Cross-border issues: an important component of onchocerciasis elimination programmes

Cross-border issues: an important component of onchocerciasis elimination programmes Abstract Endemic areas that involve national or local borders present an important challenge to the success of elimination of onchocerciasis; such cross-border endemic foci require special attention to ensure that programme activities are unified. It is vital that national programmes and the committees responsible for the oversight of progress towards elimination are aware and address such issues in their current planning and programmatic activities. Although international borders that intersect endemic zones present the biggest challenge, intracountry borders (such as between administrative districts or loiasis endemic and non-loiasis areas) can also pose problems. The recent change in the onchocerciasis programme from disease control to transmission interruption, given the historical lack of treatment in hypo-endemic areas, may have increased the already relatively high number of cross-national scenarios in Africa. It is vital that all national programmes address the issue of any cross-border endemic areas as a matter of urgency and include this important issue in their elimination plans. Cross-border, Onchocerciasis, Political issues, Language issues, Communication, Vector Introduction The control and elimination of a disease almost always involves the interaction of public health and political sectors, and necessarily requires management of local factors, influences and challenges, elements that are often underestimated in terms of programme implementation. The elimination of onchocerciasis is no different. The recent change in focus from disease control to transmission interruption has meant that certain important programmatic issues have not, so far, been given the attention they need.1,2 One of these is the challenge presented by cross-border (CB) areas of endemicity, both of onchocerciasis3,4 and of the confounding infection loiasis; these have often been given little consideration, with some notable exceptions. The importance of understanding and addressing the difficulties presented by the CB issues is being recognized more commonly, as the onchocerciasis elimination initiative now focuses on the major steps towards success. National programmes will need to recognize the unique factors that cause difficulties at CB locations and be aware of the actions and procedures that can be used to alleviate such problems. The discussion here is focused specifically on the context of onchocerciasis, but many of the principles and examples discussed will apply to other neglected tropical disease (NTD) programmes, particularly vector-transmitted diseases. CB issues in relation to matters of health and migration are well known in the developed world; for example, patient migration between Mexico and the USA, and within the European Union,5,6 often including issues of quarantine for infectious diseases. However, it should also be said that the issues in these countries are somewhat different from those in developing countries that are trying to achieve specific public health goals, such as elimination of parasitic infections. Here, in the example of onchocerciasis, the importance of CB situations is underscored by the need to ensure coverage of the whole population living in a transmission zone. However, it is not surprising that public health interventions, such as mass drug administration (MDA), taking place in a transmission zone that has a national border running through it could be quite different on the different sides of the border in terms of coverage due to timing and stage of assessment, as well as other characteristics. It is also important to note in this context that the early onchocerciasis programmes that focused on disease control did not implement any MDA in hypo-endemic areas7; this is likely to have important implications for CB planning and activities, as these areas will now be targeted for MDA under an elimination programme. Good communication and mutual understanding between national programmes that share a border are arguably the most important keys to ensuring that CB situations do not impede the progress to elimination. Types of borders The concept of ‘borders’ in the context of MDA programmes can take different forms—political, administrative and geographic, as well as the more socially and culturally oriented forms of partitioning based on tribal and language differences. History has shown how the impact of national borders, originally defined politically without consideration of social issues, can lead to important long-term issues, for example the borders defined in colonial times by Europeans and imposed on developing countries in Africa and Asia. In Africa, these new boundaries were often rivers, entities that now have a special relevance for onchocerciasis in terms of vector breeding sites. A currently infamous example of this is the border between Pakistan and Afghanistan, drawn through Pashtun tribal land; this colonial act has led to conflict because of the lack of consideration of important tribal issues by the original colonizing administrations that continues to have major effects on the politics and people of the region. Borders are usually discussed in terms of international borders, but internal borders within a country, such as provincial and district administrative divisions, can also present considerable programmatic challenges. Other than political boundaries, additional descriptors such as those based on endemicity, environment, culture (language, ethnicity, professions, customs, etc.) and risk of transmission are also important considerations (Table 1). From a national programme perspective, differences in public health interventions between administrative districts are usually manageable within a national programme’s planning mechanisms, even where districts began MDA activities at different times. In contrast, coordinating the timing of MDA programmes in different countries can be a challenge in managing intercountry CB endemic foci. Table 1. The different types of borders potentially having an impact on the implementation of MDA and other public health activities Type of border  Major characteristics  Importance to onchocerciasis programmes  Examples  International  Need for CB collaboration  Effectiveness of interventions in contiguous endemic populations and vector breeding sites (+++)*  Sudan—Ethiopia. Venezuela—Brazil. Uganda—DRC. Malawi—Mozambique  Internal administrative  Coordination of MDA and reporting  Effectiveness of interventions on transmission amongst continuous endemic populations and vector breeding sites (++)  Redefining of districts and provinces. Changes in administrative responsibilities due to redistricting  Environmental (geographic)  Often related to transmission zones  Prioritization of interventions based on environmental risk factors (+)  Mountain ranges, major rivers, desert regions, forested areas, vector breeding sites  Endemic populations  Need for good historical data and systematic processes for monitoring and evaluation of disease  Prioritization of interventions based on human infection (+)  Categorization of endemic zones (e.g. LF MDA areas)  Transmission zone borders (areas at risk)  The interaction between vector breeding sites, human populations and the presence of infection  Important due to the lack of treatment in hypo-endemic areas to date (+++)  Remapping the intimacy of onchocerciasis and identification of breeding sites (high-transmission areas)  Cultural aspects (language, ethnicity, occupation and local customs)  Effective communication and treatment coverage  Important for social mobilization during drug distribution (+++)  DRC and Uganda CB issues. Brazil and Venezuela CB issues  Co-endemic infections  A major barrier to high coverage as well as being an ethical issue  Important to avoid post-treatment severe adverse reactions (+++)  Cameroon. Nigeria. DRC. Chad. Angola  Type of border  Major characteristics  Importance to onchocerciasis programmes  Examples  International  Need for CB collaboration  Effectiveness of interventions in contiguous endemic populations and vector breeding sites (+++)*  Sudan—Ethiopia. Venezuela—Brazil. Uganda—DRC. Malawi—Mozambique  Internal administrative  Coordination of MDA and reporting  Effectiveness of interventions on transmission amongst continuous endemic populations and vector breeding sites (++)  Redefining of districts and provinces. Changes in administrative responsibilities due to redistricting  Environmental (geographic)  Often related to transmission zones  Prioritization of interventions based on environmental risk factors (+)  Mountain ranges, major rivers, desert regions, forested areas, vector breeding sites  Endemic populations  Need for good historical data and systematic processes for monitoring and evaluation of disease  Prioritization of interventions based on human infection (+)  Categorization of endemic zones (e.g. LF MDA areas)  Transmission zone borders (areas at risk)  The interaction between vector breeding sites, human populations and the presence of infection  Important due to the lack of treatment in hypo-endemic areas to date (+++)  Remapping the intimacy of onchocerciasis and identification of breeding sites (high-transmission areas)  Cultural aspects (language, ethnicity, occupation and local customs)  Effective communication and treatment coverage  Important for social mobilization during drug distribution (+++)  DRC and Uganda CB issues. Brazil and Venezuela CB issues  Co-endemic infections  A major barrier to high coverage as well as being an ethical issue  Important to avoid post-treatment severe adverse reactions (+++)  Cameroon. Nigeria. DRC. Chad. Angola  *Level of importance to the programme in parentheses. DRC: Democratic Republic of the Congo; LF: lymphatic filariasis. Managerial challenges for country programmes can occur when different international partners support different aspects of an elimination agenda within a country. For example, non-governmental development organizations (NGDOs) often support smaller portions of a countrywide programme, based on disease, implementation phase or administrative areas, which may be influenced by donor stipulations and organizational mandates. It is essential that these artificial boundaries do not create holes in coverage by a lack of communication between partner organizations that fund different areas that are part of a single focus or transmission zone. This type of issue needs adequate communication, understanding and a shared approach by all those supporting the national programme in question. This type of boundary should be managed by country national ministries of health and involve all partners at the various programmatic levels during work planning meetings or during special CB meetings. In most cases, this boundary is best managed by involving all partners at the various programmatic levels during work planning meetings with National Onchocerciasis Elimination Committees (NOECs) or during special CB meetings. An example of the type of planning meeting needed between bordering countries took place between Mozambique, Malawi and Tanzania in Malawi in July 2017 at the 1st Southern Africa Onchocerciasis Cross-Border Collaboration and Partnership Meeting. The three countries and international partners discussed the epidemiological situation at their shared borders and planned the next steps in addressing the problems related to managing the border issues related to MDA and monitoring as each country progresses to successful elimination. It is important to note, as a type example, that these three countries also have borders with additional countries, ones that either are known to have or have had endemic onchocerciasis. In addressing CB issues in the fullest manner, each country’s NOEC must consider all borders, not just those that are known candidates for cross-endemicity. Other examples of similar collaborative discussions that have occurred in the past few years include the long-standing intercountry meetings between Uganda and the Democratic Republic of the Congo, as well as between Sudan and Ethiopia. Boundaries based on landscape and environmental factors also play a part in any discussion of CB issues. The major geographic features that can be involved in CB situations are rivers, lakes, forests, mountains, deserts and islands: these all have their peculiarities. Rivers are most likely to be involved due to the nature of the vector and its riverine breeding site biology, and there are examples where rivers are in fact the border between two countries with endemic foci. A case in point here is with the onchocerciasis focus that spans between Malawi and Mozambique—an important example where there is a need for a unified approach to elimination of this whole transmission zone. One side of the border (Malawi side) has been under MDA, but across the river in Mozambique, which has always been regarded as a hypo-endemic area, treatment has never been implemented. This is an example where intercountry communication and mutual decision making is needed in terms of how and when either to declare elimination successful or perhaps to continue with or instigate MDA, a decision that is likely to involve mutual monitoring and evaluation between countries. An important intracountry and intercountry type of boundary that effects programme management is that between loiasis endemic and non-endemic areas. This filarial infection has the potential of causing severe and life-threatening post-ivermectin treatment reactions in those people carrying very high circulating loads of Loa loa microfilariae.8 Differences in the management and treatment strategy between co-endemic and loiasis-free areas are necessary to prevent adverse events. There is a need for careful mapping of the current loiasis endemic areas to ascertain where there is co-endemicity with onchocerciasis as well as lymphatic filariasis. Programmatic aspects As we have noted, CB issues are an important programmatic issue, and one that must be addressed early on by national programmes and their NOECs as they plan and implement their national programmes for the elimination of onchocerciasis. Although each situation will undoubtedly have its own characteristics, there are some fundamental steps and issues that a national programme should address and respond to if needed; many of these are listed in Table 2. It should also be noted that funding for CB issues has often not been included in partner and national programme budgeting—it needs to be. Table 2. The range of factors and issues pertaining to cross-border foci of onchocerciasis Factors and programmatic issues  Differences in endemicity (e.g. hypo-edemicity where no previous treatment has happened)  Language differences  National political differences  Differences in available programmatic support  Lack of coordination in MDA schedules  Areas of civil unrest and insecurity  Difficulties due to local geography  CB migration of people  Difficulties in organizing joint meetings  The lack of availability or non-release of funds by governments for CB activities  The lack to date of including CB issues in programmatic planning  Factors and programmatic issues  Differences in endemicity (e.g. hypo-edemicity where no previous treatment has happened)  Language differences  National political differences  Differences in available programmatic support  Lack of coordination in MDA schedules  Areas of civil unrest and insecurity  Difficulties due to local geography  CB migration of people  Difficulties in organizing joint meetings  The lack of availability or non-release of funds by governments for CB activities  The lack to date of including CB issues in programmatic planning  There are many examples of CB transmission of onchocerciasis in the African continent and these need careful and immediate consideration and planning. The importance of this issue is underscored by an example in the Latin American onchocerciasis elimination programme, a programme that has always been seen as likely to achieve success ahead of Africa,2 but even here a CB issue is hindering ultimate success. The last population to carry the parasite in this region is the Amerindian tribal people (the Yanomami) who live a nomadic life in the jungles on the border between northern Brazil and southern Venezuela; different approaches are needed for success in this difficult situation where the necessary high drug coverage is extremely hard to achieve and maintain. Examples of the major CB endemic locations from the three major regions of Africa are presented in Tables 3–5. In Central Africa (Table 3), CB issues are still in need of extensive discussion by the respective NOECs and therefore remain an issue requiring urgent attention. In East Africa there are four major intercountry defined CB foci (Table 4): Ethiopia–Sudan, Mozambique–Malawi, South Sudan–Uganda and Uganda–Democratic Republic of the Congo; it is not yet clear whether there are any CB issues for onchocerciasis between Tanzania and Mozambique, as further entomological and serological evaluation is still needed. Lastly, in West Africa, CB interactions between the involved countries are beginning to happen (Table 5). It should be noted that many countries in Africa have not yet fully established their NOECs, an important step to move these countries forward towards elimination, or an oversight expert committee implemented by the World Health Organization (WHO). The NOECs are important bodies for the discussion of CB issues that require addressing for the countries to move further with their elimination activities. Table 3. Countries in Central Africa with cross border situations Country  NOEC established  CB situation  Comment*  Angola  N  With DRC  Needing attention  Burundi  N  Unclear  Close to elimination, needs NOEC support  Cameroon  Y  CAR, Nigeria, Chad, Congo-Brazzaville  NOEC being formed  CAR  N  Cameroon, Chad, South Sudan  Civil unrest  Chad  N  Cameroon, CAR, Nigeria  NOEC needed  Congo-Brazzaville  N  Cameroon, Gabon, DRC  NOEC needed  DRC  N  Uganda, Angola, CAR, Congo, South Sudan, Zambia  NOEC needed, cross-border collaboration with Uganda happening  Equatorial Guinea  N  Cameroon, Gabon  NOEC needed  Gabon  N  Cameroon, Congo  Overall programme needed  Country  NOEC established  CB situation  Comment*  Angola  N  With DRC  Needing attention  Burundi  N  Unclear  Close to elimination, needs NOEC support  Cameroon  Y  CAR, Nigeria, Chad, Congo-Brazzaville  NOEC being formed  CAR  N  Cameroon, Chad, South Sudan  Civil unrest  Chad  N  Cameroon, CAR, Nigeria  NOEC needed  Congo-Brazzaville  N  Cameroon, Gabon, DRC  NOEC needed  DRC  N  Uganda, Angola, CAR, Congo, South Sudan, Zambia  NOEC needed, cross-border collaboration with Uganda happening  Equatorial Guinea  N  Cameroon, Gabon  NOEC needed  Gabon  N  Cameroon, Congo  Overall programme needed  *As understood at the time of writing. CAR: Central African Republic; DRC: Democratic Republic of the Congo; NOEC: National Onchocerciasis Elimination Committee. Table 4. Countries in East Africa with cross border situations Country  NOEC established  CB situation  Comment*  Ethiopia  Y  Sudan, South Sudan  Sudan CB discussion ongoing  Kenya  N  South Sudan (camps), Tanzania  NOEC to move to country verification  Malawi  Y  Mozambique  NOEC not activated as of yet  Mozambique  N  Malawi, Tanzania  CB discussions held in mid-2017  Sudan  Y  Ethiopia, South Sudan  NOEC not activated as of yet  South Sudan  N  Uganda, Ethiopia, Sudan  Civil unrest at present  Tanzania  Y  Mozambique, Burundi, Kenya  NOEC needs to address CB issues  Uganda  Y  DRC, South Sudan  CB collaboration with DRC under way  Country  NOEC established  CB situation  Comment*  Ethiopia  Y  Sudan, South Sudan  Sudan CB discussion ongoing  Kenya  N  South Sudan (camps), Tanzania  NOEC to move to country verification  Malawi  Y  Mozambique  NOEC not activated as of yet  Mozambique  N  Malawi, Tanzania  CB discussions held in mid-2017  Sudan  Y  Ethiopia, South Sudan  NOEC not activated as of yet  South Sudan  N  Uganda, Ethiopia, Sudan  Civil unrest at present  Tanzania  Y  Mozambique, Burundi, Kenya  NOEC needs to address CB issues  Uganda  Y  DRC, South Sudan  CB collaboration with DRC under way  *As understood at the time of writing. DRC: Democratic Republic of the Congo; NOEC: National Onchocerciasis Elimination Committee. Table 5. Countries in West Africa with cross border situations Country  NOEC established  CB situation  Comment*  Benin  N  Togo, Nigeria, Burkina Faso  NOEC in process  Burkina Faso  Y  Mali, Cote d’Ivoire, Ghana, Togo, Benin, Niger  NOEC established and active  Cote d’Ivoire  N  Liberia, Burkina Faso, Ghana, Mali  NOEC in process  Ghana  Y  Cote d’Ivoire, Burkina Faso, Togo  NOEC established  Guinea  Y  Guinea Bissau, Senegal, Mali, Sierra Leone, Liberia  NOEC established and active  Guinea Bissau  Y  Senegal, Guinea  First NOEC meeting planned  Liberia  Y  Sierra Leone, Guinea, Cote d’Ivoire  NOEC established and active  Mali  N  Senegal, Guinea, Cote d’Ivoire, Burkina Faso, Benin, Niger  NOEC in process  Niger  N  Burkina Faso, Benin, Nigeria, Chad, Mali  NOEC established and active  Nigeria  Y  Benin, Cameroon, Chad, Niger  NOEC established and active  Senegal  N  Guinea-Bissau, Guinea  NOEC established and active  Sierra Leone  Y  Guinea, Liberia  NOEC established and active  Togo  Y  Benin, Ghana, Burkina Faso  NOEC established and active CB collaboration occurring  Country  NOEC established  CB situation  Comment*  Benin  N  Togo, Nigeria, Burkina Faso  NOEC in process  Burkina Faso  Y  Mali, Cote d’Ivoire, Ghana, Togo, Benin, Niger  NOEC established and active  Cote d’Ivoire  N  Liberia, Burkina Faso, Ghana, Mali  NOEC in process  Ghana  Y  Cote d’Ivoire, Burkina Faso, Togo  NOEC established  Guinea  Y  Guinea Bissau, Senegal, Mali, Sierra Leone, Liberia  NOEC established and active  Guinea Bissau  Y  Senegal, Guinea  First NOEC meeting planned  Liberia  Y  Sierra Leone, Guinea, Cote d’Ivoire  NOEC established and active  Mali  N  Senegal, Guinea, Cote d’Ivoire, Burkina Faso, Benin, Niger  NOEC in process  Niger  N  Burkina Faso, Benin, Nigeria, Chad, Mali  NOEC established and active  Nigeria  Y  Benin, Cameroon, Chad, Niger  NOEC established and active  Senegal  N  Guinea-Bissau, Guinea  NOEC established and active  Sierra Leone  Y  Guinea, Liberia  NOEC established and active  Togo  Y  Benin, Ghana, Burkina Faso  NOEC established and active CB collaboration occurring  *As understood at the time of writing. NOEC: National Onchocerciasis Elimination Committee. As mentioned above, a major challenge that most onchocerciasis programmes now face as they focus on elimination is to be fully cognizant of the presence and location of the borders of the hypo-endemic zones, areas that were ignored in the past. It is likely that this means new mapping activities will need to be carried out in many areas before understanding the full extent of any CB issues. It should also be noted that the true significance of the unmapped hypo-endemic areas, in terms of being an important limiting factor to the transmission elimination effort, has not been fully understood as of yet; however, there is some limited evidence that they may indeed be of programmatic importance. The example of the Malawi–Mozambique border challenges referred to above is an case where the mapping of hypo-endemic areas in the latter country is urgently needed to completely solve the CB issues between these two countries. It is clear that more investigation in general is needed on the question of the programmatic significance of the hypo-endemic areas; the results will have a major impact on programme implementation in many ways, such as overall drug requirement, the timing of stopping treatment, country programme staffing logistics and other important issues. Needed actions The requirement for CB work was continued by the African Program for Onchocerciasis Control in 2007,9 and it can be seen from the discussion above that it is extremely important for all national onchocerciasis elimination programmes to include the issue of CB foci in their planning and national agendas. Many of the different steps that a national programme should consider are presented in Table 6. Table 6. Approaches that national programmes should consider regarding CB issues Suggested actions regarding CB foci  NOEC includes strategies for addressing CB foci in the national plan, e.g. memorandum of understanding between countries with shared transmission zones  Establish contact at all administrative levels between countries (or districts, etc., in terms of internal CB issues)  Form joint monitoring and evaluation teams across borders  Coordinate MDA activities across borders  Identify field-level team members responsible for maintaining CB contacts  Maintain communication and sharing of programme plans  Expect increases in programmatic costs for CB activities  Migrant populations need to be considered as part of CB challenges  Establish consistency in messages at the village level, accounting for language differences  Suggested actions regarding CB foci  NOEC includes strategies for addressing CB foci in the national plan, e.g. memorandum of understanding between countries with shared transmission zones  Establish contact at all administrative levels between countries (or districts, etc., in terms of internal CB issues)  Form joint monitoring and evaluation teams across borders  Coordinate MDA activities across borders  Identify field-level team members responsible for maintaining CB contacts  Maintain communication and sharing of programme plans  Expect increases in programmatic costs for CB activities  Migrant populations need to be considered as part of CB challenges  Establish consistency in messages at the village level, accounting for language differences  Although there are many challenges to addressing the needs for CB foci within the context of ensuring elimination of the disease from a country (Table 6), there are still, nevertheless, advantages to be gained with any issue that stimulates positive communication between national programmes. The CB issue provides an opportunity for countries to share experiences in their own country’s efforts to eliminate onchocerciasis; this is likely to be of great benefit to both parties, especially to countries who have not yet initiated necessary elimination activities, and can take place either relatively informally or perhaps optimally at the national programme level. Discussion Efficient and active CB coordination is required if the global targets set for the elimination of transmission of onchocerciasis are to be achieved and the requirements for official success documented correctly. A good example of collaborative work is seen in coordination among members of the Mano River Union3; however, the collaboration that is beginning to develop among other groups of countries is still largely undocumented. The context for the elimination of transmission of onchocerciasis is outlined in the WHO plan for NTDs,9,10 and a programmatic document—the ‘Guidelines for Stopping Mass Drug Administration and Verifying Elimination of Human Onchocerciasis—Criteria and Procedures’11—outlines the need for the development of NOECs. These guidelines also outline the need for the development of more robust approaches to CB work than has been generally accepted in the past. For a country to verify the elimination of transmission of onchocerciasis they must also show that CB work has been undertaken that has successfully led to the elimination of the CB foci. These border areas in most African countries are usually some of the most remote areas and thus are difficult to reach, and in countries where there are ongoing civil disturbances it can be almost impossible. This important challenge to programmes has been previously highlighted3 and this type of area has been identified as one of the emerging challenges that needs to be addressed—‘conflict prevents access to populations through disruption of health services and migration, access to remote populations in challenging geographic settings and vulnerable groups in elimination programmes’.3 As mentioned here, migrant populations are another major factor in CB situations and always need to be accounted for in CB treatment programmes. The successful management of CB issues is probably one of the most complex programmatic areas to achieve. It requires policymakers and decision makers at the central ministry level to be fully in agreement and support these activities; secondly, it requires the technical staff to agree to on the best approach for the work and finally it requires local government authorities, and perhaps non-governmental organizations, from both sides of the border to work together. This is not likely to be easy to achieve; for example, the Manu River Union CB work took 7 years to develop3 and unfortunately experienced a major setback due to the outbreak of ebola virus. Intracountry agreements for collaborative work, such as between districts or provinces, are usually relatively easy to achieve; many bilateral agreements are in place for a variety of medical and other areas of development. Work between intracountry zones, such as districts, is inherently easier to establish, aided by the fact that most programmes are undertaken at the district level. On the other hand, CB agreements are generally much more complicated to arrange, as many levels of administration are usually involved; this usually adds to the programmatic cost. Thus it often falls to external funders to cover the cost of facilitating the international meetings that are the essential step in starting and monitoring CB work. It should be noted that although many of the activities regarding CB foci and their elimination rely on close communication between the two participating countries, in this regard there are many situations where the WHO, and perhaps more usefully WHO-AFRO (including the Expanded Special Project for Elimination of Neglected Tropical Disease [ESPEN]), can become involved. These bodies can facilitate agreements between countries and organizations and, on occasion, provide fiscal support for essential meetings. In some cases there are already CB activities for other diseases in place, and these can be utilized by the onchocerciasis elimination programmes; WHO and WHO-AFRO can be useful mediators and information sources for such events. Conclusion CB foci of various types are relatively common in the onchocerciasis map of Africa, and these often exist in difficult political and geographic locations. It is extremely important that NOECs actively address and add such components to their own national programme agendas. Addressing these will probably include senior-level political activity as well as increased local management and specific attention. Communication and sharing of information between countries and the involved local administrative units are essential to success in addressing this potentially major barrier to the successful elimination of onchocerciasis. CB foci are a sector of onchocerciasis elimination programmes that must be taken seriously and considered early in programme planning. Authors' contributions: CM, SB, YS and PD all contributed to the writing of the text. CM carried out the final edits. Acknowledgements: None. Funding: None. Competing interests: None declared. Ethical approval: Not required. References 1 Mackenzie CD, Homeida MM, Hopkins A et al.  . Elimination of onchocerciasis from Africa: possible? Trends Parasitol  2012; 28(1): 16– 22. Google Scholar CrossRef Search ADS   2 Dadzie Y, Neira M, Hopkins D. Final report of the Conference on the Eradicability of Onchocerciasis. Filaria J  2003; 2(1): 2. Google Scholar CrossRef Search ADS   3 Gustavsen K, Sodahlon Y, Bush S. Cross-border collaboration for neglected tropical disease efforts—Lessons learned from onchocerciasis control and elimination in the Mano River Union (West Africa). Global Health  2016; 12: 44. Google Scholar CrossRef Search ADS PubMed  4 Brazil and Venezuela sign agreement to accelerate cross-border health interventions and interrupt transmission of onchocerciasis. Press release, World Health Organization, 20 May 2014. http//www.who.int/neglected_diseases/onchocerciasis_brazil_venezuela/en/. 5 Helble M. The movement of patients across borders: challenges and opportunities for public health. Bull World Health Org  2011; 89(1): 68– 72. Google Scholar CrossRef Search ADS   6 MacPherson DW, Gushulak BD, Macdonald L. Health and foreign policy: influences of migration and population mobility. Bull World Health Org  2007; 85(3): 200– 6. Google Scholar CrossRef Search ADS   7 Noma M, Nwoke BE, Nutall I et al.  . Rapid epidemiological mapping of onchocerciasis (REMO): its application by the African Program for Onchocerciasis Control (APOC). Ann Trop Med Parasitol  2002; 96( Suppl 1): S29– 39. Google Scholar CrossRef Search ADS PubMed  8 Gardon J, Gardon-Wendel N, Demanga-Ngangue et al.  . Serious reactions after mass treatment of onchocerciasis with ivermectin in an area endemic for Loa loa infection. Lancet  1997; 350(9070): 18– 22. Google Scholar CrossRef Search ADS   9 Onchocerciasis control in the WHO African region: current situation and way forward. Fifty-seventh session of the WHO Regional Committee for Africa. AFR/RC57/R3. Brazzaville, Republic of Congo: WHO-AFRO; 2007. 10 Accelerating work to overcome the global impact of neglected tropical diseases: a roadmap for implementation. WHO/HTM/NTD/2012.1. Geneva: World Health Organization; 2012. 11 Guidelines for stopping mass drug administration and verifying elimination of human onchocerciasis: criteria and procedures. WHO/HTM/NTD/PCT/2016.1. Geneva: World Health Organization; 2016. © The Author(s) 2018. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Health Oxford University Press

Cross-border issues: an important component of onchocerciasis elimination programmes

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Abstract

Abstract Endemic areas that involve national or local borders present an important challenge to the success of elimination of onchocerciasis; such cross-border endemic foci require special attention to ensure that programme activities are unified. It is vital that national programmes and the committees responsible for the oversight of progress towards elimination are aware and address such issues in their current planning and programmatic activities. Although international borders that intersect endemic zones present the biggest challenge, intracountry borders (such as between administrative districts or loiasis endemic and non-loiasis areas) can also pose problems. The recent change in the onchocerciasis programme from disease control to transmission interruption, given the historical lack of treatment in hypo-endemic areas, may have increased the already relatively high number of cross-national scenarios in Africa. It is vital that all national programmes address the issue of any cross-border endemic areas as a matter of urgency and include this important issue in their elimination plans. Cross-border, Onchocerciasis, Political issues, Language issues, Communication, Vector Introduction The control and elimination of a disease almost always involves the interaction of public health and political sectors, and necessarily requires management of local factors, influences and challenges, elements that are often underestimated in terms of programme implementation. The elimination of onchocerciasis is no different. The recent change in focus from disease control to transmission interruption has meant that certain important programmatic issues have not, so far, been given the attention they need.1,2 One of these is the challenge presented by cross-border (CB) areas of endemicity, both of onchocerciasis3,4 and of the confounding infection loiasis; these have often been given little consideration, with some notable exceptions. The importance of understanding and addressing the difficulties presented by the CB issues is being recognized more commonly, as the onchocerciasis elimination initiative now focuses on the major steps towards success. National programmes will need to recognize the unique factors that cause difficulties at CB locations and be aware of the actions and procedures that can be used to alleviate such problems. The discussion here is focused specifically on the context of onchocerciasis, but many of the principles and examples discussed will apply to other neglected tropical disease (NTD) programmes, particularly vector-transmitted diseases. CB issues in relation to matters of health and migration are well known in the developed world; for example, patient migration between Mexico and the USA, and within the European Union,5,6 often including issues of quarantine for infectious diseases. However, it should also be said that the issues in these countries are somewhat different from those in developing countries that are trying to achieve specific public health goals, such as elimination of parasitic infections. Here, in the example of onchocerciasis, the importance of CB situations is underscored by the need to ensure coverage of the whole population living in a transmission zone. However, it is not surprising that public health interventions, such as mass drug administration (MDA), taking place in a transmission zone that has a national border running through it could be quite different on the different sides of the border in terms of coverage due to timing and stage of assessment, as well as other characteristics. It is also important to note in this context that the early onchocerciasis programmes that focused on disease control did not implement any MDA in hypo-endemic areas7; this is likely to have important implications for CB planning and activities, as these areas will now be targeted for MDA under an elimination programme. Good communication and mutual understanding between national programmes that share a border are arguably the most important keys to ensuring that CB situations do not impede the progress to elimination. Types of borders The concept of ‘borders’ in the context of MDA programmes can take different forms—political, administrative and geographic, as well as the more socially and culturally oriented forms of partitioning based on tribal and language differences. History has shown how the impact of national borders, originally defined politically without consideration of social issues, can lead to important long-term issues, for example the borders defined in colonial times by Europeans and imposed on developing countries in Africa and Asia. In Africa, these new boundaries were often rivers, entities that now have a special relevance for onchocerciasis in terms of vector breeding sites. A currently infamous example of this is the border between Pakistan and Afghanistan, drawn through Pashtun tribal land; this colonial act has led to conflict because of the lack of consideration of important tribal issues by the original colonizing administrations that continues to have major effects on the politics and people of the region. Borders are usually discussed in terms of international borders, but internal borders within a country, such as provincial and district administrative divisions, can also present considerable programmatic challenges. Other than political boundaries, additional descriptors such as those based on endemicity, environment, culture (language, ethnicity, professions, customs, etc.) and risk of transmission are also important considerations (Table 1). From a national programme perspective, differences in public health interventions between administrative districts are usually manageable within a national programme’s planning mechanisms, even where districts began MDA activities at different times. In contrast, coordinating the timing of MDA programmes in different countries can be a challenge in managing intercountry CB endemic foci. Table 1. The different types of borders potentially having an impact on the implementation of MDA and other public health activities Type of border  Major characteristics  Importance to onchocerciasis programmes  Examples  International  Need for CB collaboration  Effectiveness of interventions in contiguous endemic populations and vector breeding sites (+++)*  Sudan—Ethiopia. Venezuela—Brazil. Uganda—DRC. Malawi—Mozambique  Internal administrative  Coordination of MDA and reporting  Effectiveness of interventions on transmission amongst continuous endemic populations and vector breeding sites (++)  Redefining of districts and provinces. Changes in administrative responsibilities due to redistricting  Environmental (geographic)  Often related to transmission zones  Prioritization of interventions based on environmental risk factors (+)  Mountain ranges, major rivers, desert regions, forested areas, vector breeding sites  Endemic populations  Need for good historical data and systematic processes for monitoring and evaluation of disease  Prioritization of interventions based on human infection (+)  Categorization of endemic zones (e.g. LF MDA areas)  Transmission zone borders (areas at risk)  The interaction between vector breeding sites, human populations and the presence of infection  Important due to the lack of treatment in hypo-endemic areas to date (+++)  Remapping the intimacy of onchocerciasis and identification of breeding sites (high-transmission areas)  Cultural aspects (language, ethnicity, occupation and local customs)  Effective communication and treatment coverage  Important for social mobilization during drug distribution (+++)  DRC and Uganda CB issues. Brazil and Venezuela CB issues  Co-endemic infections  A major barrier to high coverage as well as being an ethical issue  Important to avoid post-treatment severe adverse reactions (+++)  Cameroon. Nigeria. DRC. Chad. Angola  Type of border  Major characteristics  Importance to onchocerciasis programmes  Examples  International  Need for CB collaboration  Effectiveness of interventions in contiguous endemic populations and vector breeding sites (+++)*  Sudan—Ethiopia. Venezuela—Brazil. Uganda—DRC. Malawi—Mozambique  Internal administrative  Coordination of MDA and reporting  Effectiveness of interventions on transmission amongst continuous endemic populations and vector breeding sites (++)  Redefining of districts and provinces. Changes in administrative responsibilities due to redistricting  Environmental (geographic)  Often related to transmission zones  Prioritization of interventions based on environmental risk factors (+)  Mountain ranges, major rivers, desert regions, forested areas, vector breeding sites  Endemic populations  Need for good historical data and systematic processes for monitoring and evaluation of disease  Prioritization of interventions based on human infection (+)  Categorization of endemic zones (e.g. LF MDA areas)  Transmission zone borders (areas at risk)  The interaction between vector breeding sites, human populations and the presence of infection  Important due to the lack of treatment in hypo-endemic areas to date (+++)  Remapping the intimacy of onchocerciasis and identification of breeding sites (high-transmission areas)  Cultural aspects (language, ethnicity, occupation and local customs)  Effective communication and treatment coverage  Important for social mobilization during drug distribution (+++)  DRC and Uganda CB issues. Brazil and Venezuela CB issues  Co-endemic infections  A major barrier to high coverage as well as being an ethical issue  Important to avoid post-treatment severe adverse reactions (+++)  Cameroon. Nigeria. DRC. Chad. Angola  *Level of importance to the programme in parentheses. DRC: Democratic Republic of the Congo; LF: lymphatic filariasis. Managerial challenges for country programmes can occur when different international partners support different aspects of an elimination agenda within a country. For example, non-governmental development organizations (NGDOs) often support smaller portions of a countrywide programme, based on disease, implementation phase or administrative areas, which may be influenced by donor stipulations and organizational mandates. It is essential that these artificial boundaries do not create holes in coverage by a lack of communication between partner organizations that fund different areas that are part of a single focus or transmission zone. This type of issue needs adequate communication, understanding and a shared approach by all those supporting the national programme in question. This type of boundary should be managed by country national ministries of health and involve all partners at the various programmatic levels during work planning meetings or during special CB meetings. In most cases, this boundary is best managed by involving all partners at the various programmatic levels during work planning meetings with National Onchocerciasis Elimination Committees (NOECs) or during special CB meetings. An example of the type of planning meeting needed between bordering countries took place between Mozambique, Malawi and Tanzania in Malawi in July 2017 at the 1st Southern Africa Onchocerciasis Cross-Border Collaboration and Partnership Meeting. The three countries and international partners discussed the epidemiological situation at their shared borders and planned the next steps in addressing the problems related to managing the border issues related to MDA and monitoring as each country progresses to successful elimination. It is important to note, as a type example, that these three countries also have borders with additional countries, ones that either are known to have or have had endemic onchocerciasis. In addressing CB issues in the fullest manner, each country’s NOEC must consider all borders, not just those that are known candidates for cross-endemicity. Other examples of similar collaborative discussions that have occurred in the past few years include the long-standing intercountry meetings between Uganda and the Democratic Republic of the Congo, as well as between Sudan and Ethiopia. Boundaries based on landscape and environmental factors also play a part in any discussion of CB issues. The major geographic features that can be involved in CB situations are rivers, lakes, forests, mountains, deserts and islands: these all have their peculiarities. Rivers are most likely to be involved due to the nature of the vector and its riverine breeding site biology, and there are examples where rivers are in fact the border between two countries with endemic foci. A case in point here is with the onchocerciasis focus that spans between Malawi and Mozambique—an important example where there is a need for a unified approach to elimination of this whole transmission zone. One side of the border (Malawi side) has been under MDA, but across the river in Mozambique, which has always been regarded as a hypo-endemic area, treatment has never been implemented. This is an example where intercountry communication and mutual decision making is needed in terms of how and when either to declare elimination successful or perhaps to continue with or instigate MDA, a decision that is likely to involve mutual monitoring and evaluation between countries. An important intracountry and intercountry type of boundary that effects programme management is that between loiasis endemic and non-endemic areas. This filarial infection has the potential of causing severe and life-threatening post-ivermectin treatment reactions in those people carrying very high circulating loads of Loa loa microfilariae.8 Differences in the management and treatment strategy between co-endemic and loiasis-free areas are necessary to prevent adverse events. There is a need for careful mapping of the current loiasis endemic areas to ascertain where there is co-endemicity with onchocerciasis as well as lymphatic filariasis. Programmatic aspects As we have noted, CB issues are an important programmatic issue, and one that must be addressed early on by national programmes and their NOECs as they plan and implement their national programmes for the elimination of onchocerciasis. Although each situation will undoubtedly have its own characteristics, there are some fundamental steps and issues that a national programme should address and respond to if needed; many of these are listed in Table 2. It should also be noted that funding for CB issues has often not been included in partner and national programme budgeting—it needs to be. Table 2. The range of factors and issues pertaining to cross-border foci of onchocerciasis Factors and programmatic issues  Differences in endemicity (e.g. hypo-edemicity where no previous treatment has happened)  Language differences  National political differences  Differences in available programmatic support  Lack of coordination in MDA schedules  Areas of civil unrest and insecurity  Difficulties due to local geography  CB migration of people  Difficulties in organizing joint meetings  The lack of availability or non-release of funds by governments for CB activities  The lack to date of including CB issues in programmatic planning  Factors and programmatic issues  Differences in endemicity (e.g. hypo-edemicity where no previous treatment has happened)  Language differences  National political differences  Differences in available programmatic support  Lack of coordination in MDA schedules  Areas of civil unrest and insecurity  Difficulties due to local geography  CB migration of people  Difficulties in organizing joint meetings  The lack of availability or non-release of funds by governments for CB activities  The lack to date of including CB issues in programmatic planning  There are many examples of CB transmission of onchocerciasis in the African continent and these need careful and immediate consideration and planning. The importance of this issue is underscored by an example in the Latin American onchocerciasis elimination programme, a programme that has always been seen as likely to achieve success ahead of Africa,2 but even here a CB issue is hindering ultimate success. The last population to carry the parasite in this region is the Amerindian tribal people (the Yanomami) who live a nomadic life in the jungles on the border between northern Brazil and southern Venezuela; different approaches are needed for success in this difficult situation where the necessary high drug coverage is extremely hard to achieve and maintain. Examples of the major CB endemic locations from the three major regions of Africa are presented in Tables 3–5. In Central Africa (Table 3), CB issues are still in need of extensive discussion by the respective NOECs and therefore remain an issue requiring urgent attention. In East Africa there are four major intercountry defined CB foci (Table 4): Ethiopia–Sudan, Mozambique–Malawi, South Sudan–Uganda and Uganda–Democratic Republic of the Congo; it is not yet clear whether there are any CB issues for onchocerciasis between Tanzania and Mozambique, as further entomological and serological evaluation is still needed. Lastly, in West Africa, CB interactions between the involved countries are beginning to happen (Table 5). It should be noted that many countries in Africa have not yet fully established their NOECs, an important step to move these countries forward towards elimination, or an oversight expert committee implemented by the World Health Organization (WHO). The NOECs are important bodies for the discussion of CB issues that require addressing for the countries to move further with their elimination activities. Table 3. Countries in Central Africa with cross border situations Country  NOEC established  CB situation  Comment*  Angola  N  With DRC  Needing attention  Burundi  N  Unclear  Close to elimination, needs NOEC support  Cameroon  Y  CAR, Nigeria, Chad, Congo-Brazzaville  NOEC being formed  CAR  N  Cameroon, Chad, South Sudan  Civil unrest  Chad  N  Cameroon, CAR, Nigeria  NOEC needed  Congo-Brazzaville  N  Cameroon, Gabon, DRC  NOEC needed  DRC  N  Uganda, Angola, CAR, Congo, South Sudan, Zambia  NOEC needed, cross-border collaboration with Uganda happening  Equatorial Guinea  N  Cameroon, Gabon  NOEC needed  Gabon  N  Cameroon, Congo  Overall programme needed  Country  NOEC established  CB situation  Comment*  Angola  N  With DRC  Needing attention  Burundi  N  Unclear  Close to elimination, needs NOEC support  Cameroon  Y  CAR, Nigeria, Chad, Congo-Brazzaville  NOEC being formed  CAR  N  Cameroon, Chad, South Sudan  Civil unrest  Chad  N  Cameroon, CAR, Nigeria  NOEC needed  Congo-Brazzaville  N  Cameroon, Gabon, DRC  NOEC needed  DRC  N  Uganda, Angola, CAR, Congo, South Sudan, Zambia  NOEC needed, cross-border collaboration with Uganda happening  Equatorial Guinea  N  Cameroon, Gabon  NOEC needed  Gabon  N  Cameroon, Congo  Overall programme needed  *As understood at the time of writing. CAR: Central African Republic; DRC: Democratic Republic of the Congo; NOEC: National Onchocerciasis Elimination Committee. Table 4. Countries in East Africa with cross border situations Country  NOEC established  CB situation  Comment*  Ethiopia  Y  Sudan, South Sudan  Sudan CB discussion ongoing  Kenya  N  South Sudan (camps), Tanzania  NOEC to move to country verification  Malawi  Y  Mozambique  NOEC not activated as of yet  Mozambique  N  Malawi, Tanzania  CB discussions held in mid-2017  Sudan  Y  Ethiopia, South Sudan  NOEC not activated as of yet  South Sudan  N  Uganda, Ethiopia, Sudan  Civil unrest at present  Tanzania  Y  Mozambique, Burundi, Kenya  NOEC needs to address CB issues  Uganda  Y  DRC, South Sudan  CB collaboration with DRC under way  Country  NOEC established  CB situation  Comment*  Ethiopia  Y  Sudan, South Sudan  Sudan CB discussion ongoing  Kenya  N  South Sudan (camps), Tanzania  NOEC to move to country verification  Malawi  Y  Mozambique  NOEC not activated as of yet  Mozambique  N  Malawi, Tanzania  CB discussions held in mid-2017  Sudan  Y  Ethiopia, South Sudan  NOEC not activated as of yet  South Sudan  N  Uganda, Ethiopia, Sudan  Civil unrest at present  Tanzania  Y  Mozambique, Burundi, Kenya  NOEC needs to address CB issues  Uganda  Y  DRC, South Sudan  CB collaboration with DRC under way  *As understood at the time of writing. DRC: Democratic Republic of the Congo; NOEC: National Onchocerciasis Elimination Committee. Table 5. Countries in West Africa with cross border situations Country  NOEC established  CB situation  Comment*  Benin  N  Togo, Nigeria, Burkina Faso  NOEC in process  Burkina Faso  Y  Mali, Cote d’Ivoire, Ghana, Togo, Benin, Niger  NOEC established and active  Cote d’Ivoire  N  Liberia, Burkina Faso, Ghana, Mali  NOEC in process  Ghana  Y  Cote d’Ivoire, Burkina Faso, Togo  NOEC established  Guinea  Y  Guinea Bissau, Senegal, Mali, Sierra Leone, Liberia  NOEC established and active  Guinea Bissau  Y  Senegal, Guinea  First NOEC meeting planned  Liberia  Y  Sierra Leone, Guinea, Cote d’Ivoire  NOEC established and active  Mali  N  Senegal, Guinea, Cote d’Ivoire, Burkina Faso, Benin, Niger  NOEC in process  Niger  N  Burkina Faso, Benin, Nigeria, Chad, Mali  NOEC established and active  Nigeria  Y  Benin, Cameroon, Chad, Niger  NOEC established and active  Senegal  N  Guinea-Bissau, Guinea  NOEC established and active  Sierra Leone  Y  Guinea, Liberia  NOEC established and active  Togo  Y  Benin, Ghana, Burkina Faso  NOEC established and active CB collaboration occurring  Country  NOEC established  CB situation  Comment*  Benin  N  Togo, Nigeria, Burkina Faso  NOEC in process  Burkina Faso  Y  Mali, Cote d’Ivoire, Ghana, Togo, Benin, Niger  NOEC established and active  Cote d’Ivoire  N  Liberia, Burkina Faso, Ghana, Mali  NOEC in process  Ghana  Y  Cote d’Ivoire, Burkina Faso, Togo  NOEC established  Guinea  Y  Guinea Bissau, Senegal, Mali, Sierra Leone, Liberia  NOEC established and active  Guinea Bissau  Y  Senegal, Guinea  First NOEC meeting planned  Liberia  Y  Sierra Leone, Guinea, Cote d’Ivoire  NOEC established and active  Mali  N  Senegal, Guinea, Cote d’Ivoire, Burkina Faso, Benin, Niger  NOEC in process  Niger  N  Burkina Faso, Benin, Nigeria, Chad, Mali  NOEC established and active  Nigeria  Y  Benin, Cameroon, Chad, Niger  NOEC established and active  Senegal  N  Guinea-Bissau, Guinea  NOEC established and active  Sierra Leone  Y  Guinea, Liberia  NOEC established and active  Togo  Y  Benin, Ghana, Burkina Faso  NOEC established and active CB collaboration occurring  *As understood at the time of writing. NOEC: National Onchocerciasis Elimination Committee. As mentioned above, a major challenge that most onchocerciasis programmes now face as they focus on elimination is to be fully cognizant of the presence and location of the borders of the hypo-endemic zones, areas that were ignored in the past. It is likely that this means new mapping activities will need to be carried out in many areas before understanding the full extent of any CB issues. It should also be noted that the true significance of the unmapped hypo-endemic areas, in terms of being an important limiting factor to the transmission elimination effort, has not been fully understood as of yet; however, there is some limited evidence that they may indeed be of programmatic importance. The example of the Malawi–Mozambique border challenges referred to above is an case where the mapping of hypo-endemic areas in the latter country is urgently needed to completely solve the CB issues between these two countries. It is clear that more investigation in general is needed on the question of the programmatic significance of the hypo-endemic areas; the results will have a major impact on programme implementation in many ways, such as overall drug requirement, the timing of stopping treatment, country programme staffing logistics and other important issues. Needed actions The requirement for CB work was continued by the African Program for Onchocerciasis Control in 2007,9 and it can be seen from the discussion above that it is extremely important for all national onchocerciasis elimination programmes to include the issue of CB foci in their planning and national agendas. Many of the different steps that a national programme should consider are presented in Table 6. Table 6. Approaches that national programmes should consider regarding CB issues Suggested actions regarding CB foci  NOEC includes strategies for addressing CB foci in the national plan, e.g. memorandum of understanding between countries with shared transmission zones  Establish contact at all administrative levels between countries (or districts, etc., in terms of internal CB issues)  Form joint monitoring and evaluation teams across borders  Coordinate MDA activities across borders  Identify field-level team members responsible for maintaining CB contacts  Maintain communication and sharing of programme plans  Expect increases in programmatic costs for CB activities  Migrant populations need to be considered as part of CB challenges  Establish consistency in messages at the village level, accounting for language differences  Suggested actions regarding CB foci  NOEC includes strategies for addressing CB foci in the national plan, e.g. memorandum of understanding between countries with shared transmission zones  Establish contact at all administrative levels between countries (or districts, etc., in terms of internal CB issues)  Form joint monitoring and evaluation teams across borders  Coordinate MDA activities across borders  Identify field-level team members responsible for maintaining CB contacts  Maintain communication and sharing of programme plans  Expect increases in programmatic costs for CB activities  Migrant populations need to be considered as part of CB challenges  Establish consistency in messages at the village level, accounting for language differences  Although there are many challenges to addressing the needs for CB foci within the context of ensuring elimination of the disease from a country (Table 6), there are still, nevertheless, advantages to be gained with any issue that stimulates positive communication between national programmes. The CB issue provides an opportunity for countries to share experiences in their own country’s efforts to eliminate onchocerciasis; this is likely to be of great benefit to both parties, especially to countries who have not yet initiated necessary elimination activities, and can take place either relatively informally or perhaps optimally at the national programme level. Discussion Efficient and active CB coordination is required if the global targets set for the elimination of transmission of onchocerciasis are to be achieved and the requirements for official success documented correctly. A good example of collaborative work is seen in coordination among members of the Mano River Union3; however, the collaboration that is beginning to develop among other groups of countries is still largely undocumented. The context for the elimination of transmission of onchocerciasis is outlined in the WHO plan for NTDs,9,10 and a programmatic document—the ‘Guidelines for Stopping Mass Drug Administration and Verifying Elimination of Human Onchocerciasis—Criteria and Procedures’11—outlines the need for the development of NOECs. These guidelines also outline the need for the development of more robust approaches to CB work than has been generally accepted in the past. For a country to verify the elimination of transmission of onchocerciasis they must also show that CB work has been undertaken that has successfully led to the elimination of the CB foci. These border areas in most African countries are usually some of the most remote areas and thus are difficult to reach, and in countries where there are ongoing civil disturbances it can be almost impossible. This important challenge to programmes has been previously highlighted3 and this type of area has been identified as one of the emerging challenges that needs to be addressed—‘conflict prevents access to populations through disruption of health services and migration, access to remote populations in challenging geographic settings and vulnerable groups in elimination programmes’.3 As mentioned here, migrant populations are another major factor in CB situations and always need to be accounted for in CB treatment programmes. The successful management of CB issues is probably one of the most complex programmatic areas to achieve. It requires policymakers and decision makers at the central ministry level to be fully in agreement and support these activities; secondly, it requires the technical staff to agree to on the best approach for the work and finally it requires local government authorities, and perhaps non-governmental organizations, from both sides of the border to work together. This is not likely to be easy to achieve; for example, the Manu River Union CB work took 7 years to develop3 and unfortunately experienced a major setback due to the outbreak of ebola virus. Intracountry agreements for collaborative work, such as between districts or provinces, are usually relatively easy to achieve; many bilateral agreements are in place for a variety of medical and other areas of development. Work between intracountry zones, such as districts, is inherently easier to establish, aided by the fact that most programmes are undertaken at the district level. On the other hand, CB agreements are generally much more complicated to arrange, as many levels of administration are usually involved; this usually adds to the programmatic cost. Thus it often falls to external funders to cover the cost of facilitating the international meetings that are the essential step in starting and monitoring CB work. It should be noted that although many of the activities regarding CB foci and their elimination rely on close communication between the two participating countries, in this regard there are many situations where the WHO, and perhaps more usefully WHO-AFRO (including the Expanded Special Project for Elimination of Neglected Tropical Disease [ESPEN]), can become involved. These bodies can facilitate agreements between countries and organizations and, on occasion, provide fiscal support for essential meetings. In some cases there are already CB activities for other diseases in place, and these can be utilized by the onchocerciasis elimination programmes; WHO and WHO-AFRO can be useful mediators and information sources for such events. Conclusion CB foci of various types are relatively common in the onchocerciasis map of Africa, and these often exist in difficult political and geographic locations. It is extremely important that NOECs actively address and add such components to their own national programme agendas. Addressing these will probably include senior-level political activity as well as increased local management and specific attention. Communication and sharing of information between countries and the involved local administrative units are essential to success in addressing this potentially major barrier to the successful elimination of onchocerciasis. CB foci are a sector of onchocerciasis elimination programmes that must be taken seriously and considered early in programme planning. Authors' contributions: CM, SB, YS and PD all contributed to the writing of the text. CM carried out the final edits. Acknowledgements: None. Funding: None. Competing interests: None declared. Ethical approval: Not required. References 1 Mackenzie CD, Homeida MM, Hopkins A et al.  . Elimination of onchocerciasis from Africa: possible? Trends Parasitol  2012; 28(1): 16– 22. Google Scholar CrossRef Search ADS   2 Dadzie Y, Neira M, Hopkins D. Final report of the Conference on the Eradicability of Onchocerciasis. Filaria J  2003; 2(1): 2. Google Scholar CrossRef Search ADS   3 Gustavsen K, Sodahlon Y, Bush S. Cross-border collaboration for neglected tropical disease efforts—Lessons learned from onchocerciasis control and elimination in the Mano River Union (West Africa). Global Health  2016; 12: 44. Google Scholar CrossRef Search ADS PubMed  4 Brazil and Venezuela sign agreement to accelerate cross-border health interventions and interrupt transmission of onchocerciasis. Press release, World Health Organization, 20 May 2014. http//www.who.int/neglected_diseases/onchocerciasis_brazil_venezuela/en/. 5 Helble M. The movement of patients across borders: challenges and opportunities for public health. Bull World Health Org  2011; 89(1): 68– 72. Google Scholar CrossRef Search ADS   6 MacPherson DW, Gushulak BD, Macdonald L. Health and foreign policy: influences of migration and population mobility. Bull World Health Org  2007; 85(3): 200– 6. Google Scholar CrossRef Search ADS   7 Noma M, Nwoke BE, Nutall I et al.  . Rapid epidemiological mapping of onchocerciasis (REMO): its application by the African Program for Onchocerciasis Control (APOC). Ann Trop Med Parasitol  2002; 96( Suppl 1): S29– 39. Google Scholar CrossRef Search ADS PubMed  8 Gardon J, Gardon-Wendel N, Demanga-Ngangue et al.  . Serious reactions after mass treatment of onchocerciasis with ivermectin in an area endemic for Loa loa infection. Lancet  1997; 350(9070): 18– 22. Google Scholar CrossRef Search ADS   9 Onchocerciasis control in the WHO African region: current situation and way forward. Fifty-seventh session of the WHO Regional Committee for Africa. AFR/RC57/R3. Brazzaville, Republic of Congo: WHO-AFRO; 2007. 10 Accelerating work to overcome the global impact of neglected tropical diseases: a roadmap for implementation. WHO/HTM/NTD/2012.1. Geneva: World Health Organization; 2012. 11 Guidelines for stopping mass drug administration and verifying elimination of human onchocerciasis: criteria and procedures. WHO/HTM/NTD/PCT/2016.1. Geneva: World Health Organization; 2016. © The Author(s) 2018. Published by Oxford University Press on behalf of Royal Society of Tropical Medicine and Hygiene. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.

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International HealthOxford University Press

Published: Mar 1, 2018

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