The challenges of community-directed treatment with ivermectin (CDTI) within the African Programme for Onchocerciasis Control (APOC)

Abstract

The principal strategy adopted by the African Programme for Onchocerciasis Control (APOC), for the control of onchocerciasis in the 19 countries of Africa that now fall within the programme's remit, is that of community-directed treatment with ivermectin (CDTI). Halfway through its 12-year mandate, APOC has gathered enough information on the main challenges to guide its activities in Phase 2. An analysis of reports and other documents, emanating from consultants, scientists, monitors and national and project-level implementers, indicates that there are three broad categories of challenge: managerial; technical; and socio-political. Under these three categories, this review identifies the most pertinent concerns that APOC must address, during Phase 2, to enhance the prospects of establishing sustainable systems for ivermectin distribution. The major challenges include: (1) maintaining timely drug-collection mechanisms; (2) integrating CDTI with existing primary-healthcare services; (3) strengthening local health infrastructure; (4) achieving and maintaining an optimal treatment coverage; (5) establishing and up-scaling community self-monitoring; (6) designing and implementing operations research locally; (7) ensuring the adequacy of community-directed distributors; (8) increasing the involvement of local non-govemmental develop organizations in the programme; (9) achieving financial sustainability; (10) implementing equitable cost-recovery systems; and (11) engaging in effective advocacy. The implications of the challenges and suggestions about how they are being (or could be) addressed are also highlighted in this brief review, which should be of value to other programmes and agencies that may be contemplating the adoption of this unique strategy.

Seventeen Years of Annual Distribution of Ivermectin Has Not Interrupted Onchocerciasis Transmission in North Region, Cameroon

“…Available evidence shows that national governments are often unable to provide adequate financial resources to their onchocerciasis projects. [37][38][39] However, financial responsibility for sustaining mass treatment is increasingly falling on the governments of the endemic countries and their non-governmental organizations (NGO) partners. Given that the APOC program is scheduled to close in 2015, the questions before the onchocerciasis community are (1) has EPHP been achieved in all onchocerciasis-endemic regions?, (2) will affected governments and their NGO partners be able to maintain these achievements if APOC closes in 2015?, and (3) has the CDTI strategy of annual treatment achieved transmission interruption such that mass treatments can be halted?…”

Transmission of Onchocerca volvulus Continues in Nyagak-Bondo Focus of Northwestern Uganda after 18 Years of a Single Dose of Annual Treatment with Ivermectin

“…[4][5][6] The goal was to target the most highly onchocerciasis-endemic communities with a single annual dose of ivermectin through mass treatment using the CDTI strategy; therefore, the disease would no longer be a public health problem. [7][8][9] This goal was not defined but logi-cally taken to be when prevalence is driven below the original baseline threshold required to launch the mass ivermectin treatment program, which is an onchocercal nodule rate of 20% or an mf rate of 40%. 6 However, achieving elimination of onchocerciasis as a public health problem defined at these levels did not necessarily indicate interruption of transmission.…”

Rationale for the Coadministration of Albendazole and Ivermectin to Humans for Malaria Parasite Transmission Control

“…[112][113][114] The apparent association between STHs and malaria infection suggests that targeting populations with high malaria prevalence with both ivermectin and albendazole for a more comprehensive treatment of STHs would be a potentially efficient use of resources. A proactive, integrated control platform that targets malaria and STHs would be extremely cost-effective, especially because malaria control receives a larger portion of donor money compared to NTD control.…”