December 1996
GRPB HOLDS ITS FIRST ANNUAL PROGRAM REVIEW
The country representatives of Global 2000 River Blindness Programs in Nigeria (Dr. Emmanuel Midi), Latin America (Dr. Edmundo Alvarez), Cameroon (acting, Mr. Jean Bangob),and Uganda (acting, Dr. Dominic Mutabazi), and GRBP consultant Dr. Brian Duke joined GRBP headquarters staff at ÉäÉäÎÝ in Atlanta for the first annual Program Review of GRBP-assisted activities in the four program areas, on December 9-11. The main purposes of the Reviews, which were co-chaired by Drs. Donald Hopkins and Frank Richards Jr, were to assess the status of each program, determine impediments and problems in program implementation, and for the African programs, to discuss plans for relating to the new African Program for Onchocerciasis Control (APOC). The Program Reviews are modeled after similar reviews developed for national Guinea Worm Eradication Programs by Global 2000 and the Centers for Disease Control and Prevention (CDC), beginning with Pakistan in 1988. Each program reported on treatment activities, sustainability issues, status of ivermectin, assessment, training and research, and administrative issues. One half day was devoted to the presentation and discussion of each program. The group concluded that in 1996, 2.9 million people had been treated so far in GRBP-assisted programs (71% of 1996 treatment objective). A limiting factor was importation of Mectizan®. The map of GRBP-assisted areas in Africa is shown in Figure 1; in 1996 GRBP also has provided financial support to programs in Central African Republic, Chad, Tanzania, and Sudan. Key aspects of the technical reports presented at the Program Review are summarized in other articles in this issue.
NIGERIA: 74% OF ANNUAL TREATMENT OBJECTIVE ATTAINED SO FAR
At the end of November, the Global 2000 River Blindness Program (GRBP) in Nigeria had helped provide Mectizan® to 2,170,291 persons, or 74% of its Annual Treatment Objective (ATO) for 1996 (Table 2). Seventy-seven percent (4,445 of 5,756 villages) of the ATO for coverage of high risk villages (hyperendemic villages in urgent need of treatment due to an estimated skin snip prevalence of (60% positive) was reached during the same period. The GRBP in Nigeria is assisting distribution activities in Plateau, Abia, Anambra, Delta, Edo, Enugu and Imo States; The Lions Clubs International District 404 has continued to assist in mobilization and health education in the latter six states of southeastern Nigeria, for which funding is provided by the Lions Clubs International Foundation's SightFirst program. Epidemiogical assessments have been completed in 9,272 communities so far in the GRBP-assisted states, with complete assessment coverage in Abia, Edo, Imo, and Plateau States (Table 1). 3,654 (39%) of the assessed villages were classified as hyperendemic (estimated skin snip prevalence of (60% positive and so at high risk for severe onchocerciasis related morbidity).
(Among the new states announced by the Federal Government of Nigeria in September, Plateau State has been divided into Plateau and Nassarawa States, and Ebonyi State has been created from parts of Enugu and Abia States. GRBP will continue to work in the same geographic areas as before, including the new states Nassarawa and Ebonyi). Implementation during 1996 has been constrained by significant delays in clearance and delivery of Mectizan® to Nigeria. However, GRBP Nigeria received another 1.5 million tablets on December 6, and GRBP personnel will work over the holiday period to try to reach their 1996 ATOs. The late arrival of Mectizan® meant that more treatments had to be given during the rainy season, when only the larger villages near bigger roads were accessible. Many of the small and peripheral high risk villages inaccessible during the rains had to be left untreated until the dry season began again in December.
Progress towards sustainability: In an effort to monitor progress towards achieving sustainability of community-based distribution of Mectizan® in the assisted states, the GRBP in Nigeria has started tracking certain indices. In all of 7,014 at risk communities at slated for treatment in 1996 in Nigeria, the community members themselves had selected the community-based distributors (CBDs), each of whom had to meet the standard requirements set by GRBP and the Ministry of Health. Also, all of the CBDs are supervised by Primary Health Care workers who are a part of Nigeria's national health care system. Communities were not otherwise involved in the design of the treatment program in the GRBP-assisted states. A study conducted by the GRBP in collaboration with consultants from the University of Jos to evaluate community participation and ownership in regard to Mectizan® distribution in Plateau State (where GRBP and before it, RBF, have been assisting for five years) concluded that establishment of community health committees was vital to ensuring sustainability.
The GRBP Training Center in Jos has conducted its first in-country middle level management training for 20 participants drawn from eleven states in Nigeria. This training program was developed in collaboration with the U.S. Centers for Disease Control and Prevention (CDC), and the Rollins School of Public Health of Emory University, under a grant to the River Blindness Foundation (RBF) from Shell Corporation. The training began with a nine-day workshop in August (reported in the previous issue of River Blindness News), after which participants identified problem areas in their own projects, developed and applied solutions to those problems using the Total Quality Management (TQM) method, then returned for a December reunion workshop and presented their findings. Most participants had effected dramatic improvements in the problem areas chosen. The director-general in the Federal Ministry of Health, Dr. Julius Makanjuola, presented certificates to the participants at the end of the final workshop on December 6. Two more members of the GRBP field staff in Nigeria (Dr. Abel Eigege and Ms Ifeoma Umolu) also recently completed a six-week long training course in management and leadership skills in Atlanta. The latter course prepared them to become trainers of trainers for teaching similar courses at the Training Center in Jos.
Other news in Nigeria: The Nigerian Onchocerciasis Task Force (NOTF) held its 10th Meeting at the Evangelical Church West Africa Eye Hospital in Kano on October 3, hosted by Christoffel-Blindenmission (CBM). It was preceded by a meeting of the national NGDO Coalition on October 2. Items discussed included preparations for the 3rd Annual National Onchocerciasis Day on February 12, 1997 and preparations for applications to the African Program for Onchocerciasis Control (APOC). The next meetings of the NOTF and of the national NGDO Coalition are scheduled for April 8-9, 1997, at Minna in Niger State. The director of the Nigerian OCP, Dr. Jonathan Jiya, and his office in the Federal Ministry of Health were recently transferred to the new political capital of Nigeria in Abuja.
OEPA: IACO'96 CONVENES IN OAXACA, MEXICO
Representatives of all six endemic countries of the Americas met on November 19-21 at the sixth annual Inter-American Conference on Onchocerciasis (IACO), in Oaxaca, Mexico, where they reported on activities in their programs. Also attending were representatives from the regional office of the Onchocerciasis Elimination Program of the Americas (OEPA) and GRBP, Pan American Health Organization (PAHO), CDC, USAID, the Mectizan® Donation Program, and the Inter-American Development Bank. Participants adopted norms developed for surveillance at a meeting held in Ecuador earlier this year, and recommended the development of a process for certification of onchocerciasis elimination for the Americas. For the first time, all six endemic countries also came to the meeting with Plans of Action already prepared for 1997. OEPA staff are preparing a summary of this meeting for the Weekly Epidemiological Record of WHO.
As indicated in Graph 1, these six countries collectively have treated 165,138 eligible at risk persons, or 50% of their Annual Treatment Objective (ATO) for the year. However, the percentages of ATO achieved in each country varied from 13% in Guatemala to 94% in Ecuador. The program in Guatemala was restarted this year after an interruption in 1994 that resulted from the decentralization of health services. Although only one treatment round has been provided to about 21,000 persons at risk in Guatemala this year, more persons treated with two treatments at six monthly intervals are planned in 1997, as before. Mexico treated 87% of its 1997 ATO for persons at risk to be treated, and, as usual for the past few years, provided Mectizan® in 100% of its at risk communities. Ecuador has reached 95% of its communities at risk and 94% of its ATO for persons at risk. The newest national Onchocerciasis Elimination Programs in Brazil, Colombia, and Venezuela all carried out first round treatments in 1996, including, for the first time, treatments in both the northern and southern foci in Venezuela, the first mass treatments ever in Brazil, and treatment of the single known endemic community in Colombia. Importantly, 99% of all known high risk communities in the Region are under Mectizan® treatment (Table 2). A top priority of OEPA in 1997 will be to provide support to the Venezuelan program for epidemiological assessment of the northern foci, and establishing PAHO-accepted criteria for certification of onchocerciasis elimination.
Progress towards sustainability: In each of the six endemic countries, delivery of Mectizan® is considered to be primarily the responsibility of the government concerned. All of the country programs work within a primary health care approach, and in all countries, the onchocerciasis activities are implemented as an integrated program in conjunction with other health activities. In Ecuador, there is 100% community involvement in the design and implementation of interventions.
UGANDA: INCREASED COVERAGE OVERALL; DISRUPTION IN SOME DISTRICTS
As indicated in Table 2, despite various complications related to security, GRBP Uganda has so far attained 77% of its 1996 ATO for eligible at risk population (497,565 persons treated), and has reached 85% of at risk villages (1,119). However, recent rebel activity and movements of refugees from Zaire have increased insecurity in several of the other districts where GRBP is assisting the Ministry of Health in distribution of Mectizan®. Treatments were resumed (after delays associated with the influx of refugees) in the latter part of the year in Kabale and Rukungiri Districts. No treatments have been undertaken at all in Gulu District this year due to insecurity, and the program has never operated in Kitgum District, as intended, for the same reason. Disruptions of one kind or another have also recently affected activities in parts of Moyo, Nebbi and Kasese Districts.
Progress towards sustainability: Except for Moyo and Gulu Districts, where village leaders selected the community-based distributors (CBD), in all other districts where GRBP/RBF has worked in Uganda for the past five years the CBDs are selected by both village leaders and members of the community. All of the CBDs are volunteers; they are not paid any remuneration by the program or the community. In most of the GRBP-assisted districts, the program delivers Mectizan® to the Ministry of Health's district headquarters by public bus, except in Gulu, where it was delivered by GRBP vehicle, and Moyo and Nebbi, where it is delivered by air because of insecurity. (District Medical Officers now collect other drugs from the Central stores.) The estimated average cost per person treated in the GRBP-assisted districts is US$0.51.
Other news in Uganda: With its issue of August 1996, the GRBP Uganda's monthly newsletter In Sight began its fifth year of publication. Some supplementary Rapid Epidemiological Assessment (REA) is being conducted in Kisoro and Kasese Districts.
CAMEROON: RAPID START IN WEST PROVINCE
The new West Province Mectizan® distribution program, which was launched in September 1996 with the assistance of GRBP and Lions International's SightFirst program, has already treated over 30,000 persons. In the North Province, where GRBP/RBF assistance began in 1992, 59% of the ATO for the eligible at risk population has been reached, in 93% of the targeted endemic villages. The ministry of public health took over the North Province program administration completely in 1996, with GRBP only providing financial assistance for the past year.
The low coverage rate for persons treated in North Province, results in part from the Government of Cameroon's cost recovery requirement, which follows the directives of the Bamako Initiative. All GRBP-assisted programs in Cameroon are in keeping with the ministry of public health policy of distributing Mectizan® as part of an outreach effort from local health centers, whose personnel take the drug to the villages and distribute it with assistance by community-based health workers appointed by village health committees.
CARTER CENTER DEDICATES RIVER BLINDNESS STATUE
In a ceremony at ÉäÉäÎÝ on November 14, Former President Jimmy ÉäÉäÎÝ and Mrs. ÉäÉäÎÝ formally accepted the gift of a life-size bronze sculpture representing river blindness. The statue, entitled Sightless Among Miracles, is a gift of Mr. and Mrs. John Moores, who donated the sculpture as a symbol of ÉäÉäÎÝ's commitment to ending the scourge of river blindness. Mr. and Mrs. Moores founded the River Blindness Foundation (RBF) in 1990 with the mission of global control of onchocerciasis and, in April 1996, ÉäÉäÎÝ acquired that mission and most of the operations of the RBF, and began a new ÉäÉäÎÝ Center program, the Global 2000 River Blindness Program (GRBP). The statue depicts a young boy leading an elder man by the end of a stick after the adult has been blinded by onchocerciasis. The statue is the first major piece of sculpture in the gardens of The ÉäÉäÎÝ Presidential Center. Other speakers at the ceremony were the executive director of ÉäÉäÎÝ, Dr. John Hardman; the chairman and CEO of Merck, Mr. Raymond Gilmartin; chairman of the Mectizan® Expert Committee Dr. William Foege, and GRBP director Dr. Donald Hopkins. The sculpture, which is identical to one placed at the world headquarters of Merck & Co. Inc, in New Jersey, is the creation of Mr. R.T. Wallen of Juneau, Alaska.
SELECTED RECENT PUBLICATIONS
Gbakima AA, 1996. Integrated control of Onchocerca volvulus infection in a hyperendemic zone in Sierra Leone. East African Medical Journal. 73(3):159-63.
Hopkins DR, Richards FO Jr, 1997. Visionary campaign: eliminating river blindness. In: 1997 Medical and Health Annual. E. Bernstein, ed. Chicago: Encyclopedia Britannica, pp 8-23.
Mabey D., Whitworth JA, Eckstein M, Gilbert C, Maude G, Downham M.1996. The effects of multiple doses of ivermectin on ocular onchocerciasis. A six-year follow-up. Ophthalmology. 103(7):1001-8.
Oskam L, Schoone GJ, Kroon CC, Lujan R, Davies JB, 1996. Polymerase chain reaction for detecting Onchocerca volvulus in pools of blackflies. Tropical Medicine & International Health. 1(4):522-7.
Whitworth JA, Downham MD, Lahai G, Maude GH, 1996. A community trial of ivermectin for onchocerciasis in Sierra Leone: compliance and parasitological profiles after three and a half years of intervention. Tropical Medicine & International Health. 1(1):52-8.
World Health Organization, 1996. Onchocerciasis: Progress Towards Elimination in the Americas. Weekly Epidemiological Record, 71: , 277-280.
