the world health organization year 2012 progress report · afric a n progr a mme for o nchocerci a...
TRANSCRIPT
AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL
The World Health Organization Year 2012 Progress Report 1st September 2011 – 31st August 2012
JAF18.5
www.who.int/apocProvisional agenda item 5
© Copyright African Programme for Onchocerciasis Control (WHO/APOC), 2012. All rights reserved.
Publications of the WHO/APOC enjoy copyright protection in accordance with the Universal copyright Convention. Any use of information in the WHO/APOC Progress Report should be accompanied by acknowledgement of WHO/APOC as the source.
For rights of reproduction or translation in part or in total, application should be made to: Office of the APOC Director, WHO/APOC, BP 549 Ouagadougou, Burkina Faso [email protected]
WHO/APOC welcomes such applications.
The WHO African Programme for Onchocerciasis Control
Progress Report 20121st September 2011 – 31st August 2012
AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL
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List of tables, figures and annexes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Executive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
THE YEAR IN REVIEW
1. Community-Directed Treatment with Ivermectin (CDTI) and Health impact . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.1 DiseaseMapping. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131.1.1 Mapping of onchocerciasis prevalence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 131.1.2 Integrated mapping of NTDs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
1.2 GeographicandTherapeuticCoverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151.2.1 Status of geographical coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151.2.2 Status of therapeutic coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
1.3 Ivermectin(Mectizan®)tabletssuppliedbytheMectizanDonationProgramme(MDP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
1.4Monitoring,Evaluationandsurveillance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211.4.1 Independent Participatory monitoring . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 211.4.2 Community Self Monitoring (CSM) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221.4.3 Evaluation of Sustainability of CDTI Projects . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 231.4.4 Surveillance activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 251.4.5 Health Impact Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
2. Moving from Control to Elimination of Onchocerciasis where feasible . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
3. Co-implementation of CDTI with other health interventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 34
Table of content
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4. Strengthening Health Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
4.1 HumanresourcedevelopmentforthecontrolofOnchocerciasisandotherHealthinterventions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384.1.1 Engaging communities and training of community-directed
distributors (CDDs) by NOTFs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 384.1.2 Training of health staff (including APOC fellowships) . . . . . . . . . . . . . . . . . 404.1.3 Building capacity of countries in communication . . . . . . . . . . . . . . . . . . . . . . . . 404.1.4 Gender Mainstreaming . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
4.2 Logisticssupporttocountries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42
5. Partnerships and Government Contributions to CDTI activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.1Governmentfinancialcontributions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 465.2Directfinancialsupporttocountriesandmanagement
ofAPOCTrustFund . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
5.3 Governance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475.3.1 The Joint Action Forum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 475.3.2 Technical Consultative Committee and decentralisation of
functions to countries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 495.3.3 Committee of Sponsoring Agencies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
5.4DevelopmentandimplementationofaCDIcurriculumandtrainingmodule . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
5.5 Partnershipsandcollaboration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 535.5.1 CDTI projects and NGDO support for Onchocerciasis Control . . . . . 535.5.2 Collaboration with other programmes and institutions . . . . . . . . . . . . . 54
6. Moxidectin Development and other research . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Annex . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
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List of tables, figures and annexes
Tables Table1: Summary of ivermectin treatment in APOC countries in 2011 Table2: Therapeutic coverage thresholds reached by CDTI projects in 2011 Table3: Summary of independent participatory monitoring results in Ghana and Sierra Leone Table4: Number of communities that have undertaken community self-monitoring and stakeholder meetings Table5: Status of epidemiological evaluations in twelve onchocerciasis endemic countries Table6: Status of epidemiological evaluations in Benin, Tanzania and Chad Table7: Summary of results of phase 1a and phase 1b epidemiological evaluations in Chad and Uganda Table8: Summary of health interventions by sex for Projects that have provided data Table9: Number of health workers and CDDs trained/retrained in 2011 by NOTFs Table10: Number of health professionals trained/retrained in 2012 Table11: Number of females CDDs in APOC and ex-OCP countries, 2009-2011 Table12: Summary of logistic equipment provided by APOC to CDTI Projects Table13: Number of Projects benefitting from the APOC Trust Fund in 2011 and 2012 Table14: Number of financial reports submitted and analysed in 2011 and 2012 Table15: Achievements and challenges of development and implementation of the CDI curriculum and training module
Figures Figure1: Prevalence of schistosomiasis and CDTI project areas in Adamaoua, North and Far North regions of Cameroon Figure2: Prevalence of soil-transmitted helminths and CDTI projects area in Adamaoua, North and Far North regions in Cameroon Figure3: Trend of geographical coverage (%) in post-conflict APOC countries: 2008 and 2011 Figure4: Trend of geographical coverage (%) in Stable APOC countries: 2008 and 2011 Figure5: Trends of therapeutic coverage (%) in post-conflict APOC countries: 2008 to 2011 Figure6: Trends of therapeutic coverage (%) in stable APOC countries: 2008 and 2011 Figure7: Therapeutic and Geographical Coverage thresholds reached by CDTI projects in 2011 Figure8: Reported number of persons treated in APOC countries between 1998 and 2011 Figure9: Proportion of ivermectin tablets distributed to APOC and Ex-OCP countries in 2011Figure10: An evaluation team with community membersFigure11: Preliminary and partial results of entomological evaluation undertaken in seven endemic countries in 2011/2012Figure12: Localization of the breeding sites sampled in Nigeria and Cameroon in July/August 2012Figure13: Species identified and their localization at the border of Cameroon and NigeriaFigure14: Locations of the three Provinces in DRC co-implementing NTD control with onchocerciasis controlFigure15: Major health interventions co-implemented alongside ivermectin distribution using CDI in 10 countries in 2011Figure16: Women and men in DRC participating in a community meeting on gender mainstreamingFigure17: Allocation of APOC Trust Fund’s to the main activities in 2011 and 2012Figure18: Proportion of the budget used for administrative expenses, renewal of equipment, recurrent expenditure compared to technical and operational (2011-2012)Figure19: The current Director of APOC, Dr Paul-Samson Lusamba-Dikassa, receiving the Champalimaud Award
Annexe Annex1: Numbers of Mectizan tablets provided to APOC country programmes from 1997 to 2011
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AfDB African Development Bank
AFRO WHO Regional Office for Africa
APOC African Programme for Onchocerciasis Control
BELACD Bureau d’études, de liaison des actions caritatives et de développement.
CAR Central African Republic
Cbm Christoffel-Blindenmission (German NGO)
CCHP Comprehensive Council Health Plan
CDD Community-Directed Distributor
CDI Community-Directed Intervention
CDTI Community-Directed Treatment with Ivermectin
CHAL Christian Health Association of Liberia
CIDA Canadian International Development Agency
CRS Catholic Relief Services
CSA Committee of Sponsoring Agencies
DALYs Disability Adjusted Life Years
DFC Direct Financial Cooperation
DOTs Directly Observed Treatment Short-course
DRC Democratic Republic of Congo
GIS Geographic Information System
GSM Global Management System
HIA Health Impact Assessment
HKI Helen Keller International
HoD Head of Department
HSAM Health Education /Sensitization /Advocacy /Mobilisation
IEC Information, Education, Communication
IEF International Eye Foundation
IFESH International Foundation for Education and Self-Help
IMA Inter-Church Medical Assistance
IPM Independent Participatory Monitoring
IRC International Rescue Committee
JAF Joint Action Forum (APOC governing body)
LA Letter of Agreement
LGA Local Government Area
MDGs Millennium Development Goals
MDP Mectizan® Donation Program
MDSC Multi-Disease Surveillance Centre
MITOSATH Mission To Save The Helpless
NGDO Non-Governmental Development Organisation
NGO Non-Governmental Organisation
NOCP National Onchocerciasis Control Programme
NOTF National Onchocerciasis Task Force
NTD Neglected Tropical Disease
OCP Onchocerciasis Control Programme in West Africa
OPC Organisation pour la Prévention de la Cécité
OTD Other Tropical Diseases
PRONANUT Programme National de Nutrition
RAPLOA Rapid Assessment Procedure for Loa loa
REMO Rapid Epidemiological Mapping of Onchocerciasis
SAE Severe Adverse Event
SSOTF Southern Sudan Onchocerciasis Task Force
SS SightSavers
TCC Technical Consultative Committee (APOC scientific advisory group)
TDR WHO-based Special Programme for Research and Training in Tropical Diseases
TSA Technical Service Agreement
UFAR United Front Against River-blindness
UNICEF United Nations Children’s Fund
USAID United State Agency for International Development
WAHO West African Health Organisation
WHO World Health Organisation
WHO/OCP see OCP
WHO/TDR see TDR
Abbreviations
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Executive summary
The period 2011-2012 was an important one for APOC as the Programme prepared a Strategic Plan of Action and Budget for 2016-2025 as requested by JAF17 in view of the extension of the Programme that is foreseen in order to achieve elimination of onchocerciasis infection and interruption of transmission where feasible. At a time when funding was planned to decrease in view of the existing closing date for APOC in 2015 more intensive epidemiological surveys were undertaken to support progress towards elimination and more efforts were made to support co-implementation of control activities against other Neglected Tropical Diseases (NTDs) alongside onchocerciasis elimination. This has placed increasing demands upon the Programme, despite which, continuing progress is being made in CDTI towards the target of treating 90 million people by 2015. During the period under review a total of 80.2 million people were treated with ivermectin based on preliminary treatment data that will be verified and updated in the last quarter of 2012.
Collaboration with WHO-AFRO continued and was reinforced, especially through the provision of joint support to countries developing Strategic plans for NTD control, for example in workshops held to develop plans for DRC and Liberia in may 2011 and June 2012 respectively. In addition, WHO-AFRO continued to provide support to activities of technical staff in APOC participating countries and transfer of funds to NOTF secretariats and CDTI Projects among others.
CDTI and co-implemented community-directed health interventionsAs the APOC Programme refines the delineation of transmission zones towards the objective of elimination of infection where feasible, the numbers of people to be targeted for ivermectin treatment is increasing. As described in section 1.2, good progress is being made to reach the new target of 80% therapeutic coverage. There were also significant improvements in geographical coverage, which now averages 97%. In 2011 implementation of CDTI started in a new Project (Phase V) in Uganda in the Districts of Kitgum, Pader and Lamwo, which is an area in which ‘nodding syndrome’, a disease for which no cause has yet been identified, occurs. TCC also approved the Ituri Nord CDTI Project in DRC although a cautious phased approach to treatment has been recommended in view of the possibility of severe adverse events (SAEs) in this Region that is co-endemic for loiasis. Additional challenges remain in some of the post-conflict countries, particularly in Eastern DRC, where continuing outbreaks of violence can disrupt activities.
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As community-directed health interventions are increasingly used to deliver other health commodities, a total of 43 159 497 health interventions were provided in 10 countries for which data has been reported. This is in addition to the 80.2 million ivermectin treatments delivered through CDTI and includes data from the expanded co-implementation Programme for which USAID provides additional support, in Tanzania and the Democratic Republic of the Congo (DRC).
Strengthening community health systemsOne of the main ways in which APOC strengthens community health systems is through training, and over the period covered by this report over 83 000 health workers at different levels received training. This training covered many areas ranging from the theory and practice of community-directed interventions through to entomological and epidemiological evaluation methods and project financial management. Eight new fellowships were awarded by APOC for postgraduate studies leading to a Masters degree in entomology, public health and epidemiology.
PartnershipThe NGDO group continues to be an important APOC partner and the establishment of the NTD/NGDO Network represents the emphasis placed by many partners on the integration of the community-directed interventions (CDI) strategy and CDD Network into national NTD control programmes. In relation to this, the Director of APOC attended the second session of the NTD/NGDO Network in Nairobi, Kenya in September 2011. As detailed in section 5.6 of this report, APOC management attended numerous meetings with partners aimed at strengthening links and partnerships to support CTDI Projects and improve coordination of NTD control.
Government contributions and financial support from the APOC Trust FundIn response to JAF and the CSA, the African Development Bank (ADB) and the World Bank assisted APOC Management in preparing the Term of reference and identifying suitable health economists who have been engaged to develop guidelines and tools for assessing government’s financial contributions to onchocerciasis and other NTD control. A progress report will be presented to JAF 18. On the other hand, in 2011/2012, the APOC Trust Fund supported financially 120 CDTI Projects/Programmes and 6 NOTF secretariats for the implementation of the control/elimination activities.
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ResearchPhase 3 of the moxidectin development study has been completed but final analysis of the data from this trial is yet to be completed. Research into ivermectin response markers is continuing and initial analysis of data suggests that low susceptibility/resistance to ivermectin may have arisen independently in Cameroon and Ghana.
Epidemiological evaluations, mapping and progress towards elimination of onchocerciasis infection and interruption of transmissionActivities related to accurately defining the limits of onchocerciasis distribution and conducting epidemiological evaluations have intensified as APOC directs its attention to the elimination of infection and interruption of transmission of onchocerciasis. Epidemiological evaluations have taken place in 30 sites in eleven countries during 2012, including Tanzania, Uganda and Malawi.
Surveys for mapping the distribution of other selected NTDs (Lymphatic Filariasis, schistosomiasis and soil-transmitted helminths) were carried out in the Democratic Republic of the Congo and Cameroon during the reporting period. The mapping in DRC is a pre-requisite for starting expanded co-implementation of interventions to control the above diseases using the CDI network and structure for onchocerciasis control. Similarly, the mapping in Cameroon will contribute targeting of control interventions, especially for soil-transmitted helminths and schistosomiasis.
AdvocacyDuring the reporting period high-level advocacy visits have been made, especially to post-conflict countries in order to maintain and increase both political and financial support for the Programme. These included a visit to South Sudan, where the situation revealed a need to re-launch CDTI activities in this newly independent nation. High level advocacy also took place in DRC, and in the Central African Republic where a programme for gender mainstreaming in CDTI activities was launched through a ceremony attended by several high level representatives including the Minister of Social Welfare and Gender.
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1.1 Disease mapping1.1.1 Mapping of onchocerciasis prevalenceFollowing an in-depth review of REMO data and based on local knowledge on the status of onchocerciasis in Ethiopia, the NOTF-Ethiopia requested support from APOC to conduct surveys in order to refine REMO results in 36 districts in Ethiopia. Planning is going on and the surveys will be conducted in October-November 2012.
1.1.2 Integrated mapping of NTDsIn the reporting period, APOC provided technical and financial support for the mapping of additional NTDs in the Democratic Republic of the Congo (Lymphatic Filariasis, schistosomiasis and soil-transmitted helminths) and in Cameroon (schistosomiasis and soil-transmitted helminths).
DRC: mapping of Lymphatic Filariasis, schistosomiasis and STH
In DRC, surveys for mapping Lymphatic Filariasis, schistosomiasis and STH were conducted in three provinces: Katanga, Kasaï oriental and Kasaï occidental.
Lymphatic Filariasis (LF): in Kasaï Oriental, LF is endemic in 17 health zones, having a mean prevalence of 7%, varying from 1% to 53%. In Kasaï Occidental, 21 health zones are endemic with a mean prevalence of 2.4% varying
from 1 to 34%. In these two provinces, the epidemiological situation of LF has only been determined using the immuno-chromatographic card test (ICT test). In Katanga, the ICT test revealed 28 endemic health zones with an average prevalence of 2%, varying from 0.9% to 8%. The nocturnal microfilaraemia examinations for Wuchereriabancrofti were conducted in five health zones covering a total population of 1009 persons; no carrier of W.bancrofti was recorded. The negative results for microfilaraemia on these five endemic health zones using the ICT test suggest the need to undertake microfilaraemia tests in all endemic health zones where ICT tests were positive in order to take decisions regarding whether or not to implement mass treatment.
Schistosomiasis: In the course of mapping exercises tests to detect all forms of schistosomiasis were conducted. In Kasaï Oriental, Schistosomamansoni was the most frequently detected species, with a prevalence of 9.3%. Schistosomiasis is endemic in all but six of the health zones. In Kasaï Occidental, the distribution of the disease is focal and is limited to 9 health zones. Its prevalence is lower (0.9%) in Kasaï Occidental where the two species occurring are S.mansoni (0.86%) and S.haematobium
THE YEAR IN REVIEW 1. Community-Directed Treatment with Ivermectin (CDTI) and health impact
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(0.08%). In Katanga, schistosomiasis is confirmed to be endemic in all of the health zones except for three which have not yet been mapped and 18 health zones for which the prevalence was zero. In the other health zones, the prevalence varied from 0.4% to 47.5%, with a mean of 8.8%. S.haematobiumis the most prevalent species (5.27%) followed by S.mansoni (3.05%) and S.intercalatum (0.21%).
Soil-transmitted helminths (STH): In Kasaï Oriental, the prevalence of soil-transmitted helminths is 36%; they are endemic in all but three health zones. Hookworm is the most widespread intestinal parasite with a prevalence of 17%. All the health zones of Kasaï Occidental are endemic with a mean prevalence of 41%. Ankylostomiasis is also the dominant intestinal parasite here, with a prevalence of 24%. In Katanga, the most frequent parasite detected is ascariasis, with a prevalence of 7%. The prevalence of soil-transmitted helminths is lower (10%) in Katanga than in the two Kasaï Provinces.
Cameroon: mapping of schistosomiasis and STH
With support from APOC, the Ministry of Heal of Cameroon conducted surveys to finalise the mapping of schistosomiasis and soil-transmitted helminthiasis in the regions of Adamawa, North, and Far-North.
A total of 257 schools were surveyed in 51 health districts; 42 schools in the Adamawa region, 75 in the North region and 140 schools in the Far North region. In addition, 4 remaining schools from previous mapping studies were surveyed in the Littoral region (2 schools) and 2 schools in the South-West region. A total of 13 052 pupils from these 261 schools were registered and included in the study. Of these children registered, 13 009 (99.67%) provided urine samples and 12 892 (98.77%) provided stool samples.
The results presented in Figures 1 and 2 show the prevalence by health district overlaid with the areas treated with ivermectin by the CDTI projects in the framework of onchocerciasis elimination.
Figure1: Prevalence of schistosomiasis and CDTI project areas in Adamaoua, North and Far North regions of Cameroon.
Figure2: Prevalence of soil-transmitted hel-minths and CDTI projects area in Adamaoua, North and Far North regions in Cameroon.
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In Figure 1, in the districts coloured in red all school-age children and adults considered to be at risk should be treated for schistosomiasis once every two years with praziquantel.
In Figure 2, in the district coloured in red (Bankim) all school-age children and adults considered to be at risk should be treated for STH once a year with Albendazole/Mebedanzole. Also, pre-school, women of childbearing age and adults at high risk are to be treated.
1.2 Geographic and Therapeutic Coverage
1.2.1 Status of geographical coverageThe APOC Trust Fund supports 108 CDTI projects in 16 participating countries. Six countries are categorised as post-conflict countries (Burundi, Central African Republic, Chad, Democratic Republic of the Congo, Liberia and South Sudan). The remaining ten countries are categorised as stable countries (Table 1).
Post-conflictcountries
Burundi 10 369 369 100% 1,469,604 1,176,498 80.1%
CAR 10 6,042 5,459 90.4% 1,832,523 1,502,260 82.0%
Chad 19 3,250 3,250 100% 1,997,825 1621004 81.1%
DRC 234 39,933 38,976 97.6% 29,052,291 22,403,957 77.1%
Liberia 15 4,630 4,385 94.7% 2,935,508 2,419,509 82.4%
South Sudan 44 6,728 5,526 82.1% 5,707,037 3,467,340 60.8%
Total 332 60,952 57,965 95.1 42,994,788 32,590,568 75.8
Stablecountries
Angola 12 1,444 502 34.8% 659,557 131,487 19.9%
Cameroon 110 10,456 10,447 99.9% 6,714,005 5,403,559 80.5%
Congo 27 770 770 100% 844,656 686,127 81.2%
Eq. Guinea 1
Ethiopia 78 22,762 22,734 99.9% 5,980,772 4,741,282 79.3%
Malawi 8 2,186 2,186 100% 2,078,112 1,718,966 82.7%
Nigeria 418 36,183 36,101 99.8% 38,345,240 30,439,546 79.4%
Sudan 3 319 319 100% 403,516 329,702 81.7%
Tanzania 16 5,286 5,286 100% 1,815,224 1,456,302 80.2%
Uganda 35 6,028 6,028 100% 3,808,680 2,749,364 72.2%
Total 708 85,434 84,373 98.8 60,649,762 47,656,335 79.1
GrandTotal 1040 146,386 142,338 97 103,644,550 80,246,903 77.4
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%Country
Table1: Summary of ivermectin treatment in APOC participating countries in 2011 (data reported as at August 2012)
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In 2011, ivermectin treatment was implemented in all of the 16 participating countries in 1040 endemic districts, out of which 31.9% are post-conflict countries and 68.1% stable countries. Four projects in Angola had not yet reported 2011 treatment data as at 26 August 2012. Treatment data from Equatorial Guinea have not been received for the last two years.
Post-conflict countries
In 2011, 57 965 communities were treated in 6 countries with an average geographical coverage of 95.1%, ranging from 82% in South Sudan to 100% in Chad and Burundi. This year, results for geographical coverage have shown a significant improvement from 2009, having increased by 18% from 77% to an average of 95%.
Of the 34 CDTI approved projects in post-conflict countries, all 34 (100%) reported in 2011. Out of a total of 60 952 meso and hyper-endemic communities in those countries, 57 965 (95%) were treated. With the exception of Burundi and Chad (Table 1), the geographical coverage remains below 100% in all countries in the group. Low geographical coverage was recorded in CAR (90%), DRC (97%) and South Sudan (82%). These three countries share a long history of armed conflict with the associated health and humanitarian emergencies. However, all the countries have shown a continuing trend of improvement over the past two years except for South Sudan and Liberia, where the rate of geographical coverage deteriorated in 2011. Figure 3 shows the four year geographical coverage trend.
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Chad Liberia
Figure3: Trend of geographical coverage (%) in post-conflict APOC countries between 2008 and 2011
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Stable countriesSixty per cent of the 142 338 communities receiving treatments in the Programme were in ten stable countries. Geographical coverage (shown in Table 1 and Figure 4) remained above 90% in all the stable countries except for Angola and Equatorial Guinea. A lack of appropriate capacity to assist communities with ivermectin treatment resulting in discontinued availability
of ivermectin may explain the low coverage observed in Equatorial Guinea and to some extent in Angola.
As can be seen in Figure 4, with the exception of Angola, Equatorial Guinea, Cameroon, Nigeria, Uganda and Tanzania, the four year trend for countries in this group achieved and sustained full (100%) geographical coverage between 2008 and 2010.
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2008 2009 2010 2011
MalawiNigeria
Sudan
TanzaniaUganda
Angola
Cameroon
Eq. GuineaCongo
Ethiopia
Figure4: Trend of geographical coverage (%) in s table APOC countries between 2008 and 2011
1.2.2 Status of therapeutic coverageIn 2011, 80 246 903 people out of a total population of 103 644 550 persons were treated in 16 countries of whom 59% (47 656 335 people) were in stable countries and the remaining 32 590 568 were in post-conflict countries.
Post-conflict countriesIn the post-conflict countries the average therapeutic coverage was 76%, ranging from 61% in South Sudan to above 80% in Burundi, CAR, Chad and Liberia (see Table 1). Figures 5 and 6, comparing therapeutic coverage in post-conflict and stable countries
between 2008 and 2011, show that all the post-conflict countries except South Sudan, maintained a therapeutic coverage above the previous threshold for control of onchocerciasis of 65%. The Chad project has exceeded a therapeutic coverage of 80% since 2007, and Liberia for two consecutive years now, Burundi and CAR exceeded this threshold of 80% for the first time this year, thus reaching the threshold set by the 14th session of the Joint Action Forum for the elimination target. DRC is also making remarkable progress with a successive incremental trend in therapeutic coverage for the last four years.
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80% coverage thresholdfor elimination
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80% coverage threshold for elimination
65% coverage threshold for control
Figure5:Trends of therapeutic coverage (%) in post-conflict APOC countries from 2008 to 2011
Figure6:Trends of therapeutic coverage (%) in stable APOC countries between 2008 and 2011
Stable countries
All the stable countries except Angola, achieved a high therapeutic coverage above 70% in 2011 (Table 1) with an average overall coverage of 77.9%. For Angola, the therapeutic coverage was very low in 2011 (19.9%) but this was adversely influenced by the fact that four of projects did not report their treatment data for this year. Figure 6summarises the treatment figures in APOC Programme countries from
2008 to 2011. Malawi has consistently maintained therapeutic coverage of 80% and above for the last five years followed by Congo in the last three years.
The number of projects that achieved therapeutic coverage higher than the 65% threshold for onchocerciasis control was 95 out of 102 (93%) projects that reported these data (Table 2).
As of 2011, 108 CDTI projects had been approved in 16 of the 20 participating
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countries of APOC; 107 of these conducted treatment and 102 reported their treatment data, giving a reporting rate of routine treatment data of 95%. The projects reaching the 80% target for therapeutic coverage necessary to accelerate progress towards elimination are closed to 50% of projects reporting in 2011. Similarly, 70% of the 102 reporting projects have achieved the target of 100% geographical coverage this year, mainly related to improvement in post-conflict countries (Figure 7).
The 102 projects covered 142 338 out of a total of 146 386 meso and hyper-endemic communities, and treated 80 246 903 persons out of a total population of 103 644 550.
The reported number of persons treated in 2011 represents an 8.6% increase from
2010 and is now double of the number treated in 2005 (Figure 8).
1.3 Ivermectin (Mectizan®) tablets supplied by the Mectizan Donation Programme (MDP)
Between 1997 and 2011, the Mectizan Donation Programme has donated 2 168 732 700 tablets to APOC countries. In 2011 alone 352 594 500 (77%) tablets were supplied to 14 APOC countries and 107 939 500 (23%) tablets to three ex-OCP countries for the control/elimination of Onchocerciasis or for integrated Lymphatic Filariasis and Onchocerciasis control/elimination (Figure 9). Details of the numbers of tablets supplied to the 17 recipient countries are given in Annex 1.
CountryLeveloftherapeuticcoverage
Levelofgeographical
coverageNb of
projects reporting
<65% 65-80%(Control)
>=80%(Elimination) <100% 100%
Angola 2 2 2
Burundi 3 3 3
Cameroon 7 8 2 13 15
CAR 1 1 1
Chad 1 1 1
Congo 2 2 2
DRC 11 9 8 12 20
Eq. Guinea
Ethiopia 5 4 3 6 9
Liberia 3 3 3
Malawi 2 2 2
Nigeria 20 7 6 21 27
South Sudan 4 1 5 5
Sudan 1 1 1
Tanzania 2 4 6 6
Uganda 1 4 5 5
Total 7 46 49 30 72 102
Percentage(%) 7% 45% 48% 29% 71% 100%
Table2: Classification of the CDTI projects in relation with the therapeutic coverage thresholds reached in 2011
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20042005
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Figure7:Percentage of CDTI projects classified by therapeutic and geographical coverage categories in 2011
Figure8:Reported number of persons treated in APOC participating countries between 1998 and 2011
Figure9:Proportion of ivermectin tablets supplied to APOC and Ex-OCP countries in 2011
Ex-OCPcountries107 939 500 ivermectin tablets
APOCcountries352 594 500 ivermectin tablets
23%
77%
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1.4 Monitoring, evaluation and surveillance 1.4.1 Independent Participatory monitoringIn December 2006, during its 12th session JAF endorsed the report of a Working Group on the future of APOC and the control of onchocerciasis in Africa and approved six recommendations included a recommendation extending APOC’s mandate to include some ex-OCP countries. This was stated in the final communiqué point 12.5 as follows:
InordertomaintaintheachievementsoftheOCP,APOC’sscopeofactivitiesshouldbeexpandedtoestablishappropriateregionalsupportmechanismsincludingsupportforformerOCPcountrieswheretheepidemiologicalsituationrequiresurgentattention.
Côte d’Ivoire, Ghana, Guinea Bissau and Sierra Leone, were the four ex-OCP countries deemed to be in need of urgent attention and therefore APOC started to provide them with funds and technical support for the re-launch and reinforcement of control activities.
Independent Participatory Monitoring exercises of CDTI projects verify that they are on schedule to achieve sustainability. In a participatory manner, teams composed of external monitors, programme managers from other project areas and community members undertake these exercises.
Ghana and Sierra Leone, each after 5 years of APOC financial and technical support, underwent independent participatory monitoring exercises between 18th September to 4th October 2011 and 12th to 24th April 2012 respectively during the reporting period.
In Ghana, the exercise covered three purposively selected regions (Volta, Brong Ahafo and Northern regions)
out of nine that are Onchocerciasis endemic, based on the 2009 Rapid Epidemiological Mapping for Onchocerciasis (REMO) report, to ensure representation of the three most endemic zones.
In Sierra Leone, the exercise covered all the three regions that are Oncho endemic with a total of six districts: Kenema and Kailahun from the Eastern region, Moyamba and Bonthe from the South and Kambia and Port Loko from the Northern region.
The results of the independent participatory monitoring exercise are summarised in Table 3.
The results showed good performance of most of the indicators monitored. Significant achievements were registered in both Ghana and Sierra Leone CDTI projects as both geographical and therapeutic coverage were found to be very high in most communities. Community participation and programme ownership were also found to be high in both countries as communities participate in the selection of their CDDs, collect ivermectin from the health facility and carry out sensitisation and mobilisation of community members to take ivermectin. Nevertheless, in Ghana, the decision as to the mode and method of distribution is still highly driven by health staff (69% versus 32.1% in Sierra Leone).
While Ivermectin supplies were reported to be good in both countries, in Ghana there were concerns that delays are sometimes experienced resulting into some rounds spilling over to subsequent years.
In both countries all health workers and CDDs interviewed indicated that they receive annual training although monitors noted glaring gaps especially
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with regard to record keeping especially in Ghana where household registers were absent in some communities.
The monitors reported that in the Ghana programme, very few females, if any, are involved as CDDs. For example, it was reported that in Pru district, Brong Ahafo region, there was only one female serving as a CDD. Monitors also reported that in Sierra Leone few females (10%) were serving as CDDs in the 30 villages covered by the monitoring exercise.
Despite their little involvement in CDTI as CDDs, women were reported to be active and to attend community meetings in large numbers. Women were reported as making useful suggestions and contributions during these community meetings. Indeed, during the monitoring exercise at community meetings the turn-out for women was always higher than that of men. A number of reasons were reported to explain why few women are serving as CDDs and include; having too many domestic commitments (marriage, caring for the children etc)
that leave them little time to serve as CDDs, cultural – where the CDD role is seen to be more of a male than a female role and high illiteracy levels among women. In addition, some women viewed the work of CDDs as tedious which can only be handled by men as observed.
Out of a total of 300 households covered by the monitoring exercise in each country only 4.5% (Ghana) and 32.9% (Sierra Leone) reported having ever compensated a CDD and this compensation was mainly in the form of giving them farm work, providing means of transport, food items or at times, some little money.
There is a need to reinforce community mobilisation and sensitisation in order to improve community ownership especially to motivate the CDDs. Deliberate efforts should be made to encourage women to participate as CDDs.
IndicatormonitoredPerformance
Ghana SierraLeone
1 Treatment coverage – geographic – therapeutic
Good (90%) Good (100%)
Good (83.2%) Good (79.3%)
2 Community participation and programme ownership Good Good
3 Health Education/Mobilisation/ Sensitisation Good Very good
4 Mectizan supply, collection and distribution Good Very good
5 CDD performance Good Good
6 Gender Issues and Minority groups/ non-indigenous Poor Poor
7 Training, monitoring and supervision Good Very good
8 Integration Good Very good
9 Partnership Good Very good
10 Resources Poor Poor
Table3:Summary of Independent Participatory Monitoring results in Ghana and Sierra Leone
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1.4.2 Community self-monitoring (CSM)The importance and role of community self-monitoring (CSM) in strengthening community ownership and ensuring sustainability of CDTI projects has been emphasized by TCC. APOC management, following the request of National programme Managers (5th NOTF meeting) to financially assist projects to initiate and upscale CSM, provided funds to some countries between 2008 and 2011. Additionally, APOC management held a series of in-country consultations, using a bottom-up approach with Community Leaders/Members and health staff facilitated by social anthropologists to better understand the barriers to implementing CSM. During the reporting period 26 549 (16.4%) out of 161 603 communities implemented CSM while 43 979 (27.2%) reported having carried out stakeholders meetings. It is to be noted that while some countries like Sudan (100%), Tanzania (68.5%) are Chad (56%) are making efforts to implement CSM, many countries still do not carry out this exercise (Burundi, Ethiopia, Liberia, South Sudan and Uganda). Some countries such as Congo, Sierra Leone and Malawi that scored 100% during the reporting period prefer to have stakeholders meetings (Table 4).
In its’ 33rd and 34th sessions, TCC extensively discussed this issue and concluded that there is some weak evidence that CSM may facilitate distribution of ivermectin and improve coverage but TCC would like more scientific evidence substantiate this (TCC33). A sub-committee was formed to look into guidelines for CSM and establish if there is a need for revision. The sub-committee was also charged to form an impression of the impact of CSM on CDTI its value in terms of coverage and sustainability and to
suggest research that is needed to look into the impact in more detail and finally to discuss the issue of funding for CSM.
The sub-committee considered that there is a need for a multi-country study, able to look at different situations and examine all aspects of CSM. As this would have a cost implication for APOC management, the suggested 6-month timeline for the study would depend upon the possibility of finding the necessary funds. The TCC asked the subcommittee to put together Terms of Reference (ToR) and a budget to be submitted to APOC management and recommended that APOC should explore the possibility of conducting desk reviews at country as well as at APOC-HQ level; and convene the proposal development workshop after a decision is reached regarding the countries in which CSM assessment will be implemented.
The ToRs for the multicounty study have been finalised but because of budgetary constraints the study has been postponed to 2013. Funds are being identified to carry out the desk review on CSM in some APOC countries (Malawi and Chad) and at APOC HQ level during the later part of 2012.
1.4.3 Evaluation of sustainability of CDTI ProjectsIn the context of the shift from control to elimination where operations should be time limited, it became important to discuss and agree on the role and pertinence of sustainability as developed for the control of the disease as a public health problem. In some CDTI Projects, the performance is known to be below expectations without a formal and documented assessment of the projects. Sustainability evaluation of these Projects should be seen as the
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means by which APOC can make an in depth evaluation of the functioning of the system and identify through external evaluators the causes for poor performance, discuss the problems in the field with the Project coordinators and others involved in the Project. This allows recommendations to be made and actions to be taken that can be expected to significantly improve performance and put the Project on track to sustainability. This may involve advocacy at a high level in order to get the necessary political and administrative support from the countries authorities. An example is the evaluation of CDTI that took place in
South Sudan in 2011 that showed serious problems with the CDTI projects. That evaluation led to significant actions being taken in 2012 to re-launch CDTI in that troubled post-conflict country.
In 2012, APOC initiated evaluations of sustainability in 4 Projects in the Democratic Republic of Congo; this country has also been undergoing conflict, especially in the Eastern part of the country and this has made successful implementation of CDTI difficult. One of the evaluations, in Masisi-Walikale CDTI Project had to be terminated at the onset as renewed fighting broke out in the area just as the evaluation pre-visits were due to start.
Country Totalnumberofcommunities
CommunitiesthatconductedCSM
CommunitiesthatconductedSHM
Nbofdistricts
thatreportedNb % Nb %
Angola 1,444 74 5.1% 31 2.1% 12
Burundi 369 0 0% 84 22.8% 10
Cameroon 10,456 1,251 12% 844 8.1% 110
Central African Republic 6,042 878 14.5% 878 14.5% 10
Chad 3,250 1,821 56% 0 0% 19
Congo 770 173 22.5% 770 100% 27
DRC 39,933 8,121 20.3% 4,168 10.4% 237
Ethiopia 22,762 0 0% 14,322 62.9% 78
Liberia 4,630 0 0% 0 0% 15
Malawi 2,186 803 36.7% 2,186 100% 8
Nigeria 36,183 9,487 26.2% 9,066 25.1% 418
South Sudan 6,728 0 0% 0 0% 44
Sudan 319 319 100% 0 0% 3
Tanzania 5,286 3,622 68.5% 3,179 60.1% 16
Uganda 6,028 0 0% 0 0% 35
Cote d'Ivoire 3,454 0 0% 0 0% 46
Ghana 3,312 0 0% 0 0% 40
Sierra Leone 8,451 0 0% 8,451 100% 12
GrandTotal 161,603 26,549 16.4% 43,979 27.2% 1,140
Table4:Number of communities and districts implementing Community Self-Monitoring and stakeholders meetings in 2011
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Evaluations of sustainability were completed in the Projects of Mongala and Tshopo in DRC and in the CDTI Project in the Central African Republic (CAR) in 2012. From the results of these evaluations Tshopo Project in DRC was making progress towards sustainability, with an overall score of 2,7 whilst Mongala Project was not making progress towards sustainability, receiving an overall mean score of only 1,23. Some of the challenges faced by this, and other CDTI Projects in DRC including Tshopo, are the difficulties in transportation and communication, given the long distances and poor infrastructure, and general insecurity in the country, especially in the East such as that which occurred in Masisi-Walikale. Financial support received low score in each of the evaluations and more advocacy should be aimed at increasing the level of political and financial support given to each of these projects from the Provincial authorities.
The CAR CDTI Project was found not to be making good progress towards sustainability with an overall score of 1,87. The Project particularly did not
score well at the Front-Line Health Facility (FLHF) level. There is still insecurity in parts of the country and the lower level such as the FLHF may be most likely to be affected from this.
1.4.4 Surveillance activitiesTransmission assessments
During the reporting period, APOC Management continued to put emphasis on setting up in APOC countries surveillance/evaluation teams and systems to assess the level of transmission of onchocerciasis parasite. In addition to Chad, Nigeria and Uganda where the capacity of technicians was built and entomological evaluation activities were launched during the previous reporting period, Cameroon, DRC, Malawi and Tanzania benefited from the implementation of the same two activities. Moreover, APOC continued to monitor the status of Onchocerciasis transmission in ex-OCP countries in order to assist them with timely detection of any recrudescence of transmission. Transmission is considered to be interrupted when the infectivity rate, assessed through the
Figure10:An evaluation team in Liberia.
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pool screening techniques of blackflies (≥6000 blackflies) at a particular sampling site, is <0.5‰.
APOC countries
A total of 48 652 blackflies sampled in 2011 at 16 catching points in three countries (Nigeria, Chad and Uganda) were analysed in order to assess their infectivity rates.
In Nigeria, 10 catching points, covering Cross River, Ebonyi and Kaduna States, were assessed from August to December 2011 with the following results:
i. Cross River State: Akamkpa LGA at Kwa Falls catching point, 11 074 blackflies sampled were examined by pool screening with an infectivity rate of 0.566‰ while 2422 additional flies dissected showed one infective fly with one parasite in the head, making a partial annual transmission potential (ATP) of 10 infective larvae (L3H)/man/year; at Boki LGA, the infectivity rate at Afi catching point was 0.377‰ for 8336 blackflies screened while 1937 other flies dissected were negative for infection. TheseborderlineresultsatKwaFallscatchingpointareaindicatethatinvestigationsshouldbeperformedduringphase1binawiderareaforthewholetransmissionperiodtocarefullyassessthetransmissionandadviseonthewayforward.
ii. Ebonyi State: Izzi LGA at Onuenyim Agbaja catching point, 5825 blackflies sampled were examined by pool screening with an infectivity rate of 0.19‰; at Onuenyim Ishieke catching point, 5902 blackflies sampled were examined by pool screening with an infectivity rate of 0‰. 3175 otherflies from these catching points were dissected and none of them was carrying O.volvulus parasite. The partial ATP calculated for these catching points were nil.
Transmissionislikelytohavebeeninterrupted.Furtherinvestigationsarenecessaryunderphase1binawiderareaandcollectingmorefliestoconfirmthesatisfactorysituation.
iii. Kaduna State: At all four catching points (Kudaru, Kudaru Fulani, Gulbin Kimbi and Rafin Kurbau) within the two LGAs (Lere/Kajuru and Birnin Gwari) selected for the assessments, the number of blackflies sampled was less than the 6,000 required per catching point. The maximum number of flies sampled (3238) was at Kudaru. To address this situation, other potential catching points including Rahim Kiyaya Kimbi and Falallai were visited, but none of them was more productive. Nevertheless, 538 flies were dissected, two were positive with seven larvae in the head (L3H) but none of the parasites was O.volvulus. None of the other 3762 blackflies sampled at all catching sites in Kaduna State and examined by pool screening was infected. Transmissionislikelytohavebeeninterrupted.Furtherinvestigationsarenecessaryunderphase1binawiderareaandcollectingmorefliestoconfirmthesatisfactorysituation.
In Chad, the productivity of the rivers was very low, probably due to very weak river flow. No blackfly was captured in the foci of Bebidja while in the foci of Danamadji, 791 flies were sampled at Waltama and 1166 were caught at Sergue. None of these flies was carrying O.volvulus parasites. Althoughnoinfectiveflywascaught,thenumberofcatchingpointsandthenumberoffliessampledwerelimitedandtherefore,thephase1bassessmentsshouldbeimplementedtoeffectivelyverifytheinterruptionoftransmission.
In Uganda, four catching points (three from Kasese district (Kathembo,
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Isango and Kisanga catching points) and one from Moyo district (Amua catching point) were identified for the assessments. The site of Amua was not visited in 2011. The number of blackflies sampled on each of the three sites from Kasese district during October-November 2011 and January February 2012 (four months) did not reach the 6000 flies required. Among the 7466 flies sampled in Kasese district, 6783 flies were preserved and sent for pool screening. OVS2 positives were found in the samples from each of the three catching points. 1177 out of the 8773 flies sampled in Kasese district were dissected. One out of the 592 flies from Kathembo was carrying a parasite that will be sent to the DNA laboratory for identification. The flies dissected from Isango and Kisanga were free from infection.Complementaryassessmentswillbeundertakentounderstandtheoriginoftheinfectedfliesinareaswhereinfectionfromhumanseemstohavebeeneliminated.Itshouldbenotedthatthedistrictsconcernedareclosetoareaswhereivermectintreatmentshavejuststartedorhavetobelaunched.
Other endemic countries in Africa
In 2011, APOC provided financial support to eight ex-OCP countries (Benin, Burkina Faso, Côte d’Ivoire, Ghana, Guinea, Guinea Bissau, Mali and Niger) for entomological surveillance activities. A total of 181 359 captured flies from these countries were sent to the laboratory of molecular biology for screening. These screenings are ongoing for Guinea, Guinea Bissau, Mali and Niger while flies from Ghana, Burkina Faso, Côte d’Ivoire and Benin were already screened and the results reported as follows:
In Ghana 15 625 flies were collected from 10 monitoring sites. The infectivity rates are zero in Ghana; however, the number of flies examined per catching
point is less than the 6000 required. Consequently, the catches should continue to complete the number of flies and allow eventually confirmation of these good results.
In Burkina Faso, 51 189 flies were collected from 13 sites. The infectivity rates are equal to zero at six catching points and below the threshold of 0.5‰ on the remaining catching points. These good results should be confirmed with additional samplings.
In Côte d’Ivoire, 35 530 flies were collected from 17 catching sites. 12 of these points under evaluation have an infectivity rate equal to zero or below the threshold. In the remaining five sites, the infectivity rates are close or above the threshold. However, the number of flies examined per catching point is less than the 6000 required. Therefore, complementary assessments are needed to clarify the situation.
In Benin, in the context of the study on trans-border Simulium fly migration between Nigeria and Benin, 4974 were screened, the infectivity rates are equal to zero in all the 5 monitoring sites. These excellent transmission results were also reported in 2010.
In addition to the flies captured for screening, APOC provided support to Burkina Faso, through the laboratory of molecular biology, in identifying microfilariae collected in the course of epidemiological assessments in 12 villages of Burkina Faso. All the microfilariae have been identified as O.volvulus of the savanna strain.The preliminary results of transmission are presented below in Figure 11.
Delineation of transmission zones
During the year under review, activities were undertaken to provide information for delineation of possible transmission zones in parts of Cameroon and Nigeria
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that share common river basins. This is to determine if transmission zones cross the borders of the two countries as part of the cross border activities currently being undertaken towards the elimination agenda. The ten technicians trained last year in Nigeria undertook therefore larval sampling in rivers within Cross River, Benue, Adamawa and Taraba States in Nigeria from 14th July to 4th August 2012 and the APOC cytotaxonomy team, together with four trainees from Cameroon sampled rivers in the South West and North West Regions of Cameroon from 19th to 27th July 2012. Sampling exercise was still on going in the North Region of Cameroon at the time this report was written.
A total of 94 possible breeding sites and 39 breeding sites were visited in Nigeria and Cameroon respectively (Figure 12). With the exception of a few sites which were inaccessible, all other sites were prospected for S.damnosum s.l. larvae. Simulium larvae were collected from the 59 sites in Nigeria but members of the S.damnosums.l. were obtained from only 8 sites and in Cameroon 17 sites out of 28 sites positive for Simulium larvae were positive for S.damnosums.l. The identifications indicated the following
Figure11:Preliminary and partial results of entomological evaluation undertaken in seven endemic countries in 2011/2012
species S.mengense, S.soubrense Beffa form, S.squamosum, S.yahense, S.damnosum s.s, and S.sirbanum. The species distribution map is shown in Figure 13. Analysis for the possible transmission zones is on-going but the initial results indicate that similar populations of S.soubrense Beffa form exist on some rivers in the Cross Rivers State in Nigeria and South West Region of Cameroon. It is interesting to note that S.soubrense Beffa form was the same species that formed the migrating population between Benin and Eastern Nigeria. However, the Benin and Eastern Nigeria populations are different from the Cameroon/Nigeria populations. Maps delineating the possible vector migration routes and hence transmission zones across Nigeria and Cameroon will be prepared at the end of the analysis. In addition, samples will be collected at different seasons to get a full picture of the species that breed at the border of the two countries.
In order to accelerate the mapping of Simulium species and subsequently contribute to the delineation of transmission zones, APOC also undertook a two-month cytotaxonomy training of technicians from Cameroon
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(4), Chad (3), Central African Republic (3) and Congo (4) in Garoua, Cameroon as from 3rd of August 2012.
1.4.5 Health impact assessmentA team from Erasmus University Rotterdam (the Netherlands) is working with APOC on a comprehensive health impact assessment. Updated estimates of APOC’s health impact were presented
to the 17th session of the Joint Action Forum (Kuwait City, Kuwait), from 12-14 December 2011), based on treatment coverage data through 2010.
Overall therapeutic coverage of APOC’s target population has increased gradually over the years to reach 73% by 2010. By 2010, about 65% of the population lived in areas subjected to 10–13 rounds of mass treatment, 17% in
Figure12:Localization of the breeding sites sampled in Nigeria and Cameroon in July/August 2012
Figure13:Species identified and their localization at the border of Cameroon and Nigeria
species identified:
Nigeria:S.soubrense Beffa form, S. squamosum, S. damnosum s.s, and S. sirbanum
Cameroon:S. mengense, S. soubrense Beffa form, S. squamosum, S. yahense
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areas subjected to 6–9 rounds of mass treatment, and 19% in areas subjected to 1–5 rounds of mass treatment. As a result of these treatment activities, the prevalence of infection in the whole APOC area declined from 45% in 1995 to 31% in 2010. Similarly, the prevalence of troublesome itch declined from 14% to 6%, the prevalence of visual impairment from 1.2% to 0.8%, and the prevalence of blindness from 0.6% to 0.3%. The burden of disease expressed in Disability Adjusted Life Years (DALYs) declined from 22.8 to 9.6 per 1000 persons, a reduction of almost 60%. This metric sums years of life lost due to premature death and years of healthy life lost due to disability (i.e. years of life lived with disability, weighted with the following factors to account for the severity of the condition: 0.068 for troublesome itch, 0.0282 for visual impairment and 0.594 for blindness). In absolute terms, ivermectin mass treatment averted 8.2 million DALYs between 1995 and 2010. The prevalence of infection and associated clinical manifestations and burden of disease are expected to decline further in the coming years, provided that mass treatment is scaled up further and continues as planned. Yearly repeated ivermectin treatment
also has an impact on other tropical diseases (e.g. ascariasis and LF), which may have caused an extra 1 million DALYs being averted by 2010.
APOC achieved this health impact at very moderate costs: between 1995 and 2010, coordination of mass treatment had cost roughly US$ 257 million (68% of disbursements being made by APOC and the remainder by national onchocerciasis task forces; government salaries, drug costs and community costs not included). The ONCHOSIM model has been thoroughly revised and modernised, and was extensively tested. The Erasmus MC team is now working on some important extensions of the model. In 2010 and 2011 workshops took place to train APOC staff and programme managers in the use of ONCHOSIM for project evaluation.
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2. Moving from control to elimination of Onchocerciasis where feasible
The feasibility of Onchocerciasis elimi-nation with Ivermectin treatment in Africa was shown by Diawara et al. in 20091. Three years later, Traore et al 2. provided the proof-of-principle for Onchocerciasis elimination with iver-mectin treatment in endemic foci in Africa. Based on this scientific evidence, the African Programme for Onchocer-ciasis Control (APOC), whose interven-tion strategy is large scale ivermectin distribution, directed by communities, is conducting epidemiological evaluations to assess trends towards elimination of Onchocerciasis throughout the pro-gramme scope where ivermectin treat-ment has been conducted for at least ten
consecutive years. Between 2009 and 2011, epidemiological evaluations were undertaken in 31 foci distributed in ten countries. In 2012, epidemiological evalu-ations were completed, are ongoing or about to be initiated in 30 sites (Table 5). The detailed results of 2012 epidemiolog-ical evaluations will be reported to the Joint Action Forum in December 2012 in Bujumbura, Burundi.
Epidemiological evaluations are being conducted in Burundi (1 site), in Camer-oon (3), Malawi (2) and Tanzania (2) as at September 2012. Thirteen sites will be evaluated by November 2012 in CAR (1 site), Congo (1), DRC (2) and Nigeria (9).
1 Diawara L, Traore´ MO, Badji A, Bissan Y, Doumbia K, et al. (2009) Feasibility of Onchocerciasis Elimination with Ivermec-tin Treatment in Endemic Foci in Africa: First Evidence from Studies in Mali and Senegal. PLoS Negl Trop Dis 3(7): e497. doi:10.1371/journal.pntd.0000497
2 Traore MO, Sarr MD, Badji A, Bissan Y, Diawara L, et al. (2012) Proof-of-Principle of Onchocerciasis Elimination with Ivermectin Treatment in Endemic Foci in Africa: Final Results of a Study in Mali and Senegal. PLoS Negl Trop Dis 6(9): e1825. doi:10.1371/journal.pntd.0001825
CountryNumberofsitesevaluatedbyyear
2009 2010 2011 2012
Burundi 0 0 0 1
Benin 0 0 0 1
Cameroon 0 2 2 3
Central African Republic (CAR) 0 0 1 1
Chad 2 0 0 4
Congo 0 0 1 1
Democratic Republic of Congo (DRC) 0 2 0 2
Ethiopia 0 0 3 0
Malawi 0 0 2 2
Nigeria 5 3 1 9
Tanzania 1 1 2 3
Uganda 1 2 0 3
Totalfoci 9 10 12 30
Table5:Status of epidemiological evaluations in twelve Onchocerciasis endemic countriesA
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Epidemiological evaluations to deter-mine trends towards elimination of Onchocerciasis infection (phase 1a) were completed in Zou (Benin), in Kilosa
Country Villages Persons examined MF carriers MF prev %
Benin Zouto 123 1 0.8
Koutéou 182 0 0.0
Wassimi 86 2 2.3
Gamba 134 0 0.0
Bètagon 96 0 0.0
Gambialagon 212 1 0.5
Oké-owo I 205 0 0.0
Bako 131 1 0.8
Koudiokpara 136 3 2.2
Total Benin 1,305 8 0.6
Tanzania Dodoma Isanga 117 2 1.7
Dukani 118 28 23.7
Ibuti Ikunghuna A & B 69 2 2.9
Legeza - Mwendo Kitopeni 226 0 0.0
Makwambe 192 0 0.0
Miembeni Shuleni (Ilakala) 194 0 0.0
Mollem 79 0 0.0
Mvumi Kibodiani 242 0 0.0
Ngwila Mtoni (Tundu) 137 0 0.0
Ulaya Kibabadi 115 10 8.7
Kilosa 1,489 42 2.8
Chad Koutéré 385 0 0.0
Ndol 457 0 0.0
Lumbago 285 0 0.0
Shé I-Amboro 246 0 0.0
Bembaigane II 341 0 0.0
Lao III 506 0 0.0
Bah 248 0 0.0
Gandaye 296 0 0.0
Roïdonda 317 0 0.0
Kab 469 0 0.0
Massa 274 0 0.0
Bailalaotaye 315 0 0.0
Beissa 288 0 0.0
Koutoutou 266 0 0.0
Laokoïmassé 173 0 0.0
Belaohourmane 143 0 0.0
Oulibangala 241 5 2.1
Bam 311 0 0.0
Mini 246 0 0.0
Koumao 442 0 0.0
MoyenChari&LogoneOriental 6,249 5 0.1
Table6:Status of epidemiological evaluations in Benin, Tanzania and Chad
(Tanzania) and in Moyen Chari/Logone Oriental (Chad). In these sites the micro-filariae (MF) prevalence was respectively 0.6%, 2.8% and 0.1% as shown in Table 6.
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Phase 1b epidemiological evaluations to determine if a treatment site has reached the breakpoint for elimination of Onchocerciasis infection were carried out as at September 2012 in two sites in Chad and three in Uganda. Phase 1b evaluations seek to determine if the set treshold indicator of infection elimination has been reached. The indicators for the breakpoint are that the MF prevalence is <5% in all the villages evaluated or <1% in 90% of the
villages evaluated. Table 7 compares the breakpoint reached in evaluated sites in Chad and Uganda in 2012. In Chad all the 40 villages evaluated had zero MF prevalence. In Uganda, the prevalence of MF was below 5% in all the evaluated in Kasese (18 villages) and Nebbi (18). In Adjumani, MF prevalence was <5% in 94% of 18 villages evaluated.
Table7:Summary results of phase 1a and phase 1b epidemiological evaluations in Chad and Uganda
Geographicallocation
Epidemiologicalevaluation
Numberofpersonsexamined
MFcarriersCrudeMF
prevalence%Country Site Phase Year
UgandaNebbi
1b 2012 3,992 10 0.25
1a 2009 1,950 196 10.05
Kasese1b 2012 4,981 23 0.46
1a 2010 1,774 10 0.56
Adjumani1b 2012 4,465 63 1.41
1a 2010 2,992 22 0.74
ChadBebedja
1b 2012 4,232 0 0.00
1a 2009 1,731 0 0.00
Danamadji1b 2012 5,736 0 0.00
1a 2009 1,336 0 0.00
Geographicallocation
Totalvillages
evaluated
NumberofvillagesbyMFprevalencelevel
Breakpointofinfectioneliminationtargeted
Country Site <1% 1%-5% >=5% <1% <5%
UgandaNebbi
18 17 1 0 94.4 100
10 2 2 6 20.0 40
Kasese18 15 3 0 83.3 100
10 7 3 0 70.0 100
Adjumani18 12 5 1 66.7 94.4
9 6 3 0 66.7 100
ChadBebedja
20 20 0 0 100 100
9 9 0 0 100 100
Danamadji20 20 0 0 100 100
9 9 0 0 100 100
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3. Co-implementation of CDTI with other health interventions
Over the period September 2011 to August 2012 progress towards co-implementation of the control of other NTDs alongside onchocerciasis control continued through the contribution to the development and finalisation of National plans for NTD control and the support to the completion of the mapping of the major PCT- NTDs where possible.
The major NTDs targeted remain the same as in the previous year with a focus on Lymphatic Filariasis, soil-transmitted helminths, schistosomiasis and trachoma, whilst interventions for Vitamin A supplementation, home management of malaria, distribution of insecticide-treated bed-nets and support to immunisation campaigns also continued. Most resources targeted the expanded co-implementation of NTD control in the Democratic Republic of the Congo and Tanzania using funds provided for this purpose by USAID to supplement funds provided from the APOC Trust Fund for these countries.
Expanded co-implementation
a) TanzaniaIn Tanzania, Stakeholder meetings were held in January and April 2012 as the final version of the National Strategic Plan for NTD control was approved by the Government in order to identify in detail which activities would be supported by which Stakeholders and
what funding gaps would remain. Tanzania planned to expand co-implementation into 2 additional Regions (Tabora and Manyara) in 2012/13 supported by IMA/RTI, so that a total of 14 Regions of the country will be implementing NTD control by 2013. APOC continues to support six of these Regions – Ruvuma, Morogoro, Tanga, Iringa, Njombe and Mbeya (the number of regions has increased due to the administrative splitting of Iringa Region into two – Iringa and Njombe – but the area, the number of communities and people targeted has not changed). Delays were faced in 2011 due to national elections and some delays in drug procurement. In 2012 a person was recruited to coordinate and be responsible for drug procurement to alleviate these problems. The MDA programme in 2012 will, however, still face delays due to the fact that a National census will be undertaken during the planned period for Mass drug Administration (MDA) necessitating a later start than was foreseen.
Implementation of MDA was completed in the APOC supported Regions of Tanzania in December 2011. A preliminary combined total of 6 629 829 persons were treated for the five diseases (onchocerciasis, LF, soil-transmitted helminths, schistosomiasis and trachoma). This figure excluded some of the data for Kilosa District, which was not yet available.
Mapping of schistosomiasis has been completed throughout most of Tanzania
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but requires validation in some areas. Verification of Lymphatic Filariasis distribution is required in Babati District, Manyara region. Eighteen Districts still have to be mapped for trachoma.
b) Democratic Republic of CongoFive CDTI projects were chosen and financed by APOC to conduct co-implementation of control activities against the NTDs in the Provinces of Bas Congo, Kasaï Oriental and Katanga (Figure 14). A multi-year NTD master-plan for 2011-2015, aligned with the National Health Development Plan (PNDS), has been developed and a workshop to adopt this NTD Master-plan for DRC was organised in May 2011 with support from WHO/APOC, WHO/AFRO and CNTD – Liverpool.
The MDA for co-implemented NTD control alongside onchocerciasis control has been delayed in DRC due to the need to complete mapping. Funds provided by APOC and the Centre for Neglected Tropical Diseases at the University of Liverpool, UK have been provided to finalise integrated mapping of LF,
Figure14:Locations of the three Provinces in DRC co-implementing NTD control with onchocerciasis control
schistosomiasis and soil-transmitted helminths in all 162 Health Zones of the Provinces of Katanga, Kasai Occidental and Kasai Oriental. The results of the surveys for integrated mapping showed that 51 of the 162 health zones were endemic for LF and 73 endemic for schistosomiasis. A total of 152 of the 162 zones were endemic for soil-transmitted helminthiasis and in 6 of these zones a prevalence greater than 70% was detected.
A total of 7 677 500 Mectizan tablets were provided by MDP and received by the 5 CDTI projects for the treatment of onchocerciasis in 2011. Mebendazole and Vitamin A were procured through the National Nutrition Programme (PRONANUT) via UNICEF.
No order for Albendazole was made by the national NTD coordination office because the results of the 2010 nocturnal microfilaraemia survey of the 15 Health Zones classed as endemic and eligible for MDA in Katanga did not detect the presence of any microfilaria. An order for Albendazole for 2012 is in progress for treatment of soil-
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transmitted helminthiasis in the 3 Provinces.
Mass Drug Administration was restricted to the distribution of ivermectin, mebendazole and Vitamin A. With regard to onchocerciasis control, the five Projects treated a total of 2 673 099 persons with ivermectin out of a total population of 3 350 662 inhabitants; giving a therapeutic coverage of 79.8%. In addition to this, the National NTD Coordination Unit participated in an Annual Review of Programmes for Elimination of LF and other NTDs-CTP in Lusaka, Zambia. A total of 55 CDTI Projects in 10 countries including the ex-OCP countries of Ghana and Sierra Leone, reported on the continued provision of drugs or health interventions for NTD control in addition to onchocerciasis control over the reporting period and Figure 15 summarises the numbers of people reached with the interventions listed. A total of 43 159 497 health interventions were provided in the 10 countries for which data has been provided in addition to the 80,2 million ivermectin
Figure15:Major health interventions co-implemented alongside ivermectin distribution using CDI in 10 countries in 2011
0
5
10
15
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30
25
Mill
ions
LFSTH
Malaria LLIN
Malaria H
MM
Vitamin As
upplementatio
nSchisto
Trachoma EPI
Nutritio
nPEC
27.84
3.49 3.362.43 1.89 1.71 1.11 0.59 0.49 0.24
treatments. Whilst the number of ivermectin treatments given also represents the number of people treated, the figure for health interventions does not, as some people receive multiple treatments/interventions.
Liberia is making significant progress in integrating NTD control with onchocerciasis control. A National Review Meeting for onchocerciasis and other NTDs was held in the country in January 2012 and in May 2012 an NTD technical working group was established by the Ministry of Health. NTD mapping has been completed and the National NTD Strategic Plan was finalised in June 2012 with input from WHO-AFRO. MDA with ivermectin and albendazole is in progress in 2012 for control of onchocerciasis, LF and soil-transmitted helminths.
Taking all the co-implementation data available by sex for each of the 10 health interventions from the ten countries that provided these data, overall, a total of 31 669 326 treatments were fairly evenly spread between the sexes (Table 8).
Some of the treatments listed as LF would have been for STH
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Health intervention Males Percentage Females Percentage
Schistosomiasis 850,217 50.5% 832,851 49.5%
EPI (Polio) 140,028 42.9% 186,069 57.1%
Lymphatic Filariasis 11,827,731 49.1% 12,260,320 50.9%
Malaria HMM 194,589 44.0% 247,718 56.0%
Malaria LLIN 636,621 45.4% 766,880 54.6%
Nutrition 35,328 47.2% 39,460 52.8%
PEC 108,790 48.2% 117,044 51.8%
STH 1,008,754 52.3% 918,448 47.7%
Trachoma 456,316 56.6% 350,555 43.4%
Vit. A suppl 328,863 47.6% 362,744 52.4%
TOTAL 15,587,237 49.2% 16,082,089 50.8%
Table8: Summary of health interventions by sex where these data have been provided
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4. Strengthening Health Systems
APOC continued to provide technical and financial support to all 31 endemic countries based on the Ouagadougou Declaration on Primary Health Care (PHC) and Health Systems, according to the 58th and 59th Regional Committee Resolutions and Global Resolution (WHA62.12) on PHC including health systems.
Four Advocacy visits/missions were organised to Angola, CAR, DRC and South Sudan. It has been demonstrated that strong leadership and advocacy in health can effectively mobilise commitment at all levels and has shown the importance of partnerships.
Significant contributions have been made by APOC to develop tools for creating an evidence base for decision-making. Countries were supported to strengthen their health information systems, through both the community census approach and also through the REMO and M&E systems, and to conduct entomological and epidemiological evaluations.
More than 80 000 Health Professionals (all categories combined) from all member countries have received training to strengthen their capacities in various areas such as CDI, reporting, data management, monitoring, epidemiology, entomological and epidemiological evaluation and financial management. Eight new students, including 5 females, received postgraduate level fellowships leading to masters degrees in entomology, public health and epidemiology.
Better logistics and innovative financing mechanisms have improved
service delivery to hard-to-reach populations and, above all, these have enabled communities to direct and own community health interventions.
Financial support was provided to all countries to implement their annual Plans of Action and Budgets.
APOC continued to provide support for research and to strengthen community ownership and participation, partnership for health development.
4.1 Human resource development for the control of onchocerciasis and other health interventions 4.1.1 Engaging communities and training of community-directed distributors (CDDs) by NOTFs In 2011, a total of 82 938 health workers at different levels have been trained/retrained in 15 APOC countries and 3836 in 8 ex-OCP countries with technical assistance from NDGO partners and coordination from NOTFs (Table 9). This makes a total of 86 774 health workers trained during the reporting period. Of these trainees, 24.6% were newly introduced to the CDTI strategy.
The trained health workers, in turn, mobilised endemic communities to select 159 690 community members that were trained as Community-Directed Distributors (CDDs). In addition, 482 731 CDDs were re-trained with emphasis being put on census-taking, correct dosage of drug and implementation of multiple health interventions. That makes a total of 642 421 community
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Tabl
e9:
Num
ber o
f hea
lth w
orke
rs a
nd tr
aine
d/re
-tra
ined
in 2
011
by N
OTF
s
Coun
try
Num
bero
fpr
ojec
ts/
prog
ram
mes
re
port
ing
Num
bero
fdi
stri
cts
re
port
ing
Hea
lth
wor
kers
Com
mun
ity-
Dir
ecte
dD
istr
ibut
ors
New
ly
trai
ned
Re-t
rain
edTo
talt
rain
ed/
re-t
rain
ed%
New
ly
trai
ned
New
ly
trai
ned
Re-t
rain
edTo
talt
rain
ed/
re-t
rain
ed%
New
ly
trai
ned
An
go
la2
128
9410
27.
8%19
51,
142
1,33
714
.6%
Bu
run
di
310
3422
425
813
.2%
440
8,63
89,
078
4.8%
Cam
ero
on
1511
01,
675
3,20
24,
877
34.3
%17
,629
27,1
7144
,800
39.4
%
Cen
tral
Afr
ican
R
epu
blic
110
128
564
692
18.5
%56
85,
933
6,50
18.
7%
Ch
ad1
1955
154
209
26.3
%1,
486
2,64
64,
132
36%
Co
ng
o2
2718
160
178
10.1
%48
41,
118
1,60
230
.2%
DR
C20
237
1,83
77,
339
9,17
620
.0%
36,5
4178
,677
115,
218
31.7
%
Eth
iop
ia9
781,
095
7,88
88,
983
12.2
%5,
267
59,8
3865
,105
8.1%
Lib
eria
315
456
552
1,00
845
.2%
2,97
15,
233
8,20
436
.2%
Mal
awi
28
240
2,09
82,
338
10.3
%1,
246
14,2
3815
,484
8%
Nig
eria
2741
87,1
7727
,054
34,2
3121
.0%
50,9
1515
9,44
321
0,35
824
.2%
Sou
th S
ud
an5
4443
854
598
344
.6%
9,86
46,
603
16,4
6759
.9%
Sud
an1
31,
349
2,92
54,
274
31.6
%1,
349
1,92
13,
270
41.3
%
Tan
zan
ia6
1634
71,
172
1,51
922
.8%
1,28
510
,354
11,6
3911
%
Ug
and
a5
355,
667
8,44
314
,110
40.2
%21
,201
43,4
1564
,616
32.8
%
APO
C co
untr
ies
102
1,04
220
,524
62,4
1482
,938
24.7
%15
1,44
142
6,37
057
7,81
126
.2%
Ben
in1
5171
277
340
20.9
%0
7,90
97,
909
0%
Bu
rkin
a Fa
so1
66
109
115
5.2%
128
937
1,06
512
%
Co
te d
'Ivo
ire
146
3444
147
57.
2%24
56,
785
7,03
03.
5%
Gh
ana
140
01,
402
1,40
20.
0%96
65,
943
6,90
914
%
Gu
inea
124
1738
5530
.9%
014
,074
14,0
740%
Gu
inea
-Bis
sau
133
036
360.
0%0
1,54
41,
544
0%
Mal
i1
1714
640
755
326
.4%
148
9,02
99,
177
1.6%
Sier
ra L
eon
e1
1251
834
286
060
.2%
6,76
210
,140
16,9
0240
%
Form
er O
CP
coun
trie
s8
229
792
3,05
23,
836
20.6
%8,
249
56,3
6164
,610
12.8
%
Gra
ndT
otal
110
1,27
121
,316
65,4
6686
,774
24.6
%15
9,69
048
2,73
164
2,42
124
.9%
APOC countries Former OCP countries
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members whose capacity has been strengthened.
4.1.2 Training of health staff (including APOC fellowships) During the reporting period, APOC Management supported various training workshops to strengthen National capacity. Up to 572 health care providers (nurses, medical doctors, M&E officers, lab technicians, technical assistant) were trained on the CDTI/CDI Strategy, Entomological evaluation, epidemiology, epidemiological evaluation, treatment coverage surveys, data management and geographical information systems (GIS) (Table 10).
Master Degree in Entomology, Epidemiology and Public health In 2011, APOC continued to provide long term fellowships for candidates from seven countries selected for Scholarships. A total of 14 candidates
received scholarship. Out of this total, 6 (Cameroon: 1, CAR: 2, Kenya: 1, Malawi: 2) have completed their Master’s degrees and returned to their respective countries). Eight people from 5 countries (Cameroon: 1, CAR: 2, CHAD: 2, Côte d’Ivoire: 1 and DRC: 2) continue their studies in entomology and public health. Sixty four percent of the students who benefitted from APOC funded scholarships in 2011 were female.
4.1.3 Building capacity of countries in communicationAs APOC moves towards elimination there is an added need for a communication strategy/plan for the new activities. During the reporting period several proposals have been developed for different communication strategies for APOC that have been shared with APOC management and APOC senior staff for their comments
Areaofcapacitybuilding Countriesoftrainees Nboftrainees
Strategy on CDTI/CDI Burkina Faso, Burundi, Cameroon, CAR, Congo, DRC, Malawi, Nigeria, Tanzania, Liberia, Uganda
63
Trainers of trainers in CDI strategy Burundi, DRC 52
Entomological evaluation Cameroon (7), Malawi (10), RDC (7), Tanzania (6)
30
Cytotaxonomy Chad (3), Cameroon (4), Congo (3), CAR (3), Nigeria (10)
23
Data management and GIS Benin (1), Burkina Faso (2), Burundi (2), Cameroon (1), CAR (2), Chad (32), DRC (34), Congo (2), Côte d’Ivoire (1), Malawi (21), Niger (1), Senegal (1)
100
Master (Public Health, Epidemiology, Entomology)
Cameroon, CAR, CHAD, Cote d’Ivoire, DRC, Kenya, Malawi
14
Financial Management Angola, Guinea Bissau, Burundi, Cameroon, Congo, DRC, Nigeria, South Sudan, Tanzania, Uganda
231
Epidemiological Evaluation Benin, Burkina Faso, Burundi, Cameroon, CAR, Chad, Congo, DRC, Cote d’Ivoire, Niger
39
TOTAL 572
Table10: Number of Health Professionals trained/retrained in 2012
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and input. These include a strategy for enhanced visibility; a strategy for elimination and a strategy for co-implementation promotion using the CDI strategy. Finalisation of these communication strategies/plans will enable countries to adapt them to their own context. During the reporting period Liberia and Central African Republic have received particular attention from APOC management.
Liberia A scoping mission was carried out in February 2010 to evaluate HSAM activities and to identify gaps, weaknesses and strengths of the APOC onchocerciasis control programme. This was followed in May 2010, by a workshop to develop a communication strategy for Liberia. A draft communication strategy was developed with the onchocerciasis programme managers and other nationals working in onchocerciasis/NTD control. The draft document was endorsed by the NOTF. During the reporting period, close follow-up led the Liberian Ministry of Health to review the document and they have requested that the strategy be revised to include other major NTDs. A work-plan is therefore being developed with Liberia to see how best to revise the strategy to fit in the NTDs and how to guide the development of HSAM activities and materials for the onchocerciasis control programme.
Central African RepublicIn order to provide assistance to NOCP/CAR to develop a simplified communication plan for the fight against onchocerciasis and other NTDs, a mission was conducted in CAR from 18 February to 2 March 2012 to assess the implementation of HSAM (Health Education, Awareness, Advocacy and social Mobilisation) in CDTI. Weaknesses, strengths, best practices and needs were identified. The requirements
for improvement are summarised as follows:
• Strengthen the capacity of health workers to raise awareness
• Provide training to health workers, CDDs, and community leaders to give them a more detailed and adequate awareness about the disease, its vector, and its mode of transmission
• Routine sensitisation sessions for populations must be established and carried out effectively preceding distribution campaigns
• Develop or strengthen local communication to promote ownership of CDTI by the community with clearly defined roles and community mobilisation.
The main recommendation of this mission was that APOC should provide technical and financial support to develop a communication strategy and strategic plan for HSAM using the appropriate channels and activities and which takes account of the realities on the ground.
4.1.4 Gender MainstreamingSince 2007 APOC has maintained a gender mainstreaming strategy that monitors gender issues in onchocerciasis endemic countries, especially among community-directed distributors (CDDs) who occupy the frontline position in the fight against onchocerciasis. APOC believes that increasing the number of women CDDs participating in CDTI can significantly improve therapeutic and geographic coverage especially in areas where access to women by men is difficult, and also increase the chances of controlling the disease, eliminating its infection and interrupting its transmission within endemic countries. Countries are asked to report CDD ratios based on gender in their annual reports and are
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usually encouraged through feedback to improve the gender balance. Table 11 shows the total number of CDDs and the proportion of female CDDs in 2009 and 2010 for 12 APOC countries and the total number of CDDs and the proportion of female CDDs in 2011 for 14 APOC countries and 5 ex-OCP countries.
The number of countries that reported disaggregated data on CDDs increased in 2011 (2 more APOC countries and 5 ex-OCP countries). Overall, the proportion of female CDDs has gradually increased from 25.9% (121,976 female CDDs out of a total of 470,816 CDDs) in 2009 to 26.5% (143 167 female CDDs out of a total of 541 226 CDDs) in 2010 and 29.1% (198 579 female CDDs out of a total of 682 091 CDDs) in 2011. For post-conflict APOC countries the proportion increased from 18.8% in 2009 to 23.6% in 2010 and 28.1% in 2011, while in stable APOC countries there was a dip in the proportion of female CDDs in 2010 (29.2% in 2009 against 27.6% in 2010) and then an increase in 2011 (30.8%). The proportion of female CDDs in ex-OCP countries is relatively very low at 15.6% (5,114 female CDDs out of a total of 32 830 CDDs) in 2011.
Based on data from the CDTI Project Annual Technical Reports, APOC Management was able to identify relatively poor-performing countries where extra effort is needed to improve the involvement of women CDDs in CDTI (Table 11). Two such countries selected for action in 2011/2012 were the Democratic Republic of Congo and the Central African Republic. Between September 2011 and April 2012 APOC management conducted special activities in these two countries to improve involvement of women in CDTI.
Special activities undertaken in DRC
APOC management conducted workshops and field visits in Kinshasa,
South Katanga and Lubumbashi from 5 September to 4 October 2011. The workshops were on the topics “Gender and participatory management of community health problems” and “Leadership and participatory management of community health problems: promotion of female leadership”. Participants included stakeholders in onchocerciasis control in DRC: National Onchocerciasis Control programme (NOCP) personnel, representatives of NGDOs, community leaders including village chiefs, CDDs, administrative authorities and personnel occupying senior positions within the Ministry of Health (MOH) in the capital and within regional MOH offices.
Participants were made to understand that greater participation of women in the management of community resources and more involvement of women in health and leadership activities would yield more benefit for the entire community. The expected specific outcome of the workshop was for participants to better understand the gender concept and implement gender mainstreaming and its operational concepts in their various communities and places of work; practice the concept of gender promotion and be an example to others on gender issues. Gender mainstreaming, especially in relatively poorly performing countries can lead to an increase in therapeutic and geographic coverage to a level that can lead to elimination of onchocerciasis infection and interruption of its transmission. The gender concept is also expected to bring about a social transformation of equality between men and women in onchocerciasis endemic community for better management of the disease, other neglected tropical diseases (NTDs) and all other health problems within the communities.
Af
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og
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Tabl
e11
:Num
ber o
f fem
ale
CDD
s in
APO
C an
d ex
-OCP
par
ticip
atin
g co
untr
ies,
200
9-20
11
APO
Cco
untr
ies
Fem
ale
CDD
sTo
talC
DD
s%
Fem
ale
CDD
s
2009
2010
2011
2009
2010
2011
2009
2010
2011
Post
-con
flic
tcou
ntri
es
Bu
run
di
4,08
94,
045
3,91
88,
828
8,87
28,
999
46.3
45.6
43.5
CA
R85
260
360
4,43
15,
612
5,88
61.
94.
66.
1
Ch
ad2,
251
4,34
84,
629
13,6
0214
,201
14,7
1216
.530
.631
.5
DR
C18
,913
24,6
0828
,609
112,
254
115,
194
125,
043
16.8
21.4
22.9
Lib
eria
1,31
61,
693
2,54
66,
124
7,34
39,
002
21.5
23.1
28.3
Sud
an1,
,182
1,49
93,
428
2,91
13,
201
20,1
5140
.646
.817
Tota
l27
,836
36,4
5343
,490
148,
150
154,
423
183,
793
18.8
23.6
28.1
Stab
le c
ou
ntr
ies
An
go
la13
853
112
42,
179
4,42
11,
337
6.3
129.
3
Cam
ero
on
11,6
3518
,559
15,6
1038
,983
65,7
6444
,077
29.8
28.2
35.4
Co
ng
o33
239
340
31,
668
1,64
61,
602
19.9
23.9
25.2
Eth
iop
ia8,
058
7,158
8,01
764
,919
66,6
2365
,339
12.4
10.7
12.3
Mal
awi
8,23
79,
326
10,0
4114
,147
15,5
5916
,701
58.2
59.9
60.1
Nig
eria
65,7
4070
,747
83,7
2120
0,77
023
2,79
026
0,41
432
.730
.432
.2
Tan
zan
ia0
05,
704
00
11,4
780
049
.7
Ug
and
a0
026
,355
00
64,5
200
039
.6
Tota
l94
,140
106,
714
149,
975
322,
666
386,
803
465,
468
29.2
27.6
30.8
Ex-O
CP
cou
ntr
ies
Bu
rkin
a Fa
so0
084
00
1,13
80
07.
4
Gu
inea
Bis
sau
00
550
084
90
06.
5
Co
te D
'Ivo
ire
00
463
00
7,03
00
06.
6
Gh
ana
00
1,04
30
06,
911
00
15.1
Sier
ra L
eon
e0
03,
469
00
16,9
020
020
.5
Tota
l0
05,
114
00
32,8
300
015
.6
Gra
ndto
tal
121,
976
143,
167
198,
579
470,
816
541,
226
682,
091
25.9
26.5
29.1
Af
ric
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Several onchocerciasis endemic communities were visited and discussions were held with community leaders and members to promote gender issues and female leadership (Figure 16).
Special activities undertaken in CAR
In April 2012 APOC management undertook a mission to CAR to assess progress with gender mainstreaming activities and participate in the official launching of the plan of action for gender mainstreaming. This mission followed up on a gender workshop that was held in Boali, CAR in August/September 2010. The APOC team visited participants of the Boali workshop in Bangui and Galafondo that included senior personnel of the MOH and other departments, community leaders and leaders of social and women’s group, and held discussions with them on gender mainstreaming. In all the villages visited, the CDDs and community leaders stated that they had held meetings with community members during which they sensitised people on gender mainstreaming and promotion of female leadership.
The official ceremony to launch the plan of action on gender mainstreaming in CAR took place in Galafondo in Kemo prefecture on 14 April 2012 and was chaired by the Minister of Social Welfare and Gender. The ceremony was attended by representatives of UNFPA, the WHO Country Office in Bangui, FAO, and NGDOs as well as representatives of the Government from National and local levels. Representatives of the National HIV/AIDS Control programme, the National Blindness Prevention Programme and senior staff of the MOH, were also present together with community leaders and two staff members from APOC HQ. The importance of CDTI for the control of onchocerciasis and the benefits to communities of involving more women in CDTI were emphasised during the ceremony, following which, the plan of action for gender mainstreaming was officially launched by the Minister of Social Welfare and Gender.
Figure16:Women and men in DRC partici-pating in a community meeting on gender mainstreaming
During the community visits it was reported that 37 new CDDs were selected, of whom 23 were women who would participate in the 2011 mass administration of ivermectin. Community leaders were encouraged to involve more women and youths (male and female) in leadership positions and also in the control of onchocerciasis and other diseases that have community-based strategies.
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ric
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Current status in APOC headquarters
The prospect of training APOC headquarters staff on gender mainstreaming remains a challenge. Such training will enhance the staff’s ability to take gender into consideration in all their activities from planning to implementation so that gender mainstreaming becomes a structural issue for improving programme performance. Currently, women represent 40% of the staff at APOC headquarters (30 women out of 76 total staff), taking account of staff retirements between 2011 and 2012. The challenge is to provide them with more leadership roles and to ensure that their contributions are visibly valued and encouraged.
The NOCP, CDTI regional and district coordinators and senior personnel of the MOH should put in place a mechanism for systematic monitoring of gender issues in all health activities in DRC. APOC will continue to monitor the progress made on gender mainstreaming in CAR and other onchocerciasis endemic countries and will work with national authorities when necessary to improve gender issues for the achievement of better CDTI results. Logisticssupport APOC Ex-OCP
Transport
Vehicle (4x4) 12 5
Bicycle 1,365
Motorcycle 120
Computersandaccessories
Desktop computer 31 1
Laptop computer 16 3
Laser printer 33
Scanner 36
UPS 27 1
Communication&other
TV 10
LCD projector 5
Phone 300
Photocopier 9
Generator 8
Table12:Summary of logistic equipment provided by APOC to countries during the reporting period
4.2 Logistics support to countriesThrough the strengthening of health systems in APOC countries which involves providing quality delivery of goods, 14 countries (Angola, Burundi, Cameroon, Congo, Ethiopia, Liberia, Malawi, Nigeria, Uganda, CAR, DRC, South Sudan, Tanzania, Chad) have been supported with logistics and equipment during the period under review. The support involved provision of new equipment and replacement of old items. This includes the supply and shipment of vehicles, motorbikes, bicycles, computers and accessories, electricity generators, LCD projectors, printers, photocopiers and scanners to facilitate CDTI project activities as shown in Table 12.
In addition to APOC countries, this support has been also provided to 5 ex-OCP countries to facilitate onchocerciasis control activities.
Af
ric
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5. Partnerships and government contributions to CDTI Activities
5.1 Government financial contributionsFollowing queries from the Joint Action Forum (JAF) on the reliability of government’s financial contribution to onchocerciasis control activities, CSA requested the World Bank and the African Development Bank to develop guidelines and tools to assess government’s financial contributions to onchocerciasis control and other NTDs. These guidelines will be presented during the 18th session of the JAF if they are ready.
5.2 Direct financial support to countries and management of APOC Trust Fund
During the fiscal year 2011/2012, direct financial support was provided to 24 countries in 2011 and to 21 in 2012 (August 31). The detailed list of countries and projects benefiting from the APOC Trust Fund in 2011/2012 is shown in Table 13. This support comes to a total of US$ 42.35 million which is comprised of the amounts of US$ 23.53 million for 2011 and US$ 18.82 million for the year 2012 (as of 31 August 2012), following the overall trend of the approved budget for these two years. The budget that was used in programme implementation between 2011/2012 is divided into three components: 84.73% allocated to expenditures associated
with technical/operational activities, 12.92% allocated to staff costs and administrative expenses and 2.35% allocated to equipment procurement and recurrent costs at the headquarters of the Programme (Figure 18).
One hundred and twenty (120) CDTI Projects and/or programmes and six (6) NOTF secretariats supporting projects benefited from this financial support. Approximately 47.46% of the approved/committed budget was directly transferred to the projects/programmes. Figure 17 shows that CDTI activities represent a significant proportion (66.16%) of the expenditure in 2011 and 64.49% in 2012 (by 31 August).
Direct transfers to projects/national programmes are supported by financial cooperation agreements (DFC). Under the DFC in 2011, one hundred and forty-two (142) direct funding authorisations and certifications of expenditure reports (FACEs) were received by/from projects and 96.48% (137) of these were analysed/certified by the APOC Finance team (Table 14). In the year 2012, up to August 31, the number of FACEs received amounted to 221 out of a total of 241, which is a submission rate of 92% providing evidence of utilisation of the funds disbursed. In accordance with the schedule of implementation of certain activities in the year 2012, other FACEs are expected by December 2012 and will be reported next year.
In general, the rate of submission of financial reports by countries/projects
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Country
Nbofprojectsfinanced NbofDFCspreparedpercountry
(specificactivitiesincluded)
2011 2012 2011 2012
Supporttocountry
Angola 9/9 9/9 11 9
Burundi 3/3 3/3 7 6
Cameroon 16/16 16/16 26 20
CAR 1/1 1/1 2 4
Chad 1/1 1/1 6 5
Congo 2/2 2/2 3 4
DRC 21/22 22/22 38 26
Ethiopia 10/10 9/10 13 10
Equatorial Guinea 1/1 1/1 1 1
Liberia 3/3 3/3 8 3
Malawi 2/2 2/2 6 5
Nigeria 28/28 28/28 48 33
South Sudan 5/5 5/5 11 5
Sudan 1/1 1/1 NA NA
Tanzania 7/7 6/6 10 8
Uganda 7/7 7/7 5 4
Benin 1/1 1/1 2 1
Guinea Bissau 1/1 1/1 4 1
Burkina Faso 1/1 1/1 2 0
Ghana 1/1 1/1 3 1
Guinea 1/1 1/1 2 0
Mali 1/1 1/1 0 0
Niger 1/1 1/1 1 0
Cote d’Ivoire 1/1 1/1 3 3
Sierra Leone 1/1 1/1 2 2
Togo 1/1 1/1 0 0
OverallTotal 126/127 125/126 214 151
Table13:Number of Projects financed from the APOC Trust Fund in 2011 and 2012
between 2011 and 2012 is encouraging and supports the concerns of the Management of APOC and donors for transparent and efficient management of the APOC Trust Fund at all levels of the programme.
5.3 Governance5.3.1 The Joint Action ForumThe seventeenth Session of the Joint Action Forum (JAF), the Governing body of APOC, was hosted by the Kuwait Fund, from 12-14 December 2011 in Kuwait City, Kuwait. The session was
officially opened by His Excellency Sheikh Sabah Khaled Al-Hamad Al-Sabah, Deputy Prime Minister and Minister of Foreign Affairs of Kuwait. Twenty-four representatives of APOC and OCP countries attended the meeting and presented updates on activities in their countries. Also attending were 13 representatives of the donor community, NGDOs, Research Institutions and representatives of APOC’s statutory bodies. As requested by JAF16, members of the three CSA sub-advisory groups on co-implementation, elimination and the future of APOC
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Country
Nbofexpensessubmittedbycountry/numberofreportsof
expensesawaited
NbofFACEssubmit-tedbycountry/
NbFACEawaited (including those of
previous years and for specific activities)
NbofFACEcertified(including those of
previous years and for specific activities)/
NbofFACEsubmittedbycountry
Year/Period 2011 202 2011 2012 2011 2012
Supporttocountries
Angola 108/108 36/63 32/38 15/24 32/32 15/15
Burundi 70/70 26/28 0/19 19/23 0/0 19/19
Cameroon 192/192 15/112 30/67 40/71 30/30 39/40
CAR 12/12 7/7 1/2 1/6 0/1 0/1
Chad 12/12 0/7 0/7 3/10 0/0 0/3
Congo 8/24 30/30 1/6 5/9 1/1 5/5
DRC 252/252 95/154 13/38 48/66 13/13 44/48
Ethiopia 75/108 48/96 3/12 8/28 3/3 8/8
Equatorial Guinea NA NA NA NA NA NA
Liberia 33/36 0/24 4/8 0/11 4/4 0/0
Malawi 24/24 14/14 4/6 4/7 0/4 0/4
Nigeria 336/336 89/196 10/41 64/94 10/10 59/64
South Sudan 60/60 30/35 33/34 0/11 33/33 0/0
Sudan NA NA NA NA NA NA
Tanzania 72/72 31/42 0/15 22/29 0/0 22/22
Uganda 17/17 0/14 3/3 6/9 3/3 6/6
Benin 12/12 0/0 0/6 0/6 0/0 0/0
Guinea Bissau 22/24 0/9 4/4 0/2 4/4 0/0
Burkina Faso 12/12 0/0 3/5 0/2 3/3 0/0
Ghana 12/24 12/19 0/3 0/4 0/0 0/0
Guinea 0/12 0/12 0/4 0/4 0/0 0/0
Mali 0/12 0/12 0/2 0/2 0/0 0/0
Niger 0/12 0/12 0/2 0/2 0/0 0/0
Cote d’Ivoire 12/12 3/7 0/4 4/5 0/0 4/4
Sierra Leone 11/12 7/7 1/2 2/3 1/1 0/2
Togo 0/12 0/12 0/1 0/1 0/0 0/0
OverallTotal 1352/1467 443/912 142/329 241/429 137/142 221/241
presented their reports, followed by the final conclusions and recommendations presented by the CSA which identified scenario 3 “Onchocerciasis elimination with co-implementation for NTDs and Health System Strengthening (2015-2025)” as the one recommended. JAF reaffirmed its endorsement for the Programme to pursue the elimination of onchocerciasis in Africa as well as co-implementation of preventive chemotherapy interventions for other selected NTDs in the context of
increased support to community level health system strengthening, and therefore requested the CSA and APOC management to submit to JAF18 a detailed new plan of action with costs reflecting the new expanded strategic direction for the programme beyond 2015. The strategic plan of action with detailed costs will be submitted to the next session of JAF by the CSA for consideration.
Table14:Number of financial reports submitted and analysed in 2011 and 2012
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Figure17:Allocation of APOC Trust Fund’s to the main activities in 2011 and 2012
2011 2012
Implementation of CDTI 51.39%
Implementation of CDTI 47.46%
Equipment/supplies and utilities of HQ/APOC 1.70%
Equipment/supplies and utilities of HQ/APOC 2.35%
Mainstreaming gender in APOC operations 1.60%
Mainstreaming gender in APOC operations 0.83%
Partnerships 3.66%
Partnerships 7.93%
Research & Development 2.47%
Research & Development 0.31%
Co- implementation of multiple health interventions 10.16%
Co- implementation of multiple health interventions 3.72%
Human resources 11.34%
Human resources 12.92%
Monitoring/evaluation surveillance 14.77%
Monitoring/evaluation surveillance 17.03%
Contribution to strengthening of community health systems 2.91%
Contribution to strengthening of community health systems 7.46%
CDTIforonchoelimination=66.16% CDTIforonchoelimination=64.49%
Figure18:Proportion of the budget used for administrative expenses, renewal of equipment, recurrent expenditure compared to technical and operational (2011-2012)
2011 2012
Human resources 11.34%
Human resources 12.92%
Equipment/supplies and utilities of
HQ/APOC 1.70%
Equipment/supplies and utilities of
HQ/APOC 2.35%
Technical/ operational activities cost 86.96%
Technical/ operational activities cost 84.73%
5.3.2 Technical Consultative Committee and decentralisation of functions to countries The 33rd and 34th sessions of the Technical Consultative Committee (TCC) of APOC were held in September 2011 and March 2012 respectively, in Ouagadougou, Burkina Faso. TCC33 discussed the main findings of the CSA sub-advisory groups on co-implementation, elimination and the future of APOC summarised in presentations made by the chairs
of each sub-advisory group. Other strategic issues discussed were the progress towards elimination of Onchocerciasis infection and interruption of transmission in endemic countries, entomological studies for assessing transmission levels, NTD co-implementation issues, the new OV16 rapid diagnostic tools of PATH, ivermectin response markers, and an update on the availability of the DEC patch test. TCC33 also reviewed six operational research proposals, one
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CDTI project proposal and 42 annual technical reports of projects being implemented in the countries. TCC33 also received reports from Technical Review Committees (TRCs) of Cameroon, Nigeria and Uganda that reviewed reports of projects in these three countries that have been implemented for than six years.
TCC34 discussed various processes for the preparation of the APOC strategic plan of action and budget for the post-2012 period as well as the main outlines of the plan. The Committee was updated on the DEC patch test availability to APOC and reiterated the importance the DEC patch for the evaluation activities of onchocerciasis elimination without skin-snipping. TCC recommended that APOC write a letter to the CEO of LTS emphasising the role that the DEC patch will play in the effort to move towards elimination of onchocerciasis in Africa. TCC34 was also updated on many strategic issues including the revised study protocol for entomological studies and activities carried on in Nigeria, Chad and Uganda, the delineation of transmission zones, blackfly trapping; new diagnostic tools of PATH to monitor onchocerciasis elimination; ivermectin response markers; collaboration between Lymphatic Filariasis (LF) and onchocerciasis control/elimination programmes and the prospects for elimination of the two diseases; the thresholds, a modelling study on breakpoints and strategies in control and elimination of onchocerciasis. The Committee also gave guidance on the contribution of APOC in NTD control.
Regarding the nodding disease, TCC34 recommended that since CDC experts are already in the process of investigating the phenomenon in South Sudan, it was not necessary to conduct additional activities and that a group of experts could be formed to advise
APOC on the issue. TCC34 also reviewed two operational research proposals, one national plan for integrated control of tropical diseases, 24 technical reports of ongoing CDTI projects and received reports from the Technical Review Committees of Cameroon and Nigeria on reviews of technical reports of projects beyond six years implementation in those countries.
A Summary of the above activities of TCC is provided in the respective TCC reports.
5.3.3 Committee of Sponsoring AgenciesThe Committee of Sponsoring Agencies (CSA) continued its activities of monitoring the APOC Programme financing, management and operations. Four meetings of the CSA were held during the reporting period. The APOC Trust Fund does not pay for the participation of CSA members in the meetings. The highlights of these meetings included: (i) arrangements for responses to be given to the decision of JAF17 for CSAandAPOCmanagementtosubmitadetailednewplanofactionwithcostsreflectingthenewexpandedstrategicdirectionfortheprogrammebeyond2015forconsiderationbyJAF18; (ii) review and advices on the plan of action and budgets for the bridging period 2013-2015; (iii) discussions on the revision of Criteria and guidelines for certification of elimination of Onchocerciasis, and reinforcement of the collaboration with OEPA on onchocerciasis elimination; (iv) government contributions in the framework of the paradigm shift for elimination, and development of guidelines and tools for assessing government’s financial contributions to onchocerciasis and other NTDs elimination; (v) Preparations for JAF18 including the review of the draft
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reflections of the CSA to JAF; (vi) review of APOC operations and its financing as well as the activities of the NGDO Group in 2011/2012; (vii) the role of APOC in NTD control and the participation of CSA members in the November 2012 NTD meeting and contribution of APOC partnership; (viii) Financing of the research on ivermectin response markers, and moxidectin development; (ix) the nodding disease and claim of its association with onchocerciasis.
In addition, CSA sessions received updates on APOC operations, reports of TCC 34th and 35th sessions, the NGDO Group meetings and the signing of the revised Memorandum of Understanding of APOC by member countries; discussed ways of promoting APOC activities and results as well as the reinforcement of the collaboration between APOC and NTD/AFRO.
5.4 Development and implementation of a CDI curriculum and training module In 2007, APOC in collaboration with partners initiated the development of a curriculum and training module for the teaching of the CDI strategy in medical and nursing schools as a means of propagating the Community-Directed Intervention (CDI) strategy in Africa and thereby contributing to the production of future generations of health personnel trained and empowered to use the CDI strategy to strengthen community health systems. Two meetings were organised by APOC, in Abuja, Nigeria, 2009 and in Nairobi, Kenya, in 2010, attended by Chancellors, Vice Chancellors, Deans and Heads of Faculties of Medicine, Nursing Schools, and Institutes of Public Health and Health Sciences to promote the inclusion of the CDI strategy in the
curricula of their institutions. During those meetings 67 training institutions were made aware of CDI and out of these, fourteen sent Plans of Action and Budgets (PABs) to APOC. The PABs were reviewed and the majority were approved and funds and technical support were provided to start the pre-testing process. Eleven Institutions have so far undertaken pre-testing. Eighteen universities in Sudan participated in the CDI inclusion workshop but only four have presented proposals to UMST and are now looking for their own funds for pre-testing.
A workshop for twelve institutions was organised by APOC in Akure, Nigeria to assist in making progress with pre-testing and inclusion of the CDI training module in curricula of institutions in that country. During the workshop 44 participants representing 12 institutions agreed to carry out the pilot testing of the curriculum in their institutions. It was also recommended that the teaching of the CDI strategy should be integrated into the continued Professional Development Programmes of their various Professional groups and postgraduate curricula.
Table 15 shows achievements and challenges of development and implementation of CDI curriculum and training module.
It was also recommended that APOC should use the opportunity of the Continued Professional Development programmes to train those who are already out of school in CDI skills. Some participants agreed to create forums for workshops on CDI that would earn CME units, whereby the professionals would earn some credits for renewal of their Annual Practising Licence.
One of the recommendations of the workshop held in Nairobi in 2010 was to quickly develop a trainer’s handbook for
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the curriculum and training module. A workshop to prepare a draft of the CDI Handbook was held in Ouagadougou from 1-5 August 2011. The document has been sent to editors and a graphic stylist for finalisation and printing. This will be one of the JAF18 information documents.
A sensitisation/awareness creation workshop, followed by a training of trainer’s workshop on the CDI strategy was held in Bujumbura, Burundi, and regrouped representatives from paramedical schools, faculties of medicine and health sciences. The sensitisation workshop, which was attended by 62 participants, was opened and presided over by the Ministers of Health and Education. The training
of trainers’ workshop regrouped 28 lecturers from the paramedical schools and the faculties of medicine of Burundi.
APOC organised on the inclusion of the CDI strategy within Faculties of Medicine and Schools of Public Health in Ouagadougou, Burkina Faso, from 13 to 17 August 2012. The meeting was attended by 28 participants (Deans, Directors, HoD) representing 11 Institutions as well as WAHO, WHO-IST/West and APOC personnel.
The main objective of this meeting was to contribute to the effective integration of the CDI strategy in the curricula of health training institutions that have started the process of inclusion. At the end of the evaluation meeting,
Achievements Challenges
• 2nd edition of the Curriculum and training module (in print)
• Trainers’ Handbook finalised (in print)• 67 Faculties of Medicine and Nursing
Schools to incorporate the teaching of CDI strategy in their curricula in countries in East, South, West, Central and North Africa
• Ongoing pre-testing activities in 14 faculties of medicine, health sciences and nursing schools
• Standardised guidelines developed for submitting PABs
• Evaluation meeting organised in August 2012
• Status of inclusion of CDI curriculum in the curricula of training institutions updated
• Evaluation tool produced and adopted• Proposal for centres of excellence for CDI
accepted• Curriculum and training module on the
CDI strategy for faculties of medicine and health sciences and nursing schools adopted
• Plans of action developed by each institution
• Seven key steps and way forward agreed upon
• Development of centres of excellence for CDI strategy training
• Long-term impact evaluation of strategy in the curriculum on the performance of future generations of health professionals and community health systems
• Continued APOC support to Faculties of Medicine, health sciences and nursing schools (provision of human, material and financial resources for effective implementation of the Curriculum)
• Development of oncho control libraries in Faculties of Medicine, health sciences and nursing schools; and WHO country offices
Table 15: Achievements and challenges of development and implementation of CDI curriculum and training module
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the following outcomes were reached: status of inclusion of CDI curriculum in the curricula of training institutions updated; plans of action developed by each institution; evaluation tool produced and adopted; seven key steps for inclusion of CDI defined; next steps and way forward agreed upon; proposition of the centres of excellence for CDI accepted; curriculum and training module on the community-directed intervention (CDI) strategy for Faculties of Medicine and Health Sciences; revised version and Trainers’ handbook adopted.
APOC continues to encourage other universities to participate and adopt the CDI curriculum as a taught module in their universities.
5.5 Partnerships and collaboration5.5.1 CDTI projects and NGDO support for Onchocerciasis Control During the reporting period, APOC Management continued its efforts to strengthen partnerships, particularly in post-conflict countries.
Towards this end, a stakeholders’ meeting was organised under the leadership of APOC and co-financed by CNTD-Liverpool, on 30 May 2012 in Juba, South Sudan in order to re-organise onchocerciasis control activities in this newly formed country. In addition to CBM, which so far is the unique NGDO partner to all 5 CDTI projects in South Sudan and which renewed its commitment, additional partners who participated in the meeting expressed their willingness to provide support to the restructured CDTI activities. These included Liverpool Centre for Neglected Tropical Diseases, Sightsavers which had established an office in South Sudan in early 2012 and the Community Health Education Programme of the Diocese
of Rejaf from the Episcopal Church of Sudan. Other partners operating in the country such as IMA World Health and the Malaria Consortium were encouraged to join hands towards these efforts of strengthening partnership in South Sudan.
APOC Management welcomed with great interest the permit granted to Sightsavers in 2012 as a new NGDO partner to the Ministry of Health of Côte d’Ivoire. This development offers new opportunities for strengthening partnership in order to accelerate efforts towards the fight against onchocerciasis as well as other neglected tropical diseases. Therefore, APOC agreed to partially fund the post of a technical adviser for one year while Sightsavers is settling into the country, similar to the in-country partnerships established in 2011 with CBM in Angola and the Democratic Republic of Congo (DRC). Other in-country partnerships are being either established or strengthened with CBM for training middle level eye personnel, Helen Keller International, MAP International and the Swiss Tropical Diseases Research Centre in Abidjan for supporting the control of NTDS in the country.
In Niger, Sightsavers signed a Memorandum of Understanding with the Ministry of Health in early 2012 in order to reinforce onchocerciasis surveillance activities and as a partner for comprehensive eye-care and NTD activities in the country.
In 2012, the Director of the Bureau d’Etudes, de Liaison des Actions Caritatives et de Développement (BELACD), a national NGDO supporting Chad in development activities in most of the southern rural areas including CDTI activities, approached Sightsavers regarding the establishment of an in-country partnership to expand its onchocerciasis activities from control
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to elimination. Hopefully, this initiative will be successfully concluded in the near future.
Despite these efforts, a few CDTI projects are still lacking NGDO partners, particularly in the Democratic Republic of Congo, Ethiopia and in Nigeria. As discussed during the 39th session of the NGDO Coordination Group for Onchocerciasis Control held in March 2012 in Ouagadougou, Burkina Faso, NGDO partners working in a country in need were requested to consider new opportunities of strengthening collaboration among themselves. The Group recommended strengthening cross-border activities in close collaboration with regional organisations and stressed the need for harmonising treatment across borders and increased involvement of partners in advocacy for cross-border activities. The Group welcomed the intra-country partnership initiative to provide assistance to partners with limited funding, highlighted the need to strengthen NOTFs and encouraged APOC to post more Technical Advisors to DRC.
The critical issue of identifying new partners and resources for onchocerciasis elimination and strengthening partnerships for Onchocerciasis and other NTDs activities will be discussed during the 40th session of the NGDO Coordination Group for Onchocerciasis Control in September.
5.5.2 Collaboration with other programmes and institutionsAs part of its collaborative policy, APOC has jointly worked with other programmes and institutions during the reporting period. This collaboration has taken place through joint meetings and workshops initiated either by the APOC Programme or by other programmes and institutions. APOC representatives also attended several meetings and workshops organised by its partners to keep abreast of their prospects and priorities. These activities included:
• Official launching of the National Master Plan for Neglected Tropical Disease control in Burundi (25/02/2012 -05/03/2012);
• 2nd session of the NTD/NGDO Network held in September 2011 in Nairobi, Kenya;
• Ethiopia NOTF National Annual Review Meeting in Ethiopia (04 – 07/10/ 2011);
• Meeting on how to accelerate progress towards the WHO goals for control and elimination of NTDs by 2020 in London, UK (28 – 31 /01/2012);
• NTD Stakeholders Meeting and disease-specific meetings in Dar-es-Salaam, Tanzania (20-29/01/12);
• NTD Stakeholders Meeting to determine the specific inputs provided by partners in Tanzania (30/04/ - 03/05/12);
• Finalising a multi-country study on the “Delivery of Essential Health Services in Africa: Realities, Perspectives and People’s Perceptions” in Accra, Ghana 24-26/01/12);
• Consultation meeting to Review the Multi-country Study on the Delivery of Essential Health Services in Africa”, Brazzaville, Congo (01-11 May 2012);
• Loaloa scientific Working Group Meeting in Yaoundé, Cameroun (07-08/01/12);
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• 3rd NTD-STAG Meeting of the Global Working Group on Monitoring and Evaluation in Geneva, Switzerland (15-17/02/12);
• Technical Review Meeting on PCT/NTD in Geneva, Switzerland (17/02/12);
• The Carter Center River Blindness Program Review in Atlanta, USA (18-25 Feb 2012);
• 39th session of the NGDO group for onchocerciasis control, Ouagadougou, 08-09/03/2012;
• Teaching Sudanese students in Public Health MSc and visit to Abu Hamad Site in Sudan (23 March, 2012);
• AWOL Program Review meeting in Liverpool, UK (27-30/ 03/12);
• BFO meetings in Geneva, Switzerland (16-19/04/12);
• Thirteenth Ordinary Assembly of ECOWAS Ministers of Health in Conakry, Guinea (20-21 April 2012);
• 5th Strategic & Technical Advisory Group meeting on NTD, WHO/HQ in Geneva, Switzerland (24-25 April 2012);
• NTD Master Plan for Anglophone countries in Harare, Tanzania;
• NTD Master Plan for Francophone countries in Ouagadougou, Burkina Faso;
• Peer review workshop of annual situation and health system strengthening proposals reports, Dakar, Senegal;
• DNDI Helminths Expert Annual Advisory Group Meeting in Geneva, Switzerland (9 May 2012);
• 47th Meeting of MEC/AC in Geneva, Switzerland (19-25 May 2012);
• Regional Stakeholders’ Consultative Meeting on NTD and Inauguration of the Regional NTD Technical Advisory Groups in Accra, Ghana (25-27 June 2012).
World Health Organisation (WHO): Executing Agency to APOC
WHO/HQ provided the Programme with legal advice, technical guidance and assistance in finance management, communications, the Global System Management, audit and procurement, amongst others.
The WHO/AFRO Regional Director reaffirmed his support to the Programme by leading advocacy campaigns on the occasion of meetings and working sessions with both WHO partners and country and institution leaders in the continent. APOC continued to benefit from the support of the WHO Regional Office for Africa as regards the involvement of Regional technical Staff in APOC operations, staff recruitment and the transfer of funds to NOTF Secretariats and CDTI projects.
In addition to the continued assistance provided for the achievement of APOC missions to participating countries and to the provision of office space for all APOC Technical Advisers posted in post-conflict countries, WHO Country Offices (WCOs) have played a crucial role in the management of country onchocerciasis control programmes, travel arrangements for APOC missions, the delivery of local procurement, and indirect payments made via the WHO Global Service Centre in Kuala Lumpur to suppliers and partners.
APOC management collaborated with AFRO/NTD for the preparation of country master plans for NTD control/elimination.
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The World Bank: Fiscal Agent to APOC
During the reporting year, the World Bank, Fiscal Agent to APOC, continued to mobilise resources for the Programme and to manage the APOC Trust Fund. The Bank provided APOC Management with guidance for the success of its operations and supported the Programme in its advocacy campaigns towards participating countries and partners. APOC/HQ, for instance, received a visit of a Financial Officer in charge of its Trust Fund at the World Bank during the period under review. The World Bank also made contributions to all the deliberations of the JAF, the Committee of Sponsoring Agencies and the Technical Consultative Committee that were held during the reporting period. The formal approval by the Board of the Bank for the extension of the APOC Trust Fund to 2025 should be recorded.
The African Development Bank (AfDB)
As a donor and member of the Committee of Sponsoring Agencies of APOC, AfDB maintains regular contact with APOC Management. The implementation of the MoU between APOC and AfDB includes periodic review missions at APOC/HQ for a briefing on the most recent activities and results of the Programme, discussions on future needs in support to programme implementation and participation in field activities for a better understanding of APOC operations. In addition, AfDB contributes to the deliberations of the CSA as well as to the Joint Action Forum of APOC.
West African Health Organisation (WAHO)
WAHO has continued to play a strong collaborative role by attending all TCC sessions and the ex-OCP coordinators’ meetings. As a sub-regional health organisation in West Africa, WAHO committed itself to supporting APOC operations in the sub-region during the reporting period.
The Champalimaud Foundation
The APOC Programme was presented in Lisbon, Portugal, with the Antonio Champalimaud Vision Award 2011 in September 2011 for its outstanding contribution to the prevention of visual impairment and blindness in Africa. The recognition ceremony took place in Lisbon, Portugal and the President of Portugal, accompanied by the President of the Champalimaud Foundation, honoured the ceremony by handing the Award over to the Director of APOC (Figure 19).
In a message sent to JAF 17, the President of the Champalimaud Foundation reiterated the commitment of the Foundation to supporting APOC in its endeavour to fight against blindness in Africa. This commitment of the Foundation to continue to support APOC constitutes a promising ground for further collaboration between APOC and the Champalimaud Foundation.
Innovative Vector Control Consortium (IVCC)
The Innovative Vector Control Consortium (IVCC) is a body aiming to achieve sustainable vector control as a key component of malaria control and elimination with support from the Bill and Melinda gates Foundation. During this year’s IVCC stakeholder forum, Professor Daniel Boakye was invited to make a presentation detailing the management of insecticide resistance by OCP and how this could benefit the
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malaria control community. The title of the presentation was ‘Management of blackfly insecticide resistance in the Onchocerciasis Control Programme: Lessons for Malaria vector control” by Dr Laurent Yameogo and Prof Daniel Boakye. The meeting was attended by over one hundred people from academia, industry, WHO, the World Bank among others. The Forum was held in Edinburgh, UK, on 12th June, 2012.
University of Medical Sciences and Technology, Khartoum, Sudan
The University of Medical Sciences and Technology, Khartoum, Sudan invited APOC management to assist them in writing a proposal to introduce the CDI module into their curricula. The proposal has since been completed and submitted to APOC. The opportunity was taken to discuss the inclusion of the CDI module with lecturers from other South Sudanese universities. Prof D. Boakye gave lectures on the CDI module particularly on engaging communities for NTD control between 30 June and 5 July 2012.
Figure19:The current Director of APOC, Dr Paul-Samson Lusamba-Dikassa, receiving the Champa-limaud Award from His Excellency the President of Portugal in the presence of the President of the Champalimaud Foundation and former APOC Director, Dr Uche V. Amazigo
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6. Moxidectin development and other research
1. Moxidectin development The Phase 3 study has been completed. Due to logistical challenges with data base transfer, it was not possible to have the complete data base for final data analysis in the third quarter of 2012 as projected in 2011.
2. Ivermectin Response MarkersThis project is conducted in collaboration between laboratories in Australia, Burkina Faso (MDSC), Cameroon, Canada, France, and Ghana and funded by APOC with project management provided by TDR. The primary objective is to answer the question whether long term treatment with ivermectin results in selection of O.volvulus with a reduced response to the embryostatic effect of ivermectin. If the answer is yes, the project aims to develop a tool suitable for surveillance for such strains. The project completed year 1. The results of the bioinformatics and statistical analysis of sequence variants obtained in the genome wide search to date point to several genome regions likely to be different between low responder and good responder worms, and thus support the hypothesis of genetic selection under IVM exposure. The analysis of the data available to date on the genetic differentiation between the Cameroon and Ghana samples (independent of IVM selection) suggests that there is little O.volvulus gene flow between the parasite populations of these countries and that low susceptibility/resistance to IVM could have arisen independently in each country.
3. Update on trans-dermal delivery technology based DEC patch test availability to APOCDiscussions on the technical part of the agreement with Lohmann Therapy Systems (LTS) are continuing for the production and delivery WHO for the endemic countries.
Af
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APO
CCo
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y19
9719
9819
9920
0020
0120
0220
0320
0420
0520
0620
0720
0820
0920
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000
00
00
00
1,19
9,00
00
02,
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500
00
1,35
2,00
03,
326,
500
8,76
6,00
0
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00
00
00
440,
000
056
6,00
02,
249,
000
2,21
5,00
02,
380,
000
2,51
6,00
02,
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2,94
9,00
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,000
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770,
800
2,64
7,80
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4,87
4,00
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500
9,61
5,50
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5,27
6,00
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12,8
34,0
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,424
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13,0
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182,
600
3,25
4,00
02,
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3,01
9,00
04,
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2,80
0,00
04,
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000
00
3,00
0,00
05,
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2,85
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05,
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4,97
0,00
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3,50
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4,01
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4,25
0,50
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4,76
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877,
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635,
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17,2
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13,3
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50,5
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Eq. G
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3,92
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18,4
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13,8
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,032
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13,0
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34,8
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3,77
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Gab
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Mal
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2,00
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4,78
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Sou
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6,55
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Ann
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f Mec
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tabl
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pro
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d an
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APO
C m
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pro
gram
mes
from
199
7 to
201
0 an
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ex-
OCP
cou
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Ann
ex
Af
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59
African Programme for Onchocerciasis Control (APOC)World Health OrganizationB.P. 549 – Ouagadougou – BURKINA FASOTel: +226-50 34 29 53 / 50 34 29 59 / 50 34 29 60Fax: +226-50 34 28 75 / 50 34 26 [email protected]/apoc
AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL
© A
POC
2012
– G
raph
ic d
esig
n: L
isa
Schw
arb
– Ph
otos
: APO
C, W
HO
/TD
R, A
ndy
Crum
p –
WH
O/A
POC/
JAFJ
AF1
8.5