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Abstract The control of onchocerciasis is not only a major success story in global health, but also one of the best examples of the power of public-private partnership at the international level as well as at the national level. The onchocerciasis story is also a leading example of the contribution of a group of called Non-Governmental Development Organizations (NGDO) to operational research which resulted in important changes in treatment strategies and policies. The four case studies presented here illustrate some key contributions the NGDOs made to the development of "community directed treatment with ivermectin" –CDTI, in Africa, which became the approved methodology within the African Programme for Onchocerciasis Control (APOC). The partnership between the international, multilateral, government institutions and the NGDO Coordination Group was the backbone of the APOC programme's structure and facilitated progress and scale-up of treatment programmes. Contributions included piloting community–based methodology in Mali and Nigeria; research, collaboration and coordination on treatment strategies and policies, coalition building, capacity building of national health workforce and advocacy at the national and international level. While the Onchocerciasis Control Programme (OCP) and APOC provided leadership, the NGDOs working with the national health authorities played a major role in advocacy evolving the community methodology which led to achieving and maintaining- treatments with ivermectin for at least 20 years and strengthening community health systems.

BACKGROUND: Onchocerciasis can be effectively controlled as a public health problem by annual mass drug administration of ivermectin, but it was not known if ivermectin treatment in the long term would be able to achieve elimination of onchocerciasis infection and interruption of transmission in endemic areas in Africa. A recent study in Mali and Senegal has provided the first evidence of elimination after 15-17 years of treatment. Following this finding, the African Programme for Onchocerciasis Control (APOC) has started a systematic evaluation of the long-term impact of ivermectin treatment projects and the feasibility of elimination in APOC supported countries. This paper reports the first results for two onchocerciasis foci in Kaduna, Nigeria. METHODS: In 2008, an epidemiological evaluation using skin snip parasitological diagnostic method was carried out in two onchocerciasis foci, in Birnin Gwari Local Government Area (LGA), and in the Kauru and Lere LGAs of Kaduna State, Nigeria. The survey was undertaken in 26 villages and examined 3,703 people above the age of one year. The result was compared with the baseline survey undertaken in 1987. RESULTS: The communities had received 15 to 17 years of ivermectin treatment with more than 75% reported coverage. For each surveyed community, comparable baseline data were available. Before treatment, the community prevalence of O. volvulus microfilaria in the skin ranged from 23.1% to 84.9%, with a median prevalence of 52.0%. After 15 to 17 years of treatment, the prevalence had fallen to 0% in all communities and all 3,703 examined individuals were skin snip negative. CONCLUSIONS: The results of the surveys confirm the finding in Senegal and Mali that ivermectin treatment alone can eliminate onchocerciasis infection and probably disease transmission in endemic foci in Africa. It is the first of such evidence for the APOC operational area.

Although the depiction of a child leading a blind man is the most enduring image of onchocerciasis in Africa, research activities have hardly involved children. This paper aims at giving voice to children through drawings and their interpretation. The study was conducted in 2009 in Cameroon, Democratic Republic of Congo (DRC), Nigeria and Uganda. Children aged 6–16 years were asked to draw their perceptions of onchocerciasis and community-directed treatment with ivermectin (CDTI) in their communities. A total of 50 drawings were generated. The drawings depicted four main aspects of onchocerciasis: (1) the disease symptoms, (2) the negative consequences of onchocerciasis among children and in the community generally, (3) the ivermectin distribution process, and (4) the benefits or effects of taking ivermectin. Out of the 50 drawings, 30 were on symptoms, 7 on effects of the disease on children, 8 on distribution process, and 5 represented multiple perceptions on symptoms, drug distribution processes, benefits, and effects of treatment. The lack of clarity when treatment with ivermectin can be stopped in endemic areas requires working with children to ensure continued compliance with treatment into the future. Children's drawings should be incorporated into health education interventions.

BACKGROUND: Integrated transmission assessment surveys (iTAS) have been recommended for evaluation of the transmission of both lymphatic filariasis (LF) and onchocerciasis as the prevalence of both diseases moves toward their respective elimination targets in Nigeria. Therefore, we conducted an iTAS between May and December 2017 in five local government areas (LGAs), also known as implementation units (IUs), in states of Cross River, Taraba and Yobe in Nigeria. METHODS: The TAS comprised two phases: the Pre-iTAS and the iTAS itself. Three states (Cross River, Taraba and Yobe), comprising five LGAs and 20 communities that have completed five rounds of combined treatment with ivermectin and albendazole for LF and 12 total rounds of ivermectin, were selected for inclusion in the study. All participants were tested with the Filariasis Test Strip (FTS; Alere Inc.) and the Biplex rapid Diagnostic Test (RDT; identifying filaria antigens Ov16/Wb123; Abbott diagnosctics Korea Inc.). Pre iTAS included 100 children ages 5-9 in each 4 communities and 300 individuals ages 10 and older in a subset of two communities. For the iTAS, only LGAs where antigenemia prevalence in all sampled communities during the Pre-iTAS was < 2% for LF were selected. RESULTS: Of the five LGAs included in the study, four met the cutoff of the Pre-iTAS and were included in the iTAS; the Ikom LGA was excluded from the iTAS due to antigenemia prevalence. A total of 11,531 school-aged children from 148 schools were tested for LF and onchocerciasis across these four LGAs, including 2873 children in Bade, 2622 children in Bekwara, 3026 children in Gashaka and 3010 children in Karim Lamido. Using the FTS, all samples from Bade and Karim Lamido were negative, whereas 0.2% of the samples from Bekwara and Gashaka were positive. Using the Biplex RDT, LF prevalence in Bade, Bekwara, Gashaka and Karim Lamido was < 0.1%, 0.5%, 0.4% and < 0.1%, respectively. Moreover, all samples from Bade and Karim Lamido were negative for onchocerciasis, whereas 3.1% ...

BACKGROUND: Onchocerciasis causes a considerable disease burden in Africa, mainly through skin and eye disease. Since 1995, the African Programme for Onchocerciasis Control (APOC) has coordinated annual mass treatment with ivermectin in 16 countries. In this study, we estimate the health impact of APOC and the associated costs from a program perspective up to 2010 and provide expected trends up to 2015. METHODS AND FINDINGS: With data on pre-control prevalence of infection and population coverage of mass treatment, we simulated trends in infection, blindness, visual impairment, and severe itch using the micro-simulation model ONCHOSIM, and estimated disability-adjusted life years (DALYs) lost due to onchocerciasis. We assessed financial costs for APOC, beneficiary governments, and non-governmental development organizations, excluding cost of donated drugs. We estimated that between 1995 and 2010, mass treatment with ivermectin averted 8.2 million DALYs due to onchocerciasis in APOC areas, at a nominal cost of about US$257 million. We expect that APOC will avert another 9.2 million DALYs between 2011 and 2015, at a nominal cost of US$221 million. CONCLUSIONS: Our simulations suggest that APOC has had a remarkable impact on population health in Africa between 1995 and 2010. This health impact is predicted to double during the subsequent five years of the program, through to 2015. APOC is a highly cost-effective public health program. Given the anticipated elimination of onchocerciasis from some APOC areas, we expect even more health gains and a more favorable cost-effectiveness of mass treatment with ivermectin in the near future.