Insight-Special-Newsletter-2011.Pdf

INSIGHT 2011 SPECIAL

Proceedings of Uganda Onchocerciasis Elimination Expert Advisory Committee 4th Session, 15-17 August 2011 SERENA HOTEL, KAMPALA, UGANDA

A map of Uganda showing eliminated Foci and those targeted for elimination 2011 Group photo of most of the members of the Uganda Onchocerciasis Elimination Expert Advisory Committee and some observers and guests outside Serena Hotel, 15th - 17th August 2011 Contents table General Introduction Peace Habomugisha 1 PART A - Inaugural Activities 3 Words of Welcome & Introduction - Former UOEEAC Chairman J. Frank Walsh 3 Welcome Notes - ACHS (MOH Uganda) Dawson B. Mbulamberi 3 Welcome Remarks - WHO Representative to Uganda Joaquim Saweka 4 Welcome and Opening - DGHS Jane Ruth Aceng 6 PART B - Monitoring and Certification Issues 7 Guidelines for Certification of Onchocerciasis Elimination in Uganda Thomson L. Lakwo 7 UOEEAC in Fresh Look at Certification of Onchocerciasis Elimination Guidelines 8 PART C – Matters Specific to Individual Foci 9 Itwara Focus James Katamanywa 9 Committee Re-examines Itwara 10 Imaramagambo Focus James Katamanywa 10 Under UOEEAC Attention Once More - Imaramagambo 12 Mt. Elgon Focus Review T.L. Lakwo 12 UOEEAC Appraises Elgon Status 14 Bwindi Focus Review Christopher Katongole 14 Through the Spectacles of UOEEAC – Bwindi Focus 16 Kashoya-Kitomi Focus Review Joseph Wamani 16 UOEEAC Screens Kashoya-Kitomi Performance 18 Wambabya Rwamarongo Focus Review James Katamanywa 18 UOEEAC Weighs Up Wambabya Rwamarongo 19 Budongo Focus Review: Progress made Ephraim Tukesiga 19 UOEEAC Spotlight on Budongo 21 Nyamugasani Sub-focus: Which Next Course of Action? Joseph Wamani 21 UOEEAC’s Re-visitation of Nyamugasani 23 Maracha Terego Focus –Next Course of Action Ephraim Tukesiga 23 UOEEAC Proposes Course for Maracha Terego 24 Nyagak-Bondo Focus: Prospects for Launching New Elimination Policy Ephraim Tukesiga 24 Nyagak-Bondo Bounces Back into View of the UOEEAC 26 Updates on Cross border Activities between Uganda & the DR of Congo Tony Ukety 26 UOEEAC Delivers its Updated Position on Cross border Matters 28 Launching River Blindness Elimination in North 1 Focus Bernard V. Abwang 28 UOEEAC Takes a Look at North 1 Focus 30 VCD-Molecular Epid. Lab Updates Harriet Namanya & David Oguttu 30 What UOEEAC Said about the Epid. Lab Updates 32 Wadelai Update & UOEEAC Recommendations 32 Predictive endmember auto-Gaussian S. damnosum s.l. habitat modeling in Northern Uganda (or Remote Sensing) Thomson Lakwo, Robert Novak, Peace Habomugisha & Thomas R. Unnasch 32 Discussion of Remote Sensing 35 PART D - News from some Partners 35 Mectizan Donation Program Adrian D. Hopkins 35 Proposed shipping strategies prompt reactions 36 Progress on River Blindness Elimination in the Americas (OEPA) Frank Richards 36 Reception of Richard’s OEPA News 40 NGDO Coordination Group for Onchocerciasis Control Tony Ukety 41 Ukety’s Review of “Coalition Group” 41 African Program for Onchocerciasis Control, APOC Noma Mounkaila 42 Mounkaila’s APOC Update 43 NTD Control Program/RTI Ambrose Onapa & Harriet Namwanje 44 NTDs Review Revisited 45 PART E - Other Issues 46 Using Standard Format for Coverage Data 46 Foci Names 46 Misrepresenting Sub-foci 46 Oncho and Filariasis Coordination 46 VHTs and NTD Integration 47 PTS Plans 47 Inter-meeting Decisions 47 Getting Results Published 47 UOEEAC, Debate, Minutes and Certification 47 PART F – Closure 47 Closing Remarks by retiring Chair J. Frank Walsh 47 Closing Statements from MOH Uganda Dennis KW Lwamafa 48 PART G – Peripherals 50 Annex I - Oncho Flag - 2011 50 Annex II - Attendance List 51 Annex III - List of Abbreviations 52 Annex IV – Autobiographical Notes on Outgoing Chairman J. Frank Walsh 53 Annex V - Uganda’s Incredible Journey from Control to Elimination of Onchocerciasis: an Interview with Moses Katabarwa 55 he assumed on account of his office.

The 4th UOEEAC meeting, in one way, was historic and historical. For the first time ever, since the committee was formed in 2008, its steering changed hands. Dr. J. Frank Walsh’s term as chair ended, and Prof. Dr. Thomas R. Unnasch was elected the new chairperson, taking over straight away the chairing of the 4th session. Walsh remains a member of the committee; and he will always be remembered for ably managing the affairs of the committee, even when things were stormy, at the time of his chairmanship. Also this needs mentioning: Ephraim Tukesiga and James Katamanywa, as representatives (on the UOEEAC) of Uganda’s onchocerciasis endemic districts, had their terms of office renewed so that the committee may benefit from their long-accumu- lated expertise. Thomas Rubaale, without any committee member’s objection, was appointed new member of the committee, an honor that he readily accepted, pledg- ing to do all his best.

We are happy to report that the districts of Pader, Kitgum, Gulu and Lamwo, where onchocerciasis infections had been reported to be of high levels, did receive consider- able attention this time. Now that they have come into mainstream UOEEAC discussion, it is hoped that hence- forward they will stay in the committee’s view. Local (government and NGDO) officers whose responsibility General introduction it is to monitor the status of the fight of onchocerciasis Peace Habomugisha in that region hopefully will be more on guard. We hope too that village, district and national officials charged ganda Onchocerciasis Elimination Expert Adviso- with taking to the next level that attack, by providing Ury Committee (UOEEAC) in 2011 had its fourth necessary drugs and or through vector control and elimi- session from August 15 – 17. The host hospitality facil- nation, will get more down to business. ity was Serena Hotel of Kampala, Uganda. With regard to matters of making presentations at UOEE- Most of the faces that we have come to associate with AC meetings, by both Uganda Carter Center (UCC) and the committee’s once a year meeting, be it members of 1 VCD (MOH Uganda) field staff, a new welcome devel- the committee, observers or facilitators, were present. opment sprung from the committee’s 4th meeting. The This is a clear pointer to a strong sense and trend of UCC CDTI program, instead of contributing indirectly continuity and commitment among this body of per- through its contributions to presentations by MOH field sons working to end onchocerciasis in Uganda. For- officers (the only people who have presented for two mer Uganda National Onchocerciasis Control Program years running, i.e. 2010 and 2011), will present field Manager Richard Ndyomugyenyi who nowadays tends reports alongside the VCD (CDTI, vector control and to attend in observer capacity and Dr. Ambrose W. elimination) team. That will be the order of presenta- Onapa (himself a UOEEAC member) were among the tions in future, at least for the 2012 committee session, if familiar faces that were absent. These two individu- the development is respected and implemented. als had health-associated obligations to carry out else- where. Onapa who was scheduled to give a presenta- In few words we shall talk about the arrangement of tion had to ask Harriet Namwanje of NTDCP (at VCD, the material in this report of 2011 UOEEAC proceed- MOH Uganda) to do that for him. ings. The first pages, and coming soon after this preface, hold the addresses by experts that opened the meeting New faces this time round included Dr. Johnson – the first being by Walsh,2 the second by Dr. Dawson Ngorok, the new Sightsavers Country Director for Mbulamberi,3 the third by Dr. Solomon Fisseha who Uganda, Dr. Paul Cantey of CDC, USA, and Dr. Ste- represented the WHO Representative in Uganda Dr. phen Leak of APOC, Burkina Faso. Of Ngorok not Joaquim Saweka, and finally that by Dr. Dennis K.W. only has he replaced his predecessor Ben Male in the function of country director. He has also taken Male’s place as a member of the UOEEAC – a responsibility 2 Now better described as former UOEEAC chair. 3 The Assistant Commissioner for Health Services, MOH ¹ Look in the final pages of this document for relevant Uganda – one particularly responsible for control of vec- details in the register of persons who attended the 4th tor-borne diseases. He is the ministry’s focal officer for (UOEEAC) meeting. NTDs. Insight Special 2011 4th Session, 15-17 August 2011 1 Lwamafa who represented Dr. Jane Ruth Aceng.4 matters. Words by retiring Chair Dr. J. Frank Walsh and Dr. Den- Core presentations, i.e. presentations by Ugandan on- nis K.W. Lwamafa of the Uganda MOH headquarters chocerciasis field staff, which deal exclusively with the close the most important part of the present report. The situation of the disease on the ground (in the country), peripherals thereafter include attendance list, the list form the second and biggest body of material. This of abbreviations, notes on the outgoing Chairman, and group includes the VCD (Uganda) molecular laboratory “Uganda’s Incredible Journey from Control to Elimina- report, although the reporter of this information present- tion of Onchocerciasis”. ed nearly at the end of the meeting. Also placed in this category, because of their great potential relevancy to From what is already said, the assembling of this mate- onchocerciasis fieldwork in Uganda, is the presentation rial has used for its advantage presentations by different on “cross border issues” (by a non-local) and the one on people who are properly recognized. We want to record “remote sensing”, two of whose authors are not “local that it has also considerably benefited from one special onchocerciasis fieldworkers”. record that has been particularly useful in the writing of the report of 2011 UOEEAC’s discussions and recom- For each one of the core presentations, the presenter’s mendations on the different onchocerciasis foci where work is matched with the particular response(s) to it by the ultimate goal is elimination of onchocerciasis infec- UOEEAC, which response(s) follow(s) right after the tion as well as the interruption of the transmission of presentation.5 Presenters in that class include Thomson this disease. This is the short account whose writing and L. Lakwo, James Katamanywa, Christopher Katongole, revision were a corporate committee effort overseen by Joseph Wamani, Ephraim Tukesiga, Bernard V. Ab- the committee’s new Chairman (Thomas R. Unnasch) wang, David Oguttu and Harriet Namanya, Tony Ukety, who distributed it on 17 August 2011. It is from this and T.R. Unnasch – some of whom, as shown by the committee official that authorization has been asked for contents, for example, presented more than once.6 We (and granted)9 to use the “Unnasch-UOEEAC” text 10 have also included UOEEAC’s discussion of and rec- for purposes of the document now at your disposal. ommendations for Wadelai focus although no event had been planned in the committee’s 2011 timetable to deal In the build-up to UOEEAC 2011 and while this meet- with this matter. ing lasted, many (people as individuals or groups and organizations) lent a hand, openly and/or indirectly, to Another set of presentations, generally titled “news from help it succeed in fulfilling its agenda. The list of the some partners”, were those by some other collaborators known good doers is too large to report here. While we in the Uganda onchocerciasis program.7 In this group are thankful to one and all, it is all the partners actively of presenters we have Drs Adrian D. Hopkins, Frank participating in Uganda’s anti-onchocerciasis push – Richards, T. Ukety, Noma Mounkaila, Harriet Namwan- GOU, TCC, SS, APOC, etc. – that the UOEEAC and its je and Ambrose Onapa.8 This section is followed by Secretariat thank most deeply. another (titled “other issues”) that is devoted to the committee’s responses and recommendations toward certain The reader, finally, is encouraged to also listen to and watch the video recording of the UOEEAC 2011 proceedings (in their entirety) that is available from The 4 The new Director General of Health Services (DGHS) at Carter Center Uganda headquarter offices in Kampala. Uganda’s Ministry of Health. Being unable to personally attend this event, she sent as her representative Dr. Lwamafa who presented her speech. Lwamafa is Uganda’s Commis- IMPORTANT NOTE: Future UOEEAC proceedings sioner for Health Services in the Department of National Dis- will no longer be produced in the current format. They ease Control at the MOH. will consist of comprehensive minutes (as recommend- 5 How, anyway, was the response(s) reached? When a pre- ed by the committee in August 2011) together with ap- sentation or two, or more, was/were given, as you will see pendixes of opening and closing speeches, presenters’ from the meeting’s timetable, in the last pages of this report, presentations, and names of participants. The quality the committee would have a discussion. It was out of such discussions that there evolved the response(s), which were of each presenter or speaker’s material (in line with the the committee’s recommendation(s) on different oncho is- requirements and guidelines of the committee as well sues. as in terms of English) will be his or her responsibility. 6 Lakwo is the Uganda NOCP Ag. Manager and a UOEEAC Speakers and presenters, besides a power point copy of member, Katamanywa the DVCO Kyenjojo District, Katon- their presentations, are requested to submit to the sec- gole VCO (VCD, MOH Uganda), Wamani the VCO, Kam- wenge District, Tukesiga the DVCO Kabarole District, Ab- retariat a Microsoft (Word 97-2003 or later) version of wang the DVCO, Gulu District, Oguttu and Namanya of the their material. molecular laboratory establishment at Uganda MOH VCD, Ukety of WHO Geneva, Switzerland, and Unnasch of the 9 The request for consent from the Chair was written on 29th University of South Florida and UOEEAC. May 2012, and Unnasch’s affirmative reply was given on same 7 Some collaborators or partners, i.e., besides the govern- day ment of Uganda (GOU), Carter Center Uganda, and other 10 Unnasch-UOEEAC 2011: Report of the 4th Annual Meet- partners. ing of the Uganda Onchocerciasis Elimination Expert Advisory 8 Ngorok’s presentation, which fits in this category, was all Committee, August 15-17. We have called the account Unn- oral as he had no written text. It is therefore not published in asch-UOEEAC 2011 not because we want to distance Unn- the current proceedings. Persons interested in it will have to asch from his committee membership, but simply to stress his consult the video record of it. leading role in putting together the text. Insight Special 2011 4th Session, 15-17 August 2011 2 PART A - INAUGURAL Finally, before standing down in a few minutes, I should ACTIVITIES like to express my appreciation of Mr. Ben Male, SSI, who retired during the year, for his services to the committee. Words Of Welcome & Introduction J. Frank Walsh Welcome Notes Dawson B. Mbulamberi

Ladies and Gentlemen, elcome to the fourth annual meeting of the Ugan- Wda Onchocerciasis Elimination Expert Advisory Committee. I am avoiding mentioning individuals as I fear to miss out some important personage, get the hile you are here, indeed during this meeting, I precedence wrong or mispronounce a name – missing Wwish, on behalf of MOH Uganda, to request you out all names seems safer. In any case, I am a democrat to advise us, on the meeting’s sidelines, on the follow- (note the small‘d’). However, I do especially wish to ing issue. We are in the process of working out criteria welcome all those who are participating in a UOEEAC guidelines for certification of onchocerciasis elimina- meeting for the first time. We are essentially informal tion, but we are having a problem with foci that are co- in our deliberations and so I urge all present to take full endemic for onchocerciasis & LF. We have been doing part in the discussions. It does not matter whether you mass ivermectin distribution in this country, in some are listed as a guest, observer, or member of the com- districts we have done it for 5 years, in others (we have mittee. done it) for 6 years, but we have not yet embarked on formulating the criteria for certifying elimination of LF As the name of the committee clearly implies our task in any focus or in the country for that matter. The ques- is to provide technical advice to the Ministry of Health tion is, if you decide, and I think we have done a good on the elimination of onchocerciasis in Uganda with, I job as far as onchocerciasis is concerned, how do we hope, a fair degree of expertise. take care of LF? We are trying to answer this question A substantial part of our meeting in 2010 was concerned and each time we have had a meeting it has come up and with the development of the “National Guidelines for the Thomson Lakwo11 will recall that I kept saying “well Certification of Onchocerciasis Elimination in Uganda”, when the advisory group is here, they will probably ad- which has born fruit. We shall be revisiting the Minis- vise on the way forward”. To sum up, we have not start- try’s excellent response later on in this meeting. ed looking at the guidelines for certification of LF, but here we are - dealing with foci in which we have both The Third UOEEAC meeting also reviewed the ongoing LF and onchocerciasis. For onchocerciasis, we think we elimination situation and made recommendations in our have achieved the criteria, and we are saying that (yes) report for appropriate action in each of the actively pur- we can stop ivermectin mass treatment because we think sued foci. No recommendations were made to the Min- we have eliminated the oncho disease in some foci or istry of Health during the year (August 2010 to August that we are successfully pursuing its elimination in oth- 2011) by me, on behalf of the committee, as laid down ers. What, however, do we do with the problem of LF by protocol on inter-meeting decision making. in one and the same focus? Your advice will be highly This year, at this meeting, we shall be considering im- appreciated on this matter. portant updates, especially to the epidemiological data, which should enable us to make more positive recom- 11 Then, as of now, Lakwo was the Ag. Manager of the On- mendations. chocerciasis Control Program for Uganda. Insight Special 2011 4th Session, 15-17 August 2011 3 Another issue on which I would like to request your as- all the way from your countries, or from within this na- sistance is the question of co-implementation. Before tion, to help Uganda on the way forward as far as on- MOH (Uganda) adopted the integrated approach for the chocerciasis is concerned. I think we have done fairly a control of the PCT neglected tropical diseases (NTDs) good job but it is up to you to judge, and say whether the we had CDTI for onchocerciasis. But the ministry de- claim we are making is justified or not. cided to adopt the integrated approach for preventive chemotherapy for 5 NTDs. Some quarters have not been I thank you Mr. Chairman and everyone very much for very happy; they have complained that what we are do- the opportunity to talk to you. ing now, using the integrated approach, might compro- mise CDTI. We have thought about various ways of handling the matter; we have thought about creating a Welcome Remarks taskforce to look at it critically and advise us on the way Joaquim Saweka12 forward. We have recommended research but we have not been very lucky yet, as nobody has come forward yet to say that let us carry out a research study to see what happens to CDTI when we adopt the integrated approach. The integrated approach, we feel as MOH, is the way to go because we are hitting many enemies at the same time. We are also saving the customer plenty of time, and saving this customer cost of travel because the customer comes and we can give praziquantel, if the area is endemic for schistosomiasis, give ivermectin and albendazole rather than saying, okay today we shall give you ivermectin, then next week you can come back for praziquantel. We need your advice on this matter as well.

One more source of worry, for some quarters in this country, is what we call VHTs. We think that they should be the link between the health system and the communities. Our desire was to have Health Centers I at village level but we found that this would be very expensive; so we opted to have VHTs. These are teams of people who are residents in the different villages, who are recruited and then trained. They are given some basic knowledge Solomon Fisseha represented Joaquim Saweka so that they go round and advise the communities about issues of health. VHTs act as a link between the health n behalf of WHO, I greet you all and welcome you system and the communities. Some quarters, though, Oto this 4th session of the Uganda Onchocerciasis think that this is going to destroy structures that already Elimination Expert Advisory Committee. This annual exist. The arrangement is that these VHTs should com- meeting of this committee is important as it will criti- prise people who have acted as community medicine cally review progress made in the last 4 years since the distributors such as those who have participated in the country adopted onchocerciasis elimination as a goal. distribution of HOMAPAK in the case of malaria. Actu- The committee will, after careful review of the activi- ally preference is given to people of such background. ties done and of available data, provide recommenda- Unlike some people who think that this view of arrange- tions for consideration by the Ministry of Health on ment of things (VHTs, etc.) might kill existing good how to advance the onchocerciasis elimination efforts structures, our feeling is that we are not destroying any- in Uganda. thing. We shall be thankful too for your opinions on the issue of VHTs. As you are all aware, WHO identified onchocerciasis for possible elimination as a public health problem in 1997, I will limit myself to those three requests – requests based on the evidence available then. The attainment regarding issues that are raised every now and then in of onchocerciasis elimination in parts of the Americas some concerned quarters. and in some foci in African countries including Senegal, Mali and Uganda is evidence that this is possible in most We shall be grateful if at the end of this meeting you 12 As at the 2010 August UOEEAC’s 3rd convocation, the have some advice for us on how we can forge ahead. WHO Country Representative Saweka was represented by Dr. Solomon Fisseha who read out his boss’s message for Once again I welcome you all. I thank you for coming the event. The welcome began by recognizing the presence of the Director General of Health Services (MOH Uganda), of the person representing the APOC Director, of the main representative of The Carter Center, of the Country Director of Sightsavers International, of the Chairman of UOEEAC, and lastly, and generally, of other attendees, i.e. ladies and gentlemen in their different capacities. Insight Special 2011 4th Session, 15-17 August 2011 4 of the affected areas, and this provides more basis for 5. Monitoring community participation in onchocer- Uganda to push on with the elimination drive. However, ciasis elimination as this has been the cornerstone for there are key issues that should be put into consideration the success of this program thus far. in the onchocerciasis elimination drive and these include the following: 6. Special attention to post-conflict places: As you are aware, there is a high prevalence of onchocerciasis in 1. Use of effective, evidence based interventions taken the post-conflict districts of Acholi region.13 The at- to scale and sustained until elimination is achieved in tainment of onchocerciasis elimination in Uganda as a focus. I believe that from time to time interventions a country will be determined by how quick and effec- are reviewed to ensure that they are effective and in line tive our interventions are in this region. In this quarter, with new evidence being generated through research “Nodding Syndrome” is highly prevalent in areas with and country experiences. high onchocerciasis microfilaria prevalence. It is of interest to study the impact of significant reduction in 2. Appropriate methods and indicators for monitor- microfilaria prevalence on the incidence of the nodding ing the progress towards elimination, and documenta- syndrome. It is highly recommended that biannual mass tion of elimination when it is achieved. Onchocerciasis treatment with ivermectin be considered for this region elimination should be clearly defined so that when it is as this has been documented to result in elimination of attained there are no doubts. I know that this commit- the disease in a shorter period. tee has deliberated before on the indicators for monitoring elimination and the criteria for ascertaining that I urge this expert advisory committee to look into all it has been achieved. I hope that these have been peer these issues as you review the progress made by the on- reviewed and agreed upon internationally by WHO and chocerciasis elimination program in Uganda. other partners to ensure that the Uganda program is following credible international standards. Lastly, let me take this opportunity to commend the Government of Uganda, APOC, The Carter Center, SSI, 3. Clear guidelines on post-elimination activities to en- WHO, and other partners for their technical, financial, sure that onchocerciasis is not re-introduced in the foci and logistical support towards onchocerciasis elimina- that have already attained elimination. Specifically, it tion. I urge all to build on the country’s experiences with should be very clear when and how mass drug admin- polio and Guinea Worm eradication, as well as the re- istration should be stopped in different foci, putting into cently achieved Maternal and Neonatal Tetanus elimina- consideration the risk of re-introduction of the disease; tion14 to make onchocerciasis elimination a reality in and there should be clear surveillance strategies that will Uganda. enable quick detection of re-introduction of the disease if at all it occurs. We have noticed a tendency for com- I wish you fruitful deliberations. I would like to assure placency when elimination or eradication is achieved in you that WHO fully supports this initiative and I wish to the fight of certain diseases, but this should be avoided pledge our continued support. I thank you all for listen- in the onchocerciasis program, especially since a phased ing to me! approach is being used. Integration of post-elimination surveillance in national surveillance systems should also be explored now because sustainability of a vertical post-elimination system is quite difficult and may not be financially feasible. The committee should provide recommendations on these issues for consideration by government. As more countries in Africa move towards the elimination goal, I hope regional guidelines will be developed and that the Uganda guidelines will inform that development.

4. Clear strategy for handling cross-border transmission of infection, especially when the neighboring countries like South Sudan and DRC are at different levels of control of the disease. This is very critical as it can interfere with the elimination efforts in Uganda, if the risk for re-infection from the neighboring countries remains very high. There is need for cross-border collaboration in program planning, synchronization of activities like mass drug administration or vector control in the different countries, and strengthening of all the programs in the sub-region so that elimination becomes a sub-regional goal.

13 These are Lamwo, Kitgum, and Pader. 14 The certification of both took place about mid 2011. Insight Special 2011 4th Session, 15-17 August 2011 5 Welcome And Opening Jane Ruth Aceng15 I find it helpful to think of moving from positions to principles. If we are to move forward on the issue of elimination of onchocerciasis in Africa, and in particular Uganda, there are many issues that we need to address. We therefore need principles that can act as a lodestone or a compass as we and many others deal with the details and practical problems of onchocerciasis elimination.

Firstly, we take the availability of certification guidelines. I was reliably informed that this very committee worked on the draft text. The document has already been channeled through the technical committee of the Minis- try of Health. This document is very important if we are to move forward, and it is now available for your final scrutiny and will be the basis upon which the program will operate. If we are to achieve the goal of elimination of onchocerciasis, all the partners represented here have a role to play. It should be noted that the world is becoming increasingly integrated. It has become less and less possible for different policy areas to be handled inde- Dennis K.W. Lwamafa represented Jane Ruth Aceng pendently of each other: therefore working as a team has become the order of the day. I would like to commend t gives me great pleasure and honor to officiate on all the partners that have kept this committee moving Ithis important occasion. On behalf of the Ministry through their technical and other input. of Health, I would like to warmly welcome you all to Uganda and in particular Kampala. I extremely appreci- Secondly, building capacities at national level for on- ate your readiness to give up your valuable time to con- chocerciasis elimination should be at the forefront. The tribute your experience and expertise to this meeting. health sector, with the support of partners, has a challenge of ensuring that relevant personnel are in place to You bring with you a great variety of knowledge, experi- preserve the achievements so far made in onchocercia- ence and perspectives on onchocerciasis. This diversity I sis elimination. Already some foci are due for halting believe will contribute to the richness of discussion that of interventions, and this urgently needs strengthening I am confident you will have, provided everyone recog- of surveillance to support the post treatment effort. One nizes and respects each other’s different constraints and of the requirements for certifying a focus as free of on- responsibilities. chocerciasis is three-year Post Treatment Surveillance, an activity that needs strong support of district health Being a meeting of experts, the purpose is not to seek to teams. This preparedness is important if the affected negotiate an agreed course of action, but its main pur- communities are to understand onchocerciasis elimina- pose is to generate a better understanding of the com- tion strategy. plex issues involved in onchocerciasis elimination in Africa and specifically Uganda. The main product I ex- We need also to appreciate the fact that if we are to pect from this meeting will be a report summarizing the achieve certification of onchocerciasis, the issue of docu- main issues that will have been identified, the points that mentation becomes very crucial. Reliable data is wanted will have been made together with recommendations. at all levels to demonstrate the trend in onchocerciasis This will be important if the program is to streamline elimination in each focus, and this should be verified by and improve on onchocerciasis elimination in Uganda. the National Certification Committee. Where interventions are to be halted there should be clear evidences of transmission interruption based on the current guidelines. Effort should also be made to document every step 15 Dr. Ruth Aceng is the new Director General of Health Ser- of elimination in each of the foci. vices (DGHS) at Uganda’s Ministry of Health. Her address started off by recognizing the turnout at the meeting of the To conclude, allow me to comment on some few issues different delegates: WHO’s Representative to Uganda, APOC Director’s Representative at the event, The Director of regarding elimination of onchocerciasis in Uganda. the Mectizan Donation Program, Atlanta (USA), UOEEAC’s Chairman (Dr. Walsh at that time), the lead Representative The issues that you will discuss will essentially be sci- from The Carter Center, Atlanta (USA), The NGDO Coalition entific and technical. As such they will require techni- Coordinator, Representatives of Uganda onchocerciasis en- cal solutions that are expected to be provided by experts demic districts, and, on the whole, each one of the distinguished invited guests (ladies and gentlemen) in their vari- seated here. We need to be sure that we have all the evi- ous capacities. As institutions, MOH Uganda/GOU partners dences available for onchocerciasis elimination before in the anti-onchocerciasis effort (whether represented or not) we make any decision. were also specially recognized by the DGHS: APOC, Carter Center, GTZ, RTI/USAID, Sightsavers constituted her list. Insight Special 2011 4th Session, 15-17 August 2011 6 Background The test of a meeting like this one is not the produc- • The Government of Uganda launched tion of recommendations, nor is it the quality of report elimination policy in 2007. – although I am sure in this case, it will be a good one. • Policy aims to eliminate onchocerciasis by The test is whether better understanding of the issue of semi - annual treatment with ivermectin and onchocerciasis elimination has been fully seized in the vector control/elimination. context of Uganda and the African continent at large. • Policy is being implemented in 14 districts in These issues should further be translated into positive six foci. action within our own areas of operation and influence. • Need arose for criteria for decision making in elimination. Finally, I would like to extend my sincere appreciations: • First draft of the guidelines document was to all the partners and to The Carter Center in particular developed by UOEEAC.16 for the support they have offered towards this meeting; • Procedures for MoH to own a document is for it to to the organizers and to all the audience members for be reviewed by their various committees. having honored the invitation.

With these words, it is now my pleasure and honor to de- Present Content clare this 4th session of Uganda Onchocerciasis Elimi- • Introduction - justification of guidelines. nation Expert Advisory Committee officially open. • Elimination interventions. • Onchocerciasis Flag. Thank you for your attention. • Certification criteria – indicators. • National preparations - PTS, reports. • International Certification Committee.

PART B - MONITORING AND 16 The initial draft development took place in 2009, and the committee was still known by its older name of Uganda On- CERTIFICATION ISSUES chocerciasis Elimination Committee – the name it got at the first meeting (called in August 2008 by MOH Uganda and The Carter Center) where the committee was instituted as “the Guidelines for Certification of Onchocerciasis Uganda program for elimination of onchocerciasis (UPEO)… advisory body composed of national and international experts Elimination in Uganda that conducts annual review, monitoring and evaluation…ac- Thomson L. Lakwo tivities, recommends effective approaches and methods for hastening onchocerciasis elimination” (Onchocerciasis Elimination Program in Uganda, The Ugan- da Onchocerciasis Elimination Committee (UOEC): Terms of Reference and Procedures of Operation 2008). The name changed from Uganda Onchocerciasis Elimination Commit- tee (UOEC) to UOEEAC (Uganda Onchocerciasis Elimination Expert Advisory Committee) about mid 2010, the time of the development of the second draft of the guidelines where for the first time we hear of UOEEAC. The first draft was therefore made by UOEC, not UOEEAC. UOEEAC is not even mentioned in that oldest of the drafts – only UOEC is. See National Guidelines for Determining the Elimination of Onchocerciasis in Uganda (Draft 2, June 2010, pp. I, ii, 11-14). Under point 5.0, p.12, this draft says: “The Uganda Onchocerciasis Elimination Committee (UOEC) now renamed Uganda Onchocerciasis Elimination Expert Advisory Committee (UOEEAC) was formed in 2008 with the objective of providing technical advice to the Ministry of Health on onchocerciasis elimination in the country.” In a later version of Draft 2 (National Guidelines for Determining the Elimination of Onchocerciasis in Existing Foci in Uganda), also from June 2010, UOEEAC replaces UOEC in most places, while in a few others UOEC stubbornly escapes being replaced (pp. 2, 13- 17). The statement that we just cited from point 5.0, p.12, is repeated, word after word, as item 5.1 (p.10) of the draft edition with the name National Criteria for Determining the Elimi- nation of Onchocerciasis in Uganda (Draft: Post UOEEAC Review, August 12, 2010), a draft that appeared, as its name clearly shows, in the wake of the third UOEEAC meeting of August 10-12, 2010. See also one presentation by Thomson L. Lakwo at UOEEAC 2010 (10-12 August): Terms of Refer- ence for the Uganda Onchocerciasis Elimination Expert Advi- sory Committee (UOEEAC). There, inter alia, he writes: ‘The UOEC was renamed “Uganda Onchocerciasis Elimination Expert Advisory Committee” – UOEEAC.’

Insight Special 2011 4th Session, 15-17 August 2011 7 • Challenges & solutions. Post UOEEAC Review, August 12, 2010, pp. cover page, • Conclusion. i-iv, 1-18)...... Until about the time of the UOEEAC of • Appendices – SOPs – 10. August 2011, the document was still known as National Criteria.... Review of post-August 2010 UOEEAC draft • NCC review April 2011. We now return to the point of substitution: When salut- • CDC-Technical Working Group – 1st July 2011. ing the change from criteria to guidelines, saying the lat- • TRC – 19th July 2011. ter is more flexible than the former, the 2011 UOEEAC • Comments used to revise the document in assembly sounded caution. These guidelines are not cut conformity with MoH guidelines format. and set in stone; they are not “the ten commandments”; not the bible; it was said. They can and will likely need Review changes to be revised in certain circumstances to match realities • Title – reverts to ‘guidelines’ instead of ‘criteria’. on the ground because, as they presently are, they do not • Some of the contents move from main text to capture everything that is possible, everything likely to appendix. be confronted ahead. With time, said in different words, • Use of action verbs was strengthened. the guidelines will change as unique situations will de- • Rephrasing was conducted in some of the mand changes in the document’s stipulations. paragraphs. • National preparations included. The committee’s general wish is that MOH Uganda • Challenges, solutions & conclusion added. staff, those involved in onchocerciasis elimination in • Standard operating procedures included. particular, will not forget that the guidelines are not cut in stone and rock. These sentiments, which are results Next course of action of hands-on experience and serious learning, are not • Final comments from this committee new in the UOEEAC circle. We find them as early as (UOEEAC 2011 August). the fledgling stages of the birth and rise of the commit- • Comments from the WHO technical arm. tee. “Rigorous satisfaction of elimination certification • Presentation to Uganda MOH’s Senior criteria (indicators for elimination)”, says the committee Management Committee. (UOEC 2008) whose name was to become UOEEAC in • Presentation to Top Management Committee 2010, would “be established and periodically reviewed of MOH Uganda. in detail, focus by focus, by the Uganda Onchocerciasis • Endorsement. Elimination Committee (UOEC), a group of national and • Printing. international experts...”, adding that “the criteria used” • Dissemination and use. would “be developed by the UOEC with due reference to WHO, APOC and OEPA criteria and protocols”.

Some of the committee’s other concerns have been UOEEAC in Fresh Look at Certification of On- circulated by UOEEAC’s newly selected Chairperson chocerciasis Elimination Guidelines Thomas R. Unnasch (17 August 2011), the coordinator For work generally accomplished satisfactorily to this and chief compiler of the points. This, however, was a point, Uganda’s MOH is worthy of a pat in the back – summary of a longer text of matters that was passed on this being the reason why some of the UOEEAC mem- to MOH Uganda’s top management for attention, and bers quickly and warmly welcomed the 2011 edition of the short list can only make sense when read in conjunc- the document as an “improvement over” past drafts. tion with the July 2011 edition of the Guidelines for Cer- tification of Onchocerciasis Elimination in Uganda. This reception was not without concerns, as we proceed to exemplify. We take the reactions to the replacement of MOH (Uganda) is unquestionably the happy owner the word criteria, in the document title, with guidelines, of the Guidelines for Certification of Onchocerciasis which was in fact a return to the latter term. But first, Elimination in Uganda (July 2011 edition), although, it why is it a return? Because the document, during its ear- must be said, other bodies and individuals, named and ly formative days, has had different names. First it was unnamed, directly and indirectly, have contributed sig- called National Guidelines for Determining the Elimina- nificantly to this document’s content during 2009 - 2011. tion of Onchocerciasis in Existing Foci in Uganda (Draft Copies of the guidelines (July 2011 edition), which, by 1, December 2009, pp. 1-13 & Draft 2009, pp. 1-15). the way, are yet to be finalized and made ready for expert and non-expert consumption, may be accessed, for Later that name changed to National Guidelines for De- those who are interested in them despite being unfin- termining the Elimination of Onchocerciasis in Uganda ished, from MOH Uganda’s National Onchocerciasis (Draft 2, June 2010, pp. cover page, i-iv, 1-24), and to Control Program, UOEEAC Chair or Co-Secretaries, National Guidelines for Determining the Elimination of Uganda Carter Center or any other connected office. Onchocerciasis in Existing Foci in Uganda (Draft 2, evi- dently during later part of June 2010, pp. 1-24). After the 10-12 August 2010 UOEEAC meeting there appeared another version titled National Criteria for Determin- ing the Elimination of Onchocerciasis in Uganda (Draft: Insight Special 2011 4th Session, 15-17 August 2011 8 Itwara Focus PART C - MATTERS SPECIFIC TO INDIVIDUAL FOCI

Itwara Focus James Katamanywa

Introduction • Itwara Onchocerciasis Focus traverses districts of Kabarole and Kyenjojo. • It covers an area of 500 to 600 km2. • It has two secondary foci of Siisa and Aswa. • The vector there was Simulium neavei whose larvae develop in phoretic association on fresh water crabs. • It has a population of 95,000 people (2010 CDTI census data). • Annual ivermectin mass treatment there started in 1991; was supplemented with vector elimination from 1995 onward.

Funding • Program funding and implementation started by GTZ (1991), APOC got involved in 1998, The Carter Center (2009) and NTD/MOH (2008 to date). REMO MAP OF UGANDA SHOWING ITWARA FOCUS • Baseline data collection (1991-1994) on disease epidemiology and entomology by GTZ, Institute for Tropical Medicine (Hamburg, Germany) and MOH Uganda.

Research results • Microfilariae carrier prevalence 88%. • Community microfilariae load (CMFL)22-93 mf/snip. • Nodule carriers 49%. Itwara • Onchodermatitis prevalence 34%. Focus • Ocular oncho present with less damage. • Epilepsy and retarded growth. • S. neavei highly anthropphilic 300 fly/man/ day. • Infection rates in the vector population above 40%. • Annual transmission potential estimated at 4,500 to 6,500 infective larvae /person /year.

Results: Fly infection • Vector infection rates decreased sharply after the distribution of ivermectin but always recovered a few months later. • There was some downward trend during the first four years of treatment but transmission remained high. Insight Special 2011 4th Session, 15-17 August 2011 9 • Investigation whether the effect of ivermectin could be Conclusions enhanced by vector control measures started in 1994. • Interruption of transmission had been achieved by 2004. Results of Larviciding • With the focus isolated no threat of re-infestation. • In 1995, Simulium vector elimination extended • Annual mass treatment coverage has been going in all streams / rivers of the Itwara forest reserve. on at more than 80% coverage of eligible • By September 1996, flies had virtually population. disappeared. • The 2009 epidemiological impact assessment • For the last 15 years, no fly caught in the revealed no threat of the disease. Itwara main focus. • OV16 and skin snip PCR results for children • The last adult S. neavei caught in 2003 on also revealed no disease. River Siisa. • In 2003, only 7 larvae of S. neavei were found Recommendation in 2,268 river crabs from 32 sites. Mass treatment with ivermectin is not necessary and • One year later in February 2004, none of the should be stopped. 3,814 crabs from 39 sites carried immature stages of the vector fly(Prof R. Garms Report). Appreciation • Assessment of 2004: None of the 10,000 Extended to German Technical Cooperation (BHS); crabs was carrying early vector stages. Bernhard Nocht Institute, Hamburg, Germany; Mecti- • Assessment of 2005: None of the 4,000 crabs, zan Donation Program; Merck & Co.; The Carter Cen- from 41 sites earlier infested, was carrying ter; APOC; MOH Uganda; Vector Control Unit (Fort- young vector stages. Portal); the varied Kyenjojo & Kabarole leaderships; • S. neavei appearance eliminated from Itwara focus and the affected communities. but monitoring continues.

Committee Re-examines Itwara Epidemiological indicators impact assessment “Based upon a thorough examination of the evidence,” Epidemiological indicators impact assessment we read, “the committee...concluded that the Itwara fo- Indicators Epidemiological indicators1991 impact assessment2004 2009 cus has met the MOH guidelines for transmission inter- MicrofilariaeIndicators carriers 88%199 1 1.7%2004 0 2009(686) 0% ruption and recommends that the MOH stop communi- IndicatorsMicrofilariae carriers 19988%1 20041.7% 20090 (686) 0% CMFL 49 mf/s 0.06 mf/s 0 mf/s ty-wide interventions. Treatment should still be made Microfilariae carriersEpidemiological indicators88% impact assessment1.7% 0 (686) 0% CMFL 49 mf/s 0.06 mf/s 0 mf/s Nodules 49% 13.5% 1 (686) 0.14% available on an individual basis to the rare individuals CMFL 49 mf/s 0.06 mf/s 0 mf/s NodulesIndicators 19949%1 200413.5% 2009 1 (686) 0.14% Onchodermatitis 34% 1.3% 11 (686) 1.6% who might still be experiencing symptoms of onchocer- NodulesMicrofilariae carriers 88%49% 1.7%13.5% 0 (686)1 (686) 0% 0.14% Onchodermatitis 34% 1.3% 11 (686) 1.6% ciasis following the end of community-wide treatment. Onchodermatitis 34% 1.3% 11 (686) 1.6% Persons TreatedCMFL and Percent UTG achieved49 in mf/s Itwara 0.06Focus mf/s from 02005 mf/s-2009 The committee recommended that the epidemiological Persons Nodules Treated and Percent UTG achieved49% in Itwara13.5% Focus from1 (686)2005 -20090.14% Persons Treated and Percent UTG achieved in Itwara Focus from 2005-2009 data supporting this conclusion be prepared for publi- Onchodermatitis 34% 1.3% 11 (686) 1.6% cation in a peer reviewed journal” (Unnasch-UOEEAC 17 Persons Treated and Percent UTG achieved in Itwara Focus from 2005-2009 2011). As a signal that interruption of transmis sion has been achieved in this focus, it was placed in the light green area of the onchocerciasis flag.

Imaramagambo Focus James Katamanywa

Focus Background

Entomological indicators Entomological indicators indicators • Associated with Imaramagambo/Kalinzu FR. • Area size about 580 km2. EntomologicalEntomological indicator indicators 1991 – 1995 July 2010 Entomological indicator indicator 19911991 – 1995– 1995 JulyJuly 2010 2010 • S. neavei is suspected to be the vector. Infection rate 40% 0% InfectionEntomological raterate indicator 199140%40% – 1995 July0% 20100% • CBM survey data revealed onchocerciasis was InfectiveInfectiveInfection rate raterate rate >40%> 10%>10% 10% 0%0% 0%0% a public health problem. ATPATP Infective rate 4,500>4,500 10%4,500 – 6,500– 6,500 0%0% 0%0% • Annual ivermectin treatment started in 1993 ATP 4,500 – 6,500 0% and still ongoing in 212 villages. ItwaraItwara OV16 OV16OV16 and andand skin skin skin snip snip snip PCR PCR PCR results results results Itwara OV16 and skin snip PCR results • Attempt to assess the situation has been TestTest NumberNumberNumber screened screened screened NumberNumberNumber % % CommentCommentComment Test Number screened positiveNumberpositivepositive %p ositivepositive Comment ongoing. positive positive OV16 (Sept 2010) 3316 2 0.06 Follow up snips of the 2 Ov16 positive OV16OV16 (Sept (Sept 2010) 2010) 33163316 2 2 0.060.06 FollowFollow up up snips snips of of the the 2 2Ov16 Ov16 positive positive OV16 (Sept 2010) 3316 2 0.06 Followcases up snips of the 2 Ov16 positive • In 2004 APOC impact assessment team visited casescases cases three river systems in Kalinzu FR. SnipSnip PCR PCR (2 putative (2 putative 2 2 00 0 TheThe skin skin snips snips were were negative negative using using SnippositiveSnip PCR PCRchildren) (2 (2 putative putative 22 0 0 0 0 Themicroscopy skinThe snips skin were &snips PCR negative were negative using using positivepositivepositive children) children) children) microscopymicroscopymicroscopy & PCR & & PCR PCR • In 2007 a team from the Carter centre made Snip PCR (2009) 686 (adults and 0 0 Skin snip PCR results were negative SnipSnip PCRSnip PCR (2009) PCR (2009) (2009) 686children)686 686(adults (adultsdults and and and 00 0 00 0 SkinSkin snipSkin snip PCR snip PCR results PCR results wereresults negative were were negative negative a short visit covering 15 sites. children)children)children)

17 See the general introduction for the full details of this account. Insight Special 2011 4th Session, 15-17 August 2011 10 • In 2008 Professor Garms during his consultancy assessed 45 sites in Imaramagambo and Kalinzu FR. • All efforts focused on gathering adequate information for the next course of action.

REMO MAP OF UGANDA SHOWING IMARAMAGAMBO FOCUS

Most sites prospected in July 2008 were free of crabs

Immaramagambo Focus Survey 2008: Professor Garms, et al. • Complete absence of freshwater crabs could

not be confirmed. Most sites prospected in July 2008 were free of crabs (((( add this caption • to map No as inS. original, neavei and positionwas caught map after: Surveyby the 2008: hired Professor Garms, et al. vector collector during 1 week of catching. SurveyMost 2008:sites prospectedProfessor Garms, in July et 2008 al. were free of crabs (((( add this caption • to mapOut as ofin original, the 295 and position people map skin after: Surveysnipped 2008: Professorfrom Garms, et al. • Complete absence of freshwater crabs could not be confirmed. four sentinel villages all were negative Survey 2004: APOC impact assessment Survey• No 2008: S. neavei Professor was caught Garms, by etthe al. hired vector collector during 1 week of catching. Survey 2004: APOC impact assessment • forOutComplete ofonchocerca the 295absence people of skinfreshwater volvulus. snipped crabs from could four sentinel not be confirmed.villages all were negative for • Prospection of three river systems in • • MajorityonchocercaNo S. neavei volvulus. was(67.5%) caught by theof hired those vector examined collector during 1had week of catching. • Prospection of three river systems in Kalinzu FR. • Out of the 295 people skin snipped from four sentinel villages all were negative for Kalinzu FR. • Majority (67.5%) of those examined had taken ivermectin for < 5years. • No fresh water crabs caught during the visit. takenonchocerca ivermectin volvulus. for < 5years. • No fresh water crabs caught during the visit. • Majority (67.5%) of those examined had taken ivermectin for < 5years. • No adult flies caught during the human-baited catches. Skin Snips for PCR • No adult flies caught during the human- SkinSkin Snips Snips for PCR for PCR • Laborers of Rwenzori Highland Tea Estate interviewed had vague knowledgeAge Groupof the Number Screened Number Positive % Positive baited catches. Age Group Number Screened Number Positive % Positive • Laborersfly and the of disease. Rwenzori Highland Tea Estate 5 - 9 2929 0 0 0.000.00 interviewed had vague knowledge of the fly 10-14 7878 0 0 0.000.00 15-19 5252 0 0 0.000.00 20-29 91 0 0.00 and the disease 20-29 91 0 0.00 30-39 74 0 0.00 3040+-39 74138 0 5 0.003.62 40+Total 138462 5 5 3.621.08

ImTotalaramagambo OV16 and462 Snip PCR results 5 1.08 Imaramagambo Number OV16Number and% Snip PCR results Test Comment Imaramagambo OV16Screened and Snip P PCRositive results Positive Number Number % Collect skin snips from the positive children for TestOV16 3356 13 0.4 Comment Screened Positive Positive PCR Snip PCR (11 All the snips were negative according to 11 0 0 Collect skin snips from the positive children for OV16putative positives) 3356 13 0.4 microscopy and PCR PCR Snip PCR (11 All the snips were negative according to 11 0 0 putative positives) microscopy and PCR

Conclusion

• Data for 2004, 2007 and 2008 all suggest that there is no onchocerciasis transmission in the focus. Sites visited by J. Katamanywa et al., 2007 • There were no crabs observed in 2007 and 2008. Sites visited by J. Katamanywa et al. 2007 No crabs found No crabs found • Established catching sites and spot catches did not yield any vector flies. • Only 5 (1.08%) adults, who were all over 40 SurveySurvey of 2007: of Katamanywa 2007: Katamanywa et al. et al. • There was no sign of the vector S. neavei. years, were positive from the PCR results. • There was no sign of the vector S. neavei. • OV16 results: 0.4% (13children) were putative • •No No adult adult fliesflies were werecaught caught during the during visit. the visit. • No fresh water crabs, the obligate phoretic hosts, were caught. positive. • No fresh water crabs, the obligate phoretic • Follow up of 13 children got 11 of them hosts,• No were evidence caught. that S. damnosum could be the vector in this focus. • Skin snip examination was recommended. who were confirmed with skin snip PCR to • No evidence that S. damnosum could be the be negative. vector in this focus. • Skin snip examination was recommended. Suggested way forward • Interruption of transmission has been attained in this focus. Treatment should therefore be stopped.

Insight Special 2011 4th Session, 15-17 August 2011 11 Location of Mt. Elgon onchocerciasis Appreciation Location of Mt. Elgon onchocerciasis focus To the German Technical Cooperation (BHS); Bernhard focus Nocht Institute, Hamburg, Germany; Mectizan Dona- tion Program; Merck & Co.; The Carter Center; APOC; MOH Uganda; Bushenyi leaderships; and the different affected communities.

Under UOEEAC Attention Once More – Imaramagambo

Generally speaking, the review of Imaramagambo was Mt. Elgon encouraging despite that this focus’s position continues focus to be in the grey green zone of the onchocerciasis flag – an indicator that it is suspected that onchocerciasis transmission has been disrupted there. It was the committee’s feeling “that the focus was near to the point where transmission interruption might be declared”, al- Focus boundary and river systems though it did recommend “that surveys be undertaken in the upcoming year to confirm that the phoretic hosts of the vector have indeed disappeared from the focus”. We want to have on record as well the point that this committee “also recommended that entomological surveys be carried out to confirm the absence of Simulium damnosum at this focus” and that “community-wide treatment should continue” as those studies are being conducted (Unnasch-UOEEAC 2011).

Mt. Elgon focus review: Should intervention be halted? Thomson L. Lakwo Background • The only focus located in eastern Uganda. Trend of ivermectin treatment in Mount Elgon • Area size about 250 square kilometers of the Trend of ivermectinFocus: treatment 1994 in to Mount 2010 Elgon Focus: 1994 Mt. Elgon National Park. to 2010

• Straddles Mbale, Sironko, Bududa and Trend of ivermectin treatment in Mount Elgon Focus: 1994 to 2010

99 99 100 99 Manafwa districts. 98 97 98 98 98 97 98 600000 94 94 96 100

• Annual ivermectin treatments started in 90

500000

1994 in the focus. 80 542,260 533,995 526,516

512,152

491,274 70 • Impact assessment conducted in 2005/6 400000 481,876

58 449,088

revealed ongoing transmission. 439,406 60 • Elimination policy was introduced in 2007. 300000 50

40 %age Treated • Strategies of semi-annual treatment and Number Treated 200000

vector elimination have been applied.

196,025 194,746 193,858

190,105 189,996

15 189,071 20 185,362 184,362 180,840 176,266 175,603 173,000 172,666 170,530 169,270 100000 169,167 165,343 159,270 • The vector, there, was S. neavei living in 156,747

147,367 145,600

135,000 10 125,489 123,000

phoretic association with P. loveni. 18,678 78,650 0 0 • The focus was validated for its isolation status. 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 • Progress in elimination activities is reviewed. UTG2 Treatments UTG Treated (%) >>….disengage word descriptions from the figures >>>>> see original presentation format Main activities • Mass drug administration in the focus. Epidemiological indicators: mf rate No Sentinel villages Baseline 1994 Post-int. 2005 Post-int 2011 • Crab trapping and examinations.

• Adult fly catches in established sites. 1 Bubungi 75%(N=80) 1.9%(N=154) 0.0 (N=80) • Regular impact surveys. 2 Bunabutiti 53.8%(N=80) 0.0 (N=110) 0.0(N=100)

3 Bunabatsu 58.8%(N=80) 1.6%(N=124) 0.8%(N=118)

4 Buriri 61.3%(N=80) 0.7%(N=140) 1.8%(N=55)

Skin Snip Surveys 2011 (Children) No. No. of persons District Community % mf +ve Assessed +ve for mf Bududa Buriri 8 0 0 Insight Special 2011 4th Session, 15-17 AugustBududa 2011 Bubungi 27 0 0 12 Bududa Bunabutiti 22 0 0 Bududa Bunabatsu 15 0 0 Mbale Bukikoso 15 0 0 Totals 87 0 0

Trend of ivermectin treatment in Mount Elgon Focus: 1994 to 2010

>>….disengage word descriptions from the figures >>>>> see original presentation format

Epidemiological indicators: mf rate No Sentinel villages Baseline 1994 Post-int. 2005 Post-int 2011

1 Bubungi 75%(N=80) 1.9%(N=154) 0.0 (N=80)

2 Bunabutiti 53.8%(N=80) 0.0 (N=110) 0.0(N=100)

3 Bunabatsu 58.8%(N=80) 1.6%(N=124) 0.8%(N=118)

4 Buriri 61.3%(N=80) 0.7%(N=140) 1.8%(N=55)

Skin Snip Surveys 2011 (Children) Serological assessment (OV 16) in Elgon focus: 2010 No. No. of persons District Community % mf +ve Assessed +ve for mf District No. of Communities Age Group No. Screened Positive IgG4 % positive Bududa 1 to <5 478 0 0 Bududa Buriri 8 0 0 > 5 and ≤ 10 498 0 0 Bududa Bubungi 27 0 0 > 10 and ≤ 14 397 0 0 Bududa Bunabutiti 22 0 0 Sub total 6 1,373 0 0 Bududa Bunabatsu 15 0 0 Manafwa 1 to <5 149 0 0 > 5 and ≤ 10 1 1 5 0 0 Mbale Bukikoso 15 0 0 > 10 and ≤ 14 100 0 0 Totals 87 0 0 Sub total 3 364 0 0

Mbale 1 to <5 280 0 0 > 5 and ≤ 10 190 0 0 Epidemiological indicators: indicators: nodules nodules > 10 and ≤ 14 188 1 0.6 No Sentinel villages Baseline Post-int: Post-int: No Sentinel villages Baseline Post-int: Post-int: Sub total 4 658 1 0.2 19941994 20052005 20112011 Sironko 1 to <5 206 0 0 1 BBubungiubungi 73.3%(N=30)73.3%(N=30) 3.9%(N=154)3.9%(N=154) 2.5%(N=80)2.5%(N=80) > 5 and ≤ 10 229 0 0 > 10 and ≤ 14 221 0 0 2 Bunabutiti 60%(N=30) 2.7%(N=110) 0.0(N=100) 2 Bunabutiti 60%(N=30) 2.7%(N=110) 0.0(N=100) Sub-total 4 656 0 0 3 Bunabatsu 40%(N=30) 2.4%(N=124) 0.0(N=118) 3 Bunabatsu 40%(N=30) 2.4%(N=124) 0.0(N=118) Entire focus 1 to <5 1,113 0 0 4 Buriri 63.3%(N=30) 3.6%(N=140) 1.8%(N=55) > 5 and ≤ 10 1,032 0 0 4 Buriri 63.3%(N=30) 3.6%(N=140) 1.8%(N=55) > 10 and ≤ 14 906 1 0.1

Grand total 17 3,051 1 0.03 Entomological indicators Entomological indicators Indicators 2007 2008 2009 2010 2011 Indicators 2007 2008 2009 2010 2011 Fly density 5 FMH 0 0 0 0 Fly density 5 FMH 0 0 0 0 Conclusion Fly infection rate 7% - - - - Fly infection rate 7% - - - - • This is the only isolated focus in Eastern Uganda. Fly infective rate 0% - - - - • Fly infective rate 0%. (dissections)Fly infective rate 0% - - - - (dissections) • Low Mf prevalence of 0.8% and 1.8% in two Fly infective rate 0% - - - - (PCR),Fly infective rate 0% - - - - sentinel sites, and no children were mf positive. N=2300(PCR), • PCR pool screening (n=2300) 0%. N=2300 Trend of Crab infestation from April 2007 – June 2011 • OV16 blood spot analysis 0.03%. TrendTrend of Crab of infestation crab infestation from April 2007 from – June April 2011 2007 - June 2011 • No positive crabs in the focus now for 3 years. Trend of Crab infestation from April 2007 – June 2011 • No single adult fly caught for now 3 years. 1000 70 • Transmission has been interrupted in the focus. 900 60 59 800

52 Recommendation 50 700 47 • Based on the available evidence there is need 600 40 40 to halt intervention in Mt. Elgon focus.

36.6 500 34.4 31.6 No.of Crabs 3030 400 Acknowledgements 23.8 % Crab Crab % Infestation separate300 word labels from figures on the left & right (above) % crab infestation 21 20 Go to River Blindness Foundation; The Carter Center; 15.6 separate200 word labels from figures on the left & right (above) John Moores; Merck and Co.; African Program for On- 10 100 chocerciasis Control/WHO; NOCP, Uganda Ministry of 2.3 3.1 1 0 0.5 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 00 Jul Jul Jul Jul

Jan Jan Jan Jan Health; Mbale, Sironko, Bududa & Manafwa District Jun Jun Jun Jun Jun Sep Feb Feb Feb Feb Apr Apr Apr Apr Arp Aug Oct Aug Oct Aug Oct Aug Oct Mar Mar Mar Mar May May May May May Dec Dec Dec Dec Sept Sept Sept Nov Nov Nov Nov 2007 2008 2009 2010 2011 Local Governments; District Onchocerciasis Coordina- No. of Crabs caught tors; Entomological Assistants; Vector Collectors; & endemic communities. Trend of S.neavei catches from 2007- June 2011 Trend of S.neavei catches from 2007- June 2011

550

500 494

450

388 400 387

350

300

252

250 210 No. of flies caught flies of No.

200 183 162

150 137 137

100 85 78 76

25 12

2 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Jul Jul Jul Jul Jul Jan Jan Jan Jan Jun Jun Jun Jun Jun Sep Feb Feb Feb Feb Apr Apr Apr Arp Aug Oct Aug Oct Aug Oct Aug Oct Mar Mar Mar Mar May May May May May Dec Dec Dec Dec Sept Nov Nov Sept Nov Sept Nov April 2007 2008 2009 2010 2011

Insight Special 2011 4th Session, 15-17 August 2011 13 UOEEAC Appraises Elgon Status • All rivers drain into DRC except Elgon has “met all guidelines with the exception of Ruhezamyenda which drains into Lake Ov16 prevalence, where one seropositive individual Mutanda. was found” who was nonetheless “over ten years of age, • Annual CDTI started in 1993 and scaled to outside the age range for the guideline, and may thus semi-annual in 2007. have been exposed a long time ago” although neither • Treatment coverage over 85% for the last PCR nor skin snip confirmation of the person’s status 17 years. could be given. “Based • Preliminary entomological surveys in Kisoro on the weight of the evidence, and considering the strong were carried out in February 2010. evidence of the local extinction of the vector at this fo- • By 1962, S. neavei infection rate was 6.5% cus, the committee recommends that community-wide (A.W.R. McCrae, 1962). interventions be discontinued,” reads Unnasch-UOEE- • In 1964, Potamonautes sp carrying S.neavei AC 2011, it being said on top of that that “treatment larvae were collected from Ishasha tributaries should still be made available on an individual basis in Kanungu district (Colbourne and to the rare individuals who might still be experiencing Crosskey, 1965). symptoms of onchocerciasis following the end of com- • In 1966, A.W.R. McCrae collected munity-wide treatment.” Because it is the committee’s P. aloysiisabaudiae in Munyaga and Mbwa conviction that transmission has been interrupted in El- Rivers in Kanungu district (Prof. Neil gon, the focus was moved to the light green band of the Cumberlidge, pers. com). onchocerciasis flag. • No record of past vector control attempts.

Map of Bwindi Focus Map of Bwindi Focus Bwindi Focus Review Christopher Katongole Position of the Focus

Bwindi forest

Google Image of a strip of Bwindi forest crossing into DRC from Uganda

Introduction • Located in SW Uganda, around the Bwindi impenetrable forest. • Traverses the districts of Kisoro, Kabale and Kanungu. • Nine endemic sub-counties, 188 affected communities with 121,652 people at risk. • Vast areas have been deforested with the exception of the gazetted Bwindi impenetrable forest of which a small part extends into the DRC. • The known oncho vector is S. neavei. • The main river systems in the focus are Ivi, Ishasha, Kaku, Murungu, Ruafi and Ruhezamyenda. Insight Special 2011 4th Session, 15-17 August 2011 14 Kanungu district • The two rounds of river prospection at 8 sites in 2009 and 3 sites in 2011 revealed no crabs.

Simulium fly investigations  4 entomological sites were established in the focus.  Monthly fly collections are taken to the central laboratory for parasitological investigations using PCR.

Treatment coverage in Bwindi focus, 1994 - 2011 Black Fly Collections (June – July 2011) Entomological Adult simulium caught District River 100 98 site 225,000 97 100 June July Total 96 95 96 96 96 96 95 93 94 93 91 92 92 89 Kisoro Mugoti Ruafi 9 7 16 (s.n) 200,000 90

Kiruhura Murungu 1 0 1 (s.n)

198,606

175,000

Kabale Mukongoro Ishasha 271 447 718 (s.d) 191,270 185,014 179,134 178,629 70 175,721 Kitatemba Ishasha 766 2423 3189(s.d) 171,975 150,000

158,130 60 Kanungu Byumba Kyanya 0 0 0 125,000 151,374 10(s.n) 7(s.n) 17(s.n) 46 50 Total 1037(s.d) 2870(s.d) 3907(s.d) 100,000 %age Treated %age Number Treated Number 40 Epidemiological Findings

75,000

90,978

Epidemiological Findings

75,223

73,769

71,969

Mf Prevalence (Adults)

70,213

68,966 67,780 67,789

50,000 67,458 67,205

66,448

66,235

63,684 20 Mf Prevalence (Adults) 59,900 District Village 1993 2004 2006 2011 58,809 57,953 55,839

54,265 53,300 53,300 52,431 52,411 50,401 49,618 49,392 49,022 No. No. of No. No. of No. No. of No. No. of

25,000 44,272 10 DISTRICT VILLAGE Assessed1993 persons Assessed2004 persons Assessed2006 persons Assessed2011 persons No. No. of+ve for No. No.+ve of for No. +veNo. forof No. +veNo. for of 0 0 Assessed personsmf +ve (%) Assessed personsmf (%)+ve Assessed personsmf (%) + ve Assessed personsmf (%) +ve 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Kisoro Mugombwa 50 for mf30 (%) (60) 48 for3 mf (6.3) (%) - -for mf (%) 15 0 for mf (%) Kisoro MugombwaSuma 5050 30 (60)9 (18) 6048 33 (6.3) (5) - - - - 40 15 0 0 UTG Treatments % UTG achieved SumaKikobero 5050 9 (18)42 (84) 6560 3 (5)(4.6) - - - - 70 40 0 0 KikoberoKashaka 5050 42 (84)27 (54) 5165 33 (4.6) (5.9) - - - - 28 70 0 0 Kashaka 50 27 (54) 51 3 (5.9) - - 28 0 Gacenkye ------99 0 ENTOMOLOGICAL FINDINGS MukoGacenkye 50- 25(50)- 40- -0 - - - - 99 - 0 - TOTALMuko 25050 133(53.2)25(50) 26440 120 (4.5) - - - - - 252 - 0 Crab catches in Bwindi Focus Kabale KigaramaTOTAL - 250 -133(53.2) 264- 12- (4.5) - - - - 25259 0 0 Mburameizi ------49 0 Kabale Kigarama ------59 0 Feb 2010 Aug 2010 Feb 2011 Kinyungu ------73 0 Mburameizi ------49 0 No. of crabs No. of crabs Kitagata ------26 0 No. of crabs caught caught (No. caught (No. NdegoKinyungu ------73 53 0 0 % +ve (Mean % +ve % +ve (Mean No. of sites (No. with No. of sites with No. of sites with Kitagata ------26 0 River system crab (Mean crab crab TOTAL ------260 0 prospected immature stages of prospected immature prospected immature infestation) infestation) infestation) Kanungu KatundaNdego 50- 21 (42)- - - - - 141 - 1 (0.7) 53 44 0 0 S. neavei) stages of S. stages of S. Kibingo 50 27 (53.7) - - 155 0 44 0 neavei) neavei) TOTAL ------260 0 TOTAL 100 48 (48) - - 296 1 (0.3) 88 0 358* 12s Kanungu Katunda 50 21 (42) - - 141 1 (0.7) 44 0 Ruafi 3 100 *(18) 18 (0.23) - - - 6 10.9 (0.17) Grand total 350 181 (51.7) 264 12 (4.5) 296 1 (0.3) 600 0 (39) Kibingo 50 27 (53.7) - - 155 0 44 0 TOTAL 100 48 (48) - - 296 1 (0.3) 88 0 Kaku 2 86 *(5) 5.8 (0.07) 4 302* 5s (0) 0 4 241* 12s (0) 0 Note: Data for 2004 includes children; this has a reducing effect on the mf rates Grand total 350 181 264 12 (4.5) 296 1 (0.3) 600 0 Murungu 1 14 *(0) 0 2 50* (2) 0.04 8 131* (0) 0 (51.7)

Ruhezamyenda 2 134ѕ(0) 0 7 630s (0) 0 5 120s (0) 0 Mf Prevalence (Children <10 yrs) 2011 Ivi 2 0 (0) 0 ------DISTRICT VILLAGE No. Assessed No. of Children +ve for mf % mf +ve Ishaasha - - - 8 4s (0) 0 4 2s (0) 0 Kisoro Suma 1 0 0.0

352* 639s 730* 146s Kikobero 5 0 0.0 T o t a l 10 334(23) 6.9 (0.09) 21 0.2 (0.006) 27 5.3 (0.08) (2) (39) Kashaka 9 0 0.0 Gacenkye 5 0 0.0 Note: * Potamonautes aloysiisabaudiae ; ѕ - Small species TOTAL 20 0 0.0 Kabale Kigarama 2 0 0.0 Kinyungu 7 0 0.0 Ruafi River as it enters DRC Kitagata 7 0 0.0 TOTAL 16 0 0.0 Grand total 36 0 0.0 DRC Nodule Prevalence (Adults) 1993 2004 2011 Nodule Prevalence (Adults No. of Nodule Prevalence% of Persons (Adults) No. of Persons Persons (%) DISTRICT VILLAGE No. Assessed +ve for No. Assessed No. Assessed (%) +ve for 1993 2004+ve for 2011 nodules nodules nodules No. of Persons No. of Persons No. Assessed % of Persons KisoroDISTRICT VILLAGEMugombwa 50 50 No.48 Assessed 3(%) (6.3) +ve for No.15 Assessed 0 (%) +ve for +ve for nodules Suma 50 3 60 0 nodules 40 0 nodules Location where 43.4% of Kikobero 50 69 65 5 (7.7) 70 2 (2.9) crabs were infested Kisoro MugombwaKashaka 50 50 11 50 51 48 1 (2.0)3 (6.3) 28 15 1 (3.6)0 Gacenkye 99 2 (2.0) Suma 50 3 60 0 40 0 KikoberoMuko 50 50 2 69 40 65 0 5 (7.7) 70 2 (2.9) Uganda KashakaTOTAL 25050 11 224 51 9 (4.0)1 (2.0) 252 28 5 (2.0)1 (3.6) Kabale GacenkyeKigarama - - - - 59 99 0 2 (2.0) MukoMburameizi - 50 - 2 - 40 - 0 49 0 TOTALKinyungu - 250 - - 224 - 9 (4.0) 73 252 0 5 (2.0) Kabale Kigarama - - - - 59 0 Kitagata - - - - 26 0 MburameiziNdego ------53 49 0 0 KinyunguTOTAL ------260 73 0 0 Kanungu KitagataKatunda ------44 26 0 0 Kanungu district NdegoKibingo ------44 53 0 0 TOTALTOTAL ------88 260 0 0 • The two rounds of river prospection at 8 sites Kanungu KatundaGrand total 250 - - 224 - 9 (4.0)- 600 44 5 (0.8)0 Kibingo - - - - 44 0 in 2009 and 3 sites in 2011 revealed no crabs. TOTAL - - - - 88 0 Grand total 250 224 9 (4.0) 600 5 (0.8) Simulium fly investigations Note: Data for 2004 includes children; this has a reducing effect on the nodule rates • 4 entomological sites were established in the focus. Ov16 Results (1-9 years) • Monthly fly collections are taken to the central Purposively collected Samples from First Visit (2010) communities around Simulium Breeding laboratory for parasitological investigations sites (2010) using PCR. Samples District Number Positive Samples Collected Number Positive Collected Kabale 840 0 453 0 Kanungu 1603 0

Kisoro 1057 0 979 0 Total 3500 0 1432 0

Conclusion • No crabs have been observed on the Kanungu and Kabale sides yet. • S. neavei breeding seems to be limited to areas close to the DRC border with mean crab Insight Special 2011 4th Session, 15-17 August 2011infestation of 0.17. 15 • There is a small part of the Bwindi impenetrable forest that crosses into the DRC where transmission could be going on. • At the moment there is no evidence of ongoing onchocerciasis transmission on the Ugandan side. • It is suspected that onchocerciasis transmission in the focus has been interrupted.

Recommendations • Initiate cross border surveys (epidemiological & entomological). • Monitoring with crab trapping and vector collection should continue on established sites. • Semi-annual treatment should continue, awaiting the outcome of the cross border surveys (epidemiological & entomological).

Appreciation Offered to Mectizan Co. Inc.; River Blindness Foundation; The Carter Center; John Moores; APOC; LCIF/Uganda Lions; M.O.H-Uganda; the affected districts (Kabale, Kisoro & Kanungu); and the affected communities.

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Through the Spectacles of UOEEAC – Bwindi Focus

On course, yes; but Bwindi clearly still has some way to go as suggested by this list of things that need doing in respect of this focus: “Continue community-wide treatment activities. Entomological surveillance and analysis of Simulium damnosum flies by PCR needs to be completed. The extent of the incursion of the focus into DRC needs to be investigated. The focus consists of three ecotomes and entomological and epidemiological investigations should take this into account. The focus stays yellow on the oncho flag ...implement elimination policy...” (Unnasch-UOEEAC 2011).

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Conclusion Kashoya-Kitomi Focus Review • No crabs have been observed on the Kanungu Joseph Wamani and Kabale sides yet. • S. neavei breeding seems to be limited to areas close to the DRC border with mean crab infestation of 0.17. • There is a small part of the Bwindi impenetrable forest that crosses into the DRC where transmission could be going on. • At the moment there is no evidence of ongoing onchocerciasis transmission on the Ugandan side. • It is suspected that onchocerciasis transmission in the focus has been interrupted.

Appreciation

Offered to Mectizan Co. Inc.; River Blindness Founda- tion; The Carter Center; John Moores; APOC; LCIF/ Uganda Lions; M.O.H-Uganda; the affected districts (Kabale, Kisoro & Kanungu); and the affected communities.

Background Through the Spectacles of UOEEAC – Bwindi Focus • Size 399 km2 with about 215,000 people at risk. • Research/Control on Simulium vector flies was On course, yes; but Bwindi clearly still has some way initiated in 1989 and ran to 2004 by GTZ and to go as suggested by this list of things that need do- Bernhard Nocht Institute, Hamburg, Germany. ing in respect of this focus: “Continue community-wide • Regular APOC assistance for ivermectin treatment activities. Entomological surveillance and implementation was from 1998 to 2004. analysis of Simulium damnosum flies by PCR needs to • Experimental vector control was initiated in July be completed. The extent of the incursion of the focus 2003 with support of Bernard Nocht Institute. into DRC needs to be investigated. The focus consists of Biting density and crab infestation were three ecotomes and entomological and epidemiological suppressed, but transmission continued. investigations should take this into account. The focus • Uganda launched, in January 2007, a policy stays yellow on the oncho flag ...implement elimination to eliminate onchocerciasis. policy...” (Unnasch-UOEEAC 2011). • Kashoya-Kitomi was one of the identified foci targeted for elimination. • Plans were then made to start elimination (with semi-annual ivermectin distribution and vector elimination) activities in the focus early 2007 with support of The Carter Center.

Insight Special 2011 4th Session, 15-17 August 2011 16 Targeted Control of Simulium neavei in the Kasyoha-Kitomi focus in 2004 Kashoya Kitomi Focus Targeted Control of Simulium neavei in the Kasyoha-Kitomi focus in 2004

Position of the focus

Implementation of Elimination activities from 2007 to date • Crab trapping and examinations in river systems. Treatment coverage in Kashoya Kitomi focus, 1994 - 2011 • Adult fly catches at established catching points. 350,000 100.0 96.5 97.6 96.4 • Focal river treatment with Temephos (Abate 94.1

89.8 90.0

87.5 87.9 being the trade name) in the Kitomi system 4 weekly

300,000 86.3 331,364 325,822

82.5 314,161 313,434

80.0

78.7 305,921

302,836 from July 2007 - May 2008, and then at the reduced pace 76.1

292,232 72.1 250,000 280,480 71.2 70.0 of 8 weekly intervals from July 2008 - January 2009. 263,982 64.2 • Ngoro and Buhindagi systems were problematic: 4

60.0 200,000 55.9 weekly larviciding was implemented from July 2007 to 50.7

50.0

197,391 48.0

%age Treated November 2009; and the rest to March 2010. 8 weekly

150,000 NumberTreated

175,445 174,742 173,810

170,772 40.4 170,250 40.0

159,017

153,635 larviciding was implemented from December 2009 to 152,948 150,226 147,319 143,408

135,973 30.0

100,000 130,814

126,428 March 2010 (for Ngoro & Buhindagi), and May to Oc- 113,851

106,955

20.0 tober 2010 for the rest of the focus. 83,300 83,300 83,300 83,300 81,011 50,000 73,112 72,896

10.0 53,439 42,221 33,656 0 0.0 Trend of Crab infestation from May 2007 to June 2011 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

UTG2 Treatments UTG Treated (%) 9000 100

8000 90 Ground Larviciding 80 Simulium neavei infection 1991 to 2003 in Kashoya-Kitomi Focus: Ongoing transmission of O. 7000 Started 70

volvulus despite annual ivermectin treatment 6000 58.98 8 . 60 60

7 5000 51.10 . 6 L1-2 L3H . 49.1

46 50 45

50 44.9

4000 % Infested 40 34.48 35.4 40 34.7 4 34.0 .

Number of Crabs Caught Crabs ofNumber 3000 3 29 27.67 . 30 25.3 25

30 9 . 2000 19 20 18.5 13.76

20 4 . % Involved % 8 4

11.8

10 1000

9 4 9 10

8.9

. 3.54 3.48 3.43 6 6.0 1.84 10 5.5 5.5 0.79 0.40 0.27 0.24 0.19 0.16 0.09 0.08 0.06 0.06 0.06 0.06 0.05 0.05 0.04 0.04 0.04 0.04 0.02 0.02 0.03 0.02 0.01 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.00 3.6 3.3 2.3 1.5 0 0 Jul Jul Jul Jul Jan Jan Jan Jan Sep Sep Nov Nov Nov Nov 0 Mar Mar Mar Mar May May May May May Sept Sept 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2007 2008 2009 2010 2011 (n=713) (n=843) (n=640) (n=356) (n=518) (n=495) (n=386) (n=719) (n=289) (n=2335)(n=1148)(n=754) (n=842) S.neaveiflies caught

Kashoya-Kitomi Focus: Baseline (mf and nodule prevalence) 1991 data compared with follow up No. Crabs % Infested assessment in 2004 after 13 years of annual ivermectin distribution Kashoya-Kitomi Focus: Baseline (mf and nodule prevalence) 1991 data compared 100 The Trend of Simulium vector flies catches from May 2007 to July 2011 with 90follow up assessment84.1 in 2004 after 13 years of annual ivermectin distribution 2200

80 70 59.9 60.4 2000 1979

Ground

60 1783 1800 Larviciding 50 Started 40 34.7 1600 30 1400 20

1200 % prevalence %

10 1101

0 1000 Mf (n=560) Nodule (n=560) Mf (n= 285) Nodule (n=285) 800

Baseline (1991) Follow-up (2004) 600

Targeted Control of Simulium neavei in the Kasyoha-Kitomi focus in 2004 400 319

200 94

15 12 10 10 8 3 2 2 2 2 2 1 1 1 1 1 1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Jul Jul Jul Jul Jul Jan Jan Jan Jan Jun Jun Jun Jun Jun Oct Oct Oct Oct Apr Apr Apr Apr Sep Feb Sep Feb Sep Feb Feb Dec Dec Dec Dec Aug Aug Aug Aug Nov Nov Nov Nov Mar Mar Mar Mar May May May May May Sept 2007 2008 2009 2010 2011

Insight Special 2011 4th Session, 15-17 August 2011 17

>>>> Author says “numbers refer to table 2”, which table 2??

Way forward MAP OF WAMBABYA FOCUS

• Stopped ground larviciding in October 2010; and a follow up of 3 years was mounted to guard against re-invasion as per national criteria (August 2010) for elimination of onchocerciasis. • Conduct quarterly monitoring of Simulium catches and crab infestation in all the established sites to detect re-infestation. • Assess blood spots in children ≥ 3 to ≤ 10 years with antigen OV16 to confirm interruption of transmission in 2012. • Assess skin snips (microscopy) in the population in 2012. • Continue twice yearly treatment with Introduction ivermectin until entomological, parasitological Introduction Annual Ivermectin mass treatment in communities started in 1989 with support from Uganda Foundation for the Blind (UFB), assistance from Sight Savers International (SSI) and serological indices, for stopping • Annualand Ivermectin some support from AVSI, mass an Italian treatment NGO. in  Later in mid-1990s, SSI provided direct assistance to the program and UFB and AVSI interventions, are attained. communitiesdropped out. started in 1989 with support from • The recommendation to stop ivermectin  The Carter Center, African Program for Onchocerciasis Control and Neglected Tropical UgandaDisea Foundationses Control came on boardfor later.the Blind (UFB), treatment will be taken after the UOEEAC has  Elimination strategy through semi-annual treatment coupled with vector elimination in assistanceisolated fromfoci was launchedSight by SaversMOH and The International Carter Center in 2007. reviewed all the data and determined that the  Entomological base line data collection started in October 2008, and went on for 7 (SSI) andmonths. some support from AVSI, an Italian criteria for interruption of transmission have been met. Findings (October 2008 – May 2009) NGO. Biting detected in early morning and late afternoon at an average of 30 and 15 flies per day at • LaterRwamarongo in mid-1990s, and Katooke catching SSI sites provided respectively. direct Appreciation  Simulium neavei, a vector of onchocerciasis, found breeding on the lower reaches of Rivers assistanceWambabya and to Rwamarongo. the program and UFB and AVSI  Dissections carried out showed transmission ongoing (1 fly found with 13 third stages in the droppedhead). out. This is given to the affected communities; Bushenyi,  Infection rate at 8%. Rubirizi, Ibanda & Kamwenge district leadership; • The Fresh-water Carter crab- Center,infestation rate African at 70%. Program for  Mean infestation at 5.1. MOH, Uganda; German Technical Cooperation (BHS); Onchocerciasis Upper and lower breeding Control limits established and and Neglected confined to stretches Tropical of forest cover along the rivers. Bernhard Nocht Institute, Hamburg, Germany; Mecti- Diseases 6 and 3 dosing Control points established came on mainon Wambabya board and later. Rwamarongo respectively using Abate (Temophos 500 EC). zan Donation Program and Merck & Co.; The Carter • Elimination The focus is isolated strategy from both Mpambathrough Nkusi tosemi-annual the South and main Budongo to the North Center; and African Program for Onchocerciasis Con- treatmentEast. coupled with vector elimination in trol (APOC). isolated foci was launched by MOH and The Carter Center in 2007. • Entomological base line data collection started UOEEAC Screens Kashoya-Kitomi Performance in October 2008, and went on for 7 months.

The Kashoya-Kitomi anti-onchocerciasis program is def- Findings (October 2008 – May 2009) initely on track, but much also still has to be done there • Biting detected in early morning and late as per the specifications made by the committee: “Con- afternoon at an average of 30 and 15 flies per tinue community-wide treatment activities and continue day at Rwamarongo and Katooke catching sites entomological and crab collections. Re-evaluate Ov16 respectively. seropositivity and skin snip prevalence in 2013. The fo- • Simulium neavei, a vector of onchocerciasis, cus stays yellow on the oncho flag...implement elimina- found breeding on the lower reaches of Rivers tion policy....” (Unnasch-UOEEAC 2011) Wambabya and Rwamarongo. • Dissections carried out showed transmission ongoing (1 fly found with 13 third stages in Wambabya Rwamarongo Focus Review the head). James Katamanywa • Infection rate at 8%. • Fresh-water crab-infestation rate at 70%. Focus Location • Mean infestation at 5.1. • Located in Hoima District, Mid-western Uganda • Upper and lower breeding limits established and covers about 100 km2. and confined to stretches of forest cover along • Total Population of the onchocerciasis endemic the rivers. area is about 75,202 people. • 6 and 3 dosing points established on main • It is north and south west, respectively, of Wambabya and Rwamarongo respectively Bugoma and Budongo Forest Reserves. using Abate (Temophos 500 EC). • Major River Systems are Wambabya and • The focus is isolated from both Mpamba Nkusi Rwamarongo. to the South and main Budongo to the North East.

Insight Special 2011 4th Session, 15-17 August 2011 18 People Treated and Percente UTG Achieved in Wambabya Rwamarongo Observations Focus from 1996 to 2010 • Size of the Simulium neavei vector in this focus has reached undetectable level.

140,000 100.0 97 99 99 • Monitoring the vector presence is now through 95 95 96 93 92 94 94 89 90 90.0 crab trapping and intensified supervision of 120,000 85

81 80.0 126,100

vector collectors.

76 121,836

100,000 117,716 114,437

113,736 70.0 112,506 107,968

60.0 80,000 Recommendation

87,222 50.0 82,030 48 • If the 4th quarterly monitoring visit in October

60,000 40.0 Treated %age NumberTreated 2011 does not yield any evidence of breeding, 59,962 30.0

40,000

the focus will be visited only twice a year.

20.0 40,722

39,994 39,905 39,544

39,330

38,406 38,176 38,116

36,539

34,548 20,000 33,818 30,441 29,076 27,476

27,137 10.0 25,957 25,841 25,471 25,172 23,192 22,023 21,859 Appreciation 0 0.0 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 Goes to Mectizan Co. Inc.; SightSavers International;

Eligible Treated % UTG achieved Uganda Foundation for the Blind; AVSI; The Carter

7 Center; John Moores; APOC; Hoima district; M.O.H. Intervention Uganda; and the affected communities. • 4 weekly river dosing intervals carried out for 10 cycles and stopped. • To date, 3 quarterly monitoring visits done. UOEEAC Weighs Up Wambabya Rwamarongo • Adult fly catching by vector collectors, 2 days Persons managing this focus program, which is in the a week and supervised by the coordinator, is ongoing. yellow belt of the onchocerciasis flag and where elimination policy has to be implemented, recommended the Results committee, should “continue community-wide treatment • Crab infestation has dropped from 70% to 0 activities...conduct a follow-up of the Ov16 seropreva- for now 15 months. lence to measure the delay of response, as entomologi- • The last adult vector fly was caught in October cal evidence suggests that the vector has recently been 2009. eliminated from this focus...conduct an epidemiological evaluation in 2013...obtain archived data to get a recent historical perspective on prevalence in this focus”, be- Trend of Crab infestation from October 2008 to June 2011 sides other activities (Unnasch-UOEEAC 2011). 1600 100

90 1400 85 82 80 75 76 Budongo Focus Review: Progress Made 1200 71 River 70 Ephraim Tukesiga dosing 60 1000 started 56 60

800 50 43 40 Started Infested % Abate 40 600 trials Number of Crabs Caught

30 400 20

200 6 10 4 0 1 0 0 0 0 0 0 0 0 0 0 Jul Jul Jul Oct Apr Oct Apr Oct Apr Jan Jun Jan Jun Jan Jun Feb Mar Feb Mar Feb Mar Nov Nov Dec Nov Dec Aug Sep Aug Sep May May May 2008 2009 2010 2011 No. of Crabs % Infested

Simulium vector fly catches in Wambabya Rwamarongo focus (January 2009 - July 2011)

700

River 609 dosing 600 started

500

439 440

398 400

300 271

No. of S.N No. S.N of flies caught Started Abate trials 200

124

100 83 78

1 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul 2009 2010 2011 1 1 Insight Special 2011 4th Session, 15-17 August 2011 19

Background Budongo Focus showing • Located in Mid-Western Uganda and straddles Vector breeding sites and fly Masindi, Buliisa, Hoima districts. catching sites • The focus is associated with Budongo (364 Km2) and Siba (66 Km2) FRs. Budongo FR • Waki / Siba, Sonso and Kasokwa are the main river systems. • The vector there is S. neavei associated with P. niloticus and P. aloysiisabaudiae depending on altitude variation. • Vector control attempts using DDT 1956 to 1969 were successful but due to civil 2011 2009 disturbances, in Uganda in the 1970s, there Crabs with immature S. neavei was vector re-infestation. Crabs negative • •Ivermectin The vector there mass is S. neavei treatment associated with started P. niloticus in and the P. aloysiisabaudiae 1990s No crabs found depending on altitude variation. Catching sites with• Vector support control attempts from using Sight DDT 1956 Savers to 1969 wereInternational. successful but due to civil disturbances, in Uganda in the 1970s, there was vector re-infestation. Persons Treated and Percent UTG achieved in Budongo Focus from 1995- • •Review Ivermectin of mass Entomological treatment started in the 1990sinvestigations with support from startedSight Savers 2010 in International.2009 but was not done exhaustively. It 140,000 100 • Review of Entomological investigations started in 2009 but was not done 97 96 97 97 resumed January 2011. 94 95 exhaustively. It resumed January 2011. 93 90 90 87 86 87 120,000 85 85 83 82 83 BudongoBudongo Onchocerciasis Focus Map Focus 2011 Map 2011 80

100,000 70

Position of the focus 60 80,000

60,000 40

40,000 30

20 20,000 10

- 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Total Eligble Popn No. of Persons Treated Percent UTG Treated

ENTOMOLOGICAL INVESTIGATIONS TO ESTABLISH SIMULIUM BREEDING IN Entomological Investigations to EstablishBUDONGO Simulium FOCUS Breeding in Budongo Focus

Position Entomological investigation activities WAKI/SIBAWAKI/SIBA RIVER RIVER SYSTEM SYSTEM SONSOSONSO RIVER RIVER SYSTEM SYSTEM KASOKWAKASOKWA RIVER RIVER SYSTEM SYSTEM Entomological Investigation Activities PERIOD No. of No. Crabs Mean Crab N o . N o . Mean Crab N o . No. Crabs Mean Crab Major activities Crabs +ve (%) Infestation Crabs Crabs Infestation crabs -ve % Infestation • Establishment of Vector breeding sites along river systems. PERIOD CaughtNo. of No. Mean Crab CaughtNo. +(%) No. Mean CaughtNo. No. Mean • Identifying and establishing vector species in the area. 2009 Crabs410 99(24.1)Crabs Infestation 0.7 0Crabs 0 Crabs Crab 0 Crabs 0 Crabs 0 Crab0 Major activities July • Biting behavior and infection rates of the vector fly to be established. Caught +ve (%) Caught +ve Infesta Caught -ve % Infestat- 2011 440 148(33.6) 1.5 (%) -tion ion Specific• Establishment activities of Vector breeding sites along January •river Full-day systems. catches (7.00 a.m. – 6.00 p.m.) 2 days a week. February2009 July 410 56 8(14.2)99(24.1) 0.7 0.2 0 0 0 0 0 0 03 0 0(0.0) 0 0 • Support supervision. • • IdentifyingCrab trapping and and examination establishing for young stages vector of S. neavei species. in March2011 440- 148(33.6)- 1.5- - - - 49 7(14.3) 0.3 January the area. April 74 0 0 - - - 145 0(0.0) 00 February 56 8(14.2) 0.2 0 0 0 03 0(0.0) 0 • Biting behavior and infection rates of the vector May ------490 185(37.8) 0.8 March ------49 7(14.3) 0.3 fly to be established. June ------444 1(1.2) 0.01 April 74 0 0 - - - 145 0(0.0) 00 July 47 1(2.13) 0.02 0 0 0 84 1(1.2) 0.01 Specific activities May ------490 185(37.8) 0.8 T o t a l 1027 256(24.9) 0.52 0 0 0 1,215 392(32.3) 0.8 • Full-day catches (7.00 a.m. – 6.00 p.m.) 2 June ------444 1(1.2) 0.01 days a week. July 47 1(2.13) 0.02 0 0 0 84 1(1.2) 0.01 • Support supervision. Total 1027 256(24.9) 0.52 0 0 0 1,215 392(32.3) 0.8 • Crab trapping and examination for young stages of S. neavei. Trend of S.neavei fly catches in Budongo Waki/Siba sub-focus 2011

Insight Special 2011 4th Session, 15-17 August 2011 Preliminary information on seizures, Nyantonzi Parish, August 2011 20 Community No. of Epileptic AGE RANGE cases < 10years ≥10 to ≤ 15 >15yrs to <20yrs ≥ 20 yrs and above Rwengara 13 3 1 6 3 Katugo II 15 2 4 1 8 Katanga 15 0 2 3 10 Katugo I 7 1 0 2 4 Nyantonzi 10 0 2 2 6 Siba 2 2 Kababiito 5 0 1 1 3 TOTAL 67 6 12 15 34 Entomological Investigations to Establish Simulium Breeding in Budongo Focus WAKI/SIBA RIVER SYSTEM SONSO RIVER SYSTEM KASOKWA RIVER SYSTEM

PERIOD No. of No. Mean Crab No. No. Mean No. No. Mean Crabs Crabs Infestation Crabs Crabs Crab Crabs Crabs Crab Caught +ve (%) Caught +ve Infesta Caught -ve % Infestat- (%) -tion ion

2009 July 410 99(24.1) 0.7 0 0 0 0 0 0

2011 440 148(33.6) 1.5 January

February 56 8(14.2) 0.2 0 0 0 03 0(0.0) 0

March ------49 7(14.3) 0.3

April 74 0 0 - - - 145 0(0.0) 00

May ------490 185(37.8) 0.8

June ------444 1(1.2) 0.01

July 47 1(2.13) 0.02 0 0 0 84 1(1.2) 0.01

Total 1027 256(24.9) 0.52 0 0 0 1,215 392(32.3) 0.8

Trend of S.neavei fly catches in Budongo Waki/Siba sub-focus 2011

Preliminary information on seizures, Nyantonzi Parish, August 2011 UOEEAC Spotlight On Budongo Community No. of Epileptic AGE RANGE cases < 10years ≥10 to ≤ 15 >15yrs to <20yrs ≥ 20 yrs and above Rwengara 13 3 1 6 3 This is yet another focus where, the committee appar- Katugo II 15 2 4 1 8 ently feels, there is still a lot to be done and achieved Katanga 15 0 2 3 10 Katugo I 7 1 0 2 4 to control and, in the long run, eliminate onchocercia- Nyantonzi 10 0 2 2 6 sis infection and transmission. Watch the listing of the Siba 2 2 Kababiito 5 0 1 1 3 committee’s recommendations for the focus: “Contin- TOTAL 67 6 12 15 34 ue community-wide treatment activities. Obtain good population data on this focus, as the UTG reported data Achievements that suggest an imprecise estimate of the size of the to- • Vector mapping in Budongo focus completed. tal population. Analyze remaining blood spots with the • Field staff in Waki / Siba recruited and trained. Ov16 ELISA. Concentrate crab and fly catching activi- • Routine full-day catches in Waki/Siba in ties along the forest border. If S. naeavei flies are col- progress. lected along the forest edge, implement larviciding in • Fly catches regularly forwarded to the PCR the Kasokwa Forest Preserve.” In the classification of laboratory. the many foci nationwide, “the focus stays yellow on the flag”, declared the committee, signaling that the AchievementsChallenges project of eliminating onchocerciasis from this endemic • Vector mapping in Budongo focus completed. •• FieldKasokwa staff in Waki river / Siba system:recruited and is trained. difficult to access. area is far from the anticipated end (Unnasch-UOEEAC •• RoutineConvenient full-day catches camping in Waki/Siba sites in progress. for Kasokwa in the 2011). • Fly catches regularly forwarded to the PCR laboratory. Challenges FR are within reach of dangerous wild animals • Kasokwalike lions river system: and buffalos.is difficult to access. •• ConvenientLack of camping communication sites for Kasokwa inwith the FR the are withinoutside reach of dangerous wild animals like lions and buffalos. • Lackworld of communication during camping. with the outside world during camping. Nyamugasani Sub-Focus: Which Next Course Of Action? Joseph Wamani

Background of Nyamugasani Sub-focus • It is a sub-focus of Kasese Rwenzori focus. • Approximately 15 km east of the main focus. • Located in Kagando parish in Kisinga sub-county. • Has 7 villages with a total population of 11,270 (CDTI report 2010). • Annual ivermectin treatment started in 1993. • The focus has 2 main rivers (Nyamugasani & Kanyampara) with their tributaries. • The known oncho vector is S. damnosum ss. • Biting is low as compared to situation in the Lhubiriha/Tako system.

Map of Kasese Showing Nyamugasani Sub Focus

WayWay forward/Plan forward/plan for Waki/Siba 2011for waki/siba 2011 • The The focus, focus, it is proposed, it is isproposed, to be divided into is 2to sub-foci be divided that are to be into tackled 2 independently.  Continue sub-foci with flythat catches are for to dissections be tackled and PCR.  Carry inde out pendently.Abate trials. • Establish Continue dosing points.with fly catches for dissections  Start monthly river dosing.  Monitoring and PCR. and supervision. • Carry out Abate trials. Appreciation Sight• EstablishSavers International dosing; The Carter points. Center; LCIF/Uganda Lions; Uganda’s Ministry of Health;• Start National monthly Onchocerciasis river Control dosing. Program; Uganda Wild Life Authority; District • Monitoring and supervision.

Appreciation

Sight Savers International; The Carter Center; LCIF/ Uganda Lions; Uganda’s Ministry of Health; National Onchocerciasis Control Program; Uganda Wild Life Au- thority; District Health Officers; District Vector Officers; vector collectors; and field guides – all these are here thanked for their contribution(s) to the anti-onchocerciasis campaign.

Insight Special 2011 4th Session, 15-17 August 2011 21 Implemented Activities Results of Entomological Assessment on Nyamugasani from March 2011 Entomological • 4 catching sites were established, each with Number of Number of Number Number 2 vector collectors and a supervisor. Month L111 • Catches are conducted 6 days in a month. S.damnosum Parous Infected L1 L11 • Fresh dissections of suspected vectors. H TA • PCR. March 70* 22 1 1 0 0 0

Epidemiological April 23* • Skin sniping. • Ov16. May 38* June 136* Epidemiological Evaluation in Nyamugasani (June 2011) * Dissected fresh *Flies were preserved in alcohol for PCR • 3 villages were evaluated using standard skin Nyamugasani OV16 results snipping procedures. Nyamugasani OV16 results • The evaluation targeted community members Number Number 5 years and above. T e s t % Positive Comment • Snips were examined after 24 hours. screened positive • A total of 285 (77 children & 285 adults) were Collect skin snips from the positive snipped and examined, and all were negative OV16 1,400 2 0.1 Compare with table below children for PCR

All the snips RESULTS OF THE EPI EVALAUTION IN NYAMUGASANI FOCUS JUNE 2011 were negative Snip PCR (2 2 0 0 using microscopy (Adults & Children) putative positives ) and PCR

Number Number Village Pop Census % positive Examined positive Treatment coverage in Nyamugasani Sub Focus, 1998 - 2010

12,000 120.0

Kagando II 1392 104 00 00

10,000 100.0

99.1 99.6 96.3 97.1 97.5 96.6 97.3 97.6

92.2 10,167

9,926

87.0

Kisanga 524 102 00 00 85.2 9,377

82.1 9,128 8,864

8,000 8,828 80.0

73.6

Kamuruli 968 79 00 00

7,103 7,078 7,052

6,900 6,818 6,000 6,809 60.0

6,775 6,747

6,499 6,496 6,495 6,394 6,333

Number

5,968 5,893 5,765 %age Treated %age

5,453

T o t a l 2884 285 00 00 5,250 4,000 40.0 4,780 4,645

2,000 20.0 RESULTS OF THE EPI EVALAUTION IN KASESE DISTRICT (APOC 2010) No. % 0 0.0 Pop No. 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 Village % +ve Census Examine examine +ve UTG TX % UTG Treated d d Kyabisoro 519 334 64.9 0 0 Conclusion Muhindi 254 137 53.9 0 0 • Basing on the results of epidemiological Lhubiriha Busarya 201 68 33.8 0 0 close to and entomological evaluations of Nyamu Kighuthu 425 187 44 0 0 Nyamugasani gasani, there is indication of interruption sub focus Lyakirema 318 167 52.5 0 0 of transmission. NyakasojaNyakasojo 239 117 48.9 0 0 • There is a decline of disease prevalence as you NyamigheraNyamighera 399 180 45.1 0 0 move eastwards from the border - as indicated Lhubiriha Kyabikere 423 256 60 3 1.17 by the skin snip survey of 2010. towards the Kihondo 296 127 42.9 5 4 boarder with DRC Ighomba 373 201 54 2 1 Way forward • Transmission in Nyamugasani, it is suspected, Total 3447 1774 51.5 10 0.6 has been interrupted. • Monitoring of the vector should continue.

Insight Special 2011 4th Session, 15-17 August 2011 22 Appreciation Activities Implemented Mectizan Co. Inc.; River Blindness Foundation; The Carter Center; John Moores; APOC; LCIF/Uganda Li- Entomological investigation activities ons; M.O.H. (Uganda); Kasese district leadership; and • Establishment of vector breeding sites along affected communities are here thanked for their different river systems. direct and indirect roles in the fight of onchocerciasis in • Identifying and establishing vector species. Nyamugasani. • Establishing biting behavior and infection rates in the vector flies.

UOEEAC’S Revisitation of Nyamugasani Epidemiological investigation activities A border focus, Nyamugasani remains enclosed in • Skin snipping. some mystery, leaving unanswered many questions as is • Nodule palpation and skin examination. partly indicated by the committee’s pronouncements on gains and challenges (Unnasch-UOEEAC 2011): “Con- Trend of Simulium Fly Catches in Maracha Terego Focus 2010 & 2011 Onia-Ayi Gangu-Oru Hia-Enyau Oguvu--Enyau tinue community-wide treatment activities. Get epi data Month (Ov16 serological data and skin snips) from buffer com- 2010 2011 2010 2011 2010 2011 2010 2011 munities separating this and Lubilila focus to confirm Jan that these two are independent foci. This focus moves to Feb Dry season, much reduced water flow, some tributaries dry grey green (interruption suspected).” March April 00 00 00 00

May 00 00 00 00

June 00 00 00 00

July 00 00 00 00 00 00 00 00 Aug 00 00 00 00 Maracha Terego Focus – Next Course Of Action Sept 00 00 00 00 Ephraim Tukesiga Oct 00 00 00 00

Nov 00 00 00 00 Background Dec 00 00 00 00 • Located in West Nile Region.

• Lies in the upper and lower reaches of Inyau Crab Trapping & Examination for S. Neavei and Search for S. Damnosum Free Living Larvae and Pupae river system. S. neavei assessment S. Damnosum assessment Mean River No. of • The focus straddles the former counties of Arua Period No. of crabs crab S. Other systems crab +ve caught Infestatio Damnosum SPP. (Ayivu, Maracha and Terego). % • In the 1950 – 1960s onchocerciasis was more n Non- February Enyau, Oru, 106 0(0.0) 00 00 Vector severe in Terego County. 2010 Inve • Vectors involved have been assumed to be both Species Enyau, Ayi, Non- August Oru, Inve, 40 0(0.0) 00 00 Vector S. damnosum complex and S. neavei. 2010 • Ivermectin mass administration started in the Osu, Nyara Species Osu, Asi, Non- October 1990s by NGOs – Kuluva Hospital with CBM Enyau, Oru, 07 0(0.0) 00 00 Vector 2010 • Entomological and epidemiological review of Oluffe, Inve Species Non- January Enyau, Oru, the focus done 2009 – 2011. 64 0(0.0) 00 00 Vector 2011 Inve, Ayi species Enyau, Oru, Non- May 2011 Inve, Osu, 21 0(0.0) 00 00 Vector Map of Maracha Terego Focus Ise Species Total 238 0(0.0) 00 00 -

Position of Maracha & Terego Sub Foci MICROFILARIAE ASSESSMENT AND NODULE PREVALENCE IN TEREGO SUB FOCUS (1993 & 2007) MICROFILARIAE ASSESSMENT AND NODULE PREVALENCE IN TEREGO SUB FOCUS (1993 & 2007)

District Village 1993 2007 District Village 1993 2007 District Village 1993No. No. 2007 No. Number Number No. Positive No. Positive % mfNo. Positive % Nod % mfNo. Positive % Nod NumberExamined No. No. NumberExamined No. Positive with mf No. Number Positivewith % mfmf Positivewith % Nod Nod Number No. Positive % mf Positivewith % Nod Examined Positive % mf Positive % Nod Examined with mf % mf Positive % Nod Examined with mf with Nod Examined with mf with Nod Terego Anyangba 50with mf 48 with96 Nod 38 76 50 0 with0 Nod 2 4.0 Terego TeregoAnyangba Oguvu 50 50 48 NA96 NA38 3376 66 50 50 0 0 0 0 2 14.0 2 Terego Oguvu Totals 50 100NA 48NA 33 7166 71 50 100 0 0 0 0 1 3 2 3 Totals 100 48 71 71 100 0 0 3 3

MICROFILARIAE ASSESSMENT AND NODULE PREVALENCE IN AIVU MARACHA SUB FOCUS (March 2011) MICROFILARIAE ASSESSMENT AND NODULE PREVALENCE IN AIVU MARACHA SUB FOCUS (March 2011)

Adults Children District Village Adults Adults No. PositiveAdults No. Positive No.Children No. Positive % mf District Village % mf % Nod District Village Examined with mf with Nod Examined with mf Sentinel Villages Adults No. Positive No. Positive No. No. Positive % mf % mf % Nod Arua Aliba Examined 70 with mf 0 0.0with Nod 0 0.0Examined 35 with mf 0 0.0 Arua Aliba 70 0 0.0 0 0.0 35 0 0.0 Arua MarachaAliba Ayiko 70 80 0 0 0.0 0.0 0 1 0.0 1.3 35 30 0 0 0.0 0.0 Maracha Ayiko 80 0 0.0 1 1.3 30 0 0.0 MarachaTotals Ayiko 80 150 0 0 0.0 0.0 1 1 1.3 0.7 30 65 0 0 0.0 0.0 Totals 150 0 0.0 1 0.7 65 0 0.0 Insight Special 2011 4th Session, 15-17 August 2011 23 OV16 Results OV16 Results

Number Number Nyagak-Bondo focus: Prospects for launching new Sub Focus % Positive Screened Positive elimination Policy Ephraim Tukesiga Maracha 3300 0 0.0 Background Nyagak• Located-Bondo in Focus: West Prospects Nile Region. for launching new elimination policy Ephraim• Precisely Tukesiga occupies new Zombo District, Terego 3300 Awaiting analysis extending slightly in districts of Nebbi on the Background Southeast, Arua on the Northeast and DRC • onLocated the West.in West Nile Region. • • RiversPrecisely Nyagak,occupies new ZomboOra and District, Agoi extending are slightly the main in districts of Nebbi on the Results systems.Southeast, Arua on the Northeast and DRC on the West. • • TheRiver vectors Nyagak, Orais S.and neavei,Agoi are the breeding main systems. in the middle • 9 months of full day catches twice a month • reachesThe vector of is S. the neavei above, breeding systems. in the middle reaches of the above systems. • Annual mass treatment started early 1990s. yielded no single fly. • Annual mass treatment started early 1990s. • River prospections in potential simulium Position of Nyagak Bondo Focus breeding sites had neither S. neavei nor S. A map of Nyagak-Bondo focus damnosum early stages. • Skin snip results still indicated no microfilariae carriers. Position of Nyagak Bondo Focus • Blood spots for OV16: results showed zero positive for Maracha sub-focus; Terego awaiting analysis.

Conclusion On the basis of the entomological and epidemiological information, which has been used to assess the situation routinely for the last one year, it can be said that there is no evidence of onchocerciasis in this focus. Sentinel Villages

Appreciation Mectizan Co. Inc.; Kuluva Hospital & CBM Support; The Carter Center; John Moores; APOC; LCIF/Uganda Lions; M.O.H. (Uganda); affected districts (Maracha Terego and Arua); and the affected communities

UOEEAC Proposes Course for Maracha Terego

Those whose work it is to control and eliminate onchocerciasis in this focus are to “continue community-wide treatment activities”, “complete Terego Ov16 ELISA assays and continue entomological evaluations before making a recommendation on transmission interruption,” recommended the committee, further stating >>>> ((above)) postion to become: Position; and sentinal: Sentinel that “this focus moves to grey green” as there is suspi- Activities implemented 2010, 2011 cion that interruption has been achieved there (Unnasch- 1. River prospection. UOEEAC 2011). Activities2. Adult implemented fly catches 2010, 2011 at established sites for PCR 1. and River dissections. prospection. 3.2. Monitoring Adult fly catches and at established supervision sites for PCR of and vector dissections. 3. collectors. Monitoring and supervision of vector collectors. 4.4. Skin Skin snippingsnipping in some in sentinel some villages. sentinel villages. 5.5. CDTICDTI activities. activities.

Persons Treated and Percent UTG achieved in Nyagak-Bondo Focus from 1993-2010

Insight Special 2011 4th Session, 15-17 August 2011 24 Persons Treated and Percent UTG achieved in ComprehensiveCOMPREHENSIVE surveys SURVEYS of rivers OF systemsRIVERS SYSTEMSin Nyagak IN - Nyagak-BondoPersons Treated Focus and Percent from UTG 1993-2010 achieved in Nyagak-Bondo Bondo Focus NYAGAK-BONDO-FOCUS

Focus from 1993-2010 PERIOD NYAGAK CRABS ORA CRABS AGOI CRABS

99 99 100 99 99 99 100 97 97 98 97 97 97 98 98 98 98 96 96 96 96 95 96 96 96 96 96 96 95 95 93 94 93 91 Caught +V e (%) Caught + V e ( % ) Caught + V e ( % ) 89 90 86 85 86 85 83 83 81 82 79 JULY 209 7(3.3) 512 60(11.7) 22 13(59.1) 80 78 77 78 75 75 2010 72 70 DEC 40 3(7.5) 04 1(25) 76 6(7.9) 2010

60 56 JAN 2011 49 18(36.7) 50 42 MARCH 34 6(17.6) 121 17(14.0) 12 0(0.0) UTG UTG Coverage 40 2011

30 M A Y 44 17(38.6) 286 38(13.2) 48 15(31.3) 2011

20 JUNE 2011 38 9(23.6) 52 37(71.2) 02 1(50)

10 TOTAL 329 39(11.9) 1025 171(16.7) 160 35(21.9) 0 Nebbi Zombo Arua 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Note: No data for Arua for 1993 and 2010 Adults mf prevalence Trend of crab infestation during 2010 and 2011 Adults mf prevalence 800 60 743 700 Baselines, 1993 Follow up, 2011 51.1 50 N o . N o . % mf N o . N o . % mf P-value 600 District Community Examined positive positive District Community Examined Positive positive 40 Patek 500 Zombo Patek Athele 50 50 100.00 Zombo Athele 89 3 3.4 <0.0001 zombo Abilambe 50 48 96.00 Zombo Abilambe 100 19 19.0 <0.0001 400 378 30 Agweci 87 17 Nebbi Agweci 50 48 96.00 Nebbi 19.5 <0.0001 % positive 300 Zombo Nyandima 50 50 100.00 Arua Anguru 89 34 38.2 20

No. of crabs No. caught of crabs 18.5 Zombo Ukongo 50 50 100.00 Zombo Pachen 101 24 23.8 200 167 10.8 120 13.8 Zombo Jupa Ngali Upper 50 45 90.00 Nebbi Oloamura 66 14 21.2 92 10 100 80 8.3 70 Arua Kairo 75 30 40.0 47 10 23 T o t a l 300 291 83.1 607 141 23.6 0 0 Jul-10 Dec-10 Mar-11 May-11 Jun-11

No. of crabs caught No.positive % positive MfMf prevalence Prevalence - Children – Children > 10 years > 10years

Baselines, 1993 Follow up, 2011 Distribution of Crab infestation in the defined Nyagak - BondoDISTRIBUTION focus OF CRAB INFESTATION IN THE DEFINED No. No. % mf No. No. % mf P-value NYAGAK-BONDO FOCUS District Community Examined positive positive District Community Examined Positive positive D A T E NYAGAK ORA AGOI Patek Patek Zombo Athele 1 1 9 81.8 Zombo Athele 19 0 0.0 <0.0001 Caught +V e (%) Caught +Ve (%) Caught +Ve (%) zombo Abilambe 1 1 4 36.4 Zombo Abilambe 25 2 8.0 <0.041 JULY 44 6(13.6) 50 42 22 13(59) Nebbi Agweci 9 7 77.8 Nebbi Agweci 24 3 12.5 <0.0001 2010

Zombo Nyandima 4 3 75.0 Arua Anguru 19 7 36.8 DEC 9 3(33.3) 1 1(100) 7 6(85.7) 2010 Zombo Ukongo 1 1 1 1 100.0 Zombo Pachen 20 2 10.0 APRIL 51 25(49.0) 39 30(77.0) 19 7(36.8) Jupa Ngali 2011 Zombo Upper 12 12 100.0 Nebbi Oloamura 38 6 15.8 M A Y 23 17(74.0) 139 62(44.6) 45 15(33.3) 2011 Arua Kairo 25 4 16.0 JUNE 38 9(23.7) 53 42(79.2) 2 1(100) Adults nodule prevalence (15& above years) 2011 Adults nodule prevalence (15 & above years) TOTAL 163 60(36.4) 282 177(62.8) 95 42(44.2)

Baseline, 1993 Follow up, 2011 Trend of S. neavei fly catches in N o . N o . % N o . N o . % Trend of S. neavei fly cathes in Nyagaka - Bondo District Community Examined positive positive District Community Examined Positive positive P-value Nyagak-Bondo focus Zombo Patek Athele 30 29 100.0 Zombo Patek Athele 89 9 10.1 <0.0001 focus zombo Abilambe 30 18 96.0 Zombo Abilambe 100 14 14.0 <0.0001 Months Catching Sites

Nebbi Agweci 30 25 96.0 Nebbi Agweci 87 2 2.3 <0.0001 Anguru Akara Juba Total Jupa Ngali (Agoi) (Wariki) (Nyagak) Zombo Upper 30 27 90.0 Arua Kairo 75 15 20.0 April 01 01 01 03 Zombo Nyandima 30 26 100.0 Arua Anguru 89 13 14.6

Zombo Ukongo 30 22 100.0 Zombo Pachen 101 11 10.9 May 25 30 06 61

Nebbi Oloamura 66 3 4.5 June 24 270 10 304 180 147 97.0 607 67 10.9 July 20 1280 43 1343 Total 70 1581 60 1711

NB:NB: Flies caught have were been sent sent to the to theLaboratory lab for PCR for PCR analysis Insight Special 2011 4th Session, 15-17 August 2011 25 Achievements First session of cross-border meeting • Mapping the focus has been completed. (15 August 2008) • Field staff recruited and trained. • Routine full-day catches in progress. •Updates 3 out on of Cross-Border 8 recommendations Activities between have Uganda not andbeen DRC • Fly catches regularly forwarded to the PCR implemented yet, namely: Tony Ukety laboratory. (i) Inter-district meetings to be held prior

to conducting surveys in Rwenzori Conclusion First session of cross-border and Bwindi meeting (15 foci. August 2008) • Isolation of the focus is possible as all breeding river • 3 out of(ii) 8 recommendations Politicians have and not been district implemented authorities yet, namely: to systems begin and flow inside Uganda. However, there (i) Inter-district be meetingsinvolved to be heldin priorcross-border to conducting surveys in Rwenzori and is need to check inside DRC to see if there are other Bwindi foci. arrangements. possible breeding sites that may be connected with this (ii)(iii) Politicians Cross-border and district authorities meetings to be involved to in cross-borderbe held arrangements. focus. (iii) Cross-border alternately meetings to in be heldUganda alternately and in Uganda DRC. and DRC.

Appreciation Mectizan Co. Inc.; River Blindness Foundation; CBM/ Kuluva Hospital; The Carter Center; John Moores; APOC; LCIF/Uganda Lions; M.O.H. (Uganda); affected districts (Zombo, Nebbi & Arua); and the affected communities are gratefully recognized for the part played by them in the anti-onchocerciasis crusade.

Nyagak-Bondo bounces back into view of the UOEEAC “Annual treatment has not been enough,” the committee agreed, “to move towards elimination. However, the focus may be isolated and susceptible to eventual elimination. The committee recommends moving to twice per year treatment, evaluating possibility of vector con- Special recommendation recommendation of the 3rd session ofof UOEEAC the 3rd on “cross-border session foci of” trol activity and obtaining cross border data on extent UOEEAC“The committee,” readson the“cross-border recommendation (UOEEAC foci” 2010), “reiterated the need for of focus.” It was recommended also that the focus be “Thefurther cooperative committee,” activities in order reads to clarify the the recommendationepidemiological and entomological (UOEE status - shifted to the yellow of the oncho flag, a clear call for ACof foci which2010), appear “reiterated to cross the DRC-Uganda the need border”, for saying further as well that cooperative“the committee implementation of the elimination policy in this region activitiesrequested that APOC in assist order in facilitating to clarify the development the of epidemiological bilateral agreements, and (Unnasch-UOEEAC 2011). entomological status of foci which appear to cross the procedures and plans to realize such cross border studies”. DRC-Uganda border”, saying as well that “the commit-

tee requested that APOC assist in facilitating the devel- Achievements in 2011 Updates On Cross-Border Activities Between opment• Letter fromof thebilateral national coordinator agreements, of the Ugandan NOCP, procedures see below, and plans to Uganda And DRC realize• Letter such from Uganda’s cross Hono urableborder Minister studies”. of Health, see below. Tony Ukety AchievementsMinistry of Health, in 2011 •P.O. LetterBox 7272, fromKampala, the Uganda. national18 coordinator of the 3 February, Ugandan 2011 NOCP, see below, • Letter from Uganda’s Honourable Minister Dr. Tonyof Health, Ukety, see below. Responsible Officer, Ministry of Health, NGDO Coordination Group for Onchocerciasis Control, 18 P.O.Prevention Box of Blindness 7272, and Kampala, Deafness, Uganda. 3rd February, 2011 World Health Organization, 20 Avenue Appia, 1211 – Geneva 27, Switzerland. Dr. Tony Ukety, Responsible Officer, NGDO Coordination Group for Onchocerciasis Control, Prevention of Blindness and Deafness, 18 In its original appearance, the letter is on Uganda Ministry of Health headed paper, and has ADM. 97/153/11 as its Worldreference identity. Health Organization, 20 Avenue Appia, 1211 – Geneva 27, Switzerland.

18 In its original appearance, the letter is on Uganda Ministry of Health headed paper, and has ADM. 97/153/11 as its reference identity. Insight Special 2011 4th Session, 15-17 August 2011 26 Re: Cross-border Collaboration on Onchocerciasis in Aru and Goma districts in Eastern DRC to verify the Control/Elimination Activities between Uganda and current onchocerciasis situation. DRC The investigations will be conducted by the technical team from Uganda in conjunction with the DRC techni- Dear Dr. Ukety, cians trained in 2009. As recommended during the second and third sessions of the Uganda Onchocerciasis Elimination Expert Ad- The Ministry of Health, Uganda, hereby requests your visory Committee (UOEEAC) held in August 2009 and authorization for this team to undertake these investiga- 2010 respectively;19 may I kindly request that you fa- tions and to provide the necessary assistance at all levels cilitate contact with appropriate health authorities and to successfully accomplish this planned investigation. officials in order to implement the recommendations of the Committee on cross-border issues. This would help We would like to thank you for your unflinching support us to move on with some technical issues as we are wait- to Uganda and are confident that these activities and any ing for...higher level collaboration to be facilitated by other future collaboration within the health sector will APOC Management. receive favourable support at all levels.

Your assistance in regard to this matter is highly appre- Please accept, Honourable Minister, the assurance of ciated. our highest consideration.

Sincerely yours, Hon. Dr. Ondoa D.J. Christine Minister of Health, Republic of Uganda Dr. Richard Ndyomugyenyi National Onchocerciasis Coordinator, Ministry of Cc. Hon. Minister of Foreign Affairs, Uganda; Hon. Health Minister of State for Health, General Duties, Uganda; Uganda World Health Organization – Representative, Uganda; H. E. The Ambassador of Uganda, DRC; The Director Encl: Recommendations of 2nd and 3rd sessions of of APOC, Ouagadougou, Burkina Faso; Deputy Cabi- UOEEAC net Director – Ministry of Health, DRC –mapatanow@ yahoo.fr; Dr. Tony Ukety, NGDO Coalition, WHO/ Office of the Minister of Health, Geneva – [email protected]; Technical Advisor, APOC, P.O. Box 7272, Kampala, Uganda.20 Kinshasa, DRC; Permanent Secretary, Ministry of For- 8th July 2011 eign Affairs, Uganda; Permanent Secretary, Ministry of Health, Uganda; Director General of Health Services, Hon. Dr. Victor Makwenge Kaput, Uganda; Director Health Services (Community & Clini- Minister of Health, Kinshasa, cal), Uganda; Commissioner Health Services, National Democratic Republic of Congo. Disease Control, Uganda; and Programme Manager, Onchocerciasis Control Programme, Uganda. Honourable Minister, Follow-up of the letter of the MoH, Uganda Re: Epidemiological Investigations on Onchocer- • 3 – 4 August 2011: through the DPC WCO/ ciasis in Aru and Goma Districts in Eastern Demo- Uganda to WCO/DRC. cratic Republic of Congo • 10 August 2011: through APOC TA/DRC to MoH/DRC The Ministry of Health of the Republic of Uganda launched Onchocerciasis Elimination Policy in 2007 Challenges with the support of Health Development Partners. • Very slow procedures. This bold decision came about as a result of the encour- • A lot of diplomacy. aging impact data obtained from the long-term treatment • Involvement of high level and influential with Ivermectin. authorities.

Based on the above recommendations and to assist AFR/RC57/R3 (2007), page 2 Uganda to determine whether there is cessation of cross (c) To intensify cross-border activities to strengthen sur- border onchocerciasis transmission, and also to assess veillance and avoid spillage of infection to freed zone. whether the foci of Nyagak-Bondo in West Nile Region and Bwindi in South Uganda are isolated from poten- Acknowledgement tial onchocerciasis infested areas in the DRC, there is a TO: MoH of Uganda; WHO Country Office Uganda & proposed plan to conduct epidemiological investigations DRC; APOC; The Carter Center (HQ & Uganda); MDP; and UOEEAC.

19 As has already been said, there was no committee called UOEEAC in 2009. There was the UOEC which was to mutate into UOEEAC sometime in 2010. 20 Written on the letterhead of the Office of the Minister of Health, the communication is referenced MH/DIS/67. Insight Special 2011 4th Session, 15-17 August 2011 27 UOEEAC Delivers its Updated Position on Cross • The vector species in this focus is believed to border Matters be S. damnosum s.l. The committee’s recommendations are given in a three • Distribution of the species complex is fragmented. part statement. Some experts from the countries sharing • This fragmentation has been responsible for a common affected border, says the first section, are to numerous distinct forms. “undertake epidemiological and entomological surveys • Ivermectin treatment started in 1994 in Gulu in cross border foci. Developing such bilateral teams and Amuru districts. will ensure that the onchocerciasis elimination efforts of • In Kitgum, Lamwo and Pader districts treatment Uganda will be able to successfully attack cross border was passive until 2009. foci. The formation of such teams will also strengthen • Progress in epidemiological studies in this focus onchocerciasis control and eventually elimination ef- has been reported. forts in DRC and South Sudan.” APOC’s Executive Di- rector was asked “to follow up on high level political Map showing overview of Uganda’s success in River Blindness contacts which have been initiated between Uganda and Elimination since 2007 DRC to allow the mapping of foci that may extend into DRC from Uganda,” stipulates the second part. “The North 1 focus Committee stressed the need for continuous advocacy of the MOHs of Uganda, DRC and Southern Sudan to promote successful collaborative activities in their respective countries in line with the resolution AFR/RC57/R3 in 2007 and the Sub Regional collaboration protocol of 2003,” reports part three (Unnasch-UOEEAC 2011).

Launching River Blindness Elimination in North 1 Focus* Bernard Vincent Abwang

North1 focus (Amuru, Gulu, Kitgum, Lamwo and North 1 focus (amuru, Gulu,Pader Kitgum, districts) Lamwo and Pader districts

Northern I Focus: Population and treatments required in 2011 Mectizan® Tablet Persons Requirement Districts Total to be Total involved Population treated Treatments (Semi-annual)

Pader 220,785 187,667 375,335 1,050,938 Background • The focus covers Pader, Lamwo and Kitgum Gulu 26,433 21,675 43,350 121,380 and part of Amuru and Gulu districts. • Area size not yet known. Kitgum 151,319 128,582 257,164 720,059

• Main rivers in this focus are R. Aswa, R. Pager, Amuru 32,332 26,513 53,026 148,473 R. Ayugi, R. Unyama, R. Apa, and R. Ome.

Lamwo 118,049 100,311 200,622 561,742

* I.e. Amuru, Gulu, Lamwo, Kitgum, and Pader districts. Total 548,918 464,748 929,497 2,602,592 Insight Special 2011 4th Session, 15-17 August 2011 28 Epidemiological indicators: Kitgum and Pader districts, Other causes of eye disease in this part of Uganda 2008 (N = 400) (2009) • 54 (27.4%) out of the197 with visual im N o . % mf mf % % District Sentinel Assesse +ve density CMFL Nodules onchodermatitis pairment had cataracts, a leading cause of Village d blindness in the project area. Kitgum Laraba 50 80 39.3 18.6 84 38 Tumangur 50 62 18.6 10.8 82 18 • 36 (18.3%) out of the197 with visual impairment Pawena 50 40 4.5 4 56 32 had trachoma, and the majority of trachoma Mudu Central 50 43 16.3 9.4 11.9 16.7 cases were from Pader District. 200 56.25 19.7 10.7 58.5 26.2 Pader Ojuru 50 61.8 31.5 9.4 26 34 Ongany 50 40.3 14.7 8.4 46 28 Plan for Involvement of Local Lions Clubs Angagura 50 57 31.9 10.1 78 60 Lamac South 50 90 88.1 33.9 48 26 • A partnership will be promoted between 200 62.3 41.6 15.5 49.5 37.0 Ugandan Lions and district health services in Total 400 59.28 30.65 13.1 54.0 31.6 North I Focus to facilitate treatment of patients with cataract, trachoma, etc. Ophthalmological Survey In Northern I Focus • The Sight First Committee (SFC) will • In 2009, an ophthalmological survey (N=675 interface with: persons) in the proposed project area revealed « District health services chronic and acute onchocercal eye disease in the « Local ophthalmologists following forms: « Frontline health units personnel, & « sclerosing keratitis – 35(5.2%), « Community supervisors and CDDs « Iritis – 21(3.1%), to include training and activities « punctate keratitis (B, D & E) – 27 that will result in identification of (4%), and cataract and trachoma cases. « microfilariae in the anterior chamber – • Local Lions will organize cataract and Ophthalmological 28 survey(4%). in Northern I Focus trichiasis surgeries and monitor the delivery of • This• In 2009,level an ofophthalmologic onchocercalal survey eye (N=675 disease persons) isin theabove proposed project area revealed primary chronic eye care services, with LCIF assistance. the thresholdand acute onchocercal for elimination eye disease in theof followingon chocerciasis forms: morbid- • Lions Clubs of Uganda will advocate for eye ity (as defined sclerosing by keratitis WHO – 35(5.2%), 2001 Guidelines). care services and onchocerciasis elimination  Iritis – 21(3.1%), at national and district levels through meetings  Onchocercal punctate eye keratitis disease (B, D &occurs E) – 27 (4%), in thisand part of Ugan- with relevant administrative and political leaders  da, contrary microfilariae to the in misconceptionthe anterior chamber – 28 that (4%). Uganda does as well as TV and radio talk shows. not• haveThis level the of onchocercalblinding eye strain disease is of above onchocerciasis. the threshold for elimination of onchocerciasis morbidity (as defined by WHO 2001 Guidelines). • Local Lions will continue to attend the annual Uganda Onchocerciasis Elimination Expert WeOnchocercal estimate eye disease from occurs these in this studies part of Uganda, that contrary there to arethe misconception at least that Uganda Advisory does not Committee (UOEEAC) meeting. 5,400have thepeople blinding strainalready of onchocerciasis. visually impaired or permanently blind from river blindness in the project area. We estimate from these studies that there are at least 5,400 people already visually impaired or permanently blindRationale from river blindness for twice in the projectyearly area. treatment • North I focus has previously not benefited signifi- Rationalecantly fromfor twice the yearly ivermectin treatment (Mectizan®) donation due to insecurity. • North I focus has previously not benefited significantly from the ivermectin (Mectizan®) donation dueNorth I focus has previously • Peaceto insecurity. and security are now prevailing. not benefited significantly from the • The• Peace government and security are of now Uganda prevailing. has recommended elimi- ivermectin (Mectizan®) nation• The of government onchocerciasis of Uganda has withrecommended twice elimination yearly of distributiononchocerciasis with twice yearly donation due to insecurity. of ivermectindistribution of forivermectin rapid for rapidreduction reduction ofof its its prevalence prevalence and interruption and of transmission. Peace and security are interruption• Eye disease of will transmission. be averted. now prevailing. • Eye disease will be averted. The government of Uganda has AA Simulium Simulium damnosum damnosum breeding site in breeding Aruu falls in Padersite districtin Aruu falls in recommended elimination Pader district. of onchocerciasis with twice yearly distribution of ivermectin for rapid reduction of its prevalence and interruption of transmission.

Insight Special 2011 4th Session, 15-17 August 2011 29 Other causes of eye disease in this part of Uganda (2009) • 54 (27.4%) out of the197 with visual impairment had cataracts, a leading cause of blindness in the project area. • 36 (18.3%) out of the197 with visual impairment had trachoma, and the majority of trachoma cases were from Pader District.

Plan for Involvement of Local Lions Clubs • A partnership will be promoted between Ugandan Lions and district health services in North I Focus to facilitate treatment of patients with cataract, trachoma, etc. • The Sight First Committee (SFC) will interface with:  District health services  Local ophthalmologists  Frontline health units personnel, and  Community supervisors and CDDs to include training and activities that will result in identification of cataract and trachoma cases. • Local Lions will organize cataract and trichiasis surgeries and monitor the delivery of primary eye care services, with LCIF assistance. • Lions Clubs of Uganda will advocate for eye care services and onchocerciasis elimination at national and district levels through meetings with relevant administrative and political leaders, as well as TV and radio talk shows. • Local Lions will continue to attend the annual Uganda Onchocerciasis Elimination Expert Advisory Committee (UOEEAC) meeting. Uganda Lions Mobile surgical Unit – Look from VCD - Molecular Epidemiological Laboratory outside Updates Uganda Lions Mobile surgical Unit – Look fromHarriet outside Namanya (left) & and David inside Oguttu (right)

• Lions Clubs of Uganda will advocate for eye care services and onchocerciasis elimination at national and district levels through meetings with relevant administrative and political leaders, as well as TV and radio talk shows. • Local Lions will continue to attend the annual Uganda Onchocerciasis Elimination Expert Advisory Committee (UOEEAC) meeting.

Uganda Lions Mobile surgical Unit – Look from Uganda Lions Mobile surgical Unit – Look frominsideAcknowledgement outside (left) and inside (right) The River Blindness Foundation; NOCP, Ministry of Health; NTD Control Program; The Carter Center; John Moores; African Program for Onchocerciasis Control/WHO; Merck and Co.; District Onchocerciasis Coordinators; and endemic communities are all here acknowledged for their various contributions in the assault of onchocerciasis. aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa

UOEEAC’s Look at Mid-north 1 Focus “Committee concurs,” members agreed among themselves, “with the MOH recommendation to begin semiannual treatment. Entomological surveys to delineate sibling species of Sd21 Harriet Namanya present. Committee requests assistance of APOC in coordinating cross border studies to delineate focus and effect of human population on epidemiology of onchocerciasis in this area.” Yellow was the focus’s recommended destination given the point that the focus is Acknowledgement Theexpected River to Blindness seriously Foundation; embark on NOCP, eliminating Ministry ofonchocerciasis and its transmission. Health; NTD Control Program; The Carter Center; John Acknowledgement Moores;gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg African Program for Onchocerciasis Control/ WHO; Merck and Co.; District Onchocerciasis Coordi- The River Blindness Foundation; NOCP, Ministry of Health;nators; andNTD endemic Control communities Program; are all Thehere acknowl Carter- Center; John Moores; African Program for Onchocerciasis Control/WHO;edgedVCD for Merck- Molecular their various and Co. contributions Epid.; District Lab in Onchocerciasis theUpdates assault of onchocerciasis. Coordinators; and endemic communities are all here acknowledgedHarriet Namanya for their & David various Oguttu contributions in the assault of onchocerciasis. UOEEAC’s Look at North 1 Focus aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa“CommitteeBackground concurs,” members agreed among them - selves,• “withEstablished the MOH inrecommendation August 2007. to begin semi- annual treatment. Entomological surveys to delineate sibling• speciesFully operational of Sd21 present. May Committee 2008 after requests training of VCD-based technicians. UOEEAC’s Look at Mid-north 1 Focusassistance of APOC in coordinating cross border studies to• delineateOffers focushighly and sensitive effect of and human specific population modern techniques for monitoring onchocerciasis “Committee concurs,” members agreed amongon themselves, epidemiologyelimination. of onchocerciasis“with the inMOH this area.” recommendation Yel- low was the focus’s recommended destination given the 21 to begin semiannual treatment. Entomological pointsurveys• thatOV16 the tofocus ELISA delineate is expected on blood to sibling seriously spots. embark species on of Sd present. Committee requests assistance of APOCeliminating •in O-150coordinating onchocerciasis PCR on andSimulium crossits transmission. and border skin snips. studies to David Oguttu delineate focus and effect of human population on epidemiology of onchocerciasis in this area.” Yellow was the focus’s recommended destination21 Sd – an acronym given for Simulium the pointDamnosum that the focus is expected to seriously embark on eliminating onchocerciasis Insight Special and 2011its transmission.4th Session, 15-17 August 2011 30 gggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggggg

VCD - Molecular Epid. Lab Updates 21 Sd – an acronym for Simulium Damnosum. Harriet Namanya & David Oguttu

Background • Established in August 2007. • Fully operational May 2008 after training of VCD-based technicians. • Offers highly sensitive and specific modern techniques for monitoring onchocerciasis elimination. • OV16 ELISA on blood spots. • O-150 PCR on Simulium and skin snips.

21 Sd – an acronym for Simulium Damnosum. Background UOEEAC 2010 Recommendations • Established in August 2007. • To clear backlog of samples in the lab. O-150 PCR technique • Fully operational May 2008 after training • Follow up 13 Ov16 positive children in of VCD-based technicians. Imaramagambo for snip PCR. • Offers highly sensitive and specific modern • UOEEAC To collect 2010 Recommendations and screen blood spots from techniques for monitoring onchocerciasis Itwara,• To clear Kashoya-Kitomi backlog of samples in the lab. and more from Bwindi • Follow up 13 Ov16 positive children in Imaramagambo for snip PCR. elimination. focus.• To collect and screen blood spots from Itwara, Kashoya-Kitomi and more from • OV16 ELISA on blood spots. Bwindi focus. • O-150 PCR on Simulium and skin snips. O-150 PCR technique ActionAction on backlogon backlog since August since 2010 2010 Focus Achievement Number of Number % positive Backlog? O-150 PCR technique samples screened +ve Wambabya- Cleared backlog 3005 49 1.6 0 Rwamarongo

BudongoUOEEAC 2010 RecommendationsDiscarded 1200 80 6.7 0 • To clear backlogbacklog of samples in the lab. • Follow up 13 Ov16 positive children in Imaramagambo for snip PCR. Imaramagambo• To collect and Collectedscreen blood snips spots3356 from Itwara, Kashoya-Kitomi0 and0 more from 0 Bwindi focus. from 11 children Action on backlog since August 2010 Bwindi-Kigezi Cleared backlog 3400 0 0 0 Focus Achievement Number of Number % positive Backlog? samples screened +ve Total 10,961 129 1,2 00 Wambabya- Cleared backlog 3005 49 1.6 0 NB.Rwamarongo In Imaramagambo the 11 Ov16 positives were confirmed by PCR to be negative and 2 other children were not found. Budongo Discarded 1200 80 6.7 0 NewNew collections collections and progressbacklog and made 2010-2011progress made 2010 - 2011 Imaramagambo Collected snips 3356 0 0 0 Focus # spotsfrom collected11 children Date # screened # positive % +ve backlog Bwindi-Kigezi Cleared backlog 3400 0 0 0 Bwindi 1200 Oct 2010 1200 0 0 0 Total 10,961 129 1,2 00 NB. In Imaramagambo the 11 Ov16 positives were confirmed by PCR to be negative and 2 other children were not found. Itwara 3400 Sept 2010 3314 0 0 0 New collections and progress made 2010-2011 KashoyaFocus #1360 spots collected DateNov 2010 # 1360screened # positive10 %0.7 +ve backlog0

NyamugasaniBwindi 12001400 OctMar 2010 2011 12001400 0 2 0 0.14 0 0 Itwara 3400 Sept 2010 3314 0 0 0 Maracha-Terego 6600 May 2011 3200 1 - 3300 O-150 PCR technique Kashoya 1360 Nov 2010 1360 10 0.7 0 ObongiNyamugasani 14003300 MarJul 2011 14000 2 - 0.14 0 3300 Based on amplification ofO.volvulus DNA (0-150) in Simulium vector NB.Maracha Nyamugasani-Terego Ov166600 positive children were Mayconfirmed 2011 O. volvulus3200 negative1 by PCR. - 3300 and in skin snips of adult humans (Meredith et al. 1995, Katholi et al., Obongi 3300 Jul 2011 0 - 3300 1995). UpdateNB. Nyamugasani results Ov16 from positive all foci children were confirmed O. volvulus negative by PCR. Update results from all foci FocusUpdate results from# spots all foci Date of collection # screened # of +ve result % +ve Ov16 ELISA technique Focus #collected spots Date of collection # screened # of +ve result % +ve Ov16Ov16 ELISA ELISA technique technique collected Wadelai 30133013 MayMay 2008 2008 30133013 3 3 0.090.09 Mpamba-Nkusi 33923392 JanJan 2009 2009 33923392 1919 0.560.56  Based on detection of IgG4  Based on detection of IgG4 Imaramagambo 3400 Sept 2009 3356 0 0 in blood using Ov16 antigen ImaramagamboElgon 31503400 OctSept 2008 2009 31503356 1 0 0.030 in blood using Ov16 antigen Wambabya 3150 Jun 2008 3005 49 1.6  Early marker of exposure to Elgon 3150 Oct 2008 3150 1 0.03  Early marker of exposure to Budongo 3400 Aug 2008 1200 80 6.7 infective larval stage of WambabyaBwindi 45003150 NovJun 20092008 - Oct 2010 45003005 0 49 0 1.6 infective larval stage of O. volvulus (Lobos et al.,1991, BudongoItwara 33400400 SeptAug 2010 2008 33161200 0 80 0 6.7 Kashoya 1360 Nov 2010 1360 10 0.7 O. volvulus (Lobos et al.,1991, Bbakima et al.,1996) Bwindi 4500 Nov 2009 - Oct 2010 4500 0 0 It is done on children 2 -10 years. Nyamugasani 1400 Mar 2011 1400 0 0 Bbakima et al.,1996) ItwaraMaracha -Terego 66003400 MaySept 2011 2010 33003316 (backlog0 3300 ) 0 0 Obongi-Moyo 3300 July 2011 0 Backlog 3300 - Kashoya 1360 Nov 2010 1360 10 0.7 It is done on children 2 -10 years. NB. Maracha-Terego has 2 sub-foci, thus 6600 samples. The backlog is for Maracha sub focus.

ResultsUpdate all O- all150 fociresultsResults contd. all foci contd. Ov16 ELISA technique Focus # flies Year of collection # pools of 20 +ve Backlog? FocusKashoya -Kitomi # spots5240 2007Date of # screened249(4980) # of 6+ve 260% flies +ve collected collection result  Based on detection of IgG4 Elgon 4311 2007 115(2300) 0 2011 in blood using Ov16 antigen ItwaraWambabya 34001663 2009 Sept 2010 3316- 0 - 16630  Early marker of exposure to Kashoya SKIN 1360 SNIP PCR Nov 2010 1360 10 0.7 infective larval stage of NyamugasanMpamba-Nkusi 1400799 Jan2009 Mar 2011 1400 0 12 0 0 O. volvulus (Lobos et al.,1991, Blood spots at UOEEAC AUG 2010 i Itwara 686 May 2009 0 0 Bbakima et al.,1996) Imaramagambo 462 June 2009 5 0 • It isBased done on childrenon detection 2 -10 years. of IgG4 in blood using Ov16 antigen Maracha- 6600 May 2011 3300 (backlog 0 Focus Achievement Number of samples Terego +ve Backlog? 3300 ) • Early marker of exposure to infective larval stage of O. volvulus Plan for 2011-2012 Obongi- 3300 July 2011 0 Backlog - screened • Clear Ov16 backlog for Maracha and Obongi. (Lobos et al.,1991, Bbakima et al.,1996) Moyo 3300 • OV16 in Mpamba-Nkusi and other foci which may be recommended by UOEEAC. It is done on children 2 -10 years • O-150 on flies from Elgon, Wambabya, Nyamugasani, Bwindi, Maracha and Moyo, Blood spots at UOEEAC AUG 2010 22 Wambabya- Cleared backlog 3005 Nyagak, 46 Rubiriha. 0 Rwamarongo NB.NB. Maracha-Terego Maracha-Terego has 2has sub-foci, 2 sub-foci, thus 6600thus samples.6600 samples. The backlog The backlog is for Maracha is for Marachasub focus sub Focus Achievement Number of samples +ve Backlog? Workfocus capacity of the laboratory OV16: Blood spots at UOEEAC AUG 2010 • Maximum 17500 blood spots per year. Budongo Bloodscreened spotsReduced at UOEEAC backlog AUG 2010 1200 /3400 UpdateO-150 PCR: 80 all Update 0 -150 results2200 all O-150 results • Only 5000 reactions per year. Focus Achievement Number of samples +ve Backlog? Challenges Focus # flies Year 0f # pools of +ve Backlog Imaramagambo Collection of 3400 bloodscreened spots 3356 • Understaffing 13 (only 1 0technician on government pay roll) Wambabya- Cleared backlog 3005 46 0 Recommendations collection 20 ? Wambabya- Cleared backlog 3005 46 0 Kashoya• Min-kitomi of Health should5240 consider posting2007 at least 1 more249 technicians (4980) to6 the lab. 260 flies Rwamarongo Bwindi-KigeziRwamarongo Collection of 3400 blood spots 0 - 3400 + 1300 Acknowledgement Elgon collected4311 in2007 Oct 2010 115(2300) 0 2011 Budongo Reduced backlog 1200 /3400 80 2200 To Prof. Unnasch for technical support to the Uganda lab.; The Carter Center for establishing and maintaining the lab.; and Uganda’s MoH for posting a parasitologist to VCD. (We still Budongo Reduced backlog Imaramagambo1200 Collection /3400 of 3400 blood spots 3356 80 Total 13 screened0 2200 = 7561 Wambabyaneed more.) Total1663 backlog2009 = 6900 - - 1663 Aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa Bwindi-Kigezi Collection of 3400 blood spots 0 - 3400 + 1300 SKIN SNIP PCR NB: The 13 putative positives in Imaramagambo were to be confirmed using PCR.What 44 samplesUOEEAC were Said aboutleft out the becauseEpid. Lab Updates Imaramagambo Collection of 3400 blood spots 3356 13 collected in Oct 02010 they were duplicates. MpambaA statement-nkusi with four sections799 delivers Jan2009the committee’s views on the laboratory’s12 status0 – its work, successes, requirements, and its future. “The committee gratefully acknowledged the Total screened = 7561 Total backlog = 6900 ItwaraMOH support for the laboratory686 over theMay past year,”2009 states section 1, “in parti0 cular in 0 NB: The 13 putative positives in Imaramagambo were to be confirmed using PCR. 44 samples were left out because assigning...David Oguttu as a full time employee responsible for the laboratory operations. Bwindi-Kigezi Collection of 3400 blood spots 0 - 3400 + 1300Imaramagambo 462 June 2009 5 0 they were duplicates. As a result...the laboratory has cleared the backlog of samples that existed and is now capable collected in Oct 2010 22 A focus name pronounced and spelt differently by different people, e.g. Lhubiriha. Insight Special 2011 4th Session, 15-17 August 2011 31 Total screened = 7561 Total backlog = 6900 NB: The 13 putative positives in Imaramagambo were to be confirmed using PCR. 44 samples were left out because they were duplicates.

Plan for 2011-2012 dongo - complete Ov16 ELISA analysis of blood spots • Clear Ov16 backlog for Maracha and Obongi. (1800 samples); obtain blood spots and conduct Ov16 • OV16 in Mpamba-Nkusi and other foci which analysis on buffer villages west of Nyamugasani to de- may be recommended by UOEEAC. termine if Nyamugasani and Lubilila are indeed sepa- • O-150 on flies from Elgon, Wambabya, rate foci (3500 samples); collect and analyze blood spots Nyamugasani, Bwindi, Maracha and Moyo, from the Mpamba Nkusi focus (3500 samples); analyze Nyagak, Rubiriha.22 blood spots from the Obongi focus (3300 samples); and O-150 PCR analysis on flies collected from Bwindi (35 Work capacity of the laboratory pools), Nyagak-Bondo (17 pools) and Wambabya (15 OV16: pools)” (Unnasch-UOEEAC 2011). • Maximum 17500 blood spots per year. O-150 PCR: Wadelai Update & UOEEAC Recommendations • Only 5000 reactions per year. While there was no timetabled presentation on the Wad- elai focus, the committee was given an update by Lakwo Challenges Tom on it as we now report. • Understaffing (only 1 technician on “The committee,” as has been recorded, “was pleased government pay roll) to note that the NCC accepted the recommendation of the UOEEAC 2010 meeting that transmission was inter- Recommendations rupted at the Wadelai focus and twice per year treatment • Min of Health should consider posting at could stop. That this committee also “heard reports sug- least 1 more technicians to the lab. gesting some community resistance to stopping community-wide twice per year treatment” in the focus is on Acknowledgement record. To Prof. Unnasch for technical support to the Uganda lab.; The Carter Center for establishing and maintain- “The committee,” consequently, “recommended ing the lab.; and Uganda’s MoH for posting a parasi- strengthening community sensitization around this deci- tologist to VCD. (We still need more.) sion, informing the community clearly that while twice per year treatment will stop, once per year treatment will continue under the filariasis program.” It was again “rec- What UOEEAC Said About The Epidemiological ommended that the MOH make a statement, making it Laboratory Updates clear that interruption has been achieved at this focus, to A statement with four sections delivers the committee’s help in informing the community” (Unnasch-UOEEAC views on the laboratory’s status – its work, successes, 2011). requirements, and its future. “The committee gratefully acknowledged the MOH support for the laboratory over the past year,” states section 1, “in particular in Predictive endmember auto-Gaussian S.damnosum assigning...David Oguttu as a full time employee re- s.l. habitat modeling in Northern Uganda23 sponsible for the laboratory operations. As a result... Thomson L. Lakwo, Robert Novak, the laboratory has cleared the backlog of samples that Peace Habomugisha & Thomas R. Unnasch existed and is now capable of keeping abreast of the samples collected by the field teams, thus providing timely data to the elimination program and the UOEE- AC. The committee congratulates...Oguttu and the laboratory staff on this impressive achievement.” This facility, says section 2, “is currently working at capacity analyzing samples generated by the onchocerciasis elimination program alone”, observing also that “the recommendation that the MOH consider adding 1 or more technical positions to the laboratory” has the full backing of UOEEAC as the lab will need some extra hands should its work get bigger.

MOH Uganda’s wish “to expand the mandate on the laboratory to include diagnostic tests for other NTDs”, section 3 sys, has in principle the support of UOEE- AC, which however insists that “in order to expand the laboratory’s activities additional personnel, space and equipment will be necessary”. A six point list of labo- Thomas R. Unnasch ratory priorities for August 2011 – August 2012 was 23 In 2011 UOEEAC program terms, this presentation, whose created, as given in section 4, namely “analyze Terego presenter was T.R. Unnasch, was given as “remote sensing”, blood spots with Ov16 ELISA (3300 samples); Bu- which title is a mirror of the content of the paper. Co-con- 22 A focus name pronounced and spelt differently by different tributors Novak, Habomugisha and Lakwo received from the people, e.g. Lhubiriha. presenter due acknowledgement for their participation. Insight Special 2011 4th Session, 15-17 August 2011 32 Precambrian Rock

Precambrian Rock

Background. PrecambrianPrecambrian Rock Rock • Onchocerciasis foci currently mapped using epidemiological surveys. • Epidemiological methods require on the ground assessment of prevalence of infection. • Some communities difficult to reach for on-the- ground surveys. • Onchocerciasis foci are generally associated • Onchocerciasis with black foci fly currently breeding mapped sites, using epidemiological(thus the common surveys. • Epidemiological name river methods blindness). require on the ground assessment of prevalence of •infection. Therefore, identification of breeding sites for the vector might be a useful way to predict the • Some communities difficult to reach for on-the-ground surveys. Spectral signature of the Precambrian rock polygon at the Dienkoa study site • Onchocerciasis communities foci are most generally at risk associated for onchocerciasis. with black fly breeding sites, (thus theSpectral signature of the Precambrian rock polygon at the Dienkoa study site • Onchocerciasis foci currently mapped using epidemiological surveys. Spectral signature of the Precambrian rock polygon at the common name river blindness). DienkoaSpectral signature study siteof the Precambrian rock polygon at the Dienkoa study site • OverallEpidemiological objectives methods require on the ground assessment of prevalence of • •Therefore,infection. To utilize identification historical of breeding data sites on forSimulium the vector might breeding be a useful way to • Some communities difficult to reach for on-the-ground surveys. predict sites the in communities conjunction most at with risk for remote onchocerciasis. sensing data • Onchocerciasis foci are generally associated with black fly breeding sites, (thus the common to develop name river ablindness). spatial model capable of Overall• Therefore, objectives predicting identification breeding of breeding site sites locations. for the vector might be a useful way to • •Topredict utilizeTo the validate historicalcommunities datathis most on model Simuliumat risk for using onchocerciasis.breeding an sites independent in conjunction with remote sensing historical data to develop dataset. a spatial model capable of predicting breeding site locations. Overall• •To objectives To validate evaluate this model the using ability an independent of the modelhistorical to dataset. predict • To utilize historical data on Simulium breeding sites in conjunction with remote • To breeding evaluate the sitesability inof theother model areas to predict of breeding West Africasites in other and areas of West sensing in East data toAfrica develop a(Uganda). spatial model capable of predicting breeding site locations. Africa and in East Africa (Uganda). • To validate this model using an independent historical dataset. • To evaluate the ability of the model to predict breeding sites in other areas of West GIS polygon of Precambrian rock and associated hy- Spectral signature of breeding sites GIS polygondrologicalAfrica ofand Precambr in East data Africaian at rock(Uganda). the and Sarakawa associated hydrological study site data in at Burkinathe Sarakawa study siteFaso in Burkina Faso GIS polygon of Precambrian rock and associated hydrological data at the Sarakawa study site in Burkina Faso This is output combination of reflected light between vis and near IR Spectral- this the signature area that of breedingrepresents sites a spectral signature for pre-cambrian rock and flowing water over rock.

Spectral signature signature of breeding of sites breeding sites

Predicted S. damnosum s.l. riverine larval habitats in Burkina Faso Predicted S. damnosum s.l. riverine larval habitats in Burkina Faso Turbid Waters Turbid Waters

Turbid Waters

Insight Special 2011 4th Session, 15-17 August 2011 33

Results of ground truthing  100% of predicted sites contained larvae.  No false positives.  Specificity of model was 100% in Burkina Faso.

Extension of the model to Northern Uganda  S. damnosum area.  Identify onchocerciasis endemic areas from REMO map.  Obtain images from the area.  Extract signatures corresponding to breeding sites in Burkina Faso.  Visit predicted breeding sites (and sites not predicted as breeding habitats).

Map overlay of areas sampled in Northern Uganda

NB: Predicted breeding sites based on BF model. Also looked for larvae between sites, nothing found

Predicted S. damnosum s.l. riverine larval habitats in Burkina Faso

Closeup of predicted sites

Results of ground truthing What are the labels ...... for these pictures )))down)) ?

 100% of predicted sites contained larvae.  No false positives.  Specificity of model was 100% in Burkina Faso.

Extension of the model to Northern Uganda

Results of ground truthing  S. damnosum area.  100% of predicted sites contained larvae. WhatWhatWhat are are arethe the thelabels labels labels ...... for theseforthese these pictures pictures pictures ))) ))) down))) down))) ))) down))) ? ? ?  Identify onchocerciasis endemic areas from  No false positives.

 REMOSpecificity map. of model was 100% in Burkina Faso.

 Obtain images from the area. Extension of the model to Northern Uganda  Extract signatures corresponding to breeding  S. damnosum area. sites in Burkina Faso.   VisitIdentify predicted onchocerciasis breeding endemic areas sites from (and REMO sites map. not  predictedObtain images as from breeding the area. habitats).  Extract signatures corresponding to breeding sites in Burkina Faso.

 Visit predicted breeding sites (and sites not predicted as breeding habitats). Map overlay of areas sampled in Northern Uganda Map overlay of areas sampled in Northern Uganda

Floating Vegetation Floating Vegetation FloatingFloating Vegetation Vegetation

HowHow did the did model the do modelin Uganda? do in Uganda?  23/25 (92%) predicted positive sites contained larvae. HowHow did 28/30didthe themodel (93%) model do predicted indo Uganda? in Uganda?negative sites did not contain larvae. ► 23/25 (92%) predicted positive sites contained  23/25 Sensitivity23/25 (92%) (92%) = predicted 92% predicted. positive positive sites sites contained contained larvae larvae. .  Specificity = 93%.  28/30 larvae.28/30 (93%) (93%) predicted predicted negative negative sites sites did didnot containnot contain larvae larvae. .

 Sensitivity Sensitivity = 92% = 92%. . Further► 28/30 work (93%) predicted negative sites did not  Specificity Specificity = 93% = 93%. .  Identificationcontain larvae.of a signature to predict remaining 8% of breeding sites missed by current model. FurtherFurther► work Ground Sensitivity work truthing of new= 92%. signature in Burkina Faso. ►  Identification Delineation SpecificityIdentification of of “zones a of signature a signature =of 93%.risk” to aroundpredict to predict breedingremaining remaining sites 8%. 8%of breeding of breeding sites sites missed missed by by  currentExtensioncurrent model. model.of approach to other vector species (e.g. S. neavei).  Ground Ground truthing truthing of new of new signature signature in Burkina in Burkina Faso. Faso. Further Delineation Delineation work of “zones of “zones of risk” of risk” around around breeding breeding sites sites. .  Extension Extension of approach of approach to other to other vector vector species species (e.g. (e.g. S. neavei S. neavei). ). ► Identification of a signature to predict remaining 8% of breeding sites missed by current model. ► Ground truthing of new signature in Burkina Faso. ► Delineation of “zones of risk” around breeding NB: Predicted Predicted breeding breeding sites based on sites BF model. based Also looked on BF for larvaemodel. between Also sites, lookednothing found sites. forNB: Predictedlarvae breeding between sites basedsites, on BFnothing model. Also found looked for larvae between sites, nothing found ► Extension of approach to other vector species

(e.g. S. neavei).

Acknowledgements To: Edson Byamukama, Statistician, Uganda Carter Center; William Sam Oyet, Vector Control Officer, Pad- er District; Bernard Abwang, Vector Control Officer, Gulu District; Denis Munu, Driver, Carter Center Ugan- da; Leteace Howard, Field Technician, Penn State Uni- versity, Pennsylvania, USA; and Isaias Gomez-Garcia, Field Technician, University of California at Berkeley, California, USA.

Closeup of predicted sites

What are the labels ...... for these pictures )))down)) ? Closeup of predicted of predicted sites sites

What are the labels Insight ...... Special for these2011 pictures 4th Session,)))down)) ? 15-17 August 2011 34

Discussion of Remote Sensing Onchocerciasis: Millions of Treatments Approved There were questions, answers and comments, in what was flood-like, after Unnasch’s presentation of the model that uses the presence of Precambrian rocks (a geological feature) and fast running clear water, as detected in satellite images, to predict breeding spots of the black fly, a model that was earlier successfully used for the same aim in some West African countries, Togo included. At the present the model is being applied to Simulium damnosum, with plans to widen the scope of its application to Simulium neavei.

If there is anything that may help to expose spots (in generally hard to reach oncho endemic terrain, in Ugan- da or other places as Ethiopia) that may, until now, have Lymphatic Filariasis: Treatments in Millions Approved evaded treatment efforts by default,24 it is the now pub- licized (remote sensing) model, some committee members seemed to believe. One member even got inspired and called it the “predator” of onchocerciasis. There was a widely shared expectation that the remote sensing model, which, the audience was told, is presently also being considered by USAID as a possible measure against malaria, is potentially a powerful anti- onchocer- ciasis attack tool. The model, at least in the northern Uganda background, has not been effective a hundred percent, however; and one of the things that still have to be considered is how small rivers and streams fit in this model as potential breeding habitats. NB: Total LF patients treatments approved 121,497,228, but 28,337,564 were approved for onchocerciasis as well On use of the remote sensing model, the statement was made that this could very much be applied by local experts, a trend that would cut out reliance on foreign ex- patriates. 24 yeras old

PART D - News From Some Partners

The Mectizan Donation Program Adrian D. Hopkins

24 Because of the inadequacies of the traditional methods of identifying the vector’s breeding sites from the The future with NTDs ground. Application Review Process • Currently under discussion with WHO. Insight Special 2011 4th Session, 15-17 August 2011 35 The future with NTDs need to be made well in advance,25 months before they are expected for distribution. The point was made that Application Review Process getting flight delivery papers for an expected consign- • Currently under discussion with WHO. ment was not enough ground for one to assume that the • Development of coordinated application medical supplies will easily arrive at a warehouse from process in AFRO. where one will equally easily collect them. One has to • Probably in a modular form. do something to see to it that they are delivered sooner • Related to NTD Master Plan and Annual than later. In Africa, this responsibility will pass on to Plan of Action. individual affected nations particularly their NTD de- partments and coordinators (guided by the NTD Mas- Challenges in 2011 ter Plan and Annual Plan of Action), although AFRO (a • Supply Chain. WHO arm) is set to oversee the application and ship- • New shipping process put out to tender by Merck. ping procedures for virtually all drug requisitions. • Companies chosen not always familiar with procedures. • Delays in exoneration. • Breakdown in IT system with shipping department. Progress on River Blindness Elimination in the • Solution. Americas (OEPA) • Apply well in advance even if full report is Frank Richards not available. • Program Managers must follow dossier through importation formalities. • Keep MDP informed of problems.

25 years Evaluation • Will include some country visits (not Uganda). • Extensive review of results with partners. • Extensive review of processes. • Basis of strategic planning 2013 – 2020.

Special Events • Two special events at WHA (Geneva) and World Sight Day (London) plus special events with partners at JAF, and OEPA.

Proposed Shipping Strategies Prompt Reactions

The proposed transition, in the shipping of medicines and related stuff to their destinations in NTD-infected parts of Africa (onchocerciasis endemic areas included), seemed to have generally gone down well with the 2011 Geographic distribution and transmission status of UOEEAC addressees. Some worries were expressed, the 13 Onchocerciasis foci of the Americas in 1987 however, as examples will show. The planned changes, it was discussed, need to be piloted with and in a few 1 2 ONGOING Transmission of countries as a way of testing their viability and sustain- 3 the parasite Onchocerca 4 volvulus 5 ability. General consensus was that this is better than 6 7 simply rolling out once the new system to all affected countries as that may have its own risks and troubles that may do much wider harm. Changes will begin picking 8 9 up in 2012, with participating organizations and countries being educated that year, and with the transition starting to take effect in 2013 – all this being in line with 10 12 the saying “make haste slowly”. 1 1

13 On twice per year (onchocerciasis elimination) drugs, because twice yearly treatments are affected more by late arrival of medicines than annual ones, applications 25 The time now being given by WHO as most suited for applications is January/February of each year, the meeting was informed by Hopkins. Insight Special 2011 4th Session, 15-17 August 2011 36 Action), although AFRO (a WHO arm) is set to oversee the application and shipping procedures for virtually all drug requisitions. aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa

Progress on River Blindness Elimination in the Americas (OEPA)

Frank Richards

Geographic distribution and transmission status of the 13 Onchocerciasis foci of the Americas in 1987

Geographic distribution and transmission status of the 13 Onchocerciasis foci of the Americas May 2011 ELIMINATED!! Oaxaca 44,919 (PTS) INTERRUPTED North Chiapas 7,125 SUPPRESSED Huehuetenango ONGOING 30,239 (PTS)

South Chiapas 111,485 Santa Rosa 12,208 Central 124,269 Northcentral Northeast 13,989 Escuintla 93,009 62,590

South 8,462

Lopez de Micay 1,366 (PTS) Esmeraldas Amazonas 18,566 11,807 Brazil Updated May 2010 History of GeographicMectizan® treatment distribution in the andAmericas transmission and projection status for of 2011 -2012 the 13 Onchocerciasis foci of the Americas July 2011 ELIMINATED!! Oaxaca 44,919 (PTS) INTERRUPTED North Chiapas 7,125 SUPPRESSED Huehuetenango ONGOING 30,239 (PTS) South Chiapas 111,485 Santa Rosa 12,208 Central 124,269 Northcentral Northeast 13,989 Escuintla 93,009 62,590

ENT: <1/2000 infective flies South 8,462 EPI: <0.1 percent infection in children

MORB: <1% mf in cornea/anterior chamber Lopez de Micay 1,366 (PTS) Esmeraldas Amazonas of eyes 18,566 11,807 Brazil Updated May 2010 Insight Special 2011 4th Session, 15-17 August 2011 37

Good News! History of Mectizan® treatment in the Americas and projection for 2011-2012 History of Mectizan® treatment in the Americas and projection for 2011-2012

Resolution XIV expired New Resolution CD48.R12

OEPA

Resolution 68% XIV decrease issued

Good News! Bad News! News! Poor Progress Progress in Venezuela in andVenezuela Brazil and Brazil Discovery in 2010 in of untreated2010 of hyperendemic untreated villages hyperendemic in vil- Southlages Venezuela in South Venezuela

Geographic distribution and transmission status of Discovery inthe 2010 13 of Onchocerciasis untreated hyper-endemic foci ofvillages the Americasin South Venezuela 2011 ELIMINATED!! Oaxaca 44,919 (PTS) INTERRUPTED North Chiapas 7,125 SUPPRESSED

Huehuetenango ONGOING 30,239 (PTS)

South Chiapas 111,485 Santa Rosa 12,208 Central 124,269 Northcentral Northeast 13,989 Escuintla 93,009 62,590

South Enhanced efforts are needed 8,462 especially in Venezuela!!!

Lopez de Micay 1,366 (PTS) Esmeraldas Amazonas 18,566 11,807 Brazil Updated May 2010

Evaluación Entomológica - Simulídeos capturados, nos PB centinelas Xitei, Balawaú e Toototobi, 2009 y 2010, Brasil Insight Special 2011 4th Session, 15-17 August 2011 Nº de moscas Nº de moscas Evaluación Entomológica - Simulídeos capturados,38 Polo Comunidadnos PB centinelas Xitei,colectadas Balawaú e Toototobi,colectadas 2009 y 2010, Brasil Total agos - nov 2009 agos - oct 2010* Nº de moscas Nº de moscas Polo Comunidad colectadas colectadas Total Watatase 1 agos9.789 - nov 2009 agos - oct 2010* - 9.789

Xitei Watatase Watatase 2 1 7.5109.789 - - 7.5109.789

Xitei Evaluación Ketaa (Ketaa) Watatase Entomológica 2 2.3197.510 - Simu lídeos capturados, 3.647 - 5.9667.510

nos PB centinelas Ketaa Xitei, (Ketaa) Balawaú 2.319 e Toototobi, 2009 3.647 y 2010, 5.966 Brasil Nº de moscas Nº de moscas Polo Comunidad colectadas colectadas Total agos - nov 2009 agos - oct 2010*

Watatase 1 9.789 - 9.789

Xitei Evaluación Watatase Entomológica 2 7.510 - Simu lídeos capturados, - 7.510 nos PB centinelas Xitei, Balawaú e Toototobi, 2009 y 2010, Brasil Ketaa (Ketaa) 2.319 3.647 5.966 Nº de moscas Nº de moscas Polo Comunidad colectadas colectadas Total agos - nov 2009 agos - oct 2010*

Watatase 1 9.789 - 9.789

Xitei Watatase 2 7.510 - 7.510

Ketaa (Ketaa) 2.319 3.647 5.966

Evaluación Entomológica - Simulídeos capturados, nos PB centinelas Xitei, Balawaú e Toototobi, 2009 y 2010, Brasil Nº de moscas Nº de moscas Polo Comunidad colectadas colectadas Total Ketaa (Aplutaú) agos -3.610 nov 2009 agos - oct 2010* 6.234 9.844

Sub-total Watatase Xitei 1 9.789 23.228 9.881 - 9.78933.109 La casa comunitaria de Thorapiwei-theri

Xitei Watatase 2 7.510 - 7.510 Maxapapi Balawaú (Tapiri) Ketaa (Ketaa) 1 2.3191.392 3.647 1.462 5.966 2.854

Balawaú Maxapapi Ketaa (Aplutaú) Balawaú 3.610 6.234 9.844 Sub(maloca)-total Xitei 2 921 23.228 9.881 1.701 33.109 2.622

Maxapapi Balawaú (Tapiri) 1 1.392 1.462 2.854 Photo credit --- 3 --- 376 376 CIACET-VEN Balawaú Maxapapi Balawaú (maloca) 2 921 1.701 2.622 Sub-total Balawaú 2.313 3.539 5.852 Balawaú --- 3 --- 376 376 Toototobi Amahiki 7.251 - 7.251 Sub-total Xiruxixopiu Balawaú 2.313 14.580 3.539 - 5.85214.580

Toototobi Sub - total Toototobi Amahiki 7.251 21.831 - - 7.25121.831 Total Xiruxixopiu 14.580 47.372 13.420 - 14.580 60.792 Sub-total Toototobi 21.831 - 21.831 Total 47.372 13.420 60.792

onward! Onward!!!

ACYAPS Feliciano Yoakai, ambulatorio

Provisional (Shakripiwei – Área Shitari/Alto Ocamo) Four times per year Mectizan® treatments in Venezuela and Brazil in 2011 Four times per year Mectizan® treatments in Venezuela and Brazil in 2011

20102010 ## hyperhyper-endemic-endemic TransmissionTransmission communitiescommunities HyperHyper- underunder 4x/year 4x/year tx tx Focus endemic in 2010 (% hyper) status Focus endemic in 2010 (% hyper) status Northeast, Northeast,VZ 35 35 (100%) Ongoing VZ 35 35 (100%) Ongoing

YANOMAMI AREA (CROSS BORDER VZ AND BR)

YANOMAMI AREA (CROSS BORDER VZ AND BR) Amazonas, BR 7 3 (43%) Ongoing Amazonas, South, VZ 5 2 (40%) Ongoing BR 7 3 (43%) Ongoing TOTAL 47 40 (85%) South, VZ 5 2 (40%) Ongoing

Insight Special 2011 4th Session, 15-17 AugustTOTAL 2011 47 40 (85%) 39

nate the disease’s ATP30.

The situation of the “untreated hyperendemic villages”, which were discovered during 2010 in Venezu- ela’s southern region, just at this country’s border with Brazil,31 is our second case in point of the “reflecting aspects”. Between both countries, right in and across the border focus where the newly found village communities live, there exists poor cross border cooperation, reports Richards.

You have one government minister (on one side of the border) asking his or her counterpart (on the other side) about this or that, talking about doing one thing or the other to have both sides work together to find solutions for the border onchocerciasis problem. One main problem, however, is that Brazil (with a strong oncho program), so they say, is in a better position to deal with the Reception of Richard’s OEPA News reality of the previously untreated border communities His address, as in years past, received maximal UOEEAC than Venezuela is. A bad transport system, over and in attention, thanks in part to the way in which he structur- the border area, complicates more the degree of ability ally organized, graphically illustrated and verbally elab- and readiness (on both sides) to deal with the border orated his material. His unique style was effective - in oncho scare. There is virtually no road network there, and flying into the area is more practicable and cheaper educating, challenging and sending out wake-up calls to 32 onchocerciasis fieldworkers and officers, governments from Brazil than from its neighbour. Cooperation be- (health ministries especially) and everyone else playing tween Brazil and Venezuela, in the matter of the border a part in the oncho fight on the opposite (African) side of onchocerciasis scare, remains difficult, therefore; and the Atlantic Ocean.26 Richards’ paper in 2011 seemed while Brazil would be able to deal more easily with this to say that if the six “oncho countries”27 in the Ameri- matter (than Venezuela), that has not happened at the cas can achieve so much, in this and or that manner, in political level, said Richards. such and such time, the people of Africa (and Uganda in particular) can also achieve that much, and even more, These circumstances in many ways correspond to is- to make life better for onchocerciasis victims and those sues of cross border nature that Ukety was mandated to at risk of being made miserable by it. report on in the context of East and Central Africa as Richards told his hearers. This calls to mind cross border There were aspects of his presentation that were vivid issues, real or suspected, between Uganda and DRC, or reflections of the workings and challenges of Africa’s between Uganda and the Republic of Southern Sudan, decades-old oncho onslaught. The implications (for Af- and the DRC-Uganda and South Sudan-Uganda borders rica) of some of these aspects were apparently recog- where anti-onchocerciasis efforts are hugely undevel- nized well by UOEEAC (2011) and its guests. OEPA’s oped or largely uncoordinated where they exist – issues Program Coordinating Committee (the PCC), is one and borders that always find their way in UOEEAC’s such feature – a feature that is comparable to Uganda’s annual agenda. UOEEAC.

With all due reference and attention to relevant treatment and other data28 as well as a WHO document (Certifica- tion of Elimination of Human Onchocerciasis: Criteria and Procedures), the PCC has been making to different governments (Colombian, Ecuadorian, Venezuelan,

Brazilian, Guatemalan and Mexican) recommendations 30 29 Four of the six countries that got treatments since about on government onchocerciasis programs where sto- 1987, it is reported, have stopped Mectizan treatments. Brazil ries of complete or partial success have been registered and Venezuela are the only two still giving treatments, but in terms of achieved elimination of the disease, interrup- their progress has been described as poor. tion of its transmission, its suppression, and even where 31 The news of the finding of these people and of one case there is ongoing drug administration to control or elimi- among them that suffered badly from a strain of savannah onchocerciasis that came from Africa, got into the middle of the Amazon and now affects “American Indians”, did in fact 26 The reader, to achieve optimal gain, does in fact have to attract much attention of the 2011 UOEEAC meeting. look beyond the skeletal text above of Richard’s presenta- 32 Aircraft has actually been used to look for and take to tion: He or she must watch the video recording of it. the Indians of the densely forested area essential Mectizan 27 Namely Brazil, Colombia, Mexico, Guatemala, Venezuela treatment, and in this we have a situation corresponding to and Ecuador. the Africa onchocerciasis helicopter project of the past that

28 Which is seriously reviewed. helped to decimate or reduce the disease in some places on 29 E.g. when to stop onchocerciasis Mectizan treatments. the continent.

Insight Special 2011 4th Session, 15-17 August 2011 40

Challenges facing the Ugandan onchocerciasis elimination program

NGDO Coordination Group For ChallengesChallenges facing thefacing Ugandan the Ugandan Onchocerciasis Control onchocerciasisonchocerciasis elimination elimination program programme

Tony Ukety Ituri-North CDTI Project

Ituri-South

Highlights Beni-Butembo CDTI Project

Goma-Rutshuru CDTI Project • Membership of the Group. • New development of the Group. • Challenges facing the Ugandan onchocerciasis elimination program. Kinshasa • The way forward.

Membership of the Group 1) Charitable Society for Social Welfare; 2) Christoffel BlindenMission e.V. (CBM); PBD: Prevention of Blindness and Deafness 3) Helen Keller International (HKI); 6 4) IMA Global Health (IMA);

5) Light for the World; The Way Forward 6) Lions Clubs International Foundation (LCIF); • CBM: Appointment of an NTD Program Officer 7) Mectizan® Donation Program (MDP); Thein Kinshasa.Way Forward 8) Mission to Save the Helpless (MITO SATH); • •Sightsavers CBM: Appointment – UFAR of an NTD partnership Program Officer toin Kinshasa. support 2 CDTI 9) Organisation pour la Prévention de la Cécité (OPC) ; •projects Sightsavers (Lubutu – UFAR partnership & Ituri-Nord). to support 2 CDTI projects (Lubutu & Ituri-Nord). • Possibility of launching Ituri-Sud CDTI project 10) Schistosomiasis Control Initiative (SCI);  11) Sightsavers International (SSI); with Possibility APOC of launching support Ituri-Sud in 2012. CDTI project with APOC support in 2012. 12) The Carter Center; 13) United Front against River blindness (UFAR); 1 14) US Fund for UNICEF; and 15) Malaria Consortium.

New development of the Group • Launching of the NTD NGDO Network in September 2009. • Membership: – NGDO Group for Onchocerciasis Control. – International Coalition for Trachoma Control (ICTC). – LF NGDO Network. • First session: 21 – 23 September 2010 in Atlanta, USA (Task Force for Global Health). • Second session: 20 – 22 September 2011 in Nairobi, Kenya (CBM). aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa Challenges of interested DRC CDTI projects. 33 Ukety’s Review of “Coalition Group” • Lack of NGDO Support in Ituri-Nord, Beni- Members were reminded33 that the NGDO Coalition for Butembo and Goma-Rutshuru CDTI projects. Ukety’sOnchocerciasis Review of “Coalition Control Group” is a consortium of non-govern- • Political unrest in Goma-Rutshuru CDTI Membersmental were organizations. reminded that the NGDO At Coalition the onset, for Onchocerciasis these were: Control is some a project area. consortiumanti-onchocerciasis of non-governmental groups, organizations. some At the that onset, were these were: member some anti- in- • Delay in launching onchocerciasis control in Ituri. onchocerciasisstitutions groups, of the some International that were member institutions Coalition of the for International Trachoma, Coalition for and some organizations whose business it was to combat lymphatic filariasis. The hope, that time, was that this 33coalition Besides Ukety’s would brief presentation promote above and thewhat isfight reported here,of theonchocerciasis. reader is advised to listen to the presenter’sAs suggested live video camera by-recorded its name, delivery of thehis update coalition where we find (NGDO some detail that is not present in the summary. His original sketch, in the video record, gets expanded as he presents.

33 Besides Ukety’s brief presentation above and what is reported here, the reader is advised to listen to the presenter’s live video camera-recorded delivery of his update where we find some detail that is not present in the summary. His original sketch, in the video record, gets expanded as he presents. Insight Special 2011 4th Session, 15-17 August 2011 41 Coalition for Onchocerciasis Control) has started fruit- co-implementation, and the shift from control to elimi- ing as examples from DRC demonstrate. A substantive nation 35. officer for Kinshasa is in place, and has been in this appointment for a while. Plans that are potentially bright JAF requested APOC to work closely with its statutory are unfolding, for example, for Lubutu and Ituri-Nord. bodies (CSA and TCC) to make a proposal based on estimated cost and priority of each of the different recom- There is this other pleasant aspect: There is great hope mendations to be presented to JAF 17 in 2011. that serious implementation of strong CDTI projects, from Goma Rutshuru (in the south) to Ituri-Nord (in The Committee of Sponsoring Agencies (CSA) the north) along DRC’s eastern board, which is now in • Elaborate TORs for 3 advisory groups: plan, will significantly help Uganda to find solutions to • Future of APOC (advisory group). its known and still unknown onchocerciasis cross border • Co-implementation (advisory group). problems – those which are real, suspected or potential. • Elimination of onchocerciasis infection and But there is also this worrying reality: Despite the exis- interruption of its transmission tence of the oncho NGDO coalition, a good many CDTI (advisory group). projects in the DRC are described as not having NGDO • Nominated members of each advisory group. partners, as generally being weak as a consequence 34. Implementation of CSA decision on advisory groups African Program for Onchocerciasis Control Noma Mounkaila First meeting of the Advisory Groups Ouagadougou, 16-18 May 2011

Face to face meeting of CSA Advisory Group on Co-Implementation Amsterdam, 4-5 June 2011

Face to face meeting of CSA Advisory Group on the Future of APOC Accra, June 16-17, 2011 Face to face meeting of CSA Advisory Group on Elimination Geneva, June 21-23, 2011

Reports from the advisory groups to CSA Paris, 19-21 July 2011 CSA advisory meeting and presentation to TCC Ouagadougou, 12-16 September 2011

Elimination of Onchocerciasis of Onchocerciasis infection and interruption infection of transmission andin Africa inter - ruptionwhere feasible of transmission in Africa where feasible

• •Elaboration Elaboration and adoption and adoptionof the Guidelines of on treatmentthe Guidelines coverage and on treatmentepidemiological coverage evaluation protocol and (1-3 epidemiological March 2011, Ouagadougou, Burkina Faso) • evaluationElaboration and adoptionprotocol of the entomological(1-3 March evaluation 2011, protocol 28-30 March 2011, Ouagadougou,Ouagadougou, Burkina Faso)Burkina Faso) • •Elaboration 2011 Epidemiological and evaluation adoption of the entomological evaluation– Concluded: protocol Central African 28-30 Republic, March CAR (Basse 2011, Kotto), Ethiopia (Keffa Ouagadougou,Shekka, Bench MajiBurkina and North Faso) Gondar), Cameroon (Centre 1 and Littoral 2) • 2011– EpidemiologicalOngoing: Malawi (Malawi extension evaluation and extension), Congo – Concluded: Central African Republic, CAR – To be completed: Cameroon (1 project), Nigeria (4 projects) and Tanzania (2 (Basse Kotto), Ethiopia (Keffa Shekka, Bench projects) Maji and North Gondar), Cameroon (Centre 1 • 2011 Entomological evaluations in Cameroon, Chad, Nigeria, Uganda and Tanzania. and Littoral 2) – Ongoing: Malawi (Malawi extension and Epidemiological extension), evaluation Congo sites in 2009 – 2011 – To be completed: Cameroon (1 project), Nigeria Follow Up of JAF 16 (2010) decisions (4 projects) and Tanzania (2 projects) • 2011 Entomological evaluations in Cameroon, Following a decision of JAF 16 (year 2010), an evalua- Chad, Nigeria, Uganda and Tanzania. tion of the APOC program took place between July and September 2010.

The objectives were to evaluate: establishment of country led CDTI systems, strengthening of health systems,

34 The September 20-22 (2012) NTD NGDO Network forum that convened in Nairobi, Kenya: Habomugisha has made a report, which has a section on the NGDO Coalition for Onchocerciasis (as a member 35 See Report of the External Mid-term Evaluation of the African of the network and also as an organization that was represented and Program for Onchocerciasis Control. discussed at the 2nd session. The report is being printed.

Insight Special 2011 4th Session, 15-17 August 2011 42

Evaluation indicators and targets First meeting of the Advisory Groups Ouagadougou, 16-18 May 2011

Face to face meeting of CSA Advisory Group on Co-Implementation Amsterdam, 4-5 June 2011

Face to face meeting of CSA Advisory Group on the Future of APOC Accra, June 16-17, 2011 Face to face meeting of CSA Advisory Group on Elimination Geneva, June 21-23, 2011

Reports from the advisory groups to CSA Paris, 19-21 July 2011 CSA advisory meeting and presentation to TCC Ouagadougou, 12-16 September 2011

Elimination of Onchocerciasis infection and interruption of transmission in Africa where feasible

• Elaboration and adoption of the Guidelines on treatment coverage and epidemiological evaluation protocol (1-3 March 2011, Ouagadougou, Burkina Faso) • Elaboration and adoption of the entomological evaluation protocol 28-30 March 2011, Ouagadougou, Burkina Faso) • 2011 Epidemiological evaluation – Concluded: Central African Republic, CAR (Basse Kotto), Ethiopia (Keffa Shekka, Bench Maji and North Gondar), Cameroon (Centre 1 and Littoral 2) – Ongoing: Malawi (Malawi extension and extension), Congo – To be completed: Cameroon (1 project), Nigeria (4 projects) and Tanzania (2 projects) • 2011 Entomological evaluations in Cameroon, Chad, Nigeria, Uganda and Tanzania. Strengthening CDTI/CDI implementation Epidemiological evaluation evaluationsites in 2009 – 2011 sites in 2009 – 2011 • CDTI/CDI training workshops carried out for all levels in 4 countries: Burundi (52 people), Liberia (48), Tanzania (116), DRC (78). • Enhance onchocerciasis control in Taraba State, Nigeria. • Completion of the mapping of LF and schisto in DRC (Katanga and Kasai). • National plans to complete mapping of LF, schisto, STH, trachoma received from 6 countries (Nigeria, Cameroon, Chad, Congo, Kenya, CAR), to be co-financed by APOC, ongoing. • Enhance management of SAEs. – APOC and MDP financial, logistic and Evaluation Indicators and targets technical support to DRC. – technical advisor for Angola. Phase Evaluation objective Indicator Target 1 a. Assess decline towards Prevalence of mf ≤ predicted prevalence • Manual and handbook for integration in the curriculum of universities, medical and nursing elimination breakpoint b. Confirm that breakpoint Prevalence of mf < 5% in all villages schools. has been reached and Rx < 1% in 90% of villages • Monitoring of treatment coverage, assessment can be stopped Vector inf.rate < 0.5 infective fly / 1000 and work plan for reaching 20 million people Evaluation indicators and targets not yet covered by ivermectin treatment.

Phase2 Confirm Evaluation there objective is no InPrevalencedicator of mf TargetNo increase • Ivermectin biannual treatment in the context 1 a. Assessrecrudescence decline towards of Prevalence of mf ≤ predicted prevalence of elimination of onchocerciasis infection and Phase elimination Evaluation breakpoint objective Indicator Target 1 b.a. Confirminfection/transmissionAssess that decline breakpoint towards PrevalenceVector Prevalenceinf .ofrate mf of< <5%mf 0.5 in infective all villages≤ predictedfly / 1000 prevalence interruption of its transmission (protocol to haselimination been reached breakpoint and Rx < 1% in 90% of villages 3 b. canDetectConfirm be stoppedpossible that breakpointVectorPrevalence infPrevalence.rate of of< <0.5mf 1% infective in all villages< fly 5% / 1000 in all villages be reviewed by APOC/TCC). recrudescencehas been reached of and infectionRx < 1% in 90% of villages 2 Confirmcan be there stopped is no PrevalenceVector of mf inf.rateNo increase < 0.5 infective fly / 1000 recrudescenceinfection/transmission of Vector inf.rate < 0.5 infective fly / 1000 Collaboration for monitoring and evaluation of on- 2 infection/transmissionConfirm there is no Vector infPrevalence.rate of< 0.5mf infectiveNo fly increase/ 1000 3 Detectrecrudescence possible of Prevalence of < 1% in all villages chocerciasis recrudescenceinfection/transmission of infection Vector inf.rate < 0.5 infective fly / 1000 Results3 ofinfection/transmission epidemiologicalDetect of possibleepidemiological evaluations Vector in 2009 infPrevalence. rate– 2011evaluations of< 0.5 infective

recrudescence of infection • Trap for catching onchocerciasis vector. – 2011infection/transmission Vector inf.rate < 0.5 infective fly / 1000 Results of epidemiological evaluations in 2009 – 2011 • PATH new diagnostic tools.

Results of epidemiological evaluations in 2009 – 2011 • DOLF integrated interventions for onchocerciasis and LF mapping WHO/TDR, DEC Patch test.

Mounkaila’s APOC Update His news update was one of the updates that enthused the meeting. Several questions were asked and some comments were made as shown by samples hereunder.

The plausibility of APOC’s plan to wind up its mandate in 2015, which however is now talking of its constituen- cies going from control to elimination of onchocercia-

sis in the context of integrated administration of drugs Results of epidemiological evaluations in 2009 – 2011 for different diseases,36 was questioned by a commit- Results of epidemiological evaluations in 2009 Conclusion of evaluation Number of sites tee member. She also wondered if the talk meant that – 2011 ResultsElimination of probablyepidemiological already achieved evaluations in 2009 –9 2011 APOC’s term of life was about to be extended or that Conclusion of evaluation Number of sites Close to elimination 5 the elimination project would be left halfway as APOC closes in 2015. Here is partly why. The proposed date is EliminationOn track, but still probably some years already to go achieved 6 9 not only too near. Many of the APOC supported coun- Close to elimination 5 tries, too, still have some way to go to kill onchocercia- Total with satisfactory progress 20 On track, but still some years to go 6 sis, an example being northern Uganda districts where Results of epidemiological evaluations in 2009 – 2011 Strengthening CDTI/CDI implementation the effort to control and eliminate onchocerciasis is only TotalConclusion• CDTI/CDIwith of satisfactory evaluation training workshops progress carried out for all levelsNumber in 4 countries: of20 sites Burundi (52 beginning in earnest now after the end there of the rebel- people), Liberia (48), Tanzania (116), DRC (78). lion that had made living and working there extremely Strengthening• Enhance onchocerciasis CDTI/CDI control implementation in Taraba State, Nigeria. Elimination•• CompletionCDTI/CDI probably of thetraining already mapping achievedworkshops of LF and schisto carried in DRCout for 9(Katanga all levels and Kasai). in 4 countries: Burundi (52 • National plans to complete mapping of LF, schisto, STH, trachoma received from 6 people), Liberia (48), Tanzania (116), DRC (78). 36 On the matters of transition from control to elimination and co-im- Close• tocountries Enhanceelimination (Nigeria, onchocerciasis Cameroon, Chad,control Congo, in Taraba Kenya, CAR),State,5 toNigeria. be co-financed by plementation of medicine interventions, different African governments, • APOC,Completion ongoing. of the mapping of LF and schisto in DRC (Katanga and Kasai). their MOHs, certain NGDO and other partners and APOC were said to • National plans to complete mapping of LF, schisto, STH, trachoma received from 6 be in contact to chart the way forward. On track,countries but still some (Nigeria, years Cameroon,to go Chad, Congo,6 Kenya, CAR), to be co-financed by APOC, ongoing.Insight Special 2011 4th Session, 15-17 August 2011 43 Total with satisfactory progress 20

Strengthening CDTI/CDI implementation • CDTI/CDI training workshops carried out for all levels in 4 countries: Burundi (52 people), Liberia (48), Tanzania (116), DRC (78). • Enhance onchocerciasis control in Taraba State, Nigeria. • Completion of the mapping of LF and schisto in DRC (Katanga and Kasai). • National plans to complete mapping of LF, schisto, STH, trachoma received from 6 countries (Nigeria, Cameroon, Chad, Congo, Kenya, CAR), to be co-financed by APOC, ongoing.

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NTD Control Program/RTI Ambrose W. Onapa & Harriet Namwanje

Background on NTDs in Uganda • NTDs are diseases that affect poor rural and some urban communities in 3rd world countries. difficult. The reply was heard that when 2015 comes, Ulcer Disease (BUD); Plague; and Guinea worm (al- and time is over for APOC, its governing body (JAF)Group though 1: Difficult the to lasttreat, onerequire has management been eradicated). in hospitals and the Committee of Sponsoring Agencies will consid- Sleeping Sickness or Human African Trypanosomiasis; Kala-Azar or Leishmaniasis; er its future – this being why we may say that that future BuruliGroup Ulcer 2: Disease Amenable (BUD); Plague;to Mass and GuineaTreatment worm (although (MDA) the last one has been is mainly an issue to be settled by JAF. eradicated).- Lymphatic Filariasis (LF); River Blindness or On- chocerciasis; Bilharzia (Schistosomiasis); Intestinal Sometime back, noted a committee member, APOC’sGroup worms 2: Amenable (Soil to MassTransmitted Treatment (MDA) Helminthes); and Trachoma. Technical Consultative Committee, TCC, did consider Lymphatic Filariasis (LF); River Blindness or Onchocerciasis; Bilharzia and discuss the idea of national laboratories (for the on- (Schistosomiasis)New candidates:; Intestinal cysticercosis, worms (Soil Transmitted plague, Helminthes); tungiasis, and rabies,Trachoma. cho program) and support for them, an idea that has how- etc. ever not been heard of by the questioner ever since. With New candidates: cysticercosis, plague, tungiasis, rabies, etc. most affected African countries transiting from control NTD Overlap in the Country to elimination, noted Mounkaila, each such country,NTD Overlap in the Country ideally, should have: (1) an epidemiological evaluation team, (2) an entomological evaluation one, and (3) a relevant laboratory to examine and assess onchocerciasis associated samples. The idea, said Mounkaila, was in progress although there was no proper budget for it until 2011: still being worked on as regards most of the countries; in others, where already there are necessary facilities (Uganda, Cameroon and Nigeria), there is collaboration (on analysis of oncho-related samples) with the MDSC laboratory in Ouagadougou Burkina Faso.

NTD Control Program/Rti Ambrose W. Onapa & Harriet Namwanje

- Incentives: demand for incen- Magnitude of NTDstives in Uganda by all has reached crescendo levels.

- Districts have their own ways of doing things! BIGGEST CHALLENGE.

Magnitude of NTDs in Uganda

NTD Total endemic Population at risk Estimated infected districts (80) (in millions)** population (in millions)**

Lymphatic Filariasis 56 16.0 4.8 Namwanje represented Ambrose Onapa Onchocerciasis 36 4.4 1.5 Schistosomiasis 67 5.2 4.0 Background on NTDs in Uganda STH 112 33.2 11.0 Trachoma 35 10.8 0.7 • NTDs are diseases that affect poor rural and some ur- NB: ** At risk figures subject to change Staggering of packages during MDA ban communities in 3rd world countries. NB: ** At risk figures subject to change

Group 1: Difficult to treat, require management in hospitals - Sleeping Sickness or Human African Try- panosomiasis; Kala-Azar or Leishmaniasis; Buruli Insight Special 2011 4th Session, 15-17 August 2011 44

Key: Diseases: LF = Lymphatic Filariasis; STH = Soil Transmitted Helminths; Schisto = Schistosomiasis; Oncho = Onchocerciasis; Trachoma Drugs: IVM = Ivermectin; ALB = Albendazole; PZQ = Praziquantel; AZ = Azithromycin

Achievements registered  Capacity building at all levels - national, district, HSD, schools, etc.  Training manuals, guides, communication strategy, IEC materials developed.  Trachoma baseline surveys completed in all highly endemic districts.  Scaled up PCT to all districts, except newly mapped trachoma districts.  Extensively supported de-worming in districts during CDP.  Support to MOH programs - equipment, communications and logistics.  Impact assessments in progress especially in LF districts – some near cut off points (1%) e.g. parts of Adjumani, Moyo.  All partners have agreed to harmonise support to districts and implementation – NTDCP, TCC, SSI, APOC /NOCP.

Challenges faced in NTD implementation  Delayed and inaccurate drug deliveries to districts by NMS – in some cases by more than 6 months.  Data reporting (reliability, accuracy, and compilation) is a big problem. NTD Total endemic Population at risk Estimated infected districts (80) (in millions)** population (in millions)**

Lymphatic Filariasis 56 16.0 4.8 Onchocerciasis 36 4.4 1.5 Schistosomiasis 67 5.2 4.0 STH 112 33.2 11.0 Trachoma 35 10.8 0.7 NTDS Review Re-Visited StaggeringNB: ** At risk figures subject of to change packages Staggering of packages during during MDA MDA Namwanje, while she had the floor, would (here and there) give important information additional to what is contained above in the sketch.37 NTDs, which are diseases suffered by the poorest of the poor, said the presenter, have tended to be neglected at all levels (national and international included), so much so that even persons suffering from them tended to ignore them. She outlined the nature and extent of these diseases, including but not limited to estimated numbers of affected people. For example she said this of onchocerciasis: i.e. that the disease is endemic in 36 districts; that people

Key: Diseases: LF = Lymphatic Filariasis; STH = Soil Transmitted Helminths; Schisto = Schistosomiasis; Oncho = Key:Onchocerciasis; Diseases: Trachoma LF = Drugs Lymphatic: IVM = Ivermectin; Filariasis; ALB STH = Albendazole; = Soil Transmitted PZQ = Praziquantel; Helminths; AZ = Azithromyci Schiston = Schistoso- at the risk of being infected with onchocerciasis are 4.4 miasis; Oncho = Onchocerciasis; Trachoma Drugs: IVM = Ivermectin; ALB = Albendazole; PZQ = Praziquantel;Achievements AZ = registeredAzithromycin million across Uganda; and that 1.5 million people are  Capacity building at all levels - national, district, HSD, schools, etc. already infected by this disease.  Training manuals, guides, communication strategy, IEC materials developed. Achievements Trachoma baseline surveys registered completed in all highly endemic districts.  Scaled up PCT to all districts, except newly mapped trachoma districts. • Capacity Extensively supported building de-worming at all in districts levels during - CDP.national, district, NTDs in Uganda, noted Namwanje, have been integrat- HSD, Support schools,to MOH programs etc. - equipment, communications and logistics. ed for two reasons: (i) in order to minimize on treatment  Impact assessments in progress especially in LF districts – some near cut off points • Training(1%) e.g. parts manuals, of Adjumani, Moyo. guides, communication strategy, and associated costs; and (ii) to reduce duplication of  All partners have agreed to harmonise support to districts and implementation – IECNTDCP, materials TCC, SSI, APOC developed. /NOCP. treatment activities. She named the many challenges that face the NTDs program, one of these being the nil or lit- • TrachomaChallenges faced inbaseline NTD implementation surveys completed in all highly endemic Delayed and inaccuratedistricts. drug deliveries to districts by NMS – in some cases by more tle training of community medicine distributors (CMDs) than 6 months. 38 • Scaled Data reportin upg (PCTreliability, to accuracy, all districts, and compilation) except is a big problem. newly mapped also known as community drug distributors (CDDs). trachoma districts. • Extensively supported de-worming in districts One more example of the noted challenges was that the during CDP. data that the national NTDCP headquarter offices re- • Support to MOH programs - equipment, ceive from upcountry treatment communities are usu- communications and logistics. ally: incomplete and inaccurate, with the way in which • Impact assessments in progress especially in they are compiled being bigly problematic. The cause LF districts – some near cut off points (1%) of all this data reporting trouble was given as the insuf- e.g. parts of Adjumani, Moyo. ficient or no training given to the CMDs, who (unlike • All partners have agreed to harmonise support district level officials) have never trained in the use of, to districts and implementation nor used, integrated data collection tools that many see –NTDCP, TCC, SSI, APOC /NOCP. for the first time when national supervisors from Kam- pala go into oncho villages. Challenges faced in NTD implementation • Delayed and inaccurate drug deliveries to districts Another of the challenges, which does not appear in the by NMS – in some cases by more than 6 months. rough draft above said Namwanje, rises from Uganda • Data reporting (reliability, accuracy, and Ministry of Health’s new policy of VHTs as the essential compilation) is a big problem. connector between communities and the country’s heath • Drug combinations: some CMDs give cocktails system. “The arrangement,” says Mbulamberi early in not approved, leading to adverse events. this document, “is that these VHTs should comprise • Incentives: demand for incentives by all people who have acted as community medicine distribu- has reached crescendo levels. tors such as those who have participated in the distri- • Lack of morbidity control and disability bution of HOMAPAK in the case of malaria. Actually management is a big concern. preference is given to people of such background.”39  Drug combinations:• someDistricts CMDs have give theircocktails own not ways approved, of doing leading things! to adverse The noble thought that priority would be given to the  events. Drug combinations: BIGGEST some CHALLENGE. CMDs give cocktails not approved, leading to adverseold crop of CMDs as the source from which would be  Incentives:events. demand for incentives by all has reached crescendo levels.  Drug combinations: some CMDs give cocktails not approved, leading to adversechosen CMDs for VHT membership has however fallen   Incentives: demand for incentives by all has reached crescendo levels. Lack of morbidityevents. control and disability management is a big concern.  Lack ofAcknowledgements morbidity control and disability management is a big concern. on rock in some districts. Community leaders, in such  Districts have their Incentives: own ways demand of doing for things!incentives BIGGEST by all has CHALLENGE. reached crescendo levels.  DistrictsThe have following their own ways agencies of doing and things! partners BIGGEST are acknowledged: CHALLENGE. places, have selected entirely different new people who  Lack of morbidity control and disability management is a big concern. have not previously been involved in drug distribution. Acknowledgements  WHO;Districts Pharmaceuticalhave their own ways ofGroups: doing things! BIGGEST CHALLENGE. The followingAcknowledgements agencies andMerck partners & Co.are acknowledged: Inc. for Mectizan WHO; Pharmaceuticaldonation through Groups: MDP, Merck & Co.The Inc. following forAcknowledgements Mectizan GlaxoSmithKlineagencies donation and partners through are forMDP, acknowledged: Albendazole,GlaxoSmithKline WHO; Pharmaceutical for CWW/Johnson Albendazole, Groups: ® CWW/JohnsonMerck and &The Co.Johnson following Inc. forfor MectizanagenciesMebendazole, and donation partners Pfizzer through are for acknowledged: Zithromax MDP, GlaxoSmithKline WHO;through Pharmaceutical ITI; RTI for Albendazole,/ Groups: 37 It is very important therefore that the reader see the video record and Johnson for Mebendazole, Pfizzer for ®Zithromax® USAID forCWW/Johnson PZQ andMerck ALB; & and Co.and Johnson Inc.NGDO for Mectizanfor partners: Mebendazole, donation TCC; Sightsavers; through Pfizzer MDP, for SCIZithromax GlaxoSmithKline (UK). through for ITI; Albendazole, RTI / of that presentation. through ITI; RTI / USAID for PZQ and ALB; and® NGDO 38 She actually described them as either untrained or as having trained USAID forCWW/Johnson PZQ and ALB; and Johnson and NGDO for Mebendazole, partners: TCC; Pfizzer Sightsavers; for Zithromax SCI (UK).through ITI; RTI / USAIDpartners: for PZQ and TCC; ALB; Sightsavers;and NGDO partners: SCI TCC; (UK). Sightsavers; SCI (UK). only once. That is apparently true of the experiences of Uganda’s Ne- glected Tropical Disease(s) Control Program, NTDCP, which has had the support of USAID and RTI. The presenter’s statements of “not

much training or no training at all” do not, however, reflect the general experience of The Carter Center Uganda (for years at the forefront of

the against-onchocerciasis campaign), which always makes effort to have its CDDs (CMDs) trained. aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa 39 Mbulamberi, D.B. (2011). “Welcome Notes” in Proceedings of the aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa Fourth Session of Uganda Onchocerciasis Elimination Expert Advisory aaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaaa Committee, UOEEAC, 15-17 August. Check in the introductory pages NTDs Review Revisited Namwanje,NTDs while Review sheNTDs had ReviewRevisited the floor, Revisited wouldInsight (here andSpecial there) give2011 important 4th Session, information 15-17 August 2011 45 additional Namwanje,to what isNamwanje, contained while she while above had she the in had floor,the the sketch. floor,would37 would (hereNTDs, (here and which there)and there)are give diseases give important important suffered information information by 37 37 the poorestadditional of the poor,additional to whatsaid totheis whatcontained presenter, is contained above have above tendedin the in sketch. tothe be sketch. neglected NTDs, NTDs, atwhich all which levels are are diseases (national diseases suffered suffered by by and internationalthe poorest included),the ofpoorest the poor,so of much the said poor, so the thatsaid presenter, eventhe presenter, persons have havesufferingtended tended to frombe to neglectedbe them neglected tended at atall allto levels levels (national (national and international included), so much so that even persons suffering from them tended to ignore them.and She international outlined the included), nature and so muchextent so of thatthese even diseases, persons including suffering but from not themlimited tended to to ignore them.ignore She them. outlined She outlined the nature the nature and extent and extent of these of these diseases, diseases, including including but but not not limited limited toto estimated numbersestimated of affected numbers people. of Foraffected example people. she For said example this of she onchocerciasis: said this of onchocerciasis: i.e. that i.e. that the diseaseestimated is endemicthe numbers disease in 36 districts; isof endemic affected that in people. 36people districts; For at the examplethat risk people of shebeing at saidthe infected risk this of of being withonchocerciasis: infected with i.e. that onchocerciasisthe disease are onchocerciasis4.4 is million endemic across arein 364.4 Uganda; districts; million andacross that that people Uganda; 1.5 million at and the that risk people 1.5 of millionbeing are already infected people infected are with already infected by this disease.onchocerciasis by this aredisease. 4.4 million across Uganda; and that 1.5 million people are already infected by this disease. NTDs in Uganda, notedNTDs Namwanje,in Uganda, noted have Namwanje, been integrated have been for twointegrated reasons: for (i)two in reasons: order to (i) in order to minimize onNTDs treatment inminimize Uganda, and associated onnoted treatment Namwanje, costs; and associated and have (ii) beento costs; reduce integrated and duplication (ii) to for reduce two of duplicationreasons: treatment (i) of in treatment order to activities. minimizeShe namedactivities. on the treatment many She challengesnamed and associated the many that facechallenges costs; the and NTDs that (ii) faceprogram,to reduce the NTDs oneduplication program, of these ofonebeing treatment of these being the nil or little training of community medicine distributors (CMDs) also known as the nil or littleactivities. training She of named community the many medicine challenges distributors that38 face (CMDs) the NTDs also program, known as one of these being community drug distributors38 (CDDs). communitythe drug nil ordistributors little training (CDDs). of community medicine distributors (CMDs) also known as community drug distributors (CDDs).38 One more example of the noted challenges was that the data that the national NTDCP One more exampleheadquarter of the noted offices challenges receive was from that upcountry the data treatment that the communities national NTDCP are usually: incomplete headquarterOne offices moreand receive example inaccurate, from of the withupcountry noted the way challenges treatment in which wastheycommunities thatare compiled the data are beingthatusually: the bigly national incomplete problematic. NTDCP The cause and inaccurate,headquarter withof theall offices thisway data in receive whichreporting from they trouble upcountryare compiled was given treatment being as the bigly insufficientcommunities problematic. or noare training usually: The cause given incomplete to the of all this dataand inaccurate,reportingCMDs, trouble withwho (unlikethe was way given district in which as level the they officials)insufficient are compiled have or never no beingtraining trained bigly ingiven the problematic. useto theof, nor used, The cause CMDs, whoof all(unlike thisintegrated datadistrict reporting leveldata collection officials) trouble toolswas have giventhat never many as trained the see insufficient for in the the first use timeor of, no norwhen training used, national given supervisors to the integrated CMDs,data collection whofrom (unlike Kampala tools district that go intomany level oncho see officials) villages.for the first have time never when trained national in the supervisors use of, nor used, from Kampalaintegrated go into data oncho collection villages. tools that many see for the first time when national supervisors from Kampala go into oncho villages.

37 It is very important therefore that the reader see the video record of that presentation. 38 She actually described them as either untrained or as having trained only once. That is apparently true of the experiences 37 It is very important therefore of Uganda’s that theNeglected reader Trosee pical the video Disease(s) record Control of that Program, presentation. NTDCP, which has had the support of USAID and RTI. The 38 She actually37 describedIt is very presenter’simportantthem as either statementstherefore untrained thatof “not theor muchasreader having training see trained the or video no only training record once. at of all”That that do is not,presentation. apparently however, true reflect of the generalexperiences experience of The of Uganda’s Neglected38 TroCarterpical Center Disease(s) Uganda Control (for years Program, at the forefront NTDCP, of whichthe against-onchocerciasis has had the support campaign), of USAID which and alwaysRTI. The makes effort to have She actuallyits CDDs described (CMDs) them trained. as either untrained or as having trained only once. That is apparently true of the experiences presenter’s statementsof Uganda’s of “not Neglected much trainingTropical or Disease(s) no training Control at all” Program,do not, however, NTDCP, reflect which the has general had the experience support of of USAID The and RTI. The Carter Centerpresenter’s Uganda (for statements years at the of forefront“not much of training the against-onchocerciasis or no training at all” campaign), do not, however, which alwaysreflect themakes general effort experience to have of The its CDDs (CMDs)Carter trained. Center Uganda (for years at the forefront of the against-onchocerciasis campaign), which always makes effort to have its CDDs (CMDs) trained. This has frustrated many seasoned CMDs to the extent that they have decided to hand in their books of records, PART E - OTHER ISSUES resigned and turned to other activities.

This is another of the challenges that were tabulated Using Standard Format for Coverage Data and discussed in some good detail by the presenter: the It came to the attention of the UOEEAC meeting of ever rising demand for financial incentives by almost 2011 “that the presenters utilized different formats for every party taking part in medicine administration. In presenting coverage data, something that was confus- some districts, where there were say twelve onchocer- ing to the committee”, records the Unnasch-UOEEAC ciasis CMDs, these people, noted Namwanje, declined source. “A standardized format for the presentation of to do treatment, with the consequence that community coverage data,” the committee recommended, “would be supervisors would step in to treat the entire communi- useful”. And then this: “For elimination to be achieved,” ty. Similarly in parishes where CMDs would opt not to following MOH guidelines (Unnasch-UOEEAC 2011), treat, again because of getting no pay for their partici- “every treatment round must reach geographic cover- pation, parish supervisors would sometimes distribute age of 100% and 95% of the eligible population. The the drugs, or import CMDs from another parish to do standardized format should be designed so that the data it. She also reported that training of teachers, in many presented can be easily examined in light of the MOH districts, as drug dispensers last happened in the year guidelines.” 2007 or 2008, the time when school children last got treatment. As teachers won’t treat, partly because there Foci Names is no incentive and partly because they have other time- The nearly never ending multiplication of the number of consuming school and other obligations, some CMDs districts in Uganda has, as the UOEEAC stated it, caused in some places, after treating in communities, do go to the names of some foci to undergo “some revisions”. schools to treat there as well. This being the case, “the committee recommended that the oncho flag be revised to include a column containing Many of those CMDs asking for incentives, in certain a unique identifier number that will remain associated areas, look back to a time when they would get Uganda with each focus even if the name is altered” (Unnasch- shillings 1000 or 2000 in appreciation of their services. UOEEAC 2011). Now that this is no more, they express their unwilling- ness to continue working for free. Misrepresenting Sub-foci Uganda onchocerciasis fieldworkers, the committee has There is also this case, the last one that we shall realized, tend “to split previously identified foci into review. It was reported by Namwanje that the area of sub-foci as mapping”. It was made clear that this prac- NTD drug combinations has become a challenge (and tice, which tends to attach special importance to each terrifying) in itself as this is openly flouted and abused such sub-focus, is not favored by the committee. With- by some CMDs, for a combination of reasons apparently. out doubt, “sub foci may be useful in informing opera- Clearly shown above are the authorized combinations of tional activities,” however, they “will not be recognized medicines – a policy that takes into account the physical as independent by the committee in its evaluations,” place where they are to be given out and the NTDs that members stated (Unnasch-UOEEAC 2011). are co-endemic in that area. Some CMDs in certain districts, however, she reported, do dish out unauthorized Onchocerciasis and Filariasis Coordination drug combinations, e.g. praziquantel with azithromycin, The two diseases (onchocerciasis and lymphatic filari- ivermectin with praziquantel;40 or azithromycin with asis, LF), and most especially in foci where they are ivermectin. The unapproved cocktails, generally, she co-endemic, said Mbulamberi during the initial stages said, tend unfortunately to unpleasantly affect the users of UOEEAC 2011, were one area where MOH Uganda of the combinations. wished to be seriously advised in the course of that meeting. This ministry, to be specific, “recommended that The speaker was thanked for openly and clearly stating the UOEEAC develop a method to strengthen coordina- the challenges and problems confronting the country’s tion of its activities with the filariasis control program” NTDCP – facts that until now tended to be muted. Nam- (Unnasch-UOEEAC 2011). See also Mbulamberi’s wel- wanje’s presentation led to important comments and come remarks in the introductory pages of this report questions, many of which are unambiguously or poten- to get a better picture of the background to this matter. tially controversial. Because of that we are not reporting On this issue, the committee was able to deliver in rec- here those reactions. We recommend that readers, if they ommendation terms. “The committee added a column to so wish, secure copies of the video recording of the pre- the oncho flag,” we report (Unnasch-UOEEAC 2011), sentation and watch and assess what they hear and see. “to indicate the status of filariasis endemicity in each focus, and requested the presence of a representative of the Ugandan filariasis control program to provide the UOEEAC with expert advice on the status of filariasis in each of the foci. ...the committee recommended that 40 Ivermectin and praziquantel combinations, it was noted by her, have been shown by certain studies to be safe - further stating, how- the MOH include a filariasis program representative as a ever, that it is not yet official policy in Uganda to treat with such com- regular observer to the UOEEAC to ensure coordination bination. of activities vis a vis intervention interruption.” Insight Special 2011 4th Session, 15-17 August 2011 46 VHTs and NTD Integration committee who by majority vote, and also through e- Three things were listed by Mbulamberi’s opening mail, shall pass or reject the suggested course of action speech as items on which Uganda’s Ministry of Health (Unnasch-UOEEAC). was keen to be advised. Above, we reported UOEEAC’s response on one, and now what the committee said about Getting Results Published the other two, i.e. “integration of onchocerciasis elimi- It was of utmost significance, the committee agreed, that nation into the Village Health Team (VHT) policy for peer reviewed journals publish data generated from the integrated neglected tropical disease (NTD) control”, onchocerciasis control and elimination efforts. “This which is a new approach that calls for a shift “from CDI will provide important documentation to the appropri- to VHT structure and integration with other NTD pro- ate committees that will eventually certify onchocer- grams” (Unnasch-UOEEAC 2011). ciasis elimination in Uganda,” the committee members concurred. They were in fact happy to hear that texts of “The committee noted that the VHT policy and the CDI results from the foci of Elgon, Itwara and Wadelai were approach that has been used for onchocerciasis control being organized for possible publication in the kind of and elimination,” the source says (Unnasch-UOEEAC high-end journals that we described above. 2011), “are in many ways similar. Challenges faced in harmonizing the operations of the two in NTD control UOEEAC, Debate, Minutes and Certification (and in particular CDTI) should be addressed at the pro- It was and remains the view of the committee that the grammatic level through education of the implement- preservation of its deliberations “may be important in- ers on the approaches taken by each and developing formation for the eventual certification process”. For an agreement on how to address the few differences that reason, rapporteurs shall be required to produce between them. Harmonization of operations should be a “detailed report of the minutes and conclusions and quickly achieved to ensure no interference with mass send this to the chair, who will circulate the report to the ivermectin treatment for onchocerciasis elimination.” committee for comments and revisions”, after which the The point of harmonization is apparently part of what committee approved report is to be distributed among Noma Mounkaila calls “strengthening CDTI/CDI” in persons invited for the UOEEAC 2102 assembly dur- the midst of co-implementation efforts with other drug ing which the members will revisit the document to ap- distribution endeavors. prove, disapprove, or amend its content and that kind of stuff. It was agreed that the approved report was to be PTS plans preserved “in digital and hard copy formats” (Unnasch- That there is “need for the development of PTS plans UOEEAC 2011). that are specific to areas in which all community-wide treatments have stopped”, as well as the creation of such plans for “foci where once per year treatment is ongoing due to co-endemicity of filariasis”, was recognized. PART F - CLOSURE These plans accordingly are to “be developed over the coming year” and will “undergo committee review at the Closing Remarks by retiring Chair 2012 meeting”, said the committee (Unnasch-UOEEAC J. Frank Walsh 2011). Mr Chairman, Colleagues, Inter-meeting Decisions Thank you for your kind remarks and good wishes on More or less, this is a rephrasing of a subject matter my retirement from the Chairmanship of UOEEAC – of UOEEAC 2010, i.e. “Inter-meeting action plan”.41 a committee that is increasingly becoming important. “Because the UOEEAC meets officially once per year,” Having missed the no doubt facetious comments at the committee members reasoned (Unnasch-UOEEAC), cocktail party the other evening, I am at a loss to know “it is possible that there may be delays for some foci how George Washington crept into the picture.42 I cer- where only a small amount of follow up data are needed tainly do not see any resemblance between George and to recommend transmission interruption. To overcome me, except perhaps that I have always thought of myself this problem, the UOEEAC recommended that such late as also being something of a rebel. Mention of George breaking results will be communicated to the commit- Washington reminded me of something I wrote for the tee chair.” Using email, the chairperson is to circulate ‘0-Now!’ conference in Leiden in 1990. Perhaps George the results (plus some recommended action) among the would have made a good vector/disease controller, if he had had the chance. Bear in mind that I was writing at the beginning of the modern era of the use of ivermectin 41 “The committee recommended that if there are important or urgent decisions to be made,” it was reported, “information can be sent to the successfully to suppress onchocerciasis and was speak- Chairman by an individual. The Chairman will then contact the commit- ing on behalf of vector controllers. tee members, and if they are in agreement, recommendations would be made to the government. For example, following this meeting such decisions may include changes in the status of Itwara and Imaramag- ambo foci. This proposed mechanism, whereby urgent decisions can be made without calling a special meeting or without waiting for the annual meeting, seeks to speed up committee activities.” See “Matters Arising” in: Uganda Onchocerciasis Elimination Expert Advisory Com- mittee.... A Report of the Third Meeting, August 10-12, 2010, p. 56. The 42 It was Unnasch who, during his cocktail party remarks on 16 August subhead “Inter-meeting action plan”, was however erroneously left out 2011, at Garden City, Kampala, referred to JF Walsh as the George there by the printer Washington of UOEEAC.

Insight Special 2011 4th Session, 15-17 August 2011 47 I slightly paraphrase my closing remarks to include all Anyway, thank you all for your help during my chair- controllers: “What is clear is that the fate of any control manship and for your kind remarks on my retirement. I scheme, and especially one aimed at elimination (which wish everyone success in the coming years in this vital is after all the most cost-effective type), depends on the task of onchocerciasis elimination. quality of the pre-control surveys and studies. The limit- ing factor is not funding but the availability of the right type of staff. Good controllers must be dedicated enthu- siasts, physically tough, keen on the ‘great outdoors’, Closing Statements from MOH Uganda competent field scientists and intelligent, but at the Dennis K.W. Lwamafa46 same time perhaps a little mad. In this environmentally deteriorating world, if one has such a combination of qualities, one might better aim at becoming President or Prime Minister.”43 So you see the earlier George Wash- ington probably made the wiser choice. [Note that the quoted paper contains some serious comments on the history of attempts to control onchocerciasis in Central and East Africa.]

I hope that I have helped, in a small way, to establish the committee, to ensure that it is a pleasure to attend and that it is fun to be involved in this great endeav- our. At the same time I have tried to insist that the deliberations and recommendations of the committee are taken seriously by all concerned, particularly the MoH. I feel that great progress has been and is being made, and indeed that we are working in exciting times. Not- withstanding the habitat changes which are occurring, the elimination of onchocerciasis from the Mount Elgon Focus is a tremendous achievement. I heartily congratu- late all those involved, from Thomson Lakwo and his team and Peace Habomugisha and her team, to the last It is my pleasure to officiate at the closing ceremony of Community Volunteer. When I reported directly to the this very important meeting. First and foremost, I would Minister of Health at the beginning of the modern era like to once again welcome all the invited guests to of onchocerciasis control/elimination, which followed a Uganda and to Kampala city in particular. WHO consultancy in 1991, I had the unenviable task of dampening hopes and reporting that I did not think I believe that over the last two days you have achieved elimination of onchocerciasis from Mount Elgon would a great deal in reviewing progress in elimination, mak- be possible. By 1996 Prof Rolf Garms, Lakwo and I re- ing important decisions and recommending important ported that ‘cost effect control, or even eradication of actions to be undertaken. All these will make a real dif- the northern sector of the focus may be feasible’. This ference in ensuring that the poor people of the voiceless still implied that elimination from the whole focus might and low income endemic communities may with time not be possible,44 but now our colleagues have done it. enjoy the fruit of onchocerciasis elimination in Uganda.

As we move into the Post Treatment Surveillance era The issues you have been discussing on elimination are it is fitting that a new Chairman, with his knowledge quite crucial. Achieving the various benchmarks set in of all the sophisticated laboratory methods for confirm- the guidelines to facilitate interruption of transmission ing the disappearance of the parasite and who not only requires a lot – not only on the side of the program, but chairs, but drafts out the recommendations and much of also on the side of all the stakeholders involved in on- the proceedings in real time, should take charge of the chocerciasis elimination. I am happy that significant committee. We have already reaped the benefits at this achievements have been made in some foci, and this meeting. needs to be preserved. I am quite convinced that the necessary surveillance network will be strengthened in These few remarks have largely been written since the these foci to allow elimination to be fully achieved. end of the meeting,45 as at that time I was in a bit of a daze and failed to offer coherent thanks. 46 Uganda MOH’s Commissioner for Health Services, Department of National Disease Control. He addressed the meeting on 17 August 2011. His speech started by recognizing the presence of the Represen- 43 Walsh, J.F. 1990. ‘Review of Vector Control Prior to the OCP’, Acta tative of the World Health Organization, Uganda, who sent Dr. Solomon Leidensia 59: Nos. 1 & 2. Proceedings of the Symposium on Onchocer- Fisseha to stand in for him; that of the Representative of the Director of ciasis, pp. 61-78. APOC; that of the Director of the Mectizan Donation Program, GA, USA; 44 Walsh, J.F., R. Garms & T. Lakwo. 1996. Planning of Focal Vector that of the Chairman of the Uganda Onchocerciasis Elimination Expert Eradication in Onchocerciasis Foci in Uganda. Special Programme for Advisory Committee; that of the Representative of The Carter Center, Research & Training in Tropical Diseases (ID No. 960012). Atlanta, GA, USA; that of the Coordinator of the NGDO Coalition; the 45 The writing was complete by 28 August 2011. significance of all partners involved in the onchocerciasis program: APOC, Carter Center, GTZ, Insight Special 2011 4th Session, 15-17 August 2011 48 I believe you have shared some lessons and experiences tremely appreciated. Elimination of onchocerciasis will during this session. You have discussed the contents of set a new stage for other NTDs and will be a new experi- the current draft guidelines: this to me is the most impor- ence for the continent of Africa. tant since it will guide all the activities to be undertaken. You have heard arguments for and against some of the It is now my honor and pleasure to declare officially document contents. We should appreciate the fact that closed the 4th session of UOEEAC. we do not have this kind of guidelines for the continent of Africa where 99% of the onchocerciasis cases occur. Thank you for your attention. We have to borrow a lot from OEPA, which is quite ad- vanced in the elimination of onchocerciasis in the world. The MOH, in the process of owning the guidelines document, subjected it to a number of technical committees for it to be within the framework of the Health Sector Strategic Investment Plan. There may have been tensions, and some areas where it was difficult to agree. This is inevitable. But the task here was to think through carefully the implications of different options for all the stakeholders – even if a consensus was not reached.

There are other issues that merit our further attention. I will just take two examples (but there are others that have been presented and exhaustively discussed). First, "...... Achieving the various benchmarks you have touched several times on the issues of transmis- set in the guidelines to facilitate interrup- sion interruption and halting intervention in a focus: Our ministry (MOH Uganda) is responsible for verifying and tion of transmission requires a lot –not officially communicating to the district concerned mat- only on the side of the program, but also ters in this regard. It is crucial that adequate prepared- on the side of all the stakeholders involved ness be made at all levels in terms of strengthening the in onchocerciasis elimination. I am happy surveillance system and putting in place a good relevant that significant achievements have been documentation system. made in some foci, and this needs to be Second, we need to set very clear plans on the cross-bor- preserved." der issue as this has a lot of implications for the elimination process. As you might have heard yesterday (on 16 August 2011) a regional effort is being made to strengthen cross-border collaboration between DRC and Ugan- There may have been tensions, and some da and this, if successful, should be extended to the new areas where it was difficult to agree. This Republic of South Sudan. To move this agenda forward financial support from partners would be required. is inevitable. But the task here was to think through carefully the implications of Lastly, for any designed strategy of onchocerciasis elimi- different options for all the stakeholders – nation to be effective, it should be properly implemented. even if a consensus was not reached. For the case of twice yearly treatment with ivermectin, there should be sustained high treatment coverage while for vector elimination, proper planning and commitment of field teams are very crucial. However, both would require political support, involvement of the health work- ers47 and the affected communities. Empowerment of the communities to take care of their own health and sustainability of the elimination program must therefore remain our watchwords.

To conclude, I would like to further emphasize the commitment of program staff toward this elimination effort, and this should be supported and maintained. The support from The Carter Center and other partners is ex-

RTI/USAID; and Sightsavers; the presence of Representatives from oncho endemic districts in Uganda; that of all other distinguished invited guests in their various capacities; and of all ladies and gentlemen there present. 47 Within or in the neighborhood of the onchocerciasis endemic areas.

Insight Special 2011 4th Session, 15-17 August 2011 49 Note No. ID ID 18 17 16 14 13 12 10 11 15 9 Wambabya-Rwamarongo 8 Kashoya-Kitomi 7 Imaramagambo 6 Mpamba-Nkusi 3 5 Itwara 4 Wadelai 2 Victoria 1 PART G - PERIPHERALS Greyish Green = Green Greyish Light Green = Dark Green = Mid-North NileWest Madi Lubilila Moyo / Obongi Nyagak Bondo Bwindi Maracha-Terego Nyamugasani Mid North I Mid Budongo Elgon Mt. Focus Ye/No PTS Interruptionsuspected TransmissionInterrupted Eliminated S.damnosum S.neavei/ S. damnosum S.damnosum S.damnosum S.neavei S.neavei S.neavei/ S. damnosum S.neavei/S.damnosum S.damnosum S.neavei S. neavei S.neavei S.neavei S. neavei S.neavei S. neavei S.neavei S. damnosum Vector Pader Amuru Gulu Arua Koboko Adjumani Arua Zombo Lira Gulu Amuru Lamwo Kitgum Kisoro Kanungu Hoima Buliisa Kamwenge Ibanda Rubirizi Bududa Sironko Mbale Kyenjojo Kayunga Mayuge Kamuli Mukono Oyam Yumbe Moyo Kasese Moyo Nebbi Kabale Maracha-Terego Kasese Masindi Hoima Buhweju Bushenyi Kibale Manafwa Kabarole Nebbi Jinja District # MDA MDA # rounds annual annual Uganda's plan for onchocerciasis elimination (August 2010) 11, elimination onchocerciasis for plan Uganda's N/A N/A N/A N/A N/A N/A N/A N/A N/A 17 17 18 18 17 18 18 17 17 15 15 16 16 18 16 16 15 15 15 20 17 18 17 17 17 18 15 18 17 16 16 16 18 17 15 20 15 Annex I - Oncho Flag August 2011 Red = Blue = Yellow= semi annual # of MDA # rounds N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 7 7 7 7 7 7 7 7 7 7 7 7 7 7 7 9 Not muchNot isknown for (Need Epi stidies) Priorityfor epi studies for delineation of eachfocus beforesemi-annual treatment decision Implement elimination policy elimination Implement

Total Pop 8,7 295,822 484,271 1,4 100,311 128,582 118,049 151,319 142,565 156,714 268,046 387,707 198,160 3,6 134,696 133,661 138,063 167,076 120,047 145,945 279,312 139,656 161,630 8,1 229,292 99,508 286,615 99,718 122,797 117,084 136,302 170,377 9,0 5,7 312940 85,748 156,470 102,180 190,305 99616,909 77,422 19,946 95,780 22,938 22,911 27,956 26,989 50,823 63,850 6312,0 59,810 91,580 29,905 126,944 45,790 44,702 36,371 63,472 56,321 22,351 70,030 42,520 75,626 26,019 121,336 35,015 21260 60,668 42,457 25,645 73,316 128,792 81,562 64,396 40,781 76,375 50,253 10717,606 21,057 34,302 42,753 8902,0 47,216 23,608 28,960 06925,655 30,689 6303,3 77,060 126,100 38,530 63,050 46,330 97,478 74,600 48,739 59,412 67,396 33,698 28,764 40,604 14,382 17,739 ,0 8,377 9,701

191,033 233,428 112,011 2011 UTG1 168,969 192,992 93,024 UTG2 ongoing ongoing ongoing ongoing ongoing Interupted ongoing ongoing ongoing ongoing uncertain Interupted Eliminated Eliminated Eliminated Eliminated ongoing ongoing Interupted ongoing Eliminated ongoing ongoing ongoing Interupted ongoing ongoing ongoing ongoing ongoing uncertain uncertain Interupted ongoing ongoing ongoing ongoing Interruption Suspected ongoing ongoing Interruption Suspected Interruption Suspected ongoing uncertain Interupted Interupted Status Status of Transmission elimination Yr of of Yr 1973 1973 1973 1973 1973

Semi-Annual Semi-Annual Annual Annual Semi-Annual Semi-Annual Semi-Annual Semi-Annual Semi-Annual Semi-Annual Semi-Annual Semi-Annual No need No need No need No need Annual Annual Semi-Annual No need Annual Annual Annual Annual Semi-Annual Semi-Annual Semi-Annual Semi-Annual Semi-Annual Semi-Annual Semi-Annual Semi-Annual Semi-Annual Annual Annual Annual Annual Annual Semi-Annual Semi-Annual Annual Semi-Annual Semi-Annual Semi-Annual Annual Annual Plan for MDA treatment

Insight Special 2011 4th Session, 15-17 August 2011 50 Annex II - UOEEAC 2011 Attendence List Annex II - UOEEAC 2011 Attendence List Amazigoobserver) (invited [email protected]. Absentwith apology 38. 37. 36. 35. 34. 33. 32. 31. 30. 29. 28. 27. 26. 25. 24. 23. 22. 21. 20. 19. 18. 17. 16 15. 14. 13. 12. 11. 10. 9. 8. 7. 6. 5. 4. 3. 2. 1. SN LIST 2011 UOEEAC ATTENDANCE

Ms Ms Ms Mr. Mr. Mr. Mr. Mr. Mr. Ms Mr. Mr. Ms Ms Ms Dr.Edridah Tukahebwa Dr. Dr. Dr. Dr. Dr.Tony U Dr.Miriam Nanyunja Dr. Mr. Dr. Dr. Dr.Stephen Leak Dr.Noma Mr. Mr. Ms Mr. Dr.Moses Dr. Prof.GarmsRolf FrankDr.J. Prof.Thomas Dr. Dr. Name

Peace Zakia Harriet EdsonByamukama JacquelineIdusso StellaAgunyo PeaceHabomugisha HarrietNamwanje NarcisB. SolomonFisseha Paul Cantey AdrianHopkins C Johnson Frank Richards DennisK.W. Dawson B. ChristopherKatongole Benjamin Bernard Edward Dickson GalexOrukan David GabrielMatwale Tom Ephraim Tukesiga James Katamanywa Thomson illas s

y Mugaba Komukama Rubaale Mounkaïla Oguttu N. Namanya kety Tumwesigye

Walsh Banoba Ngorok V. Unoba Kabatereine Katabarwa R. L. : 1. Tinkitina Mbulamberi

Abwang Lakwo Unnasch

Lwamafa

Ochieng Dr.Ambrose W.(at large Onapa member UOEEAC) [email protected]; Dr. 2. RichardNdyomugyenyi (invited observer) [email protected]; Dr. 3. Uche V.

Secretariat Secretariat Observer Observer Observer Observer Observer Observer Observer Observer Observer Observer Observer Observer Observer Obs Observer Facilitator(gave some welcome remarks) Observer/Guest Observer Observer Observer Member Member Member Observer Member Member Member Co Co Member Observer Atlarge member UOEEAC Atla Atlarge member UOEEAC& Chair Facilitator MemberUOEEAC Capacityin which oneattended - - secretary(non secretary erver rgemember UOEEAC

UOEEA UOEEAC UOEEAC UOEEAC UOEEAC UOEEAC

(openedthe meeting)

( votes only in

C - voting)

a a tie )

VCD VC VCD KaseseDistr DHO’s Office VCD Gulu DHO’s Office VCD VCD PELF TCC(at VCD/MoH) UgandaMerck TCC(at VCD/MoH) VCD NTDCP/VCD/MoH VCD/MoH WHO CDC WHO/Geneva WHO MDP DHO Lions ClubUganda SightSavers APOC APOC DHO’s Office,Kabarole Kyenjoj TCC(at NOCP,VCD/MoH TheCarter Center TheCarter Center B Universityof Florida MoH MoH Institution of affiliation ernard D/

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(MoH)

oDistrict Office N VCD/MoH ocht

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(TCC)

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VCD(MoH), Kampala, Uganda VCD(MoH), Kampala, Uganda VCD(MoH), Kampala, Uganda Kasese, Box1, VCD(MoH), K Gulu Mbale VCD(MoH), Kampala, Uganda VCD VCD/MoH,Kampala, Uganda Box Kampala PlotBombo 15, R Kampala,Uganda K Box Kampala,Uganda USA Geneva,Switzerland Kamwokya USA Kabalore,Uganda MulagoHospital, Kampala Kampala, APOC APOC BoxFort 38, port Box1002, PlotBombo 15, R Kampala Atlanta,GA, USA Atlanta,GA, Hamburg LYTHAM USF,USA MoH,Kampala MoH,Kampala PhysicalAddress ampa 12027,Kampala 1661,Kampala , Uganda ,

(MoH),Kampala, Uganda

, FasoBurkina , District,Uganda la

Nebbi Burkina Uganda , Uganda , , , , Germany ,

Uganda Uganda Uganda

Kyenjojo STANNES, UK , Kampala, , Uganda

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Insight Special 2011 4th Session, 15-17 August 2011 Insight Special 2011 4th Session, 15-17 August 2011 5151 Annex III - List of Abbreviations

ALB: Albendazole. OEPA: Onchocerciasis Elimination Program for the Americas APOC: African Program for Onchocerciasis Control. Oncho: Onchocerciasis. ATP: Annual Transmission Potential. OPC : Organisation pour la Prévention de la Cécité. AVSI: International Service Volunteer Association (Italian). PCR: Polymerase Chain Reaction. AZ: Azithromycin. PCT: Preventive Chemotherapy and Transmission Control. CBM: Christoffel BlindenMission. PZQ: Praziquantel. CDC: Communicable Disease Control. RBF: River Blindness Foundation. CDI: Community Directed Interventions. RTI: Research Triangle International. CDP: Child Days Plus. SAEs: Serious Adverse Effects. CDTI: Community Directed Treatment with Ivermectin. Schisto: Schistosomiasis. CMD(s): Community Medicine Distributors. SCI: Schistosomiasis Control Initiative. CSA: Committee of Sponsoring Agencies. SOPs: Standard Operating Procedure CWW: Children Without Worms. SS/SSI: Sightsavers (International). DEC: Diethylcarbamazine STH: Soil Transmitted Helminths. FR: Forest Reserve. TCC: Technical Consultative Committee (arm of APOC). GOU: Government of Uganda. TDR: Tropical Disease Research. GSK: GlaxoSmithKline. TORs: Terms of Reference. GTZ: German Technical Cooperation. TRC: Technical Review Committee. HKI: Helen Keller International. UFAR: United Front against River Blindness. HOMAPAK: Combination Sulphadoxine/ UFB: Uganda Foundation for the Blind. Pyrimethamin (SP) and Chloroquine (CQ). USAID: United States Agency for International Development. HSD: Health Sub-District. VCU: Vector Control Unit. ICTC: International Coalition for Trachoma Control. VHTs: Village Health Team(s). IEC: Information, Education and Communication materials. WHA: World Health Assembly. IMA: Interchurch Medical Assistance Global Health. WHO: World Health Organization. ITI: International Trachoma Initiative. IVM: Ivermectin. JAF: Joint Action Forum. LCIF: Lions Clubs International Federation. LF: Lymphatic Filariasis. M.O.H., M.o.H., MOH, MoH: Ministry of Health. MDA: Mass Drug Administration. MDP: Mectizan Donation Program. MDSC – Multi-Disease Surveillance Center. MITOSATH: Mission to Save the Helpless. NCC: National Certification Committee. NGDO: Non-governmental Development Organization. NGO: Non-governmental organization. NMS: National Medical Stores. NOCP: National Onchocerciasis Control Program. NTD: Neglected Tropical Diseases. NTDCP: Neglected Tropical Disease(s) Control Program. OCP: Onchocerciasis Control Program

Insight Special 2011 4th Session, 15-17 August 2011 52 Annex IV - Autobiographical Notes on Outgoing Dusseldorf Hygiene Prize for the write up of this work. Chairman J. Frank Walsh 1981-1990 I found that my role as Chief VCU was not Name James Frank Walsh. to my liking (too much administration, not enough field Born Derby, England 1937. work), and resigned. For most of 1980s I worked as a Educated at State schools. Left school in 1954 aged 16 consultant for OCP, often as part of the control man- years with undistinguished certificates. agement team. This gave me the flexibility to register as a part-time PHD student at Salford University, with 1954-1959 Various jobs, plus 2 years in Royal Air Professor David Molyneux as my supervisor. In 1984 Force, while studying in for university entrance quali- I successfully submitted my thesis entitled ‘Aspects of fications. the Biology and Control of Simulium damnosum s.l. (Dipera: Simuliidae) in West Africa’. This was based 1959-1962 Liverpool University, Zoology Department, largely in my development of control strategies and tac- graduating with 2nd Class BSc in Zoology (special En- tics in Nigeria and the OCP, together with studies of the tomology). non-man biting behaviour of adult S. damnosum s.l. In 1962-1965 Taught pre-university level Biology in a April 1986 I was a member of the Third WHO Expert Liverpool Technical College. Committee on Onchocerciasis. Dr Brian Duke, as Sec- retary of the Committee, was the dominant personality. 1965-1969 Entomologist with Vector-Borne Diseases Professor Garms and I were joint Rapporteurs for the Control Unit, Kainji Dam, Northern Nigeria. Employed entomological side of things. This was a very interesting by Balfour-Beatty, Consultant Engineers on a very large experience. hydro-electric project. The Senior Entomologist was Mr H Goiny, one of the team who eradicated Simulium During the later 1980s I took charge of the entomologi- neavei from Kenya. I learnt a lot from him and took over cal control operations and surveillance in the eastern half as Senior Entomologist when he retired. We introduced of the OCP area, working from time to time with Profes- innovative methods of entomological monitoring. sors RA Cheke and Garms. Our knowledge of transmission by different members of the S. damnosum complex 1970 I wrote up my experiences at Kainji for WHO. was improving and I began to formulate plans for control targeted at specific limited populations of individual 1970-1973 I was recruited by WHO to the Onchocer- cytospecies, even where more than one was present. I ciasis Consultative Services team working in Ghana, presented these ideas at a Wellcome Foundation Filaria- Togo, Benin and eastern Burkina Faso. I carried out aer- sis Seminar in November 1986. This was later published ial surveys in these countries and investigated methods (JF Walsh et al. 1987. Tropical Medicine & Parasitology. for trapping S. damnosum, working with Dr AWR Mc- 38: 57-60). Later, we successfully eradicated the Djodji Crae, formerly of Uganda. form of the vector S. sanctipauli from its only known locality, on the borders of Ghana and Togo, where it co- 1973 I returned to Europe and spent most of the next existed with S. squamosum, which persisted. Transmis- year helping Mr J Hamon to draft the complex and de- sion was permanently reduced. A limited account of tailed report which was the Project Document for the this success was not published until 2008 (RA Cheke et OCP. I played a substantial part in this. Probably my ma- al. Medical & Veterinary Entomology 22: 172-174). In jor contributions were to insist that clear reference must 1990 I ceased working in West Africa, though I took up be made to the migratory prowess of S. damnosum in the membership of the Expert Advisory Committee of the introductory document. (This proved invaluable when OCP until 2000. the OCP was heavily invaded by the vector in 1975, and several senior World Bank officials wanted to cut their Uganda, 1991-1997 losses.) My other important contribution was to insist on At the suggestion of Dr EM Samba, Director OCP, in the importance of comprehensive entomological moni- March 1991 I visited Uganda, as a WHO consultant, to- toring. This had been a weak aspect of French control gether with Dr Teklemariam Ayele, to advise the Min- efforts in West Africa. I wrote, and costed, the plan for ister of Health on a possible Onchocerciasis Control the Entomological Surveillance. Dr R Le Berre led in Programme. For a month we travelled to most of the drafting and costing the Aerial Operations with my input onchocerciasis foci with Mr L Kabango. After consid- from the eastern countries. ering the existing economic situation within Uganda, the rundown state of the VCU, and the enthusiasm for 1974-1980 I joined OCP as Chief Entomological Sur- ivermectin distribution following Merck’s offer of free veillance, along with Dr Le Berre, Chief Vector Control supplies, we concluded that a control programme would Unit and Dr DAT Baldry Chief Aerial Operations. With have to be based on the annual distribution of the drug. departure of Dr Le Berre to WHO HQ I became Chief Our report did, however, also state that in certain cir- VCU. Between 1975-1979 we struggled to understand cumstances vector elimination might prove cost effec- and control a major invasion of the western sector of tive. the OCP area. Professor R Garms became our key consultant, and Dr JB Davies joined the surveillance team Back in England, a chance telephone conversation with in 1975. Eventually, we understood the origin of the in- Dr Duke led to my inclusion, as general advisor, in the vading flies and regained control. We were awarded the first River Blindness Foundation (RBF) visit to Uganda. Insight Special 2011 4th Session, 15-17 August 2011 53 I accompanied RBF Director Dr Baldwin and Medical used as the baseline document for the development of an Director Dr Duke. At our scheduled first meeting with APOC proposal. While writing this document I became the Minister of Health, the Minister greeted me warmly increasingly convinced of the value of combining iver- with words to the effect that ‘with my presence he knew mectin distribution with some level of vector control, the Ministry was in safe hands’. This was most generous, particularly to gain a rapid reduction of transmission to and a very lucky break for me. On leaving the Minister’s levels which could not be achieved by ivermectin dis- office Dr Baldwin turned to me and said, ‘Well, Frank, tribution alone. I also became convinced of the likely if the Minister thinks so highly of you, you had better cost effectiveness of focal vector eradication. In 1994 I be RBF’s man in Uganda’. I visited Uganda regularly to wrote a supplementary document The control of Human liaise with the Ministry, work with VCU, and plan for Onchocerciasis in Africa outside the OCP countries: the opening of an RBF office. Although my activities suggestions for Vector Control, Unpublished Report to were mainly administrative I continued to visit many of the World Bank, 43 pages. Apart from my TDR visit to the known foci, making contact with District Medical Uganda referred to above I also visited and reported on teams, Professor Garms and other members of the GTZ Focal Vector Eradication for Tanzania and Malawi. team, and Mr Trevor Graves of CBM and working with members of the VCU. I wrote a job description for an In discussion with Dr JH Remme in 1993, I outlined RBF Director and a Finance Officer and received ap- my ground and aerial survey experience and view that I proval for these from Dr Duke, who was my direct supe- could help to develop a rapid mapping technique for ar- rior. I then advertised these posts in the main daily news- eas where the knowledge available to De Sole (De Sole paper and asked two Makerere University professors to et al. 1991) did not exist. This resulted in my recruitment assist me in interviewing the managerial candidates. I as a TDR Special Programme Consultant. I proposed a selected eight people to interview for each of the posts. method for identifying and mapping onchocerciasis Fortunately the Professors and I were in total agreement zones, lacking detailed entomological or epidemiologi- that we should offer the post of Country Director to Mr cal data. Dr P Ngoumou, Mr J-M Mace and I prepared (now Dr) Moses Katabarwa. maps of potential endemic onchocerciasis areas in Cameroon. Dr Ngoumou carried out nodule palpation I no longer have the reports I wrote for RBF, but I cer- surveys to test the effectiveness of the approach. This tainly visited Uganda on several occasions until the RBF resulted in the publication of A Manual for Rapid Epide- was subsumed into Global 2000. I travelled in most of miological Mapping of Onchocerciasis by P Ngoumou the onchocerciasis foci where the vector is S. neavei, as & JF Walsh UNDP/World Bank/WHO Special Pro- well as some of the northern S. damnosum areas accom- gramme for Research and Training in Tropical Diseases panying many members of VCU and RBF. In 1993 I ac- and a formal publication (P Ngoumou, JF Walsh & J-M companied Dr Duke to a conference on Onchocerciasis Mace (1994) Annals of Tropical Medicine and Parasi- Control in Central and East Africa sponsored by RBF. In tology 88: 463-474). The REMO technique has greatly October 1994 together with (the now Drs) Katabarwa, aided the campaign to treat affected communities with Onapa and Kabatereine, I met the Commissioner for ivermectin. With the successful establishment of RBF Health Dr Sam Okware to discuss the visit of Ambassa- in Uganda and its incorporation into Global 2000, to- dor Easum on behalf of RBF. The views of the Ministry gether with the establishment of APOC in West Africa, regarding vector control were discussed in detail. The and the lack of enthusiasm for anti-vector measures in Ministry was strongly in favour of vector control at that that organization, my connection with the fight against time. onchocerciasis virtually ceased.

In 1996 I was back in Uganda, as a consultant for the The development of the UOEEAC TDR Special Programme. My remit was to report on In 2008 I was surprised and honoured to be invited as an the potential for focal vector eradication (see below). I ‘at large’ member of the newly convened UOEC (now asked Professor Garms and Mr T Lakwo to join me in UOEEAC) and later to be its first chairman. After a long writing a report ‘Planning of Focal Vector Eradication period on the sidelines I did not have any precise idea in Onchocerciasis Foci in Uganda’. …Katabarwa, by about the content of the first agenda. However, I was that time with Global 2000, provided logistic support. keen to get the maximum input from field workers. I We suggested as priorities for vector eradication Itwara, hoped that some active field personnel would be mem- Wadelai, Mpamba-Nkusi, Rwamarongo and possibly bers of the committee and that the maximum number of part of West Nile. VCU and district staff would be able to attend the meetings of the Committee. In my introductory remarks at 1990s Outside Uganda the first meeting I encouraged everyone present whether In the early 1990s I reported to the World Bank on the Committee members, secretariat, or observers, to ex- possibilities of controlling onchocerciasis in Africa out- press their views about the technical aspects under dis- side the OCP countries. This culminated in my Review of cussion. I hoped through this to gain maximum value human onchocerciasis in Africa outside the OCP coun- for the technical advice that the Committee offered to tries with recommendations on control, Unpublished the Ministry, to give credit where credit was due, and Report to the World Bank, 81 pages, 1993. This report at the same time to maximise cooperation between all was influential in persuading the World Bank to sup- parties (including APOC). My other particular desire port the establishment of an APOC, and was probably was that the control/elimination activities be properly the most important document that I ever wrote. It was documented and where possible results published in Insight Special 2011 4th Session, 15-17 August 2011 54 peer-reviewed journals. I thought at the time that the 1st 1991 WHO consultancy to Uganda. Advice given to meeting had gone well. MoH to control onchocerciasis by annual distribution of ivermectin. At the 2nd UOEC meeting in 2009 I again stressed the 1991-1995 Setting up Blindness Foundation (RBF) Of- advisory nature of the Committee’s work. A key part fice in Uganda and recruiting…Katabarwa to post of of our activities during the 2nd meeting was geared to- Country Director. wards developing National Guidelines which eventu- Early 1990s Preparing background documents which ally became the document ‘Guidelines for determining were influential in persuading the World Bank to sup- that Elimination of Onchocerciasis has been attained in port an APOC. Introduced the concept of Focal Vector existing foci in Uganda’. This document was necessary Eradication. because the WHO paper ‘Certification of elimination 1993-1994 Playing a signification part in the develop- of human onchocerciasis: criteria and procedures’ was ment of REMO. based on the experiences of onchocerciasis in West Af- 2008-2011 Chairmanship of the UOEC, UOEEAC. rica, where the vectors were members of the S. damnosum complex. No consideration had been given to the Annex V - Uganda’s Incredible Journey from fundamentally different situation in Central and parts of Control to Elimination of Onchocerciasis: East Africa, where the vector was S. neavei and the dis- an Interview with Moses Katabarwa ease frequently present in relatively small isolated foci. Peace Habomugisha, Stella Agunyo & Edson Byamukama At the time I thought we were making progress to the satisfaction of the Ministry. This proved not to be so. In a letter dated 24 December 2009 Dr Sam Zaramba, Di- rector General of Health Services, presented highly critical documents to me as Chairman. I responded with a strong refutation of some of the comments made and…I eventually succeeded in meeting him face to face on 16th February 2010. …. I told him of my dissatisfaction with the reaction of MoH to the UOEC 2nd Report, and especially with the criticism of the ‘at large’ members of the Committee. …. I gave him a short letter of com- plaint that I had written earlier. ... I was strongly inclined to resign at that point but was eventually persuaded by Dr Katabarwa to stay on as Chairman for the 3rd meeting. Fortunately, by August 2010 … co-operation was restored. The name of the Committee was changed to include the all-important word ‘Advisory,’ significant progress was made in drafting the Guideline document, applying the criteria to foci such as Wadelai, and in re- storing friendly relations all round.

Highlights of my career 1965-1969 Experiencing large scale vector control and monitoring on the Niger River and its tributaries in northern Nigeria. Moses Katabarwa

1973 Helping to draft the baseline documents for OCP. Introduction The story of Uganda’s war on onchocerciasis does not 1974-1980 Designing and implementing Entomologi- begin and end with Katabarwa.48 Being an old-timer in cal Surveillance for OCP. Helping to understand and the progress of that war, he does, however, know quite combat the long range migrations of S. damnosum s.l. a lot about it, and, over and above that, he has person- in collaboration with Professor Garms and Dr JB Da- ally experienced it to quite some degree, especially vies and being jointly awarded the Dusseldorf Hygiene since about the beginning of the 1990s when the fight Prize. Standardising vector collection procedures and was reenergized. Habomugisha, Agunyo and Byamu- introducing the Annual Biting. Rate (ABR). Heading kama, who interviewed Katabarwa some days before the VCU of OCP. UOEEAC’s 4th meeting of August 2011, bring to you an account of certain aspects of the struggle against on- 1986 Membership of the Third WHO Expert Committee chocerciasis as told by Katabarwa. on Onchocerciasis. The narrator tells of times of uncertainty and disappoint- 1986-1990 Introduction of control targeted at specific ment over the course of the struggle, of informed daring limited populations of cytospecies of the S. damnosum complex, and deliberately eradicating the Djodji form of S. sanctipauli. 48 Onchocerciasis is also known as river blindness. Insight Special 2011 4th Session, 15-17 August 2011 55 (sometimes even in the face of stiff opposition), of mo- to provide evidence of onchocerciasis existence in all ments of expectation of great things to come that would the affected districts of the country, to build capacity in result in open or concealed ear to ear facial smiles, and those districts through the official health delivery system so on and so forth. Bit by bit, the story unfolds as you and to encourage the communities to tackle this disease. read on. Fortunately, Merck & Co. President (then) had promised President Jimmy Carter that his company would provide Of Denial, Disaster, Partial or More Mectizan® free as long as required and in as many quan- Knowledge and Ignorance tities as needed in order to control onchocerciasis. The late 1980s and early 1990s were a period of denial of endemicity of the age- old scourge of onchocerciasis, The main challenge, at that time, was to map the distri- says Katabarwa. According to him, some local leaders bution of the disease countrywide,50 organize imple- considered the ugly skin, the uncontrollable skin itchi- mentation teams at Vector Control Division and district ness, symptoms of nakalanga syndrome (dwarfism) and level, and for the affected communities to tackle the epilepsy, all of which tend to be associated with the dis- disease. During the period 1992 to 1995, John Moores, ease, to be a disaster for the image of their respective the founder of the River Blindness Foundation, donated areas and districts. millions of dollars to assist onchocerciasis control pro- It took some time to convince Kisoro and Kabale lead- grams in the Americas and Africa. It was through this ers, with data and photographs, that parts of their dis- generous gift that river blindness control in Uganda tricts were onchocerciasis endemic. Already, the disease was massively and exceptionally re-rejuvenated. His was known in Bushenyi, Buhweju, and Ibanda districts assistance also enabled the establishment of a strong (in what was formerly Ankole), in Kyenjojo, Kabarole, coalition of non-governmental development organiza- and Kamwenge (where formerly we had Tooro), as well tions (NGDOs) with coordination mechanism at World as in Buliisa, Hoima, and Masindi districts (in what used Health Organization headquarters in Geneva. It also en- to be called Bunyoro), and efforts to treat affected com- gineered the formation of the African Program for On- munities were underway. In Nebbi district, the popu- chocerciasis Control (APOC) that was finally launched lation had appealed to President Yoweri K. Museveni in December 1996. in a memorandum asking for assistance to treat river blindness. In endemic districts not yet mapped (for the Meanwhile the Mectizan Donation Program, with Mer- disease), communities were turning to local remedies, ck & Co.’s support, had been established in Atlanta at while others had given up, convinced that superior un- the Task Force for Child Survival, now known as The derworld spirits were responsible for their fate. Taskforce for Global Health, in order to coordinate pro- curement by and delivery to affected countries of Mec- “In truth,” said Katabarwa, “only the Vector Control Di- tizan®. By 1996, The Carter Center had taken over the vision (VCD) of the Ministry of Health understood the operations of the River Blindness Foundation in Ugan- problem of onchocercaisis in the country. Other insti- da, although John Moores’s financial support continued. tutions were generally ignorant of the disease. Yet the Later, additional financial assistance came from Lions institution that had the knowledge of onchocerciasis was Clubs International Foundation and the newly formed at the verge of collapsing, with limited or no support af- APOC, where the World Bank and President Carter ter many years of the political turmoil and the economic played a key role in mobilizing donors for the new Afri- hardships of the 1970s and 1980s.” can onchocerciasis control effort.

Outside Support & Reinvigoration Mectizan Management and MOH/GOU It was during the early 1990s, with support from the Resistance German organization for Technical Cooperation (GTZ), Although Mectizan (ivermectin) was available for treat- the Bernhard Nocht Institute for Tropical Medicine in ing onchocerciasis patients, it was originally not clear Hamburg, Germany, and the River Blindness Founda- which strategy one would employ to treat all affected tion to the Vector Control Division, that the war on age- communities. One challenge was that the Ministry of old onchocerciasis was reignited.49 Health was faced with a situation in which communities were being empowered to receive and distribute the med- Katabarwa’s assignment with the River Blindness icine, something that had never been done before under Foundation, which employed him in 1992, was to pro- its jurisdiction. Before the ministry got involved (in the vide financial assistance to the Vector Control Division administration of the drug), different partners employed of Uganda’s Ministry of Health, to help it to regain its different strategies, such as mobile clinic treatment, earlier reputation as a leader in onchocerciasis control, clinic-based treatment, and community-based treatment systems ranging from places where communities were 49 It needs remembering that from the 1950s to the early not involved to where they were heavily involved. 1970s, the Vector Control Division had tackled and succeeded in onchocerciasis control through vector control with DDT in the Victoria Nile areas of Busoga and Buganda, the Mt. Elgon area of the East, and the Rwenzori area in the western parts of Uganda. Although vector control efforts in the Victoria Nile area were successful, in other areas political upheavals, dur- 50 More will be said later by Katabarwa about the subject of ing Amin’s regime, left onchocerciasis efforts incomplete and mapping abandoned. Insight Special 2011 4th Session, 15-17 August 2011 56 One side supported communities handling the medi- onchocerciasis surveillance teams. Mapping the distri- cine, with the justification that high treatment coverages bution of river blindness was also aided by the study would be attained every year in these remote commu- where Katabarwa, Onapa, and Nakileza tested, modified nities; another maintained that handling medicines was and adapted to the Simulium neavei areas in Uganda the a job for trained clinicians, and there was no way the rapid epidemiological mapping technique developed in government would allow communities to play that role. Cameroon by Frank Walsh and his colleagues for Simu- Both sides were passionate and determined to have a lium damnosum. policy that would be adopted through the health delivery system. This was in the face of shortage of trained “Mapping onchocerciasis was very challenging,” Ka- health workers, along with poor and unevenly distrib- tabarwa said. “In the 1990s, the road infrastructure was uted health facilities. Convincing relevant institutions to limited and in a very poor state. Most of the mapping adopt or support a system where communities would be in endemic areas was done on foot since many bridges empowered to treat themselves was therefore an uphill were broken and accessibility of places, by vehicles dur- task. ing the rainy season, was almost impossible.” Another challenge was ensuring that districts recruited (appropri- Based on early evidence obtained from Kabale and Ka- ately) skilled personnel to tackle onchocerciasis. Most nungu districts, Katabarwa was convinced that health districts were not aware that it was important to have workers were never going to succeed in providing Mec- trained entomologists to tackle vector borne diseases. tizan® to affected communities every year at the desired Through relentless advocacy at district levels, and with coverage of at least 90 percent of the eligible population. financial support from the River Blindness Foundation His unyielding support for community involvement did initially and later from The Carter Center, most affected not earn him a good reputation in government circles. districts hired and later maintained Vector Control Offi- Fortunately, however, the multi-country study launched cers who have now become a cornerstone for onchocer- and supported by WHO/TDR in 1996 showed that com- ciasis elimination. munities, when effectively trained, attained higher coverage rates than program-directed (including clinician Elimination of Onchocerciasis driven) treatment systems. This settled the argument in Although government of Uganda’s bold move to launch the Ministry of Health, and the community-driven treat- river blindness elimination policy came as a surprise ment program went sky-high in the affected districts. to some, says Katabarwa, leaders in the Ugandan onchocerciasis program were, from the beginning, inclined But there was also this angle to the matter under discus- to strive for elimination of the disease. “There were no sion. Basing on his experience while growing up, during questions on that, because they were certain that Uganda the hard time of President Idi Amin, when one could not as a country did not want treatment to go on indefinitely easily access medical services, Katabarwa has always with a single annual dose of Mectizan®,” he said. Ka- believed that access to health services in disadvantaged tabarwa also said: “This opinion was also supported by communities could be better if community members the late Dr. Brian Duke, then the River Blindness Foun- were trained to administer basic medicines. dation Medical Director (MD),who noted that Uganda could eliminate onchocerciasis with biannual Mecti- “There was a situation in my home area where there zan® treatment and even attain this in a shorter period was only one veterinary doctor to serve the whole com- if vector elimination or targeted vector control (where munity,” Katabarwa recalls. “This veterinary doctor feasible) were employed.” would teach people how to administer medicine to their animals, besides giving them many more empowering Indeed, impact assessments, done after more than 10 to skills. He would only be called upon when there was a 18 years of treatment with a single annual dose, observes complicated situation. All this created a feeling in his Katabarwa, have indicated that transmission is still tak- (Katabarwa’s) heart that it was possible to organize and ing place, and that treatment cannot be halted without train community members to prevent, or treat themselves the risk of disease recrudescence. The general feeling against, some endemic diseases such as onchocerciasis, among Ugandan experts, he points out, was that the on- lymphatic filariasis, and TB, to mention a few.” chocerciasis program should be allowed to do more than just distribute Mectizan® once every year. Vector elimi- Onchocerciasis Mapping & Recruitment nation activities, with assistance from GTZ, Bernhardt of Staff Institute of Tropical Medicine and APOC, in Itwara and It should be noted that mapping of onchocercia- Mpamba-Nkusi foci, had shown that the dual approach sis in Uganda began well before APOC was estab- resulted in definite success. lished. Katabarwa, along with colleagues Richard Ndyomugyenyi,51 Ambrose Onapa, and Tom Lakwo, Ironically, the opportunity for the Uganda onchocercia- with support of a highly motivated group of Vector Con- sis program to launch an elimination policy, Katabarwa trol Officers, played a key role in mapping the distribu- says, arrived when external support began dwindling. tion of onchocerciasis countrywide. That group of Vector The challenges of an indefinite annual treatment pro- Control Officers later came to form a central and district gram prompted the government to act. Such a long-term treatment policy was impossible for the government to 51 A medical doctor by training with a PhD as his terminal sustain, and posed a serious risk of disease recrudes- degree. cence in affected and disadvantaged communities - not Insight Special 2011 4th Session, 15-17 August 2011 57 to mention the risk of developing onchocerciasis resis- this may reveal that the areas that are assumed to have tance to Mectizan®, noted Katabarwa. cross border issues may actually not have them. Vector control, noted Katabarwa, is an important tool that can The idea of a countrywide elimination program, the be used to interrupt transmission or at least knock down reader is informed, originally arose out of a conversa- river blindness vectors in rivers along international bor- tion between Katabarwa (of The Carter Center, Atlanta, ders such as River Tako on the Uganda-DRC border in Georgia), Peace Habomugisha (Uganda Carter Center’s Kasese District. Country Representative) and Ndyomugyenyi, the then Uganda National Onchocerciasis Coordinator. A policy Wrap Up for nationwide river blindness elimination that attracted Although there was initial skepticism about onchocerci- wide support was then formulated and rapidly embraced asis elimination in Uganda, the successes that have been by the government of Uganda. In January of 2007, with achieved so far have shown the world that the elimina- support from The Carter Center, the government of tion of the disease (with existing tools) is possible, says Uganda launched the elimination policy. Katabarwa. In his words: “It should be noted that serious challenges in life are always overcome in a step by step Today (2011), Uganda has interrupted transmission of fashion, and indeed onchocerciasis elimination in Ugan- onchocerciasis in the Wadelai, Mt. Elgon and Itwara foci da should be done through a step by step approach. This that cover a population of about 450,000 people, said is an approach that the rest of Africa should be taking a Katabarwa.52 Transmission interruption, he also noted, keen interest in. They would do well to consider emu- is suspected in the foci of Nyamugasani (in Kasese Dis- lating Uganda’s courageous and innovative approach to trict), Imaramagambo (in Mitooma and Bushenyi Dis- disease elimination.” tricts), Mpamba-Nkusi (in Kibaale District) and Mara- cha-Terego (in Arua and Maracha Districts), which have 464,000 individuals as their total general population. During the period 1992 The Carter Center, Katabarwa’s listeners are told, has to 1995, John Moores, assisted Uganda’s Ministry of Health in establishing the founder of the River a molecular epidemiological laboratory to assess the Blindness Foundation, donated progress of interruption of transmission. It has also sup- millions of dollars ported, he informs his readers, an international technical to assist onchocerciasis control advisory committee (composed of Ugandan and foreign programs in the Americas and Africa. experts) to review relevant river blindness data, and to It was through this generous gift that advise the country’s Ministry of Health, especially by river blindness control in Uganda was providing them with recommendations pertaining to on- massively and exceptionally re-rejuvenated. chocerciasis elimination. Although government of Uganda’s bold move to launch river blindness elimination policy came as It is Katabarwa’s firm view that hope abounds that the a surprise to some, says Katabarwa, leaders in the disease (onchocerciasis) will eventually be eliminated. Ugandan onchocerciasis program were, from the He encourages every Ugandan, mostly people in the af- beginning, inclined to strive for elimination of the dis- fected areas and persons charged with killing the disease. “There were no questions on that, because they ease, that hope should not be lost even in the face of were certain that Uganda as a country did not want challenges. There have been concerns that the onchocer- treatment to go on indefinitely with a single annual ciasis elimination program in Uganda can be impeded dose of Mectizan®.” by cross-border issues, but Katabarwa had this to say The idea of a countrywide elimination program, on that: “This can be solved by creative thinking. For the reader is informed, originally arose out of a example, those same cross-border collaborations that conversation between Katabarwa (of The Carter MoH Uganda has had can be extended to the onchocer- Center, Atlanta, Georgia), Peace Habomugisha ciasis program. These collaborations were for programs (Uganda Carter Center’s Country Representative) like immunization where children from neighboring and Ndyomugyenyi, the then Uganda National countries were immunized by health personnel from Onchocerciasis Coordinator. A policy for Uganda.” nationwide river blindness elimination that attracted wide support was then formulated and rapidly He also noted that onchocerciasis in some border areas embraced by the government is naturally dying off - for example in Bwindi, where of Uganda. In January of 2007, the focus has been de-forested on the side of DR of with support from Congo, hence destroying the vector breeding grounds The Carter Center, the there. That there is need to complete delineation of foci government of Uganda in the border areas was emphasized by him, saying that launched the elimination policy.

52 Wadelai is found in Nebbi district; Elgon in the districts of Bududa, Manafwa, Mbale and Sironko; and Itwara in Kaba- lore and Kyenjojo districts.

Insight Special 2011 4th Session, 15-17 August 2011 58 This newsletter is supported by The Carter Center and the Ministry of Health Uganda. Published by The Carter Center Program and vector Control Division, Ministry of Health. Plot 15 Bombo Rd. Typset by The Carter Center P.O. Box 1207 Kampala. Telephone: +256 414 349139.

Insight Special 2011 4th Session, 15-17 August 2011 59