JOINT ACTION FORUM JAF-FAC: TENTH SESSION FORUM D'ACTION COMMUNE Office of the Chairman Kinshasa, 7-9 December, 2004 Bureau du Pr6sident
African Programme for Onchocerciasis Control 0 Programme africain de lutte contre l'onchocercose
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The World Health Organization Year 2004 Progress Report: l't September 2003 - 31 August 2004
JAF 10.5 ORIGINAL: ENGLISH September 2004 JAF 10.5 Page a
I ACKN}WLED^E\|E^fi
We thank the partners of APOC for their contributions in empowering nrral populations in Srrb-Sahar€rn Africa in the fight against river blindness JAF IO.5 Page i TABLE OF CONTENTS
LIST OF TABLES...... ry
LIST OF FIGURES... v VI vIII
1 INTRODUCTION.. 1
2 ACTIVTTIES OF THE NATIONAL ONCHOCERCIASIS TASKF'ORCES AND COMMUNITIES...... 2 2.1 Colnnnv pRoFIrEs oF CDTI tvplsurNrATloN...... 2 2.1.1 C.AMEROO\{ .2 2.1.2 CENTRALAFRICANREPUBLICrcAN.....,.,,, .-l 2.1.3 CHAD ...... 1 2.1.1 .5 2.].5 DEMOCRAT]C REPUBLIC OF CONGO (DRC) .6 2.1.6 ETHIOPIA .7 2.1.7 GABON..... ,8 2.1.8 A,IAL-A,\W...... 8 2.1 .9 NIGERA .9 2.1.10 T.1NZlNIA 10 2.1.t I UGANDA..... II 2.2 Srnrus oF r\fERMECTIN TREATMENT rN APOC couNTRrEs IN 2003 t2 2.3 IEC aNo Aovocacv sv NnrtoNAL ONcnocenclasls Tasr FoRCEs...... l5 2.1 Cori,nraurnrY sELF-MoNrronrNc (CSM) aNp SraxnnoLDERs Mnprnc (SHM) 15 2.1.1 Benefits of implementing CSLI and 16 2.1.2 Challenges of implementing CSM and SHM... I6 2.5 Opr,narroNar Rrss,aRcu (OR) pnoposAls...... , 16 3 ACTNTIIES OF THE TECHNICAL CONSULTATIVE COMMITTEE (TCC)...... 3.1 MEN{BEnsHrp or TCC ,.,.,,....,.17 3.2 Rolr, axo FuNcrroN or TCC ----...... -.....17 3.3 HtcHt-tcnrs or TCC Acgm,rt,rraBvts ...... t7 3.4 CDTI sruov oN cosr pER TREATMENT wrrH IvERMECTIN I7 4 VECTORELIMINATION...... 4.1 Irwanaroctrs.UGANDA...... t8 1.2 MpaNrse-Nrusr, UcaNoa.... .19 4.3 TLrxt-ryu Focus, TaNzaue... .19 4.4 Broro, Equaronrar GuNpn .20 5 GEOGRAPHICAL INFORMATION SYSTEITT: MAPPING OF THE, DISEASE 5.1 Rapneptor,laoI-octcAt-MAIpINGoFoNCHocERCIAsIs .2t
5.1.2 Burundi...... 5.1.3 Ethiopia 21 5 . 1 .1 Tanzania ...... 22 5.1.5 Status of REMO implementation in APOC countries...... 21 5.2 Assnsspm,vr oF THE RrsK oF occrrRRENCE op Ssnlous AovnnsE, E\ENTS cAsEs 5.2.1 Assessmenl of Loa loa in Angola 6 EVALUATION O['THE SUSTAINABILITY OF'CDTI PROJECTS AND DEVELOPING
6. I Specrar MEETTNG oN TrrE slrsrArNABrltrv or CDTI .27 6. 1 . 1 Objectives of the meeting 27 6. 1.2 The main findings of the special meeting on sustainabilitv 28 6.2 Assesspmxr oF susrArNABILITy oF CDTI rN 2004 ...... 29 JAF IO.5 Page ii 6.3 DEVELopING AND REvIEwING SUSTAINABILITY PLANS ...... 29 6.4 MoNItonTNcTTm,IMPLEMENTAIoNoFSUSTruNABILITYPLANS.... 31 6.1.1 Pre-testing of the toolfor monitoring the implementation of sustainabilitlt pIans...... 31 6.4.2 Assessment of the implementation o{sustainability plan of the CDTI prolect in lv[ahenge (fanzania) in the 6th year ...... 3,t 6.4.3 Fact-finding missions...... ".'...... 31 7 FINAI\CING PROJECTS AND OTHER ACTTVITM,S OF APOC MANAGEMDNT...... 32 7.1 Srarus oF FINANCING FIRST. sECoND, THIRD, Fotr'RTH AND FIFTH YEAR PRoJECTS 32 7.2 SrmussroN oF FTNANCIAL RETURNS To APOC FRoM THE PRoJECTS 32 7.3 Ma;on MEETINGS AND woRKSHoPS ...... 32 7.3.l Worksho p for arti c le s wri ti ng on su stai n ab i li ty eva luati on ...... 32 /.J.,J Workshop for articles writing on phase I o.f impact assessment studies -3-l 7.4 VALIDATIoN oF MOMTORING OF TREATMENT 33 8 CAPACITYBUILDING...... 22 8.1 TRANING IN DATA MANAGEMENT AND GEOGRAPHIC INFORMATION SYSTEM ...... 33 8.2 TRAINING IN FINANCIAL MANAGEMENT TN BUNTNOT ...... 33 8.3 MrssroNs. Comrrnv suppoRT AND SPECIAL vlslrs...... 33 8.3.1 Missionfor CDTI in South Sudan (Nairobi) 8-9 December 2003 .31 8.3.2 Finalisation of various arrangementsfor CDTI implementation m Southern Sudan; Nairobi l3th-l 5'h Apnl 2001 31 8.3.3 ,tlission on technical implementation and financial management of CDTI in Congo ...... 31 8.3.1 Post war assessment of the situation of CDTI in Liberia...... 3J 8.3.5 Support mr ssi ons lo NOTF/Malawi ...... 3-t 8.3.6 l[ission to Chad in March 2001 ...... -35 8.3.7 tr[ission to assess APOC activities in Equatonal Guinea.. 35 8.3.8 Training workshop on the management of S4Es in DRC .. 35 8.3.9 Expert mission in DRC Io assess SAE cases.... 36 8.3.10 Support missron to Angola, April 2001 36 8.3.1 I Mssion to Tanzania to monitor the implementotion of SustainabiliN plans 36 8.3. t 2 Factfinding missions in Mgeria and Uganda. 36 8.3.13 trAissions to donors 36 8.3.14 Review of SSI support to Onchocerciasis, Accra, Ghana...... 37 8.3. I 5 Support visits by Temporary Advisors and Consaltants J/ 9 PHASE 2 OF THE LONG-TIRIVI IMPACT ASSESSMENT OF'AFOC OPERATION...... 37
10 OVIRVIEW OF'COLLABORATION WITH OTHER WHO GROTIPS AND TIIE WORLD BANIL3II 10.1 CoonorNarroN AND MANAGEMENT oF THE ACTIVITIEs IN THE Sppclal Iurr,RvENrIoN ZoNES...... 38 10.2 CoLLasonatloN wIrH WHO/AFRO AND WHO/EMRO ...... 10.3 CollaeonanoNonWHO/HQ 10..t CoI-I-e.BonetroN wns WHO/TDR: OPERATIONAL RESEARCH. 3E 10.1.1 Drugdiscovery...... 39 10.4. l. I Target Identification and Validation .. 39 10.4.1.2 Compound Screening and Evaluation 39 10.1.2 Productdevelopment... 39 1O.4.2.1 Moxidectin...... 39 to.4.2.2 Ivermectin. albendazole and praziquantel a pftrarmacokinetic drug interaction study 39 10.,+.2.3 Evaluation of a DEC skin patch (tansdermal delivery technolory) 39 10.1.2.4 Development of a tool to detect ivermectin resistance..... 39 IO.4.2.5 Evaluation of therapeutic approaches to reduce the Loa loa load in the contexl of safe ivermectin in Loa loa / onchocerciasis co infected patients...... 40 10.4.3 Update on Onchocerciasis Implementation Research (I|/HOITDR) 10 10.1.4 trIulti-country study on additional health tasks of CDDs...... 11 10.5 CoLI-asonatloN\r,'nHWHO/HTP .41 10.6 CoLLasoRetIoN wITH THE Wom-o BaNx - ONcHocsnctAsIS UMT .41 10.7 AootrroNat- HEALTH INTERvENTIoNS ...... t I 11 CONTRIBUTION OF THE NON-GOVERNMENTAL DEVILOPMENT ORGANIZATIONS (NGDOS) COORDTNATION GROIIP...... {3 JAF IO.5 Page iii 12 AUDITING THE PROGRAMME ...43 12.l E.TTERNALAUDIT...... , .43 12.2 Iurr,nNar APOC AUDIr...... , .4J JAF IO.5 Page iv LIST OF TABLES
Table 1 Geographical and therapeutic coverage by project in 2003, Cameroon 2
Table2 Geographical and therapeutic coverage of the CDTI project of CAR in 2003 ... . -.,
Table 3 Geographical and therapeutic coverage of the CDTI project of Chad in 2003 . . . . .t
Table 4 Geographical and therapeutic coverage of the CDTI project of Congo in 2003 .. 5
Table 5 Geographical and therapeutic coverage of CDTI projects of DRC in 2003 ...... 6
Table 6 Geographical and therapeutic covemge of CDTI projects of Ethiopia in 2003 . . 7
Table 7 Therapeutic and geographical coverage from 1999 to 2003, Gabon 8
Table 8 Treatment coverage in 2003, Nigeria 9
Table 9 Therapeutic and geographical coverage in 2003. Taruania l0
Table 10 Therapeutic and geographical coverage in 2003, Uganda 11
Table I I Number of persons and communities treated by 57 CDTI projects in 2003 ...... t2
Table 12 Implementation of CSM and SHM in Nigeria in 2003 l5
Table 13 Summary of status of APOC vector elimination prqjects 18
Table 1.1 Collection and examination of river crabs for immature stages of Simulium neavei, in February-March 2004, Itwara focus, Uganda l9
Table 15 Summary of entomological results, Tukqu focus. Tanzania ...... 20
Table 16 Status of the implementation of REMO in APOC countries as at JuIy 2004 . . . . . 21
Table 17 Number of forecasted approved and launched CDTI projects by country asatJuly2004... 25
Table 18 Number of villages per category of risk of SAE according to RAPLOA sun'eys. by province in Angola 27
Table 19 CDTI projects to be evaluated for sustainability in 2004 ... 29
Table 20 CDTI projects evaluated for sustainability as at December 2003: submission and review ofsustainability plans 30
Table 2l Coverage of CDTI areas by integrated interventions in Nigeria (2003) 12 Table22 Results of 7 CDTI projects that integrate vitamin A to CDTI 12 JAF 10.5 Page v
LIST OF FIGURES
2 Figure 1 Number of persons treated by the CDTI projects of Cameroon between 1999 and 2003 (n:9) Figure 2 Number of persons treated by the CDTI project of Cenlral African Republic (CAR) from 1999 to 2003 (n=l) ...
Figure 3 Number of persons treated between 1998 and 2003 by the CDTI project 4 of Chad (n=l) ... Figure 4 Number of persons treated between 2001 and 2003 by the CDTI project 5 of Congo (n:l) ... Figure 5 Number of persons treated by year by the CDTI projects of DRC (n:4) ... 6
Figure 6 Number of persons treated by the CDTI projeas of Ethiopia (n=3) . 7 Figure 7 Number of persons treated from 1999 to 2003 in Gabon 8 Figure 8 Number of persons treated by year by the CDTI projects of Nigeria (n=26) 9 Figure 9 Numberof personstreatedbyyearbytheCDTIprojectsof Tanzania(n=5).-....'.... 10 Figure l0 Number of persons treated by year by the CDTI projects of Uganda (n=4) ... 11 Figure 1l Number of persons treated between 1999 and 2003 in APOC countries t2 Figure 12 Projects with a geogaphical coverage below 1007o in 2003 (n=26) l3 Figure 13 Projects with a therapeutic coverage below 65% in 2003 (n:12) l3 Figure l4a Projects with a therapeutic coverage equal or greater than 65%o (n=26) l4 Figure l4b Projects with a therapeutic coverage equal or greater than 65% (n=16) cont'd l4
Figure 15 Itwara focus in Kabarole Dstrict. Uganda 19 Figure 16 Rapid epidemiological mapping of onchocerciasis (REMO) results in Angola as at June 2004 ... )) Figure 17 Rapid epidemiological mapping of onchocerciasis (REMO) results in Burundi as at June 2OO4 ... 22 Figure l8 Rapid epidemiological mapping of onchocerciasis (REMO) results in Ethiopia as at January 2004 ... 23 Figure 19 Rapid epidemiological mapping of onchocerciasis (REMO) results in Tatlzania as at June 2004 ... 23 Figure 20 Rapid epidemiological mapping of onchocerciasis results in APOC countries as at July 2004 ... 24 Figure 21 Risk for occrrrence of SAEs in Cabinda province, Angola 25 Figxe22 Risk for occrurence of SAEs in Bengo, Uige, Zaire and Kwanza Norte provinces. Angola 26 Figure 23 Risk for occurence of SAEs in Lunda Norte and Lunda Sul provinces. Angola ...... 26
Figure 2.1 Average score for indicators of sustainability at different levels for 35 CDTI projects 28 Figure 25 Nigeria: Mean Sustainability Performance Score for Communities and their overall projects 29 Figure 26 Other countries: Mean Sustainability score for Communities and projects (overall) .. 29 Figxe2T Sites of the impact assessment studies in APOC countries 37 Figure 28 Prediction of prevalence of microfilaraemia by RAPLOA 40 Figure 29 Add-on intewentions in APOC countries .tl JAF 10.-5 Page vi
ACRONYMS
AFRO African Regional Offrce (WHORegional Offtce for Africa) APOC African Programme for Onchocerciasis Control APOD Acute Papular Oncho Dermatitis ATO Annual Treatment Objective BASED Bahai Agency for Social Economic Development CAR Central African Republic CBM Christoffel-Blindenmission (German NGO) CC Carter Center (The Carter Presidential Center) CDD Community-Directed Distributor CDI Community-Di rected Interventions CDTI Community-Drected Treatment with Ivermectin CHAL Christian Health Association of Liberia CPOD Chronic Papular Oncho Dermatitis CRS Catholic Relief Services CSA Committee of Sponsoring Agencies (and APOC sponsors which include representatives of UNDP, FAO, The World Bank WHO. the NGDO Group and Merck & Co. Inc.) CSM Communit_v SeIf Monitoring DEC Diethylcarbamazine DHMT District Health Management Team DMO District Medical Officer DOTS Directed Observed Treatment, Shortrcourse DPM Depigmentation EMRO World Health Organization Regional Office for the Eastern Mediterraneatt FLT{F Front Line Health Falicilitr GGG Go Give and Grow GIS Geographical Information System GRBP Global 2000 River Blindness Program (Carter Center) GTZ German Technical Cooperation (German research support agenq) HIS Health Information System HKI Helen Keller International (US NGO) HNI HealthNet International HH Health for Humanity IDP Ivermectin Delivery Program IEC Information. Education. Communication IEF International Eye Foundation (US NGO) IFESH International Foundation for Education and Self-Help IMA Interchurch Medical Assistance (US NGO) IRC International Rescue Commtttee ITN Insecticide Treated Nets JAF Joint Action Forum (APOC participant loodl) KAP Knowledge, Attitude. Practice LA Letter of Agreement LCIF Lions Clubs International Foundation LF Lymphatic Filariasis LGA Local Government Area JAF 10.-5 Page vii LOD Lichenified Oncho Dermatitis LTG Lohmann Therapie Systeme AG MDP Mectizanru Donation Program MEC Mectizanftr Expert Commrnee MIS Management of Information System MITOSAT}I Mission To Save The Hopeless MoH Ministry of Health NGDO Non-Governmental Development orrganization (see NGO) NGO Non-Governmental Organization (see NGDO) NOCP National Onchocerciasis Control Program NOTF National Onchocerciasis Task Force OCP Onchocerciasis Control Programme in West Africa OCRC Onchocerciasis Chemotherapy Research Centre OPC Organisation pour la Prdvention de la Cecite (French NGO) OV Onchocerca volvulus PHC Primary Health Care PPD Product Research and Development RBM Roll Back Malaria RAPLOA Rapid Assessment Procedure of Loa km REA Rapid Epidemiological Assessment REMO Rapid Epidemiologrcal Mapping of Onchocerciasis RNA Ribonucleic acid SAE Serious Adverse Event SANRU Projet de Soins de Sant6 Primaires en Milieu Rural SHM Stakeholders Meeting SV Special Intervention Zones SNNPR South Nations Nationalities and People Region
SST Sight Savers lnternational (British NGO) SSOTF Southern Sector Onchocerciasis Task Force TCC Technical Consultative Committee (APOC scientffic advisory goup) TDR Special Programme for Research and Training in Tropical Diseases (part of CRD, a department of CDS. WHO) UNICEF United Nations Children's Fund USAID Agenry for International Development (United States agency) VAS Vitamin A Supplementation WB World Bank (Ihe World Bank) wHo World Health Organization WHO/AFRO see AFRO WHOiEMRO see EMRO WHO/HTP World Health Organization's Health Technolory and Pharmaceuticals wHo {Q World Health Organization's Head Quarters WHO/OCP see OCP WHO/TDR see TDR JAF IO.5 Page viii
SUMMARY During the period being reported, the APOC partrrership comprising of the endemic communities, National Onchocerciasis Task Forces (NOTFs), the NGDO Coordination Group, the Technical Consultative Commiuee CICC), the Committee of Sponsoring Agencies (CSA), Merck & Co., and its Mectizan Donation Program (MDP) has made a number of achievements here summarized: (i ) Over 65,(XX) communities (65575) benefrted from ivermectin treatment in 2003. 128,877 CDDs and 131753 health workers were trained or retrained ur CDTI approach. (ii.) According to validated data, more than 31 million (311700570) persons were treated out of a total population of 48,057,039 people distributed in 57 CDTI proJect areas of 11 coturtries. (iii.) By the end of December 2003 a total of 35 CDTI projects had been evaluated for sustainability in l0 countries. ln February 20O4, a special meeting on sustainability was held to review the process, indicators, guidelines and instruments used. The meeting also assessed performance of projects evaluated so frr and documented inportant lessons from the exercise. By the end of 2004, l8 additional CDTI projects are to be evaluated. (iv ) APOC Programme supported National Onchocerciasis Task Forces (NOTFs) of Angola, Congo, Ethiopia and Tanzania in the refinement of Rapid Epidemiological Mapping of Onchocerciasis (REMO). Technical advice and financial support were provided and based on the results of the refinement, additional project proposals were written for Angola and Burundi, 111 projects are forecasted to be treating uhimately 86,311,328 persons by 2010 throughotrtthe APOC countries. Support was also given for an assessment of the risk of occulrence of Serious Adverse Events (SAEs) in Angola and DRC. (v ) Vector elimination activities through ground larviciding (n Tukuyu focus/Tanzania and Mpamba-Nkusi/Uganda) and aerial spraylng (Bioko/Equatorial Guinea) were continued. The findings from Mpamba-Nkusi and Tukuyu reflect good results ahhough there is growing evidence to show that the foci are not so isolated as originally thought ltwara surveillance results show that there is no sign of re-infestation seven years after the end of the last larviciding exercise. (vi ) The TCC reviewed 65 annual technical reports, 22 CDTI proJect and 12 operational research proposals. The committee also considered progress on MACROFIL, training, cost per treatment, RAPLOA and environmental risk mapping, vector elimination, impact assessment and modeling for implementation and oncho control, among others. Members of TCC participated in missions to Angola, DRC, Ethiopia, Equatorial Guinea, Malawi and Tanzania. (vii.) APOC Management conducted training in data management and GIS in Cameroon and Malawi; and in financial management in Burundi, Ethiopia and South Sudan. Various other support missions were sent to Congo, Democratic Republic of Congo (DRC), Ethiopia, Kenya (for Southem Sudan), Angola, Burundi, Chad, Equatorial Guinea, Liberia, Camer@n, Malawi, Tanzania and Uganda. (viii.) The second round of the long-term impact assessment of APOC operations is underway in 13 sites of 8 countries including Cameroon, Central African Republic (CAR), DRC, Ethiopia, Nigeria, Sudan, Tanzania and Uganda. Like the first round, the second round of the impact assessment is undertaking studies in four areas: dermatology, ophthalmology, sociodemography and entomology. (ix.) APOC management continues to derive its strength from the strong partrership and collaboration with WHO/HQ, WHO/AFRO, WHO/EMRO, WHO/TD& the WHO Representatives offices in the respective APOC countries, the NGDOs participating in onchocerciasis control; the Onchocerciasis Unit of the World Bank and many other partners. JAF IO.5
Page 1
1 INTRODUCTION
The strength of APOC's unique partnership comes from its participatory, complementary, and multi-stakeholder nature, which has made it possible in the year under reporting to reach tremendous milestones/objectives efficiently and effectively. APOC parhers through complementary efforts provide unprecedented evidence that the community-directed treatnent with ivermectin (CDTI) strategy is a successful method for delivering medical o, a large scale to remde communities. By adopting the CDTI approach, and embarking upon active"ip co*-rrrity participation, the Programme is also building trust and linkages between communities and the vaned heahh systems in the sub-region. Recently, APOC has taken on the task of determining whether its strategy for delivering ivermectin can be sustained; and promoting mechanisms that will maintain high treatment coverage of eligible populations, including in conflict areas, in the fi.rture after the exit of APOC. The Programme has developed a low-cost tool for rapid monitoring of coverage with ivermectin. By December 2004, APOC would also make arrailable, the results ofi study to issess the cost of CDTI projects, and a standard approach to determining the cost per person treated with ivermectin. The main objective of this report correring the period from September 2003 to August 2004 is to sharethe achievements and challenges of the APOC parfiiers in demonstrating anewwayof doing things in global health. The highlights of the report are on (i) the achievements of the communities and National Onchocerciasis Task Forces (NOTFs) in delivering ivermectin and building intersectoral partnerships, with particular reference to additional heahh interventions using CDTI infrastructure and APOC's grass roots network; (ii) inrcountry capacity building; (iii) the sustainability of CDTI including the ipecial meeting on the sustainability of CDTI; (iv) monitoring the implementation of CDTI sustainability plans of participating districts; (v) progress on the activities of vector elimination in selected foci and future challeng.r;1ri) special update and preliminary findings of the second phase of mapping impact assessment studies, (vii) rist management of APOC Trust Funds; (viil) _of onchocerciasis and Loa loa, (rx) the support of the Technical Consultative Committee and (x) NGDOs contribution to onchocerciasis control. JAF 10.5 Page2
2 ACTIVITIES OF THE NATTONAL ONCHOCERCIASIS TASK FORCES AND COMMUNITIES
2.1 Country profiles of CDTI implementation
2.1.1 CAMEROON
Community-directed treatment with ivermectin The CDTI was launched in Cameroon in October 1998. As of today, 15 CDTI projects have been approved out of which l0 are being implemented. The tenth (North-west province) is completing its first round of treatment and data are not yet available. The NGDO partners are BASED, GRBP, HKI, IEF, SSI and Health for Humanity. Status of ivermectin treatment: geographical and therapeutic coverage In 2003, 9 CDTI projects treated 5843 communities out of a total of 5899. The mean geographical coverage of 99o/o rangesbetween 89o/oand 100%(table l).2,397,949personsweretreatedoutofa total population of 3,173,455 giving an average therapeutic coverage of 760/o with a range of 6lo/oto 82%o. Figare I shows the trend of the number of persons treated in Cameroon from 1999 to 2003. Fis.l: Number of persons treated by the Table 1: Geographical and therapeutic coverage CDTI projects of Cameroon between by project 1r^2003, Cameroon 1999 and2003 Project Geographical rherapeutic coverage (7o) coverage 2 500 000 (Yr) Adamaoua 2 100.0 74.4 2 000 000 Centre I 100.0 68.7 4 r 552 026 a Cqtre2 100.0 66.8 I r soo ooo € Centre 3 100.0 73.5 I 1 010 089 100.0 71.2 I t oooooo 725 058 Linoral2 o E u2$l Norlh Province 100.0 78.3 500 000 South West I 100.0 67.0 South West 2 89.0 61.3 0 West Province 100.0 82.1 tyn 2m0 ?fr| ?fr2 2003 Government and community contributions In 2003, the Government released US$ 95,933.33 for the implementation of CDTI activities. This represents l3o% increase of the amount released (US$ 85,038.08) in 2002. Training A total of ll,5l5 communitydirected treatment with ivermectin distributors (CDDs) and 1442 health workers were trained or retrained in 2003. Detaild information on the training of 2771 CDDs provided by 4 projects reveal that 65% of the CDDs were retrained and 35olo were newly trained.
Main accomplishments X.acts in 2ffi3 In 2003, nine CDTI proje6s achieved 73o/o of fheir CDTI projects approved l5 Projects being l0 uhimate treatnent goal 13,301,823 persons). implemented Projectsyettoblaunched 5 Challenges Forecasted (o be elaborated) projects 0 without NGDO partner I Six of the ten projects being implemented are located in Toiffi 11'515 areas where onchocerciasis and loiasis are co-endemic. rrarnedorretrainedcDDs Trained or retrained health workers 1442 ln these areas at risk of Serious Adverse Events (SAEs), the communities and the National Onchocerciasis Task Force (NOTF) have to maintain surveillance and management of side effects. JAF IO.5 Page 3
2.t.2 CENTRAL AFRTCAN REPUBLTC (CAR)
Community-directed treatment with ivermectin In 1998, the Ministry of Health (MoH) and its NGDO partrer, Christoffel Blinden Mission (CBM) reoriented a community-based ivermectin distribution project to community-directed treatment with ivermectin (CDTD. Only one CDTI project is being implemented in CAR. Status of ivermectin treatment: geographical and therapeutic coyerage Since 2001, the country has experienced social and political conflicts, that adversely affected the levels of geographical and therapeutic coverage. In spite of the conflict, ivermectin mass distribution was not suspended and in 2003,4623 communities were treated out of a total of 5014 representing a geographical coverage of 92%. The therapeutic coverage which dropped in 2001 (69%) and 2002 (43%), reached 75.5% in 2003 (table 2) with 887,747 persons freated out of a total population of 1,176,572 people. The trend of the number of persons treated is presented in figure 2. Fis.2: Number of persons treated by the CDTI Table 2: Geographical and therapeutic coverage project of Central African Republic (CAR) of the CDTI project of CAR in 2003 from 1999 to 2003 Geographical Therapeutic Project coveruge (o/o) coverage (%) I 200 000 1076 292 CAR CDTI 92,2 75.5 1 000 000 887 741 778 989 I 800 000 n o f 600 000 I I 492 2E7 o G f b {00 000 I Fr .n 200 000 l. l 0 I r t999 2000 2001 1002 2003
Training /l In 2003, training and retraining on CDTI implementation concerned only community-directed distributors(CDDs);atota1of4500CDDswere^n6r_.-1tjgs,fu,200p;i ';;r approved I trained. Training of health personner ioi ProjectsSlllttl,*ts being inplemented I undertaken. Projects yet to be launched 0 Forecasted (to be elaborated) projects 0 Main accomplishments partrer The communities and the National onchocerciasis i:"*:t#tBilGDo ' o$o Task Force (NOTF) were able to sustain large scale Trained or retained health workers 0 ivermectin distribution despite the conflict situation the country experienced during the past three years. By treating 887,747 persons in 2003, the project reached 78% of its ultimate treatment goal estimated, at 1,137,640. Challenges The National Onchocerciasis Task Force of Central African Republic has to develop innovative approaches to reorganize and reinforce the National Secretariat, whose equipment was looted during the civil unrest, in order to support CDTI activities. Communities and the NOTF should work hard to bring the geographical and therapeutic coverages ofthe project to the highest levels possible. JAF IO.5 Page 4
2.1,3 CHAD
Community-directed treatment with ivermectin The CDTI project of Chad, a partnership between the Ministry of Health and the NGDO partners (Organisation pour la Prdvention de la C6cit6 and Africare), was launched in January 1998. Status of ivermectin treatment: geographical and therapeutic coverage rates In 2003, mass distribution of ivermectin (Mectizano) was accomplished in 3250 communities. The project achieved a therapeutic coverage of 66.9% (table 3) with 993,698 persons treated out of a total population of 1,486,288. The 2003 therapeutic coverage is the same as the one recorded in 2002 (66.9%\. The trend of the number of persons treated is presented in figure 3.
Ljg3.: Number of persons treated between 1998 Table 3: Geographical and therapeutic coverage and 2003 by the CDTI project of Chad of the CDTI project of Chad in 2003
alt rta ,)z )42 lrtt@t Geographical Therapeutic l60s I Project coverage (%) coverage 3Cfr., JT (%\ itgt II 100.0 66.9 tot B II Chad CDTI lrl zll ilt rrlt t Ulr lrb II T H IT I ,.cB II II I $lrfr II II *bfrt II II .:) lra b II II llti fr II II 3t tr H l& ffi fie JLli It
Training In 2003, a total of 2881 CDDs were trained or { retrained. 2% (49 CDDs) of these CDDs were trained for the first time and 98%o (2832) were retrained. Out of 201 Health workers, 7o/o were J newly trained while 93% were retrained. Main accomplishment The GDTI project in chad is a 'mature^f^:::: cDTrprojects*X*'n2003 I which experienced poor leadership and inadequate :":':'; being inplemented I support the National administrative of s;";;;;;;; :::f:: 0 ror many years. As a resurt or the "uurrutriffiiri. I:::::':,J;l[ i: :ffi:f,:.) projects 0 sustainability of the project, the Ministry of Health Total trained CDDs 2881 (MoH) appointed a new coordination team to Trained or retained health workers 201 improve the effectiveness of the project and for the first time, the government has allocated 70 millions CFA for CDTI activities in the country. Challenges The National Onchocerciasis Task Force should be more committed to the follow up of the CDTI project to maintain full geographical coverage and a therapeutic coverage above the threshold of 650/o as long as Onchocerciasis remains a public health problem in the country. Advocacy towards the decisions makers should be carried out by the National Onchocerciasis Task Force to improve the commitment and support from the Government. JAF 10.5 Page 5
2.t.4 CONGO
Community-directed treatment with ivermectin Two CDTI projects have been approved in Congo Brazzaille; the first was approved in 2000 and the second in 2003. The NGDO partner for both projects is Organisation pour la Pr6vention de la C6cit6 (OPC). To date only the project approved in 2000 has began mass distribution of ivermectin. Status of ivermectin treatment: geographical and therapeutic coverage In 2003, the CDTI project treated 719 out of 748 communities. This represents a geographical coverage of 96oh. The therapeutic coverage which was 35o% in 2002 reached 620/o in 2003 (table 4) with 353 281 persons fieated out of a total of 569 652 people. The trend of the number of persons treated is presented in figure 4. Eg[: Number of persons treated between 2001 and Table 4: Geographical and therapeutic coverage 2003 by the CDTI project of Congo of the CDTI proiect of Coneo in 2003
Geographical Therapeutic Project coverage (7o) coverage (7o) Grql lrl ,lt r Conso CDTI 96.t 62.0 tt (E fi(m I er(ID 2A2:I! - -- l9t rf I / i il(r \ It I-I I ri(m III 18(m TTI ,F ncr III q 0 M Jdrl it{i I& i- Government and community contributions ln 2002, the communities contributed US$ 959.85 to CDTI and in 2003, increased their contribution to US$ 5,837.35. The Government increased the budget allocated to CDTI activities from US$ 34,478 in 2002 to US$ 62,628.2 in 2003. This represents a percentage increase of 82%.
Training a In 2003, 763 new CDDs were trained and 1292 CDDs were retrained. Out of a total of L23 health workers, T2o/o were retrained and 28%o were trained for the first time in CDTI in 2003. Main accomplishment F'acts ln 2003 CDTI projects approved 2 In its third year of implementation, the first CDTI Projects being implemented t project reached 620/o of its ultimate fteatment goal yet 1 (562 278 persons). Despite the conflict situation Projects to be launched Forecasted (to be elaborated) projects 0 experienced by the country in 2002, ivermectin 2055 mass treatment has been maintained. Total tained CDDs Trained or refrained health workers 123 Challenges
The project has yet to reach 100% geographical coverage Rapid epidemiological assessment of Loa loa (RAPLOA) should be concluded in areas where onchocerciasis and loiasis are co-endemic to enable the extension of CDTI activities where possible in the projects' area. JAF 10.5 Page 6
2.1.s DEMOCRATIC REPUBLIC OF CONGO (DRC)
Community-directed treatment with ivermectin A total of 17 CDTI projects have been approved between 1998 and 2004, and 6 projects started implementing CDTI activities including Kasai, Ueles, Sankuru, Bandundu, Tshopo and Bas-Congo. The NGDO partners of the Ministry of Health in the implementation of the projects are CBM, CRS, IMA,IRC, Lions Club and SANRU. Status of ivermectin treatment: geographical and therapeutic coverage In 2003, 4 projects treated 9,866 out of 15, 133 communities eligible for mass treatment. The average geographical coverage was 65%o; varying from28oh in Tshopo, (its first year implementation) to 97oh in Kasai (in its fourth year of implementation). The 4 projects treated almost 4 million (3 986 590) persons out a total population of 7 627 160 people. This represents a mean therapeutic coverage of 52Yo ranging from 23o/o in Sankuru to 68oh in Kasai (Table 5). The trend of the number of persons treated is presented in figure 5.
Fiq. Number of persons treated by year by the 5: Table 5: Geographical and therapeutic CDTI oroiects of DRC coverage of CDTI projects of 3 986 590 DRC. 2003 ao0m0 1 Geographical Therapeutic 3flnm0 Project coverage (Yo\ coverage (%) 3m0m0 Kasai 97.3 68.4 o t! 51.3 28.6 o 2$0fr)o Ueles t 22.9 2m0m0 .f Sankuru 43.3 o o Tshopo 28.r To be validated ! I 500 m0 I Fi 606 420 lm0m0 I f,'acts ln 2003 3n m0 CDTI projects approved t7 0 Proj ects being inplemented 6 2001 2002 2003 -I Projects yet to be launched 1t Government and community contributions Forecasted (to be elaborated) projects 4 rhe annual contribution of the Government to cDTI T:#$11*f:r?:healthworker, 'fiflt including salaries and operating expenses is estimated at US$ 2l,5l}. To sustain CDTI activities, the Ministry of Health has allocated a budget line for Onchocerciasis control. The MoH organized a partners' forum on health and on the use of the CDTI grass roots network to improve other health interventions. Training In 2003, two CDTI projects (Kasai and Ueles) conducted refresher training for 8937 CDDs and trained 5,539 new CDDs. Overall, the projects trained a total of 14 476 CDDs who treated each an average of 236 persons. The two projects ffained a total of 1163 health workers. 52%o of the health workers were retrained and 48%o were trained in CDTI for the first time. Main accomplishment Despite the long period of conflict the country has experienced, the NOTF was able to elaborate 17 CDTI projects (which were approved) out 21 forecasted to provide mass treatment with ivermectin to the population at risk. Challenges The validation of RAPLOA delayed implementation of CDTI projects located in areas that are co- endemic of onchocerciasis and Loa loa. Cases of Serious Adverse Events (SAEs) were reported in the area of the CDTI project of Bas-Congo. The NOTF and its partners are exploring ways for minimizing risks of SAEs before ivermectin distribution is widely conducted in at-risk zones. JAF IO.5 PageT
2.1,6 ETHIOPIA Community-directed treatment with ivermectin Nine (9) CDTI projects have been approved, 3 of which are being implemented. The launching of 6 new CDTI projects was delayed in order to complete the assessment of Loa loa and to delineate the zones co-endemic of onchocerciasis and loiasis, hence, at-risk of occurrence of SAEs in case of mass treatment with ivermectin. GRBP is the NGDO partner of the Ministry of Health in the implementation of community-directed teatment with ivermectin (CDTI). Four projects do not have NGDO partner, but government has committed itself to supporting them. Status of ivermectin treatment: geographical and therapeutic coverage In its third year of CDTI implementation, Kaffa-Shekka project achieved a geographical coverage of 100% (all 3277 communities were treated). In 2003, Bench Maji and North Gondar CDTI projects were in their first year of implementation and treated 794 arrd 71 1 communities respectively. Overall, the three CDTI prqects of Ethiopia treated 4250 communities out of a total of 4782. The projects treated 1,025,859 persons out of a total population of 1,353,597 with an average therapeutic coverage of 76Yo, ranging from 68% (North Gondar) to 81.5% (Bench Maji) (table 6). The trend of the number of persons treated is presented in figure 6. Fis.6: Number of persons heated by the CDTI Table 6: Geographical and therapeutic coverage projects of Ethiopia of CDTI projects of Ethiopia in 2003
(I)0 I 200 I 025 859 Geographical Therapeutic Project coverage (%) coverage (%) I (trom0 Kaffa-Shelcka 100.0 75.2 E f ! oo@o t! Bench Maji To be P I ! 81.5 u ()0(tr0 507 807 validated rE I E roo mo 233 309 A II r0 m0 -
0 2001 2002 2003 Training .l In 2003, re-haining on CDTI was conducted for 2468 CDDs. The projects trained 3141 new CDDs and 460 health workers. v Main accomplishment N RAPLOA was conducted in all the concerned CDTI ,'' .,,..flt*ffi;:;:f$ir&t i.tt projects. g CDTI project" "ff-r"d The results revealed that Loa loa is not a risk factor of Projects being irrplemented 3 yet Serious Adverse Events (SAEs) as the disease does not Projects to be launched Forecasted (to be elaborated) projects exist or it is hypo endemic in the zones of CDTI projects. Total trained CDDs 6 new CDTI projects were elaborated and approved. CDTI Trained or retrained health workers implementation will soon commence in all the 6 outstanding projects. Challenges The National Onchocerciasis Task Force should develop innovative approaches to train the appropriate number of community-directed distributors (CDDs) and empower communities in setting up ivermectin mass distribution system. JAF IO.5 Page 8
2,1.7 GABON
Treatment with ivermectin In 19 villages, with a total population of 9434, health workers distribute ivermectin. [n2003,6425 persons were treated in the 19 villages; this represents a therapeutic coverage of 68Yo (Figure 7 and table 7). Organisation pour la Pr6vention de la Clcitl (OPC) is the NGDO partner. Training In 2003, 6 new health workers were trained and 4 were retrained.
Fie.7: Number of persons treated from 1999 to @-Z: Therapeutic and geographical 2003 in Gabon coverage from 1999 to 2003, Gabon
7 000 6 423 Year Geographical Therapeutic coverage (%) coverage (%) 6 000 5 359 1999 100.0 43.5 ! 5m0 4 228 s0.8 o 2000 100.0 n o {m0 2001 100.0 62.6 b o 2002 100.0 @.7 o 3 000 i 2003 100.0 68.1 t{ 2 000
I 000
0 1999 2000 2001 2002 2003 -4d , |^( M] I t-; 2.1.8 MALAWI d-i. _J I 3.l Community-directed treatment with ivermectin , Community-directed ffeatment with ivermectin was initiated in two districts (Thyolo and Mwanza) in 1997. The project covering these two districts is named Malawi 1. In 1999, a second project, Malawi Extension CDTI, covering five districts was approved. The NGDO partner of the Ministry of Health in implementing both projects is Intemational Eye Foundation (IEF). Status of ivermectin treatment: geographical and therapeutic coverage In 2003, 596 out of 1985 communities received ivermectin. The average geographical coverage ranged from 260/o (Malawi l) to 32.5% (Malawi Extension). In 2003, the total population of the two CDTI projects was estimated at 1,377,241 persons; 701,241 people for Malawi Extension and 676,000 persons for Malawi 1. Both CDTI projects treated 275,367 persons with an average therapeutic coverage of Z\o/oranging froml6Yo (lll,0TgtreatedinMalawi l)to23%(164,288 personstreatedin Malawi Extension project). Challenges
As at June 2003, anumber of communities in each of the 7 CDTI districts were not being reached with ivermectin. As a result, the overall geographical coverage is 30%. The reasons for the poor performance are (i) the small number of CDDs trained, (ii) lack of reliable census data on total number of communities and population eligible for mass treatment. The National Onchocerciasis Task Force is now aware that community-directed treatment with ivermectin has not been properly implemented in Malawi and in 2004 set up a monitoring system to assess full geographical coverage in the concemed CDTI districts. JAF IO.5 Page 9
2.1.9 NIGEzuA
Community-directed treatment with ivermectin A total of 27 CDTI projects were approved between 1997 and2002. All the approved projects are being implemented. The twenty-seventh (Akwa Ibom State) is completing its first round of treatment and data are not yet available. The NGDO parbrers of the Ministry of Health are SSI, GRBP, CBM, HKI, MITOSATH, IFESH, UNICEF. Status of ivermectin treatment: geographical and therapeutic coverage ln 2003,26CDTI projects treated 31,683 out of 37,287 communities with an average geographical coverage of 85% (range: 27o/oto 100%) (Table 8). The projects treated 19,011,784 persons out of a total population of 27,804,561 people representing a therapeutic coverage of 68%o. The trend of the number of persons treated is presented in figure 8.
Number of persons treated by year by the Fis.8: Table 8: Treatment coverage in 2003, CDTI projects of Nigeria Nigeria
20 000 000 18 176 074 Project 18 000 000 ls tI{ uoo
t6 000 000 t o 1{ 000 000 I Bauchi 100 49.1 E !l 12 000 000 Ekiti 100 78.6 10 000 000 Imo/Abia 100 74.1 c ? 8 000 000 Jrgawa r00 85.3 5 Fr 6 000 000 Kaduna 100 85.5 { 000 000 Kano 100 86.1 2 000 000 Kogi 100 89.6 0 Osun r00 68.0 1999 2000 2001 2w2 2003 Yobe 99.6 84:3 FCT 99.3 9l.r Government and community contributions 7-amfara 99.3 8l Cross River 99 72.4 In 2003, the NOTF received as contributions to Kebbi 98.9 89.7 onchocerciasis control activities US$ 12,000 from the Enugu, 95.4 s6.6 Federal Government, US$ 148,430 from the States and Ebony. US$ 87,202.70 from the Local Government Areas PlateauA.{assa. 90.2 89.4 (LGAs). Taraba 90.2 81.1 Training Niger 84.9 64.7 Gonfie 81.8 67.4 In 2003, 26 projects trained or retained 48,152 CDDs Borno 80.7 49.s and 9,293 health workers in ivermectin mass oyo 80.6 49.7 distribution according to CDTI strategy. Benue 78.2 47.4 Adamawa 76.1 85 Main accomplishment Ogun 74.1 69.9 All the approved CDTI projects in Nigeria are being Kwara 73.1 89.4 implemented. CDTI activities in Akwa Ibom state, the Edo, Delta 69.6 72.6 last project to be launched, were delayed in order to Ondo 26.6 57.1 delineate communities at-risk of SAEs due to co- endemicity of Onchocerciasis and loiasis. The ultimate featment goal (UTG) of the 26 CDTI projects distributing ivermectin is estimated at 27,325,207. These projects reached almost 70%o of their UTG by treating 19,011,784 persons in 2003. Challenges As shown in table 8, for a number of CDTI projects in Nigeria, the main challenge remains reaching and/ or sustaining a geographical coverage of 100% and a therapeutic coverage above 65%. Another challenge is to increase and maintain govemment contribution to CDTL JAF IO.5 Page 10 2.I.IO TANZANIA
Community-directed treatment with ivermectin Seven (7) CDTI projects were approved between 1997 and 2003 and all are being implemented except Tunduru (approved in March 2003). Morogoro CDTI project had just completed its first round of treatment and data are not yet available. The NGDO partners of the Ministry of Health in the implementation of CDTI are IMA, HKI, SSI and Lions club. Status of ivermectin treatment: geographical and therapeutic coverage In 2003,5 projects treated all the 631 eligible communities (geographical coverage 100%). They achieved an average therapeutic coverage of 715% ranging from66.7Yoto79.8%o (table 9), by treating l,058,352personsoutof atotalpopulation of 7,512,216 people.Thefiendof thenumberofpersons treated is presented in figure 9.
Fie.9: Number of persons treated by year by the CDTI }b!9_2: Therapeutic and geographical projects of Tanzania coverase in 2003. Tanzania Project Geographical Therapeutic 1 200 000 1 058 352 coverage (%) Coverage (%)
1 000 000 66.9 866 52? Kilosa 100.0 806 136 67.5 ! Mahenge 100.0 O t00 000 i! Ruvuma 100.0 66.7 o 540 757 ! Tanga 100.0 79.8 2 500 000 504 746 0 Tukuyu 100.0 76.4 ? o 100 000 A
200 000
0 1999 2000 2001 2W2 2003
Training In 2003, five CDTI projects trained/retrained 5330 CDDs and 365 health workers. Main accomplishment The projects under implementation reached a full geographical coverage and a therapeutic coverage above the threshold of 65%. Challenges Ensuring government contribution to CDTI. Launching CDTI activities is pending for one project.
CDTI projects approved 7 Proj ects being implemented 6 Projects yet to be launched 1 Forecasted (to be elaborated) projects 0 Total trained CDDs 5330 Trained or retrained health workers 365 JAF 10.5 Page 1 I
2,I.II UGANDA
Community-directed treatment with ivermectin A1l the 4 projects approved in Uganda are being implemented. The NGDO partrers of the Ministry of Health are CBM, GRBP, GTZ, and SSI. Status of ivermectin treatment: geographical and therapeutic coverage There are 4,233 communities in the areas of the 4 CDTI projects. In 2003, 4095 communities were treated representing a geographical coverage of 97%. The geographical coverage ranges from 91 % to 100%. A total of 1,703,518 persons were treated in 2003 out of a total populationof 2,242,458 people; the average therapeutic coverage of 76% ranged from 55% (Phase II project) to 88% (Phase III project) (table l0). The trend of the number of persons treated is presented in figure 10.
Fis.10: Number of persons treated by year by the p!!g-10: Therapeutic and geographical CDTI projects of Uganda coverage in 2003, Uganda
Project Geographical Therapeufic I 800 000 I 632 987 5{3 926 coverage (%) coverage (%) I 500 000 Phase I 100.0 78.0 I 400 000 1226 494 Phase tr 91.0 55.0 r 200 000 G Phase 100.0 88.0 I 000 000 III Phase [V 100.0 82.0 o 800 000 ! 600 000 & 400 000
200 000
0 199, 2000 2001 2002 2m3
Government and community contributions .L.t I In 2003, the central level government contributed US$ 37,000 while the districts and sub-counties contributed US$ 109,630 and US$ 27,234 respectively, adding up to US$ 173,864 released by the Government for onchocerciasis control activities.
Training Facts ln 2003 h 2003, 1625 CDDs were newly trained and CDTlprojectsapproved 4 32,735 CDDs retrained; 23 health workers were Projects being implemented 4 newly trained and 673 were retrained. [n summary Projects yet to be launched 0 34,357 CDDs and 696 health workers were trained Forecasted (to be elaborated) projects I or retrained. Total tained CDDs 34,357 Main accomplishment Trained or retrained health workers 696 All the approved CDTI projects are being implemented and the therapeutic coverage are above the threshold (65%) in 3 out of 4 projects.
The projects treated 78yo of their ultimate treatment goal (2,173,816 persons). Challenges Maintaining government contribution to CDTL JAF IO.5 Page 12
2.2 Status of ivermectin treatment in APOC countries in 2003 In 2003, 57 CDTI projects with a total population of 48,057,039 people treated 31,700,570 persons in 65,575 communities (table 11). Comparedto 2002 (figure 11) thenumberof persons who received ivermectin treatment in 2003 represents I l%o increase of the number of persons treated in 2002 (28,452,663 persons). Validated data shows that27 out of 53 projects reached a full geographical coverage of 100%, while 26 of them did not (Iigure 12). Therapeutic coverage for 43 projects was equal or gleater than 65% (figures 14a and 14b) while the same indicator for 11 projects was below the threshold of 65% (figure 13).
!b!el1: Number of persons and communities treated by 57 CDTI projects in 2003
Number of proiects to report &ertmont data Treated ln 2003 Total Country Expected Reported Persons Communlties Communities 4 4 1,703,518 4,095 2,242,458 4,233 27 26 19,011,784 31,683 27,804,561 37,287 l0 9 2,397,949 5,843 3,1'73,455 5,899
1 I 887,747 4,623 1,176,572 5,014
I 1 993,698 3,250 1,210,693 3,250 2 I 353,281 7t9 s69,652 748 Gabon I I 6,425 t9 9,434 l9 Tanzarlria 6 5 1,058,352 631 1,512,216 631 6 4 3,986,590 9,866 7,627,160 15,133 2 2 275,367 596 1,377,241 1,985 3 3 I 4,250 782 Total 63 57 31,700,570 48,057,039 78,981
Fiq.ll: Number of persons treated between 1997 and 2003 in APOC countries
35 000 000 31 700 570
30 000 000 25 459 s54 E 25 000 000 21 992 346 E
I 6 20 000 000 I u CL {5 000 000 o .l0 IB 000 000
5 000 000 45t 742 ffi
0 {99r t998 ,1999 2000 200'.1 2002 2003 JAF IO.5 Page 13
Fiq.12: Projects with a geographical coverage below l00oh in 2003 (n:26)
100 90 8Bo S70 c o360
:son, E40 g30c o 620 10 0 E sic EE ; 5i E i s; Es Erl5E i3 gpu E
Fie.l3: Projects with a therapeutic coverage below 657o in 2003 (n=ll)
I 00 90 s 80 o 70 61.3 trED 57.1 o 60 B 49.1 49.7 49.9 u 50 ,g 40 8. tE L 30 o t 20 10 0 o o o o ftJ Q N tr o u o F o B o o o =t th o E o G (E TI o U c0 IJJ g G' EE c0 o o cL ED ED o o U IJJ o JAF 10.5 Page 14
Fie.l4a: Projects with a therapeutic coverage equal or greater than 657o (n=27)
100 90 *^80 izo E'I Eeo Eso IJ Eloo 0co o 820 10 0 E s EE l Es r ii ! Es fi 3i i EE al, E E HE = E; EE
tr'ig.14b: Projects with a therapeutic coverage equal or greater than 65%o (n=16), continued
t00
90
80
TO
60
50
/O
30
20
10
0 (l, tt o (r) G, '6 G G o N o Gi E tt o, u Il T T o o o .o u G (l, . 0 o o o o o o g - o G G, ,9 - G' € E G IJ E (E € E - o. E - o. o o- G E o o G' E d JAF 10.,5 Page 15
2.3 IEC and Advocacy by National Onchocerciasis Task Forces Print, electronic media and documentaries are used by NOTFs for behavioral change of target communrties and to sensitize them qr the risks of Serious Adverse Events (SAEs). The NOTFs of Cameroon, DRC (Kasai Province), Nigeria, Uganda, Tanzania, Ethiopia, Chad have produced and are using tEC materials which messages are depicted in the major local languages. Information on CDTI available in the technical reports on CDTI submitted to TCC18 in March 2003 show the NOTFs took commendable initiatives to advocate for community ownership of CDTI. Most importantly, they advocated for strong political and financial support of political leaders, and decision-makers at all the levels ofthe health system and the administrative structure. NOTFs increased advocacy in order to increase &e financial contribution of the govemments as well as the creation of a budget line for CDTI activities at the ProvinciaUState level. Integration is the key element of sustainability and Nigeria is a good example because they have integrated all the activities of the heahh personnel at the front line heahh facility (Fl.ttr) level. 2.4 Community self-monitoring (CSM) and Stakeholders Meeting (SHM) Continuous monitoring and feedback is necessary to maintain hrgh coverage and long-term compliance of affected communities to ivermectin treatment. As communities take on more responsibility for onchocerciasis control it is necessary that they are able to measure their actions/ level of participation. By selecting monitors from among their own ranks and regularly monitoring indicators selected by their members, communities obtain evidence-based information upon which to improve the result of subsequent distribution. In 2000, APOC introduced community self-monitoring (CSM) after the promising results of a study in Uganda and Malawi. In 2001, the draft guide for the facilitation of CSM was distributed to ttre NOTFs and projects were advised to introduce these activities as integral part of CDTI without providing separate funds. NOTFs have been slow in introducing CSM and SHM for several reasons recorded below. Nevertheless, CSM is on going in Cameroon, Uganda, CAR and Nigeria. In April 2004, a workshop on CSM was held in Cameroon. Using participatory method and role-plays, 21 members of NOTF/Cameroon including district personnel leamt how to facilitate CSM. As a result of the workshop, CSM is being implemented in Cameroon. In May 2004, APOC management sponsored a survey to dAermine the projects implementing these activities in Nigeria. We present below a summary ofthe findings ofthe survey. Nigeria ..vr:rth 27 projects has the largest number of APOC-supported projects. The survey showed that most projects have restricted SHM to LGAs and State levels due to lack of financial support. However, between 2001 and 2003 the number of projects initiatrng CSM had quadrupled and a )0o/o increase of the number of communities implementing this activity was recorded. As shown in the table 12, n 2003, l0 CDTI projects implemented CSM without additional request of APOC Trust Funds.
Table 12: Implementation of CSM and SHM in Nigeria in 2fi)3
Projects # CDTI # Communitieswhich # of monitors selectod Communities which emmunities CSM mmmunities SHM 2301 272 l146 349 2850 85 r70 River 930 363 465 151 Ebonyi 973 312 1322 96 Gombe 961 100 500 100 Kadrna 2590 45 220 Niger 2&7 63 154 Plateau 296 Yobe 249 t2t t2t T2 I 579 280 tt2 1,&1 4,210 846 JAF IO.5 Page 16
2.4.1 Benefits of implementing CSM and SHM
The study showed that both CSM and SHM: (i.) Improve community appreciation of the workload of CDDs; help community in determining the number of CDDs required for distribution and improve community understanding of roles and responsibilities in the implementation of CDTL (ii.) Revitalize PHC structures (e.g. village health committee) within the community (iii.) Help community to identify reasons for refusals and proffer solutions. Improved therapeutic goverage in communities where coverage was low. (iv.) The stakeholders meetings (SHM) provided the forum for discussing other health and development needs of the communities- (v.) Help the health service in community diagnosis of problems."It (SHM) has really lessened our work in those communities it was carried out." Mallam Haruna Dadinkowa Alli, Gombe State Oncho Coordinator (vi.) Provided forum for quick community intervention and improvement of health delivery generally without waiting for Government.
2.4.2 Challenges of implementing CSM and SHM
The study identified constraints that have resulted in slow expansion of CSM and SHM. Some ofthese are: (D The front line health facility (FLHF) personnel are unable to carry out CSM and SHM with little assistance from the State and LGA personnel. (ii) Lack of mobility for health staff in project areas where land mass is vast, and communities are scattered. (iii) Shortage of funds, mainly due to delayed or non - release of approved funds by all partners. (iv) Inadequate understanding by project implementers of the benefits of CSM and SHM for CDTI sustainabilitY. (v) Poor management strategies by project leadership. Some project managers have failed to effectively integrate CSM and SHM activities into scheduled field visits. A guide on CSM for front line health staff and CDTI project managers has been released in English and French and available as JAF10/h[F/DOC4. Given the importance of CSM and SHM, the Programme will review the constraints of the NOTF in accelerating the initiation and expansion of these activities.
2.5 Operational Research (OR) proposals APOC Management lends gfeat support to operational research and fieldwork to address critical issues that are likely to impede the implementation of CDTI. In the period under consideration the following operational research proposals were reviewed by TCC 18: "Co-endemic Onchocerca volvulus. L:tmohatic Filariasis and Loa loa lnfootions: A Potential Constraint to the of LF Elimination with CDTI in South East Niqeria" (Nigeria)
"A Pilot S to Ascertain of Selected PHC Interventions based on the CDTI Model" Q'{igeria) "A Pilot Study to Ascertain Sustainability of Selected Community-directed Eye Care Services based on the CDTI Model" (Nigeria) JAF IO.5 Page 17
"studies on ttre possible Macrofilaricidal Effects of l0 Years of Ivermectin Treatment on Orcftocerca volrarlzs from Endemic Communities in Rain Forest Area of Southeastem Nigeria" (Nigeria) "Does Alcohol Consumption increase the Risk of Adverse Reaction to Ivermectin in the Treatment of Onchocerciasis?" (C ameroon) "Witt CtriUren proUae m ?" - a multi-country study on the institutionalization of CDTI through children's ernpowerment (Cameroon, DRC, Nigeria , Uganda) TCC rejected all but two of the proposals and recommended that APOC operational research priorities be established before approval and financing of research proposals.
3 ACTTVTilES OF THE TECHNICAL CONSULTATIVE COMMITTEE (TCC) 3.1 Membership of TCC One new member has joined the committee during the period following her appointment by the Director General of WHO as a full member of the TCC for a period of three years. One more expert is expected to be appointed in order to bring the total number to 12 in accordance with the Programme document for Phase II and the Phasing out Period. 3.2 Role and Function of TCC As the technical arm of the Programme, &e TCC continued to provide technical guidance to APOC management by vetting new CDTI projects and research proposals; reviewing projects' annual technical reports and providing appropriate advice; and making follow-up on technical matters related to implementation of APOC activities. 3.3 Highlights of TCC Achievements During their 17ft and l8m sessions the Committee reviewed a total number of 65 annual technical reports, 22 new CDTI project proposals and 12 research proposals. TCC also considered other implementation matters such as progress on MACROFIL, modelling for implementation of onchocerciasis control, training in data management and geographic information system (GIS), the study on cost per treatment estimates, RAPLOA and environmental risk mapping as it affects CDTI implementation, eraluation of sustainability of CDTI projects and the development of country plans. Other activities reviewed by &e committee are: independent monitoring, vector elimination activities, financial management of APOC funded projects, lmpact Assessment of APOC Operations; use of CDTI to initiate other health interventions, and the new annual technical reporting format. TCC members participated in various missions in Angola, Ethiopia, Equatorial Guinea, DRC, Cameroon, Malawi, Tanzania to assist the NOTFs of these countries in the refinement of REMO (Angola), planning for the second phase of the impact assessment of APOC operations (Cameroon, Ethiopia, Sudan, Uganda); to pre-test the tool for monitoring sustainability plans implementation (Ianzania), and to investigate the aetiology of the reported Serious Adverse Events (SAE) cases in Bas Congo (DRC) TCC1S considered a predictive model to assess the long-term impact of the control of onchocerciasis in Africa througlr drug distributiur. The modalities of collaboration are under discussion between APOC and London Imperial College of Medicine. If approved by both parties, this collaboration on modeling will involve training and research to support the African Programme for Onchocerciasis Control. 3.4 CDTI study on cost per treatment with ivermectin At the recommendation of the Joint Action Forum, &e Technical Consultative Committee GCC) rnitiated and advised APOC management on a study to determine the cost of treatment with ivermectin.
The study is presently underway and its main objectives are: (i ) To assess the costs of CDTI in a sample of projects. JAF 10.5 Page 18
(ii.) To document the structure of costs - e.g. what costs occur at what level, where are the greatest costs incurred, are there economies of scale, what costs are provided by what sour@s. (iii.) To determine the source of inputs needed for CDTI (iv.) To provide a standard approach to determining the cost per person treated with ivermectin and
(v.) To assess how costs vary over time. The selecticn of study sites/projects was done in a manner to captue the likely variability of costs across projects and countries considering such factors as: location of projects in areas with Serious Adverse Events (SAEs), structure of the health system, NGDO partners, densrty of target population for mass treatment, type of settlement pattem of eligible communities and distances bet*""r, project coordination offices and communities. Three countries, Camer@n, Nigeria and Uganda were selected for data collection. This study will provide the Programme a standard approach to assessing costs and reporting cost per treatment information for CDTI - and a policy response for APOC donors and govemments regarding future finding needs.
4 VECTOR ELIMINATION Four vector elimination projects were approved during the Phase I (1996-2001) of the APOC Programme: Bioko Island @quatorial Guinea), Itwara and Mpamba-Nkusi (Uganda) and Tukuyu Oanzania). [n ltwara, Mpamba-Nkusi and Tukuyu ground larviciding is the only vector control strategy used while in Bioko Islan4 in 2003, aerial spraying was combined with ground larviciding. The status of the vector elimination projects is presented in table 13 and the details are described in the sections below.
Table 13: Summary of status of APOC vector elimination projects
Itwara focus Country = Uganda Vector - S. neavei The m.iin focus is v€ctor free for > ? years following large scale ground larviciding. The subfoci have been cleardsine 2002. Entomlogical srrveillane is still pingon
Mpamba-Nkusi focus Country = Uganda Vector: S. neavei Large scale ground larviciding started 2003. Results promising. 2nd & last €mpaign in 2004
Tukuyu focus Country:Tanzania Vectot--S. dwmswm Iarge scale ground larviciding ondrcted in 2003. Cood r€sults, 2nd & last carnpaign in 2005
Bioko County = Equatorial Guinea Vector = S. damnosum Ground and aerial lawiciding in 2003. Good results. 2nd & last campign in 2005.
4.1 Itwara focus, Uganda The focus, covering an area of about 600 Km2, is also called Northem focus. It is composed of three sub foci. The largest iocus is the ltrnara forest Reserve where the vector (simulim newei) had its breeding sites in the Sighi river system. Further east to the main focus are located the sub foci of Siisa and Aswa (figure 15). JAF IO.5 Page 19
From l"' February to 13ft March 2004, an assessment was carried out in the three sub Fis. 15: Itwara focus in Kabarole District, foci of ltwara. The assessment was based on the Uganda immature stages examination of river crabs for l{orthern Onchoceruisia Focur ln X:brrolc DIfrH. (larvae, pupae, empty pupal cases) of the .% Boundaryof bes ;t vector. The summary resuhs are shown in table - -'' -+.. s.+ilriln,rrrvel baledng til8a 14. former br.{dlng 3atas 5In In the sub focus of Itwara, a total of 20 E former breeding sites were visited. Altogether, 1974 crabs were caught and examined. All the art crabs were found negative for early stages of S. t neavei. There was no sign of any re-infestation
7 years after river trealnents had been :!. suspended. In the sub focus of Siisa, 8 sites were assessed. A total of 6-54 crabs were examined, none was positive. Ten (10) sites of Aswa river and its tributaries were visited, and all the 1188 crabs examined were confirmed negative.
Table 14: Collection and examination of river crabs for immature stages of Simulium neavei, in February-March 2(XX, Itwara focus, Uganda
crabs focus caught positive Yo positive Le* positive crab wn in
Itwara r974 0 0.0 r997
Siisa 654 0 0.0 2003
756 0 0.0 2003
I Total ltwara focus 3384 0 0.0
4.2 Mpamba-NkusirUganda Located at about 20 km North East from ltwara focus, Mpamba-Nkusi focus covers an area of 300 km2. Simulium neavei is the vector of onchocerciasis in this focus. Ground larviciding was conducted in July 2003. In February 2004, an assessment of on-going vector control measures was undertaken. Six sites were visited on the main Kitomi fuver and 764 iver crabs were caught and examined. Four of the 6 sites tumed out to be positive, no crab infestations were found in its tributaries. However, potential sources of re-infestation were found on Kategula River and Buhindagi. On Kategula, 92o/o of the 39 crabs examined were positive with 127 larvae, pupae and cases of S. neavei. 960/o of the 23 crabs caught in Buhindagi River were positive with 150 larvae, pupae and pupal cases of S. neavei. The vector control activities launched in July 2003 brought the biting densities to zero; however, because of the potential sources of re-infestation, more information will be needed of S. neavei breeding sites. The mapping of the sites would be more challenging, as the terrain is more difficuh than in Itwara focus. 4.3 Tukuyu focus, Tanzania The limits of the focus were defined and potential re-invasion of the focus was assessed. One potential source of re-invasion is from Songwe River valley, West of Tukuyu focus and from Northern Malawi (where onchocerciasis is hypo endemic). The second potential source of re-invasion is the Songea focus located at 150 km from Tukuyu. From the assessment it appears that Tukuyu focus is not complaely isolated and this would make the control more difficuh. Large scale ground larviciding was conducted between July and October 2003 with the following achievements (table 15): (i) a drastic reduction of fly biting rates and of transmission up to JAF 10.-5 Page20
prospecting no detectable breeding on the Kiwira. and Mbaka rivers January- 200a; (ii) aquatic showed in the 22d week Aom commencement of ground larviciding; (iii) from the 22il week of starting ground larviciding, Lufilo main river was cleared as well as ils tributaries except Kalega and Mwalisi Lux. Challenges are the potential sources of re-invasion and the uncleared status of the tributaries of Kalega and Mwalisi Lux in Tukuyu focus wtrich were not cleared despite large scale ground larviciding. Considering the results of vector specific identification, distribution and the possibility of re- invasion, second and last ground larviciding is scheduled for 2005 in order to enhance the likelihood of success. Table 15: Summary of entomological results, Tukuyu focus, Tanzania
Month River Catching point MBR Flies caught Days Perors NulI parous July43 Lufi$o TapioBridge 4455 297 2 50 247 Mbala Ntaba 1320 88 2 13l 43 Kiwira LwangiaMasoko 5130 342 2 131 2to Lufityo Lffilyo Crater I 185 79 2 l6 63 Mbaka Kambasegela 45 3 2 0 3 Kiwira KaFta 1200 80 2 6 74 Aug43 Lrfi$o Tapio Bridge 150 l0 2 -t 7 Mbaka Ntaba 2to t4 2 4 l0 Kiwira Lwanga lUasoko 330 22 2 4 t8 Lufilyo Lrfilyo Crater 0 0 2 0 0 Mbaka Kambasegela 0 0 2 0 0 Kiwira 75 5 2 I 4 SeF43 Lufilyo 0 0 2 0 0 Mbaka Ntaba 45 3 2 -t 0 Kiwira LwangaN,Iasolo 45 -t 2 -t 0 Lufilyo Lufilyo Crater 0 0 2 0 0 Mbaka Kambasegela 0 0 2 0 0 Kiwira 45 J 2 J 0 &t-03 Lffilyo Bridge 0 0 2 0 0 Mbaka Ntaba 0 0 2 0 0 Kiwira Lwangaldasoko 0 0 2 0 0 Lulilyo Lufilyo Cralsr 0 0 2 0 0 Mbska famhsegela 0 0 I 0 0 Kiwira 0 0 2 0 0
4.4 Bioko, Equatorial Guinea The vector of onchocerciasis is Simulium damnosum, Bioko form. Large scale aerial and ground larviciding started in 2003 and the results are promising. Environmental assessment surveys before and after treatments show the number of fish species was constart and their behavior was not disturbed, quantlty of shrimps was not reduced, &e density of macro-invertebrate in 2003 was comparable to that observed in 1999. Hydrological map was completed with the rivers missed during 200i campaign. Aerial larviciding scheduled for 2004 has been postponed to 2005 because of late reception of insecticide. JAF 10.5 Page2l 5 GEOGRAPHIGAL INFORMATION SYSTEM: MAPPING OF THE DISEASE [n2004, APOC supported the National Onchocerciasis Task Forces to:
. Refine the REMO maps of Angola, Burundi, Ethiopia and Tanzania; . Implement RAPLOA in geographical areas of newly approved or forecasted CDTI projects. 5.1 Rapid epidemiological mapping of onchocerciasis Since 1997, rapid epidemiological mapping of onchocerciasis (REMO) has been conducted in all APOC countries. Due to conflict, civil unrest and insecurity, the mapping of the extent of onchocerciasis was postponed or uncompleted in some countries (Angola, Burundi, CAR, Congo, DRC, Ethiopia, Liberia, Sudan, Tanzania, Uganda). During the period under review, APOC Management provided technical and financial support to the National Onchocerciasis Task Forces (NOTF) of Angola, Congo, Ethiopia andTanzania for the refinement of REMO maps.
5.1.1 Angola
As a result of the REMO conducted previously in the l8 provinces of the country, the Joint Action Forum (JAF) approved three CDTI projects in December 2003. In 2003, a refinement exercise was carried out in 7 provinces (Bengo, Cuanza Norte, Cunene, Huila, Cuando Cubango, Lunda Norte, Moxico). The results confirmed meso/hyper endemic areas in the provinces of Bengo, Cuanza Norte, Cuando Cubango, and Huila. A further refinement exercise revealed a meso-endemic area in the province of Uige. Based on the updated REMO map, the NOTF of Angola submitted to APOC Management three (3) new CDTI project proposals to cover Bengo, Ctanza Norte, Huila and Kuando Kubango provinces. The Technical Consultative Committee (TCC) of APOC recommended the approval of 2 of the proposals for mass distribution of ivermectin in Bengo, Cuanza Norte, and Kuando Kubango.
Figure 16 shows the updated REMO map of Angola with the delineation of the approved and forecasted CDTI projects.
5.1.2 Burundi
In 2003, the NOTF decided to complete the REMO in the zones where additional data are needed to determine areas for ivermectin mass distribution. This refinement exercise allows an update of the REMO map of Burundi, the delineation of two (2) new definite CDTI areas in the provinces of Bururi and Rutana. Two CDTI project proposals have been elaborated by the NOTF and forwarded to APOC Management for consideration. The REMO map of Burundi as at June 2004 is presented in figure 17. REMO has been delayed in the provinces of Cankuzo, Kirundo and Ruyigi due to social unrest. With the improvement of the security situation, the NOTF plans to complete REMO in these provinces by September 2004.
5.1.3 Ethiopia
The NOTF conducted a REMO refinement exercise in 8 zones (Assosa, Kamashi, Metekel, East Wellega, Jimma, West Showa, Guragie and Hadiya) in 3 regions (Benshangul-Gumuz, Oromia and SNNPR) in Ethiopia. In the 29 villages selected for the suryey, the prevalence rate of onchocerciasis nodule was less than20o/o. Thus, the areas of survey have been definitely classified as non-CDTI. f igure 18 shows the updated REMO map and indicates that a refinement exercise should be carried out in North Gonder and Metekel zones.
The update REMO map of Ethiopia reveals that no new CDTI project proposal will be elaborated. JAF 10.5 Page22
5.1.4 Tanzania
In May 2004, the NOTF of Tanzania with the technical and financial support from APOC undertook a REMO refinement exercise in 9 Regions. ln the 78 villages sampled, 32.1% of the population examined had palpable nodules. The results of the refinement exercise reveals meso- endemic area in Morogoro and call for an extension of CDTI activities to the concemed areas (figure 1e).
Fis. 16: Rapid epidemiological mapping of onchocerciasis (REMO) results in Angola as at June 2004
Lat.nd
cm
-_
Fie. 17: Rapid epidemiological mapping of onchocerciasis (REMO) results in Burundi as at June 2004
Clbtokc llOozl
XrJHnza
Lo6nd
wH0/p0c2ffi2m4 o20{0 ------I JAF 10.5 Page23
Fiq. 18: Rapid epidemiological mapping of onchocerciasis (REMO) results in Ethiopia as at January 2004
. Legend E Zdncs I D6fini.tc CDTI E To be refined I llo CDTI m. Excludcd.
T
uth 0
Fis. 19: Rapid epidemiological mapping of onchocerciasis (REMO) results in Tanzania as at June 2004
Xigorna
LEGEIID 4 Mbeya ! o"o"rt
!mcon Lltldi 'fi snr*t '- Xtt rrrlP.rlel ! ur'' l'rlwara xt Eo*- 0to!tr tVH(yAP0C/tjune2004 ------'i JAF IO.5 Page24
5.1.5 Status of REMO implementation in APOC countries
The status of the implementation of REMO in APOC countries is presented in table 16 below:
Table 16: Status of the implementation of REMO in APOC countries as at July 2004
REMO comnleted REMO to be completed Cameroon, Chad, Malawi, Nigeria, Tanzania, Angola, Burundi, CAR, Congo, DRC, Equatorial Kenya, Gabon, Mozambique, Rwanda Guinea, Ethiopia, Liberia, Sudan, Uganda To date, REMO has been either partially completed or finalized in the 19 participating countries (figure 20) in stable or conflict situation. Refinement of the REMO map is being delayed in 9 countries because of conflict, insecurity, landmines and poor roads (table 16). Based on the REMO data a total of l1 I CDTI projects has been forecasted (table 17), which will protect 102,751,581 persons at risk by treating 86,311,328 people (ultimate treatment goal) by 2010. 102 CDTI projects are approved and the NOTFs are working hard to develop the remaining 9 proposals.
Fie. 20: Rapid epidemiological mapping of onchocerciasis results in APOC countries as at July 2004
? Eq Kenya Leoend Gabon ! o"r*it" cotl To be refined ! No corr i[[!r""ai"g /11Exchded
ii,ii lfatura par*s ! r*". National boundaries
KM
0 500 WHOiAPOCi 10July20O4 JAF 10.-5 Page25
Table 17: Number of forecasted, approved and launched CDTI projects by country as at July 2W
Number of CDTI pnojects Forrcasted Angola 7 5 0 Burmdi -t 1 0 Cameroon l5 l5 10 CAR I 1 1 Chad I I I Congo 2 2 I DRC 2t 17 6 Eq. Guinea I I I Ethiopia I 9 J Gabon I I I Kenya 0 0 0 ,' Liberia 3 -t l{alawi ) 2 2 Muambique 0 0 0 Nigeria 27 27 27 Rnanda 0 0 0 Sudan 6 6 I 7 7 6 u 5 4 4 r11 r02 66
5.2 Assessment of the risk of occurrence of Serious Adverse Events cases During the 18ft session in March 2004, the Technical Consultative Commiuee CICO of APOC recommended that, prior to mass treatment with ivermectin CDTI projeas in areas suspected to be co-endemic for onchocerciasis and Loa /oa should complete a Loa loa suwey in order to define risk zones and to set up preventive and early management of Serious Adverse Events (SAEs). During the period under review, the level of endemicity of Loa loa was assessed through rapid assessment of Loa ioa (RAPLOA) in Angola. RAPLOA exercise is presently underway in the South province of Cameroon and the results will be presented to the Joint Action Forum in December 2004.
5.2.1 Assessment of Loa lut in Angola Fie. 2l: Risk for occurrence of SAEs in Cabinda province, Angola RAPLOA was implemented in the provinces of Lunda Norte, Lunda Sul, Cabinda, Bengo, Cuanza Norte, Uige and Zaire, all except Zaire are located in CDTI priority areas. Table 18 summarizes the results of RAPLOA studies in Angola, while figures 21, 22 and, 23 present the map for risk of SAEs in the provinces of Cabinda (figure 21), Bengo, Uige, Zaire and Kwanza Norte (figure 22), Lunda Norte and Buco-Zau Lunda sul (frgure 23). The RAPLOA results reveal that (D the risk of SAEs is high in Cabinda and Bengo; (ii) Uige and Zaire provinces are at some level of risk; (iiD ivermectin mass distribution can be carried out in Lunda Norte and Lunda Sul provinces. Even there, the NOTF had trained the CDDs on early diagnosis of : Ebr GI &- EI- potential SAEs and quick referral to health facilities o( ry (E-,. Li.6rr cr F .Iri b ua tF - r00$ EI ralo-si for proper management according to MEC/TCC kre-!a$ D,d[r-uo guidelines. H DrdlO-0rti JAF IO.5 Page26
Fie.22z Risk for occurrence of SAEs in Bengo, Uige, Zaire and Kwanza Norte provinces, Angola
lSqri do 2bDbo XriDba Sayo fSerr Congo
S60o l.llno.
B09o
E Enlo btr!oir Outre
It rin b:
[= llfirik OnI til l_l E.rFor E Eo,iri- J El Lridl lo.ilrnr f-n of 3[ (hw. tnrq of w o:d fi kr EA lt0 - r0t$ Fiktio-retFI rii td - rem 0olone. bcr! Er",i.r tr - ieo i.nCo r L ril t0 - 0.t38 ,ll E ro ur. -J\-\
Fie. 23: Risk for occurrence of SAEs in Lunda Norte and Lunda Sul provinces, Angola
llassango I Cuilo la) Caungula Luc+a
Lunda No Lubdo
Saurin o b bundi-C Lu sur'*ntb
D.lr Ouirin a AncIJlo
Lum aqe Alto-Ianbeze :'.: I):firit: fltrI :or bicilior E LuBna (toxlEo) EI bliorl Los&ria i;L Sl! lEcv. Lirtorr oI c- trt) Iar"{ lirl tCO - rmlO E Eilr ({ - c'!0 LJ br (m - 9I0 Io rin lr - 19! !o sirl l0 - 0.99S tco I E lo lh.h (:hltm hn JAF IO.5 Page27 f4[!g-[!: Number of villages per category of risk of SAE according to RAPLOA surveys, by province in Angola
Risk of SAE No risk Low risk High risk Very high risk (Prevalence of Loa loa based on history of eye Total (0%) (t-re%) (20-3e%) (40-se%) (60-100%) worrn, restricted definition) Provinces Bengo 0 (0%o) 0 (0%,) 0 (0o/o) 0 (0%o) 7 (100.0%0) 7 Cabinda 0 (0%o) 0 (0%o) I (5.0%o) 4 (20.0%0) ts (7s.0%o) 20 'KvanzaNorte 0 (0%o) t (0%o) 3 (7s.0%o) 0 (0%o) 0 (0%") 4 'trrnaaNorrc 26 (s4.2%") 2l (43.8%o) t (2.1%o) 0 (0%o) 0 (0%,) 48 Lrmda Sul 5 (19.2%o) 2t (80.8%,) 0 (0%o) 0 (0%o) 0 (0%") 26 Uigc t8 (5 t.4%o) 14 (40.0o/o) 2 (5.7%o) I (2.9%o) 0 (0"/.) 35 Tairc 0 I 8 4 0 t3 TOTAL 49 (32.0%d s8 (37.9%) ts (9.8%o) 9 (5.9%) 22 (14.4%) 1s3
6 EVALUATION OF THE SUSTAINABILITY OF CDTI PROJECTS AND DEVELOPING SUSTAINABILITY PLANS 6.1 Special meeting on the sustainability of CDTI Since 2001, APOC has taken on the task of determining whether its strategy, community directed treatment with ivermectin (CDTI) is sustainable. The exercise has included developing and assessing indicators, aspects and critical elements of sustainability at each level of operations crucial to intervention. By 31 December 2003,35 CDTI projects and 8 headquarters support projects in l0 countries were evaluated (see tabte 20). With the approval of JAF 9, a special meeting on the sustainability of CDTI was held in Ouagadougou in February 2004.
6.1.1 Objectives of the meeting:
(i.) To review and draw lessons from the performances and achievements ofCDTI projects assessed for sustainability; (ii.) To review the indicators, guidelines, instruments, aspects and critical elements used for assessing sustainability of CDTI; (iii.) To review the guidelines for developing sustainability plans and develop criteria for reviewing such plans; (iv.) To design a tool for monitoring the implementation of projects' sustainability plans by participating governments. The meeting worked in plenary and small groups. The findings of the evaluations were discussed during plenary and recommendations made to enhance CDTI implementation and sustainability of projects. 35 CDTI projects in l0 countries (Cameroon, Chad, DRC, Congo Brazzaville, Ethiopia, Malawi, Nigeria, Sudan, Tatzania and Uganda), 120 districts/LGAs and 468 communities had been evaluated on process, input and outcome indicators. The indicators provide information on whether the seven 'aspects' and 'critical' elements of sustainability are present or not in a project. The performance of a project for each indicator was considered satisfactory on a 4-point scale if the project scored 2.5 and above. JAF IO.5 Page 28
6.1.2 The main findings of the special meeting on sustainability
Considering the four operational levels of CDTI implementation, the best performance was found at the regional/state/provincial (RSP) and community levels. The district/LcA and frontline health facility (FLHF) levels did not perform well for indicators of funding/finance and material resources. Integration of CDTI into routine activities of the health system was found satisfactory in the projects in Ethiopia, Uganda and some projects inTanzaria, Cameroon and Nigeria. Thirty-three (94%) of the 35 projects achieved above the 2.5 average scores on the indicator, 'Mectizan@ supply and Distribution' indicating that most National Onchocerciasis Task Forces (NOTFs) have put in place a good system for the delivery of Mectizan@. In more than 70%o of the projects, Mectizan@ was integrated and delivered to Sub-districts/FlHFs, for collection by communities, through the govemment system. There was concem about the lack of empowerment of the frontline health staff in several sites. The community level in 25 (71.4%) CDTI projects scored higher than the cut off point of 2.5 and had a mean score higher than other levels of operations for the same indicators (figure 24). From the results of the evaluations the meeting agreed that the performance of the FLHF influences the performance of the communities, and in cases where FLHF scored <2.5, the overall sustainability score of the project was less than2.5 irrespective of the community score of > 2.5. More importantly, the community score influenced the overall project score thus making these levels (FLHF and community) very vital to sustainability of CDTL Figures 24,25 a;nd26 illustrate this conclusion. The special meeting reviewed the definition of sustainability and agreed that it focuses on community ownership and the output indicator, i.e high treatment coverage, leaving room for projects' innovative ways of achieving these. Following the discussions at plenary session, the meeting recommended a new definition of sustainability: "CDTI activities in an area are sustainable when they continue to function elfectively for the foreseeable future, with high treatment coverage, integrated into the available health care service, with strong community ownership, using resources mobilized by the community and the government." The meeting developed criteria for reviewing CDTI sustainability plans, prepared the draft tool for monitoring the implementation of plans and made 54 recommendations on all several aspects of sustainability.
Fie. 24: Average score for indicators of sustainability at different levels for 35 CDTI projects
Aver';r ge sc u' e for Intlica tor s nt diffa' ent ls'els
s 6u o o Itr .g E o o fi o I
N=35 StbOidrid JAF IO.5 Page29
Fis.25: Nigeria: Mean Sustainability score for Communities and their overall projects
4 35 ICommunity lProjecl
3 25
2 15
1 05
0 o d*.r$""'*" i6 .::-"" """"* *"d *"$ "d*"-"s'*s"*"+"y+'o
Fis. 26: Other countries: Mean Sustainability score for Communities and projects (overall)
4 3,5 r€offirrty rProFd 3 2,5
2 1,5
1
0,5 0
*."'-","" -.:-r" e$ uod S .*"l.dn"- "*+o"c o..*"
6.2 Assessment of sustainability of CDTI in 2fiX Table 19: CDTI projects to be evaluated for sustainabitity in 2004 This year, 18 CDTI projects will be evaluated for sustainability and three are underway (table 19). The COUNTRY PROJf,CT proJects are located in Cameroon (3), Nigeria (9), CAMEROUN Centre I (3) (3) Uganda (2), and one each in Tanzania, DRC and Centre 2 Littoral 2 Equatorial Guinea. NIGERI.A Kwara 6.3 Developing and reviewing sustainability plans Zamfara oyo Of the 35 CDTI projects evaluated in 2002 and Jigawa 2043, 24 projects have submitted plans sustainability EdolDelta representatives govemment from srped by the of Oeun (3) regionaVstate and districylcA levels and NGDO Bomo pafirers. Adamawa In each proJect there are several districts, which Niger is the unit/level of operation and management of CDTI. TANZA}IIA Kilosa (3) DRC Ulele Because the district heahh management team @HMT) UGANDA Phase III has to make long-term commitrnent to sustain CDTI, it Phase IV chairs and participates in the feedback meeting and EQ. GI.JINEA CDTI workshop to develop sustainability plans. The district leaders and evaluators share the results of the evaluations, review ownership of CDTI by the community and health system, monitoring mechanisms and define altemative sources of support from govemment for sustainable financing after the cessation JAF 10.-i Page 30 of APOC. To date 256 senior heahh numagers and NOTF staff in 8 countries have participated rr developing CDTI sustainabilily plans for CDTI and other health Programmes. In the period (Sept 2003 - July 2004), APOC management had expected 376 plans. It has received 256 and reviewed 217 of them and Table 20 presents their status.
Table 20: CDTI projects evaluated for sustainability as at December 2fi)3: submission and revierv of sustainability plans.
YearPnojtrts Year Projects Plan No PrCIject evaluated #Ilistricts/LcAs #Di$ri(dLGAs Received Revised Nlalawi I Thyolo Mwama 2 Yes Yes 2 Ext. districts (5) 5 Yes Yes Nigeria 3 Bauchi State l3 No No 4 Benue State ; No 5 CmssRiverState 14 Yes No 6 Ekiti Stat€ l0 No 7 Enugu/AnambralEbonyi 42 2 of3 Yes 8 FCT Abqia 6 No 9 Combe State 10 Yes Yes 10 ImoiAbia States 24 Yes Yes l1 Ka&ma State t7 Yes No 12 Kano State 18 No 13 Kogi State 2t Yes Yes 14 Nalional HQ I Yes Yes f5 On& St rte 14 No 16 O$m State t7 No 17 Plateau/Nassarawa 24 Yes Yes 18 Taraba State t2 Yes Yes 19 Yobe State t2 No Tanzania 20 NationalHQ I Yes Yes 21 Rrluma J No 22 Tzrgt Yes Yes 23 Nlahenge ; Yes Yes 2a Tuknyu No Cameroon 25 Adamaoua 4 Yes Yes 26 Centre Itr 8 Yes Yes 27 lr{ational FIQ I Yes Yes 28 NorthProvince 6 Yes Yes 29 South West 1 9 Yes Yes 30 South West 2 5 Yes Yes 31 WestProvince 15 Yes Yes Chad 32 National,'HQ I Yes Yes 33 CDTUChad 5 Yes Yes Uganda 34 (Phase I) KisorolKasesel 4 Yes Yes Masindi 35 (Phase ID Kabale/Tvlbale/ 7 No KabarolelBushenyi/Simnkoi KendjojolKamvenge No 36 National.,?lQ 1 : Congo 37 CDTI J No Bmzzaville 38 National,*lQ I No 39 NationalrLIQ I Yes Yes Ethiopia .10 Ka&/Shelska ll Yes Yes 4l Kasai'CDTI 5 No DRC 42 NationaliHQ No Sudan 43 CDTI ; : Yes Yes JAF IO.5 Page 3 I
6.4 Monitoring the implementation of sustainability plans
Commrxrity level sustainabilrty of a CDTI project is critical but not sufficient. The results of the evaluation of projects show that sustainability of support to community actions by higher levels (govemments, in particular- district and FLHF) is critical to sustainability. It is for this reason that in monitoring the implementation of sustainability plans, APOC's emphasis is on support by participating govemments to CDTI at these levels. In addition, integration of the key CDTI activities (supervision, drug delivery, retraining of heahh staff and CDDs, mobilization and sensitisation) irto the routines of the heahh services is thought to be critical.
In the period under reporting APOC Programme did the following:
6.4.1 Pre-testing of the tool for monitoring the implementation of sustainability plans
An APOC Management Staff member together with a TCC member pre-tested the tool for monitoring the implementation of sustainability plan by govemments in Mahenge CDTI proJect. The findings are ur section 8.3.11 ofthis report.
6.4.2 Assessment of the implementation of sustainability plan of the CDTI project in Mahenge (Tanzania) in the 6ft year
In May 2004, a monitoring team visited ilre project to determine if the activities proposed in the sustainabilrty plans are being implemented as proposed by the districts and frontline health facilities. The report of the mission is available and a summary of the findings is provided in this report under section 8.3.11.
6.4.3 Fact-finding missions.
In 2002, the evaluations of the CDTI projects in Taraba and Kaduna States, Nigeria andthe Phase I districts rn Uganda reported that all three pdects were "not far .from being sustainoble" and made recommendations for the projects to implement their plans in order to enable them to be completely sustainable. In line with this recommendation, the national and district authorities drew up 3-year sustainability plans and started their implementation without any financial support from APOC. For several reasons these three prqects @hase I /Uganda, Taraba, Kaduna in Nigeria) did not receive APOC Trust Funds for 2 years, between Ian.2002 and June 2004. In May 2004, the management of APOC commissioned three fact finding missions to: (i) assess how the four districts of Phase I project, Uganda and 29 LGAs of Taraba and Kaduna projects in Nigeria were inrplementing their sustainability plans (ii) to assess success and constraints the districts/LcAs were facing in implementing sustainability plans (iii) to assess whether health workers were continuing to provide training and support supervision to CDDs (iv) to assess urhether treaUnent coverage had remained high after APOC furding had ceased. Monitoring was based on evaluation report and sustainability plans. The following indicators were monitored: Planning, support supervision, sensilization and mobilization, Training, Mectizano procurement, delivery and distribution, Transport, Finance, coverage and r€,porting.
The main findings of the assessmexrt of the Matrrenge (which received a financial support -from APOC) and the three CDTI projecs without any -financial support for two years are: (i ) Mectizano procurement and delivery at all levels uses govemment funds and controlled system; (ii ) Two (Kisoro, Kasese) out of the four districts released additional firnds from PHC conditional grant and /or subdistrict allocations to sustain CDTI core activities; integrated supervision and transport; (iii.) There is ample evidence of effective integration of CDTI with other heahh activities at all levels particularly in the Uganda proJects. In spite of lack of direct financial support, CDDs in the three projects have continued their work efficiantly. JAF IO.5 Page32
(iv ) In Taraba, based on collective decision, some cornmunities are paying CDDs 0.15 US$ for each household treated. (v) Mectizano distribution at the community level is very satisfactory" and CDTI has continued in the four projects with commendable success. The lesson is that sustainability of CDTI is achievable by governments and communities but the sustained support of the heahh system to community heahh action is lacking in some projects and this requires strong advocacy by APOC parhers.
(vi.) Most urtegration deficiencies relate to health services rather than CDTI Conclusion of monitors on CDTI projects that had no A-POC funds for two years: Taraba: "It is the opinion of the monilors that a substantial number of recommendations made in the 2002 evaluation have been addressed and the sustainability plans prepared at the time are being " rmplemented , even though no funds have been received -from APOC a-fter the 5th year. Kaduna: "The ... Kaduna state (CDTI) prqect has been satisfactonly distributtng Mectizano in the last two years btrt implementation of the three years sustainability plan has been a big challenge wfihout APOC firnd. Mectizano distribution at the community level is very satisfactory." Phase I Uganda: "There has been an increase in the level of funds provided by the distncts particularly in Kisoro and Kasese districts. Both geographical and therapeutic coverage rates have remained high as they were during APOC period."
7 FINANCING PROJECTS AND OTHER ACTIVITIES OF APOC MANAGEMENT 7.1 Status of financing first, second, third, fourth and fifth year projects During the reporting period, APOC Management reviewed 260 projecr. documents including 74 budget proposals. Fifty-four (54) leters of Agreement (LA) were prepared and processed, and the first installments of funds released to 17 projects approved for the first year of funding: Angola (2), Cameroon (4), Congo (l), RDC (7), Malawi (l), Sudan (2). Overall, fifty four (54) fund transfers were sent to the National Onchocerciasis Task Forces (NOTF) for field activities, l8 for purchase of capital equipment and24 for mher activities. 7.2 Submission of linancial returns to APOC from the projects As stated in the Letters of Agreement srgned between APOC Management and the National Onchocerciasis Task Forces, the monthly eryenditure retums should be submitted regularly by the on going projects receiving funds from APOC. Unfortunately, many projects are still experiencing more than three months delay and the Management of APOC continues to work towards solving the problem. For the period under review, 185 expenditure retums were received and 173 were analysed. The submission of the expenditure retums has enabled the Management to verify that funds are being utitized in accordance with the approved budget. Some deviations were discovered and feedbacks were sent to the concemed projects Visils in the field were organized to cross check the information received through the erpenditure reports for accuracy. These visits were conducted in Burundi, Tchad and Southem Sudan in the reporting period. 7.3 Major meetings and workshops
7 .3.1 Workshop for articles writing on sustainability evaluation
APOC management organized a l24ay workshop to write articles on the sustainability of CDTI in Ouagadougou. The participants to this workshop included the 2cmrdinators (Dr. Tarimo and Prof. Prozesky), two national coordinators and 8 independent scientists. The articles written covered key areas such as Mectizano supply and delivery systems, integration of CDTI into the PHC structure, the process of evaluation of CDTI, communrty participation, performance of CDTI at FLHF level, and assessment of feedback/planning meetings and district authorities. JAF IO.5 Page 33
7 .3.2 Workshop for articles writing on phase I of impact assessment studies
Impact assessment teams 3 and 4 conducted a workshop to complete writing articles on the baseline studies in sites assigned to them in 4 countries. This will enable APOC Management to submit by the end of the year articles for publications related to the 13 study sites in 8 countries.
7 .4 Validation of monitoring of treatment Community Directed Treatment with Ivermectin has been identified as an effective strategy of meeting the principal challenge of sustained delivery of ivermectin to all communities. However, the ONCHOSIM simulation model for onchocerciasis estimated that, depending on the prevailing level of endemicity, annual ivermectin treatment coverage of at least 650/o of the total population of the commturity, for more than 15 years, is required to eliminate the disease as a public heahh problem. This calls for regular monitoring ofthe implementation ofthe APOC CDTI. A study was conducted in three sites, namely Enugu and Kaduna States in Nigeria and Abu Hamad Province in Northem Sudan, using cross-sectional design to collect data from primary school pupils, households and CDD registers on ivermectin treatment coverage rates, between 5-6 weeks after the distribution of ivermectin in the study sites. The level of correlation of the methods was testd using Pearson' s correlation coefficient. The correlation of household survey and school-based survey from the three study sites gave a coefficient of 680/o (p<0.00017o), and showed that both school-based survey and CDD registers correlated highly with household survey (p <0 001). The study showed also that no matter the channel used to deliver the forms to the schools, reasonable outcomes were achieved. School-based survey is an efFective means of monitoring community coverage with ivermectin. As a result of this and earlier study carried out in Uganda, APOC could adopt the school-based method for accurate, simple and low-cost rapid monitoring of coverage with ivermectin.
8 CAPACITY BUILDING 8.1 Training in data management and geographic information system APOC Management contrnued the training on data management and geographic information system (GIS). ln 2004, training sessions were organized in collaboration with the NOTFs of Cameroon and Malawi. In Cameroon there were 26 participants while in Malawi tlere were fourteen. These sessions targeted CDTI pro3ect coordinators, supervisors, data managers and health information officers involved in health activities at the national, provincial and district levels. The training sessiqrs also allowed the review of data existing at NOTFs with regard to communrty level. Given the lack of centralized and comprehensive data on CDTI, it was agreed that the NOTFs should establish databases that reflect community level indicators right from the inception of each prqect As a follow-up, the NOTF of Cameroon submitted plans of action and budget proposals for 9 projects to collect retrospective data and APOC Management has already approved 4 of them and data collection is ongoing. 8.2 Training in financial management in Burundi Following the calm observed in Burundi, an APOC team visited that country in May 2004 to train the responsible officers who will be rn charge of financial management of APOC fimds. Consequently, CDTI implementation can start after a delay of more than a year due to civil unrest rn that country. 8.3 Missions, Country support and special visits The APOC Management, undertook several missions, in collaboration with the Technical Consultative Committee (ICC) members, &e Non-Govemmental Development Organizations (NGDOs) Cmrdination Group, Mectizan Donation Program and other extemal experts during the period under review. A total of fifteen (15) support visits to the National Onchocerciasis Task Forces (NOTFs) in 12 countries were made: Congo Br--aville, Ethiopia, Kenya (for South Sudan), Angola, Burundi, Chad, Equatorid Guinea, Liberia, Cameroon, Malawi, Tanzania and Uganda. The objectives of these visits included facilitating CDTI rnplementation and vector elimination activities, sustainability evaluation of CDTI Projects, administrative and financial management, JAF IO.5 Page34 advocating for stronger partnership, collaboration and political commitment to CDTI activities, data management and Geographic Information System, providing technical advice and assistance in *-"g.-.nt and implementation of projects, facilitating communication, building capacity in IEC, sensitisation, mobilization. Highlights of some ofthese missions were as follows:
8.3.1 Mission for CDTI in South Sudan (Nairobi) 8-9 December 2003
A mission was carried out to Nairobi, Kenya to inform the partrrers of CDTI particularly SSOTF of the existing discussions between APOC management and CBM with regard to CDTI implementation. The mission also discussed the coordination role of CBM with regards to other NGDOs, the best modality for channeling the firnds, the mechanisms of delivering ivermectin and the level of support to CDTI to be expected from the other participating NGDOs of Southem Sudan. During this mission partrters also exchanged views on the status of REMO and updated the map; the approved plan of Action for the SSOTF and the details of the 5 CDTI projects; the request tom epOC management to CBM to be lead NGDO and coordinate the activities involved in oncho activities; project budgets, available human and material resources; NGDOs involved in onchocerciasis control; capaclty builduag; APOC philosophy and the CDTI strategy and other practical details of implementing CDTI in this complex situation. It was agreed that onchocerciasis activities will be conducted by 5 prqects including East Bahrl el Ghazal, West Bahrl El Ghazal, East Equatoria, West Equatoria, and Upper Nile. CDTI would be the main strategy to be used for distribution of ivermectin. CBM was requested to work as part of the SSOTF to coordinate the participating NGDOs and to strengthen capacity where necessary. CDTI activities would resume beginning with the areas where ivermectur distribution had been started. Regular meetings between the NOTF/Sudan and SSOTF and integration of CDTI into the county health activities were also recommended. The group also requested APOC management to exceptionally allow REMO work to be complaed beyotd 2004.
8.3.2 Finalisation of various arrangements for CDTI implementation in Southern Sudan; Nairobi I 3th-1 5tr' April 2004
In Apnl 2004, two APOC staff members visited Nairobi, following the approval of five CDTI projects for South Sudan. This visit aimed at discussing the modality of collaboration with tlre various p".fr.rc, including the WHO coordination office for South Sudan, the future coordination role of the iead NGDO and the best way to channel APOC funds for CDTI implementation in South Sudan.
8.3.3 Mission on technical implementation and financial management of CDTI in Congo
In January 2004, the Director of the Programme had working sessions with the NOTF of Congo Braz.:arille on the technical implementation as well as the financial management of the CDTI project of that country. Advantage was also taken of that visil to discuss with the Regional Director on the 2004 workplan of ,qpOC ard tt e SIZ. Many discussions also took place with the technical and administrative staffof the Regional Office during the visit.
8.3.4 Post war assessment of the situation of CDTI in Liberia Following the end of hostilities :rmong the various rebel groups, APOC and SSI at the invitation of MoH of Liberia, conducted a joint assessment of post-war situation with regard to CDTI. During this mission the team also met with the Minister of Health, WHO Representative, conducted a field visit and a meeting with the NOTF members. The team, found extensive vandalisation and destruction of property and with assistance of the Ministry of Heatth officials, made an invurtory of damaged and lost property including 4 vehicles, 5l mctor iycles, computers, office fumiture and equipme,nt, media tools and heahh Educatiqr materials among ot6.r. A vrsit to the field also indicated that other institutions such as hospitals were looted which is a handicap to CDTI implementation. JAF IO.5 Page 35
Since the end of the war parfilers have made commendabte efforts to revrve CDTI activities amidst competing heahh priorities. The govemment has replaced some essential office furniture; one vehicle had been repaired with support from SSI while 3 cttrers needed repair. At the time of the visit, access was only limitd to Monteserrado and Margibi Counties but disarmament was underway to ensure normalcy in the other counties. A work plan to resume activities in the accessible counties was prepared by the NOTF in March. It was also recommended that due to the rntemrption of CDTI activities in the previous perid, APOC considers refinancing the North West, South East and South West as fourtl, secqrd and first years respectively, which proposal was approved by APOC management. The ministry also committed itself to integration of CDTI particularly with Vision 2020 activities.
8.3.5 Support missions to NOTF/IVIalawt
The first mission (ICC/APOC mission) took place during the period 29t September -1"' October 2003. lt had been recommended by a previous mission that regular NOTF meetings be held to review the progress as regards CDTI inplementation and the roles of the different parhers. During this meeting a number of important changes were proposed to ensure integration of CDTI into the PHC system of the Ministry of Heahh. The team also informed members of the activities of APOC management, expected roles of the NOTF and highlighted the importance of ensuring sustainability of CDTI The onchocerciasis control projects were analysed by district and an action plan drawn up.
The secmd support visit in Malawi 196-10e May 2004) was conducted in order to train ProJect staffand other parhers in data management (see section 8.1.) and to participate in the NOTF meeting for follow-up. The NOTF meeting reviewed progress made towards implementation, integration and financial support to CDTI, compliance to CDTI strategy, mobilization of communities, ordering of Mectizano and administrative and financial matters. The meding also addressed challenges like high CDD attrition and need for training. It was also found necessary to provide orientation to the key players in CDTI at district level as many officials knowledgeable in CDTI implementatior had been transferred and replaced by new ones. The third mission was held from 28t-29* Jure 2004 in order to orientate the new officials in CDTI. Two facilitators from Uganda and Nigeria facilitated a workshop on CDTI strategy including its challenges. District coordinators, heahh educators and heahh officers attended the workshop.
8.3.6 Mission to Chad in March 2004
Following the sustainability evaluation which concluded that the CDTI prqect of that country was not making progress toward sustainability and the feedback of the Management to the NOTF/Chad on their sustainability plan, an APOC mission visited the country in order to discuss with the political authorities on a better way for the CDTI project to take offagain.
8.3.7 Mission to assess APOC activities in Equatorial Guinea
A two-person mission was sent to Equatorial Guinea to assess the financial situation of the CDTI and Vector Elimination projects and for a "quick and crude" assessment of the progress of the Vector Elimination activities. The team found some administrative and financial wea}rresses in managing t}re accounts of the CDTI Project; poor sensitisatio and mobilisation of communities; and poor strategies used for Ivermectin distribution. All these were brought to the attention of the Secretary General of the Ministry of Heahh and recommendations made including the suspension of the release of funds until the concems raised had been addressed.
8.3.8 Training workshop on the management of SAEs in DRC
Three tedmical advisors from Cameroor facilitated a workshop on the management of SAEs in DRC. The workshop participants included proJect coordinators and members of the NOTF. The workshop covered the various types of SAEs and their management, reporting of cases and the nec€ssary laboratory tests. JAF IO.5 Page 36
8.3.9 Expert mission in DRC to assess SAE cases
A joint APOC/MDP mission of experts was s€rt to DRC during the first half of July 2004 to investigate the extent and aetiology of the reported SAE cases, and to search for possible particular risk factors following Mectizana treatment in the Bas Congo area. Further the mission considered SAE referral and/or management issues that require further attention.
8.3.10 Support mission to Angola, April 2004
On recommendation of the TCCI8, the APOC Management organized in April 2004, a support mission in Angola. The objectives of the mission was to assist the NOTF in: (i) revising 3 CDTI prqect proposals; (ii) refining the REMO map; (iii) conducting a RAPLOA survey in the provinces of Bengo, Kwanza Norte & Uige and (iv) assisting in launching CDTI in Lunda Norte & Lunda Sul provinces by training the NOTF in CDTI strategy and management of SAEs. The trainees are from the National Disease Cqrtrol Prqgramme (9 persons), provincial (31 persons) and district hospitalhealth areas (8 I persons).
8.3.11 Mission to Tanzania to monitor the implementation of Sustainability plans
ln 2002, the Mahenge CDTI prqect was assessed for sustainability and subsequently developed a sustainabilrty plan. This plan has now been implemented for a period of one year. In May 2004, APOC management facilitated a team of six to monitor the progress of implementation of the sustainability plan and pretest the tool prepared by APOC management following the special meding on sustainability in February 2004. The indicators of sustainability and the sustainability plans were used to assess the progress made in implementing the plans at the district level.
The findings are that regional and district levels had very good leadership and that the districts had effective administrative machinery for sustaining CDTI. However this strong leadership had nct been fully exploited by the District Oncho control team. The districts had made fund allocations to onchocerciasis in the district plans and actually released funds for specific activities. In Ulanga, Community Heahh Fund (CHF) at the community level allows the commtrnity to allocate a portion of the funds at that level for CDTI activities. The treatment coverage had increased by as high as 20o/o m both districts during the past two years ahhougb these are yet to reach the desired 65% level. Mectizano delivery has also been rntegrated in the Natiqral drug procurement system The monitors noted that the Regional Administration has a supervisory role and could play an important role in advocacy, mobilization as well as assist in the harmonization of plans to include national priorities, all of which influemce decisiqrs and rntegration at the national level. Some challenges facing the proJect were reported as (i) hrgfu rate of absentees and refusals; (ii) CDDs are poorly trained and lack the skills for mobilizatim and heahh educatiqr and have poor knowledge of the communlty (iii) The heahh personnel still influence the time of distribution rather than the communities thus leading to low coverage rates as distribution often coincides with the farming period. The mqritoring team concluded that the Mahenge CDTI Project had made considerable progress in rmplementing its sustainabilrty plan.
8.3.12 Fact finding missions in Nigeria and Uganda
Fact finding missions were conducted in Nigeria and Uganda and the fmding of these missions are contained in the section 6.4 of this report.
8.3.13 Missions to donors
Funds mobilization visits were undertaken by the Director of the Programme together with the fiscal agent, the World Banh whose responsibilrty is to mobilize firnds for the Programme. These visits were carried out in three donor countries to inform the donors on the progress in Programme activities and solicit for their commitment to APOC. JAF IO.5 Page37
8.3.14 Review of SSI support to Onchocerciasis, Accra, Ghana
APOC management and SZ staffparticipated in a workshop (3'-5* March 2004) in Accra, Ghana to examine how best to utilise its existing expertise in ivermectin distribution and to consolidate the gains ofthe past and to plan for sustainability of CDTI after the cessation of APOC. The workshop highlighted major achievements of CDTI including integration into PHC, the strategy's usefulness as an entry poirft of other heahh interventions and community involvement and ownership. Some of the challenges highlighted included attrition of CDDs especially in view of conflicting policies on remuneration of community based volunteers, CDTI in conflict areas, CDTI implementation in onchocerciasis and loiasis co+ndemic areas, competing health priorities (with onchocerciasis) among ministries of heahh and inadequate IEC materials. The role of SSI in supporting govemments and communities after the departure of APOC was also underscored. SSI commited itself to csrtinued support to CDTI but also highlighted the need for integration especially with eye care Programmes.
8.3.15 Support visits by Temporary Advisors and Consultants
In its policy of building a viable technical expertise in the domain of onchocerciasis control, the Programme engaged during the period under review a cumulative tdal of over 195 Temporary Advisers to assist countries in the evaluation of projects and developing post-APOC planning, technical advising on CDTI implementatior; advocacy, Impact assessment studies of APOC operations. These advisers are drawn from a rich mix of scientists, project managers and national coordinators within the APOC countries.
9 PHASE 2 OF THE LONG.TERM IMPACT ASSESSMENT OF APOC OPERATION Fis.27: Sites of the impact assessment studies ln 1996, decision was taken to assess the in APOC countries long-term impact assessment of APOC operations through three cross-sectional studies at five years interval. The baseline studies (phase l) were conducted between 1998 and 2000. 13 sites were selected in 9 countries, which are Cameroon, Central African Rqublic (CAR), Democratic Republic of Congo, o Ethiopia, Gabon, Nigeria, Sudan, Tanrania, and Uganda. The baseline studies finally were completed in 8 countries instead of 9 (figure 27) because during the period of the studies, Ethiopia was experiencing conflict. The second round of the impact assessment studies (phase 2) was launched in January 2004 and they are going on. Phase 3 studies are scheduled for 2009. The hypotheses of the impact assessment studies are that regular ivermectin treatment will (i) reduce severe itching, prevent development of onchocercal skin disease, may regress early skin lesions; (ii) prevent development or delay progression of onchocercal eye lesion and blindness and may regress early stages of ocular lesions; (iii) lead to reduction of vector infuivity and (iv) lead to improvement in socio-economic status of commrmty members, reduce or remove adverse socio- economic consequences of onchocerciasis. From the above hlpotheses, the impact assessment is composed of four types of study, dermatology, ophthalrnology, entomology and sociodemography. To improve the interpretation of the resuhs of the impact assessment studies, it was agreed that accurate geographical and treatrnent coverage will be needed for each study site. JAF 10.-5 Page 38
As of July 2004, the phase 2 of the impact assessment studies was carried out in Tanzania (l site), Sudan (l), Uganda (l), Ethiopia (l) and is gomg on in Nigeria (3 siles) and Cameroon (2 sites). It is expected that all the sites will be covered by the first quarter of 2005.
10 OVERVIEW OF COLLABORATION WITH OTHER WHO GROUPS AND THE WORLD BANK APOC has continued to benefit from the fruitful collaboration with various WHO groups and the Onchocerciasis Unit ofthe World Bank Washington duringthe period under review. 10.1 Coordination and Management of the activities in the Special Intervention Zones ln the framework of the mandate received from the WHO Regional Director for Africa, APOC management has given administrative and technical support to SV, without direct financial implication. The activities which are in progress in most parts of Sierra L@ne, in Benin, Ghana, Guinea/Conakry and Togo, have been strengthened as far as CDTI activilies are concemed. Aerial larviciding is being carried otrt urly in the Kara-Keran-M6 focus in Togo and Benin to supplement the ivermectin distribution. The management of the SIZ has also created opportunities for the other former OCP countries to meet and exchange data and views on the onchocerciasis surveillance and control activities going on in their respective areas after the closure of OCP. A report on the activities has been prepared and will be presented at the JAF meeting as an information document. lo.2 Collaboration with WHO/ArRO and WHO/EMRO WHO/AFRO has always been a partner for the Programme. In addition to advocacy in the Africa Region, the WHO offices in APOC countries are assisting administratively by the procurement of CapitaiEquipment and by taking the appropriate actions to facilitate the entry of ivermectin in the endemic countries. The WHO offices in the countries are also playing an important role in the replenishment of the various imprest accormts opened in the country for the CDTI and vector eliminatiqr projects and for transferring funds to the partners to cater the in-country ad hoc project activities. The WHO ofhces also assist in the organization of various workshops and meetings, providing transport to consultants and temporary advisors recruited by APOC to conduct activities such as sustainability studies, monitoring exercises and facilitation of workshops. Many financial reports from the projects were retumedto APOC through WHO countries Offices. The budget and finance office of WHO/AFRO has played an important role by providing support to the country offices for the transfer of funds to the proJect They were also requested for the Urienng and training of APOC finance office staffmembers in the accountability procrdures of WHO. In the period under reporting, APOC Managemurt inrtiated collaboration with WHO/EMRO as a way of facilitating technical advice, the transfer of funds and the necessary administrative procedures for the projects in Southem Sudan. 10.3 Collaboration of WHO/HQ During the period under review, the collaboration with WHO/HQ has continued as during the- previous y"".ri. ftq has provided administrative and financial support in funds transfer, purchase of Caprtal equipments for the projects and for APOC Headquarters. Online assistance was also provided to the new Financial and Budget Officers.
10.4 COIIAbOTAtiON With WHO/TDR: OPERATIONAL RESEARCH For the period under review, APOC contributed US$ 570.000 for drug discovery and Product development (Microfil, DEC patch test, Ivermectin resistance detection tool) and clinical research on onchocerciasis. The TDR Product Research and Development (PRD) will provide a ddailed presentation to the JAFIO under the Agenda item 10. Meanwhile, a suilnary of its activities is presented below. JAF IO.5 Page 39 presentation to the JAF1O under the Agenda item 10. Meanwhile, a summary of its activities is presented below.
10.4.1 Drug discovery
10.4.1.1 Target ldentification and Validation Intemational experts meet to discuss how to use genomic information and molecular biology technologies (RNA interference) to identifu and validate new molecular targets for the discovery of macrofilaricidal drugs. For further information, consult the web site: www.who. int/tdr/publ rcations/uublications/rnai.htm. 10.4.1.2 Compound Screening and Evaluation In the last year, a MACROFIL supported screening centre has identified tlvo classes of compounds with good activity against Onchocerca: the cyclodepsipeptides (particularly exciting as they represent entirely new class of antihelminthics) and a novel tetracycline derivatives (patent protected) have shown good activity in mouse models of onchocerciasis, however, it has not been possible to pursue these because for the owner of these compounds onchocerciasis is seen as of no commercial interest.
10.4.2 Product development
10.4.2.1 Moxidectin Development of an oral dose for human use has been completed. Safety in healthy human volunteers has been demonshated (phase 1), this has lead to an agreement between Wyeth Pharmaceuticals and WHO to jointly proceed to conduct a clinical study at Onchocerciasis Chemotherapy Research Centre (OCRC); Hohoe, Ghana. A product development team has been established. This study aims to demonstrate safety in infected persons as well as to address the question if a single teabnent with moxidectin can kill microfilaria as effectively as ivermectin but more importantly to investigate if microfilaria does not reappear in the skin within ayear or even 18 months after the featment (macrofilaricidal effect). It also will establish the dose to be used in the phase 3 study. To this effect extensive work has been conducted towards finalization of: legal agreement, development strategy, phase 2 study protocol and relevant clinical documents, preparation of the study site, data management and interaction with Ghana health authorities and WHO Research Ethics Review Committee. The initiation of the study is foreseen for September 2004. The development of moxidectin has been submitted (March 2004) as a proposal for funding to the Gates Foundation.
10.4.2.2 lvermectin, albendazole and praziquantel a pharmacokinetic drug interaction study This study has been conducted in healthy volunteers to address the question if these 3 drugs can be administered concomitantly without any unexpected safety issues or changes in blood levels relative to those when the drugs are administered alone. The information that this study will provide is fundamental for any discussions related to integration of disease control where co-administration of drugs may be considered. The study has been completed and final report with conclusions is in preparation. 10.4.2.3 Evaluation of a DEC skin patch (transdermal deltvery technology) A DEC skin patch protoqpe based on tansdermal drug delivery technology has been developed by Lohmann Therapie-Systeme AG (LTS) and is currently being tested in Onchocerca infected individuals in OCRC Hohoe, Ghana. This study will asses the safety and blood levels of DEC when this drug is applied transdermally. The study will also provide preliminary indication of efficacy of this product as a tool to detect infection. 10.4.2.4 Development of a tool to detect ivermectin resistance Correlation between multiple exposures to ivermectin and changes in gene sequences has been observed in different geographical settings. Presently we cannot conclude that these genetic changes reflect phenotypic changes in the parasite resulting in modifications in the response to ivermectin. JAF IO.5 Page 40
Several discussions on how to proceed towards "validation" of these markers as indicators of unresponsiveness, have taken place. The current recommendation is to perform an extensive parasite sampling from different geographical areas based on epidemiological and treatment history. Another approach that has been recommended is that of conducting a longitudinal "ivermectin response study" in defined areas in Ghana where the genotypic changes have been observed. Both approaches are under discussion. Contacts with several diagnostic companies have been established with the aim to develop a methodology/format that would facilitate the evaluation of the parasitological material taking advantage of the MDS laboratory in Ouagadougou. 10.4.2.5 Evaluation of therapeutic approaches to reduce the Loa loa load in the context of safe use of ivermectin in Loa loa / onchocerciasis co infected patients
Following several discussions with experts during 2003 a clinical research strategy to evaluate the use of albendazole with the objecfive towards reducing the Loa loa parusite load was developed. Calls for proposal were made. However, the research program was not implemented due to financial uncertainties, uncertainties that recently have been resolved allowing the program to be reinitiated. Hopefully the relevant studies will start later this year.
10.4.3 Update on Onchocerciasis Implementation Research (WHO/TDR)
In the year under review, TDR Implementation Research Group completed its work on the validation of the Rapid Assessment Procedures for loaisis (RAPLOA). This is a simple, low-cost method of community diagnosis of Loa loa endemicity, to delineate areas of high-risk of SAEs due to mass treatment of ivermectin where onchocerciasis and loiasis co-exist. The results from the recent validation exercises in DRC and Congo-Brazzaville indicate that the RAPLOA methodology is valid for use outside of the original area in which it was developed (i.e. Nigeria and Cameroon) to estimate the prevalence of Loa loa (figure 28). The MEC recommended that this methodology should now be used to estimate the prevalence of Loa loa in areas suspected to be endemic for this parasite. Earlier this year, the MEC and the TCC endorsed the plans by TDR to use data from the RAPLOA validation studies in Congo-Brazzaville and DRC as well as from recent RAPLOA surveys in Angola, to update the Environmental Risk Model for loiasis to increase the accuracy of the map. The probability contour maps will be particularly useful for operational planning of Loa loa mapping and Mectizan@ treatment. tr'ie. 28: Prediction of prevalence of microfilaraemia by RAPLOA
Prevalence of microfilaraemia by RAPLOA Erl
i-t 3 ripnt,t Tt
ORC Nonh.hC 50 !la n!tn
a G40 i g) a E o30 U U uC 9zo (t) I o_ t0 t
I 0
0 2t) 40 60 B0 r00 RAPLOA (%) JAF IO.5 Page 4l
10.4.4 Multi-country study on additional health tasks of CDDs
With a mandate of the Joint Action Forum, TDR Onchocerciasis Implementation Research, in the year under consideration pursued further the multi-country study on Community- Directed
I Interventions (CDI). The objectives of the study is to determine the effectiveness and efficiency of CDI compared to current systems, the extent to which the CDTI process can be used for the delivery of other health interventions and critical factors that may facilitate or hinder achieving integration of interventions. The study design will examine the complexity of integrating CDTI with vitamin A supplementation, ITN, DOTS and home management of malaria. Details of this study will be presented under agenda item 12. 10.5 Collaboration with WHOiIITP In consultation with APOC management, the ' Proctor and Gamble initiative known as the Go Give and Grow (GGG) sent through WHO/HTP two interns to Cameroon and Uganda to assist the respective NOTFs with CDTI implementation. These interns will assist the NOTFs with repackaging data, developing and/or improving reporting formats and IEC strategy development among other areas. 10.6 Collaboration with the World Bank - Onchocerciasis Unit During the period under review, the Onchocerciasis Unit of the World Bank, Washington DC has continued its invaluable collaboration with APOC. The Onchocerciasis Unit of the World Bank has provided technical assistance in: (i.) The follow up of the Donors'commitments; (ii.) The joint advocacy mission and the funds mobilization visit of the donors (to Austria, to Netherlands, to UK), (iii.) The preparation and participating to the Donors'Conference meeting in Washington in June 2004. 10.7 Additional health interventions Since the Phase II period, one of APOC strategies has been to integrate Fis. 29 : Add-on interventions in APOC additional interventions into the CDTL countries Integration other health interventions of NOTFs are scaling up additional would enhance the with CDTI in tum interventions sustainability of ivermectin distribution by capitalizing on cost savings and improving APOC CDTI reaches lhe poorest communities where National Health Services are weak or non-existent program benefits. As shown in the figure 29, notable interventions added to CDTI are: vitamin A supplementation of under- Lymphatic Filariasis Treatment fives and post-partum mothers to prevent Treatment malnutrition, blindness and death; Schistosomiasis Guinea Worm lntervention praziquantel and albendazole for the a lmmunizations (polio, measles, others) treatment schistosomiasis and lymphatic of I Eye Care (cataract identification. primary eye care) filiarisis respectively. The community- I Malaria 8ed Net Distribution + HOMEPAK directed distributors (CDDs) of ivermectin a H|V/AIDS and Reproductive Health assist with IEC, distribution of condom for the prevention of HIV/AIDS and promotion of reproductive health. Other interventions are: Primary Eye care services, rehabilitation of the blind, immunization and identification of cataract patients. During the reporting period, there has been an unprecedented increase of the use of CDTI structure, in particular, grass roots network to launch other health interventions. For example, in 2003: Uganda: Over 25,000 CDDs were trained in 2l oncho-endemic districts in using CDTI to assist Family planning program, distribute praziquantel for the control of schistosomiasis, distribution of JAF IO.5 Page 42 treated bed nets and HOMPAK for prevention and treatment of malaria and vitamin A supplementation. Nigeria: 1l (40.7%) out of 27 CDTI projects have added one form of health intervention or another to the CDTI structure. As at 2003 the proportions of CDTI personnel within the health service who have been trained and are involved in additional intervention activities in the projects are: Lymphatic C Filariasis (100%); Schistosomiasis (8%); VAS (79%); PEC (63%\. With respect to community distributors the proportions are as follows: Lymphatic Filariasis (100%); Schistosomiasis (6%); VAS Oa%); PEC (99%); Rehabilitation of the blind (3%). While logistics provided by APOC, MoH and NGDOs were used in the implementation of the different interventions, project personnel were not fully aware that APOC funds could be utilized for the implementation of additional interventions provided the area-covered fall within the CDTI belt.
In table 21, we summarize the achievements of the 1l CDTI projects in Nigeria during the period under review. Tabte 21: Coverage of CDTI areas by integrated interventions in Nigeria (2003) LGAs lmplementing Persons CDTI + dther + treated/reached interventlons interventions Lymphatic Filariasis t2 885 1,257,576 Primary Eye Care 65 6,604 60,000 Rehabilitation of the Blind I tt4 tt4 Schiiiosomiasis 4 213 107,606 VitaminA 76 5 72 I
The challenees Experience has shown that after the fifth year, CDTI requires minimal financial resources from govemments at all levels to maintain and keep it functional. The present major concern is that governments have shown fair commitment for that minimal support required, and may be handicapped also after the exit of APOC. The exception seems to be some districts of Uganda ( Kisoro, Kasese- see section on monitoring) where CDTI has been fully integrated in the district health plans and routines. The opportunities While minimal funding is critical to continued functionality of the CDTI structure, the evaluation findings also show that other indicators such as the level of involvement of the community in planning and managing the Programme, willingness of CDDs to continue in their work, and the degree of knowledge of the benefits associated with long term treatment are vital for sustainability. Furthermore, reports from the countries and pilot study by HKI on integrating vitamin A into CDTI in Nigeria showed that adding other health interventions to CDTI may potentially contribute to the sustainability of the CDTI structure. The results of the CDTl+vitamin A integrated projects in seven CDTI projects in Nigeria presented in the table 22 provide a strong evidence of the benefits of adding other interventions to CDTI to enhance the performance of projects and sustainability of CDTI. W: Results of 7 CDTI projects that integrate vitamin A to CDTI in Nigeria o/o PPM # PPM o/o Adamawa 249,088 226,117 90.7 50,235 23,559 64.8 Bomo 146,305 129,358 88.4 42,983 24,211 s6.3 A/Ibom 38,918 35,257 90.5 2,038 1,946 96.1 ClRiver 326,119 175,312 53.8 77,964 30,374 39.0 Kwara 56,819 52,751 93.0 6,219 5,247 84.0 ll7,844 105,502 90.0 34,303 29,360 86.0 Taraba 204,794 179,297 87.5 50,334 40,957 8l .3 Total 1,139,887 903,594 79.3 264,076 155,654 58.9 Source: NOTFNigeria, 2004 JAF 10.5 Page 43
,11 CONTRIBUTION OF THE NONGOVERNMENTAL DEVELOPMENT ORGANIZATIONS (NGDOs) COORDINATION GROUP Dr Adrian Hopkins replaced Mr Paul Derstine in September 2003 as the NGDO Group Chairperson for the following two years. In addition, Dr Tony Ukety who was appointed in September I arrived in Geneva in November 2003 to take up his new post as NGDO Coordinator for Onchocerciasis Control. Finally, Ms Catherine Cross krndly accepted in March 20M the role of Vice- Chair for one year. In spite of financial constraints, the Group Members ccntmue to support ivermectin treatn€nt within APOC countries. However, regretfully HealthNet Intemational left the Group in December 2003. Consequently, CBM has agreed to become the lead NGDO in Southem Sudan replacing HealthNet lntemational. Continuous efforts are made to find additional NGOs to support new CDTI projects, especially in post-conflict countries such as Angola, DRC and Sudan. krteresting contact has been made with a new NGO from Portugal who may join the Group in September 2004. The Group Members are working closely with APOC and the Ministry of Heahh of DRC in order to better numage the serious adverse events (SAEs) which occurred in Bas-Congo and Tshopo CDTI projects in December 2003 and January 2004. In order to ensure sustainability of existing CDTI projects, the Group Members are initiating integration of additional heahh and development activities into CDTI projects such as Vitamin A supplementation, eye care services, lymphatic filariasis curtrol, malaria and schistosomiasis control. Search for altemative funding is still going on in order to meet the increasing number of new proJects. Updated list ofthe Group Members: . Christoffel-Blindenmission(CBM) o Helen Keller Intemational (HKD o Interchurch Medical Assistance,Inc. (IMA) r Lions Clubs Intemational Foundation (LCIF) . Mectizan Donation Program (MDP) . Mission to Save the Helpless (MIOSATH) o Organisation pour la Pr6vention de la Cecite (OPC) . Sight Savers Intemational (SSf) r The Carter Center (CC) . US Fund for I"INICEF
12 Auditing the Programme During the period under review, the Extemal Auditors audited the Programme for 2003 activities. L2.1 External Audit During the month of February 2A04 , the extemal auditors had focused their control on the financial operations of the Programme for the 2003. They had verified the status of APOC funds to ascertain whether budgetary and financial systems mrnply with the rules and regulations and are in line with poticy guidelines ofthe donor Community. Their report was expected. 12.2 Internal APOC audit In May 2004, for improving the intemal APOC audit, a checklist form was elaborated and implemented for the feedback qr the financial reports submitted by the projects. The resuh of the audit indicated that more of the financial reports were nct submitted on time and the recommended forms were not filled by all the projects' accountants as budgetary analysis form and bank reconciliation. In general the intemal control system in place was poor and strould be improved in many areas such as the management of the vehicles and the motorcycles, the control of dher Capital Equipments, the utilization of fuel, the usage oftelephore and the monitoring of statimeries.