Fred L. Soper Lecture 62nd Meeting of the American Society of Tropical Medicine and Hygiene Thursday, November 14, 2013

The history of the regional initiative to eliminate River Blindness from the Americas ‐ Could this serve as a model for Africa? Frank Richards, Jr., MD Director , , River Blindness and Schistosomiasis Programs Chair, Program Coordinating Committee (PCC) Elimination Program for the Americas Many thanks to the Soper Committee! With respect to the Rockefeller Foundation

‘[My] capacity for fanaticism [did me in].’

Fred L. Soper, MD, DrPH Structure of the Talk • About Fred Soper and his fanaticism to ‘get to zero’ • Prospects for getting river blindness (onchocerciasis) to zero in the Americas – Successes by the Onchocerciasis Elimination Program for the Americas (OEPA) that have led to a 95% reduction in interventions – WHO ‘Verification’ of elimination in Colombia – The ‘last inch’: Venezuela and Brazil border • Influence of OEPA on African Programs (“Soper’s Law”) Eradication: Ridding the world of diseases forever? Nancy Leys Stepan Professor of History, Columbia University Cornell University Press, 2011

This book is largely about Fred Soper, a ‘larger than life character.’ Commander in Chief Soper • Not a researcher, clinician or academic, but a public health practitioner.

• Midwest (Kansas). MD in 1918 and immediately joins the Rockefeller Foundation to ultimately become its most successful field general.

• Latin America, fluent in Spanish and Portuguese, tireless, focused, and enjoyed field work (entailing camping in rough conditions).

• At best ‘uncompromising personality,’ at worst ‘a slave driver.’ Military bearing, formal manner, known for ‘abrupt dismissals.’ ‘Get action; Do things; be sane... Don’t fritter away your time, Be somebody; And get action.’

Theodore Roosevelt

Dr. Soper loved the idea of eradication • His agenda was eradication and his policy was vertical programs that delivered available tools; getting it right, at scale, all the time, beyond the ‘end of the road.’

• He took his eradication philosophy to PAHO, which he directed from 1947‐ 59.

• PAHO was and is a leader in its eradication campaigns against , YF, malaria, , , , , and RIVER BLINDNESS.

• After his retirement, he traveled widely lecturing on the virtues and methods of eradication. His reputation faltered with the failure of the MEP in the 1960s and he died just before SP eradication.

• His faith in the ideal of eradication never faltered. Control versus Eradication (Elimination) Strategy

Control

Interventions Time becomes ‘Safely’ Stopped an Enemy Eradication (Elimination)

TIME Definitions • Eradication: Zero infection globally, surveillance unnecessary

• Elimination: Zero infection regionally, interventions unnecessary, surveillance continues

• Control: Reduced disease, but both control measures and surveillance necessary NEJM 2013:368 January 3, 2013

“The term ‘elimination’ is often used imprecisely.” A word of friendly caution…….

‘Elimination as a Public Health Problem’ does not necessarily mean ‘getting to zero!’….

but getting to a point of

‘virtual disappearance.’*

*Usually defined as an acceptable prevalence or incidence figure Soper Principle Near invisibility* of a disease in a population is the point that the serious work of eradication actually begins

*There is no acceptable prevalence or incidence figure ELIMINATION • Intervention interrupts • Then stop the intervention – Post‐treatment Surveillance (PTS) • If no return of infection, then ‘Transmission is eliminated’ Mathematical Model of River Blindness (onchocerciasis) Transmission (Vector to Human): Infectious Bites per Person per Year 1000

Transmission 900

800 FAILURE detected in 700 PTS period! 600

500 Start Stop 400

300 The Valley 200 of Death 100

0 1 6 11 16 21 26 31 36 41 Years

One hundred simulations with John Davies’ SIMONA MODEL using data from Las Golondrinas – Mexico –S. ochraceum Soper Principle The crucial test of success is to discontinue all control methods… without any recurrence of the disease

Post-treatment Surveillance (PTS) River Blindness (RB) (Onchocerciasis) (Oncho) 99% in Africa

Source:WHO

Morbidity (Eye and Skin Disease)

Transmission (Black fly infection) Mass Drug Administration (MDA) Soper’s MDA program to eradicate Hookworm Ivermectin = MectizanR ( donated byMerck & Co)

These 4 tablets comprise a single adult dose (“treatment”) What does this ivermectin do? Control

Elimination While most thought of ivermectin’s effect mainly as a way to Control morbidity Soper would ask:

“How can ivermectin be used to stop transmission?’

AJTMH 1992

Need to reach 85% Treatment Coverage (Eligible Population) AJTMH 2004

‘Semi-annual ivermectin treatment of > 6 years has had a profound impact on survival and reproduction of this species.’ A SLOW MACROFIL EFFECT: adult fertility and longevity 10 min AJTMH 2006

A important caution about once per year treatment being unable to interrupt transmission The frequency & duration of MDA needed to eliminate onchocerciasis transmission has been fiercely debated for decades! 2003

Advance the great debate of Control versus Elimination goals, including once versus twice per year treatment and improved diagnostics The history of the regional initiative to eliminate River Blindness from the Americas Geographic Distribution of Onchocerciasis in the Americas

VENEZUELA 1 2 8. North‐Central focus 9. North‐Eastern focus 3 4 10. South focus MEXICO 6 BRAZIL: 5 7 11. Amazonas focus 1. Oaxaca focus (Yanomami area) 2. North‐Chiapas focus 3. South‐Chiapas focus GUATEMALA: 8 9 4. Huehuetenango focus COLOMBIA 5. Central focus: 12. Lopez de Micay focus •Solola ECUADOR: •Suchitepequez 13. Esmeraldas focus •Cayapas River 10 •Chimaltenango 12 •Santiago River 11 6. Escuintla focus •Onzole River •Satellite foci: 13 7. Santa Rosa focus - Canandé and others Soper Principle

"As satisfactory eradication techniques become available…. the importance of regional action must increase rather than diminish."

Fred L. Soper’s Remarks at the First World Health Assembly, 1948 Regional initiative Strategy: MDA twice per year with 85% coverage Objective: Break RB Transmission in the Americas

OEPA is a dedicated regional initiative with a Soperian goal of getting to zero Directly Observed Treatment (DOT) One of three PAHO Regional Resolutions

Urgency 2015 1998

2008 “The essential elements of a successful river blindness elimination program—hard work, community engagement, attention to detail, data-driven, strong partnerships, and prolonged political commitment.”

Dr. Mauricio Sauerbrey, OEPA Director Winner of the 2012 Mectizan Award on the 25th anniversary of the donation!!!

The OEPA Office is the vanguard of the initiative to get to zero! Publicity….Advocacy Program Coordinating Committee (PCC) meets twice per year XVIIIth IACO in Oaxaca, Mexico 2008

InterAmerican Conference on Onchocerciasis (annually since 1991)

Mectizan® Treatment History in the Americas 1989 ‐ 2012 and plan from 2013 ‐ 2018 T x S c g a n New l li in a Resolution g Sc CD48.R12 x p d T u o wn

OEPA 1st PAHO 95% Resolution issued “The Realm of the Last Inch” Over 11 million treatments given Sentinel Villages, Prevalence of Microfilaria in Skin, Guatemala, 1994‐2010 60 % 52 Ivermectin MDA 50

40

30 20 20 16

10 2.4 Each data point represents a sample of >1000 persons 0 0 1994 1998 2003 2007 2010 Prevalence of ocular disease attributable to onchocerciasis, Central Endemic Zone, 1981-2009 Key Political Support by President Carter

“…. We are helping the governments of the six remaining endemic countries in the Americas to eliminate onchocerciasis once and for all, and I am looking forward to meeting with those health ministers later today.”

Comments to the 2003 World Health Assembly Soper Principle

Certifiable results

Finding an acceptable definition of ZERO WHO 2001 Guidelines

ZERO IS….. ENT: <1/2000 L3 (infective) flies (PCR)

EPI: <0.1 percent infection in children (OV16 IgG4 Ab)*

MORB: <1% mf in cornea/anterior chamber of eyes

Road map for Stopping MDA

*developed @ NIH Onchocerciasis Transmission ‘Stop light’

CONTINUES

SUPPRESSED

INTERRUPTED Interrupted Eliminated

PTS

These colors are epidemiologically linked!

PTS: Post Treatment Surveillance

Based on WHO Guidelines, 2001 Status of Onchocerciasis transmission in the Americas when OEPA began in 1993 1 Oaxaca1 Oaxaca 2 2North Chiapas NorteChiapas CONTINUES 3 South Chiapas SUPPRESSED 4 Huehuetenango4 Huehuetenango INTERRUPTED 3 Chiapas Sur

5 Central 5 Central 8 North8 ‐NorCentral‐Central 9 Nororiental 6 Escuintla6 Escuintla 9 Northeast 7 Santa Rosa 7 Santa Rosa

1010 SurSouth

12 Colombia 10 12 López de Micay 13 Esmeraldas 13 Esmeraldas 11 Amazonas11 Amazonas BRASILBRAZIL Seventeen Years later, in 2009

1 Oaxaca1 Oaxaca 2 North2 Chiapas ChiapasNorte CONTINUES 3 South Chiapas SUPPRESSED 4 Huehuetenango4 Huehuetenango INTERRUPTED 3 Chiapas Sur

5 Central 5 Central 8 North8 ‐NorCentral‐Central 9 Nororiental 6 Escuintla6 Escuintla 9 Northeast 7 Santa7 Santa RosaRosa

1010 SurSouth

12 Colombia 10 12 López de Micay 13 Esmeraldas 13 Esmeraldas 11 Amazonas11 Amazonas BRASILBRAZIL Status of Onchocerciasis Transmission in the Americas, 2013

1 Oaxaca 44,919 2 North Chiapas TRANSMISSION STATUS % pop. 7,125 ELIMINATED 33% 4 Huehuetenango 30,239 INTERRUPTED 63%

3 South Chiapas ONGOING 4% 117,825 5 Central 126,430 8 North‐Central 9 Northeast 6 Escuintla 14,385 94,583 62,590 7 Santa Rosa 12,208

VENEZUELA

10 South 10,390 12 Colombia COLOMBIA  1,366 10 12 13 Esmeraldas* 25,863 11 Amazonas 12,988 ECUADOR BRAZIL  Country has satisfied the criteria to apply for WHO verification of elimination ‘SCORECARD’ Regional population at risk, no longer at risk, under PTS and eligible for treatment 2013 Pop. no Pop. Endemic Population Pop. under Transmission Focus longer at eligible for communities at risk PTS status risk tx Escuintla‐GUA 117 62,590 Eliminated Santa Rosa‐GUA 37 12,208 Eliminated North Chiapas ‐MEX 13 7,125 Eliminated Lopez de Micay‐COL 1 1,366 Eliminated Huehuetenango‐GUA 43 30,239 Eliminated Oaxaca‐MEX 98 44,919 Eliminated Esmeraldas‐ECU 119 25,863 Eliminated Northcentral‐VEN 45 14,385 14,385 Interrupted South Chiapas –MEX 559 117,825 117,825 Interrupted Central‐GUA 321 126,430 126,430 Interrupted Northeast‐VEN 465 95,567 95,567 Interrupted South‐VEN 10 11,427 9,615 Ongoing Amazonas‐BRA 22 13,600 10,880 Ongoing Total 1,850 379,234 184,310 354,207 20,495 June 2013 An Example of the Process Santa Rosa Focus, Guatemala: The first focus to apply the 2001 WHO criteria (in the world) to stop ivermectin treatments 24,941 vectors tested, all negative by PCR ENT: <1/2000 with 95% confidence 0 positives in 3232 students EPI: <0.1% infection rate in children with 95% confidence

OV16 IgG4 antibody by ELISA • MORB: No mf in anterior chamber or cornea in 363 persons examined. Acute onchocercal eye disease is <1% with 95% confidence AJTMH 2007 Santa Rosa Public Information Campaign during the PTS period 2012 The Post Treatment Surveillance Flow Chart 20 min May 24, 2013

Financial contribution to the OEPA Regional Initiative (rounded up to millions of US dollars)

Source 1991‐2012 % PAHO/WHO $1 1% The Carter Center/RBF (various donors)* $24 17% Countries (counterpart funding from MOH's) $51 40% MSD (in kind) $55 42% Total $131 100% *IDB, Lions, Gates, CDC, USAID, Alwaleed Bin Talal Foundation, OPEC, others Financial contribution to the OEPA Regional Initiative excluding MDP (ivermectin) in kind donation (rounded up to millions of US dollars) Source 1991‐2012 % PAHO/WHO $1 1% The Carter Center/RBF (various donors)* $24 31% Countries (counterpart funding from MOH's) $51 68% Total $76 100% *IDB, Lions, Gates, CDC, USAID, Alwaleed Bin Talal Foundation, average $1.14 m/year OPEC, others by donors Sept 2013

WER updates on the Regional Initiative annually since 1996

WHO verification of Colombia!!!!

23rd IACO in Quito November 2013 Ecuador’s Success!!! Ecuador Team, 2009

“….these are the victories of the countries. Today's news belongs to Ecuador." Frank Richards Ecuador Halts Spread of River Blindness AOLNews.com March 2, 2010 Status of Onchocerciasis in the Americas, 2013

96% of MDA has stopped The ‘Endgame’ The ‘Final Inch’ Soper Principle Near invisibility of a disease…is the point that the serious work of eradication actually begins. Enfermedades Desatendidas

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ma A e V Areas Proposal to improve treatment distribution at the South Focus of Venezuela

Current

Proposal HIGH LEVEL POLITICAL SUPPORT NEEDED President Carter’s visit to the Brazilian Minister of Health Fanaticism? Structure of the Talk • About Fred Soper and his fanaticism to ‘get to zero’ • Prospects for getting river blindness (onchocerciasis) to zero in the Americas – WHO ‘Verification’ of Colombia, Ecuador pending – The ‘last inch’ and biggest challenge in the Amazon • Influence of OEPA on African Programs (“Soper’s Law”) Soper’s Law

The innate power of disease eradication programs to spread beyond their original starting point until they become worldwide. Lancet Infectious Disease, November, 2013

“…a two dose-regimen [is] trickier to apply in Africa, but [Dr. Mark] Taylor believes it is a crucial next step. ‘Two doses have been shown to be very successful in Columbia [sic] and elsewhere, the African programme has to move more rapidly to endorse this strategy.’” Since 1996, American and African River Blindness Programs assisted by The Carter Center have met at an annual Program Review

Advance the great debate of once versus twice per year treatment and Control versus Elimination goals Take home messages for African Programs to consider

• Multiple doses per year • WHO guidelines • More Sensitive Techniques – PCR – Antibody testing (OV16) • ‘Soperian’ use of the term ‘Elimination’ – ZERO CarterCarter CenterCenter--AssistedAssisted MectizanMectizan DistributionDistribution TWICE PER YEAR 4X/year

Sudan Nigeria Venezuela Ethiopia

Brazil Uganda CarterCarter CenterCenter--AssistedAssisted MectizanMectizan DistributionDistribution TWICE PER YEAR 4X/year

Sudan Nigeria Venezuela Ethiopia

Brazil Uganda CarterCarter CenterCenter--AssistedAssisted MectizanMectizan DistributionDistribution Elimination Lab Support PCR and OV16

Mexico

Sudan Guatemala Nigeria Colombia Venezuela Ethiopia Cameroon Ecuador Uganda Brazil CarterCarter CenterCenter--AssistedAssisted MectizanMectizan DistributionDistribution Elimination Lab Support PCR and OV16

Mexico

Sudan Guatemala Nigeria Colombia Venezuela Ethiopia Cameroon Ecuador Uganda Brazil 2007 Uganda Policy Change

Experience with >30,000 OV16 tests

Oguttu et al. Serosurveillance to Monitor Onchocerciasis Elimination: The Ugandan Experience. AJTMH (in press) A national advisory committee with a focus purely on Onchocerciasis Elimination (this is hard work!) Dark Green = Eliminated Light Green = Transmission Interrupted Greyish Green = Interruption SuspectedUGANDA ‘SCORECARD’ COVERING 6.5 MILLION PERONS Red = Transmission Ongoing UOEEAC RECOMMENDED PLAN - AUG 2013 Total Pop likely to be declared by UOEEAC 914,154 Total # of Treatments stopped next year 500,418 Total Pop treatments not stopping due to LF 629,146 Total Pop of Interrupted Suspected 934,129

# of MDA Planned # MDA Planned semi Total Pop 2011 Semi Yr of Plan for MDA ID No. Focus Vector District annual UTG2 Total Pop Annual Status of Transmission Plan for Larviciding LF Status Cross border Remarks annual (original) UTG1 Annual elimination treatment rounds Txs 2013 rounds Txs 2013 1Victoria S. damnosum Jinja N/A N/A 198,160 508,529 Eliminated 1973 Completed Completed Source of data (UBOS) Mukono N/A N/A 387,707 561,067 Eliminated 1973 Completed Completed Source of data (UBOS) Kamuli N/A N/A 268,046 511,050 Eliminated 1973 Completed Completed Source of data (UBOS) Mayuge N/A N/A 156,714 474,014 Eliminated 1973 Completed Completed Source of data (UBOS) Kayunga N/A N/A 142,565 349,000 Eliminated 1973 Completed Completed Source of data (UBOS) 2 Wadelai S.neavei Nebbi 15 8 17,739 14,382 28,764 21,068 Interupted (2012) LF treatment Not done LF Treatment stopped in 2008 (projected by 3.5%) 4Itwara S. neavei Kabarole 20 2 30,689 25,655 35,216 Interupted (2012) PTS Status post Treatment stopped in 2009 (projected by 3.5%) Kyenjojo 20 2 63,850 50,823 73,269 Interupted (2012) PTS Status post Treatment stopped in 2009 (projected by 3.5%) 5Mt. Elgon S.neavei Manafwa 15 8 40,604 33,698 67,396 43,496 Interupted (2012) PTS Vector Elimination Treatment stopped in 2011 (projected by 3.5%) Mbale 15 8 50,253 40,781 81,562 53,832 Interupted (2012) PTS Vector Elimination Treatment stopped in 2011 (projected by 3.5%) Sironko 15 8 76,375 64,396 128,792 81,815 Interupted (2012) PTS Vector Elimination Treatment stopped in 2011 (projected by 3.5%) Bududa 15 8 161,630 139,656 279,312 173,142 Interupted (2012) PTS Vector Elimination Treatment stopped in 2011 (projected by 3.5%) 3Mpamba-Nkusi S. neavei Kibale 17 8 190,305 156,470 312,940 203,859 Interupted (2013) PTS Status post Treatment stopped in 2011 (projected by 3.5%) 6 Imaramagambo S.neavei Bushenyi 18 0 102,180 85,748 109,458 Interupted (2013) PTS Not done Treatment stopped in 2011 (projected by 3.5%) 8 Wambabya-Rwamarongo S. neavei Hoima 16 13 75,733 63,050 126,100 75,733 125,308 Interrupted (2014) Semi-Annual Vector Elimination Treatment stopped in 2013 11 Maracha-Terego S.neavei/S.damnosum Maracha-Terego 19 0 170,377 136,302 182,469 Interupted (2013) LF treatment Not done LF Treatment stopped in 2011 (projected by 3.5%) 15 Nyamugasani S. kilibanum Kasese 19 0 10,664 8,377 10,664 9,603 Interruption Suspected Annual Not done 7 Kashoya- Kitomi* S.neavei Buhweju 16 13 60,255 48,739 97,478 60,255 99,024 Interruption Suspected Semi-Annual Vector Elimination Rubirizi 16 13 77,250 60,668 121,336 77,250 127,352 Interruption Suspected Semi-Annual Vector Elimination Ibanda 16 13 26,144 21,260 42,520 26,144 43,610 Interruption Suspected Semi-Annual Vector Elimination KisoroKamwenge 15 18 13 13 36,273 45,626 29,905 35,015 59,810 70,030 36,273 45,626 58,508 74,346 Interruption Interruption Suspected Suspected Semi-Annual Semi-Annual VectorVector Control Elimination Feasibility Yes (DRC) 1710 West Bwindi Nile S.neavei/S.neavei/ S. damnosumS. damnosum Yumbe Kabale 19 15 0 13 286,615 29,428 229,292 23,608 47,216 286,615 29,428 229,292 46,900 Interruption Interruption Suspected Suspected Annual Semi-Annual NotVector done Control LF Yes (RSS) KobokoKanungu 19 15 0 13 167,076 56,735 133,661 45,790 91,580 167,076 56,735 133,661 91,874 Interruption Interruption Suspected Suspected Annual Semi-Annual NotVector done Control Feasibility LF Yes Yes (DRC (DRC) & RSS) Arua 19 0 138,063 134,696 138,063 134,696 Interruption Suspected Annual Not done LF Yes (DRC) 9 Budongo S.neavei Masindi 16 13 47,747 38,530 77,060 47,747 78,058 ongoing Semi-Annual Vector Elimination Buliisa 16 13 27,123 22,351 44,702 27,123 45,010 ongoing Semi-Annual Vector Elimination Hoima 16 13 75,325 63,472 126,944 75,325 124,448 ongoing Semi-Annual Vector Elimination 18 Mid North Pader 1 1 239,990 295,822 591,644 239,990 407,982 ongoing Semi-Annual Vector Control Feasibility LF Kitgum 1 3 132,748 128,582 257,164 132,748 226,658 ongoing Semi-Annual Vector Control Feasibility LF Yes (RSS) Lamwo 1 3 126,457 100,311 200,622 126,457 202,332 ongoing Semi-Annual Vector Control Feasibility LF Yes (RSS) Gulu 18 3 190,580 100,360 200,720 419,064 683,324 ongoing Semi-Annual Vector Control Feasibility LF Amuru 18 3 62,293 39,820 79,640 62,293 102,908 ongoing Semi-Annual Vector Control Feasibility LF Yes (RSS) Nwoya 18 1 96,465 67,536 135,072 96,465 173,146 ongoing Semi-Annual Vector Control Feasibility LF Oyam 18 1 21,388 17,606 35,212 21,388 36,118 ongoing Semi-Annual Vector Control Feasibility LF Lira 0 1 35,166 35,166 57,692 ongoing Semi-Annual Vector Control Feasibility LF 12 Nyagak Bondo S.neavei Nebbi 19 3 125,148 93,024 186,048 125,148 204,080 ongoing Semi-Annual Vector Control Feasibility LF Yes (DRC) Zombo 19 3 242,494 192,992 385,984 242,494 403,092 ongoing Semi-Annual Vector Control Feasibility LF Yes (DRC) Arua 19 3 160,844 168,969 337,938 160,844 272,440 ongoing Semi-Annual Vector Control Feasibility LF Yes (DRC) 13 Obongi / Moyo S.neavei/ S. damnosum Moyo 19 0 37,392 34,302 37,392 30,778 ongoing Annual Not done LF 16 Madi S.damnosum Moyo 19 0 86,017 99,508 86,017 71,463 ongoing Semi-Annual Ent survey needed LF Yes (RSS) Adjumani 19 0 17,696 120,047 17,696 14,588 ongoing Semi-Annual Ent survey needed LF Yes (RSS) 14 Lhubiliha S. Sebwe KaseseN.B: Population 19 figures as per 0 2013 119,407 treatment projections 99,718 119,407 98,639 ongoing Semi-Annual Vector Control Yes (DRC) Total 628 220 4,911,336 3,264,922 4,213,586 6,463,912 722,720 3,558,902 Mount Elgon Focus No.Treated 100,000 120,000 140,000 160,000 180,000 200,000 220,000 240,000 260,000 280,000 300,000 20,000 40,000 60,000 80,000 History of mass treatment with ivermectin from 1994to ivermectin with History ofmasstreatment 0 2011 in Mount Elgon onchocerciasis focus, Uganda 2011 inMountElgononchocerciasis focus, 9419 9619 9819 0020 0220 0420 0620 0820 002011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 18,678

78650

125489

147,367

159,270

169,167

165,343

172,666

Period (yrs) Period 176,266

184,362

189,071

190,105

193,858

Elimination Policy 219,275 220,131

239,989 241,887

252,501 259,651

265,951 268044

270,179 271,150 AbateR donated by BASF Dosing Points and fly catching sites on river systems where S. neavei ss breeds from in Mount.Elgon focus Elgon focus: Entomological surveillance Number vectors captured

Abate river dosing Vector elimination

Soper would love this! Manuscript now under consideration by American Journal of Tropical Medicine and Hygiene Very ‘Un-Soperian’!!!!

Flexibility… Different approaches... A Major Paradigm Shift at the African Programme for Onchocerciasis Control

Elimination Acknowledgments

Rodrigo J. Gonzalez Richard Collins Moses Katabarwa Rolf Garms Jane Richards Carlos Gonzalez Tom Lakwo Tom Rubaale Byron Arana Alfredo Dominguez Peace Habomugisha James Katamanywa Nancy Cruz-Ortiz Miguel Barrios-Giron Stella Agunyo Dennis W.K Lwamafa Nidia Rizzo Mauricio Sauerbrey Edson Byamukama Frank Walsh Guillermo Zea- Julio Castro David Ogutu Gary Weil Flores Tom Unnasch Richard Ndyomugyenyi Adrian Hopkins Eduard Catú Alturo Sanchez Ephraim Tukesiga Joanie Lawrence Robert E. Klein Rodolfo Zea-Flores Galex Orukan Ochieng Jack Blanks Ed Cupp Mynor Lopez Irene Nakke Steve Ault Mario Rodriguez Marvin Coyote Eria Emuron Edmundo Alvarez Kim Lindblade Auri Paniagua Bernard Masaba Craig Withers Auri Paniagua Edgar Lobos Francis Abwaimo Lindsay Rakers Mark Eberhard Tom Nutman Ambrose Onapa John Moores Julie Jacobson George Punkosdy David Brandling-Bennet & Don Hopkins And many others…………………………. Special OEPA Acknowledgments •Members of the affected communities •Ministries of Health •Staff of The Carter Center’s OEPA program •Program Coordinating Committee (PCC) •Centers for Disease Control and Prevention •Lions Clubs and Lions SightFirst Program •Pan American Health Organization •University of South Florida References/sources for slides shown in this presentation are available upon request Donor/Partner Acknowledgements Merck and the Mectizan® Donation Program Bill & Melinda Gates Foundation United States Agency for International Development OPEC Fund for International Development (OFID) Alwaleed Bin Talal Foundation InterAmerican Development Bank Lions Clubs International Foundation RTI/ENVISION BASF World Heath Organization African Programme for Onchocerciasis Control (APOC)/World Bank Sight Savers International National Institutes of Health Washington University (St. Louis) and many others, including generous individual donors

113 Thanks!