GUINEA Work Plan FY 2018 Project Year 7

Transcription

1 GUINEA Work Plan FY 2018 Project Year 7 October 2017-September 2018 ENVISION is a global project led 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. ENVISION is funded by the US Agency for International Development under cooperative agreement No. AID-OAA-A The period of performance for ENVISION is September 30, 2011, through September 30, The author s views expressed in this publication do not necessarily reflect the views of the US Agency for International Development or the United States Government.

2 ENVISION Project Overview The US Agency for International Development (USAID) s ENVISION project ( ) is designed to support the vision of the World Health Organization (WHO) and its member states by targeting the control and elimination of seven neglected tropical diseases (NTDs), including lymphatic filariasis (LF), onchocerciasis (OV), schistosomiasis (SCH), three soil-transmitted helminths (STH; roundworm, whipworm, and hookworm), and trachoma. ENVISION s goal is to strengthen NTD programming at global and country levels and support ministries of health (MOHs) to achieve their NTD control and elimination goals. At the global level, ENVISION in close 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: Drug and diagnostics procurement, where global donation programs are unavailable Capacity strengthening Management and implementation of ENVISION s Technical Assistance Facility (TAF) Disease mapping NTD policy and technical guideline development NTD monitoring and evaluation (M&E). At the country level, ENVISION provides support to national NTD programs by providing strategic technical and financial assistance for a comprehensive package of NTD interventions, including the following: Strategic annual and multi-year planning Advocacy Social mobilization and health education Capacity strengthening Baseline disease mapping Preventive chemotherapy (PC) or mass drug administration (MDA) Drug and commodity supply management and procurement Program supervision M&E, including disease-specific assessments (DSAs) and surveillance. In Guinea, ENVISION project activities are implemented by Helen Keller International. ii

3 TABLE OF CONTENTS ENVISION Project Overview... ii TABLE OF FIGURES... iv ABBREVIATIONS LIST... v COUNTRY OVERVIEW ) General Country Background... 1 a) Administrative Structure... 1 a) Other NTD Partners... 1 b) Ebola Virus Disease (EVD) Epidemic ) National NTD Program Overview... 6 a) Lymphatic Filariasis... 7 b) Trachoma... 8 c) Onchocerciasis d) Schistosomiasis e) Soil-Transmitted Helminths ) Snapshot of NTD Status in Country PLANNED ACTIVITIES ) NTD Program Capacity Strengthening a) Strategic Capacity Strengthening Approach b) Capacity Strengthening Objectives and Interventions c) Monitoring Capacity Strengthening ) Project Assistance a) Strategic Planning b) Advocacy c) Mapping d) MDA Coverage e) Social Mobilization to Enable NTD Program Activities f) Training g) Drug and Commodity Supply Management and Procurement h) Supervision for MDA i) M&E j) Supervision for M&E and DSAs k) Dossier Development ) Maps APPENDIX 1: Work Plan Timeline iii

4 APPENIDX 2. Table of USAID-supported Regions and Districts in FY TABLE OF TABLES Table 1a. Non-ENVISION NTD partners working in Guinea, donor support, and summarized activities. 3 Table 1b. Table of financial support for MDA per HD in FY Table 2a. Historical LF epidemiological MDA coverage rates in HDs... 8 Table 2b. Trachoma historical MDA data supported by ENVISION... 9 Table 2c. Historical SCH MDA coverage rates Table 2d. PZQ treatment cycle differences according to prevalence rates Table 3. Snapshot of the expected status of the NTD program in GUINEA as of Sept. 30, Table 4. Project assistance for capacity strengthening Table 5. USAID-supported districts and estimated target populations for MDA in FY Table 6. Social mobilization/communication activities and materials checklist for NTD work planning 25 Table 7. Planned Disease-specific Assessments for FY18 by Disease TABLE OF FIGURES Figure 1. Guinea LF, OV, SCH, STH, and Trachoma Maps Figure 2. Guinea LF, OV, SCH, STH, and Trachoma Geographic Coverage Maps Figure 3. Guinea Progress Toward LF Elimination Map Figure 4. Guinea Trachoma Progress Toward Elimination Map iv

5 ABBREVIATIONS LIST ALB APOC ASTMH CDD CDTI CLTS CNTD COR-NTD CRS DFID DQA EVD FOG FPSU GOG HD HKI IEC ITI IVM JRSM LF M&E MDA MOH NGO NTD OCP OMVS OPC OV PC PCG PGIRE Albendazole African Programme for Onchocerciasis Control American Society of Tropical Medicine and Hygiene Community Drug Distributor Community-Directed Treatment with Ivermectin Community-Led Total Sanitation Centre for Neglected Tropical Diseases Coalition for Operational Research on NTDs Catholic Relief Services UK Department for International Development Data Quality Assessment Ebola Virus Disease Fixed Obligation Grant Filarial Programmes Support Unit Government of Guinea Health District Helen Keller International Information, Education, and Communication International Trachoma Initiative Ivermectin Joint Request for Selected preventive chemotherapy Medicines Lymphatic Filariasis Monitoring and Evaluation Mass Drug Administration Ministry of Heath Nongovernmental Organization Neglected Tropical Disease Onchocerciasis Control Program in West Africa Organisation pour la mise en valeur du fleuve Sénégal (Senegal River Basin Development Organization) Organization for the Prevention of Blindness Onchocerciasis Preventive Chemotherapy Central Pharmacy of Guinea Projet de Gestion Intégrée des Ressources en Eau et de Développement des usages à buts multiples (Integrated Water Resources Management Project) PNLOC/MTN National Program for Control of Onchocerciasis and Blindness/Neglected Tropical Diseases PZQ Praziquantel SAC School-age Children SAE Serious Adverse Events SAFE Surgery Antibiotics Facial cleanliness Environmental improvements SCH Schistosomiasis SNSSU National School and University Health Service STH Soil-Transmitted Helminths v

6 TAP TAS TEO TF TIPAC TIS TT USAID WHO ZTH Trachoma Action Plan Transmission Assessment Survey Tetracycline Eye Ointment Trachomatous Inflammation Follicular (active trachoma) Tool for Integrated Planning and Costing Trachoma Impact Survey Trachomatous Trichiasis United States Agency for International Development World Health Organization Zithromax vi

7 COUNTRY OVERVIEW 1) General Country Background a) Administrative Structure Guinea is located on the Atlantic coast of West Africa, with an area of 245,857 square kilometers, bordered to the north by Guinea-Bissau, Senegal, and Mali; to the east by Mali and Côte d Ivoire; and to the south by Liberia and Sierra Leone. Guinea is divided into four ecological/geographical regions: Lower Guinea (Basse-Guinée) located on the coast; Middle Guinea (Moyenne-Guinée), which is a region of plateaus and forest; Upper Guinea (Haute-Guinée), which is a region of savannah and plateaus; and Forest Guinea (Guinée forestière). Based on the third national census conducted in 2014, and using an annual growth rate of 2.2%, the population of Guinea in 2017 is 11,233,194 inhabitants. The total estimated population of Guinea for 2018 is 11,480,324. Guinea s administrative structure is composed of 8 regions: Boké, Faranah, Kankan, Kindia, Labé, Mamou, N Zérékoré, and the specific area of the capital city of Conakry. Conakry is divided into communes, while each region outside of the capital is divided into prefectures. In total, there are five communes in Conakry and 33 prefectures, comprising 38 health districts (HDs) in the country. Each prefecture is further divided into urban and rural communes (defined by neighborhoods in urban areas and administrative districts in rural areas), called sub-prefectures. In total, there are 343 urban and rural communes, including the 5 communes of Conakry. Guinea has a total of 925 health outposts, 410 health centers, 5 higher-level health centers, 33 prefectural hospitals, 7 regional hospitals, and 3 national hospitals. The national team for negelected tropical disease (NTD) control is composed of nine people: one Programme Coordinator acting as focal point for trachoma; one Deputy Program Coordinator acting as focal point for onchocerciasis (OV); one focal point for schistosomiasis (SCH)/soil-transmitted helminths (STH); one focal point for eye health; one entomologist; one ophthalmologist technician; one administrative officer; and one accountant. The ninth person is a secondment hired by Centre for Neglected Tropical Diseases (CNTD) to act as the communications focal point for the program. At least half of these staff are not permanently working for the National Program for Control of Onchocerciasis and Blindness/Neglected Tropical Diseases (PNLOC/MTN) because they share their time between the PNLOC/MTN and other Ministry of Health and Public Hygiene (MOH) departments. a) Other NTD Partners In addition to funding from the US Agency for International Development (USAID) through ENVISION, the MOH s PNLOC/MTN receives funding from the following donors (see also Tables 1a and 1b): Centre for Neglected Tropical Diseases (CNTD) (formerly known as the Filarial Programmes Support Unit [FPSU], with funding from the UK Department for International Development (DFID): CNTD funds lymphatic filariasis (LF) and OV elimination activities in border regions along the Mano River in Guinea, Liberia, and Sierra Leone. CNTD supported mass drug administration (MDA) in six HDs for fiscal year 2016 (FY16) and developed a national strategic plan to support morbidity associated with LF. In FY18, CNTD will provide technical and financial support to the MOH to manage LF morbidity and disability. 1

8 To avoid interruption of MDA, the Senegal River Basin Development Organization (Organisation pour la mise en valeur du fleuve Sénégal, OMVS) agreed to take over support for these six HDs from FY17 to FY19. Sightsavers, with various funding sources, supports community-directed treatment with ivermectin (CDTI) for OV control in 1 HD, combined SCH and STH MDA for 3 HDs, and surgery for trachomatous trichiasis (TT) in 10 HDs, as well as the development of Guinea s trachoma action plan (TAP). Sightsavers also funds preventive health awareness-raising campaigns. Organization for the Prevention of Blindness (OPC), with funding from the Sight First Initiative (Lions Clubs International Foundation) and Coopération Française, supports CDTI for OV control in three HDs. OPC is a French nongovernmental organization (NGO) working in francophone Africa, with specific expertise in ocular public health. In addition to its technical and financial support for CDTI implementation in three HDs, OPC provides technical support at the hospital level to conduct TT surgery. OMVS Integrated Water Resource Management Project (Projet de Gestion Intégrée des Ressources en Eau et de Développement des usages à buts multiples, PGIRE), funded by the World Bank, launched a call for applications in 2016, and Catholic Relief Services (CRS) was chosen to execute PGIRE Phase II. It is anticipated that PGIRE will support MDA for LF, OV, SCH, STH, and trachoma; procurement and distribution of bed nets for malaria; and routine information, education, and communication (IEC) activities for NTDs and malaria in six HDs located in the Senegal River Basin. This activity will also be carried out in other countries along the Senegal River Basin Mali, Mauritania, and Senegal with different implementing partners. CRS has been retained to execute Phase II in Guinea for the next three years, starting with SCH MDA in two HDs in October During the FY17 work plan workshop, it was decided that CRS will start working in 7 HDs. The number of HDs supported by CRS could be gradually increased, assuming available capacity and funds. Plan Guinea supports the construction of latrines, boreholes, and wells, and increases awareness among communities on good hygiene and sanitation practices through communityled total sanitation (CLTS). Ministry of Education National School and University Health Service (SNSSU): The SNSSU can support praziquantel (PZQ) distribution in those districts that do not have donor funding for SCH MDA, and a second round of albendazole (ALB) treatment for STH in the HDs that ENVISION funds for only one annual round of treatment. For FY17, no funding was provided, and there are currently no plans for SNSSU to fund any MDA activities in FY18. However, PNLOC/MTN uses the expertise of SNSSU staff to organize MDA in schools (particularly for SCH). 2

9 Table 1a. Non-ENVISION NTD partners working in Guinea, donor support, and summarized activities Partner Location (HDs/regions) Activities Sightsavers CNTD OPC OMVS-PGIRE (CRS) Plan Guinea Guinea MOH Koubia (CDTI) Central level (TAP) Mali, Tougué, Faranah, Kissidougou, Dabola, Dinguiraye, Gaoual, Koundara, Mamou, Pita (TT surgery) N Zérékoré, Lola, and Youmou (combined SCH and STH MDA) MOH has asked for NTD support for LF in Macenta, Kissidougou, Dabola, Mamou, and Kouroussa Forécariah, Kindia, Télimélé, Mali, Tougué, Dalaba, Mamou, Pita 3 HDs (Lola, N'Zérékoré, Yomou) in FY18 Kankan, Siguiri, Kouroussa, Mandiana, Kérouané Koubia, Mali, Tougué, Labé, Dalaba, Mamou, Pita Beyla, Macenta, Guéckédou, N Zérékoré, Lola, Yomou, Kissidougou, Coyah, Dubréka, Forécariah Capital (Conakry) Technical and financial support to CDTI for OV in 1 HD Financial support for TAP workshop Technical and financial support for TT surgery campaigns in FY17, completed MDA for SCH in 3 HDs and MDA for STH in 2 HDs Technical and financial support for the management of LF morbidities The LF co-morbidities management plan Technical and financial support for CDTI Technical and financial support for TT surgery (central fixed strategy) Three cars were provided. Anticipated: support for MDA for LF, OV, SCH, STH, and trachoma, and procurement and distribution of long-lasting insecticide-treated nets for malaria 3-year program Routine IEC activities for NTDs and malaria (including 3 ENVISION-supported HDs Dabola, Dinguiraye, and Siguiri) Support for the construction of latrines, boreholes, and wells and increasing awareness of good hygiene and sanitation practices through CLTS Salary of MOH staff working on the program Steering committee support Other donors supporting these partners/activities Sightsavers; Givewell DFID Coopération Française/Sight First (Lions Club) World Bank Plan Guinea plus European Union funding Government of Guinea 3

10 Table 1b. Table of financial support for MDA per HD in FY18 Regions HD LF OV MDA Boké Conakry Faranah Kankan Kindia Labé Mamou SCH MDA STH MDA Via LF MDA or SCH MDA (1st round) STH only (2nd round) MDA Trachoma Impact survey Boffa ENV Boké ENV ENV Fria? ENV Gaoual ENV ENV ENV Koundara ENV ENV ENV Matoto? Ratoma? Dabola ENV ENV ENV Dinguiraye ENV ENV ENV ENV Faranah ENV ENV ENV ENV? ENV Kissidougou ENV ENV ENV ENV? ENV Kankan ENV ENV ENV ENV Kérouané ENV ENV ENV ENV ENV Kouroussa ENV ENV ENV ENV ENV Mandiana ENV ENV ENV Siguiri ENV ENV ENV Coyah? Dubréka? Forécariah ENV ENV ENV? ENV Kindia ENV ENV ENV ENV Télimélé ENV ENV ENV Koubia SS OMVS Labé Lélouma ENV ENV ENV ENV? Mali OMVS OMVS OMVS Tougué OMVS OMVS Dalaba OMVS OMVS Mamou OMVS OMVS OMVS OMVS Pita OMVS OMVS OMVS 4

11 Regions HD LF OV MDA N'Zérékoré SCH MDA STH MDA Via LF MDA or SCH MDA (1st round) STH only (2nd round) Beyla ENV ENV ENV ENV? Guéckédou ENV ENV ENV ENV? Lola OPC SS SS Macenta ENV ENV ENV ENV? N'Zérékoré OPC SS SS? Yomou OPC SS TOTAL (5 without funding) 17 8 (no funding for 2nd round) MDA Trachoma Impact survey 5 9 ENV = ENVISION; SS = Sightsavers? = The PNLOC/MTN is still seeking funds for these HDs in FY18. ENVISION is in discussion to determine whether gaps can be filled with other donor funding to help Guinea achieve 100% geographic coverage in FY18. b) Ebola Virus Disease (EVD) Epidemic Guinea experienced unprecedented challenges with the outbreak of Ebola that impeded planned scale up of MDA and delayed other key activities, such as mapping and disease-specific assessments (DSAs) that are necessary to reach national goals in FY14, FY15, and to a lesser extent in FY16. Now that EVD is under control and the World Health Organization (WHO) declared Guinea Ebola-free in FY16, MDA and other NTD activities have been scaled up; however, the population continues to have doubts and misgivings about any type of health activity, and communication needs to take this context into account. Although the population still has some fear of Ebola, activities have mostly returned to normal, and the strategies addressing the remaining Ebola-related challenges (described below) have been very useful. 5

12 2) National NTD Program Overview NTDs are a recognized priority by the MOH in Guinea, as evidenced by the Strategy for the Reduction of Poverty (DSRP III ); the National Plan for Health Development , which includes NTDs among the country s priority diseases; and the NTD Strategic Plan , which is being finalized and should be completed before the end of September Among NTDs recognized by WHO, eight are endemic in Guinea: Three NTDs are addressed through a case management strategy managed by separate programs within the MOH: leprosy, Buruli ulcer, and human African trypanosomiasis (sleeping sickness). Five NTDs are addressed through a preventive chemotherapy (PC) strategy, implemented as part of an integrated program: LF, OV, SCH, STH, and trachoma. In May 2004, the PNLOC was formed to lead the fight against blinding diseases in Guinea, including OV and trachoma. Historically, activities related to SCH and STH were the responsibility of the MOH Disease Prevention Division and the Ministry of Education SNSSU, with LF falling under this purview in Following the development of the first NTD Strategic Plan ( ) in 2009, the PNLOC became the PNLOC/MTN, with an expanded mandate to address LF, SCH, and STH. Within the PNLOC/MTN, the NTD Coordinator (who also serves as the trachoma focal point) oversees four other disease-specific focal points for SCH-STH, OV, LF, and blindness. With the start of USAID funding for integrated NTD control in Guinea in 2011, the MOH developed an NTD Strategic Plan for , addressing case management and NTDs treated through PC. For PC NTDs, the plan adopted the PC and transmission control strategy endorsed by WHO, which targets these five diseases as a package because they tend to overlap geographically, can be targeted with a similar preventive treatment approach using MDA, and are targeted with drug combinations that can often allow for concurrent treatment. The strategic plan also established the PNLOC/MTN and a Steering Committee that guides the plan s implementation. A workshop was organized in February 2016 to review and update the plan for the period, considering new data and progress made to date. The strategic plan was expected to be validated by the end of FY16. To date this document is not yet validated, but the PNLOC/MTN is committed to validate all pending strategic documents by the end of calendar year This is particularly important as ENVISION funds will not be available for this activity in FY19. Overall, the country s strategic objectives for the PC NTDs are the following: 1. Eliminate LF, OV, and trachoma as a public health problem by Control SCH and STH by In FY16, the PNLOC/MTN had planned MDA campaigns for LF, OV, and STH in all eligible HDs; for trachoma, in HDs that have a trachomatous inflammation follicular (TF) prevalence 10%; and for SCH in all HDs with a moderate to high risk of infection, with the support of partners and in collaboration with the Ministry of Education. The MDA rounds for SCH were completed in 15 out of 21 HDs planned (13 HDs with ENVISION support and 2 HDs with OMVS/CRS support). The PNLOC/MTN is working to secure funds for MDA in the six remaining HDs The Government of Guinea (GOG) ensures funding for the salaries of PNLOC/MTN staff, for the staff involved in the various surveys and MDA campaigns, and for treatment and management of adverse events during MDA. 6

13 a) Lymphatic Filariasis Overall, 24 HDs are endemic for LF; of these HDs, 20 are co-endemic with OV, 21 with SCH, 15 with STH, and 16 with trachoma. Guinea s goal is to eliminate LF by Specific objectives of the PNLOC/MTN are to interrupt transmission of LF, with a minimum of 65% epidemiological coverage in all endemic HDs, and to prevent and manage complications of the disease. To date, all 24 NTD-endemic HDs have implemented at least two rounds of MDA. The final HD cohort started MDA in 2016 and will complete the required five rounds of treatment by the 2020 elimination deadline. Because the clinical expression of LF is so debilitating, Guinean health services have long been aware of the disease, and cases were historically reported in 10 HDs. In 2005, a WHO-funded baseline mapping of LF endemicity was conducted in 46 villages in 24 HDs in the eight administrative regions where no previous disease data existed. This mapping survey identified 15 HDs as endemic. From 2011 to 2013, the MOH mapped the 10 districts where clinical cases had been reported historically. This was conducted with support from the USAID-funded, RTI-managed NTD Control Program through HKI in 2011, and then with support from ENVISION through HKI in FY12 FY13. This additional round of mapping confirmed a further nine HDs as endemic. The country s four remaining HDs, all in the capital city Conakry, have not and will not be mapped because an entomological survey (insect dissection and polymerase chain reaction testing, supported by CNTD) conducted in 2013 in Conakry showed that the mosquitos were not infected and would not be capable of transmitting disease in the capital. It is anticipated that when most of the LF-endemic districts reach the point of conducting transmission assessment surveys (TASs) in three years, these suspected endemic HDs, including Conakry, could form part of an evaluation unit (EU). For now, the entomology data is useful documentation for future submission of an LF elimination dossier. The endemic HDs are located within the regions of Boké, Faranah, Kankan, Kindia, Labé, Mamou, and N Zérékoré, with an at-risk population of 7,480,198 in 2018, of which 80% are considered eligible for MDA treatment. The PNLOC/MTN conducted baseline microfilaremia sentinel site surveys with ENVISION support in 2012 and The 2012 surveys were conducted in four sites Gandjin, Koundou Toh, Sounsoun, and Sinthiou and the 2013 surveys in seven HDs in the regions of Boké, Faranah, Kankan, and Mamou. In 2013, with support from CNTD, a microfilaremia survey was carried out along the border of the Mano River Union countries in sentinel sites in Faranah, Kankan, Kindia, Mamou, and N Zérékoré. The last series of sentinel sites completed set-up in FY16 in four HDs (Kindia, Lélouma, Siguiri, and Beyla) with ENVISION support. Immunochromatographic test cards were used for the surveys. By grouping the HDs based on contiguity, similar characteristics, and considering a total population of less than 1 million, parasitological data were collected in 17 sites (15 funded by ENVISION) that will serve as sentinel sites to monitor the success of the program in all 24 endemic HDs. Guinea s first LF treatment was conducted in FY14 in four HDs co-endemic for both LF and OV: Koundara in Boké Region, Dabola and Dinguiraye in Faranah Region, and Guéckédou in N Zérékoré Region. In FY15, the MOH conducted MDA in 9 of the 24 endemic HDs, 4 of which reported low coverage due to the EVD epidemic (Dabola, Dinguiraye, Kouroussa, and Dalaba). In FY16, the MOH conducted MDA in all 24 HDs, with epidemiological reported coverage rates of >70% in all HDs. These results were obtained due to new, improved social mobilization strategies put in place after the EVD outbreak. In FY17, the MOH had planned to conduct MDA in 24 HDs, 19 of which are supported by ENVISION and 5 by OMVS/CRS. To date, MDA campaigns for LF have been carried out in 20 HDs, 19 of which are supported by ENVISION and in 1 HD supported by OMVS/CRS. MDA for the remaining four HDs supported by OMVS/CRS was conducted in July August All CRS HDs reported sufficient coverage. 7

14 In FY18, ENVISION will support LF MDA in 19 HDs, with the remaining 5 supported by OMVS/CRS, as in FY17. Table 2a. MDA FY Historical LF epidemiological MDA coverage rates in HDs # of HDs treated # HDs with sufficient epidemiological coverage 8 % Name of HDs achieving sufficient coverage * 25% Guéckédou % Pita, Mandiana, Koundara, Gaoual, and Boké % 16 HDs with ENVISION support; 8 with CNTD support % 19 HDs with ENVISION support 5 with CRS *Of the three HDs that had insufficient coverage, a coverage survey was carried out in two. The results showed that the epidemiological coverage (which was 59.3%, 62.0%, and 61.4% in Koundara, Dabola, and Dinguiraye) was underestimated. The coverage survey in Koundara showed an epidemiological coverage of 80%. The national program developed a strategic plan for the management of LF-associated morbidity, with the financial and technical support of CNTD/Sightsavers. Community drug distributors (CDDs) conducted a census of LF morbidity cases during the LF MDA campaigns in FY16 and FY17, from which the data will be collated and confirmed with a study sponsored by CNTD these data will inform the strategies for the management of LF morbidity in FY18. b) Trachoma Guinea s national strategy for trachoma is elimination as a public health problem by Trachoma elimination is achieved through implementation of the WHO-recommended SAFE (Surgery Antibiotics Facial cleanliness Environmental improvements) strategy. In Guinea, trachoma-endemic areas are in Upper Guinea and the northern part of Middle Guinea areas with the country s highest poverty rates. Baseline mapping of trachoma conducted by the MOH with support from Sightsavers in 10 HDs of Upper Guinea in 2001 showed an average prevalence rate of 33% for active trachoma among children ages 1 9 years and 2.7% for TT among women older than 15 years. The MOH completed mapping in 31 HDs (trachoma rapid assessments had been conducted in some of the HDs in 2002) with USAID funding through the NTD Control Program (2011) and ENVISION ( ). These surveys confirmed that 18 districts are endemic. TF prevalence rates of 30% in 5 HDs; TF prevalence rates of 10% 29.9% in 4 HDs; and TF prevalence rates of 5% 9.9% in 9 HDs. The population at risk of trachoma in the 18 HDs with a TF prevalence rate of 5% was estimated at 5,568,411. Of these 18 trachoma-endemic HDs, 16 HDs are co-endemic with LF, 13 HDs with OV, 16 HDs with SCH, and 9 HDs with STH. The country has implemented several components of the SAFE strategy since 2012: Sightsavers provides support that focuses on the S component training surgeons for TT surgery; training health center supervisors, workers for the Expanded Program of Immunization, and those in charge of community-based services in screening and case referral of TT; and organizing surgical camps for TT in Boké, Faranah, and Labé regions.

15 ENVISION has supported the PNLOC/MTN with the A component of the strategy since FY13 with Zithromax (ZTH) and tetracycline eye ointment (TEO) MDA. MDA began in nine districts with TF prevalence rates of 10% in FY13. In FY14 and FY15, ENVISION conducted MDA in eight and seven of the nine HDs, respectively; the MDA in the remaining HDs was postponed due to the EVD epidemic. Despite this delay, ENVISION conducted MDA in all nine HDs in FY16 with good coverage rates (all nine HDs achieved the sufficient programmatic coverage required). In FY17, ENVISION supported MDA in 11 HDs. Plan Guinea supports some activities of the F and E components through CLTS, notably for latrine construction and installation of boreholes and wells, and by increasing the population s awareness for practicing good hygiene and sanitation. However, it must be noted that these activities are conducted within projects aimed at children and against EVD (not directly for trachoma) and without PNLOC/MTN consultation. Table 2b. MDA FY # of HDs treated Trachoma historical MDA data supported by ENVISION # of HDs with sufficient programmatic coverage % Faranah % HDs achieving sufficient coverage % Faranah, Kankan, Mandiana, Siguiri, Kérouané % Faranah, Kankan, Mandiana, Dinguiraye, Dabola, Kouroussa, Siguiri % Faranah, Kankan, Mandiana, Siguiri, Dinguiraye, Dabola, Kouroussa, Kérouané, Kissidougou % Boké, Boffa, Fria, Faranah, Dinguiraye, Dabola, Kouroussa, Kérouané, Kissidougou, Telimélé, Forécariah (after a mop-up) (See MDA Coverage section for more details.) The PNLOC/MTN developed a TAP with the support of Sightsavers and ENVISION (data sharing and participation in the workshop). The PNLOC/MTN organized a workshop in November The participants included all stakeholders, plus ENVISION staff. The final document is still pending from the PNLOC/MTN, despite significant advocacy for its completion by ENVISION. Sightsavers hired a consultant to finalize the TAP and funded a TAP finalization workshop was held from 26 to 28 July The consultant is working to finalize the document which will be shared with the MoH for validation. ENVISION has made the PNLOC/MTN aware that failure to validate the TAP may lead to a withdrawal of ENVISION funding for trachoma activities in FY19. In FY17, with ENVISION support, the PNLOC/MTN conducted MDA for trachoma in 11 HDs (including 5 HDs with TF prevalence rates of 5% 9.9%, which were treated for the first time) and completed TISs (using Tropical Data) in 3 HDs with TF prevalence rates between 10% and %29.9 (Kankan, Siguiri, and Mandiana) that had three rounds of treatment. A survey was also completed in one HD with an initial mapping prevalence rate of 5% to 9.9% (Koundara) because the mapping data was more than three years old. Results showed that MDA could be stopped in three HDs. These are the first three HDs in Guinea to meet the criteria for stopping MDA. In Koundara, the TF prevalence rate was <5%, thus MDA is not required. This decreased prevalence may be due to the increased F and E/water, sanitation, and hygiene (WASH) activities conducted after the EVD outbreak. In July 2017, CRS supported trachoma MDA in two additional HDs and sufficient coverage was reported. 9

16 In FY18, ENVISION will support MDA in five HDs and TIS in six HDs. OMVS/CRS will support an additional three surveys : two TISs by OMVS/CRS as well as a re-evaluation in the HD of Mali (the prevalence data are from several years ago and need to be updated). ENVISION staff are currently working with the partners involved in WASH sector to develop an analysis of trachoma interventions in Guinea. HKI/ENVISION initiated an integrated NTD-WASH approach through training support on NTD to United Purpose, an NGO working in the WASH sector. This NGO supports the GOG through community-led total sanitation (CLTS) in Moussayah, a health center in the HD of Forécariah. In FY17, HKI staff trained field staff from this NGO. These staff have been involved in the trachoma MDA, and based on the training, United Purpose is revising its social mobilization tools. c) Onchocerciasis The current national strategy is to eliminate OV by the year 2020, with continued treatment and entomological and epidemiological assessments to show the impact of treatment on reaching the criteria to stop MDA. Guinea has been on track to achieve this goal, with consecutive treatments taking place for more than 20 years in some areas. OV is endemic in 24 HDs, in seven of the eight regions. Of the 24 OV-endemic HDs, 20 are co-endemic with LF, 23 with SCH, 14 with STH, and 13 with trachoma. Currently, the total population in endemic HDs is estimated to be 6,781,592. A total of 8,229 OV-endemic villages were surveyed, with support from the Onchocerciasis Control Program in West Africa (OCP). From 1996 to 2002, with OCP support, the MOH conducted annual CDTI in all 24 endemic HDs in the regions of Boké, Faranah, Kankan, Kindia, Labé, Mamou, and N Zérékoré. From calendar year 2002 to 2012, support for OV activities in Guinea were provided by WHO through the African Program for Onchocerciasis Control (APOC) in areas qualified as Special Intervention Zones, including Faranah, Dabola, Dinguiraye, Kissidougou, Kouroussa, Siguiri, Forécariah, Kindia, and Mamou. OV activities in areas not classified as Special Intervention Zones were funded by Sightsavers and OPC. Since 1980, 531 sentinel villages from 24 endemic HDs in in 11 river basins have been identified, and assessments were conducted using the skin-snip technique, with support from OCP and then from APOC, and then later (FY12 FY14) from USAID. No surveillance activities were undertaken after In FY12 FY13, an OV epidemiological surveillance survey conducted with ENVISION support in a total of 56 villages showed some signs of recrudescence of OV in some villages (Milo/Dion basin, Niger/Mafou basin, and Mongo/Kaba basin). These data have been entered into the Integrated NTD Database. It was suspected that the recrudescence may be due to irregularity in treatment in neighboring countries (due to periods of conflict) and historically poor MDA coverage. Following the recent Mano River Union meeting on NTDs, it has been noted that treatment in all the neighboring countries is now now happening annually in all eligible HDs. However, one issue that remains to be addressed is MDA synchronization between the countries. Furthermore, it is suspected that the CDTI strategy may not have been rigorously implemented due to insufficient supervision. The PNLOC/MTN plans to reinforce supervision, especially in areas with integrated treatment for LF. In FY14, ENVISION planned to support epidemiological evaluations in 11 HDs. However, some HDs could not be reached, due to the high number of refusals by village leaders to participate in the survey, refusals that were associated with fear about the linkage between the survey procedures and EVD transmission. A total of 55 substitute villages were selected to be surveyed in other HDs in N Zérékoré Region. The results of these evaluations showed prevalence rates of between 0% and 7.6% using the skin-snip technique. In FY16, all HDs reported sufficient programmatic coverage, indicating that low coverage from issues caused by Ebola had been resolved. 10

17 After almost 20 years of ivermectin (IVM) treatment, the question of stopping drug distribution has been raised. Guinea established an OV elimination committee (OEC) in September 2016 to provide technical advice on OV elimination. The role of this committee is as follows: Support the development of a national guideline and road map Analyze national program data and confirm that the program is on track to reach the criteria for the interruption of transmission Recommend to the MOH areas where IVM can be stopped safely Prepare the elimination dossier for verification when the elimination criteria have been reached The committee is made up of national members (representatives from the MOH, NGOs involved in OV elimination in Guinea, WHO, university and scientific researchers, among others) and international members. This committee held its first meeting, which was co-financed by Sightsavers and ENVISION, March 1 3, The following items were discussed: the national program s progress in combatting OV (epidemiological and entomological surveillance and IVM treatment) and the new WHO criteria on OV elimination and transmission. The meeting generated the following main recommendations: Develop an OV elimination plan which describes the elimination strategy (the date for this plan will be discussed at the annual NTD review meeting in September 2017). Determine the current areas of OV transmission in Guinea through both epidemiological (Ov16 test) and entomological (fly pool screen) evaluations. Participants noted gaps in implementation of program activities in terms of monitoring/ evaluation, data management, and human and programmatic resources and recommended that decisions be made to address those gaps. Strengthen advocacy at the national and sub-regional levels in support of the elimination of OV and LF and NTDs in general. The program will discuss with all partners to develop the plan within an agreed timeframe during the annual NTD review. Sightsavers has already identified a consultant to assist in completing the plan. In FY16, the PNLOC/MTN conducted OV MDA in 15 HDs with ENVISION support, MDA in another 5 HDs were supported by CNTD, and 4 HDs implemented CDTI with support from Sightsavers (1 HD) and OPC (3 HDs). All HDs reported sufficient programmatic coverage in FY16. In FY17, the PNLOC/MTN conducted MDA in all 24 HDs: 17 HDs with ENVISION support, 1 HD with Sightsavers support, 3 with OPC support, and 3 with OMVS support (planned for July 2017). In FY18, the PNLOC/MTN plans to treat per the FY17 plan described above: 24 HDs (17 supported by ENVISION). It is anticipated that the OV expert committee will review all available evidence including original prevalence surveys, vector control activities, mass drug administration and develop a list of next steps for moving towards stopping treatment (in areas where this is appropriate). Following the expert committee recommendations and in accordance with the WHO 2016 guidelines on OV elimination, the national program will conduct a rapid impact assessment of OV in the 24 endemic HDs (financial support has not yet been identified). This will only be supported following the completion of the OV elimination plan (which is scheduled for completion before the end of 2017). 11

18 d) Schistosomiasis Guinea plans to control SCH in the 31 endemic HDs by the year SCH is co-endemic with LF in 21 HDs, with OV in 23 HDs, with STH in 15 HDs, and with trachoma in 16 HDs. The current implementation strategy for the national program is morbidity control through MDA with PZQ distribution targeting school-age children (SAC) in school-based and community-based MDA (with a focus on school-based MDA). The MOH recognizes that elimination may not be possible through MDA alone, and that continuous treatment and further scale up have been impeded by political instability (2013) and the EVD outbreak. Mapping in the regions of Faranah, Labé, and Mamou in 2009 and 2010 was carried out with support from OMVS. Mapping in the regions of N Zérékoré in 2010 and Kindia in 2011 was conducted with funding from Rio Tinto, with technical support from HKI. Mapping of the remaining 33 HDs was completed from 2011 to 2014 with support from USAID s NTD Control Program (2011) and ENVISION ( ). Overall, 31 out of 38 HDs are endemic for SCH (prevalence >0%), with a current population of 9,852,248 at risk. Specifically, 12 HDs are high risk (prevalence of 50%), 7 are moderate risk (prevalence of 10% and <50%), and 12 are low risk (prevalence of <10%). Among the endemic HDs, 17 have been treated at least once with PZQ since 2010, but these treatments were irregular over the years. From 2013 to 2015, MDA was not conducted due to operational constraints directly linked to national elections and the EVD epidemic. The PNLOC/MTN decided that SCH control efforts will be conducted in collaboration with those of STH in those HDs where both diseases are co-endemic and where no LF MDA has been implemented. Table 2c. Historical SCH MDA coverage rates MDA FY # of HDs treated # HDs with sufficient programmatic coverage % % Observations % 13 HDs with ENVISION support % 16 endemic HDs with ENVISION support, 3 with Sightsavers, and 2 with CRS 3 HDs out of 24 planned were not treated due to lack of financial support In FY17, the PNLOC/MTN conducted MDA in 16 HDs with ENVISION support, treating only SAC (of the 25 HDs planned for treatment in FY17, see Table 2d). Three HDs with Sightsavers support and two with CRS support. HDs with moderate prevalence are treated every two years, and HDs with low prevalence are treated every third year (see Table 2d). In FY18, the PNLOC/MTN plans to conduct MDA in 14 HDs with ENVISION support, treating only SAC (of the 24 HDs planned for treatment in FY18 see Table 2e). Three HDs will be treated by Sightsavers, two with support from OMVS/CRS, and five have no funding source identified yet. 12

19 Table 2d. PZQ treatment cycle differences according to prevalence rates PZQ treatment schedule Endemicity # HDs High 12 X X X X X 2* Moderate 5 X X X 5** X X Low 7 X X TOTAL *These 2 HDs have a moderate prevalence of 46% and 49%, so the PNLOC/MTN decided to follow the treatment protocol for high endemicity (because they are close to 50%, or high prevalence) and because these HDs border high-prevalence HDs. **These 5 HDs that could not be treated in 2017 because the program was unable to find funding support for these low-endemic areas. e) Soil-Transmitted Helminths Guinea s goal is to control STH as a public health problem (reducing prevalence rates to <20% and therefore classifying HDs as no longer needing MDA) by 2025; however, the government is aware that control may not be possible with once-yearly MDA alone and without significant improvements in hygiene and sanitation. Like the other NTDs, with the challenges faced during the past three years due to political instability and the outbreak of EVD, treatment schedules have been irregular. Mapping of Guinea s 38 HDs for STH was completed in 2014 using the WHO-recommended Kato Katz thick smear, in conjunction with SCH mapping as described above: 9 HDs are moderate risk (prevalence rates of 20% and <50%) and 8 HDs are high risk (prevalence rates of 50%). The at-risk population requiring MDA is estimated at 5,182,942. Of the 17 endemic HDs, 15 HDs are co-endemic with LF, 14 with OV, 15 with SCH, and 9 with trachoma. Since 2010, 17 HDs have received one or more rounds of treatment for STH. MDA did not take place in 2013 due to operational constraints linked to national elections. In FY14, just one of the 15 HDs targeted for STH treatment (Guéckédou) received MDA due to the EVD outbreak. In FY17, to date, the PNLOC/MTN conducted STH MDA in 15 HDs: 13 with ENVISION support and two with Sightsavers. The remaining two HDs will be treated by OMVS (by the end of July 2017) In FY18 the program plans to conduct STH MDA in all 17 endemic HDs: 13 HDs with ENVISION, two with CRS/OMVS, and two with Sightsavers. Among those 13 ENVISION-supported HDs, 7 have prevalence rates requiring two rounds of treatment per year. These HDs are co-endemic with LF meaning an integrated treatment for LF-STH will be implemented (namely ALB-IVM). Support from ENVISION will cover only one round of treatment. The PNLOC/MTN will conduct advocacy activities to find funding to ensure the second round of treatment occurs. Plan Guinea is supporting the construction of latrines, boreholes, and wells in N Zérékoré, Faranah, and Kindia, which supports, indirectly, the goals of the PNLOC/MTN for STH control. 13

20 3) Snapshot of NTD Status in Country Table 3. Snapshot of the expected status of the NTD program in GUINEA as of Sept. 30, 2017 LF Columns C+D+E=B for each Columns F+G+H=C for each disease* disease MDA MAPPING GAP DETERMINATION MDA GAP DETERMINATION DSA NEEDS ACHIEVEMENT A B C D E F G H I Disease Total No. of districts in Guinea No. of districts classified as endemic No. of districts classified as nonendemic No. of districts in need of initial mapping No. of districts receiving MDA as of 09/30/17 USAIDfunded Others No. of districts expected to be in need of MDA at any level: MDA not yet started, or has prematurely stopped as of 09/30/17 Expected No. of districts where criteria for stopping district-level MDA have been met as of 09/30/ No. of districts requiring DSA as of 09/30/17 Pre-TAS: 0 TAS: 0 OV SCH a STH Trachoma b 4 c 0 a. Of the 31 HDs, 5 HDs are not eligible for treatment in FY17 following WHO guidelines and so are not included in columns F, G, and H. b. Mali had an initial mapping prevalence of 5% to 9.9%; however, the mapping data were more than three years old and need to be re-evaluated. c. Three HDs have met the criteria for stopping MDA and a fourth has now been found to have a TF prevalence rate of 5% despite never having undergone MDA. 14

21 PLANNED ACTIVITIES 1) NTD Program Capacity Strengthening a) Strategic Capacity Strengthening Approach To reach elimination targets and sustain control activities in Guinea, areas below should be considered: Improve supply chain management for MDA drugs. Increase M&E capacity at the PNLOC/MTN to manage data, update of the Integrated NTD Database, use the Tool for Integrated Planning and Costing (TIPAC), and support M&E and surveillance activities. Three main objectives have been identified to strengthen the PNLOC/MTN program: Objective 1: Strengthen PNLOC/MTN M&E capacity: ENVISION funded a consultant's services for collection of historical data and inclusion into the Integrated NTD database in However, no MOH staff are currently able to take over this work and continue to update the Integrated NTD Database, or to analyze the data for decision-making, mainly because of a lack of expertise in data management. A complete database and the capacity to collect data from partners and use data for decision making is critical as the PNLOC/MTN moves forward. ENVISION s objective is to increase the capacity of the PNLOC/MTN by training, ongoing coaching and monitoring from a new ENVISION-funded HKI Guinea M&E staff member. Objective 2: Improve supply chain management for MDA drugs: In past years, MDA rounds have been delayed in Guinea for various reasons. One major reason has been late submission of the JRSM to WHO, which resulted in late delivery of drugs. With the support of ENVISION and other partners, the JRSM for FY18 was prepared and sent to WHO on April 16, The lack of a Drug Supply Manager has also impacted the program s ability to complete a physical inventory and carry out a strategy to collect unused drugs. Objective 3: Strengthen PNLOC/MTN supervision capacity: The scaling up of MDA activities requires competent and well-trained supervisors to maintain good coverage rates and high-quality campaigns. Currently, there is a gap in the number of trained supervisors available and those needed to participate in MDA campaigns. The PNLOC/NTD national program has fewer than 12 staff members and is obliged to recruit MDA supervisors outside the program. While this strategy provides sufficient staff to cover the entire country, the skill level and training are often not sufficient and need to be strengthened. b) Capacity Strengthening Objectives and Interventions Location in Budget: N/A Objective 1: Strengthen PNLOC/MTN M&E capacity Activity 1: Hire an M&E technical assistant in ENVISION (LOE only) In FY18, ENVISION will hire an M&E technical assistant who will be made available to assist the PNLOC/MTN to update new data into the database, provide M&E support, coach and provide on-the-job training to two PNLOC/MTN staff members who will continue to enter data when ENVISION ends and work to transition responsibility for those activities to the NTD program. The HKI Guinea M&E staff member will be mainly tasked to analyse NTD data and produce reports of actions required to 15

22 strengthen MSP s National NTD Program. S/he will assist in developing strategies and rolling out plans for capacity building for the MOH s National NTD Program. S/he will also be charged with providing support to the MOH in the use of TIPAC and other tools. A full and detailed job description with clear capacity building objectives is under development for this staff recruitment. The job description will include assisting the MOH to develop SOPs for M&E. Objective 2 Improve supply chain management for MDA drugs Activity 1: Provide support to Complete Drug Applications The M&E technical assistant (to be hired, see above) will work with the PNLOC/MTN to complete and submit the JRSM to WHO by the deadline; he/she will also work closely with HKI staff and PNLOC/MTN staff. This person will also work the PNLOC/MTN to submit the ZTH application to International Trachoma Initiative (ITI) and the TEO order to ENVISION. Activity 2: Amend Memorandum of Understanding for NTD Drug Management A memorandum of understanding among HKI, PNLOC/MTN, and the Central Pharmacy of Guinea (PCG) has been signed, setting out the responsibilities of each party from the arrival of the drugs at the airport to the transfer to the PCG warehouse, and then from the PCG warehouse to the field. HKI will encourage each party to revisit this document and will ask each party to submit an amendment to improve the drug management process. Activities will be monitored on a regular basis with a drug inventory report and meetings with the PCG when necessary. Activity 3: Collect Unused NTD Medicines HKI, with ENVISION support, will work with the PNLOC/MTN to collect all unused drugs after each MDA round has been completed and store them in a secure place. Objective 4: Strengthen the pool of NTD supervisors Activity 1: Create a Pool of Certified MDA Supervisors To strengthen the PNLOC/MTN supervisors capacity, 30 people will be trained in the MDA supervision process. The training curriculum will be based on the supervisors training currently in use in Guinea, training materials from the WHO Programme Managers Training Course, and ICTC s Preferred Practices for Zithromax Mass Drug Administration. There will be a pre- and post-training test with a minimum pass rate required. While certification is not endorsed by an outside organization, the PNLOC/MTN and ENVISION will assume that those supervisors who attend the training and reach the required level in the post-training test will be certified to participate as a supervisor. These supervisors will be evaluated at the end of the training, and those that pass the evaluation will be certified to serve as supervisors for the next campaigns. The PNLOC/MTN will only recruit from this pool of certified supervisors. The supervisors will be identified by the PNLOC/MTN from other MoH departments, universities and local NGOs. This strategy will lead to improved supervision and improved MDA results. c) Monitoring Capacity Strengthening Informal meetings, s, phone calls, as well as regularly scheduled quarterly review meetings with the PNLOC/MTN will be used to review progress made toward achieving the planned capacity strengthening outcomes, using the following strategies to measure success. Objective 1: Strengthen PNLOC/MTN M&E capacity HKI Guinea will recruit an M&E technical assistant, as described above. ENVISION will work with the MOH to convene various stakeholders, including the different MOH divisions and other partners, to 16

23 review progress in completion of the database and use of TIPAC, as well as to identify obstacles in using the Integrated NTD Database and propose solutions to overcome these. Feedback gathered during these meetings on how the database and other M&E tools could be made more user-friendly will be provided to WHO, the PNLOC/MTN, and the ENVISION M&E team. Objective 2: Improve supply chain management for MDA drugs ENVISION will meet quarterly with the M&E technical assistant to review progress toward the completion of a physical stock inventory. Prior to the FY18 MDA rounds, ENVISION will work with the PNLOC/MTN to compile data for the JRSM, ensuring the document is of good quality and ready to be signed and submitted on time to WHO (at least nine months prior to planned MDA). The indicator will be the submission of a good-quality and accurate request, submitted before the deadline. Objective 3: Strengthen PNLOC/MTN supervision capacity Just before each MDA, the PNLOC/MTN and HKI teams will organize a national supervisors refresher training to review key supervision points. At the end of the MDA, each supervisor will be evaluated based on MDA results (quality of MDA activities, campaign coverage, and quality of the supervision report) in his or her respective HD. Table 4. Project assistance area a. Strategic Planning Project assistance for capacity strengthening Capacity strengthening interventions/activities On-the-job training: work with t the PNLOC/MTN to enter data into the TIPAC g. Training (See training in Table 8.) h. Drug Supply and Commodity Management and Procurement i. Supervision for MDA j. M&E on-the-job training: The HKI M&E technical assistant will assist the PNLOC/MTN in the completion of drug orders, accurately and on time. Work with the PNLOC/MTN to develop a strategy to collect unused drugs after MDA is completed. Resource individuals: Set up a pool of certified national MDA supervisors. On-the-job training: Assist the PNLOC/MTN to continue entering historical data for all NTDs into the Integrated NTD Database. How these activities will help to correct needs identified in situation above Help the PNLOC/MTN to identify funding gaps and use TIPAC to advocate for additional funds from donors. Avoid MDA delay due to late submission of Joint Application Package to WHO The M&E focal point will also assist in serious adverse event (SAE) management. Accurate counts of physical inventory Qualified supervisors will further improve program results. Data will be used to complete the WHO Joint Reporting Form and the eventual LF and trachoma dossier when needed. M&E staff will be available for NTD surveillance activities. 17

24 1) Project Assistance a) Strategic Planning Activity 1: Meeting of the NTD Steering Committee The NTD Steering Committee is chaired by the National Director for Prevention and Community Health or the Secretary General of the MOH. Committee members include representatives of the PNLOC/MTN, SNSSU, WHO, HKI, Sightsavers, OPC, and Plan Guinea. The committee may invite other organizations if necessary. From 2017 on, actors from the WASH sector and OMVS are scheduled to be invited. The committee meets twice a year to inform the national authorities and partners about NTD activities implementation status and challenges in order to determine strategically appropriate interventions. The two meetings are generally held before the MDA campaign launch and after the main activities have been completed. To date (in 2017), one meeting was organized in February; the second is scheduled for August. ENVISION is optimistic that the Steering Committee meetings will be held in FY18 because there has been increased discussion with WHO, which is an added incentive to hold these meetings. To introduce the activities to the MOH authorities, the PNLOC/MTN and ENVISION have identified a way to request and obtain working meetings with the Ministry, the Secretary General, or the National Director for Prevention and Disease Control. These technical meetings often provide an opportunity to advance and achieve implementation of NTD control activities, even if the Ministry has other priorities, such as national polio vaccination days. They are also provide an opportunity to discuss increasing domestic funding for NTDs and the location of the NTD office after ENVISION ends in FY19. Discussions between WHO and ENVISION teams are ongoing to encourage WHO to ensure that plans for the NTD Steering Committee move forward. Advocacy activities with WHO and other partners, including ENVISION, are designed to ensure that these meetings will occur. The PNLOC/MTN and HKI will advocate for these meetings to be conducted, which will improve coordination and harmonization of activities and avoid overloading field implementers. Activity 2: Monthly meetings of the NTD technical group In 2017 with HKI leadership, an NTD technical group was set up to contribute to global efforts to eliminate NTDs and provide support for elimination dossiers in Guinea. The group will work in partnership with PNLOC/MTN and is constituted by ENVISION/HKI, SNSSU, Plan Guinea, Sightsavers, OPC, OMVS, and WHO (and is open to others involved in associated activities). Meetings of this technical group will be held monthly in a rotating manner. The meetings will focus on implementation of the integrated MDA campaigns and coordination of the partners interventions to support standardization, complementarity, and synergies and for shared learning and programming Activity 3: Annual NTD program review (HKI Strategic Planning, PNLOC FOG, and HD FOGs) An annual meeting to assess the NTD program will be held at the end of the fiscal year with the participation of all partners supporting the national NTD program, including the Prefectural Heath Directors and the Regional Health Directors. At this meeting, the FY18 outcomes will be reported to the national authorities and HKI management. The two-day meeting (and two days for travel to Kindia) will provide a platform to discuss the program s strengths and weaknesses and the measures to be taken to improve future activities. In advance of this national meeting, a review meeting will be organized at the end of the MDA campaigns at the district and regional levels, to identify lessons learned during the campaigns. These lessons learned will be discussed and shared during the annual review meeting. 18

25 During the annual review, as was carried out during the workshop in FY17, the PNLOC/MTN, with ENVISION s assistance, will use the Data for Action Planning Guide to review MDA coverage and focus on HDs that have reported poor coverage. The guide will be used to discuss potential solutions for any coverage issues and to make improvements for FY19. Activity 4: FY19 work plan development meeting (HKI Strategic Planning) The MOH, with WHO coordination, will organize a two-day workshop in July 2018 to review 2018 NTD activities to date in Guinea and to plan 2019 activities together. The workshop participants will include the PNLOC/MTN team, NTD partners already involved in Guinea (USAID/RTI/HKI, WHO, OMVS, SNSSU, Plan Guinea, Sightsavers, the World Bank, and OPC), and WASH partners. This meeting will enable partners to better coordinate activities. A three-day workshop will be held immediately after this review in Conakry. This session will involve the PNLOC/MTN team, USAID/RTI/HKI, and WHO to discuss and decide on the FY19 action and operating plan, with support from USAID. This action plan will be extracted from the country action plan already developed during the partners meeting. Activity 5: Mano River Union meeting The PNLOC/MTN will organize the Mano River Union meeting in Conakry in October The objective of this meeting is to improve cross-border coordination of NTD treatment between countries that have mobile populations and cross-border migration. The meeting aims to enable each country to support disruption of disease transmission at a regional level. As the PNLOC/MTN in Guinea will host and lead this meeting in FY18, HKI will work with the PNLOC to ensure that an objective to achieve MDA synchronization is included in the agenda and the discussion. The goal will be to achieve agreement by all countries on the dates for the MDA. Having these concrete plans will differ from previous years and ENVISION will ensure that these action points are created and agreed by all. Activity 6: Strategic (master) plan validation In FY16, ENVISION supported the development of the NTD strategic (master) plan for The document was then sent to WHO/Africa Regional Office for review, validation, and comments which are pending and will be provided before the validation meeting. Building Advocacy for a Sustainable National NTD Program b) Advocacy Activity 1: Involvement of local mining companies and WASH partners in NTD activities The advocacy strategy of PNLOC/MTN and HKI will involve preparing documentation that summarizes NTD program activities, the diseases targeted, and their impact on the health and working capacity of communities. As part of their agreement with the Government, the mining companies must contribute to local development plans. The PNLOC/MTN and its partners will seek to better understand the process by which this support is allocated. They will also request additional support for activities that supplement MDA, such as efforts to promote better hygiene and sanitation, and will explore other possibilities for support. In 2010 and 2011 a mining company, Rio Tinto, gave financial support to conduct an integrated STH and SCH mapping in Beyla and Forécariah HKI initiated a discussion process with partners involved in Guinea s WASH sector to ensure that current gains will be sustained through WASH activities to avoid resurgence of NTDs after ENVISION ends. HKI is promoting intersectoral collaboration between WASH actors and those involved in NTD control. Currently, ENVISION is working to map all WASH partners and their interventions. This NTD WASH 19

26 integration will continue and will be consolidated in FY18, through the participation of HKI in the frequent meetings within the WASH working group, where the promotion of NTD WASH interventions will be discussed. These meetings are held in Conakry, hosted by the various NGOs involved. Activity 2: Participation in MOH/partners strategic meetings Members of the PNLOC/MTN attend NTD meetings organized by other NGOs (Sightsavers, CRS, and PLAN Guinea) and MOH meetings across other related sectors (WASH, education, etc) held outside of Conakry. ENVISION will fund two HKI NTD staff members to attend one of these meetings held outside of Conakry (either MOH strategic meetings or other relevant partners meeting) during FY18. Attending these meetings will allow HKI staff to build linkages within the NTD sector with other partners and across sectors. During the meeting, HKI staff will make presentations and contributions and provide other technical support to improve activities aimed toward NTD elimination. c) Mapping Guinea has completed mapping of the five PC NTDs. d) MDA Coverage In FY18, the PNLOC/MTN plans to conduct MDA in 19 HDs with ENVISION funding and in 9 other HDs with funding from other sources (see Tables 1a and 1b for the other partners planned support). The LF/OV/STH MDA, the trachoma MDA, and the SCH MDA are scheduled from February to April Each MDA will be carried out over five days. For FY18, the PNLOC/MTN plans to conduct the following MDA campaigns with support from ENVISION: LF MDA in 19 HDs: All these districts have received at least two treatments between 2014 and OV MDA will be conducted as part of the LF MDA in 17 LF co-endemic HDs. Trachoma MDA will be conducted in five HDs where TF baseline prevalence rates were 30%. Faranah will receive its sixth round of seven treatments required. Dabola, Kissidougou, and Kouroussa will receive their fifth round of treatment. Dinguiraye will receive its fourth round of five treatments required. SCH MDA will be conducted in 14 HDs: 9 HDs with 50% prevalence among SAC 5 HDs with prevalence rates among SAC 10% and <50% 3 HDs with medium-prevalence rates will receive their second round of treatment, while the others will receive their third round of consecutive treatment. STH will be treated through the LF MDA, which combines IVM and ALB. In FY18, 13 of the 17 HDs with STH prevalence rates 20% (7 HDs with prevalence rates 50%) will receive ENVISION support for only one round of MDA. The second round of MDA for the seven HDs with prevalence 50% may be covered by SNSSU, pending funding availability. 20

27 Table 5. LF OV NTD USAID-supported districts and estimated target populations for MDA in FY18 Age groups targeted population above 5 years population above 5 years Number of rounds of distribution annually SCH SAC only 1 STH population above 5 years Trachoma Entire population Distribution platform(s) Communitybased MDA Communitybased MDA Communitybased MDA and School-based MDA Communitybased MDA Communitybased MDA Number of districts to be treated in FY18 Total # of eligible people to be targeted in FY ,188, ,544, ,648, ,434, ,349,885 The MDA strategies adopted by the PNLOC/MTN in Guinea include community-based and school-based distribution. For the former, CDDs, who are chosen from within their communities, are trained and deployed to conduct door-to-door distribution. However, treatment may be provided in public places, such as markets, mosques, churches, health centers, and schools, when centralized distributions are necessary. The beneficiaries will be asked to take the drugs under the observation of the distributors. Distributors who handle SCH school-site distribution are chosen from the teachers. Children who are not registered in school will also go to the schools for treatment. However, to ensure good coverage, the CDDs actually go to the households to look for children who are not at school. Therefore, the schoolbased strategy is in fact a pragmatic mix of community- and school-based distribution. Informal reports have shown that this approach is useful and shows positive results. The data collection tools will also be reviewed to provide information on the number of un-enrolled SAC treated the current tools do not separate enrolled and un-enrolled children. Public criers, radio stations, and parents organizations will help to transmit information about the MDA. Three HDs (to be selected by the PNLOC/MTN) will pilot a triple drug integrated treatment strategy i.e., ALB/IVM/PZQ in LF/OV/SCH-endemic districts. The MOH and PNLOC/MTN are taking into account the fact that the ENVISION project will end and are considering ways to create sustainable programs and maximize the available funding to provide treatment for the most people. The PNLOC/MTN will develop a protocol to complete this pilot in three HDs and will implement this strategy in FY18. Social mobilization strategies will be developed for this integrated community strategy for these HDs alone. The PNLOC/MTN will also ensure sufficient training is provided, e.g., to ensure children have eaten before PZQ treatment. This strategy is used in other countries and could be beneficial to Guinea in the longer term. External supervision will be conducted during the MDA to help troubleshoot and alert the MDA team to low coverage areas, and after MDA to determine if mop-up activities are needed. Methodology for external supervision is in the M&E section 21

28 e) Social Mobilization to Enable NTD Program Activities The social mobilization strategy that the PNLOC/MTN developed, with technical and financial support from ENVISION through HKI, seeks to reduce the obstacles to high MDA coverage rates. The strategy also relates to communities refusal to take the drugs and to misinformation or lack of information. All the social mobilization activities conducted around the campaign seek to inform the population about the diseases, their causes and consequences for the communities, available treatment, and the target population. It also provides information on when, where, and how to obtain treatment. Information on reducing adverse events and what to do if they occur will also be provided, particularly for drug distribution in school settings. A specific strategy to reassure the population about the safety of the drug distribution will continue to be implemented to help counter the rumor that the drugs can transmit Ebola and the general fear of health workers and health agencies in the post-ebola context. This strategy will involve intensive communications disseminated through the media and community leaders. Data on the impact of IEC materials have been collected through external supervision during FY16 MDA. This monitoring showed that radio stations and town criers are the best communication channels, with 47% and 22% respectively of the target NTD population identifying as having remembered these communication methods. This has been confirmed by the good results obtained by the HDs where these channels were used properly. Following that analysis, the use of these channels will be highly recommended during FY18 MDA. Activity 1: NTD Open House (National NTD Day) The national program will hold a day-long NTD Open House in FY18. The goal of the event is to inform the population in general and a variety of stakeholders about the significance of NTDs and the activities that the Government of Guinea has put in place to combat them. This activity is scheduled for the second quarter of FY18. Various potential partners (embassies, mining companies, NGOs, and United Nations agencies) will be invited to the event in the hope of creating interest, obtaining other types of investments, and identifying potential synergies with activities currently underway. Another indirect objective is to improve knowledge of and interest in NTDs on the part of current and future doctors and other health workers. This activity was organized before launching the FY16 MDA. The activity was well received by the public, with the enthusiastic participation of more than 200 students of medicine, pharmacy, odontology/stomatology (future health professionals), and all the NTD partners. Following the Open House, other medical school students have shown interest in NTDs, inviting the HKI NTD Program Coordinator to present on NTDs during a scientific conference organized by the students. Students have expressed their desire to be involved in NTD activities after their studies. Students will follow up with NTD partners to be involved in NTD activities (e.g., surveys) and can be involved in NTD activities during their internships. In FY18, the PNLOC/MTN will hold the Open House activity in Conakry, in partnership with the scientific cadre of a private medical school (staff and students). The activities scheduled during the NTD Open House include the following: 1. The partners involved in NTDs (PC and non-pc NTDs) will display exhibit stands that provide general information on NTDs. Posters will show images of these diseases, activities implemented, and program and research outcomes. 2. The PNLOC/MTN and its partners will hold debates on various NTD topics. 22

29 3. NTD drama sketches will be prepared and performed by the scientific circle of the medical school. These sketches will be prepared in collaboration with the PNLOC/MTN and HKI. The media will cover the event, conducting several interviews. The roundtables will be recorded and used as communications tools on MDA. ENVISION will support the costs of this day, including space rental, media coverage, printing supplies, transport of the main guests, and refreshments Activity 2: Training workshop for leaders As was done during the last fiscal year, the HD teams will invite a group of community and religious leaders from the sub-prefectures and health centers to participate in an HD-level training workshop. This workshop, primarily created to improve awareness of the NTD program during the EVD outbreak, proved very useful beyond its original scope. The workshop was also useful for the MDA campaign in reducing the number of refusals (beyond refusals caused by EVD) and preventing rumors about the campaign. ENVISION plans to continue this workshop in FY18. The workshop will provide more information on the targeted NTDs (including the symptoms of NTDs and drug adverse events) and messages that can be used to counter the rumors/misinformation that arose during the EVD epidemic, along with techniques for these leaders to use in transmitting messages and answering questions within their respective communities. Information on ways to minimize the adverse events of PZQ ensuring that children do not take the drug on an empty stomach will be provided. Previously produced laminated cards with pictures will be distributed to the leaders to aid in conveying correct information. The leaders who are trained will then train other community leaders (including members of parents groups and school inspectors) in their sub-prefectures to distribute the messages. Activity 3: MDA campaign launch ceremonies The FY18 MDA campaign will be preceded by the following activities: An official national launch to inform the general population about NTDs, disseminate details on the MDA campaign, and support advocacy efforts This launch will take place in N Zérékoré region after the NTD Open House Day. It is intended to create high levels of public and government participation in the MDA campaign. It is also a platform to encourage government decision makers and companies to take NTDs into account in their development plans. This approach produced good results in the previous campaigns, reassuring certain communities that were reluctant to take the drugs. By viewing community leaders taking the drugs, community members were more likely to take them as well. The success of this approach can be seen in community adherence and the good treatment coverages obtained. This approach also allowed the program to be more visible. 23

30 A launch in each HD Before the start of each type of MDA (LF/OV/STH, trachoma, SCH/STH), the health and administrative authorities will bring together religious and traditional authorities, teachers, drug distributors, and the general public at a public place for a launch ceremony specific to the HD. Loudspeakers will broadcast music and speeches, snacks will be available, and the individuals involved in the campaign will wear their NTD T-shirts. In HDs that will conduct two or more of these types of MDA, different locations within the district will be chosen for each launch to ensure maximum visibility. This joint initiative will help to ensure that the authorities are committed and that the public is informed about the campaign. During this ceremony, the participants and the CDDs will take the drugs publicly. In 2015, because of the EVD epidemic, many community members were distrustful of the MDA and wanted to observe the drugs effects on the first people to take them before taking the medication themselves. This situation slowed the normal MDA distribution process. During the FY18 launch ceremonies, the authorities and health workers will take the drugs, facing the population, to reassure people that the drugs are safe. The CDDs can also use this technique during the MDA if some people refuse because they are afraid of the drugs (members of the CDD team should coordinate the days on which they take the drugs because they cannot take them more than once). This approach produced good results in the previous campaigns for reassuring certain communities that were reluctant to take the drugs. Activity 4: National and local broadcasting of health messages Messages on the MDA campaigns will be broadcast on television, national radio, and community radio, with ENVISION's support. Before the FY17 MDA campaign, the NTD National Coordinator and HKI s Country Director were interviewed by a journalist from national television on the MDA activities. The broadcast of these interviews contributed to good social mobilization. This activity will be maintained in FY18 and will include the HKI NTD Coordinator and a WHO staff member. Interview topics will cover the different PC NTDs, their consequences in Guinea, and the strategies currently deployed by the Government and its partners. These interviews will be broadcast before and during the MDA campaign. The same kind of interviews will be organized by the head of each HD with well-known and trusted individuals (including the MOH Regional Director, a doctor, or another well-known local medical expert). This kind of communication will enable the leaders to discuss the subject in greater detail and to answer the most frequently asked questions on PC NTDs, including Ebola-related questions. Activity 5: Public Criers In rural areas, ENVISION will pay to hire public criers to share information on the MDA (disease targeted by the treatment, importance of treatment, the distribution date, location, strategy, target population, and treatment safety) in all sectors and villages in the target HDs. Activity 6: Mobile Sound System In urban areas, the project will support the transmission of messages using vehicles equipped with loudspeakers for those people who do not listen to the radio. Table 6 summarizes the social mobilization and communication activities and materials. 24

31 Table 6. Category Social mobilization/communication activities and materials checklist for NTD work planning Key messages The MDA will be carried out in the 19 health districts over five days (February to April). Target population Individuals 5 years of age for LF/OV, SAC for SCH, and the entire population for trachoma IEC strategy Posters Banners (previously produced) Images Where/when will they be distributed Previously produced posters are displayed in public places five days before the campaigns begin. Images (cards with pictures) are distributed to community leaders two days before the campaigns begin. Frequency Displayed before each MDA During the MDA Is there an indicator/ mechanism to track this material/activity? If yes, what? During the campaigns, the supervisors monitor the presence of posters and banners. Supervisors monitor the use of images during the MDA campaigns. Other comments Images are laminated and can be used multiple times. MDA Participation The drugs distributed are free and innocuous. The drugs may have minor adverse events that will disappear. The drugs distributed in schools are free and pose no danger. They will keep children healthy and thus improve Entire community Health centers, CDDs SAC, parents of students Radio Training module and radio stations Rural and community radio stations Rural and community radio stations broadcast before and during the campaigns. Training for supervisors, CDDs In schools and radio before and during MDA Messages are broadcast twice/day before and during the MDA. Modules are distributed during supervisor training and messages broadcast before and during the MDA. Before and during the MDA A questionnaire/ survey during the external supervision includes a question on which communication channel the communities received MDA information from. External supervision provides the information on the message broadcast. External supervision provides the information on the message broadcast. 25

32 Category Disease Prevention Other Key messages their school performanc e. NTDs can be prevented with (1) medicati ons that need to be taken each year by all communitie s and (2) individua l and environmen tal hygiene. Promoting visibility of NTD Program Target population All All IEC strategy Radio stations T-shirts with messages and logos Where/when will they be distributed In the community, before and during the MDA campaigns Where there is an MDA (worn by CDDs) Frequency Before and during the MDA During each MDA Is there an indicator/ mechanism to track this material/activity? If yes, what? A questionnaire/ survey during the external supervision will include a question on what message has been broadcast. Number of T shirts produced Other comments CDDs and supervisors will use the picture cards to inform interested people. f) Training Activity 1: Training of trainers and supervisors The scaling up of MDA activities in the Guinea NTD program requires competent and well-trained supervisors in order to maintain good coverage rates and high-quality campaigns. Currently, there is a gap in the number of trained supervisors available and the number needed to participate in the NTD campaigns. The PNLOC/NTD has 9 staff and is obliged to recruit outside the program to find MDA supervisors for NTDs. While this strategy provides sufficient staff to cover the entire country, the skill level and training are often not sufficient and need to be strengthened. In FY18, ENVISION will support the national program to create a pool of certified national supervisors. The PNLOC/NTD will identify 30 people from other MOH sectors who will be trained in Kindia during three days by NTD national coordinators and ENVISION staff. The training will include knowledge on PC NTDs and the key MDA activities (training of health workers and CDDs, social mobilization, drug distribution, management of SAEs, and MDA data analysis). The trainers will evaluate the results obtained from the HD, the number of problems recorded, the solutions proposed to these problems, and the overall performance of the HD. The training of grassroots supervisor trainers will be held in the appropriate administrative regions. A total of 38 trainers from the 19 HDs and 12 supervisors from the 6 health regions targeted in FY18 will be trained by the PNLOC/MTN. The HKI supervisors will provide supervision and capacity strengthening during the training. 26

33 Activity 2: Training of health center staff, teachers and CDDs For each HD targeted, the HD trainers will provide integrated training on all MDA campaigns (refresher training or training for new personnel) to two staff members from each health center (the head of the health center and his/her assistant) in their respective HD, plus a journalist, a member of the hospital staff, and two other supervisors from the HD team (six people in total per HD). The two health center staff members will then train/provide training to the CDDs at the health center level for the MDA. The head of the health center and a teacher will supervise the SCH campaign. The people trained will be CDDs and teachers (some will take part in multiple drug distributions). The hospital staff will monitor the need for treatment of adverse events and the journalist will monitor misinformation/rumors about adverse events on a daily basis in order to take appropriate corrective communications measures. All those involved in conducting the MDA will receive some training, whether or not they participated in prior distributions. This refresher training is necessary to upgrade knowledge and skills, thus avoiding any confusion and correcting mistakes from prior campaigns. It is also an opportunity to train new CDDs who will be involved in the different campaigns. Not all campaigns use the same CDDs. The MDA will include as many CDDs from the previous campaigns as possible to draw on existing knowledge of implementation of the activities. The training will address the following topics: (1) knowledge of the NTDs (cause, consequences, and available treatments), (2) MDA (eligible population, dosage, completing the distribution registers, reports, and managing adverse events), and (3) key messages to be transmitted to community members during the MDA that will increase acceptance of the drugs by addressing the main reasons for refusal. Role playing will be included in the training to help the heads of the health centers and the CDDs focus on the essentials during the MDA. The PNLOC/MTN recognizes that an integrated training of CDDs will ensure a more sustainable implementation in the future. This integration will be prepared in FY18 in the three HDs piloting integrated treatment and will be expanded and used for implementation in FY19 to ensure that all CDD training will be integrated in FY19. Activity 3: Training of external MDA supervisors In FY18, ENVISION will hire and train five external supervisors, which will strengthen the supervision activities during the MDA. These five supervisors plus the ENVISION staff will be able to provide highquality supervision during the MDA. Activity 4: Training for TIS surveyors In FY18, a TIS will be conducted in six HDs (Kérouané, Boké, Boffa, Fria, Forécariah, and Télimélé). The survey protocol requires that the investigators be trained in gathering data in accordance with WHO guidelines and Tropical Data. Eighteen people will be trained one team of three for each HD. To date, Guinea has eight certified graders and seven recorders. The PNLOC/MTN and HKI will supervise the quality of all the trainings. Problems observed will be corrected immediately. The lessons from these observations will be shared at subsequent training sessions to ensure that they are incorporated in the future. g) Drug and Commodity Supply Management and Procurement The quantities of drugs needed for the campaigns are evaluated based on the target population data for each disease, remaining drug inventory, average drug consumption, and population structure. The IVM order will be based on the population 5 years of age (80% of Guinea s population), and the PZQ order 27

34 will be based on SAC (25% of Guinea s population). The PNLOC/MTN uses the following population percentages for ZTH and TEO: 80.0% for ZTH in tablet form, 18.0% for ZTH in syrup form, and 2.0% for TEO. As mentioned in the Capacity Building section, HKI supported PNLOC/MTN in preparing its orders for certain drugs (IVM, ALB, and PZQ) by completing the WHO JRSM, which was submitted on April 16, The PNLOC/MTN orders ZTH separately through the Zithromax application. Pfizer supplies the ZTH and ITI delivers it to Guinea. Guinea s 2018 order was submitted on February 25, 2017; the quantity requested will cover five districts with TF prevalence rates of 30%. RTI/ENVISION provides the TEO for trachoma for its intervention areas. WHO organizes the transportation for NTD medicines from the port of entry to the national medical stores, for all drugs except for ZTH and TEO. HKI will pay for the transport of all the drugs going to 19 HDs supported by ENVISION. CRS, OPC, and Sightsavers will pay for their drug transport. For the supply of ZTH and TEO, ENVISION has a contract with the PCG to receive the drugs from customs, organize clearance, storage at the PCG warehouses, and transportation. ENVISION will fund HD staff to transport the drugs and MDA tools to the health centers. The health center staff will then send the drugs to the schools or communities, as needed. For FY17, all the drugs arrived early (between January and March 2017), which allowed the MDA implementation to take place between March and May. Since all the drugs for FY18 have been ordered early, ENVISION believes that the drugs will arrive early enough to conduct the MDA campaign by April After the MDA campaign, the heads of the health centers will return the remaining quantity of drugs and tools (two weeks after the HD evaluation meetings). The PNLOC/MTN team, with ENVISION support, will conduct a physical inventory of the remaining drugs at that time. The heads of health centers will send the remaining drugs and the drug management reports to the HDs. A collection team from HKI Guinea will recover any drugs after the MDA and bring them to Conakry just after the mop-up period (if one is needed). The drugs will be stored in a warehouse in Conakry until the next campaign, and each report will be reviewed and analyzed (including for use and percentage of waste) by the MOH s regional and central teams to assess the quality of management and to take any corrective measures necessary. Typically, the quantity of drugs remaining is fairly small (and there should not be a significant increase in the remaining quantity in FY18 because most of the drugs will be distributed during systematic mop-up efforts) and can be sent to the central-level PCG in the vehicles already mobilized for the activities. All movement of drugs is noted on a stock card, which is used to update the inventory. This is the current strategy in Guinea. The budget is currently used by HKI to travel and collect the drugs, but a more sustainable solution needs to be found, for example, leaving the drugs at the regional warehouses. The unopened drugs returned to the PCG are for use in the next MDA campaign. The empty containers are disposed of at the HD level where there are incinerators. Any expired drugs are disposed of in accordance with WHO/other donors drug contribution program instructions on proper waste disposal and/or national directives from the Department of Public Health, Hygiene, and Sanitation of the Ministry of Territorial Administration and Decentralization. The remaining MDA tools (dose poles, cards with pictures) at the health centers are retained for multiple use, in accordance with the national protocol. NTD SAEs are very rare in Guinea. For the most part, only minor adverse events have been reported since MDA began.. In 2017, numerous cases of side effects were observed in Forécariah during SCH MDA due to the fact that some children were not informed that they should eat before being treated (results of inadequate training for CDDs and health workers). This situation led to the population rallying against the MDA and disrupting the PZQ distribution in Kalia health center area, which resulted in poor coverage 28

35 (10.5%). This situation was discussed during the MDA regional review meeting and the participants decided that a mop up would be conducted after Ramadan in this area. An emphasis on achieving minimum epideomiological coverage will be placed by the region, PNLOC/NTD, and HKI teams during this mop up and for the following MDA. Although MDA SAEs are very unlikely, all staff involved in MDA are trained to make sure that every SAE is reported within 24 hours to the PNLOC/MTN National Coordinator through the community health center, HD, and regional level. This is part of the certification of supervisors. The PNLOC/MTN will inform WHO, the drug company, and international donors about the SAE. Simultaneously, HKI Guinea will inform HKI HQ, which will then notify RTI. The HKI Guinea staff will work closely with the PNLOC/MTN to ensure that SAEs are reported immediately to WHO, the drug donation program, and the drug company. The PNLOC/MTN and HKI ENVISION will also support the strategy in hope of improving the accuracy of the notification system following an investigation, several SAE notifications were found to be false alarms caused by community members who tried to obtain free treatment for pre-existing illnesses. In the event of an SAE, appropriate measures will be taken at all levels immediately upon notification. The national authorities are responsible for managing cases as a contribution to the national NTD program. At the local level, the case is managed by the closest HD health facility that can provide appropriate care. The national health system has set up resources (ambulances, drugs, and health facilities) to manage these cases. The closest health center will treat minor adverse events from the MDA. Managing the information is the most important aspect of dealing with minor, serious, or even false adverse events, particularly in the context of the post-ebola epidemic. All situations will be handled very carefully and in a timely manner. A two-person team one hospital staff member and a journalist will remain on alert during the MDA in each HD. They will receive information on managing potential MDA adverse events during the supervisors training. Thus, the team will be ready to respond to any case of reported adverse events and then monitor the situation to ensure that the appropriate protocols are followed (hospital staff) and that accurate information is relayed and rumors are dispelled (journalists). budgeted Local radio stations will be used to dispel rumors via the activities described in the Social Mobilization section. Traditional authorities and leaders will help to increase the population s awareness and reassure the public by incorporating the messages described in the social mobilization activities. Activity 1: Drug Importation ENVISION will pay for forwarding fees for Zithromax tablets and syrup to reach the PCG national warehouse. Activity 2: Drug Storage In FY18 ENVISION will contract the PCG to receive, manage, obtain the release from the port of entry (ZTH and TEO) and store the MOH s drugs (ZTH, TEO, ALB, PZQ, and IVM) at its warehouses. After the MDAs, the PNLOC/MTN team, with ENVISION support, will conduct a physical inventory of the remaining drugs at that time. Activity 3: Drug Transport from National Warehouse to District Level ENVISION will also contract the PCG to reorganize and transport the drugs and MDA-related tools and supplies for the HDs. The repackaging is carried out following the distribution plan developed by the PNLOC/MTN with HKI support. The PCG will repackage the drugs and MDA-related tools and supplies for transport in coordination with the PNLOC/MTN and HKI and will transport them to the HDs. The 29

36 distribution plan will be described in the HKI contract with the PCG and will specify the scenario, the locations, and the supplies/quantities required. Each partner will contribute financially for their share of the costs. The partners, new and existing, will come together to discuss coordination of the drug management. The distribution will be planned based on the routes that are accessible at the time the drugs are needed and will be completed before the MDA supervisors training. (ENVISION supports logistics and drug transport only for those HDs where it supports MDA activities.) HKI has contacted the PCG with the idea of using a FOG to manage drug arrival, stocks, and availability of these drugs in the HDs for the campaigns. This mechanism will be useful to fully understand the costs in advance, help management of the drug management process, and increase the flexibility and efficiency of the process. The FOG, therefore, will help the smooth implementation of the drug supply management. Activity 4: Drug Transport from HD to distribution point(s) ENVISION will fund HD staff to transport the drugs and MDA tools to the health centers. The health center staff will then send the drugs to the schools or communities, as needed. Activity 5: Reverse Supply Chain A collection team from HKI Guinea will recover any drugs after the MDA and bring them to Conakry just after the mop-up period. h) Supervision for MDA Activity 1: Supervision of LF, OV, Trachoma, STH, and SCH campaigns Prior to the MDA, the PNLOC and HKI will use the supervision checklist to set specific objectives for supervisors FY18. A report in a debriefing meeting will be expected. At the national level, PNLOC/MTN supervisors from a pool of certified supervisors will be deployed in each HD where a campaign is planned. In addition, one MOH staff from the Department of Pharmaco-vigilance will be deployed in each of the three districts where the PNLOC/MTN will pilot the triple co-distribution of IVM, ALB, and PZQ, to reinforce the pharmaco-vigilance These national supervisors will oversee preparation meetings, training for health center workers, drug distributions, and the prefectural summary at the end of the campaign. At the regional level, a team of regional supervisors (with support from national supervisors) will oversee the training, drug distributions, and make recommendations to their HD. At the HD level, the district team s members will supervise the heads of the health centers, who will supervise the CDDs. Supervision of the MDA activities conducted by CDDs may be carried out jointly by the national-, regional-, and HD-level supervisors. The distribution team s role is, first, to measure the height of the person to be treated, then administer the drug, and, last, record the cases. The PNLOC/MTN team will ensure that supervision is performed in a rigorous manner. The team will support this supervision by helping the HDs prepare action plans and updating the monitoring tools for the supervision visits to include Ebola-related questions and incorporate the lessons learned in prior years so that the most relevant aspects of the MDA are monitored and reported on and, in particular, the appropriate corrective measures are taken. Activity 2: External MDA supervision The presence of the external supervision teams and their supervisors at the MDA will also help to strengthen supervision, resolve problems, and record best practices in the areas that need 30

37 improvement, using standard report forms. When problems are observed or identified in the field during supervision activities, the supervisors are authorized to recommend or carry out the appropriate solutions or take the question to a higher level when problems cannot be resolved on site. The PNLOC/MTN will respond to all requests from field supervisors within 24 hours. The supervisors most important observations will then be discussed during the daily summaries and at the end of the campaign. The most frequently identified problems will be used to update the training and refresher training modules. To ensure that HDs receive adequate support during the MDA campaigns, the district-level trainers will inform the heads of the health centers of their responsibilities during their training. In the three pilot health districts, and in Forécariah HD, which did not achieve the target coverage in FY17, two other local supervisors will be posted in each of these districts to strengthen supervision and manage adverse events in addition to the HKI and PNLOC/MTN supervision. During the distribution, the supervisors will take note of the correct drug dose, quality of data collection, and method for completing the administrative forms and will take corrective actions in the field if necessary. The heads of the health centers will train both the existing and new CDDs, providing support for treatment and reporting of adverse events (both for school and community distributions), and will compile the results from their geographic sector for all MDAs. External supervisors will visit a defined number of urban and rural sectors, selected based on knowledge of prior satisfactory coverage data, and including difficult-to-reach areas, to assess coverage among those HDs surveyed. The questionnaire used will also help to identify barriers to access, issues in the quality of implementation and best practices, factors ensuring good coverage, and management of SAEs. This survey will be conducted both during the MDA to help troubleshoot and alert the NTD team to low coverage areas, and after the MDA to determine if mop-up treatment is needed. This will represent a major quality control measure to identify flaws in execution during the campaign and correct them in real time in 19 HDs. Existing smartphones and/or tablets will be used to record the data. The external supervision targets the LF/OV/STH and trachoma MDA, which use a door-to-door strategy, unlike the SCH MDA, which uses a fixed-site strategy (schools and/or health centers). 31

38 i) M&E Activity 1: WHO Integrated NTD Database The collection and input of historical data and then the set up of the Integrated NTD Database were completed with ENVISION support in At that time, ENVISION hired a consultant to complete the integrated database with input of available data. The consultant also collected hard-copy data from locations outside of Conakry. However, to date, the database has not been validated by the PNLOC/MTN, and because there is not yet a qualified data manager in the national program, the Integrated NTD Database has not been updated or used since. In FY18, HKI ENVISION will hire an M&E technical assistant (as mentioned in the Capacity Strengthening section). This NTD M&E assistant will be tasked with supporting the Integrated NTD Database and building capacity at the MOH for a sustainable database. A defined job description is under development to ensure that capacity building activities are clearly identified and will be reviewed quarterly to ensure goals are met. Activity 2: Data quality assessment (DQA) A DQA was conducted in September 2016 (FY16). The results from this DQA allowed the program to identify the weaknesses and strengths in MDA implementation in Lélouma and Kankan HDs. The major recommendations from this assessment included the revision of MDA management tools, the need to train a data manager, and an agreement to increase report turnaround time. The application of the recommendations allowed good data management during the FY17 MDA and HKI will identify, hire, and train a new data manager in FY18. The PNLOC/MTN plans to conduct a DQA in two new HDs in FY18. The HDs will be selected purposely based on recent data problems within the past two years. These may include denominator issues and low coverage. Once the HDs have been selected purposively, the lower levels within the HD (e.g., service delivery point) will be randomly selected. PNLOC/MTN and HKI staff, trained in FY16, have the skills and experience required to conduct the DQA. HDs will be selected nearer the time of the surveys. Activity 3: Quality assurance system by level At each level, there is a system to check the data obtained during the MDA. Routinely, the CDD completes a register and a summary sheet. The supervisor checks if both sheets are the same. All the summary sheets are compiled at the health center level, and the supervisor checks that these numbers match those from the field. There is some cross-checking carried out at the HD level during review meetings and with supervisors. The national NTD program, with HKI support, collects reliable MDA coverage data. This approach reduces errors and fraud. The data calculation sheet has been designed to automatically provide average drug consumption and coverage by health center, thus avoiding the need for manual calculation. However, problems calculating coverage rates persist because of the unreliable national census data when it is used at the sub-regional or sub-district level. Using the FY17 coverage surveys, ENVISION will examine discrepancies between coverage calculated using census data and the coverage resulting from the survey. Activity 4: TIS Surveys will be conducted in six HDs with ENVISION support: one in Kankan Region (Kérouané); where the baseline TF prevalence was 10 30% and that has received three years of the SAFE strategy; three HDs in Boké Region (Boké, Boffa, and Fria); and two HDs in Kindia Region (Forécariah and Telimélé), with baseline TF prevalence 5 9.9% that have received their one required round of treatment. Before the impact survey begins, the survey teams will be retrained by PNLOC/MTN and HKI Guinea staff already trained in the WHO Tropical Data system. A team composed of the PNLOC/MTN, HKI, and the 32

39 local HD staff will meet with community leaders, local associations, and the heads of administrative and social entities. They will be informed of the survey s objective and methodology, asked to notify the communities and individuals, and appoint trusted local individuals to introduce each of the survey teams to the communities. Activity 5: Development of the PNLOC/MTN M&E Plan ENVISION, through its M&E Officer, will work with the PNLOC/MTN to finalize the M&E plan throughout FY18. The plan will be presented to partners during one of the partners workshops. Activity 6: Pre-TAS training In advance of the planned pre-tas surveys that will take place in FY19 Q1, ENVISION will conduct a pre- TAS training for PNLOC/MTN and HKI staff. The meeting will take place in the HKI office and training will be provided by the RTI Technical Advisor. ENVISION will support M&E activities to ensure that the impact of the MDA on the disease burden is evaluated using high-quality methodology. Table 7. Disease Planned Disease-specific Assessments for FY18 by Disease No. of endemic districts No. of districts planned for DSA No. of EUs planned for DSA (if known) Type of assessment Diagnostic method Trachoma TIS Clinical grading j) Supervision for M&E and DSAs Supervision of the TIS ENVISION will provide supervision of the TISs planned for FY18. An ENVISION team member will be present during the TISs will provide supervision and support according to WHO guidelines. k) Dossier Development Guinea has not yet reached the stage of dossier development. However, in FY18, ENVISION will support the PNLOC/MTN to collect data and update the Integrated NTD Database for future development of plans for LF and trachoma dossiers. 2) Maps 33

40 Figure 1. Guinea LF, OV, SCH, STH, and Trachoma Maps 34

41 Figure 2. Guinea LF, OV, SCH, STH, and Trachoma Geographic Coverage Maps 35

42 Figure 3. Guinea Progress Toward LF Elimination Map 36

43 Figure 4. Guinea Trachoma Progress Toward Elimination Map 37