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PREFACE

APOC AT MID-POINT : SO FAR SO GOOD

PREFACE

APOC AT MID-POINT:

SO

FAR

SO

GOOD

The

African

Programme for Onchocerciasis Control (APOC) was launched in December 1995

on the tidal wave of the

resounding success

of the 2l-year old

Onchocerciasis Control Programme

in West Africa (OCP). Six

years

later and now at the mid-point of its

pre- determined existence

it

is time to take stock and plan for the second half.

This

special Supplement contains a set

of

articles that focus on some

key

areas

of

the

activities of APOC in the first phase.

Each

article

makes

a critical

appraisal

of

the major achievements and shortcomings

of

the Programme

from

the start

of

operations

in

1996 and

identifies

the main challenges

for

Phase

2. A

succinct account

of the

state

of affairs

at the

birth

of APOC would help to put the achievements and the challenges in better perspective.

The ultimate goal of APOC is "to eliminate

onchocerciasis as

a

disease

of

public

health

importance and

an important

constraint

to

socio-economic development throughout

Africa".

The prescribed strategy by which this goal is to be attained is "the establishment of a self-sustainable

ivermectin

treatment programme"

in

the

high-risk

zones

of all

the endemic countries outside the OCP

area.

Where feasible,

control would

be effected

by local

vector eradication.

The

five

main

pillars

around

which

the success

of APOC

was predicated

are:

1. The empowerrnent of the endemic communities

within

the context

of

Primary Health Care (PHC).

2.

A

unique global partnership between the private and

public

sectors

including

the affected communities themselves,

forming

a formidable alliance

in

pursuit

of

a common objective. 3.

The

development and opportune

arrival on

the scene, through research,

of

innovative tools and strategies that make the proposed

control

operations

both

feasible and cost-effective. 4.

The unprecedented commitment

of

a Pharmaceutical Company

- ^{Merck &}

^{Co. Inc., to donate}

I

through the Mectizan@ Donation Programme

(MDP)

the ivermectin (Mectizan@,

for

as long

as

needed

to treat

onchocerciasis,

and 5. The vast

experience

of OCP and the

synergy derivable from the physical

proximity

and temporal overlap

of

the two programmes.

There were major concerns

also.

Notable among these was the

probability of

'donor-

fatigue', which

has

largely

receded

in

the face

of

the impressive Economic Rate

of

Return (ERR) and general satisfaction

with APOC's

progress over the years. There were also some doubts about securing appropriate

receptivity

and commitment

of

the participating countries to the APOC

initiative

given the increasing and

conflicting

demands

of

emerging diseases on

national budgets. A third and

daunting concern

was

related

to the scientifically

derived

estimation that ivermectin would have to be

consumed

by at least 65

^o/o

of the

target populations

of all

the hyper- and meso-endemic areas at least once every year for upwards

of

20 years

if

the objective

of eliminating

onchocerciasis

from

the continent

is to

be achieved.

The progress made towards overcoming these concerns are contained

in

the accompanying papers.

There have been many changes since

APOC

commenced operations. The pre-APOC estimate

of

number

of

people a

risk

and to be treated has more than doubled as a result

of

the application

of REMO/GIS.

^The number

of

people treated every year

with

ivermectin, using

APOC's

Community-directed treatment

(ComDT)

approach has risen sharply

from

8

million

in

1996,

to over 20 million in 2000.

Substantial capacity

building

has taken place

on all fronts, including diverse training

programmes

that range in content from

administrative competence

to skills

needed

for field operations. Devolution of

operational research to endemic country scientists and the

promotion

and empowerment

of local

non-governmental

organizations (NGDOs) by the International NGDOs are crucial

investments towards

sustainability of the

programme

that augur well for other future health and

development

programmes. The

prospects

of effectively

integrating

Community

directed treatment

with

2

Ivermectin (CDTI) into the health

system,

and its potential as an entry point for

other programmes are very bright.

The potential impact of APOC on the

disease spectrum and

the

health services

of participating

countries are

enorrnous. With the empowernent of the

endemic communities

within

the context

of

PHC the health care stakes and bar of performance have been raised to a

level that must be sustained in Phase 2 of APOC.

There are many challenges

to

be faced

in APOC

Phase

2.

Some

of

these have been

identified and discussed in the seven articles of this supplement. Most of

^these

understandably have to do

with sustainability.

Suffice

it

to state that

if

these challenges are to be successfully met then the partnership that has brought

APOC to this

commendable stage

would

have

to

remain

committed.

The Management

of APOC

and

its

support systems,

like

the Technical Consultative Committee (TCC), need to be adequately strengthened so as to be able to cope

with

the ever expanding scope

of activities.

This is more so now that OCP which has provided a substantial amount

of

administrative and infrastructural back up to APOC has only a few more months before

winding

up.

As has been

observed

in all previously

successful

public health

disease control programmes, notably the global smallpox eradication programme and OCP, contemporaneous

scientific

research

is a sine qua non for ultimate success. APOC's main

investment in operational research is channeled through

WHO/TDR

where the search

for

a macrofilaricide that is suitable

for

mass treatment and a new

tool for

rapid

monitoring

of treatment continues.

In this regard

it

is nice to end on a cheerful

note.

As we were about to go to press, report of ^a

TDR-APOC

supported multi-centre study has indicated that a rapid epidemiological method

for identiffing

areas and levels of Loa

loa

endemicity has been developed that would provide an important

tool for

dealing

with

one of the major challenges that is being

caried

over from

APOC phase I to

phase

2, namely the

issue

of

severe adverse events

(SAE) following

treatment

with

ivermectin in some areas where onchocerciasis and loiasis coexist.

3

According to the Report of the External Mid-Term Evaluation, "APOC

has made

significant

and satisfactory progress towards meeting its

objectives". This

Supplement tells part

of

the story on

how it

has done so,

how

far

it

has gone and how much farther

it

must go before the curtain is drawn on its operations.

Dr. Azodoga

SEKETELI

Director,

African

Programme for Onchocerciasis Control (APOC)

4

PARTNERSHIP AND PROMISE:

EVOTUTION OF THE AFRICAN RIVERBTINDNESS

CAMPAIGNS

1

Partnership and Promise: Evolution of the African Riverblindness Campaigns

AUTHORS:

B. BENroN,' J. BuMp,'''' B. Lrcse,3Atto

A.

SEKETELI,a

ADDRESSES OF AUTHORS:

Onchocerciasis Coordination Unit, The World Bank, 1818 H. Street

NW,

Washington, DC 20433, U.S.A.

Institute of the History of Medicine, The Johns Hopkins University, 1900 E. Monument Street, Baltimore, Maryland 21205, U.S.A.

Human Development Network, Africa Region, The World Bank, 1818 H. Street NW, Washington, DC 20433, U.S.A.

African Programme for Onchocerciasis Control, 01 B.P. 549, Ouagadougou, Burkina Faso

Address

for

Correspondence

Dr

J. Bump

Institute

of the

History

of Medicine, The Johns

Hopkins University,

1900 E.

Monument

Street,

Baltimore, Maryland

21205, U.S.A E-

mail: jbump@worldbank.org

Short running

title:

Partnership and Promise of APOC

)

3.

4.

ABSTRACT

The article describes the evolution of the partnership between various health and developmental agencies that has sustained

the

campaign against riverblindness

in Africa. The

international community was oblivious to the devastating public health and socio-economic consequences

of

onchocerciasis

until

towards the end of the 1960s and the beginning of the 1970s when a UNDP- supported Mission

to

West

Africa

and a

visit to

the sub-region

by

the President

of

the World Bank culminated,

in

^1974, in the inauguration of the Onchocerciasis Control Programme in West

Africa (OCP).

OCP was

a

landmark event

for

the Bank as

it

represented

its first

ever direct investment in a public health

initiative.

The resounding success of the OCP is ^a testimony to the

power of the

partnership

which, with the

advent

of the Mectizan Donation

Program, was emboldened

to

extend the scope

of

its activities

to

encompass the remaining endemic areas

of Africa

outside

OCP.

The paper discusses the progress that has been made

in

consolidating the partnership and the prospects

of

adapting the various strategies

of

the

African

Programme

for

Onchocerciasis Control (APOC), such as the community-directed treatment

(CDTI)

concept so

as to entrench an integrated

approach

that couples strong regional coordination with

empowerment of local communities to ^address many other health

^problems.

INTRODUCTION

The control of West Africa's

riverblindness

is a glowing, but unlikely,

success

story

in international public

health.

Despite its crippling effects, this once-widespread disease remained

virtually

undetected during the colonial

period.

Lost among the numerous and varied tropical diseases, onchocerciasis ranged unchecked throughout

much of the 20h century as

well,

attracting international interest only in the last 50 years. Running since 1974,

the Onchocerciasis

Control

Programme

in West Africa (OCP) has eliminated

riverblindness (onchocerciasis) as a public health problem in the

l0

countries where

it

operates. Inaugurated in 1995,

the African

Programme

for

Onchocerciasis

Control (APOC)

extended operations to

include the remaining 19 infested

countries

on the African continent. Given the

low international

profile of

the disease and the technical

difficulty of its

control,

it is

particularly impressive that OCP and APOC have been successful. This article outlines how onchocerciasis became

visible to two

previously independent

communities-international

health experts and international development professionals-and follows the ongoing results

of

their collaboration, the OCP and APOC programmes.

Onchocerciasis

is a debilitating welter of skin

disease, blindness,

and itching to

its sufferers

(Buck, 1974).

These symptoms are the body's immunologic response

to millions of tiny

worms

(microfilaria),

spewed forth by adult worms (macrofilaria), which

live

coiled

in

the human host

for

10-14 years.

If

removed and unwound, these adult worms routinely measure 60 or more centimeters long (Malatt and

Taylor,

1992). Conveyed

in

a

juvenile

_phase via unlucky

bites of the aptly

named

blackfly

Simulium damnosum, onchocerciasis was,

until

recently, endemic to West

Africa

and even now remains a serious public health problem in the majority

of

countries on the

continent.

Commonly called riverblindness after its geographic locus and most

visible symptom, those infected are cursed with interminable itching, thickening

and depigmentation

of the skin,

and

in

an average

l}Yo of

cases, permanent

blindness. In

some

heavily

infected

villages of

^pre-OCP

West Africa, this figure was

several

times higher-

blindness among adults

often ran

above

30% (Waddy, 1969). When highly

prevalent, _the disease eventually forces communities away

from

the

fertile river

valleys as

village

blindness rates reach devastating

proportions. With too few

able-bodied people

left to

tend fields, food shortages and economic collapse evict residents. Moving to hardscrabble highlands offers some

)

respite

from

further infection,

but is

not without its own

problems-poor

soils and

little

water cripple farming

efforts.

Since 1974, OCP has sought to end this scourge.

Despite riverblindness' wide-ranging consequences,

it was an unlikely

target

of

the international

health community. Except to the

affected communities, onchocerciasis was

invisible until recently. [t went

unnoticed

by colonial

administrations even as

they

fought schistosomiasis, sleeping sickness, syphilis, malaria, and a range

of

other labor-related diseases.

Its

transmission

cycle was not

described

until

1926

(Blacklock, I926a, 1926b). It

was not

definitively linked to

blindness

until

almost 1950

(Waddy, 1949).

Riverblindness

is

also an exclusively rural disease, affecting only the poorest and most remote

communities-populations with the fewest

resources

and the

least access

to health services. Further, the

disease is technically

difficult to

control because

of

the

worm's

long lifespan, the prevalence

of

infected populations,

the vector's very long flight

range, and

the

absence

of

^suitable pharmaceutical options

before

1987. These factors combine

to

suggest that onchocerciasis

could

have easily gone unchecked, ravaging locally, unnoticed

internationally. All

the more curious then, that the international

health community

should

find one of its

greatest successes

in

onchocerciasis control.

Rising awareness among

international

health professionals

Africans were

all

too

familiar with

onchocerciasis, but

full

knowledge

of

its characteristics and symptoms eluded western medics

until

after

World

War

II.

^During the colonial period,

"craw- craw,"

as

it

was then known, was identified as a skin disease. Reaffirming European notions

of

disease and place, craw-craw went unnoticed as one among countless

tropical afflictions. A

more precise understanding began to emerge

in

1875, when Surgeon

John O'Neill

of the H.M.S.

Decoy identified craw-craw ^as a

filarial

disease, that is, one caused by a parasitic

worm.

Moored

off

Cape Coast Castle, Ghana,

O'Neill

borrowed six patients from Addah Fort Hospital, noting

"[craw-craw's]

intractability, contagiousness, and irritating nature so aroused my attention that

I

was induced

to

bestow much time on its microscopic examination, and succeeded at length in discovering

a filaria..." (O'Neill,

1875,

p.265). The filaria itself was later

described by Leuckart

in

1893, who named

it

"Onchocerca

volvulus."

The next breakthrough waited more than 30

years. In

a pair

of

1926 publications, D. B.

Blacklock of the Sir

Alfred

Lewis Jones Research Laboratory in Freetown, Sierra Leone cleverly unraveled the parasite's transmission and development

cycle (Blacklock,1926a,

D). Blacklock

4

traced the parasite through the blackfly

vector-Sizulium

damnosum-discovering that, as

with

malaria, the onchocerciasis parasite undergoes an intermediate maturation in the insect.

These discoveries

of

riverblindness' cause and transmission cycle were

followed by

^a

deepening understanding

of

the disease's

effects.

Though West

African

blindness rates were

long known as

among

the world's

highest,

onchocerciasis-historically viewed as a

skin

disease-has only

recently received

it's

share

of the blame. In its

stead,

the role of

other perennial

culprits was magnified-Vitamin A deficiency and

trachoma,

to

^name

two. ^A

tentative

link

between blindness and onchocerciasis had been made as early as 1916

by

Robles

(Luna,

1918),

working in

Guatemala, where

the

disease had been inadvertently imported by

slave

traders

(Nelson,

1991),

and by Rodhain in

1920,

working in the Belgian

Congo.

Community observations

by

Hissette

in

1931 were the

first

indication

of

a major public health

problem-studies in the

Sankuru

river

area

of

^Congo revealed among

the

population 20o/o

blindness and

50% "ocular complications." Finally, a definitive

study

by Waddy in

L949 conclusively linked onchocerciasis and

Africa's

rampant blindness. Present-day understandings

of

onchocerciasis consequently emphasize

blindness, in addition to the

long-identified dermatologic symptoms.

As the

full

effects of the scourge became known, onchocerciasis attracted more and more

attention from European and American specialists; particularly well

represented were researchers

from

ORSTOMT (assigned

to

OCCGE2),

reflecting

longstanding French colonial involvement

in

the

region.

Many

of

ORSTOM's studies later proved crucial to OCP (Le Berre, 1966; Duke, 1990)

Armed

with

knowledge

of

the disease and

its

effects,

public

health workers struggled

with

a limited arsenal. Chemotherapeutic options suramin, a macrofilaricide, (Van

Hoof,

1947)

and

diethylcarbamazine

(DEC), a microfilaricide, (Hewitt,

1947)

both ^proved

unworkable outside the hospital because of severe side effects.

A

surgical option, mass nodulectomy, proved ineffective

in trials (WHO 1987).

Vector control remained a

possibility, but

struck many as

unworkable in light of the environmental problems of

DDT

and the unsuccessful Global Malaria Eradication Programme of the 1950s and 1960s.

Large-scale international attention

first

came to the disease in

Africa in

a 1968 technical conference

in

Tunisia

(WHO

1969),

initiated

largely

by

M6dicin-G6n6ral Pierre Richet, Dr.

' Office de la Recherche Scientifique et Technique d'Outre-Mer (ORSTOM), now named " Institut de Recherche pour le Developpement (IRD)".

2 Organisation de Coordination et de Coop6ration pour la Lutte contre les Grandes Endemies.

5

Ansari, WHO's Chief of Parasitic Diseases (Duke, 1990), and an important paper later published

by B. B.

Waddy

(1969).

Arranged

by USAID,

OCCGE, and

WHO,

delegates convened to discuss the technical

feasibility of

controlling onchocerciasis

in

West

Africa,

where

its

effects were most severe. Conference attendees concluded that given sufficient resources, control might

be

^possible,

but would take two

decades

or more. Four years later, a

UNDP-supported Preparatory Assistance to Governments (PAG) mission left

for

West

Africa

to plan a long-term control strategy.

The development assistance community becomes involved

Over the

course

of the

20'h

century,

onchocerciasis worsened

in West Africa.

Growing populations, forced migration,

climatic

changes, and

colonial

ambivalence

all

exacerbated an upswing

in the

centuries-old

tide of infection (Hunter, 1966). On the

one hand,

the

rising disease

toll multiplied

the humanitarian and economic impact

of

onchocerciasis. On the other hand, an unusually harsh series

of

droughts intensified the need

for

agricultural

development-

particularly in the oncho-infested river valleys, with their better soils and ready water sources.

The confluence of these two ^pressures exacted its cost in health and productivity, but also forged the alliance that would eventually succeed against the widening scourge.

By

1972, the international health community was already

mobilizing to fight the disease.

Because

of

the drought and famine, the international development community was also focused on the fate

of

West

Africa.

Accordingly, and at the same

time

as the

PAG

mission,

World

Bank President Robert McNamara went

to

West

Africa,

where he saw the broken villages and

fallow

fields

of

the endemic zones during

a flight to

Ouagadougou, Upper

Volta

(now Burkina Faso), a then- common feafure

of

the West-African savanna. From the air he saw curious clusters

of

circular

forms-the

surviving skeletons of once-occupied homes.

Upon

landing

in

Ouagadougou, McNamara, struck

by the

devastation

of the

disease, quickly arranged a special

trip

to Bobo Dioulasso, Burkina Faso's second largest city, where he

would meet PAG mission

leader

B. B. Waddy and

French scientists, Rene

Le Berre,

an entomologist, and Jean-Jacques

Picq, a

microbiologist

in the

French

military (World

Bank, 1972). Deeply concerned, McNamara made his own investigation, discussing onchocerciasis at length

with

the scientists

in Africa.

Upon

his

return

to

Washington he continued his inquiry, making use of his extensive connections, including researchers at the Wilmer Eye Institute at the Johns

Hopkins University.

McNamara became convinced

that control of the

disease was technically possible,

given

enough

time

and

money-projected at 20

years and $120

million

6

1972 dollars

(WHO,

1,973). Armed

with

personal conviction, McNamara threw his own weight and that of the institution he led behind the budding onchocerciasis control efforts.

However,

in

managerial terms,

the World Bank

was

not

equipped

to direct a

^public

health campaign.

In

fact, at that time, the World Bank had never even made a loan

for

a health

programme.

Financing

OCP would be the Bank's first initiative in the

sector,

a

^striking

departure

from the early '70s norm of large dams and

^massive

infrastructure

projects.

Meanwhile, WHO already had scientists at work, and UNDP and FAO were developing

follow-

up agricultural plans. McNamara saw his comparative advantage-the World Bank could use its reputation and leverage

with

donors

to

fund the control programme and manage the finances.

He insisted on unrestricted contributions made as grants only, and prepared donors

for

a lengthy campaign.

The Onchocerciasis

Control

Programme

in

West

Africa

Through a combination of persistence, dedication, and happenstance, the Onchocerciasis Control Programme evolved

from

an ambitious plan

to a

sterling example

of

disease

control. At

the nexus

of

health and development, riverblindness served as a rallying point

for

many previously

distant

groups.

The

launching

of OCP in

1974 formalized

an

unprecedented collaboration between seven host countries,

four

international organizations, and

nine donors.

Sponsoring agencies included the

World

Health Organization as the executor, the

World

Bank as the fiscal

agent, and the United Nations

Development Programme

and the Food and

Agriculture Organization sharing

various

development planning responsibilities.

This

partnership joined

intemational health

professionals

with their

counterparts

from the international

assistance

community. The

confluence

of

these

two

groups reflected

growing

appreciation

for

the importance of health to development.

When Programme operations began

in

1974, the blackflies that transmit riverblindness

were so

numerous

that

protection against them

in

most

rural

areas

was impossible.

These swarns

of

flies were kept infective by a large parasite reservoir in the human

population.

In the mid-1970s, entomologists recorded

fly

biting rates in the thousands per person,

per

day

in

some

heavily infected areas (Walsh, 1977). In these and other so-called

"

oncho

zones,"

riverblindness reached devastating proportions, often infecting 90%o

or

more

of

the population

(Crisp, 1956; Brown, 1962). Without a drug

treatment,

the only effective

approach to onchocerciasis

control was to intemrpt

parasite transmission

by

substantially reducing the density

of

infected

flies.

The flies could be targeted at the larval stage because their breeding

7

sites were confined to areas

of

fast-flowing water, such as rapids and dam

spillways.

Larvicide spraying could therefore be concentrated on these locations,

killing

the disease-transmitting flies before

maturity.

Strict environmental monitoring and follow-up protective measures ensured the long-term health

of

non-target

fish, flora,

and

fauna. Until

the

late

1980s,

by

necessity, OCP was based exclusively on this strategy of vector control.

Options expanded in the 1980s when Merck's Mectizan@ (ivermectin,

MSD)

was shown to be effective against the microfilariae that manifest riverblindness

(Aziz

et

al.,

1982a,1982b;

Sutherland and Campbell 1990), without the harmful side effects

of

DEC (Greene et

al.,

1985;

Larviere et

al.,

1985; Awadzi et

al.,

1986). Because ivermectin does not

kill

adult worrns, which continue

to

produce damaging microfilariae, keeping the symptoms

at bay

therefore requires regular doses

for

the remainder

of

the adult worm's

life, up to

14

years. The

advantages

of

ivermectin are

twofold.

First,

it

relieves the symptoms and prevents further damage. Second, because

it kills

the

juvenile

worrns, blackflies are less

likely to

ingest (and later transmit) the parasites even

if

they do bite a

victim

while he or she

still

harbors productive adult

worms.

This second benefit, slowing transmission, is particularly helpful when beginning control efforts in new areas because

it initially

reduces the

microfilarial

load in the population faster than larvicide spraying. In the original OCP area, control through larviciding had been mostly achieved by the time ivermectin became available, but the drug proved ^a key advantage

in

heavily infected areas and added a therapeutic dimension to the programme, providing

relief for

victims and arresting

its progress. Additionally, World Bank staff, in

particular

were

intrigued

by the

expansion possibilities held by the new drug.

Following French regulatory approval

in

1987 (Brown and

Neu,

1990), OCP conducted extensive field trials to ^assess ivermectin's public heath potential (Remme et

al,

1990; Dadzie et

al. 1991). It

was already known as a potent drug

for

individuals, but could

it

intemrpt regional transmission? What coverage would be necessary to protect communities? Underwriting these investigations was

Merck's

pledge to donate ivermectin

in

whatever quantity needed and

for

as

long as necessary. Community trials were

supplemented

with

extensive

modeling

using

ONCHOSIM, a

transmission

simulator

developed

with OCP data by

researchers

at

the University

of

Rotterdam (Plaisier, 1990). These intensive epidemiological studies indicated that

with long-term ivermectin

coverage

alone-no larvicide spraying-it might be

possible to control riverblindness.

The

African

Programme

for

Onchocerciasis

Control

8

I

Emboldened

by their

success

in West Africa and

empowered

by Merck's

donation, the riverblindness partnership embarked on a broader

mission-defeating

the disease throughout the continent. Building on the knowledge and experience gained in OCP, the sponsoring agencies in 1995 launched a second programme

to

combat the rest

of Africa's

riverblindness, the African Programme for Onchocerciasis Control (APOC).

APOC emphasizes the ivermectin strategy studied

initially

under

OCP-using

long-term distribution

of

the drug

to

eliminate sickness and slow transmission

by

reducing the ^parasite reservoir

in humans. Larviciding is

used

only

peripherally because

APOC's

vast area makes spraying too costly, and

thick

forests covering the area's principal rivers render aerial delivery

ineffective,

as

well. APOC is

made possible

by Merck's

continued donation

of

^unlimited

supplies of

Mectizan.

This generosity and the drug's effectiveness have facilitated the expansion of riverblindness control to the remaining infested areas of Africa.

Riverblindness control based

on

ivermectin presents some advantages over larviciding alone, such as immediate

relief

for victims, but also raises new challenges, the largest of which involves sustaining a drug coverage threshold long enough to intemrpt transmission.

With

rural diseases such as riverblindness, people who most need the drugs are often the hardest

to

serve,

living

beyond the reach of national health services. And riverblindness victims need doses every six to twelve months as long as they harbor even one adult

worm.

Further, communities must take the drug

for two

decades or more to have any

definitive

impact on transmission. For this reason, APOC's Community-Directed Treatment

initiative

(Com-DT) has developed extensive networks

of

Community

Drug

Distributors

(CDDs),

appointed

by their

peers

to work with

APOC's NGDO (non-governmental development organizations) partners to distribute Mectizan on a sustainable basis and to share knowledge of the disease. APOC's reliance on the regular and continued administration

of

the drug makes this distribution crucial to success.

WHO's

expert epidemiologists estimate that communities at risk

will

need to take ivermectin for approximately

20

continuous years

to

eliminate the disease as a

public

health

problem. During this

period, these scientists calculate, APOC must ensure at least 650/o treatment coverage throughout the affected

communities. In 2000,

members

of the

Community-Directed Treatment network achieved an average ivermectin coverage

of

74%o

in

the targeted communities

(WHO

2001).

These distribution efforts were augmented by a strong commitment to capacity-building: in the same year APOC trained

or

re-trained more than 77,000

people.

The 22

million

people now reached annually

by

APOC represent less than

half of

those

who will

be targeted as APOC expands over the next few years.

9

OCP's

27

years

of

operations

form the

knowledge base

on which APOC is

founded, though

on the

surface

it would

appear that the

two

control strategies are

unrelated. In

fact,

APOC's

approach represents

a natural evolution from OCP,

incorporating

new

treatment strategies

but relying

heavily

on

OCP's technology and fine-tuned database

of

riverblindness epidemiology,

which has been painstakingly

constructed

over nearly three

decades. The involvement

of

communities

is

also a natural extension

of

the devolution integral

to

OCP all

along. While the first staff

members

in

Ouagadougou

were primarily

Westerners, the Programme set

out quickly to

hire and train

Africans.

Since 1980,

for

instance,

all

Directors have been

Africans.

Overall, OCP has funded several hundred graduate degrees,

all

awarded to Africans who were working against riverblindness (Samba,

1994). By

1984, ten years into the prograrnme, 96oh

of the staff

were

African. Now Africans

comprise

more

than ^99o/o

of

the personnel.

In addition to devolution, OCP made groundbreaking contributions in other areas as well.

From the earliest days, OCP has embodied a culture

of

operations research, which has rescued the Programme more than

once. Around

1980,

for

instance, the blackflies began developing resistance

to

the main larvicide

(Kurtak, 1990).

Thanks

to

several years

of

ongoing research, OCP scientists were able to develop and test alternatives. Using some

of

these new options in a

rotation

overcame

the

resistance

in the fly

population, restoring

the

effectiveness

of

vector

control.

Another major

difficulty

came

to light

when OCP entomologists discovered that the

fly's

effective

flight

range was 400 kilometers or more

(WHO, 1987)-nearly

10 times original estimates

(WHO, 1973).

The problem appeared as infected

flies

were discovered re-invading previously controlled areas (Garms et

al., 1979).

Ongoing epidemiological and entomological research revealed the problem

while

superb management and redoubled donor support allowed OCP

to

expand

into

the nearby zones where new

flies

had been discovered (Philippon et al.,

1990). Similarly, APOC's

operations

were

underwritten

by

extensive preparatory research including epidemiological mapping (De Sole er

al.,

1990), studying distribution methods (TDR,

1996), examining the sustainability

of

the Com-DT approach

(WHO,

2000), and investigating community compliance and the effects of ivermectin on skin disease (Brieger et

al.,

1998).

Future

Prospects

APOC is

fundamentally about riverblindness,

but the

ivermectin

distribution

network

it

^has

created stands ready

to

serve as an essential

vehicle for

addressing other widespread health problems.

As Merck

has done

with

Mectizan, several drug companies are prepared

to

donate medicines that can be delivered via APOC at minimal cost to the poorest communities. Among

10

the simplest and most effective would be vitamin

A

capsules, given free

by

Hoffman-LaRoche, which

would

help prevent blindness

in

children and improve general health

in

the rest

of

the

population. Aside from the

health benefits,

providing

additional drugs

would

strengthen the position and effectiveness

of

community Mectizan distributors. Great care must be taken not to overwhelm this nascent distribution network, but

in

the case

of

^vitamin

A, little

training would be needed, and everyone can take

it.

Further

building

local capacity

by

distributing vitamin

A

would pave the way

for

making available several other donated drugs

in

the communities that have been the hardest to reach.

The

full

value of APOC's distribution network lies in its

potential.

In

it,

the international community has a ready pathway to deliver medicines to those who need

it most.

Drugs already available

at no cost

include

the following, all of which

have

the

same dosing schedule as

Mectizan:

Vitamin A to prevent malnutrition, blindness, death

Azythromycin to cure trachoma, now the leading ^cause of blindness in

Africa

Ivermectin and albendazole to stop transmission of lymphatic filariasis (elephantiasis), one of Africa's leading causes of long-term disability

Despite recent, sharp reductions in price,

AIDS

medications are

still

quite expensive, but are among

the many health

interventions

that could

conceivably

be

delivered through this network

in

the

future.

Once

fully

developed, there would be

virnrally

no

limit to

the materials that could be distributed, including health information, condoms, multivitamins, and vaccines.

There is the very real possibility of knocking out not

just

one health problem, but several major

diseases-enough to dramatically improve public health overall, instead of just

making opportunities for diseases now of secondary importance.

The Community Directed Treatment (Com-DT)

initiative

stands as a

fitting

coda

to

the legacy established by

OCP.

What began as a top-down, vertical disease programme has evolved

into a bottom-up,

integrated approach

that

couples

strong regional

coordination

with

the empowerment

of local

communities

to

address

not only

onchocerciasis but, potentially, many

other health

problems

as well. ^{For much} of its history, OCP has been

conducted

with

helicopters, spraying against

a

formidable,

but

solitary

foe.

APOC has extended

this

success

with the help of

Mectizan

to

include

local

communities

not

as passive beneficiaries,

but

as

powerful agents impacting some

of

their own health outcomes. This grassroots involvement,

if

fully

strengthened, would complete OCP's transformation from an external programme to a

fully

African-owned and managed region-wide health system.

1l

The success

of

OCP testifies

to

the power

of

this partnership,

in which

sponsors have concentrated on their respective strengths and the donor community has lent unwavering support

for

nearly three

decades-far

longer than

for

any other operational development programme.

Given the technical hurdles, this commitment has been essential to success and remains one

of

OCP's

finest hallmarks. No

combination

of

shorter programmes

could

have achieved these results

nor

evolved

horizontally, affording potentially much wider protection of the

public

health.

The longstanding collaboration and

goodwill

developed on

all

sides

of

this partnership have generated synergies greater than those imagined, and

all

at remarkably

low cost.

Coverage has cost,

at

every

point in both

programrnes,

far

less

than

one

dollar ^per

^year,

^per

^person

protected (Benton and Skinner, 1990; Benton, ^1998).

OCP's

efforts

have

led to

widespread acclaim among

public

health practitioners, but perhaps more importantly, have

led to

broad-based support

from the

communities protected.

This gtassroots

credibility is

the single most important factor

in APOC's

success at Mectizan distribution, and portends a transformation

in

the

ability

to deliver a wide range

of

medications

in

the

future.

Development assistance prograrnmes have

long

sought comprehensive ways

of

addressing widespread public health problems

while

ensuring sustainability, local involvement, and community empowerment. OCP and APOC have achieved these goals

by

virfue

of

nearly

30 years'

dynamic partnership

with

increasingly

active host

countries

and their

constituent populations, proficient intemational agencies, and unswervingly dedicated donors.

ACKNOWLEDGEMENTS

We appreciate the valuable help given by Prof. O. O. Kale in the preparation of this paper. The assistance of Marline Alexis, Joyce Musya-Mpangu ^and Olympia Gjino of the Onchocerciasis Coordination unit of the World Bank is gratefully acknowledged.

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17

THE ACHIEVEMENTS AND CHALLENGES OF THE

AFRICAN PROGRA MME FOR ONCHOCERCIASTS

coNrRoL (apoc)

THB ACHIEVEMENTS AND CHALLENGES

OF

THE

AFRICAN PROGRAMME

FOR

ONCHOCERCIASIS CONTROL (APOC)

AUTHORS

A. sprBrell,t

G. ADEoyE,2 A. EYAMBA,3 E. I.NORU*,4 ^p. DRAMEH,' u.

v.

AMAZIGo,' M. NoMA,' F. AGBoroN,l

y. AHoLou,'o.

o. xaLp6ANDK. y.DADZTE'

ADDRESSES OF AUTHORS

l.

^{African Programme for} Onchocerciasis Control (APOC), Ouagadougou, Burkina Faso

2.

University of Lagos, Akoka, Yaba, Lagos, Nigeria

3.

The Carter Center, Global 2000 River Blindness Program, Yaounde, Cameroon

4.

Department

of

Dermatology, College

of

Medicine, University

of

Nigeria, Enugu Campus, Enugu, Nigeria

5.

^World Health Organization, Geneva, Switzerland

6.

Department

of

Preventive

and Social Medicine, University College Hospital,

Ibadan, Nigeria

7.

01905 Osu - Accra, Ghana

Address

for

Coruespondence

Dr.

Azodoga S6k6t6ti

Director, African

Programme

for

Onchocerciasis

Control

(APOC), 01 B. P. 549 Ouagadougou 01

Burkina

Faso

Tel:

(226) 34.22.77 Faxz (226) 34.48.00

E-mail:

seketelia@oncho.oms.bf

Short running

title:

Achievements of APOC

ABSTRACT

The Community Directed Treatment

with

Ivermectin

(CDTI)

strategy

of

APOC has enabled the Programme

to

reach, empower

and bring relief to

remote

and

underserved onchocerciasis endemic communities.

With CDTI,

geographical and therapeutic coverage rates have increased substantially,

in

most areas,

to

levels required

to

eliminate onchocerciasis as

a public

health

problem.

_{Over 20}

million

people received treatment

in 2000.

APOC has also used REMO-GIS

effectively to provide information on the geographical distribution and prevalence of

onchocerciasis, as a means

of

identifying

CDTl-priority

areas, and obtaining better estimates

of

the numbers

of

people to be treated.

A

unique public/private sector partnership has been at the

heart of APOC's relative success. Through efficient

capacity

building, the

Programme's operations have

positively

influenced

and

strengthened

the health

services

of

participating

countries.

These laudable achievements notwithstanding, APOC faces many challenges during the second phase

of

its operations when the

full

impact

of

the Programme is expected to be felt.

Notable among these

is

the sustainability

of CDTI,

its effective integration into the health care system and

exploiting its

^potential as an entry

point for

other health programmes such as the

lymphatic filariasis elimination

programme,

which would

feature

on the

agenda

of

many participating countries

during APOC's

Phase

2.

^Executing these other programmes without compromising

the

onchocerciasis

control

^programme

itself is a major

challenge

to

APOC.

Success

in

meeting these challenges

will

depend on the continued wholehearted commitment

of

all partners especially governments of participating countries.

2

INTRODUCTION

The vast

majority of

those

who

suffer

from

and are exposed

to

onchocerciasis

live in Africa (WHO,

1995a). The most severe consequences of the disease is blindness, which may affect one third of the adult population of the most highly affected communities and the prevention of which has been the main clinical raison d'€tre

for

initiating the Onchocerciasis Control Programme in West

Africa

(OCP)

in

1974

(Tsalikis,

1993; Benton et

al., 2001).

However

in

the last decade important pioneering studies, sponsored by the UNDPAVoTId Bank/WHO Special Programme

for

Research and Training

in

Tropical Diseases

(TDR),

have shown that onchocercal skin disease (OSD)

is

associated

with

a greater degree

of morbidity

than was hitherto appreciated. These studies demonstrated that severe OSD and intolerable itching cause a

lot of

suffering to millions of people particularly

in

the forest zone where the blinding form

of

the disease is less prevalent.

(Amazigo and Obikeze, 1991, Amazigo, 1993,

WHO,

1995b,).

It

not

only

causes psychosocial problems, ostracism and stigma (Okello et

al.,

1995;

Owga

et

al.,

1995,

WHO,

l995b,Brieger et

al.,

1998b)

but OSD also

has

a

demonstrably negative socio-economic

impact on

farmers' productivity, breastfeeding and school attendance. (Amazigo 1994;

Kim

et

a|.,1997

_; Oladepo el

al.,

1997; Benton, _{1998 ;} Vlassoff et a1.,2000). The relative contributions of both major clinical patterns,

ocular

and dermal,

to the

burden

of

onchocercal disease

and their

socio-economic consequences are considerable. (Kale, 1998).

The principal strategy of OCP from its inception was vector

control.

However the advent of ivermectin (Mectizan@) and its donation by Merck

&

Co.

in

1987, free of charge for as long as

needed, provided a second string to OCP's operational

bow.

The

first

extensive

field

studies on the suitability

of

the drug for use on a mass scale were conducted

by

the

OCP.

The favourable results

of

these studies led

to

OCP adopting mass distribution

of

Mectizan@ as an adjunct to vector

control. It

even used the drug alone

in

some areas

(Awadzi

et

al.,

1985; Dadzie et al., 1987, Remme

et al.,

1989; Dadzie

et al.,

1990; Remme

et al.,

1990; Dadzie

et al., l99l;

3

Whitworth et

al., l99l;1992

Guillet et.

al.,

1995). The application of the two strategies by OCP has led to the virrual elimination

of

onchocerciasis as a public health problem and an obstacle to socio-economic development

in the 1l

countries

of

OCP leading

to

the recognition

of

OCP as

one

of the most

successful prograflrmes

in the history of

development assistance

(Kim

and Benton, 1995).

The initial efforts

at mass distribution

of

ivermectin outside OCP were made

by

non- govemmental development organizations (NGDOs) a few years

prior

to the establishment of the

African

Programme

for

Onchocerciasis

Control (APOC). The first of the

NGDO-facilitated distribution progralnmes

in Africa

that came

to

be referred

to

as

the

Ivermectin Distribution Programme

(IDP) (Duke

and

Dadzie

1993),

was

established

Nigeria in

1989.

Many of

the pioneering NGDOs were already

well

known through their activities

in

prevention

of

blindness and were already

with the WHO

Prevention

of

Blindness Programme

(PBL). At

that time, outside

of

the OCP area, authorities

in

most countries where the disease was endemic

did

not consider

the

disease as

a public

health problem and there were therefore

no

programmes or structures

in

^place

for its control.

The NGDOs soon recognised the need

to

coordinate their separate and independent efforts

if

they were to achieve their common

goal.

Therefore

in

199?

they

came together

to form

the

NGDO

Coordination Group

for

Ivermectin

Distribution. By

1995,

it

had become clear that members

of

the Coordination Group needed considerably more resources than they could generated on their own

if

there was to be any significant expansion in

the

scope

of their activities.

Furthermore the various

NGDOs

and programmes used mobile teams and the clinic-based and Community-Based Treatment

with

Ivermectin

(CBTI)

methods in the distribution

of ivermectin.

These methods were clearly not appropriate or cost-effective

for

large-scale sustainable

distribution of the drug. In

1995

the

Task Force

on

Onchocerciasis Operational Research (OOR) of the TDR, in collaboration

with

the OCP, addressed the problem in a multi-country research

study.

The result was the development

of

the method

of

distribution

4

that has become known as the

Community-Directed

Treatment with Ivermectin

(CDTI) (WHO,l996a).

Prior to this,

and

in

response

to the

need

of

the disparate

control

programmes

of

the various

NGDOs for a rapid, reliable and

cost-effective method

of identifying

communities

endemic for

onchocerciasis

to be

targeted

for

treatment,

the OOR

developed

the

Rapid Epidemiological Mapping of Onchocerciasis (REMO), (Ngoumou and Walsh, 1993; Ngoumou et

al.,

1994l'

WHO, 1995c).

The underlying concepts and design

of REMO

drew heavily on the experience

in OCP.

The

World

Bank provided financial support

in

the development

of

REMO, which has since become a key tool in the control armamentarium of APOC.

This then was the scenario on the onchocerciasis front in Africa when APOC, inaugurated

in

December 1995, commenced operations

in

1996

with

a mandate

"to build

on the success

of

OCP and establish sustainable control (of onchocerciasis) in the remaining 19 countries in

Africa

where the disease was

still

a public health problem".

(WHO,l996b).

The entire Programme was

manifestly

predicated

on the window of opportunity provided by the Mectizan

Donation Programme

(MDP).

Thus

the control

strategy prescribed

for APOC

was "community-based treatment prografirmes

with

the drug ivermectin, supplemented

with

vector eradication

in

a few isolated

foci".

This paper is an overview

of

the achievements

of

APOC

in

the

first

(1996-2001)

of

two planned phases

of its

operations, and

a

consideration

of the

challenges

for the

second phase

(2002-2007). Six

companion articles

in this

supplement

review in

^greater

detail

some key aspects of the activities of APOC.

The

Structure

of

APOC

Governance: APOC has built a strong and effective partnership that unites the member countries

their

beneficiary communities, NGDOs, multilateral agencies, bilateral donors and the private

5

sector,

Merck & ^{Co. Inc. and the} scientific community. The

organisational

framework

is designed to reflect this partnership.

(WHO,l996b).

All

partners are represented on the

Joint Action Forum (JAF),

the main governing body

of

APOC

which

has been meeting, annually as scheduled, to review and approve the proposed plans of action and budgets, assess global financing requirements and take decisions

with

regard to overall progralnme policies.

The members of the Committee of Sponsoring Agencies (CSA) are the same as for OCP

viz. FAO, UNDP, WHO

and

the World Bank. The CSA

organizes medium and

long

term planning

of

APOC and OCP activities, approves National Plans and Project Proposals and takes interim decisions on behalf of JAF.

Programme

Management:

The headquarters

of

APOC is

in

Ouagadougou where a small core staff looks after the day-to-day affairs of

APOC.

This core staff, in conjunction

with

the NGDO liaison

office in

Geneva, has,

in

spite

of

^a heavy burden

of

work, maintained a high standard

of operations.

APOC Management has

faithfully

implemented programme

policy,

facilitated and coordinated the activities

of

the National Onchocerciasis Task Forces and their partner NGDOs and provided oversight on financial management.

It

has also assisted

in

the training of National and NGDO staff and facilitated the monitoring of ^projects.

APOC is

supported

by a Technical Consultative Committee (TCC),

made

up of

¹⁰

members. The TCC has successfully reviewed and recommended for approval 63 applications

for APOC funding of CDTI

projects, including

their

national support systems

in

addition

to

four vector elimination projects.

In the first

phase

of its

operation

APOC

has facilitated

the formation of a National

Onchocerciasis Task Force (NOTF) in every participating

country.

Made up

of

officials of the Ministries of Health

(MoH)

and Programme Managers as

well

^as all partner NGDOs operating in the country, NOTFs have made considerable improvement in their performance over the ^years.

6