COVID-19 and Fake News in the Dominican Republic.

The first case of novel coronavirus disease (COVID-19) in the Dominican Republic coincided with a period of political crisis. Distrust in governmental institutions shaped the critical phase of early response. Having a weak public health infrastructure and a lack of public trust, the Ministry of Health (MoH) began the fight against COVID-19 with a losing streak. Within 45 days of the first reported case, the political crisis and turmoil caused by "fake news" are limiting the capacity and success of the MoH response to the pandemic.

Progress toward elimination of onchocerciasis in the Americas.

The Onchocerciasis Elimination Program for the Americas (OEPA) is a regional initiative and international partnership that has made considerable progress toward its goal since it was launched in 1993. Its strategy is based on mass drug administration of ivermectin (Mectizan, donated by MSD, also known as Merck & Co., Inc., Kenilworth, NJ, USA), twice or four times per year, with at least 85% coverage of eligible populations. From 1989 to 2016, 11 741 276 ivermectin treatments have been given in the Americas, eliminating transmission in 11 of 13 foci. The OEPA's success has had a great influence on programs in Africa, especially Sudan and Uganda, which moved from a control to an elimination strategy in 2006 and 2007, respectively. The successes in the Americas have also greatly influenced WHO guidelines for onchocerciasis transmission elimination. With four of the six originally endemic American countries now WHO verified as having eliminated onchocerciasis transmission, and 95% of ivermectin treatments in the region halted, the regional focus is now on the remaining active transmission zone, called the Yanomami Area, on the border between Venezuela and Brazil. Both countries have difficult political climates that hinder the elimination task in this remote and relatively neglected region. As with other elimination efforts, 'the final inch' is often the most difficult task of all.

After 70 years of fighting an age-old scourge, onchocerciasis in Uganda, the end is in sight.

Onchocerciasis causes severe itching, serious skin disease and ocular damage leading to visual impairment or permanent blindness. It is associated with hanging groin, epilepsy, Nakalanga dwarfism and, most recently, nodding disease. This disease affected communities in 17 transmission foci in 37 districts of Uganda, where about 6.7 million people are once at risk. The efforts against onchocerciasis in Uganda commenced in the late 1940s, when vector control was launched using dichlorodiphenyltrichloroethane; by 1973, Simulium damnosum had been eliminated in the Victoria focus. Success outside of the Victoria focus was short-lived due to changes in government priorities and the political upheavals of the 1970s and 1980s. With the return of political stability, annual treatment with ivermectin through mass drug administration was launched in the early 1990s. Control of the disease has been successful, but there has been failure in interrupting transmission after more than 15 years. In 2007 Uganda launched a nationwide transmission elimination policy based on twice-per-year treatment and vector control/elimination, with a goal of eliminating river blindness nationwide by 2020. By 2017, 1 157 303 people from six foci had been freed from river blindness. This is the largest population ever declared free under World Health Organization elimination guidelines, providing evidence that elimination of river blindness in Africa is possible.

Diagnostics for onchocerciasis in the era of elimination.

In the past few years, efforts to eliminate onchocerciasis from Africa have intensified. These efforts are primarily based on the mass distribution of the anti-helminthic drug Mectizan™ (ivermectin). This program has led to the development of new guidelines by the World Health Organization for the verification that transmission has been suppressed and eventually eliminated. The requirements of diagnostic tools for this purpose differ in many ways from tests used to diagnose infection in individuals. In this review, we summarize the progress that has been made to identify diagnostics that meet the specialized requirements needed to verify onchocerciasis elimination, discuss why these tests were selected and summarize the needs that still exist to complete the arsenal of diagnostic tools that will be useful as the goal of elimination is achieved.

Onchocerciasis in Yemen: moving forward towards an elimination program.

The onchocerciasis focus in Yemen has been known for many years as an endemic area with unique characteristics, notably the atypical and most severe form of onchodermatitis, known as sowda or reactive onchodermatitis (ROD). The national effort to control the disease began in 1992 as an individual case treatment program by administering ivermectin to those presenting with ROD. The challenging geography of the endemic area and the current political and military unrest both underscore a need for special approaches when attempting to eliminate onchocerciasis from this country. An assessment of the national situation regarding this disease was carried out in 2011-2013 aimed at defining the best approach for moving from individual clinical case treatment to elimination of transmission. The history of the control efforts and the current status of the disease are reviewed and the essential changes needed to a mass drug administration (MDA) approach are identified as the national program addresses elimination. Yemen, despite the current troubles, has shown that it can successfully implement MDA programs despite many difficulties and therefore should be supported in its efforts towards countrywide elimination of this infection; however, success will need renewed national and international efforts.

For as Long as Necessary: Examining 30 years of MSD's Focus on Achieving Elimination of Onchocerciasis and Lymphatic Filariasis.

Established by MSD, also known as Merck & Co., Inc., Kenilworth, NJ USA in 1987, the Mectizan Donation Program (MDP) is the longest running disease-specific program of its kind. Initially aimed at control of onchocerciasis (river blindness), the company expanded its commitment through the MDP in 1998 to include lymphatic filariasis (LF). Both diseases are now candidates for elimination and the company is engaged in several global partnerships to help advance towards that goal. To support the steadily growing demand from country-led disease elimination programs, the company has put in place several administrative and operational improvements. In addition, the company is involved 'beyond the pill', including making financial and management contributions to partners such as the END Fund and the Expanded Special Project to Eliminate NTDs (ESPEN) to support the technical needs of elimination programs. While the time-bound elimination targets are challenging, clear progress is being made for both onchocerciasis and LF, with several national and subnational areas in Latin America and Africa having stopped transmission of one or both diseases. The company's donation of Mectizan and contributions of financial, management and technical resources reflect the company's long-standing commitment to pursue inventive ways to expand and enhance access to medicine. Continued support from MSD and other partners will enable countries to advance towards their elimination targets for LF and onchocerciasis.

Assessment of the performance of community-directed treatment with ivermectin strategy for the control and elimination of onchocerciasis in Edo State, Nigeria.

BACKGROUND: Community-directed treatment with ivermectin (CDTI) was developed in the mid 1990's as a solution for the control and elimination of onchocerciasis. It requires that ivermectin be administered continuously over a period of at least 14 years with community involvement before elimination can be achieved. OBJECTIVES: The objective of this study is to assess the performance of CDTI strategy for control and elimination of onchocerciasis in endemic Local Government areas of Edo State. METHODS: A descriptive evaluation in a cross-sectional, descriptive study design was conducted among 720 community members selected from six communities using multistage sampling technique, 11 Community directed distributors (CDDs), and 17 health workers involved in the implementation of the CDTI strategy in Edo State. Primary data were collected using an interviewer's administered questionnaire while secondary data were obtained from the State Ministry of Health. IBM SPSS version 21 software was used for data analysis. RESULTS: The highest therapeutic coverage (95.5%) was observed in Aden II community while the least therapeutic coverage (56.6%) was observed in Imeke community. Regarding the performance indicators, ivermectin supply, work of CDDs, training, monitoring and supervision, finances by communities had scores ≥2.5 and were therefore considered as having satisfactory performance. However, community participation and ownership and health education and mobilization had scores <2.5 and as such considered as having unsatisfactory performance. CONCLUSION: Sustainability of the CDTI program in the study area is likely but not guaranteed as there is need for improvement in areas regarding community mobilization, participation, and ownership.

Programmatic factors associated with the limited impact of Community-Directed Treatment with Ivermectin to control Onchocerciasis in three drainage basins of South West Cameroon.

INTRODUCTION: The CDTI model is known to have enhanced community participation in planning and resource mobilization toward the control of onchocerciasis. These effects were expected to translate into better individual acceptance of the intervention and hence high Treatment Coverage, leading to a sustainable community-led strategy and reduction in the disease burden. A survey revealed that after 10-12 rounds of treatment, prevalence of onchocerciasis was still high in three drainage basins of South West Cameroon and transmission was going on. METHODS: We designed a three (3)-year retrospective (2012, 2013 and 2014), descriptive cross-sectional study to explore the roles of operational challenges in the failure of CDTI to control the disease as expected. We administered 83 semi-structured questionnaires and conducted 12 in-depth interviews with Chiefs of Bureau Health, Chiefs of Centers, CDDs and Community Heads. Descriptive statistics was used to explore indicators of performance which were supported with views from in-depth interviews. RESULTS: We found that community participation was weak; communities were not deciding time and mode of distributions. Only 6 (15.0%) of 40 Community Drug Distributors reported they were selected at general community meetings as required. The health service was not able to meet and discuss Community-Directed Treatment with Ivermectin activities with individual communities partly due to transportation challenges; this was mostly done through letters. Funding was reported to be inadequate and not timely. Funds were not available to conduct Community-Self Monitoring after the 2014 Mass Drug Administration. There was inadequate health staff at the frontline health facility levels, and some Chiefs of Center reported that Community-Directed Treatment with Ivermectin work was too much for them. The mean operational Community Drug Distributor-population ratio was 1 Community Drug Distributor per 317 populations (range: 194-464, expected is 1:250). Community Drug Distributor attrition rate was 14% (2012), 11% (2013) and 12% (2014) of total Community Drug Distributors trained in the region. Lack of incentive for Community Drug Distributor was primary reason for Community Drug Distributor attrition. Number of Community Drug Distributors trained together by health area ranged from 14 to 127 (mean ± SD = 51 ±32) with duration of training ranging from 4-7 hours (mean ± SD = 5.05 ± 1.09). The trainings were conducted at the health centers. Community Drug Distributors always conducted census during the past three distributions (Mean ± SD = 2.85 ± 0.58). Community-Self Monitoring was facing challenge. Several of the community heads, Chiefs of Bureau Health and Chiefs of Center agreed that Community-Self Monitoring was not being carried out effectively due to lack of incentives for monitors in the communities. CONCLUSION: Inadequate human resource, funding issues and transportation challenges during distribution periods reduced the ability of the health service to thoroughly sensitize communities and supervise CDTI activities. This resulted in weak community understanding, acceptance and participation in the process. CDTI in our study area did not achieve sustainable community-led campaign and this may have led to the reduced impact on Onchocerciasis.

Onchocerciasis control in the Democratic Republic of Congo (DRC): challenges in a post-war environment.

OBJECTIVE: To evaluate onchocerciasis control activities in the Democratic Republic of Congo (DRC) in the first 12 years of community-directed treatment with ivermectin (CDTI). METHODS: Data from the National Programme for Onchocerciasis (NPO) provided by the National Onchocerciasis Task Force (NOTF) through the annual reports of the 21 CDTI projects for the years 2001-2012 were reviewed retrospectively. A hypothetical-inputs-process-outputs-outcomes table was constructed. RESULTS: Community-directed treatment with ivermectin expanded from 1968 communities in 2001 to 39 100 communities by 2012 while the number of community-directed distributors (CDD) and health workers (HW) multiplied. By 2012, there were ratios of 1 CDD per 262 persons and 1 HW per 2318 persons at risk. More than 80% of the funding came from the fiduciary funds of the African Programme for Onchocerciasis Control. The cost of treatment per person treated fell from US$ 1.1 in 2001 to US$ 0.1 in 2012. The therapeutic coverage increased from 2.7% (2001) to 74.2% (2012); the geographical coverage, from 4.7% (2001) to 93.9% (2012). Geographical coverage fell in 2005 due to deaths in loiasis co-endemic areas, and the therapeutic coverage fell in 2008 due to insecurity. CONCLUSIONS: Challenges to CDTI in DRC have been serious adverse reactions to ivermectin in loiasis co-endemic areas and political conflict. Targets for personnel or therapeutic and geographical coverages were not met. Longer term funding and renewed efforts are required to achieve control and elimination of onchocerciasis in DRC.

Elimination of African onchocerciasis: modeling the impact of increasing the frequency of ivermectin mass treatment.

The African Programme for Onchocerciasis Control (APOC) is currently shifting its focus from morbidity control to elimination of infection. To enhance the likelihood of elimination and speed up its achievement, programs may consider to increase the frequency of ivermectin mass treatment from annual to 6-monthly or even higher. In a computer simulation study, we examined the potential impact of increasing the mass treatment frequency for different settings. With the ONCHOSIM model, we simulated 92,610 scenarios pertaining to different assumptions about transmission conditions, history of mass treatment, the future mass treatment strategy, and ivermectin efficacy. Simulation results were used to determine the minimum remaining program duration and number of treatment rounds required to achieve 99% probability of elimination. Doubling the frequency of treatment from yearly to 6-monthly or 3-monthly was predicted to reduce remaining program duration by about 40% or 60%, respectively. These reductions come at a cost of additional treatment rounds, especially in case of 3-monthly mass treatment. Also, aforementioned reductions are highly dependent on maintained coverage, and could be completely nullified if coverage of mass treatment were to fall in the future. In low coverage settings, increasing treatment coverage is almost just as effective as increasing treatment frequency. We conclude that 6-monthly mass treatment may only be worth the effort in situations where annual treatment is expected to take a long time to achieve elimination in spite of good treatment coverage, e.g. because of unfavorable transmission conditions or because mass treatment started recently.

Ivermectin to reduce malaria transmission: a research agenda for a promising new tool for elimination.

BACKGROUND: The heterogeneity of malaria transmission makes widespread elimination a difficult goal to achieve. Most of the current vector control measures insufficiently target outdoor transmission. Also, insecticide resistance threatens to diminish the efficacy of the most prevalent measures, indoor residual spray and insecticide treated nets. Innovative approaches are needed. The use of endectocides, such as ivermectin, could be an important new addition to the toolbox of anti-malarial measures. Ivermectin effectively targets outdoor transmission, has a novel mechanism of action that could circumvent resistance and might be distributed over the channels already in place for the control of onchocerciasis and lymphatic filariasis. METHODS: The previous works involving ivermectin and Anopheles vectors are reviewed and summarized. A review of ivermectin's safety profile is also provided. Finally three definitive clinical trials are described in detail and proposed as the evidence needed for implementation. Several smaller and specific supportive studies are also proposed. CONCLUSIONS: The use of ivermectin solves many challenges identified for future vector control strategies. It is an effective and safe endectocide that was approved for human use more than 25 years ago. Recent studies suggest it might become an effective and complementary strategy in malaria elimination and eradication efforts; however, intensive research will be needed to make this a reality.

Towards elimination of lymphatic filariasis: social mobilization issues and challenges in mass drug administration with anti-filarial drugs in Tamil Nadu, South India.

India is a signatory to World Health Assembly resolution for elimination of lymphatic filariasis (LF) and National Health Policy has set the goal of LF elimination by 2015. Annual mass drug administration (MDA) is ongoing in endemic districts since 1996-97. Compliance rate is a crucial factor in achieving elimination and was assessed in three districts of Tamil Nadu for 10th and 11th treatment rounds (TRs). An in-depth study assessed the impact of social mobilization by drug distributors (DDs) in two areas from each of the three districts. Overall coverage and compliance for assessed TRs were 76.3 and 67.7% which is below the optimum level to achieve LF elimination. Modifiable determinants continue to be the reason for non-consumption even in the 11th TR and 20.8% were systematic non-compliers. In 76.4% of the cases, DDs failed to adhere to three mandatory visits as per the guidelines. Number of visits by DDs in relation to low and high MDA coverage areas showed a significant relationship (P ≤ 0.000). MDA is limited to drug distribution alone and efforts by DDs in preparing the community were inadequate. Probable means to meet the challenges in preparation of the community is discussed.

Maintaining effective mass drug administration for lymphatic filariasis through in-process monitoring in Sierra Leone.

BACKGROUND: Since 2007 Sierra Leone has conducted mass drug administration (MDA) for the elimination of lymphatic filariasis (LF) implemented by unpaid community health volunteers (CHVs). Other health campaigns such as Mother and Child Health Weeks (MCHW) pay for services to be implemented at community level and these persons are then known as community health workers (CHWs). In 2010, the LF MDA in the 12 districts of the Southern, Northern and Eastern Provinces un-expectantly coincided with universal distribution of Long Lasting Insecticide Treated Nets (LLITNs) during the MCHW. In-process monitoring of LF MDA was performed to ensure effective coverage was attained in hard to reach sites (HTR) in both urban and rural locations where vulnerable populations reside. METHODS: Independent monitors interviewed individuals eligible for LF MDA and tallied those who recalled having taken ivermectin and albendazole, calculated program coverage and reported results daily by phone. Monitoring of coverage in HTR sites in the 4 most rapidly urbanizing towns was performed after 4 weeks of LF MDA and again after 8 weeks throughout all 12 districts. End process monitoring was performed in randomly selected HTR sites not previously sampled throughout all 12 districts and compared to coverage calculated from the pre-MDA census and reported treatments. RESULTS: Only one town had reached effective program coverage (≥80%) after 4 weeks following which CHWs were recruited for LF MDA in all district headquarter towns. After 8 weeks only 4 of 12 districts had reached effective coverage so LF MDA was extended for a further month in all districts. By 12 weeks effective program coverage had been reached in all districts except Port Loko and there was no significant difference between those interviewed in communities versus households or by sex. Effective epidemiological coverage (≥65%) was reported in all districts and overall was significantly higher in males versus females. CONCLUSIONS: The challenges to LF MDA included the late delivery in country of ivermectin, the availability and motivation of unpaid CHVs, concurrent LLITN distribution and the MCHW, remuneration for CHWs, rapid urbanization and employment seeking population migrations. 'In process' monitoring ensured modifications of LF MDA were made in a timely manner to ensure effective coverage was finally attained even in HTR locations.

Mectizan(®) procurement and delivery for onchocerciasis mass drug administration programmes.

The discovery of Mectizan has engendered a safe onchocerciasis chemoprevention tool. To make the drug available promptly to people at risk of onchocerciasis, a procurement and delivery mechanism has been put in place around the Mectizan Donation Program, which oversees the Merck donation of Mectizan. The number of yearly approved treatment doses has increased rapidly since 1988 from 255,000 to more than 80 million in 2007 and 2008. Cumulatively, from 1987 to 2008 more than 697 million treatment doses have been approved corresponding to 1.5 billion Mectizan tablets shipped. Although the current demand for treatment is met, the ultimate goal is to cover all people at risk. A comprehensive drug policy from recipient countries is still needed to back up the current efficient procurement and delivery mechanism in order to attain the ultimate to goal, and is equally important for scaling up mass drug administration as part of national neglected tropical disease control/elimination strategies.

Community-directed interventions for priority health problems in Africa: results of a multicountry study.

OBJECTIVE: To determine the extent to which the community-directed approach used in onchocerciasis control in Africa could effectively and efficiently provide integrated delivery of other health interventions. METHODS: A three-year experimental study was undertaken in 35 health districts from 2005 to 2007 in seven research sites in Cameroon, Nigeria and Uganda. Four trial districts and one comparison district were randomly selected in each site. All districts had established ivermectin treatment programmes, and in the trial districts four other established interventions - vitamin A supplementation, use of insecticide-treated nets, home management of malaria and short-course, directly-observed treatment for tuberculosis patients - were progressively incorporated into a community-directed intervention (CDI) process. At the end of each of the three study years, we performed quantitative evaluations of intervention coverage and provider costs, as well as qualitative assessments of the CDI process. FINDINGS: With the CDI strategy, significantly higher coverage was achieved than with other delivery approaches for all interventions except for short-course, directly-observed treatment. The coverage of malaria interventions more than doubled. The district-level costs of delivering all five interventions were lower in the CDI districts, but no cost difference was found at the first-line health facility level. Process evaluation showed that: (i) participatory processes were important; (ii) recurrent problems with the supply of intervention materials were a major constraint to implementation; (iii) the communities and community implementers were deeply committed to the CDI process; (iv) community implementers were more motivated by intangible incentives than by external financial incentives. CONCLUSION: The CDI strategy, which builds upon the core principles of primary health care, is an effective and efficient model for integrated delivery of appropriate health interventions at the community level in Africa.

GlaxoSmithKline and Merck: private-sector collaboration for the elimination of lymphatic filariasis.

More than 1000 million people in 82 countries are at risk of contracting the tropical disease lymphatic filariasis (LF). Although the disease is wide-spread, transmission of the causative parasites can be stopped through mass drug administrations based on a combination of anti-parasitic medicines. For more than 10 years, the pharmaceutical companies GlaxoSmithKline (GSK) and Merck & Co., Inc., have participated in a unique private-sector collaboration to support the global efforts to eliminate LF, through donations of drugs to prevent the disease. GSK's albendazole and Merck's ivermectin (Mectizan) now reach hundreds of millions of people each year, through national LF-elimination programmes carried out in collaboration with Ministries of Health, the World Health Organization, non-governmental organizations and local communities. Working in support of the Global Programme to Eliminate Lymphatic Filariasis, GSK and Merck not only provide donated medicines but also offer financial, programmatic and management expertise to support LF-elimination efforts worldwide.

The Global Programme to Eliminate Lymphatic Filariasis: health impact during its first 8 years (2000-2007).

During its first 8 years, the Global Programme to Eliminate Lymphatic Filariasis provided more than 1900 million treatments with antifilarial drugs (albendazole, ivermectin and diethylcarbamazine) to at least 570 million people in 48 countries with endemic lymphatic filariasis (LF). As a result of this impressive global effort and an unprecedented public-private partnership, 8 years of mass drug administration (MDA) have prevented the spread of filarial infection to an estimated 6.6 million newborns, stopped the progression to clinical morbidity in 9.5 million individuals already infected with the parasites that cause LF, and drastically reduced the burden of several co-infections. The resulting health benefits of the MDA, in terms of reduced morbidity and disability-adjusted life-years, are thus enormous. The next step should be an analysis of the Global Programme's economic impact from its first 8 years of MDA.

The Mectizan Donation Program: 20 years of successful collaboration - a retrospective.

Merck is a global research-driven pharmaceutical company that, throughout its history, has devoted considerable effort to bringing its medicines, vaccines, expertise and experience to people in need around the world. Its primary responsibilities are: to discover, develop and deliver innovative medicines and vaccines that address major burdens of illness globally and/or address specific poor or vulnerable groups; to develop long-term business models that help its products reach as many people as possible; and to promote and participate in partnerships with governments, multilateral and non-governmental organizations, other private-sector organizations and communities, to build healthcare capacity and to address specific health and development challenges around the world. Merck believes that responding to global health challenges is a strategic and humanitarian necessity and that, through public-private partnerships, significant progress can be achieved. Twenty years ago, in October 1987, before collaboration between public and private sectors was common, Merck launched the Mectizan Donation Program (MDP) - a unique, multisectoral coalition involving Merck, the Mectizan Expert Committee (MEC), the Task Force for Child Survival and Development, the World Health Organization (WHO), the World Bank, the United Nations Children's Fund, national ministries of health, more than 35 non-governmental development organizations, and thousands of local community healthworkers - to treat a debilitating, disfiguring and often blinding disease called onchocerciasis (river blindness). Through this programme, Merck made the commitment to donate Mectizan (ivermectin) for as long as needed and wherever needed, to combat this disease. Since the MDP's inception in 1987, Merck has donated >1800 million tablets of Mectizan, with >530 million treatments for onchocerciasis administered since 1987. The programme currently reaches >68 million people in Africa, Latin American and Yemen annually, via community-based treatment programmes in 125,000 communities in 33 endemic countries. This 20-year-old effort has achieved a number of notable results, including positive health impacts, economic benefits, strengthened health systems, and the empowerment of communities where the delivery and administration of Mectizan are managed. The MDP serves as a model for similar health programmes in the developing world and has also laid the foundation for the current integration efforts around 'neglected' tropical diseases. It has also taught the world many valuable lessons - about how to mobilize resources to address significant health challenges - and has demonstrated that it is possible, through public-private partnerships, to deliver healthcare to long-neglected populations, despite seemingly insurmountable obstacles including inadequate financial and human resources, lack of social, economic and health infrastructures, civil unrest and political strife, and competing, high-priority health issues.

The NGDO Co-ordination Group for Onchocerciasis Control.

Since the beginning of the donation of Mectizan by Merck & Co., Inc., non-governmental development organizations (NGDO) have been actively involved in the mass distribution of this drug to control onchocerciasis. In 2006, the network of NGDO involved in onchocerciasis control assisted in the treatment of over 62 million people. The current strategy that is used for distribution in Africa, community-directed treatment with ivermectin (CDTI), is very well suited for integration with other health activities. NGDO have been the pioneers in integrating comprehensive eye care, insecticide-treated nets for malaria, the control of multiple 'neglected' tropical diseases, and vitamin-A supplementation. These expanded activities bring with them new challenges, which need to be addressed by all partners and where the NGDO will play an active role.

The Mectizan Donation Program (MDP).

The launch of the Mectizan Donation Program (MDP) in 1987, by Merck & Co., Inc., created a number of new opportunities for onchocerciasis control. The microfilaricide Mectizan was rapidly put to ?use by the Onchocerciasis Control Programme in West Africa (OCP), for mass treatment by field teams in selected areas. Other milestones in Mectizan treatment included the establishment, in 1992, of the Onchocerciasis Elimination Program for the Americas, and the creation of the African Programme for Onchocerciasis Control (APOC) in 1995, the latter programme covering all African countries in need outside of the OCP area. In 1998, the donation of Mectizan was expanded to include the treatment of lymphatic filariasis in those African countries where that disease is co-endemic with onchocerciasis. In the past, the development of a broad partnership around the MDP played a very important role, including non-governmental development organizations collaborating with the ministries of health in endemic countries. A new community-directed treatment strategy, which made it easier to reach out to all those in need, including those in remote areas, was developed by the APOC in collaboration with the World Health Organization's Special Programme for Research and Training in Tropical Diseases (TDR). Several drug-management issues, including dosing, shelf-life, safety, and the reporting of severe adverse experiences, were addressed by the MDP, through its Mectizan Expert Committee, and by Merck & Co., Inc. A major research effort for the safe treatment of onchocerciasis in loiasis-endemic areas has also been supported by the MDP. Presently there are national programmes for Mectizan mass treatment in all 33 endemic countries in need of such treatment; >69 million Mectizan treatments for onchocerciasis were provided during 2006, and this number is expected to grow to at least 100 million treatments/year by 2010. This achievement has resulted in great public-health and socio-economic benefits for the populations concerned. Future challenges will include additional support to 'fragile states' resulting from conflicts or natural disasters, and the need for a strengthened primary healthcare (PHC) infrastructure. The community-directed-treatment approach has been a great success but there is still a need to link the treatments to PHC, for the long-term sustainability of the treatments. The presence of loiasis in vast areas of Central Africa imposes a need for the mapping of that disease, and the application of safety precautions when distributing Mectizan in those areas. The recent decision to extend the APOC up to 2015 should facilitate the building of sustainable Mectizan treatment programmes that are integrated with the control of other neglected tropical diseases, such as lymphatic filariasis, intestinal helminths and trachoma. It will be important to define the safe end-point for Mectizan treatment in various settings, and an ongoing study by TDR will address this issue. There is also a need to consider the application of more frequent Mectizan treatments, possibly with adjunct measures, such as ground-based vector control in selected areas, or new chemotherapeutic approaches (as and when they become available).