90 million annually by 2015). CDTI proj ects confi rmed sustainable = 63% of 2015 target CDTI projects co-implementing other health interventions = 63% of 2015 target Examining nodules on a community member dur ing e p ide miolog ic aI ev aluat ion s. CDTI projects integrated into National Health systems = 80% of 2015 target Cost per ivermectin treatment = uss 0.58 . APOC countries using regular health budget for Onchocerciasis control = 15 Average of 375 African professionals trained in technical and flnancial management skills annually Countries displaying criteria to stop ivermectin treatment = Cameroon, Chad, Nigerla, Uganda Impact . Protection of 120 million people at-risk from developing disease . A2O% reduction ln occurrence of worm nodules in infected people (2005 data) - An86% reduction in severe itching . >500 000 cases ofblindness prevented . A33% reduction in prevalence of blindness (blindness is irreversible) . Saving of c. 1 million Disability Adjusted Life Years (DALY) annually . Estimated Economic Rate of Return of 17% onfunds invested . Onchocerca volvulusinfection probably eliminated in 6 focl with prevalence of infection equal to zero. Evaluations in 7 APOC countries confi.rmed the feasibility of onchocerciasis elimination using annual ivermectin treatment in most endemic areas. o{ o E 0 o OJ tr6I cq 0, > & (u v .Ui g o o oo fi E E oIt 3 00 & o 3 o 6 .d IU H o oN I or Or TJ og,d # )-.i .-1 -Lr B 3 3 24 I ,} I xi Value-added impact APOC operations have repeatedly conflrmed that the use of ivermectin has both direct and indirect beneficial impact on improving community health. Besides conquering River Blindness, long-term treatment with ivermectin is associated with a significant reduction in the prevalence of infection with any soil-transmltted helminth parasites (including Ascarls, Trichuris and hookworm), most or all of which are recognised as ma.1or causes of the morbidity arising from poor childhood nutrition and retarded growth. The prevalence of head lice is also markedly reduced in children taking ivermectin tablets, while scabies 1s markedly reduced in populations taking the drug regularly. A recent study concluded that "mass treatment with lvermectin was an effective and safe means of reducing the prevalence of most of the parasitic diseases prevalent in a poor community". Children's perceptions of CDTI - as shown in drawings obtained in a recent multi-country study of the social benefits of CDTI - showing a CDD with the trademark measuring stick used to determtne dosage of ivermectin. Success through the eyes of African children In 2009, APOC commissioned a study in Cameroon, DRC, Nigeria and Uganda to assess the way communities viewed CDTI and the effect control of the disease had on their lives. This included the perceptions of children, who wrll now never experience the effects of the disease flrst-hand. CDDs with their measuring sticks (used to determine the correct dose) have become a familiar feature in all participating communities receiving treatment and remain an endurlng image in the minds of children who may never now witness how, in the past, similar sticks were used to lead the blind. 1 a #*w ht)Iilu 3 D4 o o €fi EO k(U R IU r$ (u m qJ J f; tr oq 3 bs o 3 o o .n{uh h oHo r\T I or or U O lrr rd tr '- o Jrl\- 1 p" 3 B 25 i frl s? h"l 7 u\l E7r- .;iiii;E-:lu t I trk€-r-{-: r rrt'*f:L&+L'"Xt_-ffi irt LX IJ otr cG P H '- o FL.i B > B 3 26 Integrated preventive chemotherap! : Initial work in Tanzaniahas provedthe safety, efficacy and synergistic impact of integrated mass drug administration, which will be made all the more cost-effective when distributed via APOC's signature CDTI system. The APOC legacy CDTI evolution and expa.nsion APOC is a dynamic Programme that continues to evolve and adapt to changing circumstances. This represents another of its comparative advantages, as it is able to be more responsive and react quickly and creatively to fluctuating demands and requirements. One of the first multi-country studies on CDTI compared the effectiveness of having the strategy designed by professionals rather than by the communities themselves. This study confirmed the increased beneflts afforded by allowing the communities to design the details ofthe operation, such as the timing, the place and mode of de1ivery. A subsequent multi-country study was conducted in response to the interest of other health programmes adopting the CDTI strategy which wanted to use the network of CDDs and CDTI projects to better provide their own specific health improvement commodities. The oblective was to determine if there were any synergies or negative impacts arising from such "co-lmplementation". This study found that up to five additional commodities, which could include drugs or preventive items such as insecticide-treated bed nets for protection against malaria, could be delivered using the CDTI structure without any adverse effects. In fact, therapeutic coverage of ivermectin treatment for Onchocerciasis was found to actually increase in some co-implementation instances. This led to increased interest of other health programmes and of donors in expanding co-implementation, as it clearly provided an existing well-proven structure giving access to difficult- to-reach communities. Moreover, there could be signiflcant cost savings if programmes were able to share activities and resources, for example ln training local health workers or CDDs, supervising, monitoring and data collection. A third multi-country study on "External monetary policies for Communlty Volunteers" in 2008 found that donors played a signiflcant role in inducing or establishing monetary incentives. This study concluded that there was a need to formulate a general policy at the national level to gulde thls often d isruptive practice. It is APOC's firm belief that no intervention, proj ect, or programme should continue without a sound scientlflc basis for decisions that are made, and for Iogistical arrangements that are put ln place. With this in mind we are continually working to reflne our ideas of who needs our help, to understand their real needs, how to treat them, what to treat them with, and how our plans should change into the future. Both OCP and APOC have been based on evidence provided from rigorous scientific and operational research that has helped to determine the direction in which the programme has developed, as well as demonstrating to donors the effectlveness and impact [J o O* r$ -'- o l- l\. Bl\- 3 27 i !n $i fijlll r:lJ firl $ rd tu (h LI H o s $,(i () o d {"} it"' hn oHoN I h Or(rt of their financial contributions. All stakeholders are regularly made aware of their contributions and the overall impact. Disease Mapping It is essential for any public health programme working in remote areas to have reliable methods of ldentifying target populations. Furthermore, it is best if any such method ls low-cost, easy-to-use, effi cient, and preferably one that does not require the expensive and often scarce clinical skills of a medical professional, or the laboratory equipment of a scientist. One of the flrst things that APOC had to do was to accurately identify the distribution and prevalence of Onchocerciasis in the 19 countries in which it was to operate. This would allow identiflcation of sites for the CDTI projects - the meso- and hyper- endemic areas of infectlon where Iocal populations would be treated with ivermectin. The task necessitated a decade-1ong research project to survey all countries where the disease was suspected to occur and produce Iocation maps of all villages that required treatment. Mapping of the disease was a massive challenge. It entailed initiai examlnation of existlng maps to identify major watercourses and primary and secondary Iine communities along their Iength. These hard-to-reach communities were then visited to carry out examinations of adults ln order to establish the prevalence of infection. The technique for surveying uses an obvious symptom, the onchocercal nodule (aggregations of adult worms). The nodules are most common around bony ridges such as the shoulder biades and hips. The presence and abundance of such nodules in a set sample size of community members allows a swift decision about whether the community requires treatment. The areas surveyed were then mapped using Geographical Information System (GIS) software. Psdence f,dulB (%) o0 O r,9 o 1G19 o 2G39 o 4G1m Tanzanb REUO map I h6nle CDTI ar6as tr M COTI areas Extuded zon6s Rsgios bundades TrrrrTrrrTTn 0 $100 2m mkm Rapid Epidemiological Mapping of Onchocerciasis {REMO), Tanzania. The innovative methodology developed is called Rapid Epidemiologlcal Nlapplng of Onchocerciasis (REMO). Now complete, the series of detailed maps produced have enabled sound evldence- based decision making, identlfication and charting of communities that had often not been recognised before, while connectlng many remote settlements to health services for the first time. In 2010, analysis of data using a geo- statistical technique called "Kriging" was also carried out. 6 o Ef p H o & o dfi t o o q o f a t oU 3 bs H o 3 ll o u .n a) 11 o oN I or CN Us S.. rs q tr .-1 oI B B 3 B 2A s This allows predictlve maps of Onchocerciasis transmisslon zones to be produced by interpolation of data collected in 13 000 villages. The story behind the mapping of Onchocerciasis is told in a booklet produced by APOC entitled Charting the Lion's Stare - the story of River blindness mapping in Africa (available in both English and French). From 1997, Iarge-scale mass distribution of ivermectin was successfully introduced by APOC in forest zones. In 1999, cases of neurologic serious adverse events (SAEs) following ivermectin treatment were recorded in individuals in Cameroon having high I. loa microfllaraemia, resulting ln three deaths. This serious complicatlon, arising from ivermectin impact on non-target parasites, jeopardized mass ivermectin administration, operations being immediately suspended while the SAEs were fully investigated. A thorough TDR/APOC study established a link between the prevalence of L. loa microfilaraemia and the leve1 of SAE risk. This led to the development in 2001 of a Rapid Assessment Procedure for Loiasis (RAPLOA), whlch was to be carried out to assess the prevalence ofloiasis in all relevant areas before lvermectin distribution could be resumed. Ivermectin dlstribution subsequently recommenced safely in L loa-endemic districts of Cameroon and other countries following strict guidelines. Subsequent ivermectin use in Lymphatic filariasis control programmes in Africa created a similar challenge. Between 2002-2010, APOC undertook a RAPLOA survey in 4808 villages in 11 countries covering almost the entire Ioiasis belt in sub-Saharan Africa. With its expertise in disease mapping, APOC is now uniquely supportlng countries wishing to carry out control of various other NTDs, exploiting the CDTI system. This has enabled them to conduct integrated mapping of these NTDs as an essential first step to establish baseline disease data upon which to base control or elimination programmes. Distribution of on(ho{e(iasis Predidioo map Preval€nce of nodule Grierr {%) 0-1 w 2-4 r 5-9 r0-14 ar 15-19 r 20-29 r 10*39 r 40-49 r 50-59 r 60-100 Predicted distribution of Anchocerciasis in Africa (2010) - in the absence of control measures - based on REMO mapping in 13 000 villages and Kriging analysis. APOC CDTI projects only tahe place in meso and hyperendemic areas with a nodule prevalence of 20% or above" I (harting the lion! stare Ihe nory driv{blhdnes m.priB inArt. @ (u fi Fq {u > FC o d o o ilo tr tr oU 3 ho( o 3 o v! .( 0) 6 o oN Iuto Ol LJ o P. c6 JF) tr '- LJ +--{ L t>F BF* 29 6u,nm oCapacity Building CDDs and Communities The key individuals that make CDTI work are the CDDs -the Community- directed distrlbutors of ivermectin (and now many other health-improvement products as well). Every year thousands of CDDs, selected by their communities, are trained or re-trained so that they have the necessary knowledge and skills to perform their important tasks. The "m.atron of CDDs" inNri Community in Liberia has been with APOC since the begtnning. Despite the hardships, she cantinues, "I want to help the community. That is why I am doing this, to stop the eye blindness and the other diseases." In 2009, APOC trained or re-trained some 5O3 256 CDDs, with the cumulative total since the programme's inception being well over 930 000. This predominantly voluntary workforce, already well connected to the peripheral health service, is available for use in distributing a wide variety of health interventions and to help determine the real health needs and health metrics of their own communities. Perhaps most importantly, we train communitles to understand the disease, recognise the importance of treatment, and demand more from their health services. Health system staff Our public health programme is different from others in that we rely on national staff from all levels to lead the programme and promote APOC's ethos of community ownership through education and training. As a result, the programme not only provides treatment to communities in need but it also provldes a rich intellectual legacy in terms of human resources. This is most evident among health system staff,local, district and nationai government managers, accountants and researchers. A11 of these beneflt from speciflc training reiated to technical, administrative and financial management of Onchocerciasis control activities, as well as from APOC's guiding oversight and sharing of knowledge between countries. Details of the extent of human resource capacity building within the member countries are shown in Table 1. Community Drug Distributors 930 381 Health workers 75 146 Table r Cumulative numbers of health workers and community drug distributors trained (1997- 20a9). APOC has supported the development of new cadres of scientists and technicians for monitoring and evaluating project progress, including the evaluation of the sustainability of community-drlven CDTI projects and development of sustainabllity plans based on the outcome of these evaluations; we train staff at all levels lndividuals trained (1997 to 2009) ff0(u Et E o & (u+(t ts o o 6 0, # og s 3 00 H ,l(x o 7 o eH .d o o oAI I gr(n U o tr r$ P. H "-J FL{L .'.> B 3 3 30 I in mapping techniques, diagnosis of Onchocerciasis and potential side- effects of ivermectin. APOC has also established a large body of professional managers and experts covering a wide range of disciplines, including finance, communication, transport and logistics, Capital equipment In order to undertake a1l phases of our work, including in locations beyond the 'end-of-the-road' and in post-conflict countries, specialised equipment, computers and basic laboratory equipment need to be made available. Various means of transport, to and within countries, are needed to support treatment distrlbution. IVIeans to allow accurate record keeping are also needed. And products and systems to safely maintain all equipment and data also need to be put in place. APOC plays a pro-active role in providing either the necessary equipment or access to it. New drugs and diagnostics Whiie we use ivermectin as the drug of choice to prevent Onchocerciasis, we recognise the potential value of new, more selective drugs, especially those that could target adult worms: as their availability could shorten the length of time needed to eliminate River Blindness. The APOC Trust Fund provides flnancial support for ongoing research and clinical trials in this area, facilitating meetings of experts, reviewing evldence and promoting publication of key data to move this fleld forward as quickly as posslble so that communities might soon see the benefits. APOC is working with researchers internationally, in the North and South, to search for new, safe, appropriate and affordable drugs and the development of new diagnostics that might accelerate the elimination of Onchocerciasis. In-country research by nationals APOC promotes studies undertaken by nationals of Nlember States designed to seek solutions to operational problems and which will consequently improve proj ect performance. These research projects range from studies on the participation of women in CDTI or the use of kinship structures to improve drug delivery to assessing new and traditionai repellents for combating the nuisance of Simulium biting. Even when communities are protected from the risk of onchocercal infection, the irritating, constant biting of the flies can be a constant nuisance. This activity also provides an opportunity to develop the capacity of African researchers by providing them with the funds and support necessaryto undertake thls work. Some examples of published operational research proj ects are listed at the end ofthis booklet. Knowledge management We understand that our projects and individuals responsible for their success will mostly be living and working ln difficult conditions, because that is what public health work in rural Africa requires. We therefore invest in and promote operational research for all projects to find the most effective ways of adapting the programme's phllosophy to the numerous complex environments prevailing in Africa. m ql rdI Fq }{qr & o (g (u o o fi E E oU 3 o0t o 3q o 6 t! o 0 o r\I I rrt or Or [J o $-,fd tr '- o -q B =3 31 Newly-selected CDDs learning how to complete the treatment register during a training sessfon in Nigeria Observations and best practices, together with all the results from sclentiflc research and studies, are pooled and shared to provide a comprehensive knowledge database for all, for application and exploitation to create successes elsewhere. By 2009, APOC had a comprehensive database on50 374 communities in 9 countries. This includes geographical coordinates, number of CDDs, population censuses and vital information on gender for each village, a1l freely available to other health programmes. Legacy Challenges No health or development programme working in remote rural areas of Africa ls without substantial challenges. APOC has always been ready to address a1l challenges by seeking innovative ways to overcome them where necessary. At present and over the next five years, APOC is and wlll be facing at least three key dlfficulties: 1. Volunteerism and incentives Several other programmes have been established to provide health lnterventions to some of the rural communities where APOC is active. Ideally this should Iead to complementarities and opportunities for collaboration and for greater cost- effectiveness, but it can also lead to additional challenges, especially the prospect of competition. Some weli- funded health programmes initially found it easler to recruit and retain community health workers if they gave them some monetary allowance or other financial incentives. This has several implications that are causing obstacles for CDTI. Firstly, if a financial incentive is given by one programme and not by another there will inevitably be a motivation to transfer loyalty to the programme providing an allowance, thus undermining the programme that does not pay. Secondly, priorities of health systems will shift to the richer, well-funded programmes at , 0 (, u trt H(u & o .n (u o o E oI B uo c o 3 tt o hH .! OJ o oAI I Ol('r s 's ? ? fl * U t). cs # H .-': o .c ;i 3 3 B 32 the expense of others. Thirdly, the community health workers that are paid will have a different perspective towards the provision of health care. They may no longer be motivated by a wish to serve themselves and their community. This will not only undermine community collective efforts to participate as a partner in health but setback efforts to revitalise Primary Health Care ln the sub-region unless correctlve, balanced action is taken by governments and donors. 2. Civil unrest A significant challenge for any health or other development programme in Africa occurs when working in conflict or post-conflict countries. The reasons are obvious and include residual insecurity, damaged, absent or weak infrastructure and depleted human resources, in addition to working with populations who are, or have been displaced. This clearly affects the ability of programmes such as APOC to deliver health commodities as effectively as in stable countries. To meet this challenge APOC has recruited Technical Advisers (TAs)with experience and a proven track record in the control of River Blindness in six post confllct countries (ango1a, Central African Republlc, Chad, Democratic Republic of Congo, Liberia and Sudan) where we work. These TAs provide additional support and guidance for the National Onchocerciasis Task Forces (NOTFs) in how to best overcome confl ict-related obstacles. 3. Ecological concerns APOC deals with a naturally-occurring disease and the complex environmental and ecological interactions and factors associated with it. Onchocerciasis is inextricably linked with water and watercourses. As elsewhere in the tropics, the impact and results of on-going climate change in sub- Saharan Afrlca are unknown and certainly un-quantifled. What is almost certain is that rainfall patterns will alter and that river basins and major watercourses will be signiflcantly affected. Agricultural production will also be impacted by forthcoming Green Revolution for Africa inltiatives. The outcome may severely impact on Onchocerciasis control activities and APOC is pro-actively engaged in work to prevent or help minimlze any such negative impact. Riverside land is both highly fertile and, in the past, provided prime sites for disease transmis- sion, as the vectar Jlies breed in fast-flowing waters. t fi m(u k Fq k{u ts & o .{ tr (u o il(u E E ou 3 us &x o 3 o tDH {1, $a o o(\t Irt or Oi L., o A. r+{ ! o +-rf,dt d F>F 3 33 ; sl ']: . .'-*"<l II I I I I I I I * wm -trz:;-tr - 4S. !., .1'{d ::d I I (' '\ \ & :r I r:!LI I I ffil1 t 7 ,d# f IJ o9.d g '- .( B B 3 3 34 These bright-eyed children, born after the inception of APOC, can look forward to a much healthier hfe, free of the threat of Onchocercio.sis and several other diseases - if they continue to be supported by robust and sustainable community- driven health interventions such as those pioneered by APOC. U s The future Elimination of Onchocerciasis? APOC's goal has recently undergone a profound and fundamental evidence- based shift. The aim has moved from elimination of Onchocerciasis "as a public health problem" to elimination of the disease itself. Donors have traditionally been cautious about committing to an indefinite programme for Onchocerciasis control and one of APOC's key objectives has been to determine when and where ivermectin treatment could be stopped without risking the gains that have been made through previous investments. In 2009, evidence emerged showing that ivermectin treatment alone can interrupt disease transmisslon by removing the reservoir of infection necessary for continued transmission, thereby leading to elimination of infectlon as well. Consequently, now there is promise of a hitherto unimaginable return on investment. Based on the new evi.dence, APOC's Governing Board agreed that the programme should amend its primary objective and, instead, to focus on efforts to eliminate lnfection and interrupt transmission of Onchocerciasis (where feasible) in Afrlca. This will certainly enable a shrinking of the map of River Blindness in Africa by 2015,APOC's previously projected closure date. By this time, severe itching may well have been eliminated but infection will still remain, necessitating continued distribution of ivermectin in some places. Recent multicountry studles have provided rrrefutable evidence that elimination of infection is feaslble through prolonged annual ivermectin treatment. Evaluations in 17 foci in, Cameroon, Chad, DRC, Nigeria, Tanzania and Uganda found the prevalence of mi.crofllaria (mf) in 15 foci equal to or less than that predlcted. In 6 of these foci it appeared that elimination had already been achieved, with mf 1 mr (%) 01r\ 20% , 40q, a 160% mr (%) t 200" a 'to 1+I a60% Figure 4: Before and after: The impact of long-term ivermectin treatment - Epidemiological evaluations such as the one illustrated above are finding that infection with onchocerciasis is being eliminated in same foci - graphic shows elimination from a focus in Kaduna, Nigeria. 6fi p (u H {u .{ c E (u o+ 6 a) s5 f;g og 3 @ o 3 o tt .! o 5 o o r\t I or or U r.J A-., ct -P l-{ '- o(- t\5 B F*{5 3 35 I '1 I l prevalence belng zero in all villages surveyed. A further 5 foci appeared to be approaching the "critical point'l indicating that treatment could soon be stopped. The studies also suggested that if treatment coverage is lncreased, eliminatlon of infection may be reached much earlier. Guidelines are now being formulated which, when implemented, will allow authorities to decide when and where treatment can be stopped. With flve years of its mandate to go, APOC underwent a forward-looking external evaluation in 2010, to provide guidance for the continued evolution and progress of the Programme. Due to the revelation that elimination of the disease had become a distinct possibility, at the annual end-of-year lolnt Action Forum meeting, APOC's Governing Board endorsed a proposal to extend the lifespan of Programme activities, although exact details of the extension will not be decided until the next meeting in December 2011. In the past children lost their childhood as they were required to assist adults blinded by onchocerciasis... now they are able to attend school and live a relatively normal life free of the threat of onchocercal skin disease and blindness. CDI strategy for holistic health care: co-implementation APOC's achievements and the realisation of many promising innovations has had an immeasurably benef,cial impact on disease control in Africa and elsewhere. APOC has proven beyond a doubt that it is possible for health services, affected communities, private pharmaceutical companles, governments (at all levels) and non- governmental organis ations to work together in cohesive partnership. Furthermore, the major success in Onchocerciasis control has helped the NTDs compete well for the attention and funds which have latterly been directed almost solely on the "Big Three'diseases, HIV/AIDS, malaria and tuberculosis. Indeed, drugs to prevent or control many NTDs have now been donated for mass drug administration programmes, with the CDTI process having proved the worth of such ventures. It is clear, given the recognltion that CDTI is an effective vehicle for providing other health services to remote communities, that with new interest in, and funding for, the control of various NTDs, the donor community and pollcy-makers would like APOC to take a Iead in this area. They are already chan- nelling funds through the APOC Trust Fund, and countries and NGDOs are mak- ing use of APOC's CDD network for this purpose. This is an activity that APOC is undertaking cautiously so as to avoid any negative impact on Onchocerciasis con- trol, for example by overburdening CDDs orfrom other aspects affecting the logis- tics of deiivering integrated but diverse public goods, medicines, treatments and health education. The target diseases for E oo o HE c FA o & o (t g c, o oo tr o E# 3 00 J4H o B o 6 .6(u o oN I Or Or U o tr-..f$ JJ C ,- o B B 3 F 36 <l*a\ rt'f ,( ! /\ CDDs distribute an insecticide-treated bednet along with ivermectin tablets to a housewife in Nigeria co-implementation of preventive chemo- therapy are Lymphatic Filariasis, Schis- tosomiasis, soil-transmitted helminths and Trachoma, alongside Onchocerciasis, although Vitamin A supplementation, insectlcide-treated bed nets, home-man- agement of malaria and other interven- tions have also been factored in on a small scale for many years. Utilising the CDD system creates synergy and markediy lowers costs. Prospective integrated disease control APOC's 15-years of experience and innovation have proved conclusively that iffuture integrated disease control activities are to be effective, they have to be accompanied by concurrent mapping of disease distribution and populations at risk, constant monitoring to evaluate and quantify the real lmpact of interventions and regular and long-term surveillance to ensure that control successes are maintained. In addition, the search for new diagnostics and means of prevention or curative treatment need to be actively pursued and encouraged, especially in instances where the appearance of resistance may relatively qulckly render use of a drug virtually useless. In Africa at least, individual popuiations need to be involved in a1l aspects of planning and implementation of health programmes, not least to help engender the critical feeling of ownership, while a detailed knowledge of Iocal customs, social structures and cultures are also key to success. In addition to the CDTI strategy, APOC's expertise 1n disease mapping is proving to be a valuable and substantive contribution for policy making. A flrst step for any co-impiementation is the mapping of the prevalence and distribution of al1 other target diseases. APOC is also supporting Nlember States by helping to develop Natlonal Strateglc Plans for NTD control and, in doing so, is helping to build the sustainabillty of these disease control programmes, as well as further strengthening the fundamental capacity of national health systems. (J 60 {,} lri tkri fi,| sl u o 0r C} ts H,lir o rd {JF, otso r\t I h(rt O! F-ri fi{ Lr rs-r F-_ 5 F>l-* 5 37 To find out more APOC Publications APOC, being an innovative, entrepreneurial, evidence-based programme, documents as many of its activities and achievements as possible Some of the more detailed studies are published in peer-reviewed scientifi c journals, whilst other information is published by WHO-APOC directly. BUEMlmBTEOEDINEMEXM'OE'B!&II@ Below are examples of a few of the WHO-APOC publications that are available (in both English and French versions) upon request. Further information can be obtained from the APOC website: www.who.int/apoc ,F,,lnr:,.s:::,P. @@ {i Y |'" rlr t. \.nsde rlnreMd'.. sls E es d F..d16 d. M&l.s @ 6)ELi:'rr.* 6s{, B{ Fq o x (u r! CJ o h(u tr oIt 3 oo H o 3 o uH .d(u >' H o o6t I Or Or P- LU q ffi '- s k rJ "fF" F\ d5" FJt"- l-t 38 I @ttt'tttt'"' Ef€cilAL ia!€TiE! lNcttru€ P0Lrl{5 ff[: @ ,-. PHAS€ II ANO PHASINO.OUT F€RIiO @, PEEGEATHE AFEII:AII1 BE LUTTE EEIITI?E L'IIlCHOCEEDDsE Rqr.hls.t6 tu t6,rt Ls6la .n&dcFruF *!ilfi$ {DsH!"* (:urrn:!l!' d MdnlPd. r'd'nr'd t @ S#H I r-r- h6hri*dmrstu3lormFh.r6@@h{* 'I .: Examples of the many research publications related to APOC operations: 1. Abiose, A., Homeida, M., Liese, B., Ivlolyneux, D.H. & Remme, H. (2000). Onchocerciasis control strategies. La n cet, 3 5 6, 1523 -1524. 2. Afework, H.T. et. al. (2010).lntegrated rapid mapping of Onchocerciasis and loiasis in the Democratic Republic of Congo' Impact on control strategies. Acta tropica, in press. 3. Akogun, O.B. et. al. (2001). Community- directed treatment of Onchocerciasis with ivermectin in Takum, Nigeria. Trop. Med. Int. Health, 6, f ,2f2-243. 4. Amazigo, UV., Boatin, B. & Boakye, D.A. (2006). The future of Onchocerciasis control in Africa. Ian cet, 3 68,79 46-19 47. 5. Amazigo, UV. et. al. (2007). Performance of predictors: Evaluating sustainability ln Community-Directed Treatment projects of the African Programme for Onchocerciasis Control (APOC). Soc. Sci. Med.,64 2070-2082. 6. Anosike,l.C. et. al. (2007). The varied beneflcial effects of ivermectin (Mectizan@) treatment, as observed within Onchocerciasis foci in south-eastern Nigeria. Ann. Trop. IVied. Parasit.,7O7, s93-600. 7. Boussinesq, M. et al., (2001) Studies on the microfllarial population of Onchocerca volvulus in hyper-endemic villages of the Central Province of Cameroon . Ann. Trop IvIed Parasit., 95, 379-3 88 8. Brieger, W.R. et. al. (2007). Feasibility of measuring compliance to annual lvermectin treatment in the African Programme for Onchocerciasis Control. Tr op. Me d. Int. He alth, 12, 2, 260 -768. 9. Brieger, W.R. et. al. (2002). Factors associated with coverage in community- directed treatment with ivermectin for Onchocerciasis control in Oyo State, Nigeria. Tr o p. IvIe d. lnt. H e alth, 7, 1,, 77-78. 10. Diawara, L. et. al. (2009). Feasibility of Onchocerciasis elimination with ivermectin treatment in endemic foci in Africa: First evidence from studies in MaIl and Senegal. PI OS Neglect. Trop. Diseases, 3, No.7 online. 11. Katabarwa, IVi., Habomugisha, P & Agunyo, S. (2002). Involvement and performance of women in community- directed treatment with ivermectin for Onchocerclasis controi in Rukungiri District, Uganda. Health Soc. Care Comm., 10,5,382-393. 12. Katabarwa, M. et. al. (2010). Traditional kinship system enhanced classic community-directed treatment wlth ivermectin (CDTi) for Onchocerciasis control in Uganda. Trans. Roy. Soc.Trop. Med. Hy7.,104, 4, 265-272. 13. Ndyomugyenyi, R., Lakwo, T., Habomugisha, P & Nlale, B. (2007). Progress towards the eiimination of Onchocerciasis as a public health problem in Uganda: Opportunities, challenges and the way forward. Ann. Trop. IVIed. Parasit.,7O1.,4 321-333. 14. Noma, M. et. al. (2002). Rapid Epidemiological Monitoring of Onchocerciasis (RENlO): Its application by the African Programme for Onchocerciasis Control (APOC). Ann. Trop. lvled. Parasit.,96, Suppl. 1, S29-S40. 15. Remme,l.H.F., Amazigo, UY, Engels, D., Barryson, A. & Yameogo, L. (2007). Efficacy of ivermectin against Onchocerca volvulus in Ghana. Ian cet,370,7724. ffiENKffi *{ APOC headquarters staff (2011} -r" t' i HM u il & 0, .! u ci tr o F D*t 3 6X(.r F\ o o .\l I O'lgr LJ o A-.,($ ..1 o +-{ =3 3 B 39 "For 15 years, the progressive, and most impressive, success of the African Programme for Onchocerciasis Control has empowered communities to take charge of their own health, especially in rural areas. Thanks to APOC's community-directed intervention strategy, large populations in Africa have helped themselves to better health in an efficient and sustainable way." Dr Margaret Chan, WHO Director-General AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL African Programme for Onchocerciasis Control (APOC) World Health Organization B.P. 549 - Ouagadougou - BURKINA FASO Tel: +225-50 34 29 53 t 50 34 29 59 I 50 34 29 60 Fax: +225-50 34 2875 I 50 34 25 48 dirapoc @oncho.afro.who.int www.apoc.bf @ World HealthOrganization