The World Health Organization

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1 AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL JAF 16.5 The World Health Organization Year 2010 Progress Report 1st September st August 2010

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3 Joint Action Forum Office of the Chairman Forum d Action Commune Bureau du Président JAF-FAC: Sixteenth Session Abuja - Nigeria, 7 9 December, 2010 The World Health Organization Year 2010 Progress Report 1st September st August 2010 African Programme for Onchocerciasis Control Programme Africain de Lutte Contre l Onchocercose JAF 16.5 ORIGINAL: ENGLISH September 2010 AFRICAN PROGRAMME FOR ONCHOCERCIASIS CONTROL i

4 The CDI strategy works In the world s most impoverished region Where there are no roads no doctor no drugs Where hunger is greatest incomes are lowest health information is scarce poverty is rife Where there is the greatest need Bringing medicines to those most in need Copyright African Programme for Onchocerciasis Control (WHO/APOC), 2010 All rights reserved. Publications of the WHO/APOC enjoy copyright protection in accordance with the Universal copyright Convention. Any use of information in the WHO/APOC Progress Report should be accompanied by acknowledgement of WHO/APOC as the source. For rights of reproduction or translation in part or in toto, application should be made to the office of the APOC Director, WHO/APOC, 01 BP 549 Ouagadougou, Burkina Faso, dirapoc@oncho.afro.who.int. WHO/APOC welcomes such applications. ii

5 Table of contents Tables, figures and annexes iv Abbreviations/acronyms v Executive summary THE YEAR IN REVIEW: 1 Community-Directed Treatment With Ivermectin (Cdti) and Health Impact Disease Mapping Mapping of onchocerciasis and Loa loa prevalence Integrated mapping of NTDs Geographic and therapeutic Coverage Status of Geographic Coverage Status of therapeutic coverage Mectizan tablets supplied by the Mectizan Donation Programme (MDP) External Mid-Term Evaluation of APOC Monitoring Evaluation and Surveillance Independent Participatory Monitoring (IPM) Community Self Monitoring (CSM) Monitoring of Evaluation of Sustainability of CDTI Projects Surveillance activities in ex-ocp countries Cross border collaboration Health impact of CDTI Moving from Control to Elimination of Onchocerciasis where Feasible Epidemiological Evaluations Delineating Transmission Zones Co-Implementation of Cdti with Other Health Interventions Control of NTDs building on CDTI Up-scaling malaria prevention through CDI Strengthening Health Systems Human Resource Development for the control of onchocerciasis and other health interventions Engaging communities and training of community-directed distributors (CDDs) Training of health staff Building Capacity of countries in communication Gender Mainstreaming Logistic support to countries Partnerships and Government Contributions Government Financial Contributions to CDTI activities Direct Financial Support to Countries and Management of the APOC Trust Fund Governance The Joint Action Forum Technical Consultative Committee Committee of Sponsoring Agencies (CSA) Advocacy and Outcomes Advocacy for increased government financial commitment Development and implementation of a CDI curriculum and training module Technical Support to countries Partnerships Macrofil and Other Research Transition to National Ownership and Sustainability ANNEX iii

6 African Programme for Onchocerciasis Control Progress report Tables, Figures and Annexes Tables Table 1: Summary of ivermectin treatment in APOC countries in Table 2: Indicators to measure the CDTI process Table 3 Number of communities which conducted CSM in 2007, 2008, Table 4: Scores for evaluations of sustainability Table 5: Summary of epidemiological evaluations providing evidence for elimination Table 6: Summary of Co-implementation activities in 10 Countries in Table 7: Up-scaling malaria prevention through CDI in Nigeria Table 8: Number of health workers and CDDs trained/retrained in 2009 by NOTFs Table 9: Capacity building of country health staff Table 10: Summary of logistic equipment provided by APOC to CDTI Projects during the period under review Table 11: Government funds disbursed for CDTI activities Table 12: Status of activities for adoption of the CDI curriculum and training module Figures Figure 1: Prevalence of Loa loa in Cameroon Figure 2: Map of areas at risk of onchocerciasis in 15 APOC countries Figure 3: Trend of geographical coverage (%) in post-conflict and stable APOC countries: Figure 4: Trends of therapeutic coverage (%) in post-conflict and stable APOC countries: Figure 5: Numbers of people treated with ivermectin from 1997 and 2009 (data up to August 2010) Figure 6: East Bahr el Ghazal: Difficult access to communities in Sudan Figure 7: An Evaluation team with community members in Adamaoua I CDTI Project, Cameroon, November Figure 8: Results of sustainability evaluation in 6 project in 3 countries Figure 9: Onchocerciasis surveillance network in ex-ocp countries in Figure 10: Results of onchocerciasis surveillance in ex-ocp countries and Nigeria in Figure 11: a) Pre- and post-control nodule prevalence in Ebonyi focus Nigeria (1997/2000) b) mf prevalence Figure 12: Pre-control distribution of onchocerciasis endemicity (a) and coverage endemicity zones by Community-directed treatment with ivermectin projects (b) Figure 13: Major health interventions co-implemented with ivermectin distribution using CDI based on data from 49 projects in 10 countries in Figure 14: Swahili language treatment register for co-implementation in Tanzania Figure 15: Proportions of the budget used for Administration and Management and for Operational costs in Figure 16: Allocation of APOC Trust Fund to major activities in Annexes Annex Table 1: Number of Mectizan tablets* provided and shipped to APOC countries programs from 1997 to Annex Table 2: Funds disbursed for Core CDTI activities Annex Table 3: Numbers of projects that received APOC Trust Fund in 2009/ Annex Table 4 Numbers of financial returns submitted and analysed 2009/ iv

7 Abbreviations/acronyms AfDB African Development Bank AFRO WHO Regional Office for Africa APOC..... African Programme for Onchocerciasis Control BELACD... Bureau d études, de liaison des actions caritatives et de développement. CAR Central African Republic Cbm Christoffel-Blindenmission (German NGO) CCHP..... Comprehensive Council Health Plan CDD Community-Directed Distributor CDI Community-Directed Intervention CDTI Community-Directed Treatment with Ivermectin CHAL..... Christian Health Association of Liberia CIDA..... Canadian International Development Agency CRS Catholic Relief Services CSA Committee of Sponsoring Agencies CSSW..... Charitable Society for Social Welfare DALYs..... Disability Adjusted Life Years DFC Direct Financial Cooperation DOT Directly Observed Treatment Short-course DRC Democratic Republic of Congo GIS Geographical Information System GSM Global Management System HIA Health Impact Assessment HKI Helen Keller International HSAM..... Health Education /Sensitization /Advocacy / Mobilisation IEC Information, Education, Communication IEF International Eye Foundation IFESH..... International Foundation for Education and Self-Help IMA IMA World Health IPM Independent Participatory Monitoring IRC International Rescue Committee JAF Joint Action Forum (APOC governing body) LA Letter of Agreement LCIF Lions Clubs International Foundation LGA Local Government Area MDGs..... Millennium Development Goals MDP Mectizan Donation Program MDSC..... Multi-Disease Surveillance Centre MITOSATH. Mission To Save The Helpless NGDO..... Non-Governmental Development Organization NGO Non-Governmental Organization NOCP..... National Onchocerciasis Control Programme NOTF..... National Onchocerciasis Task Force NTDs Neglected Tropical Diseases OCP Onchocerciasis Control Programme in West Africa OPC Organisation pour la Prévention de la Cécité OTD Other Tropical Diseases RAPLOA... Rapid Assessment Procedure for Loa loa REMO..... Rapid Epidemiological Mapping of Onchocerciasis SAE Severe Adverse Event SCI Schistosomiasis Control Initiative SOTF Sudan Onchocerciasis Task Force SS Sightsavers TCC Technical Consultative Committee (APOC scientific advisory group) TDR WHO-based Special Programme for Research and Training in Tropical Diseases TSA Technical Service Agreement UFAR United Front Against River-blindness UNICEF.... United Nations Children s Fund USAID.... United State Agency for International Development WAHO..... West African Health Organization WHO World Health Organization WHO/OCP. see OCP WHO/TDR.. see TDR vafrican Programme for Onchocerciasis Control Progress report

8 African Programme for Onchocerciasis Control Progress report Quote from a Tanzanian community member from Luandai Sone village in Tanzania: Before this programme started there was no such thing in the village as doing health work by the villagers. The only community work we had then was to help dig roads. Having used this new method through the APOC programme, today we can organise ourselves to use this same system to do work in the environment i.e. sanitation; care for our chronically sick people like fetch firework for them and regularly give them their medication, carry out home-based care for HIVAIDS patients; participate in family planning, sensitising our community, distributing condoms and contraceptives. We have found out that when we go to give ivermectin it is best to do other things related to health at the same time (2010) Regional Director of WHO AFRO, Dr Luis Gomes Sambo at the opening of the 60th session of the Regional Committee of WHO for Africa: There is significant progress in onchocerciasis control and I would like to especially mention and express satisfaction at Equatorial Guinea s success in the elimination of the onchocerciasis vector in the Island of Bioko. This success has freed the people of the related hazards and also enabled the resumption of agricultural and economic activities by the local communities. (2010) President of Equatorial Guinea, Obiang Nguema Mbasogo at the opening of the 60th session of the Regional Committee of WHO for Africa: In the fight against pandemics, we have real cause for optimism regarding the control of Onchocerciasis, the vector of which has been eliminated from the island of Bioko, as demonstrated by surveys conducted recently by WHO experts. We await the transfer of this experience to the Continental part of the country. (2010) Eyes full of hope and expectation vi

9 Executive summary In the current reporting year (1 September August 2010), country National Onchocerciasis Task Forces (NOTFs) and APOC management have focussed on two major areas in which there is a new emphasis of the Programmes activities. One of these areas is the shift from control of onchocerciasis as a public health problem to elimination of infection and interruption of transmission of the disease. The second area is expanded co-implementation of multiple health interventions against malaria and other NTDs alongside CDTI and effectively using the network already established for that strategy. These two sets of activities required additional planning for implementation and funding. The Programme is also being submitted to an external mid-term evaluation, following a decision made by JAF 15 in Tunis that such an evaluation should be held in Whilst carrying out these activities, APOC maintained its main programme activities to ensure that progress continues to be made with community-directed treatment with ivermectin and that the new activities and the challenges that came with them would not have any detrimental effects on the Programme s primary mandate. The main activities of the Programme were: 1. CDTI Implementation In 2009, over 66.9 million people from 132,997 out of the 142,164 communities in the 108 APOC supported CDTI projects were treated with ivermectin. This represents sustained progress towards the objective of treating 90 million people by The large increase in numbers treated compared to 2008 was largely due to expanded treatment in the Democratic Republic of Congo (DRC). Despite the well-known challenges faced in most post-conflict countries, such as An exciting new development was the progress made with geographical modelling of disease distribution using GIS technology to carry out spatial analysis by krigging, a technique for interpolating existing geo-referenced epidemiological data to predict disease distribution in other areas. APOC s available maps on distribution and prevalence of onchocerciasis will be refined where necessary in order to more precisely identify transmission zones, which is essential for achieving elimination of infection. poor or absent infrastructure and an acute shortage of experienced health professionals, overall, progress has continued to be made in increasing therapeutic coverage in most projects in these countries. A multi-country study on the Social Benefits of CDTI was completed in the last quarter of 2009 and the findings are being prepared for publication in scientific journals. This, and other social science studies conducted in 2010 in Nigeria, Liberia, Uganda and Malawi have revealed more qualitative benefits of CDTI willingness of communities to contribute to CDTI, even at financial or opportunity costs to themselves, and awareness of community members, including children, of the advantages of community participation as a means of delivering these interventions. Evaluations of sustainability and Independent Participatory Monitoring Of the six evaluations of sustainability reported here, all projects were judged to be making satisfactory progress towards sustainability. The evaluations were for African Programme for Onchocerciasis Control Progress report 1

10 African Programme for Onchocerciasis Control Progress report It is getting better; I can see you clearly now because of Mectizan. says teacher Mrs Martina Okoli. three Projects in Cameroon, two in Burundi and one in DRC. However timely financial support from national Governments and provision of adequate transport facilities remain the most important constraint to sustainability. This is to be expected in view of the competition for resources that led to the CDTI strategy being set up to serve communities beyond the end of the road but emphasises the need for continuing advocacy on their behalf. The results of Independent Participatory Monitoring in 3 post-conflict countries (DRC, Angola and in the southern part of Sudan) highlighted the lack of human capacity and inaccessibility of onchocerciasis villages as daunting challenges. Epidemiological and REMO/ RAPLOA risk assessment Using a spatial analysis technique (krigging) the onchocerciasis distribution maps of Africa were updated and improved. These maps will be made available to all member countries and other partners and will be published in International journals in They will contribute to the planning of interruption of transmission of onchocerciasis where feasible. Two sub-regional Ministerial meetings of Central African countries were held during the reporting period. The Ministerial meeting held in Douala, Cameroon in October 2009 recommended that APOC supports Ministries of Health to map the distribution of loiasis in areas where the prevalence of this filarial disease is not yet available. APOC management in partnership with NOTF partners has continued its efforts in many countries including Cameroon, Angola and in the southern part of Sudan. The distribution The truth is that the difference is clear because about 5 6 years ago, it was becoming very embarrassing for us here because even in the market square, you would find people using sticks to scratch their legs or hands. There are some young people who could not go to the city to look for jobs because of their condition but if you look around now, only those that are still in secondary school can be found here in the village. The others have gone to the cities to look for work because they no longer have irritated skin to be ashamed of (male youth, Nigeria) 2

11 of loiasis is now known throughout Cameroon following complementary surveys conducted in 2010 in 269 villages of 85 health Districts in 7 Regions. Moving from control to elimination where feasible The measures required for or that have been undertaken towards shifting from control to elimination included: 1. Identifying additional mapping requirements associated with the shift from control to elimination of onchocerciasis and interruption of transmission. 2. Epidemiological evaluations in more foci with over 10 years of ivermectin experience to assess progress towards elimination. In 2010, the epidemiological evaluations took place in 11 foci in 6 countries (Cameroon, Central African Republic, DRC, Nigeria, Tanzania and Uganda). The results of these studies will be presented to JAF16 in Abuja, Nigeria. Contributions of participating governments to onchocerciasis control In 2009 eleven countries contributed a total of over US $1.1 million for core CDTI activities that are presented in section 5.1 of this report. Local Government/District authorities were the main contributors to implementation of CDTI. 2. Strengthening Health Systems through Capacity building (including logistic support) The strengthening of health systems in sub-saharan Africa is essential for ensuring sustainability of primary health care interventions. APOC therefore supported training on the CDI approach, with emphasis on the community level and provided logistic support to countries. During the reporting period a total of 503,256 CDDs and 36,682 health workers were trained or re-trained in 15 countries. The number of CDDs trained represents a 19.2% increase on figures for Mr Seth Gussin loves to serve his community and spends three weeks distributing Mectizan each year and the trainees came from 132,997 of the 142,164 communities in 15 countries. At a higher level, CDI training workshops were held for participants from Uganda, Tanzania, Malawi, southern Sudan and Angola. Capacity building workshops on disease mapping and surveillance, use of GPS instruments and administrative and financial procedures were supported for nationals from Cameroon, Liberia, Nigeria, DRC and the Central African Republic. Details of other training to strengthen entomological surveillance and detection of potential recrudescence of disease transmission are described in this report. Fifty three vehicles, 121 motorbikes and over 3,600 bicycles were provided to CDTI Projects and CDDs among other essential equipment in Among the bicycles were 1300 provided by a donation to APOC coming from the Global Network for Neglected Tropical Diseases through the Sabin Institute. These bicycles will facilitate the work of CDDs working in difficult conditions and will also contribute to the well being of communities in other ways. African Programme for Onchocerciasis Control Progress report 3

12 African Programme for Onchocerciasis Control Progress report 3. Co-implementation of multiple health interventions building on CDTI community and health system structures: Nearly 26 million treatments or commodities were delivered to people in five countries in 2009, representing a significant increase compared to 2008.The expanded coimplementation of NTD control building on CDTI projects in Tanzania and DRC continued during , consolidating earlier progress that has been achieved, taking note of the challenges involved. In Tanzania, MDA is being implemented with APOC financial support in Districts which were not formerly part of CDTI Projects and for which there was therefore no existing CDTI structure. This was a result of the Government s wish to change from treating the entire five Regions in which there are CDTI projects, instead of just Onchocerciasis affected Districts in those Regions. The experiences and challenges of co-implementation will be presented to JAF16 in December A key area of APOC s support to countries for NTD control is integrated mapping. A workshop for integrated mapping was held in 2010 for 13 countries which have gaps in the mapping of NTDs following a WHO/AFRO meeting in Twenty-two participants from 13 countries developed draft plans to fill the gaps. 4. Financial support from the APOC Trust Fund Direct financial support was provided to 14 APOC countries and limited support to eight ex-ocp countries. A total of US $29.83 million was disbursed in 2010 with 82% of this being provided for technical/operational activities. An updated manual of Financial and Administrative Procedures was disseminated to all partners as a means of addressing the challenge of delayed financial reporting due to new WHO/GSM requirements. It is anticipated that this will result in a smoother and more timely distribution of funds in coming years. 5. Research and Drug Development Following completion of the Phase 2 Moxidectin development study in Ghana, a decision on the study on community trials will be possible on completion of the data analysis and it is hoped and anticipated that these studies will then be able to start in

13 THE YEAR IN REVIEW 1 Community-Directed Treatment with Ivermectin (CDTI) and Health impact 1.1 Disease Mapping Mapping of Onchocerciasis and Loa loa prevalence The cost-effectiveness of combining the mapping of onchocerciasis and loiasis has been documented (Wanji et al., 2005; Afework et al., 2010). During the period under review, the Programme conducted integrated mapping of the two diseases in Kibombo and Tunda health zones in Maniema province, D.R. Congo. A total of 55 villages were surveyed out of which 78% had a prevalence of onchocerciasis nodules carriers 20%. These results contributed to a better understanding of the pattern of onchocerciasis distribution in D.R. Congo. In February 2010, with financial and technical support from APOC, the NOTF of Cameroon conducted RAPLOA surveys in 269 villages within 85 health districts of 7 regions. The distribution of loiasis is now known for the entire Cameroon, including non-onchocerciasis areas (Figure 1). Areas with 40% prevalence and above are at high risk of severe adverse events (SAEs) as those areas are highly endemic for Loiasis. The lymphatic filariasis elimination programme now has sufficient information to plan its activities in Cameroon, whilst responding to recommendations of a Scientific working group on co-endemicity with Loa loa and onchocerciasis and/or lymphatic filariasis held in April African Programme for Onchocerciasis Control Progress report Prevelence of history of eye worm (%) 0 1 9% 10 19% 20 39% % Nigeria Chad Cameroon Central African Republic N Equatorial Guinea Km Equatorial Guinea Gabon Congo Figure 1: Prevalence of Loa loa in Cameroon 5

14 African Programme for Onchocerciasis Control Progress report In-depth review and analysis of APOC REMO data APOC management has pooled all REMO data from over 13,000 villages in 19 countries within a common database. To date, >478,000 persons from those villages have been examined for the presence of nodules. Following the acquisition of new GIS tools, a critical review of all REMO data and maps using krigging analysis was carried out during a special workshop which was held in Ouagadougou from 8-12 February This permitted maps of onchocerciasis distribution in APOC countries to be improved (Figure 2), and will allow a better delineation of areas of high onchocerciasis prevalence for use in planning to interrupt onchocerciasis transmission where feasible. In-depth analysis of APOC RAPLOA data In 2010, APOC signed an agreement with Lancaster University, United Kingdom, to conduct collaborative analysis of data from RAPLOA surveys. The main objectives of the collaboration are to analyse the spatial distribution of RAPLOA-based prevalence estimates, taking account of any association with greenness of vegetation (NDVI) and height above sea-level (elevation), and to use calibration equations between RAPLOA-based and parasitological prevalence estimates to produce maps of Loa loa high risk areas Integrated mapping of NTDs In line with the APOC Strategic Action Plan and following recommendations of the first and second Ministerial meetings of Central African countries held in 2009 and 2010, the Management of APOC organised a meeting of NTD programmes managers held from May 2010 in Ouagadougou, Burkina Faso. The purpose of this meeting was to respond to increasing requests from countries for APOC to provide technical and financial support for identification of gaps and finalisation of the mapping of NTDs. Twenty-two participants from 13 countries (Angola, Cameroon, Chad, Congo, DRC, Distribution of onchocerciasis Prediction map Prevalence of nodule carriers (%) Figure 2: Map of areas at risk of onchocerciasis in 15 APOC countries Ghana, Kenya, Liberia, Mali, Nigeria, Sudan, Tanzania and Uganda) developed preliminary, or in some cases advanced, plans of action and budgets to finalise the mapping of the main NTDs in their respective countries. Six action plans and budgets have been submitted and are being reviewed by a consultant engaged by APOC Management. The experience gained by APOC in implementation of integrated mapping of NTDs has contributed to the development of a WHO/AFRO Manual for Integrated mapping of Neglected Tropical Diseases (NTDs) in sub-saharan Africa. APOC management contributed to the development of a WHO-AFRO Strategic Plan for NTD control following a joint meeting held in Entebbe in October 2009, teleconferences and revision of the final document. APOC will continue to provide a significant supporting role to AFRO in the implementation of its NTD Programme. 6

15 1.2 Geographic and Therapeutic Coverage Status of geographic coverage The APOC Trust Fund supports 108 Community-Directed Treatment with Ivermectin projects in 15 participating countries. Forty projects are in post-conflict countries (Angola, Burundi, Central African Republic, Chad, Democratic Republic of Congo, Liberia and Sudan). The remaining 68 projects are in stable countries (Table 1). In 2009, ivermectin mass treatment was implemented in 106 of the 108 CDTI projects. One project, Bengo/Cuanza Norte/Uige, in Angola will implement ivermectin mass Country Projects A. Post-conflict countries Projects reporting Total communities distribution, after refining the mapping of Loa loa in order to define the area at risk of severe adverse events (SAEs). A CDTI Project in Gabon covers a hypo-endemic area in which only clinic-based treatment with ivermectin is applied and is therefore not included among the 15 countries. The reporting rate for the 106 CDTI projects was 97.2% (103/106 projects) in A total of more than 431 million treatments have been provided to countries since The total number of persons treated in 2009 was 66,949,850 out of a total population of 93,795,637. This represents an increase of 17.2% over the number treated in Thirty-eight percent (38%) of the persons treated (25,769,642 people) were in post conflict countries. Table 1: Summary of ivermectin treatment in APOC countries in 2009 (data available in July 2010) Communities treated Geographical coverage Total population Population treated Angola 6 5 2,251 1, , , Burundi ,406,983 1,044, CAR 1 1 5,014 4, ,399,294 1,080, Chad 1 1 3,250 3, ,871,174 1,513, DRC , ,036,661 17,503, Liberia 3 3 5,954 2, ,176,273 1,224, Sudan 6 5 6,473 5, ,605,726 2,974, Therapeutic coverage Total Post-conflict ,793 51, ,339,486 25,769, African Programme for Onchocerciasis Control Progress report B. Stable countries Cameroon ,253 10, ,373,612 4,809, Congo , , Equatorial Guinea ,206 56, Ethiopia ,316 22, ,756,141 4,613, Malawi 2 2 2,186 2, ,978,306 1,638, Nigeria ,351 35, ,352,380 25,589, Tanzania 7 7 5, ,207,132 1,616, Uganda 4 4 4,823 4, ,947,581 2,239, Total Stable ,470 81, ,456,151 41,180, Grand total , , ,795,637 66,949,

16 African Programme for Onchocerciasis Control Progress report Geographic coverage (%) Burundi Chad Post-conflict countries DRC CAR Sudan Liberia Figure 3: Trend of geographical coverage (%) in Post-conflict and Stable APOC countries between 2006 and 2009 Post-conflict countries: Out of a total of 63,793 meso and hyper-endemic communities 51,976 (81.5%) received ivermectin treatment. As can be seen in Figure 3, showing the trend of geographical coverage in postconflict APOC participating countries from 2006 to 2009, Burundi and Chad reached and maintained 100% geographical coverage. In Sudan, CAR and to a lesser extent DRC, geographical coverage increased, whilst in Liberia no overall progress was recorded between 2006 and Stable countries: Out of a total of 82,470 meso and hyper endemic communities in stable countries 81,021 (98.2%) were treated. Angola Malawi Congo Ethiopia Stable countries Cameroon Nigeria Uganda Tanzania Eq. Guinea therapeutic coverage in post-conflict and stable countries between 2006 and 2009, shows that Burundi, Chad and CAR maintained a therapeutic coverage above the control threshold of 65%. The Chad project has exceeded a therapeutic coverage of 80% since 2007, thus reaching the target set by the 14 th session of the Joint Action Forum. Sudan, DRC, Liberia and Angola, are making remarkable progress. Stable countries: All the stable countries achieved a high therapeutic coverage above 70% in 2009 (Table 1) with an average overall coverage of 77%. Figure 4 summarises the treatment figures in APOC Programme countries from 2006 to Status of therapeutic coverage In 2009, 66,945,850 people were treated in 16 countries of whom 61.5% (41,180,208 people) were in stable countries and the remaining 25,769,642 were in post-conflict countries. Ninety out of 103 projects that provided data achieved higher than the 65% threshold of therapeutic coverage in 2009 (Table 1). Post-conflict countries: In the post-conflict countries the average therapeutic coverage was 63.9%, ranging from 50.8% in Angola to 80.9% in Chad. Figure 4, comparing The increasing progression in numbers of people treated from 1997 to 2009 is shown in Figure 5. The large increase from 2008 to 2009 was largely due to increased treatments in DRC Mectizan tablets supplied by the Mectizan Donation Programme (MDP) Between 1997 and 2009, the Mectizan Donation Programme has donated 1,290,196,700 (1.29 billion) tablets to APOC countries. Details of the numbers of Mectizan tablets distributed to the countries are shown in Annex Table 1. 8

17 Stable countries Therapeutic coverage (%) Target (65%) up to 2008 Target since da n An go la M al aw i Et hi op ia Co ng o Ug an da Ni ge ria Ca m ar oo n Ta nz an ia Eq.G ui ne a er ia C 2007 Su 2006 Lib DR CA R ru nd i Bu Ch ad Figure 4: Trends of therapeutic coverage (%) in Post-conflict and Stable APOC countries between 2006 and External Mid-Term Evaluation of APOC to assess the progress of APOC towards meeting its objectives. The review will make recommendations regarding the future of APOC. This evaluation is currently in progress and the external evaluation team will present their findings and recommendations to JAF 16 in Abuja in December The Joint Action Forum, at its last session in Tunis in 2009, requested that an external mid-term evaluation of the APOC Programme should take place in 2010 as part of its rigorous follow up and African Programme for Onchocerciasis Control Progress report Post-conflict countries Bumber of people treated (milions) Figure 5: Numbers of people treated with ivermectin from 1997 to 2009 (data up to August 2010). 9

18 African Programme for Onchocerciasis Control Progress report 1.4 Monitoring, Evaluation and Surveillance Independent Participatory Monitoring of CDTI Projects Independent Participatory Monitoring of CDTI projects is conducted by teams composed of external monitors, programme managers from the respective project areas and community members. The monitoring takes place 2 years after the launch of a CDTI project to ensure that processes of engaging communities in control activities are in place and that each partner is playing its role correctly. Project performance based on the indicators listed in Table 2, is assessed and finally the monitors make recommendations to improve the participation of communities and to ensure future sustainability. Monitoring CDTI projects in post-conflict countries During the reporting period a total of 10 projects in 3 post-conflict countries underwent monitoring. The countries concerned were Angola (Huila and Moxico CDTI), Democratic Republic of Congo (Lubutu, Butembo Beni, Masisi Walikale, Rutsuru Goma and Ituri Nord CDTI projects) and South Sudan (East Bahr el Ghazal, East and West Equatoria CDTI projects). The overall results showed that out of the 10 indicators projects performed well for two indicators. The two indicators varied from one project to another. In most cases efforts are being made to implement HSAM 1 and to ensure timely procurement of ivermectin. The other indicators are considered to be weak and this presents great risks for future sustainability. Activities such as sensitisation and mobilisation of communities, which improves their engagement, and monitoring and supervision, are highly dependant on NGDO and APOC funding and any delay in funding affects project performance and community participation. 1 Health Education, Sensitisation, advocacy and Mobilisation Table 2: Indicators to measure the CDTI process Community participation and programme ownership Mectizan supply, collection and distribution Coverage CDD performance Health Education/Mobilisation/Sensitisation Gender Issues and Minority groups/ non-indigenous Training, monitoring and supervision Integration Partnership Resources These 3 post-conflict countries being monitored still face many challenges in the implementation of CDTI, including inadequate human resources and poor road infrastructure. Some of the monitors reported having to trek or ride on bicycles or motorbikes to reach these communities. Figure 6 shows the difficult circumstances involved in accessing communities visited in the East Bahr el Ghazal CDTI project in Sudan. With the recruitment of Technical Advisors stationed in the post-conflict countries, 2 in Democratic Republic of Congo and 1 in Sudan, it is expected that engaging the communities will rapidly improve implementation of control activities in the near future. Advocacy to Governments to increase financial support is also being carried out by APOC Management Community Self Monitoring (CSM) Community Self Monitoring is critical for the sustainability of CDTI and should be an integral part of CDTI key activities. Experience from many communities in different APOC countries clearly demonstrates that communities are capable of selecting monitors from among their ranks and monitoring their CDTI projects. This task had usually been that of the FLHF staff. By empowering communities to carryout out CSM, this also helps to strengthen the health system, offering more opportunities for it to achieve the health MDGs. 10

19 Figure 6: East Bahr el Ghazal: Difficult access to communities in Sudan Between 2007, 2008 and 2009, close to 73,000 CSM exercises were implemented. Table 3 shows the number of communities implementing CSM by country and by year. In 2008, the challenges of up-scaling CSM were discussed at an NOTF meeting held in Addis Ababa at which countries recommended that APOC should financially assist countries with this activity. Hence, in 2009, a total amount of US $112,752 was approved and disbursed to 20 CDTI projects in 5 APOC 2 Angola (1 project), Burundi (3), Cameroon (5), CAR (1), and Nigeria (10);.2010 countries: Angola, Burundi, Cameroon, CAR, Congo, Ethiopia, Malawi, Nigeria and Sudan. countries for this purpose 2. In 2010, a total of US $266,278 was approved for up scaling CSM implementation in 9 countries. To fund CSM at the current cost of US $37/community to train monitors would cost US $4,440,000 per year. Alternative methods of up-scaling this important activity of health system strengthening are being explored. In-country consultations to up-scale CSM have already taken place in Burundi and the results are still being analysed. Similar consultations will take place elsewhere to ensure that CSM is conducted in as many communities as possible. African Programme for Onchocerciasis Control Progress report Table 3: Number of communities which conducted CSM in 2007, 2008, 2009 Country Name Communities implementing CSM Communities treated Total Total Angola ,018 1, ,627 Burundi ,104 Cameroon 1,566 1, ,407 9,445 9,587 10,144 29,176 CAR 0 3,195 3,092 4,097 10,384 Chad 1,992 2,259 4,251 3,250 3,250 3,250 9,750 Congo ,310 DRC ,827 21,793 22,905 19,090 63,788 Equatorial Guinea Ethiopia 13,908 13,120 16,692 43,720 22,486 22,973 22,316 67,775 Liberia 5 5 4,370 3,265 2,114 9,749 Malawi ,186 2,186 2,186 6,558 Nigeria 4,230 5,997 2,456 12,683 33,915 34,308 35, ,771 Sudan ,710 6,683 5,737 14,130 Tanzania 1,901 2,206 2,055 6,162 5,848 4,883 4,263 14,994 Uganda 0 4,934 4,781 4,618 14,333 Grand Total 24,807 23,697 24,481 72, , , , , data is partial data. Zeros indicates that information was not provided in Annual Technical Reports submitted to TCC 11

20 African Programme for Onchocerciasis Control Progress report Figure 7: An Evaluation team with community members in Adamaoua I CDTI Project, Cameroon, November Evaluation of sustainability of CDTI projects Evaluation of sustainability of CDTI projects using the tools/instruments developed for this purpose by APOC (APOC documents WHO/APOC/MG/04.1), is a means of ensuring that CDTI projects will continue to perform sustainably following the closure of APOC in The evaluations provide a quantitative and qualitative assessment of key elements determining the sustainability of a project in their third or fifth years, and 3 give an opportunity to project staff and managers at all levels from the FLHF up to the senior policy and decision making officials of the Ministries of Health, NGDOs and the National coordinating office. This provides an opportunity to review progress, identify weaknesses and prepare plans for consolidating sustainability based on the outcomes of the reviews. During the reporting period, evaluations of sustainability were conducted for 4 projects in 2 countries (Burundi and Cameroon). Also reported here are evaluations of sustainability conducted late in 2009 and not included in the 2009 Annual Progress Report; Average score 2 1 Results of evaluations of projects are summarised in Figure 8 and Table 4. Sustainability plans were produced for all evaluated projects in accordance with evaluation guidelines. 0 Cameroon Est Cameroon Sud Cameroon Adamaoua l Burundi Bururi Burundi Rutana DRC Kasongo Figure 8: Results of sustainability evaluation in 6 project in 3 countries Arrangements are in progress to conduct 7 evaluations of sustainability in the Ubangui Sud and Mongalla CDTI projects of DRC and East Bahr-el-Ghazal, East and West Equatoria projects of South Sudan. The latter CDTI projects in Sudan will be evaluated in December 2010 and results will therefore be provided in the 2011 Annual Progress Report 12

21 Projects are judged to be making progress towards sustainability if the achieve a score of 2-5 or above out of a total possible score of 4. The results of evaluations of sustainability for the projects reported here (Table 4), judged all six (100%) to be making satisfactory progress towards sustainability. Kasongo Project in DRC was on the borderline, with an average score of 2.5 with transport and finance being the weakest indicators. Therapeutic and geographic coverage scored well at all levels except at the community level for Cameroon Sud CDTI project (2.3) and at State level for Kasongo Project in DRC (2.2). The categories of Finance and Transport/ material resources tended to achieve the lowest scores, often falling below the level required for Table 4: Scores for evaluations of sustainability Country/ Project Administrative level Planning Leadership Monitoring & Supervision Mectizan sustainability. This again emphasises the need for local and State Governments to increase their support to CDTI projects and thus assume joint ownership in partnership with the communities involved Surveillance activities in ex-ocp countries During the reporting period, APOC Management put emphasis on monitoring the status of onchocerciasis transmission in ex-ocp countries in order to assist them with timely detection of any recrudescence of transmission. Fifty-four catching points (listed in Figure 9) were monitored, in collaboration with MDSC, in nine (9) countries (Benin, Training HSAM Integrated Activities Transport Human Resources CDTI Project in Cameroon Est State (17 Aug LGA Sept 2009) FLHF Comm Sud State (Nov 2009) LGA FLHF Comm Adamaoua 1 State (7 30 Nov LGA ) FLHF Comm CDTI Projects in Burundi Bururi State (12 26 Oct LGA 2009) FLHF Comm Rutana State (12 26 Oct LGA 2009) FLHF Comm CDTI Project in DRC Kasongo State (Aug 2009) LGA FLHF Comm Finance Coverage Average Overall average African Programme for Onchocerciasis Control Progress report 13

22 African Programme for Onchocerciasis Control Progress report Active surveillance site Figure 9: Onchocerciasis surveillance network in ex-ocp countries in 2009 Burkina Faso, Côte d Ivoire, Ghana, Guinea Bissau, Mali, Niger, Togo and Senegal). More than 475,000 blackflies were analysed during these surveillance activities as well as through studies of vector movement between Benin and Nigeria and onchocerciasis elimination feasibility studies. Figure 10 shows the global results of this entomological surveillance, which indicates that: 1. Apart from sites in Nigeria on the Benin border, Simulium caught elsewhere were not carriers of human onchocerciasis parasite. 2. The entomological situation at the monitored sites shows no risk of recrudescence of human onchocerciasis transmission. Although the study did not cover a complete year, data collected from the blackfly movement study demonstrated that: 1. The predominant species of blackfly in Nigeria were of the forest type, with a few savanna flies caught in January 2. Infections were almost nil in the flies and were found in some rare forest flies while only savanna flies were infected in Benin 3. Most of the flies in Benin were the savanna form 4. Hetero-duplex analysis characterised the savanna flies as S. damnosum s.s. and the forest flies as S. soubrense Beffa. As the study was not carried out all year round, no firm conclusions could be drawn; it was therefore decided that the study should be extended for one year to cover a full dry and rainy season. In addition, CDTI implementation in Nigeria should be very well documented and an epidemiological evaluation conducted covering a large area. Concurrently with surveillance activities and in view of the ageing of the technicians involved, 13 new entomology technicians from seven countries including two APOC countries (Cameroon and Central African Republic) were trained (see section 4.1.2). In addition, APOC and MDSC are collaborating with the University of Alabama at Birmingham (UAB), USA, to develop a model for spatial prediction of onchocerciasis foci in former OCP countries that will be adapted to the APOC countries. The project will use satellite-derived and entomological-epidemiological data from the former OCP. The first phase of this collaboration includes a strong capacity building component Cross-border collaboration In 2008, JAF 14 decided that emphasis should be placed on cross-border collaboration for disease surveillance and control. Two subregional Ministerial meetings were organised in 2009 one for West African (host country: Burkina Faso) and one for Central African countries (host country: Cameroon), and one in 2010, for countries of Central Africa (host country Chad). 14

23 Infectivity rate <0.5 per 1000 Infectivity rate >0.5 per 1000 In progress Figure 10: Results of onchocerciasis surveillance in ex-ocp countries and Nigeria in 2009 Arising from these meetings (co-financed by the host countries and APOC) recommendations were made; (i) to train a national team in entomology, (ii) to integrate NTD control into National Health Information Systems and (iii) to organise harmonisation workshops for motivating community-directed distributors (iv) Countries should include budget lines for control and operational research on NTDs, (v) identify onchocerciasis transmission zones and treat them; thus, accelerating progress towards elimination of onchocerciasis (vi) APOC s partners were invited to provide technical and financial support to countries to complete mapping, identify priority NTDs for cross-border activities and to develop national and inter-country action plans to control the priority NTDs. In addition, results of recent epidemiological evaluations undertaken in Côte d Ivoire and Burkina Faso, particularly in the Comoé river basin, led APOC management, together with officials of the Ministries of Health of these two countries to hold a consultation workshop in Ouagadougou in April 2010 financed by APOC. The workshop decided that the two countries should immediately implement CDTI in the zone which had only benefitted from successful vector control up to 2000, and is now subject to intensive human cross-border movements, and would undertake surveillance activities, eventually to be extended to the Leraba basin in order to assess the extent of the unsatisfactory epidemiological situation. A meeting of partners is planned for October 2010 to explore possibilities for financing these activities. African Programme for Onchocerciasis Control Progress report In 2009, the West African countries decided to involve the West African Health Organisation (WAHO) in trans-border surveillance and disease control. Subsequently, a meeting was held in Mali in June 2010, at which the countries and partners decided to institutionalise cross-border meetings centred on health services. The meeting also decided to develop a Guide of Standard Operating Procedures for the management of priority diseases in cross-border zones and to reinforce sanitary measures at borders. Border Districts will receive technical and financial support from partners to implement these activities and synchronise planned health interventions. Since 2001, similar meetings were organised between Benin and Togo, initially with financial and technical support of OCP, and subsequently of APOC and Sightsavers (SS) after the closure of OCP and the Special Intervention Zones of the former OCP in An outcome of the 2009 meeting (funded by SSI) was that the two countries agreed to organise joint supervision of synchronised CDTI campaigns in the border zone Benin/ Togo after first preparing and disseminating, a list of border villages to all partners. Vector control by ground larviciding of breeding sites, to reduce the nuisance caused by Simulium biting, will be undertaken where possible, 15

24 African Programme for Onchocerciasis Control Progress report and repellents and traditional remedies will be evaluated. Each country should include all specific groups (nomadic Fulani/peuhls, gold-diggers, fishermen etc) in CDTI and epidemiological evaluations. Benin and Nigeria, having held joint meetings for six, years are now emphasising entomological aspects of blackfly movement and its epidemiological consequences. Thus, a fourth meeting, financed by APOC and in collaboration with MDSC, was held in February 2010 in Benin, to analyse data collected between 2007 and Participants noted that climatic and hydrological data would permit better interpretation of the results of entomological studies in More communities would be included in evaluations conducted around Kaboua and M betekoukou in Benin and Igbojaye and Iganna in Nigeria where infected Simulium had been captured. In August 2010, a meeting was held in Kara, organised by MDSC to review onchocerciasis entomological surveillance activities in Togo with the NOCP and technical support staff. These activities were planned for 2009 but field operations started in 2010 in selected sites at the peak blackfly breeding season. Entomological surveillance took place at eight vector collection sites in 2010 with support from APOC/MDSC. Vector collection started at 4 sites (Agbamassoumou on the Bassa-Oti River, Akaba on the Anié River, Amou-Oblo on the Amou River, and Landa-Mono on the Mono River) in July 2010 and samples of blackflies collected were transferred to the MDSC molecular biology laboratory in Ouagadougou. Vector collection at four other sites (Doungue on the Koulougona River, Tapounde and Titira on the Kéran River, and Tchanaga on the Oti River) started in August 2010 supported by Sightsavers. Vector collection will continue at all 8 sites up to November or December 2010, depending on the development of the blackfly populations. The August 2010 meeting in Kara recommended that future support from partners should be used to implement crossborder entomological surveillance activities with Benin and Ghana; both bordering Togo and sharing river basins that constitute blackfly breeding habitats Health Impact of CDTI The Erasmus University Rotterdam (the Netherlands) is working with APOC on a comprehensive health impact assessment. The ONCHOSIM simulation model is used to estimate changes in infection and disease prevalence due to APOC operations. The burden of disease in terms of DALYs by 2009 had been reduced by almost 60% of the expected burden with no control. Details will be presented to JAF 16 in The Erasmus team is also working to refine and validate the ONCHOSIM model, so as to enhance the accuracy and reliability of the estimates. The adapted ONCHOSIM model will be made available to country scientists and project managers for use in evaluation of the programme or specific projects. Erasmus University will transfer the technology by conducting training on the ONCHOSIM model in October 2010 and details will be presented to JAF Moving from Control to Elimination of Onchocerciasis where Feasible 2.1 Epidemiological Evaluation The attainment of APOC s objective is expected to contribute towards the elimination of onchocerciasis as a disease of public health and socioeconomic importance throughout Africa and to improving the welfare of its people. Current trends from results of evaluations indicate that the primary objective of the Programme has largely been achieved in some countries. APOC began in 2010 to assist countries to determine when and where onchocerciasis treatment can be safely stopped. A longitudinal study undertaken in three hyper endemic foci in Mali and Senegal with 15 to 17 years of ivermectin treatment has provided the first evidence that ivermectin treatment can be safely stopped (Diawara et al., 2009). Elimination of onchocerciasis 16

25 Table 5: Summary of epidemiological evaluations providing evidence for elimination of onchocerciasis infection Country CDTI Project/Focus Number of villages surveyed infection and interruption of transmission with ivermectin treatment alone are therefore feasible. In the last three years ( ) six countries, supported by the APOC Trust Fund, have conducted epidemiological evaluations to assess the prevalence of infection of onchocerciasis in selected hyper and meso-endemic foci in APOC countries in which annual ivermectin treatment has been implemented for at least 10 years and for which the pre-control onchocerciasis prevalence level is known. Persons examined (skin snip) Persons positive Nigeria Cross River 19 2, % positive Ebonyi 22 3, Edo Kaduna 29 3, Ondo Taraba 10 1, Zamfara 7 1, Cameroon North West 19 2, Uganda Adjumani 4 1, Kasese 10 1, Moyo 5 1, Nebbi 10 1, Chad Chad: Bebedja 9 1, Chad: Danamadji 9 1, DRC Kasai 12 2, Tanzania Mahenge 10 1, Total: APOC countries ,588 1,404 Mali (ex OCP) Bakoye 40 9, Senegal (ex OCP) River Gambia 42 7, Total: Ex-OCP countries 82 17, Table 5 summarises the results of the epidemiological evaluations carried out in 21 foci (2 in 2008, 8 in 2009 and 11 in 2010) distributed in 6 countries. A total of 30,588 persons were examined (skin snip) in 183 communities. Table 5 shows the mean prevalence of onchocerciasis microfilaria in post-control and other data for all foci in the six countries. As an example, Figure 11 shows the pre- and post-treatment epidemiological evaluations for Ebonyi in Nigeria. African Programme for Onchocerciasis Control Progress report a b Figure 11: a) Pre- and post-control nodule prevalence in Ebonyi focus Nigeria (1997/2000) b) mf prevalence

26 African Programme for Onchocerciasis Control Progress report a Pre-control distribution of onchocerciasis endemicity Nodule prevalence (%) Although two foci (Edo Delta, Nigeria and Mahenge, Tanzania) still had a higher than expected prevalence, community-directed treatment with ivermectin has effectively eliminated transmission of the disease in a significant number of foci (Table 5). This is an impressive impact of APOC operations. In 2010, NOTFs are continuing to provide more evidence on where and when mass distribution of ivermectin treatments can be stopped. The results of these epidemiological evaluations will be presented to JAF during its 16 th session in Abuja, Nigeria. Lymphatic filariasis Malaria ITNs Malaria HMM Schistosomiasis Vitamin A HIV/AIDS Leprosy STH EPI/Immunisation Trachoma Guinea Worm TB Co-implementation in Numbers of people reached with the intervention (millions) Figure 13: Major health interventions coimplemented with ivermectin distribution using CDI based on data from 49 projects in 10 countries in The cumulative total of interventions is not equal to the total number of people reached because some people received more than one intervention b Coverage by APOC projects Figure 12: Pre-control distribution of onchocerciasis endemicity (a) and coverage endemicity zones by Community-directed treatment with ivermectin projects (b) Nodule prevalence (%) APOC project 2.2 Delineating onchocerciasis transmission zones and Criteria for Elimination of Onchocerciasis where Feasible in Africa To determine APOC s strategy for the elimination of onchocerciasis, an informal expert consultation on elimination of onchocerciasis transmission with current tools in Africa was held in Ouagadougou. Among action points for moving from control to elimination recommended by the informal consultation on elimination, held in Ouagadougou in 2009, were to review target areas for mass treatment and delineation of transmission zones (the report of the informal consultation is available). Rapid epidemiological mapping of onchocerciasis was carried in more 13,000 villages distributed in the 19 member States of the Programme. APOC management decided to use this database to critically analyse and refine ivermectin treatment areas and to define potential transmission zones. Figure 12 shows the potential transmission zones in the scope of the Programme based on REMO data with an overlay of areas where ivermectin treatment is already being carried out showing that the majority of the potential areas for transmission are under treatment (Figure 12b). Draft criteria and guidelines for countries to move from Control to Elimination of Onchocerciasis where Feasible are under preparation and will be pre-tested through national consultative meetings in Cameroon and Nigeria in October

27 3 Co-Implementation of Cdti with other Health Interventions 3.1 Control of NTDs Building on CDTI In 2009, twelve additional health interventions were delivered along with Ivermectin treatment in 49 projects in ten countries for which data are available. Among the additional interventions were: treatments for lymphatic filariasis and trachoma, eradication of Guinea Worm, and schistosomiasis, distribution of Insecticide-treated bed nets (ITNs), vitamin A supplementation, deworming, immunization, and health education on HIV/AIDS as shown in Figure 13. The distribution of LF drugs was the most frequent, in combination with ivermectin. In 2010, with additional financial support of USAID, APOC continued supporting coimplementation built upon CDTI structures in 5 Regions of Tanzania and DRC that was launched in The target diseases for which treatment was provided in addition to onchocerciasis were: lymphatic filariasis, soil-transmitted helminths, schistosomiasis and trachoma. The implementation of this programme included training of health staff, school-teachers and CDDs, sensitisation and mobilisation of communities and administrative staff and advocacy at all levels to solicit support. In Tanzania, additional training materials and treatment registers in Swahili (Figure 14) were printed and Figure 14: Swahili language treatment register for co-implementation in Tanzania distributed at the Front Line Health Facility level in 5 Regions. In DRC, 5 CDTI projects in 3 Provinces provided multiple health interventions including ivermectin and mebendazole (for treatment of onchocerciasis and soil-transmitted helminths respectively) and provided vitamin A supplementation. Although not all projects submitted reports on co-implementation, the partial data available for the reporting period revealed that, 288,094 CDDs were able to reach 86,999 communities and more than 28 million health commodities were provided to affected people (This does not represent 28 million people as some received multiple commodities and it is currently not possible to compute the total number of people served) (Table 6). This is approximately 84% of the population targeted for CDI and represents a significant increase over figures given in the African Programme for Onchocerciasis Control Progress report Table 6: Summary of Co-implementation activities in 10 Countries in 2009 Country Number of Projects Reporting CDI implementation Number of Districts Involved Total No. CDDs Involved No. of Communities Reached CDI Target Population Total population reached Cameroon ,245 12,617 6,459,802 6,480,854 Ethiopia ,126 27,518 7,906,520 5,349,485 Liberia ,173 0 Malawi ,083 3,259 2,817,432 2,440,001 Nigeria ,148 18,064 8,252,870 4,232,476 CAR ,421 89,337 Sudan , , ,638 Tanzania ,367 6,186 8,681,908 5,845,650 DRC ,729 11,724 1,830,663 Chad ,602 3,250 1,886,308 1,886,308 TOTAL ,094 86,999 37,865,832 28,425,412 *Data for the target population were incomplete. Two projects from Tanzania are still validating their data. Incomplete data (Not available for Lualaba Project in Katanga Province, DRC). 19