Tanzania Work Plan FY 2018 Project Year 7

Transcription

1 Tanzania 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 Tanzania, ENVISION project activities are implemented by IMA World Health (IMA). ii

3 TABLE OF CONTENTS ENVISION Project Overview... ii TABLE OF TABLES... iv TABLE OF FIGURES... iv ACRONYMS LIST... v COUNTRY OVERVIEW ) General Country Background...7 a) Administrative Structure...7 b) NTD Implementing Partners and Collaborators...8 2) National NTD Program Overview a) Lymphatic Filariasis b) Trachoma c) Onchocerciasis d) Schistosomiasis e) Soil transmitted Helminths ) Snapshot of NTD Status in Country PLANNED ACTIVITIES ) NTD Program Capacity Strengthening a) Strategic Capacity Strengthening Strategy b) Capacity Strengthening Objectives and Interventions c) Monitoring and Evaluating Proposed Capacity Strengthening Interventions ) Project Assistance a) Strategic Planning b) NTD Secretariat c) Building Advocacy for a Sustainable National NTD Program d) Mapping e) MDA Coverage f) Social Mobilization to Enable NTD Program Activities g) Training h) Drug and Commodity Supply Management and Procurement i) Supervision for MDA j) M&E k) Supervision for M&E and DSAs l) Dossier Development APPENDIX 1: Work Plan Timeline iii

4 APPENDIX 2. Table of USAID-supported Regions and Districts for MDA in FY18 -MDA APPENDIX 3. Table of USAID-supported Regions and Districts for DSAs in FY TABLE OF TABLES Table 1: Non-ENVISION NTD partners working in country, donor support, and summarized activities..10 Table 2: Snapshot of the expected status of the NTD program in Tanzania as of September 30, Table 3: Measuring progress of capacity strengthening 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..31 Table 7: Planned DSAs for FY18, by disease TABLE OF FIGURES Figure 1: MOHCDGEC leadership and governance levels... 7 iv

5 ACRONYMS LIST AFRO Africa Region Office, WHO ALB Albendazole APOC African Programme for Onchocerciasis Control CCHP Comprehensive Council Health Plan CDC U.S. Centers for Disease Control CDD Community Drug Distributor CDTI Community-Directed Treatment with Ivermectin CHMT Council (or District) Health Management Team CNTD Centre for Neglected Tropical Diseases DC District Council DED District Executive Director DEO District Education Officer DFID UK Department for International Development DMO District Medical Officer DSA Disease-Specific Assessment EPIRF WHO Epidemiological Data Reporting Form EU Evaluation Unit FLHF Frontline Health Facility FLHW Frontline Health Worker CTND Filariasis Programmes Support Unit (Liverpool School of Tropical Medicine) FTS Filariasis Test Strips FY Fiscal Year GAELF Global Alliance for the Elimination of Lymphatic Filariasis GoT Government of Tanzania GTMP Global Trachoma Mapping Project HKI Helen Keller International ICT Immunochromatographic Test IEC Information, Education, and Communication ITI International Trachoma Initiative IVM Ivermectin JRSM Joint Request for Selected Medicines KCCO Kilimanjaro Centre for Community Ophthalmology LF Lymphatic Filariasis M&E Monitoring and Evaluation MC Municipal Council MDA Mass Drug Administration MOHCDGEC Ministry of Health, Community Development, Gender, Elderly and Children MMDP Morbidity Management and Disability Prevention Program MSD Medical Stores Department NBS National Bureau of Statistics NGO Nongovernmental Organization NIMR National Institute for Medical Research NTD Neglected Tropical Disease OV Onchocerciasis PC Preventive Chemotherapy PCR Polymerase Chain Reaction v

6 PMO-RALG PZQ QEDJT RDT REMO RHMT RPRG SAC SAE SAFE SCH SCI STH STTA TAF TAS TEMF TF TFDA TFGH TIPAC TIS TOEAC TOT TT TWG TZNTDCP USAID WHO ZTH President s Office Regional Administration and Local Government Praziquantel Queen Elizabeth Diamond Jubilee Trust Rapid Diagnostic Test Rapid Epidemiological Mapping of Onchocerciasis Regional Health Management Team Regional Programme Review Group School-Age Children Serious Adverse Event Surgery Antibiotics Face cleanliness Environmental improvements Schistosomiasis Schistosomiasis Control Initiative Soil-Transmitted Helminth Short Term Technical Assistance Technical Assistance Facility Transmission Assessment Survey Trachoma Elimination Monitoring Form Trachomatous Inflammation Follicular Tanzania Food and Drug Administration Task Force for Global Health Tool for Integrated Planning and Costing Trachoma Impact Survey Tanzania Onchocerciasis Elimination Expert Advisory Committee Training of Trainers Trachomatous Trichiasis Technical Working Group Tanzania NTD Control Program United States Agency for International Development World Health Organization Zithromax vi

7 COUNTRY OVERVIEW 1) General Country Background a) Administrative Structure Tanzania is divided into 31 regions, 5 of which make up the semi-autonomous islands of Zanzibar which have a different government structure. Mainland Tanzania has 26 regions with 185 administrative councils. These districts are subdivided into divisions, wards, and villages, which are further subdivided into hamlets. Each village and ward has a chairperson and executive officer, and each hamlet has a chairperson. District councils (DCs) are the governing body at the district level and are headed by district executive directors (DEDs). These local government councils have substantial decision-making power for planning, budgeting, and implementation of policy and development matters. Elective representation levels begin at the villages, moving upward to wards and then districts, which are the primary units responsible for public service delivery, including primary health care. The Ministry of Health, Community Development, Gender, Elderly and Children (MOHCDGEC) formerly known as the Ministry of Health and Social Welfare guides policy development, strategic planning, resource mobilization, quality control, and evaluation and provides guidelines to regions and districts on the overall direction of health program implementation and service delivery throughout Tanzania. Service delivery, leadership, and governance are decentralized, with key roles and responsibility divided among four levels (Figure 1). Regional Health Management Teams (RHMTs) interpret policy and provide overall technical supportive supervision to the respective Council (or District) Health Management Teams (CHMTs) of that region. The CHMTs develop health plans and budgets as well as implement, monitor, and evaluate the impact of these plans. The district level is where the national plan execution and coordination occur. The lowest level of the health system is the community. Activities incorporated into the CHMT health plans are derived from community needs identified through community (village) health committees. The national health budget is developed annually based on comprehensive Figure 1: council health plans (CCHPs). The MOHCDGEC and the President s Office Regional Administration and Local Government (PMO-RALG) provide inputs on prioritization and guidelines for the development of CCHPs. CCHPs are funded through district basket funding, which is made up of funds from the MOHCDGEC, PMO-RALG, Ministry of Finance, and domestic and international development partners. Many district councils also have activity-specific funding from various other sources that does not flow through the established government mechanism. The Tanzania Neglected Tropical Disease (NTD) Control Program (TZNTDCP) is under the MOHCDGEC s Office of the Chief Medical Officer, Directorate of Preventative Services, and is housed at the Tanzania National Institute for Medical Research (NIMR). At the central level, there is a national NTD Program 7 MOHCDGEC leadership and governance levels MOHCDGEC Policy and Policy Guidelines Development, Strategic Planning, Resource Mobilization Regional Health Management Team Policy Translation and Supportive Supervision District Health Management Team Planning and Implementation of Strategic Plans Community (Village) Health Committee Health Services Demand Generation and Utilization

8 Coordinator and four program officers who are paid for by the MOHCDGEC. NIMR also pays for five support staff to help in the implementation of NTD activities. The NTD Program Coordinator is assisted by the NTD Secretariat for overall program coordination and management. Several partners support the NTD Secretariat by providing technical and management resources to work on a secondment basis with the MOHCDGEC. ENVISION has seconded five officers to the Secretariat, namely, a senior technical advisor for monitoring and evaluation (M&E), two M&E program officers, a drug logistics officer, and a finance/administrative officer; the Centre for Neglected Tropical Diseases (CNTD) of the Liverpool School of Tropical Medicine (formerly the Filariasis Programmes Support Unit [FPSU]) funds a database manager; and Sightsavers, through Helen Keller International (HKI), funds a program officer who manages the UK Department for International Development (DFID) SAFE activities (Surgery Antibiotics Face cleanliness Environmental improvement) from the NTD Secretariat side and works closely with the Trachoma Focal Point. The NTD control program is largely integrated into the existing primary health care system. The NTD program works through the RHMTs, CHMTs, and local communities to plan and implement NTD control activities and is led by national, regional, and district coordinators at each respective level. At the district level, there are cascade leaders and zonal managers who provide the frontline health workers (FLHWs) with supportive supervision and aid in data collection. At the community level, community drug distributors (CDDs) are trained to distribute medicines to the household level and report accordingly. On average, one FLHW is responsible for supervising 15 to 20 CDDs. For school-based interventions, mainly targeting soil-transmitted helminths (STH) and schistosomiasis (SCH), primary school teachers help distribute the medicines and report to the health facilities. Redistricting Since 2010, redistricting has increased from 132 districts in 2010 to 166 by August In fiscal year 2017 (FY17), an additional 20 districts were created, increasing the total number of districts to 186. There is no anticipated redistricting for FY18. However, Tanganyika DC in Katavi Region has fallen under Mpanda DC and Mpimbwa DC administration, and thus, officially, the full district count for Tanzania goes from 186 to 185. The redistricting aims to bring social and economic services closer to underserved areas of bigger districts, which has presented challenges for the program in using data across the years, as well as for planning and human resources allocation. First, newly formed districts commonly take quite a long time to set up the key infrastructure, including staff with technical expertise necessary to become fully functional and support the health system in these new districts. Second, the process further weakens the already weak systems in the original districts because some of the key personnel, such as district medical officers (DMOs) and district education officers (DEOs) are transferred to take roles in the new districts without any replacements being assigned in the districts that they leave. Third, some of the previously established lead NTD personnel are given roles outside of NTD programming, resulting in a big loss to the TZNTDCP, which invested in these persons in terms of training and acquired experience. b) NTD Implementing Partners and Collaborators NTD control and elimination activities in Tanzania are supported by many partners (Table 1). The MOHCDGEC provides funding for the TZNTDCP staff mentioned above as well as salaries for all MOHCDGEC-linked staff working in the NTD program from regional to district levels. Also, the MOHCDGEC provides vehicles at the district and regional levels for implementation and supervision of activities. As described below, the US Agency for International Development (USAID) has provided funding for NTD programming in Tanzania since 2010 through the NTD Control Program ( ) 8

9 and ENVISION (2011 to date). Both efforts have been managed by RTI International centrally and IMA World Health in country. USAID also provided funding for the African Program for Onchocerciasis Control (APOC) to implement an integrated NTD program in six regions (Ruvuma, Mbeya, Iringa, Njombe, Tanga, and Morogoro) from APOC supported pre- and post-mass drug administration (MDA) activities as well as M&E activities (such as funding for onchocerciasis [OV] epidemiological and entomological surveys and pre-transmission assessment surveys [pre-tass]). APOC ended in December 2015, and ENVISION took on the programmatic support in these six OV-endemic regions in FY16. DFID funds several partners to support the TZNTDCP. DFID funding to the TZNTDCP through CTND supports community-based lymphatic filariasis (LF) MDA in six districts of the Dar es Salaam Region. In FY17, CTND funding included training, community mobilization, MDA, and data collection. In addition, CTND has also established lymphedema care and hydrocele surgeries in the three districts where they completed the LF morbidity mapping. They have provided funding and technical assistance to complete more than 700 surgeries to date. CTND has also worked closely with the TZNTDCP to develop a national morbidity management and disability prevention (MMDP) program strategy and framework for scaling up MMDP activities across the country. As noted above, CTND also employs a database manager seconded to the NTD Secretariat. For FY18, CTND plans to continue to provide funds for MDA in the Dar es Salaam Region, as well as pre-tas and TAS1 for the six districts of the Dar es Salaam Region. In addition, CTND plans to provide funding for hydrocelectomies for more than 1,000 additional patients. DFID funds the Schistosomiasis Control Initiative (SCI) to address SCH and STH. SCI has supported schoolbased MDA in the Lake Zone regions (Mwanza, Kagera, Kigoma, Mara, and Shinyanga) and Dar es Salaam Region. In FY18, SCI will continue to provide funding to TZNTDCP to support praziquantel (PZQ) and albendazole (ALB) school-based MDA in the five Lake Zone regions and Dar es Salaam, as well as transition of Simiyu Region (6 districts) from ENVISION. SCI is also in discussion with the TZNTDCP to finalize arrangements for the transition of school-based MDA from ENVISION in Geita and Kilimanjaro regions in FY19. In addition, SCI will fund SCH/STH sentinel site assessments across Kagera, Mwanza, Shinyanga, Mara, and Kigoma. SCI also procures PZQ for areas where it operates. For several years, World Vision International provided approximately 4 million PZQ tablets, which were used in Dar es Salaam school-based MDA. However, the supply ended in 2016, and there has been no further information on whether it will continue to supply PZQ going forward. DFID also funds a five-year SAFE project through Sightsavers. The project has worked on the S (surgery) component of the SAFE strategy since July 2014, with linkages to other partners and sectors for other components. The project works to support national-level trachoma surgery planning and coordination through its Tanzania coordinating partner, HKI. DFID also supports partners to carry out trachomatous trichiasis (TT) surgeries, with activities in regions distributed as follows: IMA supports surgeries in Mtwara; Sightsavers in Pwani; and Kilimanjaro Centre for Community Ophthalmology (KCCO) in Arusha and Manyara. The Queen Elizabeth Diamond Jubilee Trust (QEDJT) is funding a three-year project (April 1, 2016 March 31, 2019) to expand SAFE efforts. Currently, QEDJT funding supports partners to carry out TT surgeries, with activities in regions distributed as follows: Sightsavers in Lindi, Kongwa Trachoma Project in Dodoma, and KCCO in Arusha. DFID/SAFE is also funding the facial cleanliness ( F ) and environmental improvement ( E ) components of the SAFE strategy. Simavi receives funding for Dodoma Region and HKI for Arusha and Pwani regions. DFID plans to conduct more TT-only surveys in districts where needed and to be determined for FY18, but funds are limited. 9

10 Sightsavers/Tanzania has focused on eye care, education, and rehabilitation services. It has provided training and funding for eye examinations and implements the S, F, and E components of the SAFE strategy in two districts in the Morogoro and Ruvuma regions. Furthermore, as noted above, Sightsavers seconds a program officer to the NTD Secretariat. It has also provided TT surgeries in Tanga and Ruvuma, in addition to Pwani Region, where it works under the DFID SAFE project. KCCO as mentioned above works under DFID/SAFE and QEDJT, in Arusha and Manyara regions. KCCO also supports research projects for trachoma, including treatment for endemic villages in the Siha District in the Kilimanjaro Region. The Kongwa Trachoma Project receives funding from the International Trachoma Initiative (ITI) to conduct bacteriological trachoma infection research in children and tracks antibodies formation in another cohort of children. The research is focused in a few selected villages of Dodoma Region. ITI first funded Zithromax (ZTH) MDA campaigns until its funding priorities changed and ENVISION took over Zithromax distribution in ITI also works closely with the TZNTDCP to prepare its ZTH applications for submission to the Trachoma Expert Committee, and it assists with drug shipping and clearance. Furthermore, ITI funded the Trachoma Action Plan workshop in FY17 and continues to provide some funding for cross-border meetings. The End Neglected Tropical Diseases (END) Fund has been working on and off in Tanzania for several years, and it receives all of its funding from private donors (individuals or corporations, etc.). The END Fund has been providing support for TT surgeries in Tanga and Tabora, as well as some funding for hydrocelectomies in Tanga Region. In FY18, the END Fund plans to continue support in the same regions, as well as expand hydrocelectomies to Tabora Region. The END Fund s priority area for Tanzania is morbidity management. Statoil is an international offshore oil company based in Mtwara, southern Tanzania. As part of its corporate social responsibility, it supports hydrocelectomies in Mtwara Region. In 2015, Statoil supported 103 hydrocelectomies at Mikindani Town Council (TC), and it has pledged to support 100 hydrocele surgeries in Mtwara DC for FY17. In addition, it has conducted a follow-up health economic assessment of its beneficiaries. Finally, CBM International has also provided funding for TT surgeries periodically throughout the country. Table 1: Non-ENVISION NTD partners working in country, donor support, and summarized activities Partner Location Activities CBM Country office in Dar es Provision of some TT International Salaam surgeries HKI Manyara, Singida, and Tabora regions as well as coordinating partner for DFID/SAFE and QEDJT-funded regions (Pwani, Lindi, Mtwara, TT surgery coordination; potential funding for F and E components of SAFE strategy Is USAID providing NTD financial support to this partner? No No Other donors supporting these partners/ activities? Other DFID/SAFE and QEDJT 10

11 Partner Location Activities Arusha, Manyara, and Dodoma) Is USAID providing NTD financial support to this partner? Other donors supporting these partners/ activities? IMA World Health Center for Neglected Tropical Diseases (CNTD) Sightsavers SCI Mtwara Region TT surgery No DFID/SAFE Dar es Salaam, and other regions covered periodically through TAS and other research efforts Morogoro, Pwani, Lindi, and Ruvuma regions Kagera, Kigoma, Mara, Mwanza, Shinyanga, Dar es Salaam, and Simiyu Funding for MDA and M&E in Dar es Salaam; seconded database manager to NTD Secretariat; hydrocelectomy Focused on eye carerelated activities, including trachoma control; support mainly for TT surgeries; seconded program officer to NTD Secretariat School-based MDA for SCH/STH; various studies KCCO Kilimanjaro Region TT surgeries; research and treatment of highprevalence villages in Siha District Kongwa Trachoma Project ITI Dodoma Trachoma-endemic districts No No No No TT surgeries, research No and technical assistance in Kongwa DC and MDA in Chamwino Supply Zithromax (ZTH) No DFID; other DFID/SAFE, DFID, and QEDJT DFID DFID/SAFE and QEDJT DFID and QEDJT Pfizer Statoil Mtwara Hydrocele surgery (100 No None surgeries planned for FY18) END Fund Tanga, Tabora Hydrocele surgery No None 11

12 2) National NTD Program Overview Several NTDs are endemic in Tanzania, the five most common being LF, OV, SCH, STH, and trachoma. A large portion of the population is at risk of co-infection of two or more of these diseases. The overall TZNTDCP goals for elimination and control are as follows: 1. Continue to implement a modified community-directed treatment with ivermectin (CDTI) approach to community MDA in targeted regions. Ivermectin (IVM), ALB, and ZTH will be distributed using a modified CDTI approach 1 that relies on active community participation with supervision from the TZNTDCP, focusing on empowering communities to take responsibility in MDA activities. This includes advocacy for more MDA activities to be funded by regions and districts, which is increasingly important because donor resources are changing. 2. Sustain the national geographic coverage achieved through phased expansion. The TZNTDCP started in FY09 in six regions, then expanded in FY10 to seven additional regions, and in FY11 to two additional regions. In 2013, TZNTDCP expanded further to Dar es Salaam and Mwanza regions; in 2014 into four additional regions; and in 2015 expanded to Kigoma, Shinyanga, Kagera, and Mara regions to cover all 26 regions of Mainland Tanzania. During this expansion, the national NTD Secretariat has gained knowledge and experience in coordination and implementation of an integrated NTD program. 3. Expand MMDP efforts. Currently, MMDP activities such as TT and hydrocele surgery are being supported by partners, including Sightsavers International, IMA, CTND, CTND, HKI, END Fund and Statoil. The TZNTDCP would like to expand MMDP activities to reach hydrocele and lymphedema patients in Dar es Salaam, but also the large numbers of cases in Tanga, Mtwara, Pwania, and Lindi regions, which are believed to have the majority of hydrocele and lymphedema cases. Additional activities include training, hydrocelectomy, and lymphedema management the TZNTDCP is seeking partner support to fund these activities. a) Lymphatic Filariasis By August 1, 2017, Tanzania has been able to stop LF MDA in 74 districts, and anticipates reaching the national elimination goal (elimination of LF by 2020) early, stopping MDA in all districts in FY19. In FY17, the country also experienced new redistricting where, of the total 185 districts, 64 are regarded as nonendemic, and only 120 were ever endemic. Of the 120 endemic districts, 73 (61%) had reached the criteria for stopping MDA, and only 47 districts required MDA in FY17. The scale down of MDA is based on rigorous disease monitoring carried out by the program. LF mapping in Tanzania was carried out from 1999 to 2004, and the results showed that LF was endemic in all districts in the country. Mapping data indicated high endemicity in the coastal regions and lower levels further inland. Accordingly, the national strategy was to start MDA campaigns in areas with high endemicity first and then progressively add regions further inland. 1 In traditional CDTI, the community determines everything related to the MDA (i.e., when, where, and by whom). In the modified approach, some aspects are determined by the Ministry of Health at the central level to ensure harmonization across the entire country. In Tanzania, the TZNTDCP determines when drugs and funds will be available and determines a national MDA schedule. In traditional CDTI, different communities within a region/district may choose different dates to suit their specific local conditions; in Tanzania, TZNTDCP plans a schedule so that all districts in an entire region conduct MDA at the same time. 12

13 MDA began in 2000 in districts along the coast where prevalence at the time of mapping was very high; however, treatment was at times interrupted due to lack of funding support. Since regular funding support was initiated by USAID (through ENVISION and APOC) and DFID (through CNTD), MDA campaigns have been an annual feature of the TZNTDCP. The LF MDA package in Tanzania includes IVM and ALB and is distributed once a year. This IVM+ALB package is distributed house to house in all endemic communities by CDDs. Remapping In 2012, CNTD funded a TAS in Mwanza Region, even though treatment with IVM+ALB had never been initiated in the region. Results indicated there was no ongoing transmission. Following consultation with the World Health Organization (WHO) s Africa Regional Office (AFRO) Regional Programme Review Group (RPRG), the TZNTDCP decided to remap the 63 districts where MDA had not yet started, including those in Mwanza Region, with funding from ENVISION and the Task Force for Global Health (TFGH). Results indicated that all 63 districts were below the MDA threshold. This reduced the number of LFendemic districts from 185 to 120 in LF MDA In FY17, MDA was conducted in all 41 ENVISION-supported districts, targeting 7,850,199 people. Of these, 7,688,853 people were treated, with 97.9% program coverage and 82.15% epidemiological coverage. In this MDA round, all districts (i.e., 100%) met epidemiological coverage targets. As the program approaches the 2020 elimination target date, concerted efforts are directed toward providing quality MDA in the remaining districts, with adequate epidemiological coverage. It is projected that only 28 districts (22 ENVISION funded) will need LF MDA in the October 2017 round and only 13 (ENVISION) in the August 2018 round. This will mark significant steps toward the 2020 goals. Optimal coverage is one of the factors that will propel the program to LF elimination. The program has carefully planned the August 2018 MDA to be implemented 10 months after the October 2017 MDA (refer to a detailed justification in the MDA section). This will help streamline MDA rounds back to the original schedule, which was disrupted in 2014 following integration of IVM+ALB with the national immunization campaign. It is thus expected that in FY19, the remaining 10 districts will be due for a pre- TAS and subsequently pass TAS1, and by 2020, all districts will have proceeded to the surveillance phase. LF M&E LF disease-specific monitoring is an ongoing process, and various districts are at different stages of LF elimination. The district is the implementation unit and would typically be monitored at baseline, midterm, and after five MDA rounds. Routine impact assessments and progress monitoring through sentinel and spot-check sites at midterm (i.e., at completion of three rounds of MDA) or pre-tas (after five rounds of MDA) have been implemented if funds are available. To determine TAS eligibility, the post-fifth-round sentinel and spot-check site assessments are conducted in every district in accordance with WHO guidelines. This strategy has allowed Tanzania to monitor programmatic progress as well as to present clear data about TAS eligibility for decision making by the program and the RPRG. To ensure strong program monitoring and to gather data for decision making toward LF elimination, the TZNTDCP s long-term strategy has been to establish two integrated sentinel sites in each new region when treatment starts, to monitor the impact of LF MDA rounds over time and make informed decisions about when to stop MDA. The TZNTDCP recommends that wherever possible, any parasitological sentinel/spot-check site assessment should be integrated and include samples from three NTDs LF, STH, and SCH. When determining where to establish new sentinel and spot-check sites, the TZNTDCP 13

14 uses the disease-specific WHO Guidelines. 2 For LF in each implementation unit, the TZNTDCP selects one village as the sentinel site and one as a spot-check site. Criteria for village selection include (1) stable population, (2) approximately 500 inhabitants or more, and (3) known high LF endemicity or expected low coverage. Within the site, individuals ages five years and older are tested for circulating filarial antigen (CFA). For STH and SCH sites, the TZNTDCP selects two schools in known hightransmission zones and in similar ecological zones. In each school, 50 pupils in Standard (Grade) 3 are examined; techniques used include Kato Katz, urine filtration, and anthropometric measurement. The TZNDTCP conducted TAS1 in 27 districts in July Based on preliminary field results, of the 27 districts, 25 districts achieved criteria for stopping LF MDA. One evaluation unit (EU) consisting of two districts (Chemba and Kondoa DC) did not pass TAS1. In FY17, Kondoa DC split into two districts (Kondoa DC and Kondoa TC), and thus MDA took place in three districts Chemba, Kondoa TC, and Kondoa DC in FY17. Based on the FY16 TAS results (the most recent available), thus far 73 of the 120 LF-endemic districts have met the stopping MDA criteria, and thus 61% of endemic no longer require treatment. Overall, using the FY17 redistricting as a baseline, only 47 districts needed LF MDA in FY17, 41 of which will be treated with ENVISION support and 6 with CNTD support. In FY17, LF TAS2 was conducted in six districts, and all reported CFA levels <2%, signaling sustained interruption of transmission in Newala DC, Newala TC, Mkuranga, Lushoto, Bumbuli, and Muheza. ENVISION provided support for five districts and TFGH supported one district (Muheza). The TAS2 in Muheza, Lushoto, and Bumbuli were integrated with OV monitoring, thus providing useful disease prevalence data for the program that was presented to the Tanzania OV Elimination Expert Advisory Committee (TOEAC) for strategic planning and decision making during the February 2017 meeting. Furthermore, 30 districts are scheduled for a pre-tas in July Of these, it is expected that 24 EUs will be formed for TAS1 in August 2017 in Manyara, Tabora, and Morogoro regions. In Morogoro region, in the nine districts, the TOEAC advised to integrate the TAS1 surveys with OV monitoring using the experience and lessons learned from the previous integrated surveys. The TZNTDCP has received approval from the TFGH for F-TAS" (integrated LF/OV TAS) in one district. The program is currently seeking funding for OV monitoring activities in the remaining eight districts. In FY18, the MOH plans to conduct TAS in a total of 78 districts. There will be 19 TAS1: 6 will be supported by CNTD (Dar es Salaam Region) and 13 TAS1 will be supported by ENVISION. ENVISION will also support 59 TAS2 districts. Among the TAS1 districts are Kondoa TC, Kondoa DC, and Chemba DC, which failed a TAS1 in Prior to TAS1, all 19 districts will undergo a pre-tas (pre-re-tas in the case of Kondoa TC, Kondoa DC, and Chemba DC) to determine if they meet the CFA levels of 2% or less. The 59 districts eligible for TAS2 in FY18 signify a great step in LF elimination efforts in Tanzania. These districts are in the formerly APOC-supported regions of Ruvuma, Mbeya, Iringa, Njombe, and Iringa. MMDP Tanzania has assessed LF morbidity in the Dar es Salaam Region with funding and technical assistance from CNTD. Unfortunately, funding has not been available for LF morbidity burden assessments in the rest of the country. As discussed above, CNTD provided funds and technical assistance for LF morbidity mapping. Volunteers were used to collect information house to house via a questionnaire, using mobile 2 WHO, Global Programme to Eliminate Lymphatic Filariasis. (2012). Monitoring and epidemiological assessment of mass drug administration in the global program to eliminate lymphatic filariasis: A manual for national elimination programs. Geneva. WHO. 14

15 data collection devices. An estimated total of 6,000 patients have been identified. CNTD supported hydrocelectomy for 1,000 patients in 2016 and an additional 500 patients in 2017 in Dar es Salaam via routine hospital-based surgeries and special hydrocelectomy camps in Dar es Salaam. IMA received funding from the Izumi Foundation for hydrocele surgeries in the Mtwara and Lindi regions. The project subsidized surgeries for 1,320 men suffering from hydrocele before the project ended in History of USAID Support In FY10, under the NTD Control Program, USAID started supporting LF MDA (IVM+ALB) in seven regions (Mtwara, Lindi, Coast, Dodoma, Singida, Rukwa, and Katavi), and in FY11 under ENVISION, two additional regions (Tabora and Manyara). In FY16, ENVISION began funding IVM+ALB MDA in addition to school-based PZQ+ALB MDA in the six OV-endemic regions previously supported by APOC. Under ENVISION, integrated LF/STH/SCH sentinel and spot-check site assessments as well as pre-tas and TAS were also carried out. In FY15, in collaboration with TFGH, ENVISION supported LF remapping efforts for 63 districts where no LF MDA had been initiated. b) Trachoma The TZNTDCP s goal is to eliminate blinding trachoma in Tanzania by Mapping for trachoma was completed in 2014, with ENVISION providing funding and technical assistance for grader and enumerator training through our role in the Global Trachoma Mapping Project (GTMP). Through inclusion of Tanzania in the GTMP and electronic data capture during baseline and impact surveys, mapping speed and quality were improved significantly. Based on baseline surveys, a total of 61 districts were trachoma endemic with >5% trachomatous inflammation follicular (TF) prevalence. Following redistricting, the total number of districts estimated to have TF prevalence rates of 5% is 71. By the end of FY15, all districts that require MDA were receiving treatment, thus achieving 100% geographical coverage. As the program interventions took place, some districts achieved TF prevalence rates below 5%, thus achieving the criteria for stopping MDA. In FY17, only 18 endemic districts (25%) needed MDA. To eliminate blindness resulting from trachoma, the SAFE strategy must be implemented for one to five years in districts determined to be endemic (depending on baseline prevalence) before impact surveys are conducted. The TZNTDCP carried out trachoma impact surveys (TISs) in 2009, and then annually since 2012 in various districts. By the beginning of FY17, 53 endemic districts (75%) have reached the criteria for stopping MDA for trachoma (<5% TF). Of the 18 endemic districts where MDA is ongoing in FY17, 6 districts are not yet eligible for TIS; 5 districts had a TIS that resulted in TF prevalence rates of 5% 9.9% and were eligible for one additional MDA round; and 7 had TF prevalence rates of 10% following TIS, requiring three more MDA rounds. By the end of FY17, the TZNTDCP will have completed TIS in nine districts. Tropical Data recently updated the protocol for trachoma surveys. The new protocol requires countries to split districts into EUs of no more than 250,000 population. Since Tanzania has some very populous districts, the nine districts above were split into 12 EUs. Of these, one district, Misungwi, was mapped in 2013 using the GTMP methodology and originally classified as not endemic (TF<5%). A later review of the GTMP data resulted in recategorizing the district as having a TF prevalence >5%. The district was not treated but since more than three years have passed, it was surveyed in late FY17 and had TF prevalence <1%. The remaining 8 districts where TIS was completed were eligible for TAS after the minimum rounds of treatment. Preliminary data indicate that 7 of 8 districts had TF <5% and Kalambo DC has TF of >5% but <10% and will require one more round of treatment. 15

16 Twenty districts will have pre-validation surveillance surveys in August 2017, and those districts will be split into 20 EUs Preliminary results indicate of that of the 20 districts, 18 had TF <5% and two had TF >5% and <10%. ENVISION and the MOH are consulting with the WHO to determine next steps for these districts. In FY18, a total of 14 districts will continue MDA: 6 districts that are not yet eligible for TIS 6 that had TF prevalence rates 5% after failing a TIS in previous years 2 that had TF prevalence 5% after failing a TSS in FY17. In FY18, trachoma surveillance surveys (TSS) are planned in 20 districts (20 EUs) and TIS in 10 districts (12 EUs). Among the 10 districts to undergo TIS, 6 will be eligible for their first impact survey, 3 will be eligible for repeat TIS after MDA, and one will be eligible for TIS following failure of TSS and one round of treatment. Previous experience suggests at least 2 districts surveyed in FY17 will have a prevalence rate of 5% 10%. Looking at the current trend, the TZNTDCP is on track for meeting trachoma 2020 elimination goals. The last two trachoma-endemic districts to undergo TIS will be Kiteto and Simanjiro in FY19. In addition, there is much effort by the TZNTDCP with support from the SAFE/DFID and QEDJT projects (described in the Partner Support section) to reach the ultimate intervention goals for TT surgery. These projects cover Lindi, Mtwara, Dodoma, Arusha, Manyara, and Pwani regions. Through these combined efforts, the TZNTDCP anticipates the TT surgery backlog to be cleared in these regions. However, there is a substantial TT burden in 16 districts that do not have support for TT management; these districts require TT-only surveys to inform planning for TT surgery services. c) Onchocerciasis The TZNTDCP s goal is to eliminate OV by 2025 in line with WHO targets, and as guided by the new WHO guidelines for OV elimination. OV is endemic in 7 foci across 28 districts in 6 regions: Mbeya, Morogoro, Njombe, Ruvuma, Iringa, and Tanga. The CDTI program was launched by APOC in Tanzania in The 7 CDTI foci, comprising 21 districts, were treated with APOC support through a phased scale-up approach: Tanga, Tukuyu, Ruvuma, Tunduru, Mahenge, Kilosa, and Morogoro. By 2009 when three additional districts (Ludewa, Mufindi, and Njombe) were included, the TZNTDCP had moved to an integrated MDA approach and treated all districts in the six regions with IVM+ALB with funding from APOC and, later, ENVISION. Due to redistricting, the number of OV-endemic districts has increased from 23 in FY16 to 28 in FY17; a new region, Songwe, was established in 2016, thus increasing the number of OV-endemic regions from six to seven in FY17. All OV-endemic districts are co-endemic for LF, and since 2009, these districts have received IVM+ALB through annual community-based MDA. From 2009 to 2015, APOC supported OV activities with USAID funding. By FY16, all districts had received 10 to 16 rounds of IVM MDA with effective coverage. In FY16, ENVISION started supporting training, pre-mda, and MDA in the OV-endemic regions. Under APOC support, nine districts in Tanga and Mbeya regions had conducted Phase 1b epidemiological evaluation in 2012 and showed 0% Onchocerca volvulus microfilaremia. However, these districts never had an entomological assessment to ascertain OV prevalence in the vector, Simulium spp. In February 2017, the TZNTDCP had its second meeting of its national elimination committee, the TOEAC. The committee reviewed the progress of the OV program and December 2016 and January 2017 OV elimination surveys, and provided recommendations on the way forward in several key areas related 16

17 to OV elimination. Of note, the TOEAC will advise on next steps for OV treatment (e.g., continued treatment on annual basis, alternate treatment strategy, or stopping MDA) based on the results of any monitoring and mapping activities. Further, the TOEAC recommended that the MOHCDGEC develop a budget and plan for upcoming activities (e.g., monitoring, epidemiological evaluations, entomological evaluations, elimination mapping, MDA), to source necessary funds from the government and other national and international partners. The TOEAC also recommended that the MOHCDGEC develop an OV flag to provide a quick way of identifying the situation in each focus/district and to help with advocacy efforts. The next meeting is planned for February OV MDA In FY17, the program stopped LF MDA in 33 districts across the OV-endemic regions; however, 28 of those districts will continue with district-wide IVM+ALB MDA due to co-endemicity with OV and STH. Due to OV and LF co-endemicity, the TOEAC recommended to continue with MDA until the evaluations for stopping OV MDA can be carried out. However, the program has received limited support so far for epidemiological and entomological evaluations, which are the WHO prerequisites for a decision to stop MDA. Thus, district-wide IVM+ALB MDA rounds will continue in the 18 LF/OV co-endemic districts. Because MDA was delayed until August in FY17 in three districts of Morogoro region, 25 districts will have MDA in October 2017 and 28 districts are planned for August OV M&E The TZNTDCP, with guidance from the TOEAC and funding from ENVISION, implemented its first OV epidemiological assessment survey in Tukuyu focus (Ileje, Rungwe, Busokelo, and Kyela districts) in December A total of 3,198 children, 6 9 years of age, were assessed and 1 (0.03%) was positive (as measured using an OV16 rapid diagnostic test [RDT]). This is a good indicator of progress toward elimination. However, WHO requires definitive results from OV16 enzyme-linked immunosorbent assay (ELISA) analysis for a decision to stop MDA. TFGH has agreed to fund the analysis of the dried blood spot samples in When the results are available, the program will present them to the TOEAC for review and guidance. It is hoped the Tukuyu focus will meet the WHO MDA stopping criteria. Other OV monitoring surveys were conducted with ENVISION funding in Tunduru and Tanga foci in January and February Tunduru s OV16 RDT positivity rate was at 0.4% in the general population (5 years and above). OV16 RDT positivity was 0% and 0.06% in children 6 9 years old in Bumbuli and Lushoto districts, respectively. The Lushoto and Bumbuli OV monitoring surveys were nested in the LF TAS2 and were carried out among primary school pupils in Grades 1, 2, 3, and 4, representing age groups 6 9 years old. In FY18, due to lack of data for decision making in OV elimination, it is proposed that nine districts eligible for TAS 2 also conduct OV monitoring. They include districts in Ruvuma Region (Mbinga DC, Nyasa DC, Madaba DC, Songea DC, Songea Municipal Council [MC], Namtumbo), Iringa Region (Mufindi DC) and in Njombe Region (Ludewa DC and Njombe DC). WHO recommends monitoring OV endemicity after every 4 to 5 years of MDA to determine if a district is ready for stop MDA epidemiological and entomological evaluations. In FY16 and FY17, upon review of available prevalence data, the TOEAC recommended that the Tanzania program routinely collect prevalence data to inform decision making. It was noted in particular that Ruvuma has completed 18 years of MDA ( ), with only 1 Phase 1a epidemiological assessment, which reported 3.4% microfilaremia. This was based on skin-snip microscopy and nodule palpation techniques that are no longer recommended in the new WHO guidelines. Results from these assessments will help inform the TOEAC to provide useful guidance to the program and the MOHCDGEC. 17

18 d) Schistosomiasis SCH was mapped in 2004 through blood-in-urine questionnaires administered to SAC in all districts. Results indicated a high prevalence ( 30%) in 13 districts and a moderate prevalence (>1 and <30%) in 153 districts. It is important to note that this questionnaire provides information about Schistosoma haematobium, but does not provide a baseline profile of S. mansoni. Of the 185 districts that are endemic, 15 are treated annually (high prevalence) and 119 biannually (moderate prevalence) through ENVISION and 51 treated biannually by SCI; other districts are covered by SCI. SCH control efforts target school-age children (SAC) who are enrolled in primary schools as well as the ones who are not enrolled. The TZNTDCP reviewed mapping and sentinel site data to determine a more optimal treatment strategy going forward. The information was presented at the Annual Joint Planning Meeting in June 2017 and provided information down to the ward level. This initial review included analysis of mapping and sentinel and spot-check site data on S. haematobium and S. mansoni, in order to update district and ward endemicity data and shape the treatment strategy. Currently, all districts are either treated annually or biennially, and high-risk adults are not treated. This analysis helped identify which districts can be treated less frequently (twice during a child s school years) and those where a high prevalence in identified foci/communities require treating high-risk adults with PZQ as per WHO protocol for SCH control. SCI is looking into purchasing PZQ for treatment of high-risk adults. Until the new strategy is formally adopted (perhaps before the end of FY17 in SCI-supported areas), the TZNTDCP has been advised to continue to distribute PZQ with ALB in a separate school-based distribution. In districts where community MDA campaigns with IVM and ALB take place, PZQ+ALB will be distributed six months after the community MDA. In districts where there is no community distribution with IVM+ALB, PZQ+ALB will be distributed through school-based MDA campaigns. Currently, 18 districts require annual treatment with PZQ, and 167 districts are treated every other year with PZQ. In off years, districts in the latter category are treated with ALB only. In FY17, all districts having reported data have achieved the treatment target, except one split district, where baseline data are yet to be verified and because the population estimate has not yet been agreed upon. Generally, the program is constantly working to address coverage issues with SCH due to poor denominator estimations. The denominator includes enrolled SAC, who are found in school and can be easily verified, and non-enrolled SAC, who are difficult to enumerate. So the program relies mostly on national population census data to estimate these figures and triangulate them with reported total SAC from the district MDA report. When districts split, it takes times for both parties (parent and new districts) to properly estimate/adjust the number of SAC, thus potentially impacting the coverage being reported. In FY17, SAC estimation considered split districts, and the TZNTDCP triangulated this with available reported data. In the past, treatment coverage has been low in most regions, in part due to overestimation of the denominator as described below in the STH section. The SAC population was previously estimated using a blanket percentage projected from the national population census provided by the National Bureau of Statistics (NBS). As noted in the STH section, district-specific proportions have been applied to estimating SAC, and the TZNTDCP will use these estimations going forward. The TZNTDCP has learned from the coverage and Knowledge, Attitudes, and Practices studies that the primary inhibitor to taking PZQ during MDA is fear of adverse events (AEs). This has led to parents not allowing their children to attend school during MDA days. The program has worked on targeted social mobilization strategies that involve school management committees and parent associations to respond to these myths and attract increased MDA participation. Furthermore, the program requires that a meal be eaten before PZQ MDA in schools. Teachers work with parents to collect food and prepare a meal for 18