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

Table of Contents:

1997 GRBP Second Annual Program Review

The Global 2000 River Blindness Program (GRBP) hosted its second annual Program Review on February 25-27, 1998 at The Carter Center in Atlanta. In attendance were the GRBP country representatives from Nigeria (Dr. Emmanuel Miri), Cameroon (Dr. Albert Eyamba), Uganda (Mr. Moses Katabarwa), and the Onchocerciasis Elimination Program for the Americas -OEPA (Dr. Mauricio Sauerbrey and Dr. Guillermo Zea Flores). Also present was the Chair of the Sudan Higher Commission for Onchocerciasis Control (Dr. Mahmoun Homeida), and representatives from HealthNet International (Ms. Irene Goepp), the Mectizan® Donation Program (Dr. Stefanie Meredith and Dr. Bruce Dull), and Global 2000 staff. Dr. Charles McKenzie (Michigan State University) was a special guest for the Sudan presentations. The objectives of the program review were to 1) assess the status of each program, 2) assess impediments and problems in program implementation, and 3) promote sharing and standardization of information. Each GRBP-assisted program (Nigeria, Uganda, Cameroon, Sudan, and OEPA) spent three hours reporting to the group on treatment and training activities, sustainability issues, status of Mectizan® stores, epidemiological assessment activities, operations research, and administrative issues.

In 1997, 5,103,222 eligible at risk persons (earp) were treated with Mectizan® in GRBP-assisted programs (93% of the 1997 treatment objective); this represented a 33% increase in treatments over 1996. Most (75%) treatments were in Nigeria

Of the treatments in 1997, 3,327,975 (65%) were treated in partnership with the Lions Clubs International Foundation's SightFirst program (LCIF). GRBP works with LCIF in Nigeria, Cameroon, and Sudan.

Key recommendations for GRBP actions in 1998 included: 1) continued emphasis on monthly reporting of Mectizan® treatments related to defined objectives, 2) focus on concise epidemiological assessments to determine how to deliver Mectizan® to those villages in greatest need of treatment, 3) monitoring sustainability of the programs, 4) adaptation of the onchocerciasis/Mectizan® community-based distribution model to other diseases, and 5) monitoring the interruption of transmission of onchocerciasis, especially in Latin America. The GRBP Annual Treatment Objective (ATO) for eligible at-risk population (earp) projection for 1998 is 6.1 million treatments with Mectizan®, a 20% increase over 1997.

Following is a synopsis of 1997 activities in each of the GRBP-assisted countries:

Nigeria: In 1997, GRBP Nigeria helped provide Mectizan® to 3,852,532 persons, which was 104% of its ATOearp. The program also exceeded its ATO for coverage of high-risk villages (hyperendemic villages in urgent need of treatment due to an estimated skin snip microfilaria prevalence of >60% positive) by providing treatment in 7,229 villages of 7,062 targeted (102%). In those states where GRBP and LCIF are partners, 3,070,000 persons were treated (which is 82% of the total for Nigeria of 3,852,532). Dr. Miri, country representative in Nigeria, announced that treatments in the GRBP-assisted states in Nigeria during 1998 will not increase significantly due to the fact that GRBP Nigeria has reached complete at risk village coverage in its areas of operations (ivermectin is being delivered in all villages in need of mass treatment).

Dr. Miri shared the forms developed in collaboration with local Lions (District 404) that are now being used to track "devolution" (transfer) and sustainability of the ivermectin distribution programs at the village, Local Government Area (LGA), and state levels . Transfer of responsibility at the village level includes formal agreement to distribute ivermectin, as well as evidence of active involvement, ownership, and locally decided methods for community-based distributor compensation. Transfer at the LGA level includes acceptance of responsibility to support local onchocerciasis control teams (LOCTs), including meeting their transport needs. At the state level, issues of integration of activities into the primary health care infrastructure and workplan development will be monitored.

Uganda: GRBP Uganda achieved 85% of its 1997 ATOearp (744,603 persons treated), and reached 100% of its at-risk villages (1,713) despite insecurity and unusually rainy weather. However, the districts of Kasese, Adjumani, and Nebbi all dropped below 80% earp coverage due to refugee and cross border issues. Mr. Katabarwa, GRBP country representative in Uganda, discussed his ongoing research in monitoring sustainability using weighed indices of desirable coverage patterns over time (see River Blindness News No. 7 for a discussion of Mr. Katabarwa's work on this).

Cameroon: GRBP Cameroon achieved only 35% ( 211,914 Mectizan® treatments in two GRBP-assisted Provinces) of its 1997 ATO earp. Fifty-one percent of all GRBP-assisted treatments in Cameroon were distributed in partnership with LCIF. The low coverage was principally the result of an overly ambitious ATO for West Province of approximately 465,000, only 25% of which was reached (120,519 persons treated). In contrast to West Province, North Province reached 75% of its ATO earp (91,395 persons treated). However, Dr. Albert Eyamba, the new GRBP Cameroon country representative, noted the dramatic increase in treatments (Figure 2) in December accomplished in West Province, and was confident that the 1998 ATO in West Province of nearly 650,000 will be met given the strong leadership of Dr. Admadou Fopa (West Province Delegate for Health), and Dr. Kamso (West Province Chief of Community Health). He noted also that coverage in Cameroon is influenced by a cost recovery policy that requires people to pay about $0.17 (100 CFA) to help defray costs of ivermectin delivery, as well as a policy of outreach treatment delivery by public health nurses (rather than community based distribution).

Sudan: A total of 93,138 people were treated in Sudan in 1997, a decrease of 35 % over the 1996 total of 143,414 treatments. The reduction of activities was attributed to constraints associated with increased fighting in 1997. GRBP assisted in the treatment of 44,228 (47% of the total) of these persons, with LCIF support. These treatments were conducted by GOS health workers and several NGOs working under the auspices of OLS in southern Sudan.

OEPA: The six endemic countries (Brazil, Colombia, Ecuador, Guatemala, Mexico, Venezuela) collectively treated 231,588 eligible at-risk persons, or 60% of their 1997 ATO of 361,851. The percentages of ATO achieved in each country varied from 18% in Venezuela to 92% in Ecuador. However, Mectizan® treatments were delivered to more than 95% of the known high-risk villages in the American region. The vast areas in need of epidemiological assessment in northern Venezuela have become one of the primary areas of OEPA's focus in 1998. It is hoped that significant progress will be made toward better understanding of the epidemiology of this 'last frontier' of onchocerciasis in the Americas before the 1998 InterAmerican Conference on Onchocerciasis is convened in Caracas in November.

Cameroon: Mid-term evaluation of LCIF SightFirst Program
Dr. Frank Richards traveled to Cameroon in January to participate in the mid-term evaluation of the LCIF-funded SightFirst program, which supports a coalition of four NGDOs (The Carter Center, Sight Savers International, International Eye Foundation, Helen Keller International). The NGDOs work closely with the ministry of health to deliver Mectizan® in West, Adamaoa, and Center Provinces. Present were Dr. Daniel Etya'ale (NGDO coordinator, WHO, Geneva and chief evaluator for the midterm), Ms. Susan Longworth (LCIF, OakBrook), and Ms. Pamela Dreyer, (Regional Coordinator, Sight Savers). Dr. Richards and GRBP country representative Dr. Albert Eyamba also met with Cameroon's new Minister of Health, Dr. G. Monekosso.

OEPA: New acting director appointed by The Carter Center
Dr. Mauricio Sauerbrey has been appointed acting director of the OEPA program in Guatemala, replacing Dr. Edmundo Alvarez, who resigned from the post at the end of 1997. Dr. Sauerbrey is a citizen of El Salvador, and holds a Masters degree and a PhD in Medical Parasitology from Tulane University. He is an internationally recognized expert in malaria and Chagas' disease, and a frequent consultant for WHO, PAHO, AID, and CDC.

Nigeria: Don Hopkins and Andy Agle travel to Nigeria. Dr. A. Seketeli to attend the next Nigerian NOTF meeting
Dr. Donald Hopkins, Associate Executive Director of The Carter Center, traveled to Nigeria in January to visit the southeastern GRBP/ LCIF-assisted states. He also met with Nigerian officials to discuss collaboration on lymphatic filariasis, dracunculiasis, and schistosomiasis efforts. Mr. Andy Agle, Director of Operations, Global 2000, traveled to Nigeria in February to review administrative elements of Global 2000 activities in Nigeria. APOC Programme Manager, Dr. Azodoga Seketeli, will attend the next Nigerian National Onchocerciasis Task Force (NOTF) meetings on May 4-5, 1998 to be held in Makurdi, Benue State, Nigeria.

National Onchocerciasis Day was held in Nigeria on February 12, 1998 in the capitol of Abuja. Honorable Minister of Health Rear Admiral Jubrila Ayinla gave a speech to the press.

Dr. Frank Richards traveled to Burkina Faso March 30-April 3 to participate in the meetings of the Nongovernmental Development Organization Coordinating Group for Ivermectin Distribution (chaired by Ms. Catherine Cross of SightSavers International), where it was noted that a total of 13.7 million persons were treated with Mectizan by NGDO coalition-assisted activities in 1997 (GRBP-assisted treatments amount to 35% of this total).

The NGDO meeting was followed by the meeting of the Technical Consultative Committee (TCC) of APOC (chaired by Dr. Oladele Kale). In addition to the review of proposals submitted to APOC for funding, other important TCC deliberations concerned the need to get APOC funding to areas of greatest need (i.e., hyperendemic areas in need of urgent treatment), and to encourage APOC projects to include operations research aimed at improving the coverage and sustainability of Mectizan® distribution.

The Conference on Global Disease Elimination and Eradication as Public Health Strategies was held in Atlanta on February 23-25, 1998. The Conference was sponsored by The Task Force for Child Survival and Development, The Carter Center, CDC, UNICEF, WHO, PAHO and others. The goals of the Conference were to assess the role of elimination and eradication in decreasing the global burden of disease and more effectively utilizing health resources. More than 200 representatives from 81 organizations and 34 countries participated. The proceedings are scheduled to be published in late 1998 in a supplement to the Bulletin of the World Health Organization. Dr. Hopkins, Dr. Richards, Mr. Agle and other Global 2000 staff participated in the conference. Dr. Richards chaired the subgroup on onchocerciasis.

The International Conference on Emerging Diseases was held in Atlanta in March. Dr. Richards presented a paper authored by Dr. John Ehrenberg, OEPA epidemiologist, entitled 'Monitoring the emergence of new foci of onchocerciasis in the Americas.

Selected References
Akogun OB, Akoh JI, Okoto A. Comparison of two sample survey methods for hyperendemic onchocerciasis and a new focus in Dakka, Nigeria. Rev Biol Trop 1997; 45(2): 871-876.

Bockarie MJ, Alexander Nd, Hyun P, Dimber Z, Bockarie F, Ibam E, Alpers MP, Kazura JW. Randomised community-based trial of annual single-dose diethylcarbamazine with or without ivermectin against Wuchereria bancrofti infection in human beings and mosquitoes. Lancet, 1998; 351 (9097): 162-168.

Duong TH, Kombila M, ferrer A, Bureau P, Gaxotte P, Richard-Lenoble D. Reduced Loa loa microfilaria count ten to twelve months after a single dose of ivermectin. Transactions of the Royal Society of Tropical Medicine and Hygiene, 91(5): 592-593.

Fischer P, Bamuihiiga J, Buttner DW. Treatment of human Mansonella streptocerca infection with ivermectin. Tropical Medicine in International Health, 1997; 2(2): 191-199.

Guderian JR, Anselmi M, Espinel M, Sandoval C, Cooper PJ, Rivadeneira G, Guderian RH. Onchocerciasis in Ecuador: prevalence of infection on the Ecuador-Colombia border in the Province of Esmereldas. Mem Inst Oswaldo Cruz, 1997; 92(2): 157-162.

Guderian RH, Anselmi M, Cooper PJ, Chico ME. Macrofilaricidal effects of chloroquine on adult Onchocerca volvulus by local infiltration of palpable onchocercal nodules. Revista Da Sociedade Brasileira de Medicina Tropical, 1997; 30(6): 469-473.

Newell ED, Hicuburundi B, Ndimuruvugo N. Endemicity and clinical manifestations of onchocerciasis in the province of Bururi, Burundi. Tropical Medicine in International Health, 1997; 2(3): 218-226.

Newell ED, Vyungimana F, Bradley JE. Epilepsy, retarded growth and onchocerciasis, in two areas of different endemicity of onchocerciasis in Burundi. Transactions of the Royal Society of Tropical Medicine and Hygiene, 1997; 91(5): 525-527.

Tume CB, Ngu JL, McKerrow JL, Seigel J, Sun E, Barr PJ, Bathurst I, Morgan G, Nkenfou C, Asonganyi T, Lando G. Characterization of a recombinant Onchocerca volvulus antigen (OV33) produced in yeast. American Journal of Tropical Medicine and Hygiene, 1997; 57(5): 626-633.

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