ENVISION · Research Triangle Park, NC 27709 -2194 . ... iv . ACRONYMS LIST AE Adverse Event . AFRO...

ENVISION FY17 PY6 Semi-Annual Report, Q1–Q2 October 1, 2016–March 31, 2017

ENVISION FY17 PY6 Semi-Annual Report, Q1–Q2 October 1, 2016–March 31, 2017 Cooperative Agreement No. AID-OAA-A-11-00048

Submitted to USAID May 15, 2017

Prepared for Rob Henry, AOR Office of Health, Infectious Diseases and Nutrition U.S. Agency for International Development 1300 Pennsylvania Avenue, NW Washington DC, 20532 Prepared by RTI International 3040 Cornwallis Road Post Office Box 12194 Research Triangle Park, NC 27709-2194

ENVISION is an eight-year project funded by the U.S. Agency for International Development (USAID) aimed at providing assistance to national neglected tropical disease (NTD) control programs for the control and elimination of seven targeted NTDs: lymphatic filariasis, onchocerciasis, schistosomiasis, three soil-transmitted helminths (roundworm, hookworm, and whipworm), and trachoma. ENVISION contributes to the global goal of reducing the burden of these targeted NTDs so that they are no longer a public health problem.

ENVISION is implemented by RTI International, in partnership with CBM International, The Carter Center, Fred Hollows Foundation, Helen Keller International, IMA World Health, Light for the World, Sightsavers, and World Vision. The period of performance for ENVISION is September 30, 2011, through September 30, 2019.

Cover Photo: DRC launched its 1st trachoma MDA, January 2017

RTI International is one of the world’s leading research institutes, dedicated to improving the human condition by turning knowledge into practice. Our staff of more than 4,150 provides research and technical services to governments and businesses in more than 75 countries in the areas of health and pharmaceuticals, education and training, surveys and statistics, advanced technology, international development, economic and social policy, energy, and the environment, and laboratory testing and chemical analysis. For more information, visit www.rti.org. RTI International is a registered trademark and a trade name of Research Triangle Institute.

i

TABLE OF CONTENTS ACCELERATION TOWARD 2020 CONTROL AND ELIMINATION GOALS ......................................................... 1

1. Elimination of LF in ENVISION-supported Countries ....................................................................... 5 2. Elimination of Trachoma in ENVISION-supported Countries ........................................................... 8 3. Control and Elimination of OV in ENVISION-supported Countries ................................................ 12 4. Continued Control of SCH in ENVISION-supported Countries ....................................................... 16 5. Continued Control of STH in ENVISION-supported Countries ....................................................... 20

IR 1: INCREASED MDA COVERAGE AMONG AT-RISK POPULATIONS IN ENDEMIC COMMUNITIES ............ 22 1. Mass Drug Administration (MDA) .................................................................................................. 24 2. Drug and Commodity Supply Management and Procurement ..................................................... 32

IR 2: IMPROVED EVIDENCE BASE FOR DETERMINING AND ASSESSING ACTION TO CONTROL/ELIMINATE TARGETED NTDS.......................................................................................................................................... 36

1. Baseline Disease Mapping ............................................................................................................. 37 2. National Program M&E Data Quality ............................................................................................. 37 3. Disease-Specific Assessments and Surveillance............................................................................. 45 4. Preparing for Elimination ............................................................................................................... 48

IR 3: STRENGTHENED ENVIRONMENT FOR IMPLEMENTATION OF NATIONAL AND INTEGRATED NTD CONTROL AND ELIMINATION PROGRAMS ................................................................................................. 53

1. Capacity Strengthening and Training ............................................................................................. 54 2. Sustainability for SCH and STH Control Programs ......................................................................... 60 3. Operational Research (OR) ............................................................................................................ 61 4. Dissemination of Best Practices ..................................................................................................... 64 5. Global Partnerships ........................................................................................................................ 75 6. ENVISION Support to the NTD Donor Community ........................................................................ 80 7. Technical Assistance Facility (TAF) ................................................................................................. 80

APPENDIX 2: ENVISION’S FY17 RESULTS BY INTERMEDIATE RESULT AREA ................................................ 81

ii

LIST OF TABLES

Table 1. Districts Meeting Coverage Criteria for MDA coverage of ≥80%, when implemented with direct ENVISION support ...................................................................... 9

Table 2. Trachoma impact and surveillance surveys supported by ENVISION ............................... 10

Table 3. Districts targeted for OV-only MDA in FY17 that were previously treated for LF/OV...... 13

Table 4. ENVISION procurement in FY17, Q1-Q2 ........................................................................... 34

Table 5. Summary of M&E tools ..................................................................................................... 40

Table 6. Post-MDA coverage surveys with ENVISION support, FY17 ............................................. 41

Table 7. Uptake of the Integrated NTD Database .......................................................................... 43

Table 8. Post-MDA surveillance for LF, FY16 and FY17* ................................................................ 49

Table 9. Post-MDA surveillance for trachoma, FY16 and FY17* .................................................... 50

Table 10. ENVISION alignment with WHO-USAID Global Capacity Strengthening Strategy ............ 57

Table 11. Training courses supported in FY17, Q1–Q2 .................................................................... 58

Table 12. Key manuscripts published through ENVISION-MOH collaboration in FY17 .................... 67

Table 13. ENVISION contributions to global working groups, beyond WHO, Q1-Q2 FY17 .............. 79

Table 14. ENVISION partner support by country ................................. Error! Bookmark not defined.

Table 15. ENVISION’s Operations focal points .................................... Error! Bookmark not defined.

Table 16. ENVISION’s NTD focal points ............................................... Error! Bookmark not defined.

Table 17. ENVISION’s Central Country Teams ..................................... Error! Bookmark not defined.

Table 18. ENVISION’s M&E focal points .............................................. Error! Bookmark not defined.

Table 19. ENVISION’s Communications focal points ........................... Error! Bookmark not defined.

Table 20. ENVISION’s Capacity Strengthening focal points ................. Error! Bookmark not defined.

iii

LIST OF FIGURES

Figure 1. ENVISION’s results framework ........................................................................................... 4

Figure 2. Projected percentage of LF-endemic districts under post-MDA surveillance* .................. 7

Figure 3. Projected percentage of trachoma-endemic districts where criteria for stopping MDA have been achieved+ ............................................................................................... 11

Figure 4. MDA treatments supported by ENVISION: FY12–FY17 *.................................................. 24

Figure 5. Once treated geographic coverage in FY17, by disease* ................................................. 25

Figure 6. Districts reaching sufficient coverage, steady improvement across diseases FY12–FY16................................................................................................................................... 26

Figure 7. Number of district-level MDA with insufficient coverage, by country and disease in the last MDA (FY16 or 17) ............................................................................................. 28

Figure 8. Knowledge management cycle under ENVISION .............................................................. 65

Figure 9. Stages of dissemination .................................................................................................... 70

Figure 10. Summary of progress made on ENVISION-supported resources ..................................... 70

Figure 11. Toolbox visits as % of total pageviews from NTD-endemic countries .............................. 74

Figure 12. Data flow from national NTD programs to WHO, USAID, and other projects ............ Error! Bookmark not defined.

iv

ACRONYMS LIST

AE Adverse Event AFRO Africa Regional Office (WHO) ALB Albendazole AOR Agreement Officer’s Representative APOC African Programme for Onchocerciasis Control ASTMH American Society for Tropical Medicine and Hygiene AZT Azithromycin BEST Behavior, Environmental Improvement, Social Inclusion, and Treatment BMGF Bill and Melinda Gates Foundation CBM CBM International CCA Circulating Cathodic Antigen CDC U.S. Centers for Disease Control and Prevention COR-NTD Coalition for Operational Research on NTDs CY Calendar Year DBS Dried Blood Spots DDL Development Data Library DEC Diethylcarbamazine DFID U.K. Department for International Development DQA Data Quality Assessment DRC Democratic Republic of the Congo DSA Disease-Specific Assessment ELISA Enzyme-linked Immunosorbent Assay END in Africa End Neglected Tropical Diseases in Africa project END Fund End Neglected Tropical Diseases Fund EPIRF Epidemiological Data Reporting Form ESPEN Expanded Special Project for the Elimination of NTDs FHF Fred Hollows Foundation FMOH Federal Ministry of Health (Nigeria) FOG Fixed Obligation Grant F-TAS Filariases Transmission Assessment Survey FTS Filariasis Test Strip FY Fiscal Year GAELF Global Alliance to Eliminate Lymphatic Filariasis GET 2020 Global Elimination of Blinding Trachoma by 2020 GHD Global Health Division (RTI) GIS Geographic Information Systems GSA Global Schistosomiasis Alliance GSK GlaxoSmithKline GTMP Global Trachoma Mapping Project HKI Helen Keller International HQ Headquarters ICTC International Coalition for Trachoma Control IDA Foundation International Dispensary Association Foundation IEC Information, Education, and Communication

v

IMA IMA World Health IOC Independent Oversight Committee IR Intermediate Result Area ITI International Trachoma Initiative IVM Ivermectin JAP Joint Application Package JRF Joint Reporting Form JRSM Joint Request for Selected PC Medicines KAP Knowledge, Attitudes, and Practices KM Knowledge Management LF Lymphatic Filariasis LFTW Light for the World M&E Monitoring and Evaluation MDA Mass Drug Administration MEB Mebendazole MEC Mectizan® Expert Committee MMDP Morbidity Management and Disability Prevention MOH Ministry of Health MOU Memorandum of Understanding NGDO Nongovernmental development organization NGO Nongovernmental organization NNN NTD NGDO Network NTD Neglected Tropical Disease NTP National Trachoma Program OCP Onchocerciasis Control Program in West Africa OMVS Senegal River Basin Development Organisation (Organisation pour la Mise en Valeur

du Fleuve Sénégal) OR Operational Research OV Onchocerciasis PC Preventive Chemotherapy PCR Polymerase Chain Reaction PFSA Pharmaceutical Fund and Supplies Agency PGIRE Le Programme de Gestion Intégrée des Ressources en Eau et de Développement des

Usages Multiples (Integrated Water Resource Management Project) PMTC Program Managers’ Training Courses PZQ Praziquantel RAPLOA Rapid Assessment Procedure for Loiasis RDT Rapid Diagnostic Test REMO Rapid Epidemiological Mapping of Onchocerciasis RHB Regional Health Bureau RPRG Regional Program Review Group RTP Research Triangle Park SAC School-Age Children SAE Serious Adverse Events SAFE Surgery–Antibiotics–Facial cleanliness–Environmental improvements SAR Semi-Annual Report SCH Schistosomiasis SCI Schistosomiasis Control Initiative

vi

SEARO Southeast Asia Regional Office (WHO) SMS Short Message Service SOP Standard Operating Procedure STH Soil-transmitted Helminths TA Technical Assistance TAF Technical Assistance Facility TAS Transmission Assessment Survey TCC The Carter Center TEC Trachoma Expert Committee TEMF Trachoma Elimination Monitoring Form TEO Tetracycline Eye Ointment TF Trachomatous Inflammation–Follicular TFGH Task Force for Global Health TIPAC Tool for Integrated Planning and Costing TIS Trachoma Impact Survey TOT Training of Trainers TRA Trachoma Rapid Assessment TSS Trachoma Surveillance Survey TT Trachomatous Trichiasis TZNTDCP Tanzania NTD Control Program U.K. United Kingdom U.S. United States of America USAID U.S. Agency for International Development WASH Water, Sanitation, and Hygiene WHO World Health Organization WPRO Western Pacific Regional Office (WHO) WV World Vision ZTH Zithromax®

vii

ENVISION in Brief The United States Agency for International Development (USAID)’s ENVISION project (2011–2019) supports the vision of the World Health Organization (WHO) and its member states by targeting the control and elimination of seven neglected tropical diseases (NTDs): lymphatic filariasis (LF), onchocerciasis (OV), schistosomiasis (SCH), trachoma, and three soil-transmitted helminths (STH; roundworm, whipworm, and hookworm). ENVISION’s goal is to strengthen NTD programming at the global and country levels and support Ministries of Health (MOHs) to achieve their NTD control and elimination goals.

At the global level, ENVISION—in coordination and collaboration with WHO, USAID, and other stakeholders—contributes to several technical areas in support of global NTD control and elimination goals, including the following:

• Technical assistance

• Monitoring and evaluation

• Global policy leadership

• Grants/financial management

• Capacity strengthening at global and country levels

• Dissemination

At the country level, ENVISION provides support to national NTD programs in 19 countries in Africa, Asia, and Latin America by providing strategic technical, operational, and financial assistance for a comprehensive package of NTD interventions, including the following:

• NTD program capacity strengthening

• Strategic planning

• Advocacy for building a sustainable national NTD program

• Social mobilization to enable NTD program activities

• Mapping

• Mass drug administration

• Drug and commodity supply management

• Supervision

• Monitoring and evaluation

ENVISION-supported countries are Bangladesh, Benin, Cambodia, Cameroon, Democratic Republic of the Congo (DRC), Ethiopia, Guinea, Haiti, Indonesia, Laos, Mali, Mozambique, Nepal, Nigeria, the Philippines, Senegal, Tanzania, Uganda, and Vietnam.

1

ACCELERATION TOWARD 2020 CONTROL AND ELIMINATION GOALS

2

ENVISION Fiscal Year 2017 (FY17) Work Plan Strategic Roadmap ACCELERATION TOWARD 2020 CONTROL AND ELIMINATION GOALS IR1: Increased Mass Drug Administration (MDA) Coverage among At-Risk Populations in Endemic Communities 1. MDA

Geographic Scale Up Achieving required program and epidemiological coverage

Objective 1: Strengthen the use of cost-effective strategies for social mobilization Objective 2: Strengthen capacity to assess when coverage is low and to take action during

MDA Objective 3: Generate solutions for reaching hard-to-reach populations: urban, migrants, and

nomads, and those living in conflict-affected settings

Objective 4: Share knowledge on how to improve coverage by documenting and disseminating case studies

2. Drug and Commodities Supply Chain Management and Procurement Objective 1: Procure medicines for use by ENVISION-supported countries Objective 2: Coordinate with WHO and donation programs to track drug applications,

shipments Objective 3: Support ENVISION-supported countries to complete disease-specific

assessments (DSAs) through procurement of diagnostics Objective 4: Continue to strengthen in-country supply chain

IR2: Improved Evidence Base for Action to Control and Eliminate Targeted NTDs

1. Baseline Disease Mapping

2. National Program Monitoring and Evaluation (M&E) Data Quality Objective 1: Strengthen national program capacity to address data quality concerns Objective 2: Increase functionality and use of the Integrated NTD Database Objective 3: Increase access to analyzed, synthesized, and ready-to-use information

3. Disease-Specific Assessments and Surveillance Objective 1: Strengthen capacity to implement high-quality transmission assessment survey

(TAS) and trachoma impact survey (TIS) Objective 2: Ensure that TAS, TIS, and trachoma surveillance survey (TSS) are implemented in

a timely manner Objective 3: Support national programs to collect, process, review, approve, use, and archive

high-quality trachoma prevalence data Objective 4: Investigate DSA failure Objective 5: Understand STH distribution to inform strategy post-lymphatic filariasis (LF)

4. Preparing for Elimination Objective 1: Help countries prepare for documenting elimination Objective 2: Address the lack of WHO guidelines for post-validation surveillance

3

ENVISION FY17 Work Plan Strategic Roadmap IR3: Strengthening the Environment for Implementation of National and Integrated NTD Control and Elimination Programs

1. Capacity Strengthening and Training Objective 1: Reinforce program management capacity Objective 2: Strengthen in-country NTD M&E capacity Objective 3: Strengthen capacity on disease specific assessments and surveillance Objective 4: Foster sharing of best practices across countries Objective 5: Continue global leadership in capacity strengthening for NTDs

2. Sustainability for SCH & STH Control Programs Objective 1: Improve knowledge of national programs’ needs and appropriate platforms to

sustain ENVISION gains

3. Operational Research 4. Dissemination of Best Practices

Objective 1: Support the dissemination of information on results, challenges, and lessons learned from countries to policy makers and the global community

Objective 2: Disseminate new WHO guidelines and policies to national programs Objective 3: Disseminate the NTD toolbox

5. Global Partnerships Objective 1: Contribute to global policy decision through participation in WHO Global Forums Objective 2: Support leadership and collaboration for the management of NTD global

medicines Objective 3: Contribute to global learning and policy decisions through participation in global NTD forums

6. Technical Assistance Facility (TAF) Project Management

1. ENVISION Partnership Objective 1: Facilitate and promote ENVISION partner coordination Objective 2: Ensure expert, committed project staffing

2. ENVISION-USAID Partnership Objective 1: Maintain continuous communication with USAID on all matters affective the

project and implementation Objective 2: Provide M&E assistance for the USAID NTD portfolio

3. ENVISION and the NTD Community Objective 1: Engage regularly with WHO bodies and offices as well as other NTD stakeholders

4. Project Communications Objective 1: Develop a new communications strategy Objective 2: Generate ENVISION communication products and disseminate information on

activities and services Objective 3: Effectively communicate NTD data, working with ENVISION’s technical teams Objective 4: Communicate and celebrate NTD elimination successes, in coordination with

USAID, WHO, and MOHs 5. ENVISION Cost Share and Complementary NTD work

4

Figure 1. ENVISION’s results framework

JRF = Joint Reporting Form (WHO) TEMF = Trachoma Elimination Monitoring Form TA = technical assistance TIS = trachoma impact survey TAS = transmission assessment survey

5

1. Elimination of LF in ENVISION-supported Countries

USAID’s goal for LF is to help countries achieve the World Health Assembly’s resolution to eliminate LF as a public health problem by 2020. With all mapping for LF completed in fiscal year 2016 (FY16) in ENVISION-supported countries (excluding areas in Nigeria that are not supported by the project), ENVISION is now focused on three objectives for LF: (1) accelerating the scale up of quality LF MDA activities, (2) implementing quality TAS, and (3) preparing for validation.

Accelerating scale up of quality MDA activities. Scale up of MDA to all populations requiring treatment means ensuring 100% geographic coverage nationally and at least 65% epidemiological coverage in districts targeted with MDA. There was moderate scale up in geographic coverage from FY15, when 58% of districts requiring LF MDA in ENVISION-supported countries were treated, to FY16, when 65% were treated. Note that FY16 figures do not yet include data from all non-USAID-supported districts, particularly in Ethiopia and Indonesia, so the final FY16 geographic coverage will be higher. The biggest challenges to reach full geographic coverage are found in the Democratic Republic of the Congo (DRC) and Nigeria, where only 3% and 22% coverage is expected in FY17, respectively. Senegal also experienced geographic coverage challenges in the 17 districts where World Bank support was delayed and will also cover fewer years than anticipated. The ongoing triple drug (ivermectin [IVM]-diethylcarbamazine [DEC]-albendazole [ALB]) trials, one of which was conducted in an ENVISION-supported area in Haiti, have shown promising results in lowering prevalence in a shorter time frame. This could lead to new WHO guidance in FY18, with potentially a decrease in the number of required MDA rounds before moving to TAS. Although this guidance could be very useful in helping national programs such as Haiti, Nepal or Indonesia meet 2020 goals, particularly in areas of high baseline prevalence, the programs will still have to ensure effective coverage to implement this strategy.

In terms of achieving effective coverage, LF programs are making substantial progress. Overall, in FY16, 91% of ENVISION-supported districts achieved effective epidemiological coverage for LF MDA, an increase from 74% in FY15. Only Benin had less than 70% of districts reach effective coverage in FY16, because of issues with properly recording all treatments as well as different data sources for the total population.

Impact of ENVISION Support: LF Program Performance

Countries supported (MDA): 13

% mapping completed: 100%

Persons treated MDA (FY16): + 25.5m to 102.1m

Geo coverage MDA (FY16): ↑ 7% pts to 65%

% districts achieving sufficient epi coverage MDA (FY16):

↑ 17% pts to 91%

TAS1 Pass Rate: 92%

TAS2 Pass Rate: 92%

% people no longer needing MDA, living in ever endemic areas (FY16):

↑ 14% pts to 41%

Countries that received TA for LF elimination dossiers in FY17 Q1-Q2:

2

91% of districts achieved sufficient

epidemiological coverage for LF

MDA, up from 74% in FY15

6

Implementing quality TAS. In FY17, ENVISION is supporting 126 TASs, covering about 283 implementation units. In Quarters 1 and 2 (Q1 and Q2), 17 TASs were implemented in Haiti, Indonesia, Nepal, and Tanzania, of which only 1 (a TAS2 in Nepal) failed. To date on the project, 92% of ENVISION-supported TAS1 have “passed” (e.g., met the criteria for stopping MDA), and 92% of the first post-MDA surveillance TAS (TAS2) have passed. Please see the Appendix 2 for more details on TAS by country and fiscal year. Although this pass rate shows the success of the MDA activities in most districts, ENVISION recognizes the need for quality implementation, follow-up of TAS results, and a proactive approach to TAS failure as the number of surveys continues to increase. In FY17, ENVISION rolled out WHO’s Improving TAS Outcomes checklists in countries where TAS is supported (see Disease-Specific Assessments and Surveillance section for more details).

In addition, the aforementioned countries also implemented the following activities to ensure quality TAS in FY17 Q1 and Q2: (1) review data with national program staff to ensure eligibility for TAS, (2) review TAS protocols, (3) have ENVISION staff supervise TAS with the MOH to provide extra technical skills and model supportive supervise (see country reports for more information).

A key focus for ENVISION in FY17 is working with WHO to clarify guidance on determining how to stop MDA in LF and onchocerciasis co-endemic areas. ENVISION is also contributing to guidance for stopping MDA in these areas by facilitating Filariases Transmission Assessment Survey (F-TAS) operational research (OR) in Mali and Nigeria.

Preparing for validation. In early 2017, WHO released the LF Validation Handbook, Validation of elimination of lymphatic filariasis as a public health problem, which describes the steps that national programs need to follow to develop and submit a dossier. ENVISION has helped raise awareness of it through email blasts and discussions between Technical Advisors and MOH staff, as well as a webinar scheduled for quarter 3 (Q3; see Dissemination of Best Practices section for more information). To help operationalize guidance for post-validation surveillance for countries nearing elimination, ENVISION has been involved in planning WHO’s LF post-validation surveillance meeting in Cambodia on June 12–13, 2017 (see Preparing for Elimination section for more information).

This guidance is very timely since 41% of people in ENVISION-supported countries now live in areas where criteria to stop LF MDA have been achieved. In fact, the number of persons living in areas where MDA for LF has stopped is projected to increase dramatically from 112 million at the end of FY15 to 279 million by the end of FY17, reflecting the impact of assistance from USAID for MDA and evaluation activities. Indeed, there will be a substantial increase in the percentage of districts that are projected to be under post-MDA surveillance for LF between FY16 and FY20 (Figure 2).

41% of people living in LF-

endemic areas no longer require

MDA due to successful

interventions

7

Figure 2. Projected percentage of LF-endemic districts under post-MDA surveillance*

Country Projected Percentage of LF-endemic districts under Post-MDA Surveillance

By end of FY16 17 18 19 20 21 22+

Cambodia 100% 100% 100% 100% 100% 100% 100% Vietnam 100% 100% 100% 100% 100% 100% 100% Bangladesh 95% 100% 100% 100% 100% 100% 100% Cameroon 28% 91% 100% 100% 100% 100% 100% Uganda 75% 84% 100% 100% 100% 100% 100% Mali 75% 75% 100% 100% 100% 100% 100% Laos 0% 0% 100% 100% 100% 100% 100% Haiti 72% 91% 96% 100% 100% 100% 100% Tanzania 61% 83% 93% 100% 100% 100% 100% Mozambique*** 0% 75% 88% 100% 100% 100% 100% Nepal 41% 61% 84% 100% 100% 100% 100% Benin 48% 75% 75% 100% 100% 100% 100% Philippines 49% 76% 80% 89% 100% 100% 100% Ethiopia*** 0% 0% 6% 11% 84% 100% 100% Indonesia 17% 37% 40% 51% 78% 100% 100% Senegal 0% 0% 20% 26% 26% 100% 100% Nigeria*** 5% 29% 35% 46% 75% 86% 100% Guinea 0% 0% 0% 0% 13% 46% 100% DRC*** 0% 0% 0% 0% 2% 2% 100% *Data reflect the percentage of districts achieving the milestone. Projections data are based on FY17 1st SAR Workbooks. Data reflect what has been reported to ENVISION as of April 4, 2017. **Assumes all districts achieve at least five rounds of sufficient epidemiological coverage in remaining years, pass pre-TAS and TAS 1. ***Reflect data received by ENVISION as of April 4, 2017. Data will continue to be updated as additional information from non-USAID supported areas is received.

8

2. Elimination of Trachoma in ENVISION-supported Countries

ENVISION’s and USAID’s goal is to contribute to the elimination of trachoma as a public health problem by the year 2020, including the elimination of associated blindness. To meet this ambitious goal, in FY16, ENVISION focused on increasing MDA geographic coverage, improving MDA program coverage, and completing trachoma action plans.

Completing trachoma mapping. Trachoma mapping in most ENVISION-supported countries1 was completed in FY16 through the U.K. Department for International Development (DFID)- and USAID-funded Global Trachoma Mapping Project (GTMP). In FY17, ENVISION will complete mapping in 24 evaluation units (35 health zones of DRC), using WHO-endorsed methods through the Tropical Data System (refer to section on baseline mapping for trachoma). Mapping has not been completed in 19 and 29 suspected-endemic districts of Ethiopia and Nigeria, respectively, the latter due to insecurity.

Improving MDA coverage. Full geographic coverage, high-quality and effective MDA with antibiotics (azithromycin [AZT] and tetracycline eye

ointment [TEO]) is important to achieve GET 20202 targets. WHO recommends at least 80% program coverage for MDA with AZT. With support from ENVISION, national programs have improved MDA program coverage for trachoma from 54% of districts achieving effective MDA (i.e., 80% program coverage) in FY14 to 88% in FY15.

Based on data reported as of April 2017 (see Table 1), 86% of districts with most-recent ENVISION-supported MDA in FY16 or FY17 achieved the program coverage target of 80%. In 6 out of 9 ENVISION-supported countries, the target of effective MDA of 90% had been achieved. There were 9 districts with recurrent low coverage, most of which were in Uganda (5).

1 Trachoma-endemic, ENVISION-supported countries include: Benin, Cambodia, Cameroon, DRC, Ethiopia, Guinea, Laos, Mali, Mozambique, Nepal, Nigeria, Senegal, Tanzania, Uganda, and Vietnam. 2 WHO Alliance for the Global Elimination of Blinding Trachoma by the Year 2020.

Impact of ENVISION Support: Trachoma Program Performance

Countries supported (MDA): 9


Persons treated MDA (FY16): + 12.9m to 31m

Geo coverage (FY16): ↑ 9% pts to 38%

% districts achieving sufficient program coverage (FY16):

89%

% TIS with TF <5%: 64%

% TSS with TF <5%: 100%

% people no longer needing MDA, living in ever endemic areas (FY16):

35%

Countries that received TA for trachoma elimination dossiers in FY17 Q1-Q2:

8

89% of districts achieved

sufficient program coverage for

trachoma MDA, up from 54% in

FY14

9

Table 1. Districts Meeting Coverage Criteria for MDA coverage of ≥80%, when implemented with direct ENVISION support

Country (year latest data available)

No. of districts

treated in last MDA

% Districts meeting sufficient

coverage**

No. of Districts

Not meeting criteria

Coverage median (range)

in those not meeting criteria

No. of districts not meeting criteria that also have recurrent low

coverage Benin (FY16) 4 100% (4) 0 - 0 Cameroon (FY16) 5 100% (5) 0 - 0 DRC (FY16) 3 100% (3) 0 - 0 Ethiopia (FY17) 91 89% (81) 10 74% (55%-79%) 2 Guinea (FY16) 9 100% (9) 0 - 0 Mozambique (FY16) 24 92% (22) 2 77% (76%-79%) 0 Senegal (FY16) 8 100% (8) 0 - 0 Tanzania (FY17) 14 64% (9) 5 65% (22%-80%) 2 Uganda (FY16) 10 30% (3) 7 69% (59%-79%) 5 TOTAL 168 86% (144) 24 - 9 In March 2017, the International Trachoma Initiative (ITI) launched the Zithromax® Shipment tracker (http://www.trachoma.org/zithromaxr-shipment-tracker) that aims to improve transparency between country programs and partners and facilitate timely, and effective, MDA implementation. The tracker allows users to subscribe to receive updates on applications and shipment for individual countries. ENVISION has reviewed the applications and planned shipments for all ENVISION countries for 2017 shipments. To make the data for all ENVISION-supported countries readily available under one page, an MS Excel™ based summary has been compiled and will be updated regularly and shared with staff and USAID.

Implementing quality impact and surveillance surveys. Table 2 shows the number of impact and surveillance surveys undertaken with ENVISION support from FY12 to FY16. Impact surveys were undertaken in 228 districts, of which 64% were below the target for elimination of TF of <5%. Ethiopia had the highest number of districts where TF was >5%, entirely from impact surveys done in Amhara region by The Carter Center through ENVISION in FY13. For all surveillance surveys undertaken in 41 districts, since FY12, all had TF<5% and thus these districts have moved to pre-validation phase. Recent WHO guidelines advocate for TT-only surveys in districts where pre-validation survey TF prevalence is <5% but TT prevalence in people aged ≥15 years is ≥0.2%.

http://www.trachoma.org/zithromaxr-shipment-tracker

10

Table 2. Trachoma impact and surveillance surveys supported by ENVISION

Country

FY12 FY13 FY14 FY15 FY16 Total

No.

of s

urve

ys c

ondu

cted

Prop

ortio

n w

ith T

F <5

%

No.

of s

urve

ys c

ondu

cted

Prop

ortio

n w

ith T

F <5

%

No.

of s

urve

ys c

ondu

cted

Prop

ortio

n w

ith T

F <5

%

No.

of s

urve

ys c

ondu

cted

Prop

ortio

n w

ith T

F <5

%

No.

of s

urve

ys c

ondu

cted

Prop

ortio

n w

ith T

F <5

%

No.

of s

urve

ys c

ondu

cted

Prop

ortio

n w

ith T

F <5

%

Impact surveys Cameroon 7 71% 2 100% - - 9 78% Ethiopia 41 5% - 41 5% Mozambique 15 100% - 15 100% Nepal 7 86% 1 100% 2 100% 2 100% - 12 92% Nigeria 29 90% 1 100% - 30 90% Senegal 5 20% 3 67% 10 100% 18 72% Tanzania* 8 75% 19 63% 21 76% 8 38% 56 66% Uganda* 4 25% 13 54% 13 92% 17 88% 47 74% Sub-total 7 86% 54 19% 75 71% 57 88% 35 80% 228 64% Surveillance surveys Nepal 10 100% 8 100% 18 100% Nigeria 6 100% 6 100% Tanzania* 1 100% 8 100% 9 100% Uganda* 8 100% 8 100% Sub-total 11 100% 30 100% 41 100%

*Data from trachoma elimination dossier templates Since June 2016, all ENVISION-supported countries transitioned to using the WHO-led Tropical Data system. To meet the increasing need for impact and surveillance surveys, training on Tropical Data has been undertaken for country programs (see section on Disease-Specific Assessments and Surveillance, Objective 1 and 3). In addition, in FY17, a trachoma survey tracker has been developed to help support country programs to undertake surveys in a timely manner and make timely decisions on districts where continued MDA is needed (see section on Disease-Specific Assessments and Surveillance, Objective 2).

For the future, impact surveys and surveillance surveys are the areas needing the most technical support, as evidenced by the increasing percentage of districts anticipated to achieve the criteria for stopping MDA between FY16 and FY20 (Figure 3)

Preparing for elimination. In 2016, WHO published the standard operating procedures (SOPs) for validation of elimination of trachoma as a public health problem.3 According to the SOPs, a country

3 WHO. (2016). Validation of elimination of trachoma as a public health problem. Available at: http://apps.who.int/iris/bitstream/10665/208901/1/WHO-HTM-NTD-2016.8-eng.pdf

http://apps.who.int/iris/bitstream/10665/208901/1/WHO-HTM-NTD-2016.8-eng.pdf

11

meets the criteria for validation if all previously endemic districts demonstrate sub-elimination thresholds for prevalence of trachomatous trichiasis4 (TT; <0.1% in the total population or <1/1,000 total population) and trachomatous inflammation–follicular (TF, <5% in children aged 1–9 years) in adequately conducted pre-validation surveillance surveys. WHO requires member states that have reached the trachoma elimination targets to prepare a dossier documenting the achievement of elimination. Several ENVISION-supported countries are nearing trachoma elimination.

In FY16, ENVISION supported dossier development in Laos and Cambodia; their dossiers were reviewed and finalized and submitted to WHO in early FY17. ENVISION supported drafting of dossiers in Nepal and Vietnam, which are awaiting completion of the remaining surveillance surveys. In addition, ENVISION supported completion of dossier data templates in Mozambique, Senegal, Tanzania and Uganda. In Q3-Q4, ENVISION will support Nepal to complete its dossier and will work with Mozambique, Senegal, Tanzania, and Uganda to draft their dossier narratives.

Figure 3. Projected percentage of trachoma-endemic districts where criteria for stopping MDA have been achieved+

Country Projected Percentage of Trachoma-endemic districts under Post-MDA Surveillance

By end of FY16 17 18 19 20 21 22+

Nepal 100% 100% 100% 100% 100% 100% 100% Mali 92% 100% 100% 100% 100% 100% 100% Cameroon 33% 100% 100% 100% 100% 100% 100% Senegal 48% 63% 100% 100% 100% 100% 100% Mozambique 23% 40% 100% 100% 100% 100% 100% Uganda 77% 95% 95% 100% 100% 100% 100% Vietnam 89% 89% 89% 100% 100% 100% 100% Benin 0% 0% 50% 100% 100% 100% 100% Nigeria*** 23% 38% 74% 99% 100% 100% 100% Tanzania 71% 88% 95% 95% 100% 100% 100% Guinea 0% 22% 72% 94% 100% 100% 100% Ethiopia*** 1% 16% 65% 75% 94% 100% 100% DRC*** 0% 0% 37% 40% 97% 97% 100% Data based on FY17 1st SAR reports. *Data reflect the percentage of districts achieving the milestone. Endemicity and projections data are based on FY17 1st SAR Workbooks. Data reflect what has been reported to ENVISION as of November 4 2016. These data now include districts with baseline TF prevalence 5-9.9%; previous figures did not include these districts, so values may have decreased to account for the change in definition of endemic. **Assumes all districts achieve the minimum number rounds required of sufficient epidemiological coverage in remaining years, pass TIS. ***Reflect data received by ENVISION as of April 4, 2017. Data will continue to be updated as additional information from non-USAID supported areas is received.

4 Prevalence of <0.1% in total population equates to <0.2% among people aged 15 years and older (the population sampled during trachoma surveys).

12

3. Control and Elimination of OV in ENVISION-supported Countries

USAID’s goal for OV is elimination where USAID determines it is feasible, and control elsewhere. This determination affects the types of activities that ENVISION supports in each of the OV-endemic countries that the project supports.

Challenges in reaching OV elimination vary from one country to another and may include high pre-control endemicity; difficulty in sustaining high treatment coverage over the long lifespan of the adult Onchocerca volvulus worm; strong presence of the Simulium damnosum vector; co-endemicity with Loiasis, which can make treatment with IVM dangerous for the population; endemicity across international borders; and/or conditions of conflict and/or instability that impede the necessary surveys or treatment.

Mapping. All 10 OV-endemic countries supported by ENVISION (MDA)8 have mapped their meso- and hyper-endemic areas, in most cases via rapid epidemiological mapping of OV (REMO) with physical examination for nodules or examination by microscope of microfilaremia in skin snips. Countries that were part of the Onchocerciasis Control Program in West Africa (Benin, Guinea, Mali, Nigeria, and Senegal) also mapped their hypo-endemic areas,9 as did certain countries that were part of the African Programme for Onchocerciasis Control (APOC; Cameroon, DRC, and Ethiopia) and received specific support from that purpose in selected regions.

With the shift from control (of the disease, in general terms) to elimination (of transmission) as the goal of endemic countries in Africa, “elimination mapping” (the term proposed by WHO/Geneva)10 may be required. DRC, Mozambique and Tanzania all have wanted to conduct some form of elimination mapping but have not been able to secure the necessary funding. The Expanded Special Project for the Elimination of NTDs (ESPEN) has pledged to fund an entomological evaluation in Ethiopia this year.

5 Mapping was conducted with the intent of determining priority areas for control interventions, focusing on zones where OV had led to visual impairment, and thus may have excluded areas where transmission was thought to be below the priority thresholds (meso-endemicity in countries supported by APOC, hypo-endemicity in countries supported by OCP). Such areas could still have transmission of the disease. 6 Districts that did not conduct MDA because they are pending survey implementation or results are classified as non-endemic for purposes of this figure. 7 For Nigeria, this includes USAID-supported states only. 8 Benin, Cameroon, DRC, Ethiopia, Guinea, Mali, Nigeria, Senegal, Tanzania, and Uganda. 9 Defined by APOC as <20% prevalence of palpable nodule carriers, as determined through a rapid epidemiological assessment sample of at least 50 adult men. 10 Geneva, Switzerland, April 2017.

Impact of ENVISION Support: OV Program Performance

Countries supported: 10

% mapping completed: 100%5

Persons treated MDA (FY16) + 11m to 33m

Geo coverage (FY16): ↑ 3% pts to 62%6

% districts achieving sufficient program coverage (FY16):

↑ 2% pts to 86%7

% people no longer needing MDA, living in ever endemic areas (FY16): 2%

Countries with Independent Oversight Committees 6

13

Loiasis co-endemicity. Mapping Loiasis is a key activity in OV-endemic ENVISION-supported countries that are known to have areas endemic for Loiasis (Cameroon, DRC, and Nigeria).

In FY15, DRC re-mapped selected areas suspected to be co-endemic for OV, LF, and Loiasis and that were not treated for OV or LF, with support from the Task Force for Global Health (TFGH) and ENVISION; final results have not yet been shared by the MOH. This year, Cameroon plans to conduct integrated mapping of OV and LF in Loiasis-co-endemic areas, with support from the TFGH. In Nigeria, a 2016 study found no high-intensity Loiasis infections in ENVISION-supported areas, and consequently Nigeria’s Federal Ministry of Health (FMOH) is requesting MEC approval to initiate IVM MDA this year.

ENVISION has continued to support OR for OV control in Loiasis-co-endemic areas as appropriate. The project will also seek to participate in the proposed WHO sub-working group on Loiasis.

MDA coverage. ENVISION supports MDA in 10 endemic countries.11 Counting support from all sources, four countries (Benin, Cameroon, Mali and Nigeria) reached 100% geographic coverage for all OV-endemic districts, and another four countries (Ethiopia, Guinea, Tanzania, Uganda) were above 80%. Geographic coverage is substantially lower in DRC (2%) and Senegal (13%) – in DRC, due to incomplete data (actual coverage was undoubtedly much higher), and in Senegal, because of delays in funding by the Senegal River Development Organization (Organisation pour la Mise en Valeur du Fleuve Sénégal [OMVS])’s Integrated Water Resource Management Project (PGIRE), which was slated to support integrated MDA in seven out of the country’s eight OV-endemic districts.

In FY16, four countries (DRC, Ethiopia, Guinea, Senegal) achieved sufficient program coverage for OV in all ENVISION-supported districts; three countries (Cameroon, Tanzania, Uganda) achieved sufficient coverage in 90% or more of ENVISION-supported districts. In two countries (Mali, Nigeria), 80–81% of ENVISION-supported districts achieved this target, but with strong median coverage (above 90%). In Benin, median coverage in ENVISION-supported districts was not far below the target, but fewer than 40% of districts reached that target; reasons are discussed in the country semi-annual report., Senegal) achieved sufficient program coverage for OV in all ENVISION-supported districts; three countries (Cameroon, Tanzania, Uganda) achieved sufficient coverage in 90% or more of ENVISION-supported districts. In two countries (Mali, Nigeria), 80–81% of ENVISION-supported districts achieved this target, but with strong median coverage (above 90%). In Benin, median coverage in ENVISION-supported districts was not far below the target, but fewer than 40% of districts reached that target; reasons are discussed in the country semi-annual report.

In many districts in Africa, OV and LF are co-endemic and treated together—with IVM for both diseases, adding ALB for LF. As some of these districts reach the point of stopping MDA for LF, it is important to determine whether MDA for OV (with IVM) needs to continue in the same district. As of April 2017, 51

11 Principally in hyper- and meso-endemic areas, as well as in hypo-endemic areas where MDA activities were initiated previously.

Table 3. Districts targeted for OV-only MDA in FY17 that were previously treated for LF/OV

Country No. of districts

Cameroon 9

Mali 15

Tanzania 18

Uganda 9

Total 51

14

districts that were previously treated for both LF and OV with USAID funding have stopped MDA for LF and plan to conduct OV MDA with ENVISION support in FY17 (Table 3).

Independent Oversight Committee (IOC). To advise on specific strategies and programmatic decisions within endemic countries, WHO’s Guidelines for stopping mass drug administration and verifying elimination of human onchocerciasis: criteria and procedures (2016) recommend the creation of an IOC by the MOH. The national IOCs provide the MOH with important technical support in reviewing data and recommending strategies and next steps; and at a later stage, can assist the MOH in preparing for verification of elimination. Currently, among ENVISION-supported countries, Ethiopia, Guinea, Nigeria, Senegal, Tanzania, and Uganda have established IOCs, and it is expected that Benin (which is planning a joint LF-OV committee), Cameroon, and Mali will do so by the end of the CY17.

Ethiopia (with support from The Carter Center [TCC], with non-USAID funds), Guinea (with joint support from ENVISION and Sightsavers), and Senegal and Tanzania (both with support from ENVISION) held their CY17 committee meetings during this reporting period; for Guinea and Senegal, these were the countries’ first. As noted in the Capacity Strengthening section of this report, ENVISION has facilitated the establishment of committees in Francophone countries in 2017, by enabling MOH personnel from Benin, Guinea, and Mali to participate in Senegal’s meeting (which, in February 2017, was the first of the four countries’ meetings to take place). These MOH representatives already have been, or will be, key players in establishing committees in their respective countries. DRC has a National OV Task Force that meets regularly, presently with funding from Liverpool School of Tropical Medicine.

OV assessments. In FY16, Mali and Uganda had districts that had stopped OV MDA. This included 2 districts in Mali and 18 districts in Uganda, accounting for 9% and 41% of endemic districts, respectively.

The national IOCs assist in recommending which type of survey to conduct and when, and in interpreting the results. In FY17, ENVISION is supporting monitoring surveys (Nigeria, Tanzania, and Uganda), stop-MDA surveys (Mali, Nigeria, Tanzania, and Uganda), and post-treatment surveillance surveys (Uganda). In most cases, the entomological component of surveys will need to be supported by another partner, and laboratory capacity strengthening may be needed for Ov16 ELISA testing as well.

For the epidemiological component of Mali’s stop-MDA survey, the MOH is planning to use skin snip microscopy as it has not yet approved Ov16 ELISA testing for use. It is anticipated that the entomological component of the survey will be supported by the World Bank.

Tanzania conducted OV impact monitoring surveys using Ov16 rapid diagnostic tests (RDTs) during the reporting period. In Bumbuli and Lushoto districts (which together with three other districts are part of Tanga focus), these were nested in school-based LF TAS2 surveys of 6-9-year olds; these surveys found Ov16-positivity of 0% and 0.06%, respectively. In Tunduru Focus, people aged ≥5 years were surveyed, finding Ov16-positivity of 0.4%. Tanzania also collected dried blood spots (DBS) as part of the epidemiological component of an OV stop-MDA survey in Tukuyu Focus (Busokelo, Ileje, Kyela, and Rungwe districts); the MOH is seeking support to run Ov16 ELISA tests of these DBS.

Uganda has continued to conduct a range of OV surveys and assessments including epidemiological assessments with Ov16 ELISA, entomological assessments, and monthly vector surveys. The epidemiological assessments included collection and analysis of DBS from Mahagi (Ituri Region, DRC) (21 positives out of 3,145), Kiryandongo (0 positives out of 2,816), and Kashoya-Kitomi Focus (0 positives out of 3,266). Based on the results from Mahagi, Uganda is conducting interventions on the Ugandan side of the border (West Nile and Nyagak-bond Foci); while Kashoya-Kitomi Focus has completed 3 years of post-treatment surveillance. Entomological assessment in Bwindi Focus, where TCC is supporting vector control (with non-USAID funds), showed that the vector population has declined; and in Madi Mid North Focus, showed that transmission is ongoing. Based on these findings, the MOH will continue to monitor

15

the vector and to conduct MDA in foci where transmission is suspected (Budongo and Nyagak-Bond), and to monitor the vector in the other foci in the area. In nine foci where transmission is interrupted or interruption is suspected, the MOH is conducting monthly vector surveys; these maintained vector-free status, with no Simulium. neavai flies found. In six additional foci, the MOH is conducting entomological assessments every two to three months.

OV elimination guidelines and their application. In January 2016 (French-language version published in February 2017), WHO issued updated guidelines on the elimination of OV that focused on the phases from stopping treatment to verification of elimination. The guidelines identify the Ov16 ELISA serological test in children aged <10 years as the epidemiological diagnostic and O-150 polymerase chain reaction (PCR) (Poolscreen) examination of L3 O. volvulus larvae in black fly heads as the entomological diagnostic to be used for decisions about stopping MDA and confirming elimination. To monitor the impact during the intervention (treatment) phase, the guidelines suggest using in-depth parasitological (skin snip microscopy), entomological, and serological surveys, every 4–5 years, in line with existing regional OV programs.12

Unfortunately, laboratory capacity for ELISA testing of Ov16 and for PCR examination of black flies in ENVISION-supported countries is limited. Currently, three ENVISION-supported countries (Ethiopia, Nigeria, and Uganda) have laboratories, each supported by TCC, that are equipped to conduct the necessary PCR testing of flies; the other ENVISION-supported countries that have conducted entomological surveys (Mali, Senegal, and Tanzania) have relied on the Multi-Disease Surveillance Center laboratory in Burkina Faso. In Tanzania, laboratory personnel from the National Institute for Medical Research’s Tanga Research Centre received training from the United States Centers for Disease Control and Prevention (CDC) on O-150 PCR pool screening of black flies and on ELISA testing of Ov16.

Other ENVISION-supported countries (DRC, Nigeria, Senegal, and Uganda) have generally relied on US-based laboratories for Ov16 ELISA testing, which involves shipping biological samples internationally and is therefore administratively and logistically complex. ENVISION will coordinate with other USAID-supported initiatives tasked with development of laboratory capacity.

12 WHO/APOC. (2013). Evaluation of the impact of community treatment with ivermectin using skin snip method; WHO/OCP. (2002). Training module for national entomologists in the management and supervision of entomological activities in onchocerciasis control; WHO/OCP. (2002). Training module for entomology technicians in charge of entomological activities in onchocerciasis control.

16

4. Continued Control of SCH in ENVISION-supported Countries

USAID’s and ENVISION's goal for SCH is to build national programs’ capacity to continue SCH activities when USAID support is no longer available. This requires the development of national plans of action that outline appropriate, evidence-based strategies for SCH and STH control (as outlined in the next section), and document funding resources and gaps. Out of 19 ENVISION-supported countries, 15 are endemic for SCH13.

Mapping. Two countries (DRC and Ethiopia) still have mapping activities planned in FY17. In Ethiopia, the Ethiopian Public Health Institute is conducting mapping with support from the Schistosomiasis Control Initiative (SCI) and WHO’s Africa Regional Office (AFRO) mapping project. Mapping efforts are focused on districts in three regions (Afar, Amhara, and Somali) where risk of infection is considered low. Surveys in Afar have recently been completed, with surveys planned in Amhara and Somali in the upcoming two months. The results of these surveys will be available to inform program design before the end of FY17. In DRC, ENVISION is liaising with WHO-AFRO’s mapping project to encourage completion of the few remaining districts. Additionally, Nigeria has mapping gaps remaining in the insecure northeast of the country.

Improving MDA coverage. ENVISION supports national programs to plan and implement integrated control of SCH and other preventive chemotherapy (PC)-NTDs (STH, LF, OV, and trachoma) in co-endemic districts. ENVISION also supports SCH-only treatment, where such an approach has historically been identified as the MOH’s preferred approach or where other diseases no longer require treatment. The number of districts treated in ENVISION-supported countries (capturing all funding sources) has increased yearly from 354 districts in FY13 to 645 districts in FY1614. Geographic coverage including districts that have ever treated increased substantially from 49% in FY15 to 70% in FY16. The corresponding figure for FY17 to date is 65%. This reflects the substantial increase in the number of districts identified as endemic (from 1,700 in FY15 to 2,200 in FY17) which in turn is due to the following: (1) inclusion of nationwide data from Nigeria for the first time, and (2) an increase of districts initiating MDA in Ethiopia by non-ENVISION partners.

Although geographic coverage has increased in many countries across the portfolio, it should be noted that this does not address the complicating issues of MDA frequency (which is specific to SCH) and lack of clarity over treatment of adults. Regarding MDA frequency, the recommended treatment approach is once every two years in moderate endemic areas and twice during schooling in low endemic areas. For adults, it is recommended that those classified as high risk be treated in highly-endemic areas; however, there is inconsistency about how to identify these high-risk populations. Consequently, estimating the appropriate treatment target per year is not straightforward. This issue affects the wider SCH

13 Benin, Cambodia, Cameroon, DRC, Ethiopia, Guinea, Indonesia, Laos, Mali, Mozambique, Nigeria, Philippines, Senegal, Tanzania, and Uganda 14 Benin, Cameroon, DRC, Guinea, Mali, Nigeria, Senegal, Tanzania, and Uganda

Impact of ENVISION Support: SCH Program Performance

Countries supported 9


Persons treated MDA (FY16) +2.5m to 18.8 m

% districts achieving sufficient coverage MDA SAC (FY16): ↑ 4% pts to 75%

Countries supported with SCH surveys (FY16): 4

17

community. ENVISION is working with WHO and the Global Schistosomiasis Alliance (GSA) to identify opportunities to improve the accuracy of the population counts that requiring treatment per year.

In Q3–Q4, ENVISION will analyze data to compare coverage of SCH (and STH) between school-based and community-based platforms. Although coverage is expected to vary between countries, this analysis should allow the identification of any systematic differences.

In FY16, ENVISION supported the treatment of 18.8 million individuals against SCH, comprising 16.3 million school-age children (SAC) and 2.5 million adults. This represents a steady year-on year scale up since the start of ENVISION with 13.7 million treated in FY15, 8.6 million treated in FY14 and 5.6 million treated in FY13.

Progress is being made each year in achieving the project’s epidemiological coverage target of ≥75% in school-aged children. In FY16, 75% of districts treated with ENVISION support achieved ≥75% coverage. This represents an annual increase every year since FY12. However, this is the lowest coverage of the five diseases so it is clear that further progress is required. Low coverage is a result of several factors, including delivery platform (and low school attendance) and MDA timing.

In FY17, ENVISION is encouraging several “best practices for SCH programs” that affect coverage, such as implementing MDA at the beginning of the school year when attendance is high or preferably before the peak of SCH transmission (hot season). To mitigate the problems around denominator issues—census versus administrative data—ENVISION is promoting taking a census before MDA for better quantification of drugs. Reaching SAC out of schools is a priority given the drive for gender-equity and school enrollment-equity and the likelihood that this population is more heavily infected and therefore more likely to develop morbidity and to contribute to transmission. Although reaching “non-attending” SAC will require country-specific approaches, there are lessons that can be shared between countries. For example, an approach that worked successfully in Guinea involved encouraging the country to identify opportunities (e.g., cultural events and sports in schools and in communities) to reach SAC who do not attend school. Moreover, ENVISION is supporting intensified information, education, and communication (IEC) activities and advocating for access to private and religious schools. In addition, ENVISION is exploring the provision of more time in the schedule to conduct school-based MDA—“longer MDA”—and will support mop-up approaches to reach children missed by rounds of drug distribution.

High-risk adults in districts with SCH prevalence of 50% and greater are recommended to be included in treatment campaigns. ENVISION is working to reinforce social mobilization by including high-risk adults as targets into SCH IEC messaging and by promoting the use of community-based distributions as effective platforms for reaching high-risk adults. A review of social mobilization messaging using a bespoke toolkit developed by Sightsavers under the ENVISION project has been implemented successfully in Ethiopia and Uganda, with plans to be rolled out to additional countries in FY17 and beyond. Most countries are conducting SCH treatment through schools only and therefore high-risk adults are systematically excluded. This is driven partly by the lack of praziquantel (PZQ) donation for adults and the inconsistency in WHO’s guidelines. The ENVISION-supported countries that target-risk adults are: Uganda, for whom PZQ is purchased by ENVISION; Cameroon, Senegal and Mali using WHO-donated PZQ; and Ethiopia (external to the ENVISION project) using a combination of SCI-procured and WHO-donated PZQ.

To overcome these issues systematically, ENVISION and partners continue to advocate to WHO for the PZQ donation to be extended to high-risk adults, and for its treatment guidelines to be clarified, strengthened, and aligned with disease goals through ENVISION’s role in the GSA.

18

ENVISION is encouraging countries to review their SCH data and use it to respond to programmatic issues, such as the identification of hotspots and adjusting the frequency of treatment. Additional TA support is available to this end. Hotspots are sources of persistent disease transmission that sustain high prevalence and can constitute a reservoir for re-infection. Hotspots can be caused by high underlying transmission, poor treatment coverage, sub-optimal responses to treatment, itinerant populations, or a combination of these factors. Identification and characterization of the hotspots are the first steps before implementing alternative treatment strategies to address persistent transmission. With ENVISION’s support Uganda is using sub-district data to effectively target its treatment activities to the most-needed areas. In addition, ENVISION continues to work with WHO and SCH partners to develop guidelines for the identification of hotspots, the appropriate adjustment of treatment approaches, and monitoring impact.

PZQ management. The pharmaceutical company Merck Serono (Merck KGaA) has expressed interest in close monitoring of PZQ consumption and management in supported countries. ENVISION is working with supported countries to strengthen their supply chains in order to streamline management, distribution, and quantification through planning and physical stock inventories of PZQ (and other drugs). Mali and Senegal have made improvements throughout the PZQ supply chain; see country reports for more details. Ethiopia has seconded a supply chain focal point to the Pharmaceutical Fund and Supply Agency (PFSA). Nigeria has successfully rolled out a cascaded supply chain management training to assist with drug management and stock rotation. Note that ENVISION will no longer look to support a consultant to work across countries as anticipated in FY17. Rather this support will come from sharing lessons from the ENVISION portfolio. ENVISION is working to establish and reinforce systematic inventories of leftover drugs, strengthen drug storage practices, and improve the management and the reverse logistics of unused drugs.

Sentinel sites and prevalence assessments. ENVISION is supporting the implementation of sentinel site surveys and prevalence assessments that align with WHO guidelines in selected countries—Senegal, DRC, and Tanzania. In FY16, ENVISION supported 91 SCH surveys (62 evaluations and 29 sentinel sites) in Mali, Senegal, Tanzania, and Uganda. Overall, 56 SCH surveys will be implemented with ENVISION support in FY17 (106 with all funding). However, there is inconsistency in WHO’s guidelines about when both sentinel sites and prevalence assessments should be conducted, which is related to the lack of clarity of how the results should affect treatment decisions. ENVISION is working to develop standard protocols across the portfolio, and advocating to WHO to update and strengthen its guidelines.

USAID encourages the addition of STH to any planned TAS where such an addition will contribute to decision making regarding future treatment regimens. In FY17 this is being conducted in 23 evaluation units in Benin, Haiti, and Uganda. In areas that are also co-endemic for intestinal SCH, ENVISION will take the opportunity to advocate for collection of prevalence data that are available from Kato-Katz slides and therefore contribute synergistically to the development of a sustainable STH and SCH strategy. To this end, Schistosoma mansoni and STH data will be collected as part of a TAS survey in Uganda as part of an OR activity comparing the performance of Kato Katz with PCR. This OR will be conducted in the July 2017.

Transitioning SCH MDA and strengthening capacity. In anticipation of the discontinuation of LF program platforms to support SCH MDA, assisting countries to establish sustainable SCH (and STH) MDA platforms that can continue to leverage drug donation programs is a priority in FY17 and throughout the remainder of ENVISION. In so doing, USAID will be able to transition away from SCH control activities in districts that no longer require LF MDA.

This transition requires a country assessment of viable alternative platforms, including the integration of SCH MDA into existing deworming or nutrition platforms (e.g., child health days) or other public health

19

campaigns. A draft transition plan capturing such information and support needs by country has been developed in partnership with USAID. ENVISION aims to pilot this transition plan in the second half of FY17 in selected countries. ENVISION will provide support to assess the performance of school versus community MDA platforms in achieving SCH program objectives. As part of this exercise, ENVISION will encourage clear communication with MOHs so that the implications of choosing school or community platforms are understood; e.g., the trade-off between coverage of SAC and other targeted populations, and costs (that will need to be borne by the MOH or other partners). The NTD programs will be encouraged to hold meetings with other sectors of the MOH and government more broadly to discuss potential co-implementation. It is anticipated that co-implementation may increase coverage and also decrease program costs due to efficiencies of scope and scale. Additionally, in the second half of FY17, ENVISION will test and pilot community platforms for SCH MDA in four districts in Benin. The experience will also be informative for other country programs.

ENVISION continues to emphasize the need to build strong collaboration and partnerships with water, sanitation, and hygiene (WASH) projects, and synergies with education and socioeconomic development sectors. This includes the encouragement of resource mobilization, through government WASH budgets, and through government leadership and coordination of WASH partners. Naturally, WASH improvements will benefit all five PC-NTDs (and far beyond) and WASH is embedded in the trachoma SAFE15 strategy, and the new BEST (Behavior, Environmental Improvement, Social Inclusion, and Treatment) framework. Additional information will be provided by the CARE/Johnson & Johnson pilot project in Ethiopia and the planned Children’s Investment Fund Foundation project to demonstrate SCH and STH elimination in Ethiopia. The lessons from these collaborations and activities will be used to support countries to develop national plans of action in FY17 and FY18 outlining appropriate, evidence-based strategies for SCH and STH control.

15 SAFE = Surgery–Antibiotics–Facial cleanliness–Environmental improvements

20

5. Continued Control of STH in ENVISION-supported Countries

USAID’s goal for STH (Ascaris lumbricoides [roundworm], Trichuris trichiura [whipworm], and hookworms) is to build national programs’ capacity to continue STH activities when USAID support is no longer available. This will require the development of national plans of action that outline appropriate, evidence-based strategies for SCH and STH control and document funding resources and gaps.

MDA coverage. A strong foundation for STH control has been established in ENVISION-supported countries—most countries have completed their mapping, and have achieved 100% geographic coverage for at least one round of STH MDA. More than 40 million SAC (and 91 million people in total) were treated with USAID support in countries supported by ENVISION in FY16. The treatment was delivered mainly through the LF MDA platform, during which IVM/diethylcarbamazine (DEC) treatments were distributed alongside ALB, effectively treating both LF and STH (and OV, where co-endemic).

In those districts that implemented MDA, STH epidemiologic coverage in ENVISION-supported districts was 83% of targeted SAC in FY16, an increase from 75% in FY15. While country transition strategies are under development, ENVISION will continue to support STH-only MDA in areas that have previously received it, including districts that receive STH-only MDA due to stopped LF MDA. In FY17, this includes 106 districts with STH-only treatments to be supported by ENVISION: Nigeria (30 districts), Cameroon (26), Mali (18), Senegal (15), Tanzania (15), DRC (1), and Benin (1). Cameroon is the only country that has already conducted STH-only MDA so far this fiscal year, in its 26 districts. The remaining MDA activities are scheduled for Q3–Q4 of FY17. In addition, 31 districts are targeted for SCH alone (Benin [2], Nigeria [3], and Uganda [26]) and 82 districts will receive support for SCH and STH alone (Benin [1], Cameroon [10], Mali [10], Nigeria [4], Senegal [3], and Tanzania [54]).

In total, ENVISION is supporting 219 districts across 8 countries for STH and/or SCH only MDA in FY17 while working with the national programs to identify sustainable platforms to support the STH transition.

Surveillance. The impact that multiple years of deworming is having on STH prevalence can be seen in certain ENVISION-supported countries; e.g., across 165 surveyed districts in Haiti and Uganda, a median 21 percentage point reduction in STH prevalence was observed from sentinel site surveys. Whether these reductions in prevalence are sufficient to stop STH MDA requires additional information and clarity on treatment guidelines from WHO. For countries that have collected sentinel and spot-check data on SCH and STH, additional consolidation and analysis of these data may provide some answers. In other situations, programs are recommended to capitalize on other planned assessments, such as LF TAS, to collect additional STH infection measures to determine future treatment regimens and develop a sustainable STH strategy. ENVISION is supporting three countries – Benin, Haiti and Uganda with STH

16 Benin, Cameroon, DRC, Ethiopia, Guinea, Haiti, Indonesia, Mali, Nepal, Nigeria, Senegal, Tanzania, and Uganda

Impact of ENVISION Support: STH Program Performance

Countries supported MDA16 13


Persons treated MDA (FY16) +16.6m to 91.3 m

Geo coverage MDA (FY16): ↑8% pts to 54%

% districts achieving sufficient epi coverage MDA – SAC (FY16): ↑ 8% pts to 83%

Countries implementing STH integrated TAS (FY17): 3

21

integrated TAS this year. Country approaches are described in the Disease-Specific Assessments and Surveillance section.

SCH–STH Transition. ENVISION-supported countries are now rapidly transitioning away from the integrated NTD treatment platform (specifically including LF) as a significant percentage of LF-endemic districts are achieving the criteria for stopping MDA with IVM/ALB or DEC/ALB. Treatment delivery platforms for STH will dramatically change in many countries over the next several years (Figure 2). The potential change in strategy provides an opportunity for national programs to reiterate national goals for STH, re-evaluate the epidemiologic situation after multiple years of treatment, revise treatment frequencies and target populations, and determine a new course for sustaining long-term control activities. The change is strongly recommended to be considered in the 2017–2021 strategic planning developed by the countries.

In developing these strategies, national programs will need to address the various issues that affect sustainability and effectiveness of control efforts. For example, the issues of integrated versus disease-specific treatment, elimination versus control, community versus school-based MDA, prevalence-based decision making versus intensity of infection decision making, and any STH decision making versus species-specific decision making.

As part of the work planning process for FY17, USAID requested seven countries (Haiti, Tanzania, Uganda, Nepal, Mozambique, Benin, and Mali) develop a supplementary section to their work plans on the STH transition. These supplements clarified which country programs specifically request USAID support to develop transitional strategies that will lead to the establishment of sustainable STH and SCH MDA platforms—ideally platforms that will continue to leverage drug donation programs after USAID support ends. The targeted countries submitted their transition plan along with their work plan as requested by USAID. ENVISION plans to pilot the USAID STH transition guide in four of these countries (Tanzania, Uganda, Haiti, and Benin). This pilot is scheduled to be conducted by the end of FY17.

These four countries can potentially learn from the experiences of other programs, but also help influence strategies in other countries that have a growing number of districts receiving ENVISION support for STH-only and/or SCH-only MDA activities. A positive example of national programs managing the transition is Nepal, where the MOH is funding and managing all STH treatments in areas where LF MDA has stopped. This new model still needs careful monitoring and coordination between partners and government agencies to ensure that key reporting indicators and basic M&E activities for STH are maintained. ENVISION will pay special attention to Haiti and Mozambique as the funding they receive for STH-only MDA from the Inter-American Development Bank and DFID (with technical support from Liverpool School of Tropical Medicine and SCI), respectively, will end in FY17.

As documented in countries that have stopped LF MDA, reporting on STH treatment data and conducting basic M&E activities may be diminished during the post-LF transition period. ENVISION is continuing to assist these countries in focusing attention to the sustainability of basic M&E activities and promoting the use of data through increased use of the Integrated NTD Database and application of the Data for Action Guide as described in the Data Quality section of the work plan.

ENVISION continued to support countries this year by providing TA from ENVISION staff to help self-selected countries determine their STH intervention needs (including combining STH infection measures with TAS, in Benin and Haiti for example, using WHO guidelines) and to assess alternative delivery strategies and treatment frequencies. The main challenge remains the lack of funding and the disappointingly low coverage reported by most of the existing “alternative” platforms that could potentially be utilized. Working with USAID, ENVISION will continue to highlight these issues for discussion at global policy meetings.

22

IR 1: INCREASED MDA COVERAGE AMONG AT-RISK POPULATIONS IN ENDEMIC COMMUNITIES

23

MDA under ENVISION The successful implementation and scale up of MDA is a core activity of the ENVISION project. All seven NTDs targeted by the ENVISION project can be controlled and treated through MDA, using safe, single-dose medicines. ENVISION’s support for MDA efforts follows existing WHO guidelines on who to treat and with what frequency, based on prevalence data.

Platforms for delivery: In general, MDA is delivered through community- and school-based platforms for all the targeted PC NTDs. Drug packages for SCH and STH, which target SAC, are normally delivered in schools. OV MDA interventions are typically conducted in communities, as part of the community-directed treatment with IVM strategy.

Where there are multiple drug packages (e.g., IVM + ALB; PZQ; AZT/TEO), MDA activities are typically staggered, with a defined period separating delivery of each package. Triple drug administration involving the co-administration of IVM, ALB, and PZQ together has not been widely approved by MOHs, although field trials have shown that co-administration of IVM, ALB, and PZQ is safe and more cost-effective than staggered MDA.

Drug company contributions are key: To date, USAID-supported countries have received more than $15 billion worth of drugs donated by several pharmaceutical companies and their respective drug donation programs, including Pfizer, which donates Zithromax® (ZTH) through ITI; Merck & Co., which donates IVM through the Mectizan® Donation Program; GlaxoSmithKline (GSK), which donates ALB; Johnson & Johnson, which donates mebendazole (MEB); Eisai, which donates DEC; and Merck Serono, which provides PZQ—through WHO. WHO manages country drug requests through country submissions of the Joint Request for Selected PC Medicines (JRSM) form by individual countries. ENVISION supplements drug donations by procuring PZQ in some instances and TEO.

Measurement of MDA: Geographic, program, and epidemiologic coverage measurements are used to determine whether programs are achieving treatment targets over multiple years. In general, treating at least 80% of the eligible population targeted (program coverage) is indicative of the ability of programs to reach planned targets. Disease-specific epidemiologic coverage rates are used to determine when to conduct disease impact assessments, which in turn determine when MDA can be stopped.

24

1. Mass Drug Administration (MDA)

The delivery of treatments for NTDs has scaled up rapidly since the beginning of ENVISION:

• More than 1.1 billion cumulative treatments are estimated to have been delivered by the end of FY17

• The number of districts targeted for treatment increased from 500 in FY12 to 1,159 in FY17

• The number of persons targeted for treatment increased from 56 million in FY12 to 122 million in FY17.

For the first time since the start of ENVISION, the number of treatments distributed in FY17 is anticipated to be less than that of FY16 (Figure 4), reflecting the increasing number of districts that are now able to stop MDA for LF and trachoma.

What this means for the project is that increasing efforts need to be made to reach the harder-to-treat populations—where geographic scale-up has stalled and where program coverage is low.

Figure 4. MDA treatments supported by ENVISION: FY12–FY17 *

*Data reflect achievements made with ENVISION support. These values do not include MDA funded through USAID-supported APOC in Tanzania or PSSC II in Senegal. Data reflect what has been reported to ENVISION as of April 3, 2017; there may be changes as countries finalize their work plans.

**Targets reflect expected population to be treated and may not represent entire eligible population. Geographic scale up: Projected FY17 geographic coverage, for districts having treated at least once since FY12, is shown in Figure 5. Most ENVISION-supported countries are forecasted to reach national scale for LF, OV, and trachoma by the end of FY17 except for DRC and Nigeria. Nineteen districts across Mali (3), Senegal (13) and Tanzania (3), have 5-9.9% prevalence. Two districts in Tanzania were treated and

0

50,000,000

100,000,000

150,000,000

200,000,000

250,000,000

300,000,000

Number of persons treated Number of treatments provided

FY12 FY13 FY14 FY15 FY16 FY17 targets**

Due to districts reaching stop-MDA criteria, ENVISION will support distribution of FEWER treatments in FY17 than last year

—a project first

25

two in Senegal are being targeted for treatment in FY17. All other districts are pending impact survey results or implementation in the next calendar year.

Geographic scale up for STH and SCH has been rapid, with full national scale reached in most countries. Exceptions are SCH MDA in Benin, Cameroon, and Nigeria and STH MDA in Indonesia and Nigeria where 25-50% of endemic districts remain untreated. As treatment for LF and trachoma is stopped, the treatment gap for STH and SCH is likely to increase, unless alternative platforms and funding are found.

Country-specific plans to reach 100% geographic coverage are presented in detail in the country reports.

Figure 5. Once treated geographic coverage in FY17, by disease*

Country LF OV SCH STH TR Bangladesh 100% - - 100% - Benin 100% 100% 75% 100% 100% Cambodia++ 100% - 100% 100% - Cameroon 100% 100% 61% 100% 100% DRC 3% 8% 2% 3% 13% Ethiopia 100% 100% 90% 98% 77% Guinea 100% 100% 94% 100% 100% Haiti 100% - - 100% - Indonesia 100% - 100% 57% - Laos++ 100% - 100% 100% - Mali 100% 100% 100% 100% 100% Mozambique 100% - 100% 100% 100% Nepal 100% - - 100% 100% Nigeria** 61% 28% 54% 56% 58% Philippines 100% - 100% 100% - Senegal 100% 100% 100% 100% 100% Tanzania 100% 100% 100% 100% 100% Uganda 100% 100% 98% 100% 100% Vietnam 100% - - 92% 100%

*Numerator includes all districts that have been treated with all funding since FY12 as reported to ENVISION, or are targeted for MDA with all funding in FY17, or have successfully achieved the criteria for stopping MDA. Denominator includes districts ever endemic above treatment threshold. +Benin, Cameroon and Nigeria are targeting districts below the STH treatment threshold due to in part to national policy and/or counting LF treatments also for STH. There are some districts that are endemic for STH but not treated in Benin, which is not captured by this figure. **Reflect data received by ENVISION to date. Data will continue to be updated as receive additional information from non-USAID supported areas. Nigeria includes entire country and data may not reflect treatment or targets outside of the 10 USAID-supported states. - Not applicable because disease is not endemic. Please note that Mozambique is hypoendemic for OV; since the disease distribution and associated interventions are not yet known, it is being classified as 'not endemic' for the purposes of this figure. ++While Cambodia and Laos are on the WHO list of trachoma endemic countries, mapping in 2014 and 2015 found TF prevalence below the threshold to implement MDA. Therefore, they will not implement MDA but will submit dossiers to validate elimination as a public health problem to WHO in FY17.

26

Achieving required program and epidemiological coverage. In addition to scaling up, if elimination and control goals are to be met, the quality of MDA being implemented is important. Quality is measured by MDA program and epidemiological coverage.

MDA quality, in districts supported by ENVISION, has steadily improved since the start of the project in FY12 (Figure 6). During FY12 to FY16, while the total number of districts treated increased, the number (as well as percent) with low coverage decreased. Overall, 83% of districts across all diseases met coverage targets in the last reported MDA (FY16/FY17). For LF and trachoma, the percent of district-level MDA not reaching sufficient coverage decreased from 25% in FY12 to 9% in FY16, meaning 91% have now reached their ”sufficient coverage” goal.

Figure 6. Districts reaching sufficient coverage, steady improvement across diseases FY12–FY16

Improvements and lessons learned

Substantial improvements in coverage were observed in FY16 as compared to FY15, across all diseases, in Guinea, Mali, Nigeria, and Senegal.

Guinea. Strong emphasis on implementing an improved social mobilization strategy allowed rapid recovery post-Ebola.

91% of districts have reached their

“sufficient coverage”

goal for LF and trachoma.

27

Mali. Drugs were ordered and arrived on time and the in-country drug supply chain was improved by hiring staff for new supply chain positions.

Nigeria. An increase of districts achieving sufficient coverage for LF was reported—from 35% in FY15 to 93% in FY16. The number of community drug distributors trained has increased in many districts and a school-based distribution strategy was added to the community-based strategy. As the Nigeria NTD program has also been focusing on improved data quality, coverage surveys are being conducted to confirm these results.

Senegal. Greater emphasis was put on all the different elements of MDA delivery: microplanning, social mobilization, ratio of distributors to households, supervision, and data management. Real-time coverage review was also conducted during MDA, with daily reporting of numbers treated. This was supported by both high-level MOH involvement and recruitment of embedded partner staff in the regional MOH offices.

A steady increase in coverage performance has been achieved over a period of 3 to 5 years in Tanzania and Uganda.

Tanzania. Coverage has increased across all diseases: the average number of districts meeting sufficient coverage increased from 44% in FY12 to 83% in FY17. Since FY15, more emphasis has been placed on reaching the harder-to-treat population of nomadic pastoralist communities in Manyara Region, where tailored social mobilization strategies have been implemented based on results of social science research in this community.

Uganda. Only 53% of districts achieved the required 65% epidemiological coverage for LF in FY12. This increased to 65% in FY13 and to 95% in FY16. Similarly, districts achieving 75% coverage of SAC for SCH increased from 39% in FY12 to 75% in FY16. Interventions to improve coverage in Uganda have focused on strengthening delivery, including improved supervision, strengthening planning at the district level, and increasing the number of community drug distributors and supervisors.

Targeted interventions designed to address historically hard-to-treat districts, with recurring low coverage helped Benin, Indonesia, and Nepal reach coverage targets.

Benin. Improved OV coverage in five districts across three regions, from 52–74% in FY15 to 82–97% in FY16 after efforts to improve registers, reinforce training and supervision, and revise IEC activities and materials. Two other districts in Borgow region improved coverage for SCH and STH from 73% in FY15 to 80% in FY16 in N’Dali, and from 42% to 92% in Tachaourou, following efforts that resulted in a new memorandum of understanding (MOU) being signed by the MOH and the Ministry of Education to facilitate in school distributions. Also, first-time MDA for trachoma in four districts had excellent coverage (89–94%).

Indonesia. Coverage has also been a struggle in the urban center of Kota Batam due to the high rate of chronic disease in the population with cadres afraid to treat in case of adverse events (AEs), lack of trust in the community for people distributing drugs, and negative messaging from the medical community who were advising people not to take drugs. Coverage here increased from 45% in FY14 to 52% in FY16. These small, but hard-earned, gains were seen after implementing a package of interventions that included keeping posts open longer; shifting broadcasting public service announcements to more popular national channels; training physicians on serious adverse events (SAEs) and side effects; and increased advocacy meetings with local organizations, including the military, police, and private doctors. Then, in FY16, the municipality leaders advised that the district population census is more accurate than the previously used national census. Using the district denominator, FY16 coverage is now reported as 73%.

28

Nepal. Struggles with low coverage in urban areas were ended by dividing up the urban area in the Kathmandu Valley and conducting pre-TAS and then TAS. All but one area passed allowing treatment to be stopped. The remaining area was more rural in nature and coverage has been good.

Causes of continued low coverage

Although achieving quality in over 80% of MDA activities conducted is an excellent result, treatment must be effective 100% of the time if MDA is to be stopped and elimination goals are achieved. As learned from other elimination programs, the last mile is always the hardest. Therefore, as challenges remain in certain districts, ENVISION is putting more and more effort into isolating causes and finding solutions.

As national programs mature, the reasons for low coverage are less often due to challenges in routine delivery. That said, when these problems do occur, they impact many districts. The countries with the largest number of low coverage MDA in FY16 were Benin, Cameroon, and Nigeria (Figure 7). Benin and Nigeria reported late MDA running into the rainy season as the main reason for much low coverage, but also cited not having enough drug distributors as a common problem. Cameroon had a serious drug shortage of PZQ and MEB.

Figure 7. Districts with insufficient MDA coverage, by country and disease

0 10 20 30 40 50 60 70 80 90 100

Cameroon (FY16)

Benin (FY16)

Nigeria (FY16)

Tanzania (FY17)

Uganda (FY16)

Mali (FY16)

Haiti (FY16)

Ethiopia (FY17)

Nepal (FY16)

Indonesia (FY16)

Mozambique (FY16)

Senegal (FY16)

DRC (FY16)

Guinea (FY16)

NUMBER OF DISTRICTS WITH INSUFFICIENT COVERAGE

COU

NTR

Y (Y

EAR

OF

MO

ST R

ECEN

T AV

AILA

LBLE

TRE

ATM

ENT

DATA

)

LF OV SCH STH TR

29

Increasingly, the remaining districts with low coverage are due to harder-to-treat populations – where there have been rumors of SAEs (Ethiopia and Indonesia); urban centers (Haiti, Benin, Nigeria, and the Philippines); nomadic/migrant populations (Benin, Mali, Tanzania, the Philippines, and Uganda); border towns (Benin); where there is insecurity (Ethiopia, Mali, Nigeria, and the Philippines); reaching both in-school and out-of-school SAC (Benin, Cameroon, and Nigeria); and places with especially weak infrastructure, including low capacity of drug distributors (Nigeria and Uganda).

LF specific: In the last reported MDA (FY16–FY17), 52 out of 5,612 district-level MDA (sum of disease-specific MDA results) did not achieve sufficient coverage for LF, with most (86%) of these found in just 5 countries: 18 in Benin (mix of reasons), 5 in Cameroon (only partial districts treated due to loa loa), 7 in Haiti (urban issues), 7 in Mali (insecurity), and 8 in Nigeria (various reasons).

Trachoma specific: Twenty-four out of 168 districts did not achieve sufficient coverage for trachoma. Most of these low coverage districts (91%) are found in just three countries: 10 in Ethiopia (recent FY17 MDA and still exploring reasons), 5 in Tanzania (due hard-to-reach pastoralist nomads, although the situation is improving), and 7 in Uganda (in places where infrastructure is especially poor and capacity of drug distributors is low).

Programs for STH, SCH, and OV are going to need longer-term, sustained treatment; achieving quality MDA is also important for these diseases.

OV specific: OV programs, which have a long history, generally have good coverage. The one exception in ENVISION-supported countries is Benin, where the issue is thought to be due to inaccurate sub-district level denominators.

SCH and STH specific: Most of the MDA activities with lower coverage for STH and SCH are found in Benin, Cameroon, Nigeria, Tanzania, and Uganda, where common themes are found for causes of low coverage: reaching the out-of-school children in school-based distributions, reaching in-school children in community-based distributions, and being able to accurately assess the population at risk for SCH. In Cameroon, many districts reported low coverage due to drug stock out.

Priorities, objectives, and activities

Based on the aforementioned issues, ENVISION’s focus in FY17 is to support countries with the larger number of low coverage districts, and to provide guidance to country programs struggling with treating hard-to-reach populations, especially urban centers, areas affected by conflict, migrant populations, and groups with strong traditional beliefs. To date, this support has taken several forms, including creating opportunities for cross-country learning by convening 2-3 project staff working on supporting different countries to discuss the challenges and extract lessons learned; preparing literature reviews that identify solutions to specific problems; formally documenting case studies for wider dissemination; and hosting webinars that are open to the global community.

Specific objectives being targeted in FY17 are -

Objective 1: Strengthen the use of cost-effective strategies for social mobilization

86% of low coverage

districts for LF are found in just 5

countries

91% of low coverage

districts for trachoma are found in just 3

countries

30

Objective 2: Strengthen supervision and planning

Objective 3: Generate solutions for reaching hard-to-reach populations: urban, migrants, and nomads, and those living in conflict-affected settings


Objective 1: Strengthen the use of cost-effective strategies for social mobilization

All MDA programs need a strong communication and social mobilization campaign to ensure that the target population has access to treatment, understands the importance of taking the treatment, and knows when and where to get it. In addition, many of the specific causes of low coverage identified above require a tailored social mobilization solution; e.g., addressing fears of AEs and SAEs, and treating the hard-to-reach populations. Through the ENVISION project, RTI and Sightsavers are working to provide support to national programs improve social mobilization by targeting specific needs in ENVISION-supported countries and making lessons learned more widely available across USAID’s portfolio and to the broader NTD community.

Activity 1: Test, adapt, and disseminate the Social Mobilization Planning Guide. In Q1–Q2, the Social Mobilization Planning Guide, developed in FY16 with Sightsavers under ENVISION, was successfully tested in Ethiopia and Uganda. Results of these workshops have generated feedback that will be incorporated in a revised edition of the guide as well as modifying social mobilization materials and strategies in both countries. ENVISION hosted a webinar highlighting the experience of these two countries using the guide in March 2017, in both English and French.

Activity 2: Rapid review of country social mobilization plans for FY17. Individual consultation on specific social mobilization plans was provided in Q2 to several ENVISION-supported countries: to Cameroon on their IEC materials assessment planned for FY17; to Haiti who have identified the need for a new communication strategy in the metropolitan area of Port Au Prince; to Mali where only 45% of people reported having advance notice about previous MDA activities and where there is the challenge of conflict settings; and to Mozambique, the Philippines, and Nigeria who plan to use the guide to review IEC materials in Q3-Q4 of FY17.

Activity 3: Provide technical support to strengthen national NTD social mobilization plans. ENVISION will provide feedback on the draft FY18 social mobilization plans in Q3-Q4.

Activity 4: Assess and report on the impact of changes made to social mobilization strategies in FY16. Data are being collected and will be reported in Q3–Q4.

Objective 2: Strengthen supervision and planning

An important objective for ENVISION in FY17 is to strengthen MDA planning (especially in districts with historically low coverage) and during MDA supervision. Good supervision provides an opportunity for corrective actions, including refining key communication messages, deploying additional drug distributors, revisiting households where persons were not present, extending the MDA time frame, conducting mop-up among targeted communities and/or sub-population groups, and adjusting drug stock.

31

In FY17, ENVISION is reviewing MDA planning practices and supervision strategies used during MDA activities. This includes sharing strategies used across countries and getting feedback on tools developed to support supervision, specifically:

Activity 1: Learn from country experience using independent MDA monitoring. This activity is ongoing and will be completed in Q3–Q4.

Activity 2: Learn from country experience using the coverage supervisory tool. Country experiences were presented by the TFGH at the WHO-led partners meeting on M&E tools, held in Geneva in October 2016. Participants from that meeting recommended renaming the tool, Supervisors Coverage Tool, to place it in the context of supervision, and continuing to test. The group proposed that country experiences be documented for wider dissemination. ENVISION will document country experiences and share these at the next WHO-led M&E implementing partners’ meeting planned for June 2017.

Activity 3: Learn from country experience using daily MDA reporting. This activity will be completed in Q3–Q4.

Activity 4: Learn from country experience using supervisory monitoring forms. This activity will be completed in Q3–Q4.

Objective 3: Generate solutions for reaching hard-to-reach populations: urban, migrants and nomads, and those living in conflict-affected settings

Activity 1-3: Review public health literature/Host expert meetings/Create a short job-aid with guidance on how to do MDA in difficult settings.

In Q1–Q2, activities have addressed issues for populations in urban centers and areas affected by conflict. These efforts will be finalized and disseminated in Q3–Q4 and more focus will be placed on addressing issues of reaching migrants and populations with traditional beliefs.

Urban MDA activities: RTI has collaborated with researchers at CDC and Georgetown University to complete a literature review on delivering treatment in urban settings – with a focus on MDA activities for NTDs and immunization programs. Using a standard framework, information on MDA activities conducted in Haiti, Indonesia, Mali, and Nepal were also collected. Results of literature reviews and case studies were shared in at a meeting at Georgetown University on March 28, 2017, featuring expertise of urbanization experts, and guidance was drafted. This experience is now being documented for two different types of publications: a technical brief targeted at implementers and a literature review for publication in a peer-reviewed journal. In Q3–Q4, plans include further developing the Mali (and possibly Haiti) case studies for presentation at meetings and/or publication and exploring whether there are more case studies to be conducted in countries supported by the End Neglected Tropical Diseases (END) in Africa project.

Conflict-affected zones: ENVISION and USAID jointly chaired a panel on conducting treatment interventions in conflict-affected zones during the American Society for Tropical Medicine and Hygiene (ASTMH) meeting in 2016. These case studies are now being written up for further dissemination.


See above and SAR section, “Dissemination of Best Practices”

32

2. Drug and Commodity Supply Management and Procurement

The successful implementation, scale up, and scale down of MDA constitute the core activities of the ENVISION project. To support these functions, the ENVISION project procures NTD medicines and diagnostics for its countries, supports supply chain management, and provides global leadership around NTD drugs and diagnostics.

Objective 1: Procure medicines for use by ENVISION-supported countries

Objective 2: Coordinate with WHO and donation programs to track drug applications, shipments

Objective 3: Support ENVISION countries to complete disease-specific assessments (DSAs) through procurement of diagnostics

Objective 4: Continue to strengthen in-country supply chain

Objective 1: Procure medicines for use by ENVISION-supported countries

Activity 1: Procure and ship PZQ to two ENVISION-supported countries. ENVISION awarded contracts to suppliers International Dispensary Association (IDA) Foundation and MissionPharma to supply PZQ in FY17, and orders were placed for Tanzania and Uganda. During Q1-Q2, ENVISION delivered 10,675,000 tabs of PZQ to Tanzania. The 6,370,000 tabs of PZQ are ready to be shipped to Uganda, pending import approval from Uganda’s national drug authority, and will arrive in FY17 Q3.

Activity 2: Procure TEO for ENVISION-supported countries. ENVISION awarded a contract to supplier IDA Foundation to supply TEO in FY17, and orders were placed for Benin, DRC, Guinea, Ethiopia, Mozambique, Uganda, and Senegal. During Q1–Q2, orders of TEO were delivered to Guinea (437,500 tubes), Uganda (20,200 tubes), and Benin (52,600 tubes). DRC’s order of TEO (176,000 tubes) is currently ready, but will ship after IDA Foundation completes the country registration renewal process in May. Orders for Mozambique (231,500 tubes), Senegal (160,150 tubes), and Ethiopia (1,563,200 tubes) are currently being manufactured and will be delivered to countries in the coming months.

Objective 2: Coordinate with WHO and donation programs to track drug applications and shipments

Activity 1: Continue to track JRSM and TEMF. ENVISION staff provide monthly updates to the Joint Application Matrix, which tracks country submission data of the Joint Application Package (JAP). ENVISION continues to encourage timely and high-quality submissions by countries of the JRSM to WHO and the TEMF to WHO and ITI, and engages in reviewing applications whenever possible. ENVISION staff followed up closely with country programs to ensure on-time submission of the TEMF and ZTH application by the March 1, 2017 deadline.

WHO recently added another JRSM submission deadline of April 15 for countries that treat during the first half of the calendar year, although the effectiveness of communications about this new deadline is questionable. It is worth noting that AFRO appears to have communicated a deadline of February 15, 2017 for countries in the region, given the timing of the RPRG meeting in April 2017. Benin, Ethiopia, and Tanzania were aware of the new deadline and submitted their JRSMs for 2018 medicines to WHO. ENVISION staff were permitted to review Benin’s and Tanzania’s applications.

During the April 2017 RPRG meeting, ENVISION reminded the RPRG about the three submissions (there appeared to be miscommunications such that the RPRG had not received the applications). Fortunately, with quick feedback from ENVISION staff, the JAP containing the JRSM was re-sent and was able to be

33

reviewed. ENVISION expects that all other countries in the portfolio will submit their applications by the August 15, 2017 deadline, and will continue to follow up with MOHs to ensure that this deadline is met and good quality applications are submitted.

The recent roll out of the iNTegrateD database (renamed NTDeliver), which tracks the progress of WHO-managed drugs (ALB, PZQ, and MEB), has been communicated to ENVISION staff. All RTI ENVISION Technical Advisors and ENVISION sub-partner technical leads have been provided with log-ins to this new system. Technical Advisors are encouraging MOH staff to also get log-ins.

Activity 2: Implement ZTH tracker with ITI. ITI recently rolled out a database to track Zithromax® shipments from signed MOU to confirmation of receipt. The shipment data is accessible to partners through the ITI Zithromax® Shipment Tracker, a website where interested parties (including Ministries of Health, implementers, and funders) can sign up for updates each time a shipment’s status changes. The updates are emailed automatically to the subscriber. ENVISION staff have also been encouraged to subscribe to the to receive regular updates on ZTH shipment milestones, and staff are reaching out to MOHs to encourage them to subscribe as well.

ENVISION has also begun using the data available through ITI’s database to maintain an internal ZTH shipment tracker for all ENVISION countries. This ENVISION-specific tracker provides a project-wide view of planned shipment and MDA dates, quantities of approved and shipped ZTH, and shipment status. The internal ENVISION tracker was recently launched, and will be updated and shared with ENVISION staff monthly.

Objective 3: Support ENVISION countries to complete DSAs through procurement of diagnostics

Activity 1: Procure LF diagnostics. During the first half of FY17, ENVISION procured filariasis test strips (FTS) from Alere for pre-TAS and TAS in Benin (20,820 tests), Cameroon (56,880 tests), Haiti (3,360 tests), Mali (11,760 tests), Nigeria (10,620 tests), and Tanzania (8,520 tests). See Table 4. Vietnam’s order of FTS (990 tests) is ready and currently waiting for country import approval, and orders for Tanzania (59,700 tests) and Nepal (10,020) have been placed with Alere and are expected to arrive in country in Q3–Q4 of FY17. ENVISION has faced delays and communication issues with Alere, and is making efforts to place FTS orders far in advance to limit the impact of production delays.

ENVISION also procured Brugia Rapid tests from Reszonics for Indonesia (8,125 tests) and the Philippines (7,500 tests). An additional 1,600 tests are ready to be shipped to Vietnam, pending country import approval and will arrive in the Q3–Q4 of FY17.

In addition to ENVISION’s procurement of FTS, Haiti and Uganda have also participated in WHO’s FTS donation program, with mixed results. The process worked well for Uganda, where FTS arrived as planned in late February 2017. Unfortunately, production delays at Alere led to the late arrival of FTS in Haiti. Delays in the FTS arrival pushed back the start date for ENVISION-funded TAS1 and TAS2. RTI is following up with WHO and Alere on this issue and encouraging countries to work with WHO to ensure that orders are placed in July–August when FTS are needed early in the calendar year to prevent delays in future.

Activity 2: Procure SCH/STH diagnostics. During Q1-Q2 of FY17, ENVISION procured Kato Katz kits from Sterlitech (a WHO-approved supplier of the tests) for use in an STH assessment in Benin (9,500 tests), STH-TAS surveys in Haiti (3,500 tests), and a SCH-STH prevalence evaluation survey in Senegal (4,000 tests).

34

Table 4. ENVISION procurement in FY17, Q1-Q2

Country TEO

(tubes) PZQ

(tablets) FTS

(tests) Brugia Rapid™

(tests) Kato-Katz

(tests) Benin 52,600 — 20,820 — 9,500 Cameroon — — 56,880 — — DRC — — — — — Ethiopia — — — — — Guinea 437,500 — — — — Haiti — — 3,360 — 3,500 Indonesia — — — 8,125 — Mali — — 11,760 — — Mozambique — — — — — Nepal — — — — — Nigeria — — 10,620 — — Philippines — — — 7,500 — Senegal — — — — 4,000 Tanzania — 10,675,000 8,520 — — Uganda 20,200 — — — — Vietnam — — — — — FY17 Q1–Q2 Total 510,300 10,675,000 111,960 15,625 17,000

Objective 4: Continue to strengthen in-country supply chain

Activity 1: Promote good stewardship of PZQ through physical inventory of donated product in large-user countries. Following discussions with USAID about potential sensitivities around ENVISION being perceived as playing an oversight role of the host government’s supply chain system, this activity was cancelled.

Activity 2: Strengthen in-country drug supply chain. ENVISION continues to support seconded Drug Logistics Officers in Ethiopia, Tanzania, and Uganda, and supports a drug logistics consultant in Mozambique. These positions illustrate part of ENVISION’s role in strengthening the health system as they help ensure that donated and purchased medicines are managed properly and used efficiently, which is essential for successfully implementing MDA programs.

In Ethiopia, ENVISION funds a Drug Logistics Officer who is seconded to the PFSA. The seconded Drug Logistics Officer plays a key role in building the capacity of the PFSA to manage Ethiopia’s NTD supply chain and coordinating in-country NTD drug management issues between the FMOH, PFSA, Regional Health Bureaus (RHBs), and NTD implementing partners. Ethiopia has integrated all NTD drugs into its national drug management system, although collaboration between the various agencies involved in the NTD supply chain is still being fine-tuned. For example, the seconded Drug Logistics Officer organized trainings for local PFSA staff to be introduced to local NTD program staff from the RHBs and woredas, and for those staff to learn how PFSA operates. Unfortunately, because of tensions between FMOH and PFSA, PFSA staff could not participate in the trainings. ENVISION will work with the FMOH and PFSA to identify future opportunities to bring these parties together. The seconded Logistics Officer also developed SOPs for NTD supply chain management in Ethiopia, and will be working on finalizing and disseminating the manual during Q3–Q4 of FY17.

35

In Mozambique, the ENVISION-supported drug logistics consultant interacts with Centre for Drugs and Medical Supplies (the national medical store) to facilitate seamless clearance of AZT and TEO. He also repackages drugs into MDA kits, which contain the necessary amount of AZT, TEO and IEC materials for each district’s MDA. The MDA kits help reduce the logistical burden on the NTD program by simplifying the delivery of sufficient MDA supplies to each district. During the first half of FY17, ENVISION and ITI discovered the possible mismanagement of donated ZTH in Mozambique. To address the issue, ENVISION supported a physical inventory in all 5 provinces and worked with ITI on a comprehensive program assessment, which will be completed, in collaboration with the MOH, during the second half of FY17.

In Tanzania, ENVISION funds a Drug Logistics Officer who is seconded to the NTD Control Program (TZNTDCP), who works to build the NTD supply chain management capacity of the TZNTDCP and NTD Secretariat. During the first half of FY17, the drug logistics officer assisted with forecasting medicines and supplies needed for MDA, supported completion of the JRSM and TEMF/ZTH application, and coordinated clearance, storage, and transportation of imported drugs and diagnostics. The seconded Drug Logistics Officer also led the development of national NTD supply chain management guidelines, which cover NTD drug inventory, quantification, reverse logistics, reporting forms, and SAE management. So far, the guidelines have been incorporated into supply chain training for 158 regional and district-level pharmacists from across Tanzania.

In Uganda, ENVISION’s Logistics Officer helped the MOH and Central Medical Stores with clearance of the TEO and PZQ that ENVISION procured and delivered in Q1–Q2 of FY17. He will continue to assist with customs clearance of the second shipment of PZQ, which will arrive in May 2017.

36

IR 2: IMPROVED EVIDENCE BASE FOR DETERMINING AND ASSESSING ACTION TO CONTROL/ELIMINATE TARGETED NTDS

AND ELIMINATE NTDS

37

1. Baseline Disease Mapping

Strategic Approach

With the conclusion of the GTMP, most suspected endemic districts had completed baseline trachoma mapping globally by the start of CY16. ENVISION expected all trachoma mapping in ENVISION-supported countries to be completed by the end of FY16 (excluding inaccessible areas of Ethiopia, Guinea, and Nigeria and parts of DRC). The last areas targeted for baseline trachoma mapping in FY16 included limited areas of Nigeria and Ethiopia; however, these have been inaccessible due to insecurity issues and it is unknown when they will become accessible.

Activity 1: Complete trachoma baseline mapping in DRC and Cameroon refugee camps. In DRC, following the initial mapping in 46 priority health zones, reviews of the data during FY17 work-planning suggested that trachoma was more widespread than originally anticipated; thus, further mapping was recommended. Areas contiguous to known endemic health zones were prioritized for mapping with ENVISION support in FY17 (38 health zones) in former Katanga, former Equateur, and Ituri. In addition, RTI’s Trachoma Focal Person, Jeremiah Ngondi, in consultation with the MOH, selected 51 health zones for trachoma rapid assessment (TRA) to determine if further mapping will be necessary. Due to security concerns, North and South Kivu will not be mapped in FY17. In Cameroon, ENVISION planned to map the Minawao refugee camps and Kolofata health district, which have been experiencing insecurity issues. The MOH has recently raised the possibility of conducting coordinated mapping in these two areas, and discussions with UNHCR are moving more slowly than anticipated. As a result, the trachoma mapping will not take place in FY17, and will be discussed further during FY18 work planning.

Activity 2: Utilize the WHO-led Tropical Data system. In February and March 2017, ENVISION trained the MOHs from Cameroon and DRC on the Tropical Data system for disease assessments. In DRC support was provided to the MOH and partners to undertake planning for proposed trachoma surveys and a TRA. In addition, DRC MOH supervisors were trained on how to conduct refresher training for survey recorders and graders. The surveys for DRC are scheduled for June and July 2017, during the dry season.

Following Tropical Data super training (high-level training for master trainers) for survey graders and recorders in June and July 2016, and TA support in Cameroon, DRC, Vietnam, and Nepal, all ENVISION-supported countries are now using the Tropical Data system for trachoma surveys. In FY17, ENVISION is supporting additional super-training sessions to ensure that country programs have enough capacity to train graders and recorders for future impact and surveillance surveys.

2. National Program M&E Data Quality

Strategic Approach

ENVISION’s primary objective around national program M&E data quality is to ensure data are accessible, of high quality, and that they inform national decision making.

National program managers have reported that data use is constrained due to multiple barriers, including the following:

• Concerns about the accuracy of data on numbers of persons treated and on denominators prevent programs from using the information they have (especially data for SAC populations and for target populations defined at a subdistrict level).

38

• The lack of capacity to store and manage data makes it challenging to accurately report data and use them for requests for drug procurement, to determine eligibility to stop MDA, and for validation of elimination.

• The amount of information becomes overwhelming if not appropriately synthesized and visualized.

• Lack of timely access to coverage data means programs need to wait another year to improve coverage.

ENVISION has developed resources and tools over the past few years that address these challenges (Table 8).

To address concerns on accuracy of numbers treated and of denominators:

The post-MDA coverage survey can be used to assess the validity of routinely reported coverage rates. If the post-MDA coverage survey shows that routinely reported coverage information is sufficient to identify low-performing districts, then emphasis should be put on using that data—prioritizing activities in low-performing districts. When the coverage survey is combined with a knowledge, attitudes, and practices (KAP) questionnaire, additional information is available on why there is low performance. On the other hand, when the post-MDA coverage survey identifies large inaccuracies in the data, then measures need to be taken to improve the data reporting system used during MDA. A data quality assessment (DQA) in turn generates information on where the weakness lies and points to specific actions that can be taken to strengthen the quality of reported data.

To improve a program’s ability to store, manage, and report its data:

During the AFRO M&E workshops held in 2012, national programs voiced their need for an NTD database. ENVISION then worked with WHO and other stakeholders to develop the Integrated NTD Database. This tool has now been introduced in nearly 50 countries through regional and in-country trainings, and 11 ENVISION countries have developed a historical data plan and are in various stages of completing data entry. As this is rolled out, however, there is a need to support new users, promote its use for generating automated reporting forms, ensure updates are made, and increase its functionality for generating reports and/or figures that can be used to guide action plans.

To increase data synthesis and visualization:

ENVISION has developed two tools to aid data synthesis and visualization—the Data for Action Guide and an online map-making tool, USAID’s NTD Map Tool. These will be disseminated in USAID-supported countries for feedback in FY17 with the purpose of synthesizing large amounts of data, communicating key information, and facilitating action.

To improve access to coverage data during MDA:

Several new approaches are being tested for ease-of-use-at-scale and for effectiveness in FY17, including the independent monitoring tool, coverage supervisory tool, and real-time reporting to national level (see MDA coverage section). Results of these efforts will inform future plans.

39

In FY17, ENVISION will prioritize strengthening national program capacity on M&E by working closely alongside MOH staff in ENVISION countries to address challenges—by strengthening the cadre of local M&E experts available to support national programs, by focusing on the dissemination of tools and approaches that have been developed previously to solve these problems, and by continuing to collaborate closely with WHO.

This section contains four objectives for FY17, with related activities, that follow the strategic approach presented above:

Objective 1: Strengthen national programs’ capacity to address data quality concerns so that data can be used.

Objective 2: Increase functionality and use of the Integrated NTD Database to increase accuracy in reporting.

Objective 3: Increase access to analyzed, synthesized, and ready-to-use information.

Objective 4 (addressed in the MDA Section): Increase use of coverage data during MDA activities.

40

Table 5. Summary of M&E tools

M&E Tool Purpose Description of tool Methods

Post-MDA Coverage Survey

Validate reported coverage and identify population groups and reasons for not participating in MDA.

Paper-based or electronic survey

1. Sample districts, households, and individuals. 2. Ask individuals if they took part in MDA, and reasons for not participating. 3. Compare surveyed coverage to reported coverage. 4. Develop recommendations and then operationalize with corrective actions as needed.

DQA Determine the quality of data and reporting system and take actions to strengthen weaknesses.

Excel-based survey 1. Sample at each level where data are aggregated and collected. 2. Recount data at each sampled site and compare to what were reported. 3. Assess data management system through key informant interviews. 4. Develop action plan and operationalize with corrective actions as needed.

Integrated NTD Database

Provide central repository for national programs to store, manage, analyze, and report their data.

Microsoft Access using .net platform

1. Compile historical data and enter it into the database. 2. Update as additional data become available. 3. Generate reports to analyze, share, and use data.

Tool for Integrated Planning and Costing (TIPAC)

Accurately estimate costs and funding gaps of NTD programs.

Excel-based program 1. Gather cost data. 2. Use National Strategic Plan as a basis to determine upcoming NTD activities. 3. Populate tool. 4. Share with key stakeholders for input and use. 5. Update annually.

Data for Action Guide

Synthesize large amounts of information to drive clear, actionable planning.

MS Word-based facilitation guide

1. Gather all relevant information. 2. Synthesize relevant information. 3. Present the critical information in a slide presentation with accompanying handout. 4. Facilitate change: the process of turning recommendations into planned and budgeted activities. 5. Evaluate: follow up to ascertain activities were implemented as planned and intended outcomes were achieved. Include in “gather” stage next year.

Online Map-Making Tool

Visualize data geographically to facilitate planning and track progress.

ArcView web-based platform

1. Select country. 2. Select desired attribute (e.g., LF endemicity, STH geographic coverage). 3. Generate maps to analyze, share, and use data.

41

Objective 1: Strengthen national programs’ capacity to address data quality concerns

Activity 1: Strengthen in-country capacity to use post-MDA coverage surveys. Most ENVISION-supported countries plan to implement post-MDA coverage surveys this year. See Table 6. In Q1-Q2, ENVISION worked with WHO and TFGH to develop a packet of guidance materials, now available on the NTD Toolbox. This packet is sent to local survey organizers six to eight weeks before each survey’s start date. Materials include the 2016 WHO guidance on Coverage Evaluations (WHO), a document of frequently asked questions for logistics and planning, a planning timeline, the Coverage Survey Sample Builder (TFGH), the standard coverage and KAP questionnaire developed by ENVISION, a report outline guide, and examples of exemplary reports in English and French to promote country-to-country learning.

The goal of this guidance is to ensure that national programs are aware of and able to implement the new WHO guidance, and that they are prepared to employ best practices in the planning, implementation, and analysis of their surveys. In some countries, such as DRC, Indonesia, and Nepal, local capacity already exists in implementing the previously-endorsed EPI approach, which is still considered valid by WHO. These countries have chosen to continue leveraging that capacity, given the added field time and retraining requirements to change to the more recent guidance. In these cases, ENVISION has and will continue to advise survey planners to weigh both options and select the approach that best suits a country’s needs.

Table 6. Post-MDA coverage surveys with ENVISION support, FY17

Country FY17 Coverage

Survey FY17 KAP module

expected

Experience with or knowledge of new WHO

survey guidelines (as of April 201717)

Cameroon Yes Yes No

DRC Yes Yes Yes Ethiopia Yes Yes Yes Guinea Yes Yes No Indonesia Yes Yes Yes

Mali Yes Yes No Mozambique Yes Yes No Nepal Yes Yes Yes Nigeria Yes No No Philippines Yes No No

Uganda Yes Yes Yes Total (Yes) 11 9 5

17 None of the ENVISION-supported surveys thus far have used the new approach since it requires resources and retraining. While WHO considers the old approach as still valid, ENVISION is currently surveying all 14 countries to see what other institutions might have this capacity. Results will arrive after SAR submission.

42

ENVISION also reviews protocols for country teams before their surveys to ensure enumerators are visiting houses effectively and ethically, and that sampling approaches are appropriate to each survey’s specific goals. To date in FY17, ENVISION reviewed protocols for DRC, Indonesia, Mozambique, Nepal, and Uganda.

In addition to material guidance and protocol review, the coverage survey focal point for ENVISION at RTI (Brian Fuller) initiated dialogue with local survey planners to reinforce their understanding of best practices and of the new WHO guidance. This headquarters (HQ)-based coaching directly addressed relevant questions, including electronic data collection methods, survey goal setting, budget estimates, survey question development, analysis, and data visualization.

Country-led ENVISION support was also provided, jointly with WHO, to support training of trainers (TOT) from MOH and from local research institutes on post-MDA coverage surveys in Ethiopia.

Activity 2: Implement TOT for new post-MDA coverage survey sampling approach. The TOT, to be held in the second half of FY17, will focus on operationalizing the 2016 WHO guidance on coverage surveys; building a pool of practitioners who can share mastery of the process, both inside and outside their respective countries; and, where feasible, strengthening institutional capacity. A needs assessment is currently underway, and activities will be implemented in Q3–Q4 based on results.

Activity 3: Maintain DQA tool. Originally developed by ENVISION in collaboration with WHO, the DQA tool and associated manual were revised in FY16 to incorporate feedback from field experience in multiple countries. ENVISION supported updates, translated the tool into French, and presented the final version at WHO’s M&E Tool Orientation in Geneva in early October 2016. The updated manual and tool were sent to WHO for final review and to undergo internal editing and formatting. As of March 2017, WHO anticipates publishing the tool and manual in early Q3. ENVISION will update the training materials (PowerPoint presentation, Facilitator’s Manual, Participants’ Workbook, and pre/post-tests) to reflect the finalized WHO tool and guidelines. They will be translated into French and Portuguese and disseminated in the second half of the year.

Activity 4: Strengthen capacity of ENVISION-supported countries to implement DQA. After the DQA was launched in most ENVISION countries, examples of local ownership and adoption are emerging. In Ethiopia, the DQA was included in a standardized NTD M&E tools package and is being integrated into the standard M&E training for health extension workers. RTI local staff and WHO supported a TOT (of FMOH, partners, and local research organizations) for this effort. Senegal pulled components of the DQA into a new supervisory tool for central-level staff. It is anticipated that this updated supervisory form will be used during the upcoming integrated MDA campaign. ENVISION will provide mentorship and on-the-job training during the planning and implementation phases of the DQA in Mozambique and Senegal during the second half of FY17, as well as ensure that recommendations are put into action.

ENVISION will continue to follow up on DQA use and implementation of findings in the countries that implemented DQAs in previous years.

Objective 2: Increase functionality and use of the Integrated NTD Database

Activity 1: Maintain and improve Integrated NTD Database template; support tool transition to full WHO ownership. During the first half of FY17, RTI began transferring the management of the Integrated NTD Database to WHO. During a meeting between RTI and WHO in Geneva in February 2016, it was agreed that RTI would complete pending database development activities in FY17, and that all further database development would be conducted by WHO. Following the meeting, RTI shared the source code

43

for the database with WHO. Meetings with WHO to ensure a smooth transition and collaboration during this period continue.

In the first half of FY17, RTI fixed all reported user bugs to date and added standard reports, e.g., for planning TISs and TASs. In addition, the updated WHO EPIRF can now be generated using the Integrated NTD Database.

Activity 2: Support MOH implementation of Integrated NTD Database. In FY17, Q1–Q2, ENVISION continued to support MOHs to establish and maintain their part of the Integrated NTD Database. The adoption of the database has varied across countries. In some countries, ENVISION continues to advocate for dedicated personnel at the MOH to manage and maintain the database after the initial collaboration between ENVISION and MoH to enter historical data in the database. In others, MoH has the proven capacity and competency to maintain and manage the database on their own, so ENVISION continued to offer technical assistance whenever it is requested. In some countries, the database is fully adopted by the MoH, regularly being used to monitor performance indicators, and historical data extensively at district level microplanning sessions. The progress in adopting the Integrated NTD Database in 25 USAID-supported countries is shown in Table 7. In brief, the overall status of Integrated NTD Database use is as follows:

• 19 countries have received training on the Integrated NTD Database. • 18 countries have started historical data entry into the Integrated NTD Database. • 8 countries have completed data entry (to date) into the Integrated NTD Database. • 4 countries have used the Integrated NTD Database to submit WHO forms.

Bangladesh was trained as part of WHO’s Southeast Asia Regional Office (SEARO) regional training, and remote support will take place in FY17. Tanzania, Philippines, and Vietnam use a different database. Cambodia and Laos are in the final stages of their NTD program and do not see a need for an Integrated NTD Database.

Activity 3: Develop three to five online tutorials to strengthen country capacity to use the Integrated NTD Database. To be completed in Q3–Q4, in close collaboration with WHO.

Activity 4: Establish a Community of Practice for the Integrated NTD Database. Planning is underway to launch the Integrated NTD Database Community of Practice in Q3. ENVISION drafted a two-page promotion flier with mini country case studies and program manager testimonials in support of this activity.

44

Table 7. Uptake of the Integrated NTD Database

Country name In-country training?

USAID support for historical data entry?

Historical data entry started?

Historical data entry

complete?

Ever used database to

generate any WHO forms?

Bangladesh Benin Cambodia Cameroon DRC Ethiopia Guinea Haiti Indonesia Laos Mali Mozambique Nepal Nigeria Philippines Senegal Tanzania Uganda Vietnam Burkina Faso Cote d'Ivoire Ghana Niger Sierra Leone Togo

Status of Integrated NTD Database by country Yes No

Objective 3: Increase access to analyzed, synthesized, and ready-to-use information

Activity 1: Support development of the Data for Action Guide. ENVISION has shared examples of use of this guide, or similar approaches, in Benin, Indonesia and Uganda, with the HQ M&E and TA teams who are taking this forward for use during planning for FY18 work plans. The guide is also available in English and French in the ENVISION NTD Toolbox:

Activity 2: Roll out map-making solutions. ENVISION, its supported national programs, USAID, and others regularly request geographic information systems (GIS) maps to illustrate disease burden, project

http://www.ntdenvision.org/sites/default/files/docs/ntd_data_action_planning_guide_v2.pdf

http://www.ntdenvision.org/sites/default/files/docs/ntd_data_action_planning_guide-french.pdf

45

activity, and other district-level data. In response to this need, ENVISION developed a web-based mapping tool (http://maps.ntddatabase.org/), called USAID’s NTD Program Map Tool, to allow users to produce a limited number of maps on demand and with little-to-no training in the use of GIS software. As of Q2, maps that show endemicity, geographic coverage, program/epidemiological coverage from both FY15 and FY16 MDA activities, and areas with recurrent low-coverage problems are available for each of the five diseases (equaling 25 different maps available for each of USAID’s 25 supported countries). Maps are available in English, French, and Portuguese.

HQ-level RTI and USAID logins, individual country logins, and partner account logins have been distributed. Use of the tool will be followed up in Q3–Q4 by obtaining user feedback and results from Google Analytics.

It is anticipated that the tool will be updated at least three times annually to correspond with each of the reporting seasons (work planning, SAR 1, SAR 2), and use of this tool will allow future automation of standard maps for reporting.

In addition to these standard maps, RTI continued to support requests for custom GIS maps presented by ENVISION country teams.

3. Disease-Specific Assessments and Surveillance

Strategic Approach

As outlined in the FY17 work plan, ENVISION’s approach is to strengthen national program capacity to implement high-quality DSAs and use the resulting data to inform program strategies. ENVISION prioritizes DSAs in areas where USAID previously supported MDA activities, with preference given to both LF and trachoma assessments when necessary due to funding limitations. Please see Appendix 2 for country-specific progress toward implementation of DSAs in FY17.

This section contains five objectives for FY17, with related activities, that follow the strategic approach presented above:

Objective 1: Strengthen capacity to implement high-quality TAS and TIS.

Objective 2: Ensure TAS, TIS, and trachoma surveillance surveys (TSS) are implemented in a timely manner.

Objective 3: Support national programs to collect, process, review, approve, use, and archive high-quality trachoma prevalence data.

Objective 4: Investigate DSA failure.

Objective 5: Understand STH distribution to inform post-LF strategy.

Objective 1: Strengthen capacity to implement high-quality TAS and TIS

Activity 1: Carry out strategy and TA for country trainings for TAS. In the first half of FY17, ENVISION supported TAS trainings in Benin, Haiti, Laos, and Nepal. Trainings were adapted to country context. For example, in Benin—where TAS had been implemented extensively—the training focused on proper use of FTS and coordination with the STH survey, while the training in Laos—where TAS had never been conducted—included all WHO modules, with a focus on completing the TAS eligibility form and the survey sample builder. Similarly, in Nepal, where local nongovernmental organizations (NGOs) had implemented TAS in the past, but the MOH, the Vector Borne Disease Research Training Centre, and the

46

national public health laboratory will implement the surveys this year, the training included all WHO modules. In Haiti, two trainings were held—a refresher training focused on use of FTS and STH assessments, and a training for new TAS implementers, which followed the WHO modules. TAS checklists on preparation and supervision were also introduced and adapted to country context during the trainings. Previously trained MOH staff and/or ENVISION staff, as well as U.S. CDC staff facilitated trainings in Benin and Nepal. Post-test results showed good understanding of the material presented, with an increase from an average of 39% to 82% in Nepal, and an average post-test score of 77% in Laos (where a pre-test was not administered).

ENVISION also worked with WHO AFRO to plan two regional TAS trainings, tentatively scheduled for May 30–June 2, 2017.

Activity 2: Carry out strategy and TA for country trainings for TIS and TSS. To date during FY17, ENVISION focused on enabling use of Tropical Data for trachoma surveys in all country programs. The project provided TA and training on the Tropical Data system to Cameroon, DRC, Vietnam, and Nepal. The number of trainees certified, per country and trainee category, included the following:

• Cameroon: 15 graders, 15 recorders, and 2 supervisors

• DRC: 4 training of trainers and 4 MOH supervisors

• Vietnam: 12 graders, 10 recorders, and 2 supervisors

• Nepal: 5 graders, 5 recorders, and 2 supervisors.

Other support provided to all ENVISION-funded countries included drafting and review of survey protocols and assistance with survey applications in the Tropical Data system.

In addition to supportive TA provided directly by ENVISION, there have also been south-to south collaboration activities between countries. For example, Tropical Data trainers from Uganda supported training in Eritrea in November 2016, and Lusophone trainers from Mozambique supported training in Guinea Bissau. The ENVISION staff in Senegal helped Burundi by undertaking a teleconference to discuss survey planning and budgeting for a mapping survey.

Objective 2: Ensure TAS, TIS, and TSS are implemented in a timely manner

Activity 1: Maintain the TAS tracker. ENVISION sent the TAS tracker to USAID monthly and included updated information on eligibility for TAS, timing of TAS, and TAS results. In addition, the project modified the tracker to include columns on co-endemicity with STH and OV. In addition to the monthly updates, ENVISION used the tracker to capture information in advance of October 2016 and April 2017 AFRO RPRG meetings. Specifically, information related to TAS eligibility and results was included to improve USAID and ENVISION advocacy with the RPRG to ensure activities were not delayed while countries awaited RPRG recommendations.

Activity 2: Maintain the trachoma survey tracker. ENVISION implemented a new trachoma survey tracker in FY17 to support coordination of trachoma surveys and timely collation of survey results for programmatic decision making. The tracker is an MS Excel™-based spreadsheet with a list of districts where trachoma surveys are planned and the dates when surveys are scheduled. The tracker also has a

South-to-south exchange to expand use of Tropical Data

Uganda → Eritrea Mozambique → Guinea Bissau

Senegal → Burundi

47

section for TF and TT prevalence results that is completed after surveys are completed. The tracker is updated and shared with ENVISION and USAID teams every month.

Using the tracker, ENVISION prioritizes TA for survey applications using Tropical Data, survey planning, and survey training. In FY17, a total of 168 surveys are planned, comprising 26 mapping, 86 impact, and 56 surveillance surveys. By the end of Q2, a total of 66 surveys (39% of the total, mainly impact surveys) had been completed. In April and May 2017, survey fieldwork is planned in Senegal, Uganda, Nepal, Mozambique, and Vietnam, during which 30 surveys will be completed. The remaining impact and surveillance surveys will be conducted when the lead times of 6 months after MDA (for impact) and 24 months after impact surveys (for surveillance) have been attained.

Objective 3: Support national programs to collect, process, review, approve, use, and archive high-quality trachoma prevalence data

Activity 1: Strengthen capacity through international TOTs (super trainings). The international TOTs aim to strengthen capacity for country programs18 to conduct trachoma surveys using the Tropical Data system. In FY16, following Tropical Data’s launch, super trainings were conducted in June 2016 for Anglophone countries and in July 2016 for Francophone countries. The number of trainees certified at these trainings included 11 master trainers, 21 grader trainers, 28 recorder trainers, and 6 graders. Based on the increasing demand for impact surveys and surveillance surveys, further Tropical Data super trainings are scheduled for Anglophone countries in May 2017 (in Arusha Tanzania) and Francophone countries in July 2017 (in Senegal). The super trainings focus on increasing the number of certified graders and recorders for country programs.

Activity 2: Provide epidemiological support for trachoma impact and surveillance surveys. The Tropical Data system aims to standardize collection of high-quality survey data for programmatic decision making and evaluation of attainment of elimination targets. Through ENVISION’s Regional NTD Technical Advisor, based in Tanzania, ENVISION has provided epidemiological support to all ENVISION-supported trachoma-endemic countries, helping country programs to develop robust survey protocols and survey plans. The Regional NTD Technical Advisor has also provided support for developing a protocol for impact and surveillance surveys for Eritrea and TT-only survey protocols for Uganda and Mozambique through his role as epidemiologist on Tropical Data.

Activity 3: Advise on project systems. The Tropical Data platform, hosted and managed by ITI, builds upon GTMP’s legacy. The Tropical Data system uses a smartphone application (app) and a secure, cloud-based database to support trachoma surveillance and impact surveys. The Tropical Data System not only supports data collection, data analysis, and data use, but also scientific protocol review, project registration, and help-desk services. With ENVISION funding, RTI provided technical advice for the development of the Tropical Data registration system, mobile app, server database, and web application.

Since its launch in June 2016 to date, Tropical Data recorded applications for surveys in 420 districts across 19 countries. The applications included baseline (156 districts), impact (203 districts), surveillance (45), and TT-only (16) surveys. Of the 420 districts scheduled for surveys, 285 (68%) had been completed

18 It should be noted that the ENVISION-supported trainings for Tropical Data are available to all countries globally, not just the USAID-supported countries.

All ENVISION-supported

countries are now using

WHO’s Tropical Data system for

trachoma surveys.

48

by the end of Q2. ENVISION-supported countries have submitted their applications for FY17 and are on schedule to implement surveys as planned.

Activity 4: Provide global leadership and coordination for the Tropical Data system. Tropical Data system has replaced the GTMP as the WHO-accredited system for conducting trachoma mapping and impact, surveillance, and TT-only surveys. ENVISION continues to participate in weekly Tropical Data calls and other meetings to ensure coordination of activities with WHO, ITI, and Sightsavers, the global partners leading Tropical Data.

Objective 4: Investigate DSA failure

Activity 1: Provide TA to countries to use the “Investigating TAS Failure Checklist” to explore TAS failure. ENVISION provided support through TAS trainings (see above) and visits by Technical Advisors to LF national programs on adaption and use of TAS checklists. In Cameroon, for example, the ENVISION Technical Advisor convened a meeting with the local research group involved in TAS, the MOH team, and the Helen Keller International (HKI) team to present the checklists question by question and adapt them to the Cameroon context. This will be further enforced during the upcoming TAS training. In terms of the “Investigating TAS Failure Checklist,” only one TAS failure has occurred in Q1–Q2: Bara district in Nepal failed TAS2. The MOH and the ENVISION team analyzed past MDA data and TAS1 and TAS2 results, and will collect further data, using the checklist as a guide to design qualitative research in Q3 to better understand the causes of failure.

Objective 5: Understand STH distribution to inform post-LF strategy

Activity 1: Promote inclusion of STH assessment in TAS. Operationalizing the inclusion of STH assessments into TAS has met with varying success in ENVISION countries. In Haiti, where a plan to collect STH data in every TAS1 commenced in 2016, ENVISION supported an STH assessment integrated with TAS in February 2017, with other surveys planned for March through May. Uganda is planning integrated assessments using WHO’s methodology in April through July 2017, including one survey with OR to test PCR diagnostics for STH. It is envisioned that the STH results will be shared with relevant partners to plan the Child Health Day deworming activities. On the other hand, in Benin, STH assessments will be integrated with TAS but will not follow WHO’s STH-TAS methodology. Instead, because some implementation units within an LF evaluation unit were classified as not requiring STH MDA, STH data will only be collected from schools in areas that required STH MDA at baseline.

4. Preparing for Elimination

Strategic Approach

At the end of FY16, 5 ENVISION-supported countries had at least 75% of districts in the post-MDA surveillance phase for LF; by the end of FY17, this will increase to 11 countries (Table 8). These projections assume all districts achieve at least five rounds of sufficient epidemiological coverage in the remaining years and pass pre-TAS and TAS1. Similarly, for trachoma, four countries had more than 75% of districts in the post-MDA surveillance phase in FY16, and this is projected to be six countries in FY17 (Table 9). Among the 10 ENVISION-supported countries for OV, Uganda has stopped MDA in one-third of districts classified as requiring treatment, and Mali and Senegal are expected to scale down treatment over the next two fiscal years. Given this progress toward elimination, ENVISION focused on supporting pre-dossier development and dossier finalization in Q1-Q2, FY17. This support will continue in the

49

remainder of the fiscal year, and a planned celebration of trachoma elimination will take place in Laos in Q4.

For this report, post-MDA surveillance for LF is defined as the time period between stopping MDA and submission of the dossier validating elimination of LF as a public health problem. This pre-validation surveillance period encompasses the required periodic TAS and any other ongoing surveillance (if carried out). Trachoma surveillance refers to the period after the impact survey documenting district levels of TF <5%.19

Table 8. Post-MDA surveillance for LF, FY16 and FY17*

Country % of total endemic districts under

post-MDA surveillance**

% of total persons living in endemic areas that are under post-MDA

surveillance**

End of FY16 End of FY17 (projected) End of FY16

End of FY17 (projected)

Bangladesh 95% 100% 91% 100% Benin 48% 75% 48% 73% Cambodia 100% 100% 100% 100% Cameroon 28% 91% 39% 92% DRC 0% 0% 0% 0% Ethiopia 0% 0% 0% 0% Guinea 0% 0% 0% 0% Haiti 72% 91% 44% 85% Indonesia 17% 37% 35% 55% Laos 0% 0% 0% 0% Mali 75% 75% 88% 87% Mozambique 0% 75% 0% 78% Nepal 41% 61% 51% 68% Nigeria*** 20% 29% 21% 28% Philippines 50% 76% 48% 75% Senegal 0% 0% 0% 0% Tanzania 61% 83% 50% 73% Uganda 75% 84% 71% 80% Vietnam 100% 100% 100% 100% TOTAL 30% 46% 41% 54%

19 According to WHO’s SOPs, trachoma surveillance should include both TF and TT. USAID’s current NTD data capture system does not yet gather data for TT in all supported countries. “Pre-validation trachoma surveillance should be conducted as a cluster random sample survey undertaken, in general, in each district in which trachoma elimination interventions have been required, two years after a district-level impact assessment shows that elimination targets for trachomatous trichiasis (TT) and trachomatous inflammation-follicular (TF) have been reached.”

50

Table 8. Post-MDA surveillance for LF, FY16 and FY17*

Country % of total endemic districts under


% of total persons living in endemic areas that are under post-MDA

surveillance**



* Data reflect the percentage of districts achieving the milestone. Projected data are based on FY17 SAR1 workbooks. Persons living in areas no longer at risk are based on populations reported in FY17 SAR1 workbooks. Percentages reflect data received by ENVISION as of April 4, 2017. ** Assumes all districts achieve at least five rounds of sufficient epidemiological coverage in remaining years and pass pre-TAS and TAS1. *** In Nigeria, endemicity data were reported only in USAID-supported states through FY16. Starting in FY17, endemicity data were reported for the entire country, including non-USAID-supported states. Percentages reflect data received by ENVISION as of April 4, 2017. Data will continue to be updated as additional information from non-USAID-supported areas is received.

Table 9. Post-MDA surveillance for trachoma, FY16 and FY17*

Country

% of total endemic districts under post-MDA surveillance**

% of total persons living in endemic areas that are under




Benin 0% 0% 0% 0% Cambodia + + + + Cameroon 33% 100% 35% 100% DRC 0% 0% 0% 0% Ethiopia 1% 15% 1% 16% Guinea 0% 22% 0% 31% Laos + + + + Mali 93% 100% 96% 100% Mozambique 23% 40% 18% 38% Nepal 100% 100% 100% 100% Nigeria*** 86% 38% 86% 37% Senegal 48% 63% 47% 57% Tanzania 72% 86% 73% 88% Uganda 77% 95% 86% 97% Vietnam 89% 89% 99.9% 99.9% TOTAL 22% 35% 35% 45%

* Data reflect the percentage of districts achieving the milestone. Projected data are based on FY17 SAR1 workbooks. Persons living in areas no longer at risk are based on populations reported in FY17 SAR1 workbooks. Percentages reflect data received by ENVISION as of April 4, 2017. **Assumes all districts achieve the minimum number rounds required of sufficient epidemiological coverage in remaining years and pass TIS. *** In Nigeria, endemicity data were reported only in USAID-supported states through FY16. Starting in FY17, endemicity data were reported for the entire country, including non-USAID-supported states. Percentages reflect data received by

51

Table 9. Post-MDA surveillance for trachoma, FY16 and FY17*

Country

% of total endemic districts under post-MDA surveillance**

% of total persons living in endemic areas that are under




ENVISION as of April 4, 2017. Data will continue to be updated as additional information from non-USAID-supported areas is received. + Although Cambodia and Laos are on WHO’s list of trachoma-endemic countries, mapping in 2014 and 2015 found TF prevalence rates below the threshold to implement MDA. Therefore, these two countries will not implement MDA; they submitted dossiers to WHO in March 2017 to validate elimination of trachoma as a public health problem.

This section contains two objectives for FY17, with related activities, that follow the strategic approach presented above:

Objective 1: Help countries prepare for documenting elimination.

Objective 2: Address lack of WHO guidelines for post-validation surveillance.

Objective 1: Help countries prepare for documenting elimination

Activity 1: Short-term TA and ENVISION staff support for pre-dossier development. In Q1–Q2, the project provided TA for LF pre-dossier development to the Philippines. In Q3–Q4, consultants will assist LF programs in Haiti, Tanzania, and Uganda to enter mapping, MDA, and TAS data and draft the complementary narrative sections.

For trachoma, ENVISION staff worked with MOH teams in Mozambique, Senegal, Tanzania, and Uganda to enter data into trachoma dossier Excel sheets. Teams continue to gather missing data, particularly related to F&E activities of the SAFE strategy. In addition, in Nepal, ENVISION facilitated a half-day meeting to introduce the dossier template to the National Trachoma Program (NTP) (a local NGO responsible for implementing trachoma activities) and the MOH. A consultant then compiled a draft narrative based on bullet points and the completed Excel sheets provided by the NTP. In Vietnam, trachoma pre-dossier development continued, and a draft dossier has been compiled. Lessons learned from dossier development include the following:

• Comparison of data from different trachoma survey methods (trachoma rapid assessment [TRA] versus acceptance sampling trachoma rapid assessment [ASTRA] versus population based prevalence survey [e.g. GTMP] is difficult.

• Historical data on TT surgery activities is difficult to find and capture in the Excel template.

FY17 Support for Pre-dossier

Development For LF

Haiti (Q3–Q4)

The Philippines

Tanzania (Q3–Q4)

Uganda (Q3–Q4)

For Trachoma

Mozambique

Nepal

Senegal

Tanzania

Uganda

Vietnam

52

• Confusion still exists about what data is needed to declare TT elimination goals and if TT-only surveys are always needed.

• LF post-validation surveillance guidance is needed.

• When conflicting data exists at the national level, decentralized programs may need to collect data again from lower levels.

Activity 2: Finalizing dossiers. MOHs in Cambodia and Laos officially submitted dossiers to WHO to validate elimination of trachoma as a public health problem in March 2017. WHO is in the process of convening Regional Dossier Review Groups to confirm the country narratives and associated data files, with the aim to have a decision on validation by June 2017. Vietnam plans to informally submit its LF dossier to WHO if non-endemicity is confirmed in the three districts implementing mini-TAS in April 2017; ENVISION is working with Vietnam to finalize the dossier with this data. Concurrently, it will submit the dossier through MOH processes, which will likely take at least six months to complete.

Objective 2: Address lack of WHO guidelines for post-validation surveillance

Activity 1: Hold post-validation surveillance meeting for Southeast Asia countries. In coordination with WHO’s Western Pacific Regional Office (WPRO), the Coalition for Operational Research on NTDs (COR-NTD) project managed by the NTD Support Center, and CDC, ENVISION is helping to organize a post-validation surveillance meeting for the ENVISION-supported countries of Cambodia, the Philippines, and Vietnam, as well as for Malaysia, Vanuatu, and Tonga. Scheduled for June 12–13, 2017, in Cambodia—directly following the WPRO RPRG meeting—this meeting will be an opportunity for national LF programs to present draft plans for post-validation surveillance and receive feedback from global experts. In Q2, ENVISION staff collected pre-meeting information on areas at highest risk of recrudescence; potential post-validation surveillance platforms; and supply chain, laboratory, and entomology capacity from the Philippines and Vietnam. ENVISION is also helping design the agenda and country presentation template.

FY17 Support for Finalizing Dossiers

For LF

Vietnam

For Trachoma

Cambodia (Submitted to WHO in

3/17)

Laos (Submitted to WHO in

3/17)

53

IR 3: STRENGTHENED ENVIRONMENT FOR IMPLEMENTATION OF NATIONAL AND INTEGRATED NTD CONTROL AND ELIMINATION PROGRAMS

54

1. Capacity Strengthening and Training

Strategic Approach

In Q1–Q2, ENVISION continued providing support to MOH-owned national NTD programs, strengthening their capacity by ensuring access to TA, training, and supporting their understanding of existing resources and tools to implement functional and sustainable programs.

Capacity strengthening for NTD control and elimination remains a priority for the ENVISION project. Special attention has been directed toward building capacity for M&E for NTD programs as well as DSAs and surveillance, all while expanding interventions beyond in-person trainings to new methods considered current best practice in capacity development and adult learning. In turn, these interventions make resources more widely accessible and take the transfer of knowledge, skills, and experience from a top-down model (i.e., from WHO and ENVISION HQs to countries) to a networked, peer-to-peer model (i.e., from country to country). Highlights of this approach during the reporting period include increasing channels for sharing best practices across countries via expert social networks, communities of practice, webinars, country exchange visits, and making learning resources available to all countries at any time via the NTD Toolbox.

FY17 ENVISION capacity strengthening activities focus on achieving the following objectives:

Objective 1: Reinforce program management capacity.

Objective 2: Strengthen in-country NTD M&E capacity.

Objective 3: Strengthen capacity on DSAs and surveillance.

Objective 4: Foster sharing of best practices across countries.

Objective 5: Continue global leadership in capacity strengthening for NTD programs.

Objective 1: Reinforce program management capacity

Activity 1: Explore and test options for improving program management skills. This activity is scheduled for Q3–Q4.

Activity 2: Provide TA to improve grants management skills. The ENVISION Nepal team, with support from the Senior Manager for Operations and Grants, implemented a grants management training in Q2 for 15 NGO staff responsible for overseeing the completion of LF MDA activities in 13 districts. The Senior Manager for Operations and Grants provided TA for grant packages in Indonesia, Nepal, Uganda, and Senegal and began preparatory activities (identification of country programs/participants and preparation of outline) for the NTD technical roundtable via webinar on grants management and fixed obligation grants (FOGs) currently scheduled for Q3.

Activity 3: Strengthen the functionality and use of TIPAC. In Q1–Q2, the project assessed the status of each country’s current use of the TIPAC and helped the countries establish goals, based on each country’s current interest and capacity to use the tool. In February 2017, RTI organized and facilitated a TIPAC training in Mali for 30 staff members from the MOH and HKI, and an MOH focal person was identified to complete the TIPAC files. RTI also led a TIPAC training for HKI HQ staff in January 2017, which HKI had requested so that its staff could become more familiar with the tool and advocate for its use in HKI-implemented ENVISION countries. RTI is providing ongoing support for countries using the TIPAC, and several countries are planning to complete their TIPAC files and use the tool to generate the JRSM for the first time this year. RTI is also developing resources to help countries understand how they

55

can use the TIPAC during post-LF MDA planning to generate advocacy-related cost data for STH/SCH drug distribution.

Activity 4: TIPAC online tutorials. ENVISION has deprioritized TIPAC online tutorials due to limited demand. The tutorials may be re-visited in the future if there is demonstrated interest from the NTD community.

Activity 5: Support implementation of WHO district-level NTD training. ENVISION has not received any requests from WHO or identified specific needs to support a district-level NTD training. We will continue to assess the need for this training through discussion with WHO in Q3-4.

Activity 6: Support implementation in 1–2 regions for the WHO Program Managers' Training Course (PMTC). ENVISION has not received any requests from WHO or identified specific needs to support a PMTC training.

Activity 7: Support implementation of online WHO national and district-level NTD trainings. The PMTC materials are now available on WHO’s website in English and French. Final formatting is underway of the English, French, and Portuguese district-level NTD training materials and Portuguese PMTC materials; once complete, they will be made available for public access on WHO’s website.

Activity 8: Manage implementation of SAE eLearning course. During the reporting period, ENVISION investigated options for platforms for hosting the eLearning course, which will be launched and promoted later in FY17.

Activity 9: Develop adaptable resources for cascaded MDA training. This activity will take place in Q3–Q4 of FY17.

Objective 2: Strengthen in-country NTD M&E capacity

Capacity strengthening for M&E is covered in the National Program M&E Data Quality section under Intermediate Result (IR) 2.

Objective 3: Strengthen capacity on DSAs and surveillance

Activity 1: Facilitate exchange visits to assist in establishing OV Expert Committees. Because four Francophone countries planned to launch their committees in FY17, ENVISION supported an exchange visit enabling MOH representatives from three of the countries (Benin, Guinea, and Mali) to participate in the inaugural committee meeting of the fourth country (Senegal), which was the first of the group to organize its meeting. The visiting MOH representatives have already been, or will be, key players in establishing committees in their respective countries. Guinea organized its first meeting in March 2017, with support from both Sightsavers and ENVISION, and Benin and Mali are scheduled to hold their first meetings before the end of FY17 (both with support from ENVISION).

The Senegal committee meeting also launched a dialogue among Guinea, Mali, and Senegal around the management of shared, cross-border OV foci, one of the topics discussed in a breakout group session during Senegal’s inaugural meeting.

Activity 2: Develop DSA job aids in coordination with WHO. ENVISION initiated discussions with WHO to develop an OV DSA job aid later in FY17, after WHO is further along in the development of its OV program manager’s guide. This will ensure complementarity between the guide and the job aid.

56

Objective 4: Foster sharing of best practices across countries

Activity 1: Continue support for communities of practice. During Q1–Q2, the concept of a community of practice was further refined and tested, and ENVISION is collaborating with WHO to launch the Integrated NTD Database Community of Practice in Q3. Plans are underway to host a sharing-focused technical roundtable via webinar among the ENVISION community of grants management practitioners. The roundtable webinar will be much more discussion-based than past webinars and will focus on practitioners sharing experiences, common challenges, and best practices with one another.

Activity 2: Conduct webinars. During the reporting period, ENVISION conducted one webinar and began planning two additional webinars. In partnership with the Ethiopia FMOH, ENVISION Uganda, and Sightsavers, ENVISION led a webinar in English and French titled “IEC and Social Mobilization Toolkit: Overview and practical experience from Ethiopia and Uganda.” It was well attended, with 53 participants joining the English version and 8 joining the French version. An additional 20+ views of the posted recordings of the webinars occurred following the events. The webinars gave rise to many relevant questions from participants and several follow-up discussions on the Toolkit and managing AEs.

ENVISION also planned two additional webinars that will take place in the second half of FY17: (1) a technical roundtable via webinar that will focus on experience sharing by ENVISION country offices on FOGs and grants management (noted above) and (2) a webinar in partnership with WHO and country champions on LF dossiers.

Activity 3: Build a cadre of NTD experts and trainers on ENVISION-developed and WHO NTD tools. ENVISION maintains a list of experts on NTD tools and topics in an Excel spreadsheet that is accessible to the ENVISION HQ team and can be referenced when trainers or consultants are needed. This list indicates the geographic location of each expert to encourage facilitation of local expertise and limit the need for HQ travel. The project adds potential trainers and consultants to the list as they are identified.

Activity 4: Expert (social) network analysis. To further encourage cross-country sharing and to better understand the complex network of subject-matter experts available to assist program managers, ENVISION staff conducted an expert network analysis, also known as a social network analysis, during the reporting period. The two main topics explored were LF dossier development and health service delivery platforms for reaching SAC.

The survey was designed to identify who national program managers contact for technical advice, evaluate expert networks, and assess the relative strength of networks based on the frequency of inter- and intra-personal interactions among countries and organizations. ENVISION developed an initial network framework by reaching out to individual country contacts using Polinode™ software. For each network question, the project generated a network diagram to show connections between individuals and country programs and, conversely, where those connections are lacking. This visual process to show relationships helped identify bridges between otherwise unconnected people as opposed to people who are in tightly knit groups or people who already share connections.

ENVISION will share results and recommendations from the expert network analysis with USAID in Q3. The results will be used to strengthen existing networks through existing programs, organizations, and structures for both LF dossier development and SAC platforms. Results will also be crucial in developing communities of practice that include influencing nodes, especially linking people who currently are not connected.

57

Objective 5: Continue global leadership in capacity strengthening for NTD programs

Activity 1: Support implementation of WHO-USAID Global Capacity Strengthening Strategy. ENVISION’s capacity strengthening approach is closely aligned with WHO’s strategy (see Table 10). ENVISION worked with USAID and WHO to draft a capacity strengthening strategy. The strategy aims to help WHO, donors, NGOs, and other stakeholders to organize their capacity strengthening approaches around a few, fundamental, practical areas of focus: strengthening national governance and leadership for NTDs, NTD laboratory capacity, technical capacity of national programs, and implementation research. The last draft of the Global Capacity Strengthening Strategy was sent to WHO and is now under review.

Table 10. ENVISION alignment with WHO-USAID Global Capacity Strengthening Strategy

WHO-USAID Strategy objective ENVISION alignment

Develop a clear, mutual understanding of each county’s critical NTD program capacity needs.

ENVISION has conducted the previously noted needs assessments of its countries to inform broader strategy development.

Make existing tools, training, and guidance for NTD programs widely available

ENVISION will focus on dissemination of tools, resources, and WHO guidance.

Create communities of practice to foster learning and problem-solving.

ENVISION will focus on sharing best practices across countries, including through communities of practice

Build partnerships that extend the ability of NTD programs to reach communities.

ENVISION will focus on district-level resources and dissemination.

Activity 2: Participate in WHO’s Working Group on Capacity Strengthening. WHO’s Working Group on Capacity Strengthening was inactive during the reporting period. There are no activities to report for this Working Group.

Activity 3: Collaborate with WHO HQ and regional offices. In Q1–Q2, ESPEN requested support from ENVISION to provide facilitators for regional TAS workshops for monitoring and epidemiological assessment of LF MDA activities, with special reference to use of new FTS and integrated assessment of STH infections. These workshops will be a TOT, and participants are expected to support the national programs and conduct further national/subnational training in respective countries. ENVISION will provide experts for the Francophone and Anglophone workshops scheduled for May 2017.

Table 11 summarizes the various training courses that received ENVISION support in Q1–Q2, FY17.

58

Table 11. Training courses supported in FY17, Q1–Q2

Training No. of training

participants Profile of training

participants Countries or

regions ENVISION’s role Collaborators and

their role

Grants management 18 Partners Nepal Facilitators, participants, venue n/a

Supply chain management 19 Regional MOH supply chain staff Nigeria Facilitators, participants, venue n/a

Supply chain management 38 District MOH supply chain staff Nigeria Facilitators, participants, venue n/a

Finance 49 District and regional accountants Tanzania Facilitators, participants, venue n/a

OV monitoring 50 Regional lab technicians, research assistants, and NTD coordinators

Tanzania Facilitators, participants, venue n/a

TAS 14 National MOH staff Laos Facilitators FHI 360/M.A.C. Foundation: participants, venue

Tropical Data trachoma grading and recording 25 Provincial eye health staff Vietnam Facilitators, venue

Fred Hollows Foundation (FHF): participants

Trachoma mapping 15 National-level MOH and partner staff DRC Facilitators, participants,

venue n/a

Coverage supervision tool 21 Provincial MOH staff, district nurses, and chief medical officers DRC Facilitators, participants,

venue n/a

Follow-up for LF elimination program 9 National level MOH staff Cameroon Facilitators, participants,

venue n/a

Tropical Data trachoma grading and recording 34 National level MOH staff Cameroon Facilitators, participants,

venue n/a

TAS 28 National level MOH staff Cameroon Facilitators, participants, venue n/a

Tropical Data trachoma grading and recording 12 National level graders and

recorders Guinea Facilitators, participants, venue n/a

Independent monitors training 99 Independent monitors Guinea Facilitators, participants, venue n/a

59

Table 11. Training courses supported in FY17, Q1–Q2

Training No. of training

participants Profile of training

participants Countries or

regions ENVISION’s role Collaborators and

their role

Supply chain management 70 National level MOH staff Mali Facilitators, participants, venue n/a

TAS 20 TAS survey teams and pharmacists Mali Facilitators, participants,

venue n/a

TIPAC 30 National-level MOH staff and partners Mali Facilitators, participants,

venue n/a

TAS implementation refresher training 36 District-level lab technicians,

nurses, and data collectors Haiti Facilitators, participants, venue n/a

TAS implementation training 18 District-level lab technicians, nurses, and data collectors Haiti Facilitators, participants,

venue n/a

MOH central supervisor training 45 National-level MOH Uganda Facilitators, participants,

venue n/a

NTD focal person training 56 District NTD focal persons Uganda Facilitators, participants, venue n/a

Central supervisors’ data supervision training 28 National-level MOH Uganda Facilitators, participants,

venue n/a

TAS3 and STH surveyor training 37 National-level MOH Benin Facilitators, participants, venue n/a

TIS trachoma grader and refresher training 22 District trachoma grading teams Ethiopia Facilitators, participants,

venue n/a

NTD supply chain management 62 Regional and zonal pharmaceutical logisticians Ethiopia Facilitators, participants,

venue n/a

Grants training 212 Regional and district-level doctors, NTD focal points, and accountants

Senegal Facilitators, participants, venue n/a

TIPAC 7 RTI and HKI HQ staff USA Facilitators, participants, venue n/a

60

2. Sustainability for SCH and STH Control Programs

Strategic Approach

National programs for LF, trachoma, and, to a lesser extent, OV are increasingly achieving their goals and shifting from community-wide MDA implementation toward elimination and post-treatment surveillance. Therefore, new strategies and guidance are required to ensure the long-term sustainability of programs for SCH and STH disease control. Some countries (such as Cameroon, Nepal, the Philippines, Senegal, and Uganda) have always implementing MDA activities for STH or SCH independently of MDA for the other NTDs; others (such as Mali and Tanzania) have continued STH MDA implementation after LF MDA activities stopped. However, there is still a need for more knowledge about which gaps in MDA support will occur in all countries after LF, trachoma, and/or OV MDA implementation stops and USAID discontinues support of SCH or STH MDA.

In FY16, ENVISION began collaborating with USAID and other partners on a framework for determining the gaps left in support to STH programs resulting from LF MDA scale-down. From those conversations, USAID and ENVISION developed an STH transition program guide to help countries determine the status of STH prevalence and which platforms need to be continued (or transitioned to) to maintain the gains in reduction of STH prevalence and intensity achieved under the LF MDA activities. Similar activities are ongoing in the global SCH community. In FY17, ENVISION began implementing activities in priority countries to better understand the STH and/or SCH situation and help national programs determine their STH/SCH goals, platforms, and funding gaps. Seven countries (Haiti, Tanzania, Uganda, Nepal, Mozambique, Benin, and Mali) have been targeted for this support, and they all submitted their STH/SCH transition plans along with their FY17 work plans.

This section contains one important key objective—to improve knowledge of national programs’ needs and appropriate platforms to sustain ENVISION gains—for FY17, with several activities, in response to the strategic approach presented above.

Objective 1: Improve knowledge of national programs’ needs and appropriate platforms to sustain ENVISION gains

Activity 1: Pilot the STH transition program guide. This guide will be piloted in the second half of FY17. ENVISION will continue to work with USAID focal points to develop a final transition guide.

Activity 2: Pilot test the new GSA tool to assess the status of SCH control/elimination. This tool has not yet been developed by GSA. In Q3–Q4, ENVISION will work with partners at GSA and USAID on the development of such a tool. ENVISION will also identify in which countries such a tool could be piloted but it is doubtful the test will be piloted in FY17.

Activity 3: Conduct a desk review to identify and follow up with countries where a comprehensive review of SCH data is needed to determine MDA frequency needs. ENVISION is encouraging countries to ensure district-level SCH data (and sub-district-level data where appropriate) are available, circulated to in-country partners, and analyzed appropriately. Making data available will be critical to updating SCH treatment

61

strategies for entry into the FY18 work plans. In addition, ENVISION will continue to partner with and advocate to WHO for the updating and clarification of SCH treatment guidelines, particularly in areas that have received multiple rounds of treatment.

Activity 4: Support the USAID cross-sector NTD collaboration strategy. ENVISION continues to support the NTD collaboration strategy as required, in partnership with USAID.

3. Operational Research (OR)

Strategic Approach

As programs move toward elimination and control of PC-NTDs, many countries are now facing increasing or persistent gaps in knowledge. These gaps are hampering or delaying progress toward successful control or elimination. OR can play an indispensable role in filling the gaps in knowledge where there are pressing needs to test novel corrective actions and apply potential solutions to recurring technical problems. New and more effective diagnostic tools and innovative techniques are now available. With support from various partners, country programs could use these new diagnostics and tools not only to respond to unsatisfactory traditional diagnostics and methods, but also to fill the gaps in terms of programmatic and technical knowledge.

In FY17, ENVISION is working with key partners such as TFGH, CDC, and national research institutions to roll out OR activities in selected countries. ENVISION staff are assisting countries, TFGH, and USAID in developing and reviewing OR protocols, while also working to ensure the needs assessments, the rollout of the activities, and the use of results for programmatic purpose are precise, detailed, and well documented. In addition, for OR on the use of new diagnostics, ENVISION is specifying the context, the epidemiological settings, the thresholds being proposed and how they are established, the proposed sample size and sampling methods, and how the countries will use the data for any actionable items. ENVISION is working to ensure that OR does not disrupt MDA activities nor compromise any critical and programmatic NTD interventions planned in the countries.

ENVISION’s role is to assist countries in identifying OR needs. The ENVISION team also helps program managers in developing proposals and contributes to securing the partnership and funding necessary to implement OR projects. ENVISION continues to play a central role in the conception and implementation of OR and will play a key role in documenting and disseminating OR results in collaboration with the supported countries. The project is gathering and analyzing information from country programs and conceptualizing OR projects in response to identified programmatic needs.

In supported countries, ENVISION accompanies the rollout of OR activities through planning, supervision, and logistical support. In collaboration with the NTD Support Center and the COR-NTD project, ENVISION developed a list of OR topics that reflects the status and/or the need of disease-specific programs. After discussion with USAID, this list was updated and countries where specific OR will be implemented were identified. ENVISION will continue to liaise with these countries to determine the timing, channels, and processes for an effective and smooth rollout of OR.

62

Details on OR activities that have benefited from ENVISION support and collaboration in FY17 are provided below. To be cost-effective, ENVISION staff members’ travel to places where OR is being implemented is coordinated with other programmatic country travel planned and budgeted in the work plan. There is no associated budget line for ENVISION’s collaboration on OR.

OR supported by ENVISION in FY17, by disease

LF

• Surveillance

− The project is exploring opportunities to add Wb123 rapid diagnostic tests (RDTs) to TASs in the ENVISION portfolio. This activity (along with the addition of Wb123/Ov16 RDT biplex and Ov16 RDT monoplex) will be used to compare the diagnostic performance of antibody with FTS antigen tests. ENVISION plans to incorporate Wb123s into TAS in Tanzania in July 2017 and in Haiti in the second half of FY17.

− In Vietnam, DBS were collected in March and April 2017 for comparison with FTS during mini-TAS.

− Assessment of LF status in two urban settings of Benin (Cotonou and Porto-Novo) is complete.

• Treatment of LF-endemic areas with ALB alone in L. loa-endemic African countries

− The project is supporting “elimination mapping” for OV to exclude its presence in LF-positive areas where OV is not known (or certain) to be endemic (i.e., untreated areas that are below the previously determined “meso-endemic” levels). In Cameroon, mini-TAS was implemented to assess the prevalence of LF/L. loa and OV in 24 districts before restarting twice-yearly ALB. Data analysis is ongoing.

• Effective elimination strategy for both LF and OV in co-endemic areas

− In DRC, the project is supporting epidemiological assessment of LF and OV by ELISA and RDTs. This involves a comparison of the Biplex-RDT and ELISA antibody tests for OV and LF across all age-groups. Fieldwork activities have been completed, and a report is being prepared by the MOH and TFGH.

− The ENVISION treatment platform is being leveraged to conduct F-TAS surveys to assess both LF and OV in Mali and Cross River State, Nigeria.

• Critical cutoffs in Brugia spp.-endemic areas

− In Indonesia, in Brugia spp.-endemic areas, antibody information will be collected during pre-TAS for all ages through Brugia Rapid™ tests and DBS/ELISA to allow the calculation of antibody age-prevalence curves. This activity is planned for Q3–Q4.

63

• Dissemination of LF OR results

− A post-validation surveillance meeting for WPRO countries to share lessons is planned for June 2017.

− A TAS costing paper was published by Brady et al in PLoS NTDs20 (see Table 15 for more details).

Trachoma

• Assessment of the value of targeting treatment to sub-populations in endemic communities

− A segmented mapping approach was trialed successfully in Touba District, Senegal. Results were presented at the Trachoma Scientific Informal Workshop in April 2017.

• Dissemination of trachoma OR results

− A TIS/TSS costing analysis is underway by ENVISION, with initial results presented at the Trachoma Scientific Informal Workshop in April 2017 (see publications section for more details).

OV (in addition to joint LF/OV activities above)

• Replacement of skin snips by Ov16 RDTs

− In DRC, field activities to compare Ov16 ELISA serology and Ov16 RDTs with skin snips to detect OV infection are completed. A report and publication are forthcoming. The results can potentially be used for mapping, impact evaluation, stopping MDA, and surveillance.

• Elimination mapping for OV in LF areas

− The project is supporting “elimination mapping” for OV to exclude its presence in LF-endemic areas. In Cameroon, mini-TASs have been implemented to assess the prevalence of LF/L. loa and OV in 24 districts before restarting twice-yearly ALB. The MOH and TFGH are analyzing data and will develop a project report shortly.

SCH

• Exploration of the use of circulating cathodic antigen (CCA) tests and circulating anodic antigen tests to redefine SCH prevalence pre- and post-treatment and for decision making

− In Senegal, ENVISION is supporting the development and testing of the point-of-care CCA diagnostic against the Kato Katz assessment for detection of S. mansoni infections. Field work is completed and initial analysis has been conducted. The results can

20 http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0005097

http://journals.plos.org/plosntds/article?id=10.1371/journal.pntd.0005097

64

be used to feed into meta-analysis from other programs and be used to validate the relationship between CCA and Kato Katz across a wide range of prevalence figures.

STH

• Redesigned/improved diagnostic tool (PCR) to assess and quantify STH (and SCH)

− Plans are being developed to compare PCR and Kato Katz diagnostics for STH (and SCH) in Uganda in Q3–Q4, using the TAS platform to collect data.

• Coordination of TAS with STH and SCH assessment

− This is being conducted in 23 evaluation units in Benin, Haiti, and Uganda.

Multi-disease

• Triple drug administration

− In Haiti, a triple drug administration trial of DEC, ALB, and IVM was conducted successfully in January 2017. RTI, with partner input, are developing a report, which will be submitted for publication.

• Coverage surveys

− This OR explores the impact of alternative approaches to coverage surveys. This activity will compare the cost, time, and feasibility of three different survey sampling methodologies (the Expanded Program for Immunization approach, lot quality assurance sampling, and design and probability sampling) for conducting coverage surveys.

4. Dissemination of Best Practices

Strategic Approach

Policies, guidelines, and program management tools and resources for NTDs are being developed concurrently with actual project implementation. As USAID’s flagship NTD project, leading NTD control and elimination globally and supporting MOH efforts in 19 countries, ENVISION plays an important leadership role. This section outlines the project’s dissemination strategy, an integral part of the knowledge management for capacity strengthening cycle shown in Figure 8, which has the following three objectives:

Objective 1: Support the dissemination of information on results, challenges, and lessons learned from countries to policymakers and the global community.

Objective 2: Disseminate new WHO guidance and policies to national programs.

65

Objective 3: Disseminate the NTD Toolbox and its contents.

Figure 8. Knowledge management cycle under ENVISION

Objective 1: Support the dissemination of information on results, challenges, and lessons learned from countries to policymakers and the global community

ENVISION supports the dissemination of information from countries, between countries, and to and from policymakers. The goal is to provide opportunities for national programs to share their results, challenges, and lessons learned with the global community as well as to acquire new ideas and information. Priority information for dissemination in FY17 includes the following:

• DSA results and understanding the factors associated with these

66

• Lessons learned on how to improve coverage

• Trachoma mapping results

• Challenges and solutions in the transition from disease elimination (LF and trachoma) to sustainable SCH and STH programs

• Results of testing new diagnostic and programmatic tools at the country level

• Success stories as countries increase the number of persons living in areas that are no longer considered to be at risk of disease

• Raising awareness of NTDs and of USAID’s work in the wider development community.

Activity 1: Present at the Annual Meeting of the ASTMH. ASTMH has been the primary scientific conference targeted for sharing best practices from the project. This venue provides an opportunity to disseminate country results, lessons learned, and challenges. At the 2016 annual meeting held in Atlanta, GA, ENVISION showcased many important findings, with three symposia, seven oral presentations, and 12 poster presentations. Thanks to travel support provided by the NTD Support Center with Bill and Melinda Gates Foundation (BMGF) funding, national NTD program staff from nine USAID-supported countries presented on their work during the conference. Additionally, ENVISION participated in the COR-NTD technical meetings, organized by TFGH, and led a very popular and successful session on improving coverage.

In Q1–Q2, ENVISION also worked closely with USAID to identify topics and discuss plans for ENVISION presence at ASTMH 2017, which will take place in November in Baltimore, MD. Following these discussions, ENVISION submitted proposals for one symposium, and began preparing 19 abstracts for oral or poster presentations (submitted for review by the ASTMH scientific program committee in April). Acceptance notifications are expected in May and September, for the symposium and presentations respectively. ENVISION will continue to work with field teams to develop abstracts for submission as “last-minute” additions or for other important venues, as appropriate. The project and USAID also brainstormed on several session topics for submission to COR-NTD.

Activity 2: Continue to publish articles in peer-reviewed journals. In Q1–Q2, ENVISION published 10 peer-reviewed articles already, equivalent to the entire previous fiscal year’s contributions. See Table 12.

Recognizing the considerable effort that is required to produce peer-reviewed publications, ENVISION has been working closely to prioritize topics and questions relevant to the project and to advancing the global NTD community’s agenda. The project maintains a tracker for publications at different stages of development, which it has shared with USAID. The tracker is updated on a quarterly basis. Publications submitted for publication in the first half of FY17 are listed in Table 15; these publications focus on documenting trachoma mapping, LF impact results, and lessons learned for building strong partnerships and implementing strong programs.

67

Table 12. Key manuscripts published through ENVISION-MOH collaboration in FY17

Title ENVISION contributing authors* Journal

Building a global schistosomiasis alliance: an opportunity to join forces to fight inequality and rural poverty Achille Kabore

Infectious Diseases of Poverty

Controlling neglected tropical diseases (NTDs) in Haiti: Implementation strategies and evidence of their success

Maggie Baker, Abdel Direny, Kalpana Bhandari, Katie Crowley, Richard Reithinger, Eric Ottesen

PLoS NTDs

Baseline trachoma surveys in Kaskazini A and Micheweni districts of Zanzibar: Results of two population-based prevalence surveys conducted with the Global Trachoma Mapping Project

Lisa Rotondo, Jeremiah Ngondi

Ophthalmic Epidemiology

Progress of trachoma mapping in Mainland Tanzania: Results of baseline surveys from 2012 to 2014 Lisa Rotondo, Katie

Crowley, Jeremiah Ngondi Ophthalmic Epidemiology

Prevalence of Trachoma in Niger State, North Central Nigeria: Results of 25 population-based prevalence surveys carried out with the Global Trachoma Mapping Project Alex Pavluck, Ben Nwobi

Ophthalmic Epidemiology

Initiating NTD programs targeting schistosomiasis and soil-transmitted helminthiasis in two provinces of the Democratic Republic of the Congo: Establishment of baseline prevalence for mass drug administration

Achille Kabore, Jean Jacques Tougoue, Eric Ottesen

Acta Tropica

Costs of transmission assessment surveys to provide evidence for the elimination of lymphatic filariasis

Molly Brady, Margaret Davide-Smith, Jim Johnson

PLoS NTDs

Partnering for impact: Integrated transmission assessment surveys for lymphatic filariasis, soil transmitted helminths and malaria in Haiti Abdel Direny

PLoS NTDs

Success of lymphatic filariasis control in Benin: Effects of ivermectin and albendazole on microfilaremia

Achille Kabore, Aboudou Dare

Journal of Parasitology and Vector Biology

Evaluation of lymphatic filariasis and onchocerciasis in three Senegalese districts treated for onchocerciasis with ivermectin

Abdel Direny, Mawo Fall, Daniel Cohn, Achille Kabore

PLoS NTDs

*RTI unless otherwise stated

68

ENVISION launched the ENVISION Publications Notice in FY17. This new dissemination mechanism highlights key lessons learned from recent ENVISION publications in a quick and more reader-friendly email summary. Two Publications Notices were sent during this reporting period, in October 2016 and April 2017, to the ENVISION mailing list of more than 1,200 contacts in the NTD community. Overall, readership and engagement with this new platform has been positive. Further dissemination of ENVISION publications is expected in Q3–Q4, with several articles currently in the publication pipeline.

Activity 3: Publish more grey literature. While peer-reviewed publications are targeted for their broad reach, sustainability, and credibility, as described above, the project has also determined the need for another communication method that allows faster sharing of lessons and results to a broader audience. In response to this need, a series of technical briefs/case studies is being developed. This series is intended to be systematic with strong technical rigor, while also communicating in a manner more appealing to program implementers then researchers. In the future, material in these technical case studies may be further expanded or combined for publication in a peer-reviewed journal. Work has started on several technical briefs that are expected to be published on the project website by the end of FY17:

• How NTD programs are working to strengthen the health system in NTD endemic countries

• Preparing a dossier for LF elimination: What you need to know

• Securing high coverage in mass drug administration campaigns for NTDs

• Considerations for conducting an MDA in urban areas

• MDA strategies in conflict zones

• Reaching traditional populations with MDA

• Philippines integrated STH MDA

Objective 2: Disseminate new WHO guidelines and policies to national programs

WHO continues to work on updated and revised guidelines, incorporating evidence gathered during NTD program implementation and research. Ensuring global adoption of these guidelines is a key priority for ENVISION.

Activity 1: Develop a dissemination plan for new WHO guidance. For adoption of new WHO guidelines and policies to take place, countries must first be aware of and have access to them. To ensure this, ENVISION places high importance on dissemination. In Q1–Q2, ENVISION developed a comprehensive dissemination strategy for new or updated WHO guidelines and policies. The strategy includes the following elements for each new WHO document:

• Dissemination goals and milestones

69

• Target audiences, from within the ENVISION team, to national through district-level NTD program personnel

• Identification of successful use cases, or country “champions,” because countries are more likely to understand the importance and usefulness of resources that have been successfully used by their peers

• An exhaustive list of communication channels through which to disseminate the guidelines to the target audiences

• Evaluation of effectiveness of dissemination

Additionally, during the reporting period, ENVISION developed and began implementing individual dissemination plans for the new WHO OV guidelines and the WHO Validation of Elimination of LF as a Public Health Problem Handbook.

Activity 2: Disseminate new guidelines on OV. Disseminating the new WHO guidelines on OV elimination was a high priority during the reporting period. As noted above, ENVISION developed a dissemination plan for these guidelines. As a first step to implementing the dissemination plan, ENVISION and USAID collaborated to develop a memo to help countries understand the context for the guidelines and the key points included therein. ENVISION sent electronic copies of each of the following to all ENVISION country teams as part of an “OV elimination guidelines package”:

1. WHO’s Guidelines for Stopping Mass Drug Administration and Verifying Elimination of Human Onchocerciasis: Criteria and Procedures (revised version, May 2016)

2. WHO’s Guidelines for Stopping Mass Drug Administration and Verifying Elimination of Human Onchocerciasis: Criteria and Procedures: Annexes (January 2016)

3. WHO’s Corrigenda on the Guidelines (May 2016)

4. A memorandum developed in coordination with USAID regarding the Guidelines (June 2016).

ENVISION then sent hard copies of the Guidelines to the 11 OV-endemic countries (Benin, Cameroon, DRC, Ethiopia, Guinea, Mali, Mozambique, Nigeria, Senegal, Tanzania, Uganda).

ENVISION is also prepared to develop an OV job aid when WHO is closer to completion of its OV Program Manager’s Guide, to ensure complementarity between the job aid and the guide.

Activity 3: Promote learning and dissemination of resources on dossier development. In Q1–Q2, ENVISION focused on the dissemination of the WHO Validation of Elimination of LF as a Public Health Problem Handbook along with the accompanying dossier. To implement the project dissemination plan, ENVISION sent an electronic copy of the Handbook to all ENVISION staff and country programs. Additional plans are in place to include the Handbook in the next ENVISION e-newsletter; to develop case studies on countries that have successfully developed their dossiers; and to conduct a webinar in partnership with WHO on the Handbook, including presentations from champion countries explaining the

70

need for early preparation and data gathering—years before country programs anticipate preparing a dossier. The Integrated NTD Database will be highlighted as a tool to support this data gathering.

Objective 3: Disseminate the NTD Toolbox

ENVISION has used its in-country experiences to respond to identified needs and develop several tools (e.g., databases and TIPAC) and resources (e.g., online training modules, videos, handbooks, checklists, and guides) to strengthen NTD program management and implementation.

As tools are developed, they go through a process: from identification of the need; to design, testing, and feedback; to finalization and dissemination; and finally, to the maintenance phase when acceptability and use is monitored and feedback is used to refine the tool (Figure 9).

Figure 9. Stages of dissemination

Building on work conducted in FY16 when many tools were finalized, in Q1–Q2, FY17, ENVISION focused on disseminating these tools and resources. Figure 10 lists all ENVISION-supported tools on which progress has been made during this reporting period.

Figure 10. Summary of progress made on ENVISION-supported resources

Status of tool development

Testing in selected ENVISION-supported

countries

Dissemination and feedback in USAID-

supported countriesGlobal dissemination

71

ENVISION-supported NTD tool or resource

Iden

tify

need

Desig

n

Test

and

feed

back

Revi

se d

esig

n

Tool

acc

essib

le o

n w

ebsit

e

Diss

emin

atio

n st

rate

gy u

nder

way

WH

O R

ecom

men

ded

PLANNING NTD PROGRAMS

Advocacy Booklet (Country Example: Uganda)

MANAGING MDAs

Serious Adverse Events Job Aid Packet

Data for Action Guide

MDA Preferred Practices Guide

Social Mobilization Planning Guide

Webinar: Preparation, Implementation and

Evaluations: Lessons Learned in Haiti, Benin and Burkina Faso

IMPACT ASSESSMENTS and SURVEILLANCE

WHO LF dossier template

Trachoma Disease-specific Assessments Job Aid

DATA MANAGEMENT and M&E

Calculating Coverage Job Aid

Independent MDA monitoring

Coverage Supervisory Tool (CST)

72

Online Mapping Tool

Coverage Survey + KAP Questionnaire

Activity 1: Disseminate the NTD Toolbox. As a key piece of ENVISION’s dissemination strategy, the NTD

Toolbox was developed in FY16 as a major vehicle through which tools and resources developed by ENVISION, WHO, and partner organizations working in NTDs could be made accessible to any NTD practitioner. Although the NTD Toolbox was officially launched at the very end of FY16, almost all subsequent activities focusing on the dissemination of the Toolbox have taken place in Q1–Q2 of FY17, including improvements to the Toolbox and dissemination activities, which have led to positive results thus far.

Improvements to the Toolbox. During the reporting period, ENVISION garnered feedback from team members, partner organizations, and in-country users of the toolbox to understand how users interact with it and what improvements would be beneficial. Many of those suggested improvements have been discussed with the developer, and appropriate modifications were made to the toolbox, including how tools are labeled, organized, and searchable.

Dissemination activities. Having a user-friendly Toolbox will have little impact unless its target audience is aware of its availability. To begin building awareness and use of the toolbox, ENVISION used various communications channels, including the following:

• Email promotion of the NTD Toolbox to ENVISION’s extensive contact lists post-launch

• Inclusion of link to the NTD Toolbox on WHO’s website

• Creation and dissemination of a postcard promoting the toolbox

• Promotion of the NTD Toolbox at various meetings, including the NTD NGDO Network (NNN), ASTMH, the COR-NTD Innovation Lab, and partners’ meetings (including the USAID Partners’ Meeting and the ENVISION Partners’ Meeting).

• Featuring the NTD Toolbox in the January ENVISION e-Newsletter

• Tweets on the NTD Toolbox at various times, including during the 5th Anniversary of the London Declaration

• Inclusion of hyperlinked NTD Toolbox information in email signatures of ENVISION staff

Furthermore, NTD leaders from outside ENVISION have voluntarily started promoting the NTD Toolbox themselves—e.g., at the recent AFRO training on the Integrated NTD Database and at various Pan-American Health Organization trainings.

Light green indicates status of tool before reporting period Dark green indicates progress made during reporting period

WHO IS USING THE NTD TOOLBOX? More than 400 unique visitors in Q1–Q2, FY17. 64% of visits are from return users. More than 75% of users clicked on multiple pages. Users from multiple NTD-endemic countries,

including those supported by ENVISION.

http://www.who.int/neglected_diseases/preventive_chemotherapy/Capacity_strengthening/en/

73

Results. Preliminary results through Google Analytics on use of the Toolbox thus far have been promising and show the following:

• Adoption of the Toolbox has been strong: More than 400 unique visitors visited the Toolbox during the reporting period.

• Most people who use the Toolbox return: 64% of visits to the Toolbox are made by return users.

• Users stay and interact with the Toolbox: More than 75% of users clicked on multiple pages.

• Target countries are being reached: Users from NTD-endemic countries, including ENVISION countries, are evincing strong interest in the Toolbox. Figure 11 shows from which NTD-endemic countries pageviews of the Toolbox occur most frequently. Additionally, many users come from the U.S., U.K., and Switzerland, where NTD partner organizations and WHO HQ are located.

74

Figure 11. Toolbox visits as % of total pageviews from NTD-endemic countries

Kenya14%

Ethiopia13%

Angola11%

India11%Nigeria

11%

Uganda8%

Burkina Faso6%

Indonesia4%

Senegal5%

D.R. Congo -Kinshasa

3%

South Africa3%

Cameroon3%

Mali3%

Zambia3%

Mozambique2%

75

5. Global Partnerships

Strategic Approach

Policy dialogue takes place at many different levels, starting globally but extending to the regional, national, and local levels. At each of these levels, ENVISION plays an active role, bringing its real-world experience to bear on policy decisions. ENVISION staff work closely with USAID to provide technical leadership by actively participating in global and national forums, including with WHO, the pharmaceutical donor community, the national MOH level, and others.

This section outlines the project’s role in global partnerships, which has the following three objectives:

Objective 1: Contribute to global policy decisions through participation in WHO Global Forums.

Objective 2: Support leadership and collaboration for the management of NTD global medicines.

Objective 3: Contribute to global learning and policy decisions through participation in global NTD forums.

Objective 1: Contribute to global policy decisions through participation in WHO Global Forums

Activity 1: Participate in WHO Global Forums. ENVISION staff continued to represent the project and project-supported country programs at WHO technical meetings during FY17. Because ENVISION staff are intimately involved with national NTD program implementation, their participation helps national NTD program perspectives be heard in global WHO policy development meetings in both Geneva and regional HQs. In addition, ENVISION staff bring first-hand knowledge of the tools developed by or with support from ENVISION that are now adopted by WHO’s global NTD programs. Highlights from ENVISION’s participation in global meetings and working groups in FY17 to date is provided below.

In Q1, ENVISION (Achille Kabore) attended the WHO AFRO, PC: 5th Meeting—NTD-RPRG (October 10–12, 2016). The WHO/AFRO, PC: 5th Meeting was held in Kunduchi, Dar es Salaam, Tanzania, with attendance from RPRG members and observers. The RPRG meeting was a combination of open plenary meetings and breakout meetings consisting of countries divided into working groups based on various thematic areas. During the meeting, key discussions focused on the status of drug delivery and supply chain management, dossier development, timely communication of RPRG recommendations to countries, and strategies to improve program coverage. Specifically, low program coverage for SCH and STH were discussed, with recognition of the need for a clear strategy for control and/or elimination of SCH and the lack of PZQ for high-risk adults. In discussions on the JAP, countries were encouraged to submit their applications well in advance—and if possible, many months before—the MDA for better management of the drug procurement and supply. Observers encouraged the RPRG to encourage countries to communicate and share their drug applications with partners before submission to WHO/AFRO to allow the inclusion of updated information in the applications and reports.

Lisa Rotondo and Jeremiah Ngondi represented ENVISION at ITI’s Trachoma Expert Committee (TEC) Meeting (November/December 2016). During the meeting, the TEC reviewed (1) country applications for ZTH for program year 2017; (2) evidence from districts that presented

76

with 5%–9% prevalence (at impact and baseline) and that had conducted one round of district-wide MDA, followed by an impact survey, to determine whether there is adequate evidence to establish a formal TEC policy; (3) evidence on providing patients with ZTH following trichiasis surgery to determine whether to continue donating for this purpose; and (4) evidence from the refugee camps in Ethiopia and proposed recommendations from the TEC Refugee Subcommittee for considering future requests to treat displaced persons. By the conclusion of TEC 15 meeting, ITI reported a total of 84 million treatments approved for MDA in 2017 in a total of 577 districts. ENVISION representation at these meetings continues to be important for monitoring and informing the global plans for ZTH allocation. Additionally, ENVISION staff are in regular communication with ITI to appraise them of changes in planning and timing of trachoma MDA implementation.

ENVISION (Molly Brady) participated in the WHO SEARO and WPRO Brugia Meeting (December 2016) with attendees from WHO SEARO and WPRO NTD staff, LF program staff from Malaysia and Indonesia, and global experts. The meeting was convened in Malaysia to discuss potential causes of persistent transmission of Brugia malayi and determine immediate programmatic and research actions to address the issue. Key outcomes from the meeting included agreed-upon proposals to implement research on (1) antibody age-prevalence curves in Brugia-endemic areas, by adding Brugia Rapid™ antibody testing onto pre-TAS in Indonesia; (2) TAS3 failure in Alor, Indonesia; and (3) the role of animals in transmission in Malaysia. The WHO WPRO and SEARO RPRG meetings are planned for June 2017, and ENVISION intends to participate.

ENVISION (Mike French) attended the STH Coalition Meeting (Jan 30–Feb 3, 2017). Held at the Royal Institution of Great Britain in London, the meeting was convened to review STH accomplishments, revise and update the STH Coalition Annual Work Plan for 2017, and promote information sharing and collaboration.

ENVISION (Amy Doherty) participated in the ESPEN Meeting (February 6–7, 2017) in Brazzaville, Republic of the Congo. The meetings were attended by AFRO, WHO local representatives, NTD program coordinators and other MOH representatives from the 14 priority countries, RPRG members, donors, and implementing partners. The meeting was opened with remarks from partners (ESPEN, USAID, and the Mectizan® Donation Program), and the ESPEN implementation framework was presented. Alex Tiendrebeogo presented a country coordination framework and emphasized strengthening coordination mechanisms in countries—in terms of partner coordination as well as intra- and inter-sectoral collaboration. During the two-day meeting, country groups worked to start, complete, and/or update 2017 action plans, and each MOH representative reported in plenary on program progress and current funding gaps. BMGF has provided funding to Speak Up Africa to assist ESPEN with its advocacy, communication, and domestic resource mobilization needs.

ENVISION (Lisa Rotondo) participated in a Trachoma Global Forecasting Meeting to discuss plans for an annual review of the GET 2020 data and projections for the elimination of trachoma as a public health problem, including both TT or “S” and TF or “AFE” (from the SAFE strategy). The current data are based on surveys, and the projections are based on a set of identified and conservative assumptions. The WHO GET 2020 Alliance review process will align these projections with national program input through regional offices. They will collectively inform messaging for the trachoma community and guide priority actions for 2020. On behalf of the Alliance, International Coalition for Trachoma Control (ICTC) convened a small working group to review projection data for ZTH distribution prepared by ITI. RTI participated as a member of this working group with WHO, ITI, ICTC, Pfizer, and Sightsavers.

77

Objective 2: Support leadership and collaboration for the management of NTD global medicines

Activity 1: Participate in NTD global medicines forums. In March 2017, Project Coordinator Dano Gunderson traveled to Geneva, Switzerland to attend the biannual meeting of the NTD Supply Chain Forum. The NTD Supply Chain Forum is a small group composed of the companies that donate NTD drugs, the donation program administrators, WHO, DHL (international logistics company), and BMGF. The group is generally concerned with the “first mile” of supply chain management—forecasting, quantification, manufacture, and shipment to the beneficiary countries. RTI is regularly invited to the Forum’s meetings to represent implementing partners and provide perspective on “last mile” distribution issues. Key topics discussed include the following:

• WHO highlighted that timely submissions of drug applications are improving, but low-quality applications and timely import approval from countries continue to be issues. WHO introduced an April 15 deadline for JAP submissions from countries that treat during the first half of the calendar year, which is expected to spread production burden and minimize drug delays. However, communication to countries about this new deadline has been unclear, and AFRO introduced its own February 15 deadline to better fit the RPRG’s April review meeting schedule.

• WHO noted that Alere is facing a backlog of orders due to flu vaccine production and is encouraging countries to order as soon as possible, to avoid TAS delays.

• GSK shared the results from a recently completed shipping temperature monitoring study, which demonstrated that ALB is very stable at high temperatures and that high temperature excursions during shipping are rare. Merck KGaA is still waiting for further guidance from its quality control office, but for now, donated PC drugs will continue to be shipped at ambient temperature; ENVISION intends to follow suit.

• The iNTegrateD Database is an online supply chain management system that houses purchase order and shipping data for ALB, MEB, and PZQ. The database will be renamed as “NTDeliver” to avoid confusion, and the Forum is taking steps to make the database more accessible to partners and countries.

• RTI gave a presentation about the role that ENVISION supply chain seconded staff and consultants have played in strengthening in-country capacity to manage donated medicines in Ethiopia and Mozambique.

Activity 2: Provide ongoing coordination between national NTD and drug donation programs. ENVISION field staff assisted MOHs to complete the TEMF and ZTH application, and to ensure that these forms were submitted to WHO and ITI by the March 1 deadline. Notably, with the assistance of ENVISION, DRC submitted on time and included data from the first ZTH MDA in the country (also supported by ENVISION).

ENVISION staff also helped to advocate for proper delivery of WHO-managed drug donations to Senegal and Cameroon. In the case of Senegal, RTI and USAID staff immediately notified RTI HQ and the WHO country and regional offices that the drugs were late; RTI HQ notified WHO Geneva and ensured expedited delivery of ALB and PZQ so that planned MDA activities would not be late. In the Cameroon situation, HKI raised the alarm in country and to Geneva, then notified RTI HQ. RTI followed up with WHO AFRO and Geneva to learn why requests for medicine were

78

delayed. During this period, ENVISION also learned that Cameroon had a stockpile of unused, unexpired ALB (approximately 4 million tablets at central level) and that its need for ALB in FY17 was significantly reduced from its request. Ultimately, WHO and GSK arranged for the ALB requested by the Cameroon national program to arrive quickly. ENVISION will continue to follow up on this situation with the Cameroon MOH, USAID, and WHO at all levels.

Both ITI and the NTD Supply Chain Forum rolled out databases for drug tracking in the first half of FY17. RTI ensured that all NTD Technical Advisors and sub-partner technical leads have access to NTDeliver, and began encouraging MOH staff to obtain log-ins. Currently, the database does not provide much data that is useful for a country program manager, so ENVISION will be collecting feedback and sending it to the database developers, and will share this feedback at the next NTD Supply Chain Forum meeting. ENVISION staff have received log-ins to the ITI ZTH Shipment Tracker and have begun receiving emails about the status of the drugs.

Objective 3: Contribute to global learning and policy decisions through participation in global NTD forums

Activity 1: Participate in other global forums. In addition to ENVISION’s existing partnerships with WHO and pharmaceutical donors, there are several other critical global-level working groups in which RTI participates, summarized in Table 16. These working groups, along with participation at global meetings—Uniting to Combat NTDs, Global Alliance to Eliminate Lymphatic Filariasis (GAELF), GET2020, GSA, ICTC and The Carter Center Review Meetings—are important forums in which ENVISION shares experience from USAID-supported countries; significantly shapes the formulation of policies, strategies, and best practices for nongovernmental development organization (NGDO) support to national NTD programs; and highlights gaps requiring programmatic support or funding. ENVISION will maximize these opportunities to ensure its technical expertise and knowledge of field realities counterbalance political interests that may not be evidence based.

The NTD Summit is planned for April 19–22, 2017 in Geneva. In commemoration of the 5th anniversary of WHO’s Roadmap on NTDs and the London Declaration, Uniting to Combat NTDs and WHO will hold the NTD Summit to celebrate these milestones, launch the fourth WHO report on NTDs, and spur further global support for NTD control and elimination goals. As part of these meetings, GAELF, GET 2020, and ICTC will hold concurrent meetings. ENVISION is planning to participate in these meetings, in some cases providing technical support for the planning or presentation of sessions. More information will be provided in the subsequent report.

As illustrated in Table 13, ENVISION staff lead and participate in many of these global forums. Virtual and in-person gatherings of these groups are opportunities for ENVISION to support international and regional platforms and to influence best practices.

79

Table 13. ENVISION contributions to global working groups, beyond WHO, Q1-Q2 FY17

ENVISION staff Name of working group or sub-working group

Lisa Rotondo NNN—Past Chair, current Executive Committee member Uniting to Combat NTDs Stakeholder Working Group, under NNN—Past Chair TEC—Member

Eric Ottesen BMGF STH External Advisory Group Coalition for Operational Research on the NTDs, TFGH

Achille Kabore Global Schistosomiasis Alliance—Co-Chair, Implementation Working Group Molly Brady LF NGDO Network—Past Chair Katie Crowley NTD Supply Chain Forum—Member Philip Downs STH Coalition

NNN WASH Working Group Sharone Backers NNN WASH Working Group Scott McPherson NNN Morbidity Management and Disability Working Group Jeremiah Ngondi TEC—Observer Michael French Global SCH Alliance and STH Coalition Abdel Direny STH Coalition

NNN WASH Working Group Activity 2: Participate in the NNN 2017 Meeting. The NNN 2017 meeting is planned for September 28–30, 2017 in Dakar, Senegal. In Q1–Q2, RTI staff contributed to ongoing discussions regarding the planning of this meeting. As Immediate Past Chair, Lisa Rotondo continues to support and represent the NNN’s External Representation Committee. More information on the NNN 2017 meeting will be provided in the year-end report. ENVISION has contracted Maximize Your Time as the professional conference organizers.

Activity 3: Participate in the East Africa Trachoma/NTD Cross-Border Partnership Meeting. The East Africa Trachoma/NTD Cross-Border Partnership Meeting will be held in the second half of FY17 and will be detailed in the year-end report.

Activity 4: Continue coordination with World Bank and its funded projects. As guided by USAID through its donor-to-donor relationship with the World Bank, ENVISION continued to support efforts to coordinate with the World Bank and its funded projects, the Sahel Malaria and Neglected Tropical Diseases Project and OMVS. The Sahel project focuses on scaling up disease control interventions at the community level in cross-border areas in Burkina Faso, Mali, and Niger—all USAID-supported NTD-endemic countries. The OMVS project is implemented in Senegal,

80

Guinea, and Mali. During Q1–Q2, ENVISION field and HQ staff continued to seek ongoing dialogue with these World Bank-funded projects to maximize synergies and avoid overlap of efforts.

Activity 5: Provide opportunities for field staff to contribute to and participate in global forums. ENVISION field staff provide essential insight into program implementation experience in USAID-supported countries, which ultimately shapes global policy and best practices. In addition, they play a substantial role in providing TA to MOHs and sharing global learning and resources needed to advance program progress. In Q1–Q2, ENVISION provided support for 12 field staff to attend COR-NTD and ASTMH events, to share country experiences and strengthen their NTD technical capacity. In addition, support from the NTD Support Center with BMGF funding allowed national NTD program staff from nine USAID-supported countries to attend COR-NTD and ASTMH events and present country achievements and experiences.

6. ENVISION Support to the NTD Donor Community

Through the global leadership role on ENVISION, RTI staff provide technical and operational assistance to several global NTD donor organizations, including the Bill & Melinda Gates Foundation and the End Fund. This unique support and consultation ensures that top technical expertise is informing funding, design, and evaluation of other NTD projects. Examples of this support include advising on the design of post-MDA coverage surveys, stakeholder analysis and gap identification in ENVISION-supported countries, costing of MDA activities, and evaluation of other NTD initiatives.

7. Technical Assistance Facility (TAF)

Strategic Approach

USAID and RTI created the TAF to provide technical support to NTD programs in non-ENVISION-supported countries. Since its inception, the TAF supported key NTD interventions—mapping, DSAs, technical meetings, and situation analyses—in more than 10 countries and was instrumental in ensuring that these interventions were carried out. The TAF’s focus in FY16 was on conducting M&E. In FY17, it is anticipated that the TAF will continue supporting M&E activities and will include LF and trachoma assessment and surveillance surveys (TAS, TIS, and TSS) and DQA. As several countries prepare to document the success of their LF and trachoma elimination programs, the TAF will be available on demand to provide technical support for pre-dossier development in non-ENVISION-supported countries.

81

Appendix 2: ENVISION’s FY17 Results by Intermediate Result Area

See separate attachment.

ENVISION · Research Triangle Park, NC 27709 -2194 . ... iv . ACRONYMS LIST AE Adverse Event . AFRO...

Documents

Transcript of ENVISION · Research Triangle Park, NC 27709 -2194 . ... iv . ACRONYMS LIST AE Adverse Event . AFRO...