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The Global 2000 River Blindness Program of the Carter Center October 1997

Table of Contents:

SUDAN: Standardization of reporting andmonitoring of treatment activities emphasized by GRBP at APOC meeting in Sudan

In early September the Workshop on thePhilosophy of APOC, Concept, and Harmonization of Community-directed Treatmentwith Ivermectin took place in Khartoum, Sudan. The purposes of theworkshop were to reach a common understanding among the APOC partners inSudan on how to establish sustainable Community Directed Treatment withIvermectin (CDTI) projects integrated into Sudan's existing health caresystem.

In addition, participants sought a model solution to the implementationof CDTIs in countries with unstable populations for use in other APOC countries,where appropriate. The 34 participants who participated were from Juba,West Yambio, Jur River, Tonj, Rumbek, Abu Hamad, Jonglei, South Dafur,and El Radom, and included Dr. Gasim Barnaba Kisanga, State Minister ofHealth, Juba, Bahr el Jabal, and Dr. Charles Guli, Director General, Ministryof Health, Western Equatoria. The meeting was organized by Sudan NationalOnchocerciasis Task Force (NOTF), led by Dr. Mamoun MA Homeida, Chairman,NOTF.

Ms. Irene Goepp of Health Net International (HNI) and coordinatorof the Southern Sudan Onchocerciasis Control Program working under OperationLifeline Sudan in Nairobi also attended. Mr. Elvin Hilyer, G2000 residentadvisor, played a major role in the organization and support of this meeting.APOC participants included Dr. Uche Amazigo, Dr. Mounkaila Noma, Dr. DanielEtya'ale (NGDO coalition-liaison), Dr. Jean Baptiste Roungou, WHO's AfricanRegional Office, and Mr. Celestin Zinkone. APOC facilitators included Dr.Pierre Ngoumou (Cameroon), Dr. Henry Edeghere (Nigeria), Mr. Jeff Watson(CBM, Nigeria), and Dr. Josephine Namboze, (WHO/Uganda). A special guestwas Dr. Charles Mackenzie of the University of Michigan. Dr. Frank Richardsfrom Global 2000 headquarters in Atlanta also was present.

The opening ceremony was held on the morningof 1 September at Friendship Hall in Khartoum, and attended by the VicePresident of Sudan, Mr. George Kongor Arob, and the Minister of Health,Dr. Ihsan el Bhabshawi. In his speech, the Vice President thanked APOC,WHO, The Carter Center, the Lions Club SightFirst Program, HealthNet, andMerck. He noted that he was from a village in an onchocerciasis-endemicregion of Bahr el Ghazal, and as a child he had seen people blinded fromonchocerciasis. The name for the condition in Bahr el Ghazal was not "riverblindness," but "Jur Blindness" named from the Jur river.

From the Global 2000 perspective, one ofthe most important topics of discussion at the workshop was the issue ofreporting treatment activities. Similar to operations in other Global 2000-assistedonchocerciasis and dracunculiasis programs, Mr. Hilyer and Dr. Richardsemphasized the need for monthly reporting of treatments in Sudan, relatedto annual treatment objectives for persons and villages to be treated.So far in 1997, the Government of Sudan has reported 4,254 treatments,while Operation Lifeline Sudan NGDOs reported a total of 23,000 treatments.

It is known, however, that significantlymore treatments have occured this year, but reports are delayed due toincreased strife in some endemic areas.

WHO's Weekly Epidemiological Recordrecently published an article on the status of health activities inSudan since the Guinea worm cease-fire in March 1995 (see references).The article reported remarkable progress in southern Sudan despite constraintsof civil strife and inadequate funding. 143,414 persons at risk of onchocerciasiswere treated with ivermectin in 1996. The article referred to the needfor further assessment in some dracunculiasis and onchocerciasis endemicareas in order to continue progress there.

NIGERIA: 1997 Annual Treatment Objectivefor eligible at-risk population goal close to being reached
After treating 527,359 people during themonth of August, GRBP Nigeria reported having reached 92% of their AnnualTreatment Objective for eligible at-risk population (ATO earp) for 1997and 90% of the 1997 objective for treating high-risk (nodule prevalence>40%) and at-risk villages in assisted areas. Nigerian treatments makeup 82% of all GRBP treatments so far in 1997. GRBP in Nigeria has devotedmuch effort to advocacy visits at the Local Government Areas (LGAs) level,during which discussions are held on the devolution of the responsibilityfor the distribution program to the LGA authorities.

In October, Dr. Emmanuel Miri, countryrepresentative of GRBP in Nigeria, attended the NGDO and NOTF meetingsheld October 8 and 9 respectively in Benin City. During the meetings itwas reported that about 5.6 million people have been treated in all ofNigeria so far during 1997.

At the NGDO meeting, Dr. Miri was electedchair of the coalition for another year, after which Dr. Elizabeth Elhassanof SightSavers will succeed him in that post. Recommendations from theNGDO meeting included the need for identifying opportunities to integrateinto Mectizan distribution other health programs such as schistosomiasis(treatment with praziquantel), lymphatic filariasis (ivermectin possiblyin combination with albendazole), prevention of trachoma, and malaria control.The NGDO meeting also recommended that the APOC CDTI strategy be implementedin all programs regardless of APOC funding status; and that Nigeria's NationalOnchocerciasis Day in February 1998 be celebrated in the onchocerciasisendemic village of the Honorable Commissioner for Health in Abia State,whose Mectizan distribution program is jointly assisted by Lions ClubsSight First program and GRBP.

UGANDA: Coverage of more than 50% of 1997ATO since April
The GRBP-assisted program in Uganda hastreated 53% of its ATO (426,919) so far this year. According to the projectednumber of treatments for the remaining months in 1997, the outlook is goodthat Uganda will come close to achieving 100% coverage. However, a majorimpediment to complete treatment coverage is insecurity in some of thedistricts where GRBP-assisted programs operate.

Acting country representative, Mr. DominicMutabazi, has been working with the Tropical Disease Research (TDR) programon the development of a new protocol for evaluating sustainability andCDTI methods. Mr. Moses Katabarwa is finishing his Emory University MPHthesis entitled "Selection and validation of indicators for sustainabilityof community-based ivermectin distribution for onchocerciasis control inUganda-a retrospective study." He will return to Uganda in late Decemberto resume his duties as country representative.

CAMEROON: New Country Representative

The Carter Center welcomes Dr. Albert Eyambaas its Global 2000 River Blindness Program Country Representative in Cameroon,replacing Mr. Jean Bangob. Dr. Eyamba is a Cameroonian with an MD fromCentre Universitaire des Sciences de la Santé (1976), andan MPH from Tulane University (1984), with additional training in epidemiologyat the CDC in Atlanta.

He served as chief of medicine in various hospitalsin West Province from 1976-1981, and was chief administrator of a medicalclinic in New Orleans from 1985-1995. We welcome Dr. Eyamba and look forhim to make an important contribution to the many dimensions of Cameroon'sstruggle against onchocerciasis. Mr. Jean Bangob, who did an excellentjob as acting country representative since 1996, will continue as administratorof the program.

Treatment activities: In the GRBP/LCIFassisted areas of West Province, 35,845 people have been treated so farin 1997. During the month of September, training activities were conductedin the ten health districts of the North Province, with more than 250 doctors,nurses, and health workers participating. Dr. Eyamba, who has served asa GRBP consultant in West Province since September, helped in providinginstruction in onchocerciasis disease and its treatment, rapid assessment,health education, ivermectin distribution and monitoring for adverse reactions,integration of ivermectin distribution into the primary health care system,training and supervision, and record keeping for monitoring treatment activities.In North Province, 91,395 (75% of the ATO earp) has been achieved so far.

The midterm evaluation of the InterAmericanDevelopment Bank (IDB) grant to OEPA is planned for November. In addition,OEPA staff are busy preparing for the seventh InterAmerican Conferenceon Onchocerciasis to be held in Cali, Colombia November 19-21, 1997. Amongthe guests at this year's conference will be Dr. Donald Hopkins, The CarterCenter's Associate Executive Director for the Control and Eradication ofDisease, Dr. Yankum Dadzie, WHO's OCP and ai APOC Director, Dr. Mary Alleman,Associate Director of the Mectizan® Donation Program, and Dr. PhilippeGaxotte of Merck. The theme of this year's IACO is "Criteria for theCertification of the Elimination of Onchocerciasis".

New reporting of indices of sustainability:The GRBP Cameroon, Uganda, Nigeria, and OEPA programs have begun to providethree sets of indices for sustainability in their monthly reports: Communityinvolvement (absolute and expressed asa percentage of total communities treated), Governmentinvolvement (absolute and expressed asa percentage of total communities treated), and Costs(absolute and expressed as cost per treatment). The last variable is tobe calculated as well in terms of government and APOC contributions.

Community involvement is definedas the number and percent of treated villagesin which the community is involvedin the design and implementation of the treatment program and (where appropriate)the selection of their community-based distributor (CBD). Other supportindicators for community involvement include monetary or in kind communitysupport for CBDs, and formation of village health committees.

Government involvement is definedas the number and percent of treated villagesin which the CBD is a part of, or is supervised by, the primaryhealth care system. An additional indicatorhere is: does the government have a lineitem for onchocerciasis control in its budget? If yes, how much?

Cost per treatment: the cost perperson treated with Mectizan is estimated by two indices:

  1. Actual costs of treatment: Thiscalculation includes all costs, including: a) a proportion of HQ costs,overhead and salaries, b) local GRBP HQ costs, overhead and salaries, c)delivery of Mectizan from the port of entry to community, including collectingthe drug from a central point by CBD, d) training, e) MOH/PHC supervisionand monitoring of the program, and f) remuneration/incentives paid to CBDsby the community, which could include cost recovery mechanisms.
  2. Cost provided by national government:The government provided cost per treatment, and the percentage the governmentis paying of actual costs. Does not include village support.


Dr. Donald Hopkins attended the meeting of APOC'sTechnical Consultative Committee in Burkina Faso, Ouagadougou September19-20.

Two symposia are planned to celebrate the 10thanniversary of Merck & Company's decision to donate Mectizan.They will be held in Bamako November 5 and in Liverpool December 8-9. Topicsof the symposia include: the impact of Mectizan on disease transmission,the critical role of developing partnerships, community participation,cross-border challenges, and future Mectizan research.

Preceding the symposium in Liverpool, theannual meeting of the Joint Action Forum will be held December 3-5. PresidentJimmy Carter, Global 2000 Chairman, will attend the meeting.

Selected References

Addiss DG, Beach MJ, Streit TG, Lutwick S, LeConteFH, Lafontant JG, Hightower AW, Lammie PJ. Randomised placebo-conrolledcomparison of ivermectin and albendazole alone and in comnbination forWuchereria bancrofti microfilaraemia in Haitian children. Lancet1997 350(9076):480-4.

Awadzi K, Opoku NO, Attah SK, Addy ET, Duke BO,Nyame PK, Kshirsagar NA. The safety and efficacy of ivermectin on the clinicaland parasitological response to treatment. Annalsof Tropical Medicine & Parasitology 1997 91(3)281-96.

Boussinesq M, Gardon J. Prevalences ofLoa loa microfilaremia throughout thearea endemic for the infection. Annalsof Tropical Medicine & Parasitology1997; 91 (6): 573-589.

Boatin B, Molyneux DH, Hougard JM, ChristensenOW, Alley ES, Yameogo L, Seketeli A, Dadzie KY. Patterns of epidemiologyand control of onchocerciasis in West Africa. Journalof Epidemiology 1997; 71:91-101.

Calcoen D, Mabor M. Onchocerciasis monitoring andmass treatment with ivermectin under unstable war conditions in south-westernSudan. Bulletin of Tropical Medicineand International Health: Newsletter of the Royal Society of Tropical Medicineand Hygiene. 1997, 5(2): 1-4.

Caumes E. Ivermectin and tropical dermatoses. Bulletinde la Societe de Pathologie Exotique 1997;90(1):37-8.

Cousens SN; Cassels-Brown A; Murdoch I; BabalolaOE; Jatau D; Alexander ND; Evans JE; Danboyi P; Abiose A; Jones BR. Impactof annual dosing with ivermectin on progression of onchocercal visual fieldloss. Bulletin of the World HealthOrganization . 1997; 75(3): 229-36.

Guderian RH, Chico ME, Cooper PJ. Observationson the formation of new onchocercal nodules in Ecudaor. Annals of TropicalMedicine & Parasitology. 1997; 91(4)437-41.

Guderian RH, Lovato R, Anselmi M, Mancero T, CooperPJ. Onchocerciasis and reproductive health in Ecuador. Transactionsof the Royal Society of Tropical Medicine and Hygiene1997; 91(3): 315-7.

Kelly MG, Akogun OB. Rapid assessment of onchocerciasisprevalence and a model for selecting communities for ivermectin distributionin West Africa. Zentralblatt fur BakteriologieParasitenkunde Infektionskrankheiten und Hygiene. 1997; 286(1):146-54.

Newell ED. Effect of mass treatments with ivermectin,with only partial compliance, on prevalence and intensity of O. volvulusinfection in adults and in untreated 4 and 5 year-old children in Burundi.Tropical Medicine in InternationalHealth 1997; 2(9): 912-6.

Newell ED, Ndimuruvugo N. [Endemic disease andclinical manifestations of onchocerciasis in the province of Rutana (Burundi)].Bulletin de la Societe de PathologieExotique 1997; 90(2): 107-10.

Plaisier AP, Alley ES, van Oormarssen GJ, BoatinBA, Habbema JD. Required duration of combined annual treatment and vectorcontrol in the Onchoerciasis Control Programme in West Africa. TheBulletin of the World Health Organization1997; 75(3)237-45.

Schwartz EC, Huss R, Hopkins A, Dadjim B, MadjitoloumP, Henault C, Klauss V. Blindness and visual impairment in a region endemicfor onchocerciasis in the Central African Republic. BritishJournal of Ophthalmology. 1997; 81(6):443-7.

World Health Organizations. Dracunculiasis andOnchocerciasis: Sudan. Weekly EpidemiologicalRecord. 1997 (72)297-301.

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