Onchocerciasis control programme in West Africa: seventeenth session Cotonou, 2-4 December 1996

Onchocerciasis Control Programme in West Africa Programme de Lutte contre I'Onchocercose en Afrique de I'Ouest JOINT PROGRAMME COMMITTEE JPC . CCP COMITE CONJOINT DU PROGRAMME Office of the Chairman Bureau du Pr6sident JOINT PROGRAMME COMMITTEE Seventeenth session Cotonou. 2-4 December 1996 JPCl7/INF/DOC.1 ORIGINAL : ENGLISH October 1996 ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA ONCHOCERCIASIS CONTROL PROGRAMME IN WEST AFRICA Information document Onchocerciasis, its transmission and control The disease. its manifestations and repercussions 1. Onchocerciasis is a parasitic disease caused by a filarial (threadlike) worm, Onchocercavolvulus. The adult female wonns (macrofilariae), which are 4045 cm long, lodge in nodules under the skin of infected humans, although they can also be found free in subcutaneous tissue. In patients in Africa the nodules are commonly distributed around the pelvis, particularly over the iliac crest. When fertilized by the smaller male worm, the females, which live for 12 years on average, can produce millions of embryos (microfilariae) about 0.3 mm in length. The microfilariae live for around two years and give rise to the clinical manifestations of the disease. 2. The microfilariae are found in the intercellular fluid, including that of the eye, and their death and subsequent disintegration result in inflammatory reactions. If the microfilarial load is high following a prolonged period of exposure to massive infection, this may lead to serious visual impairment, including blindness. In addition, the microfilariae give rise to intensely itching rashes, to wrinkling, thickening and depigmentation of the skin, to Iymphadenitis resulting in hanging groins and elephantiasis of the genitals, and to general debilitation, including loss of weight. 3. The colloquial name "river blindness" denotes both the endemic location and the most serious manifestation of the disease. Microfilariae are transmiued by the blackfly, belonging in Africa to the Simulium damnosum species complex, which abound near the rivers. A distinction is made between the severe blinding form of the disease in the savanna areas and the "forest" type which has only limited ocular manifestations. 4. Fertile riverine areas are therefore often deserted through fear of the disease so that onchocerciasis, in addition to being a major public health problem, constitutes a serious obstacle to socioeconomic development. 5. Blackfly larvae develop in fast-flowing rivers: for S. darnnosumthe time from laying the eggs to the emergence of adults varies from eight to twelve days. Blackflies live for up to four weeks and can cover several hundred kilometres in flight. A few of the microfilariae ingested during a bloodmeal (necessary for the maturation of the blacktly's eggs) from an infected person develop in the vector into infective larvae (L3) before transforming in the person next bitten into adult males and female worms (macrofilariae). 6. The time between the entry of L3 larvae and the appearance of microfilariae in the skin (incubation period) varies between one and three years. Symptoms of the disease and associated pathology develop gradually over time. The severity of the disease and the risk of ocular manifestations correlate with the intensity of transmission, itself related to the prevalence and intensity of infection in the community as well as the density and cytospecies of the blackfly population. Control 7. Treatment with diethylcarbamazine (DEC) which kills microfilariae (microfilaricide) and suramin, which kills the adult worm (macrofilaricide), necessitates medical supervision given the serious side-effects, and is therefore unsuitable for large-scale application. 11 October 1996 a8. On the other hand, ivermectin (Mectizano Merck & Co.) a microfilaricide available for human treatment since 1988, has proved itself to be a valuable therapeutic agent, easily dispensed under field conditions but without the originally hoped for decisive impact on transmission although more recent experience seems to indicate a limited reduction of onchocercal transmission by large-scale ivermectin distribution. The drug, given once a year in tablet form, reduces the microfilarial load to practically nil within a month or so, after which the microfilariae gradually repopulate in the skin to a half of the pre-treatment level after the first 12 months. Ivermectin therefore needs to be given regularly over an extended period. The benefis in terms of prevention of eye lesions and relief from skin manifestations are impressive. 9. Intemrption of transmission is obtained by spraying insecticides to kill the blackfly larvae at their breeding sites in fast-flowing rivers. Aerial larviciding, the principal mqms of OCP control, is now being combined with community-wide ivermectin distribution within the Programme area to secure the immediate and longer term benefits of the drug. Also, adding ivermectin distribution to larviciding reduces the total period of control from 14 to 12 years, such a long period is required as a result of the drug's limited reduction of transmission referred to in the preceding paragraph. As larviciding combined with ivermectin control started as late as 1990/1991 in parts of the extension areas, OCP operations will need to continue through 2002. Geogranhical distribution of onchocerciasis 10. Onchocerciasis is prevalent in tropical Africa, Yemen and part of Latin America with an estimated 17.5 million people infected by O. volvulus. Before the start of OCP operations in 1974 West African countries were the most seriously afflicted with up to 60% of the population infected while in certain "front line" villages up to one-tenth of the aduls were blinded by the diseaset. The Onchocercfusis Control Programme in West Africa Preoarations ll. A joint US-AID2/OCCGE3/IVHO Technical Meeting on the Feasibility of Onchocerciasis Control hetd in July 1968 in Tunis, Tunisia, recommended that a large-scale control programme based on transmission control through aerial larviciding be implemented in West Africa given the particularly serious situation prevailing in that area: more than one million people suffering from the disease of whom 100 000 presented serious eye manifestations including 35 000 blinded by the disease. 12. A Preparatory Assistance Mission to the Governments of the Participating Countries @AG), co- sponsored by UNDP, FAO, the World Bank and WHO, then prepared a programme of operations in the seven countries4 located in the Original OCP area laying down the control strategy, defining the duration of the Programme at twenty years and estimating the resource requirements. OCP operations commenced in 1974 with WHO as the Executing Agency while the World Bank assumed responsibility for fund-raising and management of the Onchocerciasis Fund. For information re current situation, see 'Report of a WHO Expert Committee on onchocerciasis control" WHO Technical Report Series, 852, 1995 Agency for International Development of the United States of America Organisation de Coordination et de Coop6ration pour la lutte contre les Grandes Enddmies. Benin, Burkina Faso, C6te d'Ivoire, Ghana, Mali, Niger and Togo -3- Programme area 13. The Original Programme area covered 654 000 km2 in Benin, Burkina Faso, C0te d'lvoire, Ghana, Mali, Niger and Togo (start of vector control: geographical Phase I in February L975, Phase II in January 1976, and Phase III @ast and West) in March 1977). An extension of the area (110 000 km2) into the south of COte d'Ivoire (Phase IV) took place in 197811979 thus bringing the Programme area to 764 000 km2. 14. The Original Programme area was extended in 1986 to include also pars of Guinea, Guinea- Bissau, Sierra Leone and Senegal as well as the southern parts of Benin, Togo and Ghana increasing the operational area to L 235 000 knf, with a total population of more than 30 million. In the Extension areas an estimated number of 2.4 million people harboured the parasite of whom 45 000 were blind due to onchocerciasis. The areas under control are those where the "savanna" blinding form of the disease predominates. Programme structure 15. The overall authority for policy making, planning, programming, implementation, financing and evaluation of OCP operations is vested in the Joint Programme Committee (JPC) whose membership consists of representatives of the Participating Countries, the Donors and the Sponsoring Agencies (UNDP, FAO, the World Bank and WHO). JPC meets once a yqr. 16. The independent Expert Advisory Committee (EAC), made up of not more than 12 scientists, carries out annual assessment of OCP operations and provides technical and scientific advice to JPC and to the Programme Director. A sub-committee of EAC, the frve-member Ecological Group, monitors the effect of larviciding on the aquatic environment. Is Terms of Reference have recently been expanded to cover studies of the rivers in respect to the possible impact of changes in land use as a result of increased population pressure in areas freed from the threat of onchocerciasis. 17. Representatives of UNDP, FAO, the World Bank and WHO constitute the Committee of Sponsoring Agencies (CSA) which meets three or four times a year to monitor Programme operations, consider management issues and review documentation for JPC. CSA can provisionally authorize supplementary budgets and approve transfer between budget lines. The Committee also supports socioeconomic development of the oncho-controlled areas. In addition, the Committee functions since 1996 as the CSA for the African Programme for Onchocerciasis Control (APOC). 18. The Programme structure at OCP headquarters in Ouagadougou, Burkina Faso, is now made up of the Office of the Programme Director, the Unit of Vector Control, the Unit of Planning, Evaluation and Transfer, and the Unit of Administration and Management. The OCP/TDR Chemotherapy Research (Macrofil) unit and a liaison oft-rce are located at WHO/HQ. 19. The Programme is financed by Donor countries, international development banks, multilateral institutions and UN agencies. Participating Countries make staff available to OCP, provide office space and offer operational facilities. Financial contributions are deposited in the Onchocerciasis Fund which is administered by the World Bank. Pledging of Donor contributions takes place during the annual session of the Joint Programme Committee. A list of the current Donors can be found in Annex 1. 20. Medium-term plans and budget forecasts are laid down in six-yeat' Plans of Operations corresponding to "Financial Phases" each covered by an Onchocerciasis Fund Agreement signed by the "Contributing Parties", which constitutes the legal basis for the funding and operations of the Programme. A Memorandum of Agreement, describing the institutional and operational :rrangements of OCP and signed by WHO and each of the Participating Countries forms part of the Onchocerciasis Fund Agreement. The Plan of Operations for the Phasing-out Period covers five years only: 1998-2002 -4- Prosramme objective 21. "To eliminate onchocerciasis as a disease of public health importance and as an obstacle to socioeconomic development throughout the OCP area and for the Participating Countries to maintain this achievement". Programme operations Vector control 22. Aerial operations are carried out by a fleet of helicopters available on commercial contract. Weekly flight plans and dosage schedules for larvicides :re determined on the basis of entomological and hydrological data (collected by the Programme-wide entomological surveillance network) which are communicated to the operational bases by means of the OCP radio system and relayed to pilots by means of instant ground-to-air communication. 23. Thehydrologicalmonitoringnetworkin l996consistof l50water-gaugesincludingT9 equipped with hydrological beacons. These beacons make use of automatic devices in rivers and teletransmit the data (water level and discharge rates) via satellite to the operational centres in real time (ARGOS system). This system linked to a discharge forecasting software @ERLE) that relies on the teletransmitted data, makes it possible to improve considerably the efficacy of the larviciding and allows for the most cost-effective selection of larvicides taking into account their crry, purchase and transportation cost as well as the potential for resistance developing. 24. The surveillance network consists of sectors and sub-sectors manned by entomologiss, laboratory technicians, vector collectors, radio operators and drivers. By 1997 the network will constitute five sectors, seven sub-sectors and 12 operational bases located in the Western Extension area. All OCP centres are connected through a radio system. Thus the latest entomological data could be transmitted to them during the weekly briefing session, for larviciding decision-making. Some of the centres are equipped with teletype for easy transmission of written messages. 25. Since 1988/89 when larviciding became a permanent feature in the extension areas, the Programme area has, for the purpose of vector control, been divided into the Eastern Operational Area (EOA) with operational headquarters in Kara, Togo, and the Western Operational Area (WOA) with headquarters in Odienn6, COte d'Ivoire. The aerial bases are located in Kara and Odienn6. The OCP centre for testing of larviciding (the Insecticide Laboratory is located in Bouak6, COte d'Ivoire. Routine monitoring of larval susceptibility to larvicides in current use is carried out with the aid of field teams located in Kara, Bouakd and Odienn6. New insecticide formulations are tested at a field station in Soubre on the Sassandra river in COte d'Ivoire. The length of rivers under vector control varies between 2 000 km during the dry season and l0 000 km at the height of the rainy season. 26. OCP benefits from the advice of the Ecological Group and the support of a Programme-wide network of aquatic monitoring stations in its efforts to ensure that the effect of larviciding on the non- target fauna remains insignificant. In 1996, the OCP hydrobiological service in collaboration with the national teams monitor invertebrates at 13 sites and survey fish populations at l1 stations. Moreover, the Ecological Group performs environmental risk assessments through field studies and laboratory investigations on new insecticides before use in vector control operations. 27. Vector control in the Original OCP area resulted in practically complete interruption of transmission as shown by the values of the Annual Biting Rate (ABR)6 and the Annual Transmission The number of blackfly bites a person would receive if he or she were to sit at the river bank for 11 hours a dry,365 days a year. The tolerability level is set at an ABR of 1000 a criterion to be applied in association with the below ATP limit. ''r''"i "i" I -5- Potential (ATP)? which are below the epidemiological threshold. Since larviciding ceased in the major part of that area after 14 years of control, entomological post-treatment surveys have been made to assess blackflies infectivity. Blackflies were thus collected for dissection at predetermined sites for two years following the cessation of vector control. The results have been entirely satisfactory insofar as in only a limited number of sites did post-control surveillance demonstrate infective blackflies above the threshold levelt necessitating time-l imited resumption of larviciding. 28. In the extension areas, and in those circumscribed zones within the original area still under control, the inclusion of ivermectin distribution as an addition to larviciding has accelerated the decrease in morbidity rates and resulted in an earlier prevention of ocular manifestations and regression of skin symptoms than what is obtained by vector control alone. Epidemiological evaluation 29. Epidemiological evaluation relies on repeated examination of indicator villages consisting of "simple evaluations" (search for microfilariae in skin-snips and visual testing) and "detailed evaluations" (ophthalmological examination added). Most of this work is now carried out by OCP+rained national teams supported financially by the Programme. The data obtained from the evaluation of indicator villages allow for the computation of the incidence, prevalence and community load of infection. These indices, which constitute the elements for trend analysis and assessment of the impact of vector control have taken on added importance in the Original Programme area where they are used to determine where and when onchocerciasis has reached the level below which larviciding can cease. 30. As skin-snipping mees with increasing resistance among the populations examined (no perceived benefits of submitting to snipping and fear of transmission of hepatitis and HIV) and has limited sensitivity in low-level infection situations, the search for alternative diagnostic methods are being intensified. Field testing of a topical DEC patch test is being evaluated for possible use by the Programme. Operational research are continuing on immunodiagnostic and DNA tests capable of detecting onchocercal infection. 31. The capability of the OCP molecular biology laboratory in Bouak6 to apply the DNA methodology to separate the forest (less severe) from the savanna (blinding) O. volvulus parasite and from the cattle parasite (O. ochengi) as well as to identify different species of the blackfly has helped vector control to focus on those areas where onchocerciasis gives rise to serious eye manifestations and been a particularly cost/effective development of Programme-supported research. Ivermectin treatment 32. Ivermectin distribution is applied in all areas under vector control in the two Extension areas. The drug is also distributed in the northern half of the Western Extension area and in the southern half of Sierra Leone, as the sole means of control (biannual treatment in certain foci) as well as in a few circumscribed zones within the Original Programme area. The results are encouraging as demonstrated in the Gambia basin (twice-yearly treatment) where no new infections have occurred especially among children below 5 years of age. The number of infective larvae (L3) which might have been transmitted to the person under I above by the biting flies. The level of tolerability has been set at an ATP of 100 corresponding to the limit below which the risk of contracting serious onchocercal ocular lesions is remote. One infective blackfly per 1000 parous female blackflies. -6- 33. Large-scale, mobile distribution of ivermectin has for several years been entirely undertaken by national staff with logistical and financial support from OCP, while community-based self-treatment has expanded in most of the Programme area. In all, over 2,6 million people were under treatment during 1996 with an average coveragee of 77 percent and a compliance rateto of more than 80%. Biostatistics and information systems 34. Analysis of operational data as well as planning and evaluation of field studies are being carried out in collaboration with national staff with a view to prepare them in the analysis of epidemiological data when OCP ceases; OCP has developed is information system and trained its staff in is use. Similar system was installed in the main operational stations. 35. A major achievement has been the development of a epidemiological computer'tzd transmission model, ONCHOSIM, which is capable of producing epidemiological forecasts under varying control scenarios. Model simulations have thus shown that 14 years of larviciding is required to eliminate the human reservoir of the onchocercal parasite but that the duration of vector control can be reduced by two years if larviciding is combined with ivermectin distribution. 36. As regards recrudescence, computer simulations have led to the conclusion that after 14 years of successful larviciding (unaccompanied by ivermectin control), the risk of reappearance of the disease is less than l%. However, if control is restricted to 12 years of larviciding only, the projection suggests that tlre Community Microfilarial Load (CMFL) will reach between 5% and LO% of the pre-control value within 15 years and 100% of that value after about another 15 years. The model predictions also suggest that an annual incidence of more than 1.0 to l.SVo among adults between surveys undertaken every three/four years would result in recrudescence. The model further predicts that such an occurrence of recrudescence, if detected early, could be controlled with annual ivermectin treatment given for at least 15 years. Maintaining Proeramme achievements 37. To maintain the achievements of the Programme - essential for attaining the second part of the Programme objective - national authorities undertake epidemiological surveillance aiming at early detection of foci of infection/disease, and the timely control of recrudescence by ivermectin treatment. 38. These activities will become an integral part of national Multidisease Surveillance and Control systems and OCP is reinforcing is transfer of surveillance/control methodologies and know-how to the national level. 39. In respect to the process whereby national health authorities develop comprehensive epidemiological surveillance and control systems to a Ievel permitting the integration of effective onchocerciasis recrudescence detection and control within such systems, it is understood that any support required should be provided by WHO/AFRO, the World Bank and other international and bilateral organizations. 40. The OCP-financed fellowship programme is now almost entirely oriented to the training of nationals in such disciplines as epidemiology and health services management (see Table 1 on page 8). Proportion of target population treated Proportion of target population following the treatment regularly I -7 - Management 41. The overall direction of OCP, including implementation of general policy and Programme management, is entrusted to the Director's Office which includes the position of a Coordinator. Chief, Administration and Support Services, is responsible for budget and finance matters, personnel, equipment and supplies, transport and communications. 42. To obtain the best possible cost/effrciency ratio of Programme operations, close attention is given to all activities at all levels to ensure the greatest'benefit at the lowest cost. In this connection, continuing training imbues operational and administrative staffwith a high degree of cost-consciousness. 43. In preparation for Participating Countries to assume responsibility for maintaining the achievemens of OCP when Programme operations come to an end, the majority of the remaining Programme staff is now in national employment assigned to OCP duties. Thus, 550 staff members are employed nationally (of whom 22lhavetheirsalaries paid by OCP) against 187 on WHO/OCP contracr. Research 44. The OCP research programme has always aimed at enhancing the quality of operations and their cost-effectiveness in line with the recommendations made by the Expert Advisory Committee. The research priorities fbcus on six major operational issues: vector control (Simulium bionomics and larvicides); identification of parasite strains; diagnostic testing; chemotherapy (search for a macrofilaricide, effect of ivermectin on transmission (alone or in combination with vector control)); and modelling. 45. An example of the operational impact of research and field investigation is the continuing search for new insecticides applicable in vector control and the efforts made to improve formulations of larvicides already in use. The Programme started off with only one insecticide, temephos, to which resistance developed after several years of operation. Additional products to be used in rotation were therefore necessary so as to overcome the risk of lowered sensitivity in the larval population. The search, carried out in the field by the Bouakd Insecticide Unit has resulted in seventr insecticides now being available which has virrually eliminated the problem of resistance in recent years. Consequently, the search for new insecticides has come to an end and the research focuses on the improvement of Bacillus thuringtensis H-14 (8.r. H-14) fbrmulations. 46. By the end of 1997 financing of the joint OCP/TDR'2 Macrotil project will be modified; it will be supported by OCP, TDR and the new African Programme for Onchocerciasis Control. The research activities will continue to aim at making available a field-applicable macrofilaricide for use in onchocerciasis/lymphatic fi lariasis control. Bacillus thuringiensis H-14, temephos, phoxim and pyraclofos (organophosphorous compounds), permethrin (a pyrethroid), carbosulfan (a carbamate) and etofenprox (a pseudo-pyrethroid) WHONNDP/World Bank Special Programme for Research and Training in Tropical Diseases !q) t= (! o O bo d\o o. o\ '5 o\ (niA.E -(!92 -tr \o!D O\JO\ -Y _oi c,\O.-() o (g o rE o d) ca q) F I @ I (u EES o.:v o \or$o o€-F- r- o@^cn \o -oc.r { .o to-rr) (\l o(.lFN 6o\r- C- 61 st-(*) f- n \o-6l va ro 9.c.l 6 qVIot 19 * .cs$ -x(g () ;q rlx '-o t'- O Prr Ss 3* 3- o Sro (.I c{ x- R_ K- *s I*+t tr -o =dU9 'J< €rrl I I I i6r I I H(i1 .o\vd. oc) .Jbod dc, EE B.E{ t -c{ 9 c.r trn -c{ .,' H:E EoE:EiE @H oi ol \ct i C.l 6l c.t $.a \o +o G o a0 o \O \O r- ol o.l c't t: (nN N c.l FT $o *Ot.f oi o>r .: o0qO i:o d:E r- a{ r r\r \ar $l $ot :Ol$oi oE -o(!J()AIE \OF rf Cnr (') - NH ffar c.t s-Ci F- o .ooI) €o aoql ': all .tl o @l Nl (.tl (nr $- to E r;,ErE qOE 9aJedx x7 0 -9F.=L.! -!'i 6 o (nr (,'l I S' \o tl Ofl t\t ot oI(rt C- s.l >\ a0 + ftw O (n c,.l (-)$ \o o $ @ (.t@ \a 6 t'l@ a\i raglX >r& Ep. > frr I r:. ll:. ln Ir. >r& lrr Eg. >r& lrr ^+Es o €x6: a\a tr oU z zH ra o rn l& z Vc lq tq& o n a rrlF .O U z () t!z D() I u)(n ca I iI1z D o r.l A & 1{o z J Q E]2H cD IrIz ot! .l && EI(r, oo oH J ko t< r.l &)tI]<zt<EloOt- f-'r q) rE Q) _€) , o0 tr(! € o(! o o ] e AU .1 !6 .E {) a o-a o ooc A * I a II -9 - Milestones in the development of the Prosramme 47. During the first Financial Phase (1974-1979) vector control, based exclusively on temephos, expanded gradually throughout the seven-country Original Programme area with the result that transmission was controlled in two thirds of that area. The second Financial Phase (1980-1985) was characterized by continued larviciding, troubled by the end of the Phase by such operational problems as reinvasion and circumscribed instances of resistance to organophosphorous compounds. These problems were accentuated at the beginning of the third Financial Phase (1986-1991) but successfully overcome by the extension of vector control to the sources of reinvasion in the South-east and in the West and by instituting a rotational scheme for the application of the five larvicides then available. Also, the end of that Phase saw the advent of ivermectin as an effective means of control of onchocercal manifestations. During the fourth Financial Phase (1992-1997) vector control ceased in practically all the Original Programme area where the OCP objective had been attained. In the Extension areas larviciding was combined with ivermectin treatment (except in the northern part of the Western Extension area and the southern part of Sierra Leone both under exclusive ivermectin treatment) resulting in an early suppression of clinical manifestations of the disease and in a shortening of the larviciding period required to eliminate the human parasite reservoir. Achievements of the Programme 48. Onchocerciasis is no longer a problem of public health importance or an impediment to socioeconomic development within the Participating Countries, although OCP control need to continue for yet a few years in the Extension areas to consolidate that achievement given the "late start" of vector control in these areas. The disease has practically disappeared in the seven-country Original Programme area where vector control has ceased and there is virnrally no risk of onchocercal blindness in the Extension areas. 49. Expressed in figures, more than l0 million children born within the OCP area since the start of OCP operations have been spared the risk of onchocercal blindness; more than 30 million people are protected from infection by the disease; more than 185 000 have been prevented from going blind; 1.5 million have lost their onchocercal infection; and more than two million have received ivermectin treatment. 50. On the socioeconomic side, 25 million hectares of fertile riverine land, previously uninhabited through fear of infection by the disease, have been "liberated" for resettlement and resumed cultivation expected to produce enough tbod for 17 million people annually. 51. The contribution of the Programme to scientific knowledge has been impressive. The subjecs investigated include identification of the vector members of the S. damnosum complex; identification of the parasites, species and strains of Onchocerca; vector biology and transmission; application of DNA technology; and testing and operational use of larvicides. 52. To maintain the achievements of the Programme, the Participating Countries have instituted effective onchocerciasis recrudescence detection and control or are in the process of preparing for such national activities. Costs of Programme operations 53. The costs of the Programme by Financial Phases and activities are presented in Table 2 (page 10). q ID hEO\:EO\E F6) a.xo \$ ol v? bs(n (v) - \C) -Es _in c'l Eso- qEs eEe -00 o, BRC.i: -q bsoar \ESO(.l q o +ts SE q x c) q(n N nEs\a \o - \Cl -Bs c'l Esc,- c-r Es 9bsHf\ r- SRc.i = I -q EeON 9BsOcn 0 C)k aa, Eo\ ;=O\Edo axq) \,.) -o C.l abs\o 6lr\o \o 6RJto cl Es aBs -\!,) r- E9 c.i 9 un Eq .(n(rl : aERQN rt': ESQ< ooL (\? O\=O\E -a) o.x o \ rn 9Es -ooc.l \o cl bS\o EqJn or BqJt ot sR6i r' ro bR..; = abso- qEsO(o saoo\ E+ Eh()=, .<f o!t(n "es KS c., BR qHoci I Es qN @$ '+r nER ol- 9Esrn ol BSol .=o6c oo\6o-tr(!r E A.@ EO\(+lv n c-r- c-'l BR O !'l cn c- o' ER \ci $ ot uR \bR-r\ ssR .{ co \oo tbs Esol .: l,r1 o@ E egtr<!r 'rifig EO\se q \oo qbR f- coF- C- ,r? Es 61 t"t <bR F l-- oq Es\n ra qBs nbe I 3Aor\c oo! 3T !=-q$II. or r- eo\ \c; rn \ESocl!t t-- 9\eC\ \r| r- \9oi= 9EsO< t? Esc{ r.l EllFil (HEoLC3.9EEqo rD O.-3e*O Q.E EI trl ol :l ol 8l >t (I, o bI) o (t)= fi'B q tr C) odh ?a .Yo .98((,tra\o ..Y E.= tr o o C) o FU o rE ot<o(! a q-€ -egE!F Qaa\ 8E E'6 Aalltr HE E >E> o E C) 'o ci oo v) o o o& tJ. oo(! J 0 0 oo cl a(l L) U) o) o CI, >l .o oE (! trOao.Eoo , q= o otr| €(r+ 2 crt ^ -.,(! o) o o o(J N q) F I - 11- Planning and evaluation 54. The basic strategy for OCP's activities, centered on larviciding for the control of transmission, was laid down by the PAG Mission and reinforced by the adoption in 1984 by JPC of a Long-Term Strategy (LTS) which outlined the operations required to bring the Programme to a successful end. Control operations and their resource requirements are worked out in some detail in the six-yearly Plans of Operations and further detailed in the annual Programme Budget documents presented to JPC for its approval. 55. The main thrust of the LTS was the expansion of OCP activities into the Southern and Western Extension areas intended both to protect the populations in those areas and to prevent reinvasion of infective blackflies into the Original Programme area. 56. A WHO Independent Commission on the long-term prospects of the Onchocerciasis Control Programme, set up in 1979, recommended tnter alia in its 1981 report that OCP operations be gradually extended westwards (the southward extension had already been approved in principle); that funds be provided to pharmaceutical companies to search for a macrofilaricide; that a transmission/control mathematical model be elaborated; that devolution start as from 1991; and that the Programme be eventually transtbrmed into an intercountry disease surveillance training and advisory centre. 57. In 1985 the US-AID undertook an impact assessment of the Programme with a view also to examining the extent to which OCP experience might be of use in planning future AlD-supported programmes. The Agency concluded that "... the OCP, to date, must be considered oneof the more successful multidonor programmes in the short history of development assistance." 58. The AID Mission suggested that lower-cost vector control methodologies, more amenable to devolution, should be looked for; that national involvement should be increased with a view to full integration of the OCP vertical operations within the national health delivery systems; that the search for chemotherapeutic agents be continued; that training be reinforced; that immunodiagnosis be developed; that the Programme continue to address socioeconomic issues; and that there would be a need for an "Inter-Country Facility" as an OCP successor body. 59. In 1990, an External Review concluded that transmission had been virtually eliminated in the Original seven-country OCP area; that major obstacles of resistance and reinvasion had been successfully overcome; that there had been significant achievements in improving larviciding, in ecological monitoring, in entomological research, in epidemiological surveillance and in treatment of onchocerciasis; that there was a need for continued donor support for at least 14 years from the start of larviciding in any given area as well as a need for continued suppoft for the effective institutional arrangements, including autonomy, tlexibility and internal checks and balances. 60. The Review further concluded that the success of OCP could be aftributed to: clear objective; realistic timeframe; choice of best available technology; contracting out of highly specialized task; priority given to operational research; high degree of autonomy; delegation of authority; long-term commitment of Donors and Participating Countries; specified medium-term goals in six-year financial planning cycles; transparency and free information flow among constituent bodies; strong vertical management; and high quality staff. -t2- 61. The report also stressed the need for strong support to: (a) institutional strenglhening in the Participating Countries with special aftention to training and management, O) creation of a Devolution Unit at Programme headquarters and (c) operational research as well as the need for continued search for a field-applicable macrofilaricide. Particular attention was paid to a recommendation to prepare an intercountry facility to provide a framework for post-OCP intercountry collaboration. The Review finally called for continued collaboration among CSA, Participating Countries and Donors to support socioeconomic development in onchocerciasis-freed areas. 62. The findings and recommendations of the Expert Advisory Committee in is 1994 Mid-Term @hase IV) Prospective Evaluation report are reflected in the Plan of Operations for the Phasingout Period (1998-2002). _13- Annex l: List of Donors as at 1996 African Development Bank Belgium Calouste Gulbenkian Foundation Denmark European Union France Germany Italy Japan Kuwait Luxembourg Netherlands OPEC Fund for International Development Pornrgal Saudi Arabia Switzerland UNDP United Kingdom United States of America wHo World Bank