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The Global 2000 River Blindness Program of the Carter Center May 1996

Table of Contents:

In November 1995, the Boards of Trustees of The Carter Center, Inc. and the River Blindness Foundation (RBF) agreed that the Center's Global 2000 program would assume the mission of the RBF. The transition was completed as of April 30, 1996. The new program is known as The Carter Center's Global 2000 River Blindness Program (GRBP). Global 2000 has worked on the eradication of dracunculiasis (Guinea worm disease) in Africa and Asia since 1986. The director of that program, Donald Hopkins, M.D., has been named the director of GRBP. Working with him are Frank Richards Jr., M.D., who has worked on onchocerciasis for more than nine years, including five years in Guatemala; and Mr. Andrew Agle, director of operations for Global 2000. Brian Duke, M.D., former medical director of RBF, will continue to serve as medical consultant to GRBP.

The GRBP will be responsible for directing and providing oversight of former RBF project operations in Cameroon, Nigeria, Uganda, and the Onchocerciasis Elimination Program in the Americas (OEPA), which comprises Guatemala, Mexico, Venezuela, Brazil, Ecuador and Colombia. The program also will continue the new project begun in Sudan with the cease-fire in 1995 (see page 3). GRBP will continue to collaborate with other nongovernmental development organizations (NGDOs) in endemic countries and remain an active member of the international coalition of NGDOs that are assisting in the distribution of Mectizan®. In addition, GRBP will continue to oversee NGDO grantees provided with funding by RBF. GRBP will work in close collaboration with the Division of Parasitic Diseases, National Center for Infectious Diseases of the Centers for Disease Control and Prevention (CDC). GRBP is distinct from the Mectizan® Donation Program (MDP), which was established by Merck & Co. to promote and monitor appropriate distribution of Mectizan® to endemic countries. MDP is a program of the Task Force for Child Survival and Development, a nonprofit organization focused on improving the health of children world wide, which is affiliated with The Carter Center.


Number of Persons at Risk of Onchceriasis Treated with Mectizan: Nigeria, 1989-1995

The National Onchocerciasis Task Force (NOTF) of the Nigerian Onchocerciasis Control Program (NOCP) held its most recent meeting on January 23. The meeting was conducted at the national headquarters of the River Blindness Foundation in Jos, Plateau State, Nigeria, under the chairmanship of NOCP director Jonathan Jiya, M.D. The semi-annual meeting was preceded by a meeting chaired by RBF's Emmanuel Miri, M.D., of the Coalition of NGDOs that are assisting the program (see Table 1).

The NOCP is poised to reach significantly more of its population in 1996, having made arrangements with UNICEF/Nigeria for the latter to facilitate clearing the donated Mectizan® upon its arrival in Nigeria. The two meetings in Jos also reviewed progress toward completing the Rapid Epidemiological Mapping of Onchocerciasis (REMO) surveys of Nigeria, which will give the program more precise data about the distribution of onchocerciasis. Those findings are expected to be completed soon.

Table 1:

Number of Persons Treated with Mectizan® in Nigeria 1989-1995 by assisting NGDO Agency

NGDO/AGENCY 1989 1990 1991 1992 1993 1994 1995 Africare 49,556 50,688 71,205 134,491 238,747 482,016 723,546 RBF/GRBP 224,427 676,200 *1,110,139 *1,786,863 UNICEF 212,214 225,230 525,459 1,061,967 Sight Savers 197,709 511,305 IFESH 40,921 42,096 CBM 96,725 World Vision 15,390 TOTAL NIGERIA 49,556 50,688 71,205 571,132 1,140,177 2,356,244 4,237,892

*In collaboration with Lions Clubs International Foundation Sightfirst

Information presented at the two meetings and since then reveal that approximately 4.2 million Nigerians at risk of onchocerciasis received Mectizan® during 1995. While it is still well short of the estimated 40 million Nigerians at risk, the 1995 achievement nearly doubled the number of persons treated by the program in 1994, despite delays in clearing Mectizan® and consequent shortages of the drug in the country in 1995.

On February 13, the Nigerian program marked the second annual National Onchocerciasis Day, as a means of raising awareness about the disease and its prevention. The theme of this year's celebration was "Take Mectizan® to Save Sight and Skin." At a press conference held to commemorate the re-launching of the NOCP on February 12, 1991, the Federal Minister of Health, Ihechukwu Madubuike, M.D., summarized the challenge posed to Nigerians by onchocerciasis. After stating the federal government's intention "to take a lead in drawing [Africa Program for Onchocerciasis Control (APOC)] assistance for its citizenry under the scourge of onchocerciasis," he concluded by observing: "Ladies and gentlemen, we need to remind ourselves that we cannot afford to depend entirely on organizations and agencies for help. The problem is ours. The task is to put in place a community-based, self-sustaining program.....The fight against onchocerciasis is a fight that must be won."

While attending Sudan's first National Conference on Dracunculiasis Eradication on March 27, 1995, The Carter Center's chairman, former President Jimmy Carter, completed negotiations for a two-month cease-fire in the Sudanese civil war. The cease-fire, which began on March 28 and was later extended for another two months, permitted health officials on both sides, and their international partners, to accelerate measures to eradicate dracunculiasis (Guinea worm disease), as well as to undertake community assessments and distribute Mectizan® for onchocerciasis. The interruption of hostilities also was used to immunize children and to distribute oral rehydration solution and vitamin A supplements. The Carter Center's Global 2000 Program established offices in Khartoum and Nairobi to coordinate its assistance during and after the cease-fire. Strong support was provided on very short notice by Sudanese health officials and organizations, Operation Lifeline Sudan (OLS), UNICEF, the Centers for Disease Control and Prevention (CDC) and several international NGDOs working in association with OLS, especially Medecins Sans Frontieres- -Belgium (MSF-B), International Medical Corps (IMC), the Mectizan® Donation Program, CARE, Norwegian People's Aid, the Sudan Relief and Rehabilitation Association, Health Net, Michigan State University, and Action Africa in Need.

As a result of the herculean efforts, fifty persons from 18 organizations were trained in a two-day workshop in Lokichokio, Kenya; about 250 community distributors were trained, more than 5,000 communities were assessed for onchocerciasis, and more than 100,000 persons at risk were treated, most for the first time (see Figure 2). National authorities believe that at least one million people are infected with onchocerciasis in Sudan, which includes communities with some of the highest rates for blinding onchocerciasis in the world. In Sudan, the disease mostly occurs among populations living along rivers in Bahr Al-Ghazal and Western Equatoria in the southwest of the country, although there are smaller foci on the southeastern border with Ethiopia and in the north around Abu Hamad and Radoun.

Number of Persons in Sudan Treated with Mectizan

Late in July, President and Mrs. Carter visited one of the strongholds of onchocerciasis in southern Sudan, during a one-day trip to Tambura, in Western Equatoria near the border with Central African Republic. Accompanied by Sudan's Minister of Health, they also visited a dracunculiasis-endemic area at Nyamini, west of Juba, to review accomplishments of the cease-fire.

Early in 1996, the River Blindness Foundation made grants of $20,000 to Prof. Mamoun Homeida to help support extension of Mectizan® distribution to endemic areas of Upper Nile State for the first time, and grants of $15,000 each to International Medical Corps and Medecins Sans Frontieres--Belgium to support further treatments in Western Equatoria.

In 1995, the Uganda Onchocerciasis Control Program treated 1,023,607 of the estimated eligible target population of 1,265,641. This program also treated over 70,000 Sudanese refugees in Uganda in 1995. 581,125 of the total treatments were in project areas assisted by the River Blindness Foundation that included 1,718 endemic villages. Other organizations assisting the Ugandan program include Christoffel Blindenmission (CBM), the German assistance agency GTZ, Kuluva Hospital of the Church of Uganda, Sight Savers International, and World Vision International. The Ugandan program, which began Mectizan® treatments in 1991, had already treated more than 780,000 persons at risk by 1993. The national coordinator of this program is Richard Ndyomugyenyi, M.D.; the director of the GRBP in Uganda is Mr. Moses Katabarwa.

In August 1995, the Lions International Foundation's SightFirst program announced a grant of more than $2.1 million to assist in extending the fight against onchocerciasis in Cameroon. The proposal for this grant, which was submitted by the Lions Club 403B, the Cameroonian ministry of public health, and a coalition of NGDOs (Helen Keller International, International Eye Foundation, River Blindness Foundation, and Sight Savers International), will support treatments in Adamawa, Central, and Western Provinces, which are among the most highly affected areas of the country. Of the estimated 6.5 million persons at risk in the country, less than 10% were treated with Mectizan® in 1995. The new grant will allow the Cameroonian program to expand its reach to an estimated 50% of the population at risk. The German assistance agency GTZ is also facilitating Mectizan® distribution in Cameroon. A new national coordinator, Ncharre Chouaïbou, M.D., has been named following the assignment of the former coordinator, Pierre Ngoumou, M.D., to the African regional office of WHO. The director of the GRBP in Cameroon is Christine Godin, M.D. The new Coalition of NGDOs will be chaired by Madame Dominique Coste.

OEPA Brasilia:
The 1995 Inter-American Conference on Onchocerciasis (IACO'95) met at the offices of PAHO in Brasilia, Brazil on November 6-11, 1995. A grant from The World Bank helped OEPA and PAHO support this, the fifth annual IACO meeting. Key programmatic 1994 data were presented by the delegations from the six national programs. Mexico reported having continued twice yearly Mectizan® treatments of essentially 100% of the 123,711 eligible persons at risk, including all hyper- and mesoendemic communities. The program in Ecuador is similarly advanced, having treated some 14,568 persons of the 16,104 eligible population at risk (90.5%) twice a year since 1990. Studies of children under five years old born in the Esmeraldas hyperendemic area in 1990-1995, since Mectizan® distribution commenced, reveal a dramatic reduction in prevalence of microfilaria in skin snips (from 64% to 0%) and in detectable nodules (from 9% to 0%), compared with 1985 prevalence rates in children born in 1980-1985, before Mectizan® was available. Guatemala had provided biannual treatments to 122,815 persons, or 98% of the eligible at-risk population in the principal (central) focus near Lake Atitlan in 1993 and 1994.

However, decentralization of the Guatemalan Ministry of Health (MOH) in 1995 has resulted in an 80% decrease in treatment activities. The Guatemalan delegation said that progress was being made in re-establishing the program in 1996. In Brazil, where an affected population of about 7,000 persons lives in a vast and remote area of the Amazon Basin, the first round of mass Mectizan® treatment ever in that country will begin as a pilot project in 1996. Most of the burden of onchocerciasis in Venezuela occurs in two northern foci, which will be further assessed epidemiologically in 1996. In 1995, Colombia completed an extensive epidemiological assessment that showed onchocerciasis was confined to one small endemic area in the Department of Cauca.

Only about 700 persons are known to be at risk, and only about 50 persons have been diagnosed as being infected in the entire country. Participants at the IACO meeting were excited about these findings, and suggested that an integrated program of Mectizan® treatment and vector control be instituted with the aim of quickly eliminating onchocerciasis morbidity and perhaps infection from Colombia. IACO concluded that additional standardized epidemiological and entomological data were needed to document changes in morbidity from infection and parasite transmission in the region, and that mapping of disease prevalence in northern Venezuela was urgently needed.

As a result of recommendations made at IACO'95, the Onchcocerciasis Elimination Program for the Americas (OEPA) sponsored a conference in Esmeraldas, Ecuador, January 15-23, 1996, to further refine the guidelines for interpreting the impact of ivermectin treatment in the Americas. Discussions centered on definitions of population at risk, endemicity, methodology of assessments of sentinel communities, use of indicator groups, and ento-mological and ophthalmological assessments. The results of this meeting will be useful in formalizing reporting mechanisms for delegations to future IACO meetings.

Important leadership changes in OEPA for 1996: Mr. Jack Blanks passed the responsibility of director of OEPA to Edmundo Alvarez, M.D. Guillermo Zea Flores, M.D., will continue as deputy director. In 1995, the OEPA office added consultants supported by the InterAmerican Development Bank: John Ehrenberg, M.D., epidemiology; Michael Richards, M.D., health education; and Mr. Freddy Clark, information systems specialist. Because of its expansion, in 1996 the OEPA office was moved from Antigua, Guatemala to Guatemala City. The new address is: Onchocerciasis Elimination Program for the Americas (OEPA), 14 Calle 3-51 Zona 10, Murano Center Oficina 801, Guatemala City, Guatemala 01010, Guatemala, Email, FAX 5022-666127. Raphael Cedillos, M.D., completed his term as director of the Program Coordinating Committee (PCC) of OEPA, and was succeeded by Richard Collins, M.D., of the University of Arizona.

WHORepresentatives of The World Bank, the World Health Organization (WHO), Merck & Co., ministers of health of endemic African countries, The Carter Center's Global 2000 Program, and several other NGDOs attended the first meeting of the Joint African Forum (JAF) in Washington, D.C. on December 4-5, 1995 to formally launch the African Program for Onchocerciasis Control (APOC). The twelve-year-long program (1996-2007) will assist all 16 African countries where onchocerciasis is endemic outside of the Onchocerciasis Control Program (OCP) area of West Africa.

APOC will establish community-based, sustainable national programs for distributing Mectizan® in order to control the disease. Up to 75% of program costs will be funded by a trust fund established by the Bank, and the remainder will be funded by the affected countries and their other partners. An estimated $124 million will be needed over the course of the program, of which about $30 million had been committed by December 4. (An additional $12 million has been lined up in the first quarter of 1996). The entire amount is from a total of 16 donors. Merck will contribute approximately 410 million tablets of Mectizan®, valued at several hundred million dollars. WHO will be the executing agency for the new program, just as it is for the OCP.

The other two co-sponsoring organizations, in addition to World Bank and WHO, are the United Nations Development Program (UNDP) and the Food and Agriculture Organization (FAO). APOC is expected to announce guidelines for preparing proposals for funding later this year.

Among the dignitaries present at the launching were World Bank President J. Wolfensohn, World Bank Vice-President for Africa E. Jaycox, WHO Director-General H. Nakajima, former U.S. President Jimmy Carter of The Carter Center's Global 2000 Program, WHO Regional Director for Africa E. Samba, Merck & Co. Vice-President K. Frazier, UNDP Assistant Administrator for Africa E. Johnson-Sirleaf, and FAO Assistant Director General A. Sawadogo. Also present were Mr. Bruce Benton, head of the onchocerciasis unit at The World Bank, and former Nigerian minister of health Prof. Olikoye Ransome-Kuti, the JAF chairman. NGDO Coalition Chairman Allen Foster also took this opportunity to convene an informal meeting with representatives of Africare, Global 2000, Christoffel Blindenmission, Helen Keller International, International Eye Foundation, Interchurch Medical Assistance, Lions Clubs International SightFirst, the Mectizan® Donation Program, Organisation pour la Prevention de la Cecite, River Blindness Foundation, Sight Savers International, and World Vision International.

This is the first edition of the "new" River Blindness News under the aegis of The Carter Center's Global 2000 River Blindness Program. The News is intended to be primarily a technical newsletter to help disseminate information about onchocerciasis activities in GRBP-assisted countries and to report on other related activities. The last edition of the River Blindness News of the River Blindness Foundation was distributed in Summer 1995. This newsletter will be issued quarterly, and a French edition (translation) is being considered.

The contact point is:

Editor, River Blindness News
Global 2000
The Carter Center
One Copenhill
Atlanta, Georgia 30307
fax #: 404-874-5515

Congratulations to Jude Anosike of the GRBP in Imo/Abia for obtaining his Ph.D. in parasitology from the University of Jos, Nigeria.

Baraka O.Z., Khier M.M., Ahmed K.M., Ali M.M., el Mardi A.E., Mahmoud B.M., Ali M.H.. Homeida M.M., Williams J.F, 1995. Community based distribution of ivermectin in eastern Sudan: acceptability and early post-treatment reactions. Transactions of the Royal Society of Tropical Medicine & Hygiene, 89(3):316-8.

Boussinesq M., Chippaux J.P., Ernould J.C., Quillevere D, Prod'hon J. 1995. Effect of repeated treatments with ivermectin on the incidence of onchocerciasis in northern Cameroon. American Journal of Tropical Medicine and Hygiene, 53: 63-67.

Burnham G.,1995. Ivermectin treatment of onchocercal skin lesions: observations from a placebo-controlled, double-blind trial in Malawi. American Journal of Tropical Medicine & Hygiene, 52(3):270-6.

Chavasse D.C., Whitworth J.A., Lemoh P.A., Bennett S., Davies J.B., 1995. Low level ivermectin coverage and the transmission of onchocerciasis. Transactions of the Royal Society of Tropical Medicine & Hygiene, 89(5):534-7.

Chippaux J.P., Boussinesq M., Prod'hon J., 1995. Apport de l'ivermectine dans le controle de l'onchocercose.[The use of ivermectin in the control of onchocerciasis]. [Review][French]. Sante, 5(3):149-58.

Ducorps M., Gardon-Wendel N., Ranque S., Ndong W., Boussinesq M., Gardon J., Schneider D., Chippaux J.P., 1995. Effets secondaires du traitement de la loase hypermicrofilaremique par l'ivermectine. [Secondary effects of the treatment of hypermicrofilaremic loiasis using ivermectin]. [French] Bulletin de la Societe de Pathologie Exotique, 88(3):105-12.

Fischer P., Kipp W., Kabwa P., Buttner D.W., 1995. Onchocerciasis and human immunodeficiency virus in western Uganda: prevalences and treatment with ivermectin. American Journal of Tropical Medicine & Hygiene, 53(2):171-8.

Guillet P., Seketeli A., Alley E.S., Agoua H., Boatin B.A., Bissan Y., Akpoboua L.K., Quillevere D., Samba E.M., 1995. Impact of combined large-scale ivermectin distribution and vector control on transmission of Onchocerca volvulus in the Niger basin, Guinea. Bulletin of the World Health Organization, 73(2):199-205.

Issaka-Tinorgah A., Magnussen P., Bloch P., Yakubu A., 1994. Lack of effect of ivermectin on prepatent guinea-worm: a single-blind, placebo-controlled trial. Transactions of the Royal Society of Tropical Medicine & Hygiene, 88(3):346-8.

Kollo B., Mather F.J., Cline B.L., 1995. Evaluation of alternate methods of rapid assessment of endemicity of Onchocerca volvulus in communities in southern Cameroon. American Journal of Tropical Medicine and Hygiene, 53:243-247.

Molyneux D.H., 1995. Onchocerciasis control in West Africa: current status and future of the Onchocerciasis Control Programme. Parasitology Today, 11:399-402.

Plaisier A.P., Alley E.S., Boatin B.A., Van Oortmarssen G.J., Remme H., DeVlas S.J., Bonneux L., Habbema J.D., 1995. Irreversible effects of ivermectin on adult parasites in onchocerciasis patients in the Onchocerciasis Control Programme in West Africa. Journal of Infectious Diseases, 172(1):204-10.

Remme J.H.F., 1995. The African Programme for Onchocerciasis Control: preparing to launch. Parasitology Today, 11:403-406.

Richards, F.O. Jr., Klein R.E., Gonzales-Peralta C., Zea-Flores R., Roman S.G., Ramirez J.C., Zea-Flores G., 1995. Knowledge, attitudes and practices during a community-level ivermectin distribution campaign in Guatemala. Health Policy and Planning, 10:404-414.

Rodriguez-Perez M.A., Rodriguez M.H., Margeli-Perez H.M., Rivas-Alcala A.R., 1995. Effect of semiannual treatments of ivermectin on the prevalence and intensity of Onchocerca volvulus skin infection, ocular lesions, and infectivity of Simulium ochraceum populations in southern Mexico. American Journal of Tropical Medicine and Hygiene, 52:429-434.

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