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The Global 2000 River Blindness Program of the Carter Center January 1998

1997 Provisional GRBP Treatment figures

By the end of December 1997, a provisional total of 5,005,384 Mectizan® treatments were provided through GRBP-assisted programs in 1997 for a coverage of 91% of the 1997 GRBP Annual Treatment Objective (ATO) of 5,475,450. Treatments in 1997 exceeded by 31% those for 1996, when 3,828,180 treatments were distributed. Most GRBP activities were in Nigeria which represented 77% of the treatment total (3,852,731). The GRBP-assisted program in Uganda ranks second in numbers of treatments provided (763,063), which is remarkable given the security constraints and heavy rains that prevented activities in many districts - GRBP Uganda reached 94% of its ATO for 1997, while GRBP Nigeria exceeded its ATO.

Figure 1

Overall, 1997 treatment of at-risk villages (13,940) and high-risk villages(11,479) (villages in urgent need of treatment due to an estimated microfil Verdana prevalence of >60%) also achieved GRBP objectives. ATOs for 1998 will be finalized at the GRBP Program Review to be held in Atlanta in February.

Onchocerciasis Elimination Program for the Americas (OEPA): 1997 InterAmerican Conference on Onchocerciasis

The Seventh InterAmerican Conference on Onchocerciasis (IACO) was heldin Cali, Colombia November 19-21. The theme for the meeting was "Criteria for the Certification of Elimination of Onchocerciasis." Sponsors of the meeting included the Pan American Health Organization (PAHO), the Ministry of Health of Colombia, the InterAmerican Development Bank (BID)and The Carter Center.

The approximately 65 attendees included representatives from all six endemic countries in the Americas (Brazil, Colombia, Ecuador,Guatemala, Mexico, Venezuela), OEPA staff (Dr. Edmundo Alvarez, Ms. VivianAlvarez, Dr. John Ehrenberg, Dr. Guillermo Zea Flores, Ms. Alba Lucia Morales,Mr. Marco Antonio Morales, Mr. Roberto Saenz, and Mr. Juan Carlos Solares),Dr. K.Y. Dadzie (Director of Onchocerciasis Control Program-OCP, and acting Director of the African Programme for Onchocerciasis Control-APOC), Dr.Philip Gaxotte (Merck & Co.), and Dr. Mary Alleman (Mectizan® Donation Program. Dr. Donald Hopkins, Associate Executive Director of the Carter Center, led the five-person Carter Center delegation. The Program CoordinatingCommittee (PCC) of OEPA, chaired by Dr. Richard Collins, met during the course of the IACO.

1997 Treatments: Each country director presented information on Mectizan® treatments (Table 1). As of October 1997, 244,449 persons had been treated with Mectizan® in the Americas, 70% of the regional 1997 ATO. As shown in Table 3, attainment of ATO varied, with Mexico, Ecuador,and Colombia having the greatest success toward their objectives. Ecuador has returned to a policy of semi-annual treatments after recognition of new cases of onchocerciasis in children after the institution of annual treatment in 1996. Venezuela made progress in epidemiological evaluations of the extensive northern foci that remain the largest areas in the Americas to be fully characterized. Venezuela has over 800,000 persons estimated to be at risk of onchocerciasis in the Americas, or about 60% of the totalat risk population in the region.

1997 Mectizan® treatments of eligible at-risk populations by Country as of November 1997

OEPA ATO Cum 1997 % ATO
Brazil 2800 852 30%
Colombia 432 347 80%
Ecuador 17347 11890 69%
Guatemala 167499 78256 47%
Mexico 151773 151773 100%
Venezuela 22000 1381 6%
Total 361851 244499 68%

Elimination Certification: One of the primary outcomes of IACO 1997 was the recommendation that PAHO form an international commission to establish an elimination certification process for onchocerciasis in the Americas. To assist such a commission, the PCC submitted to IACO draft criteria prepared by Dr. Ronald Guderian, Dr. Ed Cupp, and Dr. John Ehrenberg that might be used to certify elimination of onchocercal morbidity, and O.volvulus transmission. Criteria also were introduced that might be used to evaluate and confirm reports of suspected new foci of onchocerciasis in the Americas. Working groups at IACO further refined these draft criteria,which were then adopted during a plenary session.

IACO urged that a status report of progress toward the goal of onchocerciasis elimination by the year 2007 be given to the next PAHO Directing Council, and that the Council be asked to form a certification commission and to strengthen the resolve to eliminate onchocerciasis from the Americas using a strategy of semi-annualMectizan® treatments.

Other OEPA news items: Dr. Edmundo Alvarez, the director of OEPA,announced his resignation effective January 1998. In addition, Dr. Richard Collins and Dr. Gonzalo Rivadeneira completed their PCC terms. GRBP andthe OEPA community thank them for their efforts and wish them well in their new endeavors. Dr. Augusto Corredor of Colombia was welcomed as a new member of the PCC, and Dr. Robert Klein, CDC, was elected the new chair of the PCC. Dr. Guillermo Zea Flores is the acting director of OEPA.

African Program for Onchocerciasis Control (APOC): President Carterattends the third meeting of the Joint Action Forum in Liverpool.
In December, President Carter, Mrs. Carter, Ms. Pam Wuichet, Directorof Development at The Carter Center, and Dr. Frank Richards, TechnicalDirector, GRBP, attended the third meeting of APOC's Joint Action Forum(JAF) of APOC in Liverpool, England. The meeting was chaired by Dr. David Nabarro, Head of the Health and Population Division, Department for International Development, UK. The JAF approved 26 new Community-Directed Treatment with Ivermectin (CDTI) projects for implementation in 1998, including 3 projects in which GRBP is a partner (Plateau and Nasarawa States in Nigeria; North Province, Cameroon; and Kasese and Kisoro districts in Uganda). During the second day of the meeting, President Carter spoke about the excellent cost effectiveness of APOC (which has an estimated economic rate of returnof 17%), and urged all OCP donor nations to fully contribute to the APOC effort.

December Celebrations of the 10th Anniversary of the Mectizan®Donation in Liverpool and Orlando: 100 million Treatments with Mectizan®Announced. GRBP Staff Present Papers on Nigeria and Latin America.
Immediately following the JAF meeting, the 10th anniversary symposium on Mectizan® distribution was held at the Liverpool School of Tropical Medicine, where the MDP announced that 100 million treatments with Mectizan® had been enabled since 1987. The symposium was chaired by Professor David Molyneux, director of the Liverpool School. GRBP was represented at the celebration by Dr. Richards, Dr. B.O.L Duke, Dr. Emmanuel Miri (GRBP country representative for Nigeria), and Dr. Albert Eyamba (GRBP's new country representative for Cameroon). Dr. Miri presented a paper entitled "Problems and Perspectives of Programme Management- A Case Study of the Plateau State Programme, Nigeria."

He described the managerial challenges in the implementation of one of the pioneering ivermectin distribution projects in Nigeria, which was initiated in 1991 by the River Blindness Foundation (RBF) in collaboration with the Ministry of Health. The Plateau State Program has been very effective, in part due to a policy of problem-identification and problem-solving through continuous review and evaluation of programactivities, and prompt implementation of new or revised strategies to ensure program objectives are met. Dr. Miri ended by noting that the program now needs to be transformed from a program-designed and program-directed strategy into the new CDTI strategy being promoted by APOC. The challenges of the transition require middle-level managers with effective, efficient management skills.

Dr. Richards, Dr. Eric Ottesen (WHO), Dr. Ken Brown (Merck), and Dr.B. Boatin (OCP) immediately departed Liverpool after the symposium and traveled to Orlando, Florida, to participate in a symposium organized by Dr. Ottesen entitled "Ivermectin, Onchocerciasis, and the Mectizan® Donation Program," at the 46th meeting of the American Society of Tropical Medicine and Hygiene. Each presented a paper: Dr. Richards 'was entitled "The Better News: Onchocerciasis in the Americas after 10 Years of the MDP." In his talk, Dr. Richards described the PAHO call for the elimination of onchocerciasis from the Americas by the year 2007 through a multinational, multiagency partnership (consisting of PAHO,the six endemic countries, non governmental development organizations, the CDC, academic institutions, and funding agencies).

Dr. Richards ended bynoting that OEPA, established as a secretariat to the initiative, has provided financial and technical support to stimulate new national programs in Venezuela,Brazil, and Colombia, while strengthening the pre-existing programs in Mexico, Guatemala, and Ecuador. In 1996, 98% of all known high-risk communities(i.e., communities with hyperendemic onchocerciasis) in the Americas were treated with ivermectin.

CAMEROON: Lion's Clubs International Foundation midterm evaluation
A midterm evaluation of the NGDO Coalition in Cameroon is being conducted in January by The Lion's Clubs International Foundation Sight First Program.Dr. Daniel Etya'ale, NGDO onchocerciasis liaison officer at WHO, Geneva,will carry out the evaluation, together with Ms. Susan Longworth of Sight First's Oakbrook Illinois headquarters. Participating in the evaluation will be Mrs. Dominique Coste, President of the NGDO coalition and National Director,Lions District 403B; Ms. Pamela Drameh, Regional Director of Sight Savers International; Dr. Joseph Enyegue Oye, Sight Savers; Mrs. Marie Pascaline Menono, International Eye Foundation; Mr. Tiburce Nyiama, Helen Keller International; Dr. Albert Eyamba, GRBP country representative; and Dr.Frank Richards, Technical Director, GRBP. Among the many programmatic areas to be assessed will be implementation and management, Mectizan® supply issues, training, community education and participation,and sustain ability/integration into the Primary Health Care system.

UGANDA: Moses Katabarwa, GRBP Country Representative's thesis on sustainability'scores'
The Uganda GRBP country representative, Mr. Moses Katabarwa, returned to Uganda in December after successfully defending his MPH thesis at the Rollins School of Public Health at Emory University in Atlanta. The edited abstract from his work, entitled "Selection and Validation of Indicators for Sustainability of Community-based Ivermectin Distribution for Onchocerciasis Control-a Retrospective Study," is excerpted below:

"The purpose of this study was to select and validate indicators for monitoring sustainability of Community-Based Ivermectin Treatment Programs (CBITPs). Ivermectin treatment requires an annual dose per eligible person for at least 10 years, but external resources are scarce and the need for CBITPs to be sustained by local communities and local governments is critical for continued effects and benefits of the Merck donation. The new program known as African Program for Onchocerciasis Control (APOC), which will cover 19 African onchocerciasis- endemic countries, has made sustain ability one of its main components. Proposals are only approved if they show orindicate potential for sustainability, and each program can only be funded by APOC for five years. Yet the 'sustainability indicators' proposed by APOC to monitor such programs have not yet been validated. APOC and WHO'sTropical Disease Research program are prospectively evaluating indicators for validity, reliability, comparability, and ease in interpretation.

This study uses the retrospective quantitative data collected from the Ministry of Health/River Blindness Community-Based Ivermectin Treatment Programs in Uganda from 1993 to 1996, and qualitative data collected from a sample of communities for 1996 to select and validate potential sustainability indicators that might be considered by the APOC program. Three districts(Kabale, Kisoro and Rukungiri) with a total of 71 communities engaged in CBITPs were selected for the study. Coverage at the community level overtime was used to derive the two new variables (Program Sustainment 1--PS1and Program Sustainment 2--PS2) that were weighed scores of 'desirable' annual coverage and patterns of annual coverage over time. Results from a regression model showed that number of Community-Based Distributors (CBDs)per capita, incentives to the CBDs, health education expenditures, and cost per person treated were significant contributors to PS1 and PS2 sustain ability scores."

Nigeria: Sustainability indices - Cost per treatment
GRBP programs now are being asked to report quarterly on three categories of indices for sustainability. Community involvement, National and Local government involvement, and Costs. The cost per person treated with Mectizan® includes HQ and local GRBP costs, overhead and salaries, delivery of Mectizan® from the port of entry to the community,training, supervision, and remuneration/incentives paid to CBDs by the community, which could include cost recovery mechanisms. GRBP Nigeria recently has calculated costs per treatment for Abia/Imo and Enugu/Anambra/Ebonyiprograms, which are programs currently being executed in partnership with the MOHs and Lions District 404/LCIF Sight First. Total cost per treatment and GRBP/Lions contributions have progressively decreased over the three year period to <$0.15 per treatment. Unfortunately, local government and state contributions have not increased significantly over time, and remain at about $.05 per treatment. Data for community contribution to cost per treatment are not available.

Dr. Brian O.L. Duke, the River Blindness Foundation Medical Director and GRBP consultant, completed his tenure with GRBP on December 31, 1997.GRBP thanks Dr. Duke for his hard work in helping to make the RBF-Carter Center transition period a successful one.

The Global Disease Elimination and Eradication as Public Health Strategies Conference will be held February 23-25 in Atlanta, and will be immediately followed by GRBP's second annual Program Review.

The 5th meeting of the Technical Cooperative Committee of APOC will be held March 30- April 2, 1998 in Ouagadougou, Burkina Faso.

Correction: In the 5th edition of the River Blindness News we reported that the Plateau State government and the five LGAs of Plateau/Nasarwa released fifty million naira and forty-two million naira respectively. The correct amounts are fifty thousand naira and forty-two thousand naira respectively.

Selected References
Cruel T, Arborio M, Schill H, Neveux Y, Nedelec G, Chevalier B, TeyssouR, Buisson Y. Nephropathy and filariasis from Loa loa. [Apropos of 1 case of adverse reaction to a dose of ivermectin]. Bulletin de la Societede Pathologie Exotique. 1997; 90(3):179-81.

Eberhard ML ; Hightower AW ; Addiss DG ; Lammie PJ. Clearance of Wuchereriabancrofti antigen after treatment with diethylcarbamazine or ivermect in.American Journal of Tropical Medicine and Hygiene 1997; 57(4):483-6.

Fischer P, Garms R, Buttner DW, Kipp W, Bamuhiiga J, Yocha J. Reduced prevalence of onchocerciasis in Uganda following either deforestation orvector control with DDT. East African Medicine Journal. 1997; 74(5):321-5.

Guderian RH, Anselmi M, Espinel M, Mancero T, Rivadeneira G, ProanoR, Calvopina HM, Vieira JC, Cooper PJ. Successful control of onchocerciasis with community-based ivermectin distribution in the Rio Santiago focusin Ecuador. Tropical Medicine in International Health. 1997; 2(10):982-8.

Mace JM, Boussinesq M, Ngoumou P, Enyegue Oye J, Koeranga A, Godin C.Country-wide rapid epidemiological mapping of onchocerciasis (REMO) in Cameroon. Annals of Tropical Medicine and Parasitology1997, 91:379-91.

Murdoch ME, Payton A, Abiose A, Thomson W, Panicker VK, Dyer PA, JonesBR, Maizels RM, Ollier WE. HLA_DQ alleles associate with cutaneous features of onchocerciasis. The Kaduna-London-Manchester Collaboration for Researchon Onchocerciasis. Human Immunology. 1997; 55(1):46-52.

Ochoa JO, Castro JC, Barrios VM, Juarez EL, Tada I. Successful controlof onchocerciasis vectors in San Vicente Pacaya, Guatemala, 1984_1989.Annals of Tropical Medicine & Parasitology. 1997; 91(5):471-9.

Oyibo WA, Fagbenro-Beyioku AF. Reduced prevalence of onchocerciasis following mass treatment with ivermectin.East African Medical Journal.1997; 74(5):326-30.

Traore S, Diarrassouba S, Hebrard G, Riviere F. [ Natural vector capacitylevel of Simulium damnosum s.l. (Diptera:Simuliidae) at the ecology stationof Tai (Cote d'Ivoire)]. Bulletin de la Societe de Pathologie Exotique.1997;90(3):196-9.

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