Review of the factors influencing the motivation of community drug distributors towards the control and elimination of neglected tropical diseases (NTDs)

Barriers and facilitators to programmatic mass drug administration in persistent schistosomiasis hotspot communities: An ethnographic study along Lake Albert, midwestern Uganda

BACKGROUND

The WHO Neglected Tropical Disease Roadmap for 2021-2030 includes the goal of eliminating schistosomiasis as a public health problem in all endemic countries. Despite heightened efforts since 2012, critical action is still required in addressing barriers to Mass Drug Administration, the primary control method. This includes improvement in adherence by the populations in persistent schistosomiasis hotspots. One such hotspot is the shoreline of Lake Albert, Uganda, where schistosomiasis control is provided to school-aged children and adults. An overemphasis on regular treatment, without comprehensively addressing factors that result in low uptake of treatment in these high-risk populations is likely to impact the elimination of schistosomiasis as a public health problem.

METHODS

An ethnographic study using in-depth interviews, key informant interviews, focus group discussions and participant observation was conducted at two study sites along Lake Albert. Thematic content analysis was used during data analysis.

RESULTS

The study revealed that the size, taste and smell of the drug, along with its side-effects; poor community integration and occupational behaviour resulting in non-mobilisation; and unfounded rumours and beliefs remain reasons for persistent low uptake of praziquantel by some. Conversely, lived experience of improved health through participation and knowledge of the dangers of the disease if not treated, facilitated treatment uptake. Positive attitudes to localised sensitisation by community drug distributors show social influence facilitates crucial knowledge attainment. Treatment uptake is further facilitated by the delivery of the drug at no cost at home. Crucially, for the majority of participants the facilitating factors were found to outweigh the inhibitory factors related to the drug's side effects.

CONCLUSION

We recommend a good community engagement strategy that provides continuous education and sensitisation, with improved recruitment and training provision for Community Drug Distributors to facilitate programme reach to groups with current poor engagement.

A Mixed-Methods Evaluation of Mainstreaming Mass Drug Administration for Schistosomiasis and Soil-Transmitted Helminthiasis in Four Districts of Nigeria

In Nigeria, mass drug administration (MDA) for schistosomiasis (SCH) and soil-transmitted helminthiasis (STH) has often been coordinated with other programs that receive greater external funding. As these programs reach stop MDA milestones, SCH and STH programs will likely need to transition implementation, or "mainstream," to domestic support. A mixed-methods study was conducted in four districts before (2021) and after (2022) mainstreaming to evaluate its impact on MDA coverage. Household surveys were done in 30 villages per district pre- and post-mainstreaming. All selected communities were eligible for STH treatment; around a third were eligible for SCH treatment. Mass drug administration was primarily conducted in schools. A total of 5,441 school-aged children were included in pre-mainstreaming and 5,789 were included in post-mainstreaming. Mass drug administration coverage was heterogeneous, but overall, mebendazole coverage declined nonsignificantly from 81% pre-mainstreaming to 76% post-mainstreaming (P = 0.09); praziquantel coverage declined significantly from 73% to 55% (P = 0.008). Coverage was significantly lower among unenrolled children or those reporting poor school attendance in nearly every survey. For the qualitative component, 173 interviews and 74 focus groups were conducted with diverse stakeholders. Respondents were deeply pessimistic about the future of MDA after mainstreaming and strongly supported a gradual transition to full government ownership. Participants formulated recommendations for effective mainstreaming: clear budget allocation by governments, robust and targeted training, trust building, and comprehensive advocacy. Although participants lacked confidence that SCH and STH programs could be sustained after reductions in external support, initial results indicate that MDA coverage can remain high 1 year into mainstreaming.

Availability and readiness of health facilities providing services for other infectious diseases to treat neglected tropical diseases in Ethiopia: implications for service integration in high burden areas

BACKGROUND

The burden of neglected tropical diseases (NTDs), HIV/AIDS, tuberculosis, and malaria pose significant public health challenges in Ethiopia. This study aimed to the explore service availability and readiness for NTD care among Ethiopian health facilities treating tuberculosis (TB), HIV/AIDS, and/or malaria.

METHODS

This study utilized secondary data from the Ethiopian Service Provision Assessment 2021-22 survey. The availability of services was calculated as the percentage of HIV/AIDS, tuberculosis, or malaria facilities providing NTD services. Facilities were considered highly prepared to manage any type of NTD if they scored at least half (> 50%) of the tracer items listed in each of the three domains (staff training and guidelines, equipment, and essential medicines). Descriptive statistics and logistic regression models were employed to present the study findings and analyze factors influencing facility readiness, respectively.

RESULTS

Out of 403 health facilities providing NTD care nationally, 179, 183, and 197 also offer TB, HIV/AIDS, and malaria services, respectively. The majority of TB (90.1%), HIV/AIDS (89.6%), and malaria (90.9%) facilities offer soil-transmitted helminth services, followed by trachoma (range 87-90%). The percentages of the aforementioned facilities with at least one trained staff member for any type of NTD were 87.2%, 88.4%, and 82.1%, respectively. The percentage of facilities with guidelines for any type of NTD was relatively low (range 3.7-4.1%). Mebendazole was the most widely available essential medicine, ranging from 69 to 70%. The overall readiness analysis indicated that none of the included facilities (TB = 11.9%; HIV/AIDS = 11.6%; and malaria = 10.6%) were ready to offer NTD care. Specifically, a higher level of readiness was observed only in the domain of medicines across these facilities. Hospitals had better readiness to offer NTD care than did health centers and clinics. Furthermore, a significant associations were observed between facility readiness and factors such as facility type, region, presence of routine management meetings, types of NTD services provided, and fixed costs for services.

CONCLUSIONS

Ethiopian health facilities treating TB, HIV/AIDS, and malaria had an unsatisfactory overall service availability and a lack of readiness to provide NTD care. Given the existing epidemiological risks and high burden of TB, HIV/AIDS, malaria, and NTDs in Ethiopia, there is an urgent need to consider preparing and implementing a collaborative infectious disease care plan to integrate NTD services in these facilities.

Community Involvement in Onchocerciasis Post-elimination Surveillance in Bududa District, Eastern Uganda: A cross-sectional study

BACKGROUND

Globally, there are an estimated 20.9 million cases of onchocerciasis, with Africa bearing the greatest burden. The World Health Organization (WHO) has targeted the disease for elimination by 2030. As of August 2023, there were 15 foci in 37/48 (76%) districts and one city in Uganda that had reached the elimination phase. However, there is a paucity of data on community involvement in post-elimination surveillance (PES) activities. The communities in the post-elimination phase are expected to maintain surveillance, provide health education, refer cases for treatment, and participate in surveillance. However, it is not clear whether this is being done. In this study, we assessed the feasibility of community involvement in post-elimination surveillance activities in Bududa District, Eastern Uganda, to draw key generalisable lessons for similar settings.

METHODS

This was a cross-sectional study employing rigorous mixed methods of data collection. We used a semi-structured questionnaire to collect quantitative data on randomly sampled study participants in two sub-countries in the district. Community involvement in post-elimination surveillance (PES) was our dependent variable, measured using Yes or No questions, and our independent variables were measured on different scales. Computations of proportions and associations were done using Stata 15 software. Conversely, qualitative data were collected via focus group discussions (FGDs) for community participants and key informant interviews (KIIs) for local leaders. For the qualitative component, we had 2 FGDs, each consisting of 8 gender-balanced participants per group and 8 KIIs. Qualitative data analyses were done using a robust thematic framework approach, ensuring the reliability and validity of our findings.

RESULTS

A total of 422 participants with a mean age of 51.4 years (SD = 15.8) participated in the study. Community involvement in post-elimination surveillance was low (14%). Factors associated with involvements were district support [Adjusted odd ratio AOR 14, 95 CI = (2.5, 81.7)], seeing black flies in the environment in a week preceding the survey [AOR 8, 95% CI = (1.5, 42.5)], in one month [AOR 3.8, 95% CI = (1.1, 13.2)], and being a community volunteer in the Ivermectin treatment program [AOR 4.3, 95% CI = (1.03, 17.9)]. Lack of funding, poor motivation, poor program sustainability planning, and a lack of drugs at health facilities were key challenges affecting community involvement in post-elimination surveillance.

CONCLUSION

Community involvement in onchocerciasis post-elimination surveillance activities in Bududa District in Eastern Uganda was low but could be improved by increased district support, funding, community motivation and sensitisation.

Community preferred drug delivery approaches for pilot roll-out of a potential novel paediatric schistosomiasis treatment option in two endemic counties of Kenya: A mixed methods study

Treating preschool age children (PSAC) for schistosomiasis has remained a challenge due to lack of a pediatric formulation. In response to this unmet need, the Paediatric Praziquantel Consortium has developed a potential novel paediatric treatment option. In advance to its roll-out to follow regulatory response, we conducted a social science study to gather information on preferred drug delivery approaches to inform implementation. A cross-sectional study was conducted in eight villages in two purposively selected Kenyan counties. A questionnaire was administered on 690 parents/guardians of PSAC at household level. Preferred drug delivery approaches were analyzed using frequencies and proportions. We conducted key informant interviews with 17 opinion leaders and 28 healthcare workers, and 12 focus group discussions with parents/guardians of PSAC and 7 with community health volunteers (CHVs). Thematic analysis was performed on the qualitative data. Majority of the 690 respondents were women 594 (86.1%) with a mean age of 34.1 (SD = 11.3, min-max = 18-86). Community-based mass drug administration (cMDA) was the most preferred drug delivery method by 598 participants (86.7%), followed by health facility/fixed points by 398 participants (57.7%). Similarly, in the qualitative data participants indicated they prefer cMDA since the CHVs who would distribute the medication are familiar with households with PSAC and are trusted to explain the drug effects. Health facilities/fixed points were the second most preferred drug delivery approach, but some health workers we interviewed expressed concern about potential understaffing and overcrowding of facilities. Appropriate timing of the drug distribution, not to interfere with farming activities, was considered critical, irrespective of the approach used. All profiles of study participants preferred cMDA over the other delivery approaches due to the convenience of receiving drugs at home and providing explanations about the new drug. For positive outcomes, adequate planning, proper timings and community involvement are highly recommended.

Synthesis of findings from the literature and a qualitative research study on the impacts of gender, disability, and ethnicity in Neglected Tropical Diseases programs

INTRODUCTION

Act to End NTDs | West, a USAID-funded program that supports national governments to eliminate or control five neglected tropical diseases (NTDs) in West Africa including trachoma, lymphatic filariasis (LF), onchocerciasis, schistosomiasis and soil-transmitted helminthiasis, conducted a gender and social inclusion analysis to determine how NTDs differentially impact various populations and how gender and social norms impact NTD programs to inform future programming.

METHODS

The study used a mixed methods approach including a literature review; primary qualitative data collection; and monitoring data in Côte d'Ivoire, Sierra Leone, and Ghana.

RESULTS

Women and girls face additional health risks from many NTDs compared to men and boys. In addition to differential health burden, the social and economic impacts of NTD-related disability or infertility can be particularly dire for women and girls. Men were somewhat less likely to participate in mass drug administration (MDAs) due to: lack of information about campaigns, lack of access due to work, and higher levels of mistrust of the government and concerns about side effects of the medicines. Pregnant and breastfeeding women were sometimes excluded by community drug distributors (CDDs) from certain types of MDAs for which they are eligible. Training participation rates for CDDs and supervisors were nearly universally higher for men than women, even though feedback on the effectiveness of female CDDs was overwhelmingly positive, and female CDDs often have more access to other women in conservative households. The role of a CDD can lead to career and social opportunities for women. However, challenges faced by CDDs were seen as a greater barrier for women, including transportation, safety, household responsibilities, lower education levels, and low or lack of wages.

DISCUSSION

Programs to address NTDs can promote equity and improve programming by increasing women's participation as CDDs and providing financial compensation. Additionally, programs should prioritize inclusive training for CDDs, and inclusive messaging about MDA for communities.

Perceptions of the roles, impact, challenges and needs of community drug distributors in the control and elimination of neglected tropical diseases in difficult-to-access communities in Ghana

INTRODUCTION

The success of mass drug administration (MDA) campaigns to control and eliminate neglected tropical diseases (NTDs) in Ghana depends, to a large extent, on the essential role community drug distributors (CDDs) play. This study aimed to investigate community's perceptions of CDDs' roles, impact of CDDs' work, challenges faced by CDDs, and views on resources required to enhance CDDs' work to sustain MDA campaigns.

METHODS

A cross-sectional qualitative study employing the use of focus group discussions (FGDs) with community members and CDDs in selected NTD endemic communities together with individual interviews with district health officers (DHOs) was conducted. We interviewed 104 people aged 18 and over, purposively selected, through eight individual interviews, and 16 focus group discussions.

RESULTS

Participants in the community FGDs noted that health education and the distribution of drugs were the main roles of CDDs. Participants also perceived that the work of CDDs had prevented the onset of NTDs, treated symptoms of NTDs, and generally reduced the incidence of infections. In the interviews with CDDs and DHOs, lack of cooperation/non-compliance by community members, demands by community members, lack of working resources and low financial motivation were mentioned as the main challenges to the work of CDDs. Moreover, the provision of logistics and financial motivation for CDDs were identified as factors that will enhance their work.

CONCLUSIONS

Incorporating more attractive schemes will incentivise CDDs to improve output. Addressing the challenges highlighted is an important step for the work of CDDS to be effective in controlling NTDs in difficult-to-access communities in Ghana.

Role and capacity needs of community based surveillance volunteers in the integrated management of skin neglected tropical diseases (skin NTDs): a qualitative study from central Ghana

BACKGROUND

Community Based Surveillance Volunteers (CBSVs) have been instrumental in the management of Neglected Tropical Diseases (NTDs) but a concern that their services in scale up programmes may be affected due to high attrition rates has been widely acknowledged. We explored the roles and capacity needs of existing CBSVs to inform for a successful integrated NTD management programme in Ghana and similar contexts.

METHODS

We conducted qualitative interviews with 50 CBSVs, 21 Community Nurses, 4 Disease control officers, 7 skin NTD researchers, 2 skin NTD patients and a Director of District Health Services in Central Ghana. Interviews were digitally recorded, transcribed and coded prior to translation and thematic analysis.

RESULTS

The roles of CBSVs in NTD management were shown to have an impact on disease identification, surveillance, health seeking behaviours and status of CBSVs. Lack of motivation, inadequate structures for engagement of CBSVs within the health system and delayed management of reported cases were identified as gaps that hinder effective delivery of CBSV roles. Provision of incentives as recognition for the unpaid services rendered by CBSVs was seen as a major factor to reduce the rate of CBSV attrition in this scale up programme. Other factors included the formulation of policies by government to guide CBSV engagement, regular training of CBSV in NTD management as well as provision of resources and logistics.

CONCLUSION

Measures including continuous training, institution of rewards and incentivization are important for ensuring the sustainability of CBSVs in the provision of skin NTD services in Ghana.

Behaviour change interventions for the control and elimination of schistosomiasis: A systematic review of evidence from low- and middle-income countries

BACKGROUND

For the last two decades, schistosomiasis control efforts have focussed on preventive treatment. The disease, however, still affects over 200 million people worldwide. Behaviour change (BC) interventions can strengthen control by interrupting transmission through modifying exposure behaviour (water contact) or transmission practices (open urination/defaecation); or through fostering treatment seeking or acceptance. This review examines these interventions to assess their effectiveness in modifying risk practices and affecting epidemiological trends.

METHODOLOGY/PRINCIPAL FINDINGS

A systematic multi-database literature search (PROSPERO CRD42021252368) was conducted for peer-reviewed publications released at any time before June 2021 assessing BC interventions for schistosomiasis control in low- and middle-income countries. 2,593 unique abstracts were identified, 66 were assigned to full text review, and 32 met all inclusion criteria. A typology of intervention models was outlined according to their use of behaviour change techniques and overarching rationale: health education (HEIs), social-environmental (SEIs), physical-environmental (PEIs), and incentives-centred interventions (ICIs). Available evidence does not allow to identify which BC approach is most effective in controlling risk behaviour to prevent schistosomiasis transmission. HEIs' impacts were observed to be limited by structural considerations, like infrastructure underdevelopment, economic obligations, socio-cultural traditions, and the natural environment. SEIs may address those challenges through participatory planning and implementation activities, which enable social structures, like governance and norms, to support BC. Their effects, however, appear context-sensitive. The importance of infrastructure investments was highlighted by intervention models. To adequately support BC, however, they require users' inputs and complementary services. Whilst ICIs reported positive impacts on treatment uptake, there are cost-effectiveness and sustainability concerns. Evaluation studies yielded limited evidence of independent epidemiological impacts from BC, due to limited use of suitable indicators and comparators. There was indicative evidence, however, that BC projects could sustain gains through treatment campaigns.

CONCLUSIONS/SIGNIFICANCE

There is a need for integrated interventions combining information provision, community-based planning, and infrastructure investments to support BC for schistosomiasis control. Programmes should carefully assess local conditions before implementation and consider that long-term support is likely needed. Available evidence indicates that BC interventions may contribute towards schistosomiasis control when accompanied by treatment activities. Further methodologically robust evidence is needed to ascertain the direct epidemiological benefits of BC.

Perceptions of the roles, impact, challenges and needs of community drug distributors in the control and elimination of neglected tropical diseases in difficult-to-access communities in Ghana

The success of mass drug administration (MDA) campaigns to control and eliminate neglected tropical diseases (NTDs) in Ghana depends, to a large extent, on the essential role community drug distributors (CDDs) play. This study aimed to investigate community's perceptions of CDDs' roles, impact of CDDs' work, challenges faced by CDDs and views on resources required to enhance CDDs' work to sustain MDA campaigns. Methods : A cross-sectional qualitative study employing the use of focus group discussions (FGDs) with community members and CDDs in selected NTD endemic communities together with individual interviews with district health officers (DHOs)was conducted. We interviewed 104 people aged 18 and over, purposively selected, through eight individual interviews, and 16 focus group discussions. Results : Participants in the community FGDs noted that health education and distribution of drugs were the main roles of CDDs. Participants also perceived that the work of CDDs had prevented the onset of NTDs, treated symptoms of NTDs and generally reduced the incidence of infections. In the interviews with CDDs and DHOs, lack of cooperation/non-compliance by community members, demands by community members, lack of working resources and low financial motivation were mentioned as the main challenges to the work of CDDs. Moreover, provision of logistics and financial motivation for CDDs were identified as factors that will enhance their work. Conclusions : Incorporating more attractive schemes shall incentivise CDDs to improve output. Addressing the challenges highlighted is an important step for the work of CDDS to be effective in controlling NTDs in difficult-to-access communities in Ghana.

Evaluation of opportunities to implement community-wide mass drug administration for interrupting transmission of soil-transmitted helminths infections in India

BACKGROUND

The World Health Organization Neglected Tropical Disease (NTD) guidelines recommend control of soil transmitted helminth (STH)-associated morbidity with targeted deworming of preschool and school-aged children who are disproportionately affected by STH-associated morbidity. However, this strategy leaves many adults untreated and reinfection within communities perpetuates transmission even when mass drug administration (MDA) coverage of children is high. Evidence suggests that it may be possible to interrupt STH transmission by expanding MDA to a community-wide MDA (cMDA).

METHODS

This multi-methods study of organizational readiness survey, key informant interviews, and program mapping, were conducted with government stakeholders in three Indian states, Goa, Sikkim, and Odisha, to assess readiness of the states for transitioning from school-based MDA to cMDA and identify opportunities to leverage existing infrastructure from other NTD programs like lymphatic filariasis (LF) for STH cMDA.

PRINCIPAL FINDINGS

Overall, all three states indicated a highly favorable policy environment, effective leadership structure, adequate material resources, demonstrated technical capacity, and adequate community infrastructure needed to launch a STH cMDA program. The findings indicated a high-level of health system readiness to implement provided human resources and financial resources to deliver cMDA is strengthened. Areas with a significant overlap between LF and STH MDA platforms, particularly at the community-level, may be best primed for transitioning. Immunization, maternal child health, and non-communicable disease control programs were the other programs for possible integration of cMDA. States indicated having effective leadership structures in place at the state-level, however, engaging local leaders and community groups were considered crucial for successful implementation of cMDA. In-migration was a perceived challenge for estimating drug requirement and preventing possible stockouts.

CONCLUSIONS

Findings from this study are intended to proactively support government decision making, prioritization, and program planning across heterogenous implementation contexts in India to speed the translation of research findings into practice.

CLINICAL TRIAL REGISTRATION

NCT03014167; ClinicalTrials.gov.

Community engagement in health services research on elimination of lymphatic filariasis: A systematic review

This study aimed to contextualize the extent, nature, and quality of community engagement in health services research on eliminating lymphatic filariasis in low-and middle-income countries of Southeast Asia and Pacific Region. We performed a systematic review, and the results were reported according to the PRISMA-S checklist. Relevant studies were searched in health-related electronic databases, and selected according to the inclusion criteria. Sixteen studies with various study designs were identified. The majority (68%) were conducted in India. Lay people, community leaders, and volunteers were the most common groups of community members (12/16,75%). Overall, the majority (13/16, 81%) were at the 'moderate level' of engagement in research context mainly by 'collaboration' in 'developing methodology' 'collaboration' in data collection and 'collaboration' for 'dissemination of findings. The common barriers to the community engagement were lack of involvement of participating bodies and technology-related issues. In conclusion, the insufficient description of the community engagement process in the studies limits a deeper understanding and analysis of the issue. Future well-designed prospective studies with attention to the description of mechanisms of engagement, facilitating the whole process and reporting the community level outcome are recommended.

Towards elimination of Lymphatic Filariasis in Kenya: improving advocacy, communication and social mobilization activities for mass drug administration, a qualitative study

Introduction

The Kenya Breaking Transmission Strategy for Neglected Tropical Diseases (NTD) from 2019 to 2023 intensifies advocacy, coordination, and partnerships. The purpose of this study was to explore views and experiences of stakeholders and health workers on ways of improving the Advocacy, Communication and Social Mobilization (ACSM) activities of Mass Drug Administration (MDA) for Lymphatic Filariasis (LF) programs through participatory approaches in Kilifi County, Kenya.

Methods

Two wards were purposely selected in the Kaloleni sub-county, Kilifi County, where there was an average treatment coverage of 56% in 2015, 50.5% in 2016. Qualitative data collection methods were employed, which included participatory meetings with county stakeholders to understand their views, experiences, and suggestions on how ACSM strategies can be improved in MDA for LF. Twelve In-Depth Interviews (IDIs) were conducted (six with opinion leaders and six with Community Health Extension Workers (CHEWs) and two semi-structured interviews (SSIs) were held with county and sub-county coordinators involved in MDA administration. The aim was to better to understand their perceptions of the NTD program about ACSM, challenges to ACSM strategies, and ways to improve the strategies for ACSM in MDA for LF. The Data was organized and classified into codes and themes using QSR NVIVO version 12.

Results

The study observed the low participation of stakeholders in the ACSM activities of MDA for LF and identified potential areas for stakeholders’ involvement to strengthen the activities. Challenges hindering effective implementation of ACSM activities include late delivery of Information, Educational and Communication (IEC) and few IEC materials, insufficient funding, inadequate time allocated to reach the assigned households with messages, messaging, and packaging of information for dissemination due to the vastness of the area. The stakeholders recommended innovative strategies and techniques to improve ACSM activities.

Discussion and conclusion

The results of this study show key challenges to ACSM implementation of MDA for LF. Implementers need to pay attention to these challenges to enhance the effectiveness of MDA per the Kenya NTD Breaking Transmission Strategy. ACSM efforts in MDA for LF control and elimination should be linked with overarching efforts to mainstream partnerships and coordination in control and elimination.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40794-022-00172-8.

Barriers and Enablers to Health-Seeking for People Affected by Severe Stigmatising Skin Diseases (SSSDs): A Scoping Review

People affected by severe stigmatising skin diseases (SSSDs) often live in the poorest communities, within the poorest countries, and experience a range of barriers to seeking timely, quality care. This scoping review analyses the available literature on health-seeking for patients affected by SSSDs, to identify enablers and barriers to health-seeking. We searched MEDLINE complete, CINAHL, Global Health databases for suitable articles published between 2010 and 2020. Search strings were compiled for health-seeking, SSSDs and lower middle-income countries (LMIC). Our search returned 1004 studies from across three databases. Of these, 136 potentially relevant studies were identified and full texts were reviewed for eligibility against the inclusion criteria, leading to the inclusion of 55 studies. Thematic narrative analysis was used, with results framed around the Levesque framework to analyse barriers and enablers to health-seeking along the continuum of the patient pathway. This scoping review has revealed barriers across the patient pathway, from both supply and demand aspects of health services. Spiritual beliefs emerged strongly relating to care-seeking and underlying stigma. Curative care was a focus for the majority of studies, but few papers emphasised holistic care (such as physical rehabilitation and psychosocial support). From our analysis, greater community engagement is needed to reduce barriers along the patient-care pathway.

The viability of utilising phone-based text messages in data capture and reporting morbidities due to lymphatic Filariasis by community health workers: a qualitative study in Kilwa district, Tanzania

Background

Globally, there is recognition of the value of using mobile phones among health providers in improving health systems performance. However, in many Low- and Middle-income countries where there is shortage of health providers, Community Health Workers have assumed some responsibilities especially relating to identifying and reporting on health problems within their communities. Despite the known benefits of using mobile phone technology to deliver health services, there is limited information on the extent to which Community Health Workers are able to effectively use the technology in data collection and reporting. The aim of this study was to determine the feasibility of utilizing phone-based text messages on Lymphatic Filariasis morbidity surveillance by Community Health Workers.

Methods

This was a cross sectional study whose data was collected through key informant interviews and focused group discussions among community health workers, health providers and staff of neglected tropical diseases control program. Collected transcripts were analysed through Thematic content analysis as it allowed for the identification of data codes through inductive reasoning.

Results

The use of mobile phone-based text messages in data collection and reporting lymphatic filariasis morbidity cases by Community Health Workers was perceived by study participants to be a relevant tool and feasible due to the ease of use of the technology. The tool was reported by end-users to significantly increase their performance and efficiency was gained in terms of reduced paper work, increased the number of patients accessing health care services and the ability to report in real-time. All respondents were confident that Community Health Workers were the right persons to interact with communities in tracking and reporting morbidity cases using mobile technology.

Conclusion

Mobile phone-based text messages have proven to be effective in routine workflows such as, data collection and reporting on Lymphatic Filariasis morbidity cases, patient to provider communication, decision making and supportive supervision. Mobile phones have also improved efficiency and general performance of end users in terms of increased number of cases identified and efficiency gained in terms of reduced paper work and the ability to collect and report in real-time.

Community perceptions and acceptability of mass drug administration for the control of neglected tropical diseases in Asia-Pacific countries: A systematic scoping review of qualitative research

BACKGROUND

Preventative chemotherapy and mass drug administration have been identified as effective strategies for the prevention, treatment, control and elimination of several NTDs in the Asia-Pacific region. Qualitative research can provide in-depth insight into the social dynamics and processes underlying effective implementation of and adherence to mass drug administration programs. This scoping review examines published qualitative literature to examine factors influencing community perceptions and acceptability of mass drug administration approaches to control NTDs in the Asia-Pacific region.

METHODOLOGY

Twenty-four peer reviewed published papers reporting qualitative data from community members and stakeholders engaged in the implementation of mass drug administration programs were identified as eligible for inclusion.

FINDINGS

This systematic scoping review presents available data from studies focussing on lymphatic filariasis, soil-transmitted helminths and scabies in eight national settings (India, Indonesia, Philippines, Bangladesh, Laos, American Samoa, Papua New Guinea, Fiji). The review highlights the profoundly social nature of individual, interpersonal and institutional influences on community perceptions of willingness to participate in mass drug administration programs for control of neglected tropical diseases (NTD). Future NTD research and control efforts would benefit from a stronger qualitative social science lens to mass drug administration implementation, a commitment to understanding and addressing the social and structural determinants of NTDs and NTD control in complex settings, and efforts to engage local communities as equal partners and experts in the co-design of mass drug administration and other efforts to prevent, treat, control and eliminate NTDs.

CONCLUSION

For many countries in the Asia-Pacific region, the "low hanging fruit has been picked" in terms of where mass drug administration has worked and transmission has been stopped. The settings that remain-such as remote areas of Fiji and Papua New Guinea, or large, highly populated, multi-cultural urban settings in India and Indonesia-present huge challenges going forward.

A mixed-methods exploration into the resilience of community drug distributors conducting mass drug administration for preventive chemotherapy of lymphatic filariasis and onchocerciasis in Côte d'Ivoire and Uganda

Volunteer community drug distributors (CDDs) have been vital to progress made in the elimination of onchocerciasis and lymphatic filariasis; two neglected tropical diseases amenable to preventive chemotherapy (PC-NTDs). However, formative work in Côte d'Ivoire and Uganda revealed that CDDs can encounter considerable challenges during mass drug administration (MDA). CDDs must be resilient to overcome these challenges, yet little is known about their resilience. This mixed-methods study explored the resilience of CDDs in Côte d'Ivoire and Uganda. The characteristics and experiences of 248 CDDs involved in the 2018 MDAs in Côte d'Ivoire (N = 132) and Uganda (N = 116) were assessed using a micronarrative survey. Thematic analysis of CDDs' micronarratives was used to identify challenges they encountered during MDA. Resilience was assessed using the Connor-Davidson Resilience Scale 25 (CD-RISC-25). Variables from the micronarrative survey found to be individually associated with mean CD-RISC-25 score (P<0.05) through bivariate analyses were included in a multiple linear regression model. Post-hoc, country-specific analyses were then conducted. Thematic analysis showed that CDDs encountered a wide range of challenges during MDA. The aggregate model revealed that CDDs who had positive relationships or received support from their communities scored higher on the CD-RISC-25 on average (P<0.001 for both), indicating higher resilience. These trends were also observed in the country-specific analyses. Mean CD-RISC-25 scores were unaffected by variations in district, age, gender, and length of involvement with the NTD program. Community support during MDA and positive community-CDD relationships appear to be associated with CDDs' personal capacity to overcome adversity. Involving communities and community leadership in the selection and support of CDDs has the potential to benefit their well-being. This study establishes the CD-RISC-25 as a useful tool for assessing the resilience of CDDs. Further research is needed to understand, promote, and support the resilience of this valuable health workforce, upon which NTD programs depend.

Membrane Technology for Rapid Point-of-Care Diagnostics for Parasitic Neglected Tropical Diseases

Parasitic neglected tropical diseases (NTDs) affect over one billion people worldwide, with individuals from communities in low-socioeconomic areas being most at risk and suffering the most. Disease management programs are hindered by the lack of infrastructure and resources for clinical sample collection, storage, and transport and a dearth of sensitive diagnostic methods that are inexpensive as well as accurate. Many diagnostic tests and tools have been developed for the parasitic NTDs, but the collection and storage of clinical samples for molecular and immunological diagnosis can be expensive due to storage, transport, and reagent costs, making these procedures untenable in most areas of endemicity. The application of membrane technology, which involves the use of specific membranes for either sample collection and storage or diagnostic procedures, can streamline this process, allowing for long-term sample storage at room temperature. Membrane technology can be used in serology-based diagnostic assays and for nucleic acid purification prior to molecular analysis. This facilitates the development of relatively simple and rapid procedures, although some of these methods, mainly due to costs, lack accessibility in low-socioeconomic regions of endemicity. New immunological procedures and nucleic acid storage, purification, and diagnostics protocols that are simple, rapid, accurate, and cost-effective must be developed as countries progress control efforts toward the elimination of the parasitic NTDs.

Community Drug Distributor Knowledge, Attitudes, and Motivation Surrounding Mass Drug Administration for Soil-Transmitted Helminths in India

Background: DeWorm3 is an ongoing multi-country community-based cluster-randomized trial assessing the feasibility of interrupting transmission of soil-transmitted helminths (STH) with community-wide mass drug administration (cMDA). In Tamil Nadu, India, community drug distributors (CDDs) worked with DeWorm3 field staff to counsel community members and deliver door-to-door deworming treatment. As CDDs were likely to influence successful delivery of cMDA, we describe drivers of CDDs' knowledge, attitudes, and motivation toward delivery of cMDA.

Methods: In this convergent mixed-methods study, a questionnaire on STH and cMDA was administered to 104 CDDs and 17 focus group discussions (FGDs) were conducted. Key outcomes in the quantitative and qualitative analyses included CDDs' knowledge about STH and cMDA and attitudes toward cMDA for STH. Univariate and multivariable logistic regression analyses were performed to determine the strength of associations between independent and outcome variables. The FGDs were analyzed using a priori thematic coding.

Results: CDDs who completed at least secondary school education [adjusted odds ratio (aOR): 2.71, 95% CI: 1.16–6.33] and had prior experience in health programs (aOR: 2.72, 95% CI: 1.15–6.44) were more knowledgeable about STH and cMDA. CDDs belonging to the scheduled castes and scheduled tribes (aOR: 2.37, 95% CI: 1.04–5.39), and to households engaged in a skilled occupation (aOR: 2.77, 95% CI: 1.21–6.34) had a more positive attitude toward cMDA for STH. The FGDs showed that while there were myths and misconceptions about STH, many CDDs believed that the adult population in their communities were infected with STH, and that a door-to-door drug delivery strategy would be optimal to reach adults.

Conclusions: Educational and socioeconomic backgrounds and experience in health programs should be considered while designing CDD trainings. Along with cMDA delivery for STH, as CDD do share community myths and misconceptions around STH, they should be proactively addressed during the CDD training to strengthen competency in counseling.

Factors influencing mass drug administration adherence and community drug distributor opportunity costs in Liberia: a mixed-methods approach

Background

Preventive chemotherapy delivered via mass drug administration (MDA) is essential for the control of neglected tropical diseases (NTDs), including lymphatic filariasis (LF), schistosomiasis and onchocerciasis. Successful MDA relies heavily on community drug distributor (CDD) volunteers as the interface between households and the health system. This study sought to document and analyse demand-side (households) and supply-side (health system) factors that affect MDA delivery in Liberia.

Methods

Working in two purposively selected counties, we conducted a household MDA access and adherence survey; a CDD survey to obtain information on direct and opportunity costs associated with MDA work; an observational survey of CDDs; and key informant surveys (KIS) with community-level health workers. Data from the CDD survey and Liberian minimum wage rates were used to calculate the opportunity cost of CDD participation per MDA round. The observational data were used to calculate the time spent on individual household-level tasks and CDD time costs per house visited. KIS data on the organisation and management of the MDA in the communities, and researcher reflections of open-ended survey responses were thematically analysed to identify key demand- and supply-side challenges.

Results

More respondents were aware of MDA than NTD in both counties. In Bong, 39% (103/261) of respondents reported taking the MDA tablet in the last round, with “not being informed” as the most important reason for non-adherence. In Maryland, 56% (147/263) reported taking MDA with “being absent” at the time of distribution being important for non-adherence. The mean cost per CDD of participating in the MDA round was −$11.90 (median $5.04, range −$169.62 to $30.00), and the mean time per household visited was 17.14 min which equates to a mean opportunity cost of $0.03 to $0.05 per household visited. Thematic analysis identified challenges, including shortages of and delays in medicine availability; CDD frustration over costs; reporting challenges; and household concerns about drug side effects.

Conclusions

Improved adherence to MDA and subsequent elimination of NTDs in Liberia would be supported by an improved medicine supply chain, financial compensation for CDDs, improved training, healthcare workforce strengthening, greater community involvement, capacity building, and community awareness.

Graphical Abstract

Supplementary Information

The online version contains supplementary material available at 10.1186/s13071-021-05058-w.

Ethical dimensions of neglected tropical disease programming

The global movement to control and eliminate neglected tropical diseases (NTDs) is grounded in an ethic of social justice, solidarity and health equity. NTD programmes deliver significant health benefits in socially complex environments characterized by poverty and economic disparity. We used two ethics frameworks—principlism and Upshur's public health framework—to examine ethical challenges faced by NTD programmes. They include management of serious adverse reactions associated with preventive chemotherapy, centralization of decision-making, ‘opt-out’ policies for school-based deworming, incomplete evidence for ‘pro-poor’ impact and persistent inequities in global partnerships. NTD programmes must actively address ethical challenges while pursuing global health goals.

Eliminating onchocerciasis within the Meme River Basin of Cameroon: A social-ecological approach to understanding everyday realities and health systems

BACKGROUND

Onchocerciasis affects some of the world's most marginalized people, perpetuating poverty and inequalities. Mass Drug Administration (MDA) with Ivermectin has taken place within the Meme River basin region in Cameroon for over 15 years. Despite this, onchocerciasis is still prevalent in the region due to existing and emerging contextual challenges. Using a social-ecological approach we explore the everyday realities of communities, highlighting the challenges and potential solutions that could support Neglected Tropical Disease (NTD) programmes when transitioning from control to elimination of onchocerciasis in this highly endemic area and other similar communities.

METHODOLOGY/PRINCIPAL FINDING

In-depth interviews (71) with community members and Community Drug Distributors (CDDs) were conducted to understand current knowledge, attitudes, and behaviours in relation to transmission, prevention and treatment of onchocerciasis. Through application of the social-ecological model, four key themes were identified: 1. Contextual factors on health promotion interventions (Onchocerciasis history and understanding of the disease, prevention and mitigation strategies and MDA experience); 2. Social determinants (poverty and livelihoods, economic and social impacts on CDD volunteers and stigma); 3. Environmental determinants (exposure, housing, occupation and poverty); and 4. health seeking pathways and decision making for treatment (access, cost and preferable treatment routes). We discuss these core and cross cutting themes (gender differences and community participation/ownership) in relation to intersectoral collaboration, gender equity and health systems support, making recommendations for NTD programmes within the context of integrated and interdisciplinary approaches. These include the need for; intersectional and gender analysis at the local level, addressing environmental dimensions of onchocerciasis through integrated and regular health promotion, vector control strategies and access to safe water sources; reflection and action that embeds responses to social and economic barriers to MDA; integrated case detection and management that is responsive to onchocerciasis symptoms and related stigma and a fair and just support network for CDDs.

CONCLUSION/SIGNIFICANCE

NTD programmes need to respond to diverse community circumstances and behaviours. Communities are not a homogeneous risk group and treating them in this way will delay elimination. A deeper understanding of individual needs and their capacity to seek prevention and treatment must be considered if onchocerciasis is to be eliminated and the remaining impacts managed.

Community-directed distributors-The "foot soldiers" in the fight to control and eliminate neglected tropical diseases

The neglected tropical diseases (NTDs) affect hundreds of millions of people, predominantly in rural, often difficult-to-access areas, poorly served by national health services. Here, we review the contributions of 4.8 million community-directed distributors (CDDs) of medicines over 2 decades in 146,000 communities in 27 sub-Saharan African countries to control or eliminate onchocerciasis and lymphatic filariasis (LF). We examine their role in the control of other NTDs, malaria, HIV/AIDS interventions, immunisation campaigns, and support to overstretched health service personnel. We are of the opinion that CDDs as community selected, trained, and experienced "foot soldiers," some of whom were involved in the Ebola outbreak responses at the community level in Liberia, if retrained, can assist community leaders and support health workers (HWs) in the ongoing Coronavirus Disease 2019 (COVID-19) crisis. The review highlights the improved treatment coverage where there are women CDDs, the benefits and lessons from the work of CDDs, their long-term engagement, and the challenges they face in healthcare delivery. It underscores the value of utilising the CDD model for strong community engagement and recommends the model, with some review, to hasten the achievement of the NTD 2030 goal and assist the health system cope with evolving epidemics and other challenges. We propose that, based on the unprecedented progress made in the control of NTDs directly linked to community engagement and contributions of CDDs "foot soldiers," they deserve regional and global recognition. We also suggest that the World Health Organization (WHO) and other international stakeholders promote policy and guidance for countries to adapt this model for the elimination of NTDs and to strengthen national health services. This will enhance the accomplishment of some Sustainable Development Goals (SDGs) by 2030 in sub-Saharan Africa.

Factors affecting the uptake of preventive chemotherapy treatment for schistosomiasis in Sub-Saharan Africa: A systematic review

Background

Schistosomiasis affects nearly 220 million people worldwide, mainly in Sub-Saharan Africa (SSA). Preventive chemotherapy (PC) treatment, through regular mass-drug administration (MDA) of Praziquantel tablets remains the control measure of choice by Ministries of Health. Current guidelines recommend that 75% of school-aged children receive treatment. Many programmes, however, struggle to achieve this target. Given the risk of high reinfection rates, attaining sustained high levels of treatment coverage is essential. This study provides a comprehensive review of the barriers and facilitators operating at different levels of analysis, from the individual to the policy level, conditioning the uptake of PC for schistosomiasis in SSA.

Methodology/Principal findings

A systematic literature search was conducted in several databases for publications released between January 2002 and 2019 that examined factors conditioning the uptake of Praziquantel in the context of MDA campaigns in SSA. A total of 2,258 unique abstracts were identified, of which 65 were selected for full text review and 30 met all eligibility criteria. Joanna Briggs Institute’s Critical Appraisal and the Mixed-Methods Assessment tools were used to assess the strength of the evidence. This review was registered with PROSPERO (CRD42017058525).

A meta-synthesis approach was used. Results indicated publication bias, with the literature focusing on East African rural settings and evidence at the individual and programmatic levels. The main influencing factors identified included material wellbeing, drug properties, knowledge and attitudes towards schistosomiasis and MDAs, fears of side effects, gender values, community and health systems support, alongside programme design features, like training, sensitisation, and provision of incentives for drug-distributors. The effect of these factors on determining Praziquantel uptake were explored in detail.

Conclusions/Significance

Multiple determinants of treatment uptake were found in each level of analysis examined. Some of them interact with each other, thus affecting outcomes directly and indirectly. The promotion of context-based transdisciplinary research on the complex dynamics of treatment uptake is not only desirable, but essential, to design effective strategies to attain high levels of treatment coverage.

Schistosomiasis is a parasitic infection that affects nearly 220 million people worldwide. Long-term effects include anaemia, growth stunting, bladder cancer and infertility. Currently, the main approach to schistosomiasis control involves mass preventive chemotherapy treatment. Current guidelines recommend treating 75% of school-aged children but many programmes struggle to achieve this target. This study conducted a comprehensive review of factors conditioning the uptake of treatment in Sub-Saharan Africa across different levels of analysis: individual, interpersonal, organisational, community and policy. This examination showed, first, that the literature suffers of publication bias, with most studies based in rural East African sites and focusing in discussing individual- and policy-level factors. It indicated as well that people’s livelihoods, food security, and school-enrolment, alongside knowledge and attitudinal factors influenced treatment uptake at the individual level. Various contextual factors concerning interpersonal relations, organisations’ resources, and prevalent socio-cultural features (e.g., gender) further shaped people’s responses to MDA campaigns. Finally, it was observed that the effectiveness of programme-level decisions on sensitisation, training, and drug-delivery strategies were constantly re-shaped by mediating factors operating at lower levels of analysis. We conclude that the promotion of context-based transdisciplinary research is essential to design effective strategies to promote sustainable high levels of treatment coverage.

Keeping communities at the centre of efforts to eliminate lymphatic filariasis: learning from the past to reach a future free of lymphatic filariasis

Since the launch of the Global Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000, more than 910 million people have received preventive chemotherapy for lymphatic filariasis (LF) and many thousands have received care for chronic manifestations of the disease. To achieve this, millions of community drug distributors (CDDs), community members and health personnel have worked together each year to ensure that at-risk communities receive preventive chemotherapy through mass drug administration (MDA). The successes of 20 y of partnership with communities is celebrated, including the application of community-directed treatment, the use of CDDs and integration with other platforms to improve community access to healthcare. Important challenges facing the GPELF moving forward towards 2030 relate to global demographic, financing and programmatic changes. New innovations in research and practice present opportunities to encourage further community partnership to achieve the elimination of LF as a public health problem. We stress the critical need for community ownership in the current Covid-19 pandemic, to counter concerns in relaunching MDA programmes for LF.

Implementation challenges and opportunities for improved mass treatment uptake for lymphatic filariasis elimination: Perceptions and experiences of community drug distributors of coastal Kenya

Community drug distributors (CDDs) who are volunteers have the responsibility of awareness creation, household census, drug distribution and record-keeping and are thus key stakeholders in the campaign for Lymphatic Filariasis (LF) elimination. Taking into account their experiences and perceptions is important for a successful elimination campaign. We conducted a qualitative study in 2018 to identify implementation challenges and opportunities for improved mass drug administration (MDA) uptake based on the CDDs perceptions and experiences. Within a larger study that used mixed methods quasi-experimental design, we collected qualitative data from two wards in Kaloleni Sub-County of Kilifi County which was purposively selected owing to its low, 56% and 50.5% treatment coverage in 2015 and 2016 respectively. Focus group discussions (FGDs) (n = 8) and in-depth interviews (IDIs) (n = 8) with CDDs, IDIs (n = 22) with opinion leaders and IDIs (n = 8) with health workers were conducted and the data analyzed by QSR NVIVO version 10 according to thematic areas. The results showed that based on the perceptions and experiences of the CDDs, several challenges: communities’ refusal to take the drugs; absenteeism during MDA; non-adherence to CDDs selection criteria; inadequacy in number of CDDs engaged during the campaign and training provided; insufficiency of drugs issued to CDDs; lack of CDDs supervision and low motivation negatively impact on MDA uptake. Opportunities to address the challenges included: awareness creation on MDA, health education on LF and observation of hygiene during drug administration, increased duration of awareness creation and drug administration, adherence to CDDs selection criteria and putting into consideration the vastness of an area and population density while deploying CDDs. Other opportunities include: improved CDDs training and scheduling; issuing of enough drugs to CDDs to meet the communities’ demand and improved supervision and motivation of CDDs. Addressing the challenges highlighted is an important step of maximizing MDA uptake. The opportunities presented need to be considered by the NTD program personnel, the county health personnel and the community while planning the implementation of MDA campaigns.

Elephantiasis infection which is common in tropical areas is targeted for elimination globally through delivery of drugs to all populations living in areas where infections occur. Community Drug Distributors (CDDs) are persons who live in the affected communities and who volunteer themselves to distribute drugs after receiving training from the health care workers. Understanding the challenges and opportunities for improved community drug uptake from the perspectives and experiences of the CDDs is important for a successful elimination campaign.

As part of a larger study to address barriers of drug uptake in Kenya, we collected qualitative data to explore the challenges and opportunities for improved drug uptake in two wards of Kilifi County. The data was collected through focus group discussions and in-depth interviews and analyzed.

For drug uptake to be improved, the CDDs’ mentioned challenges related to how their selection is done, number of CDDs engaged, quality of their training, quantities of drugs issued to them, supervision and motivation that need to be addressed. The communities targeted for treatment need well scheduled health education activities on elephantiasis, awareness creation on drug distribution and drug reaction for them to understand the importance of receiving the treatment. These findings suggest the need for strong collaborations between NTD program, county health personnel and the community that are useful in the planning the implementation of successful national programs.

Mass administration of medicines in changing contexts: Acceptability, adaptability and community directed approaches in Kaduna and Ogun States, Nigeria

Nigeria has the highest burden of NTDs in sub-Saharan Africa. Commitments to reach the control and elimination of many Neglected Tropical Diseases (NTDs), particularly those amenable to preventive chemotherapy (onchocerciasis, schistosomiasis, soil transmitted helminths, lymphatic filariasis and trachoma) by 2020 are detailed in the London declaration. Strategies to reach targets build on existing approaches, one of which is the use of community directed intervention (CDI) methods to deliver the mass administration of medicines (MAM). However, treatment using this approach has been inconsistent and there are questions about the acceptability and adaptability of these interventions during periods of programmatic, social, and political change. This paper explores the current strengths and weaknesses of CDI approaches in MAM delivery. We consider the acceptability and adaptability of existing MAM approaches to ensure equity in access to essential treatments. Using qualitative methods, we explore implementer perspectives of MAM delivery. We purposively selected programme implementers to ensure good programmatic knowledge and representation from the different levels of health governance in Nigeria. Data collection took place across two States (Kaduna and Ogun). Our results indicate that CDI approaches have underpinned many historic successes in NTD programme acceptance in Nigeria, specifically in Kaduna and Ogun State. However, our results also show that in some contexts, factors that underpin the success of CDI have become disrupted presenting new challenges for programme implementers. Capturing the tacit knowledge of health implementers at varying levels of the health system, we present the current and changing context of MAM delivery in Kaduna and Ogun States and consolidate a platform of evidence to guide future programme delivery and research studies. We situate our findings within the broader NTD literature, specifically, in identifying how our findings align to existing reviews focused on factors that shape individual acceptance of MAM.

Nigeria has the highest number of people affected by neglected tropical diseases in sub-Saharan Africa. Many of these diseases (onchocerciasis, lymphatic filariasis, schistosomiasis and soil transmitted helminths) can be prevented and treated using mass administration of medicines (MAM), which involves giving everyone in communities medicines based on their height. MAM has been going on for a long time in Nigeria and has achieved many successes, however, the programmatic, social, political and economic context in Nigeria is rapidly changing and there is limited evidence about the ability of current MAM approaches to ensure everyone who needs these medicines is able to access them during this time of change. We asked MAM programme implementers at different levels of the health system in Nigeria to tell us what they thought the key strengths and weaknesses of the current programme were and what they would do to make it better to ensure that everyone who needs the medicines would still be able to access them. They told us that the commitment of health workers and community leaders to telling communities about the medicines and encouraging them to accept them as well as the knowledge of the disability these diseases can cause had supported programme success. However, they also told us that in some areas, such as those with security concerns or where communities feel fatigued by the programme, the way communities respond is changing. To address the change in community responses our study participants felt that we need to support programme implementers with the time, tools and resources to build stronger more trusting relationships with communities to ensure everyone can access medicines.

The roles of stakeholder experience and organizational learning in declining mass drug administration coverage for lymphatic filariasis in Port-au-Prince, Haiti: A case study

The World Health Organization (WHO) defines an effective round of mass drug administration (MDA) for lymphatic filariasis (LF) as one that reaches at least 65% of the target population. In its first round of MDA in 2011–2012, the National Program to Eliminate LF in Haiti achieved a 79% epidemiological coverage in urban Port-au-Prince. In 2013, coverage dropped below the WHO threshold and has declined year-over-year to a low of 41% in 2017. We conducted a retrospective qualitative case study to identify key factors behind the decline in coverage in Port-au-Prince and ways to address them. Our findings suggest that the main contributors to the decline in MDA coverage appear to be the absence of effective documentation of practices, reporting, analysis, and program quality improvement—i.e., learning mechanisms—within the program’s MDA design and implementation strategy. In addition to their contribution to the program’s failure to meet its coverage targets, these deficits have resulted in a high cost for the MDA campaign in both lost momentum and depleted morale. Through a proposed operating logic model, we explore how the pathway from program inputs to outcomes is influenced by a wide array of mediating factors, which shape potential participants’ experience of MDA and, in turn, influence their reasoning and decisions to take, or not take, the pills. Our model suggests that the decisions and behavior of individuals are a reflection of their overall experience of the program itself, mediated through a host of contextual factors, and not simply the expression of a fixed choice or preference. This holistic approach offers a novel and potentially valuable framing for the planning and evaluation of MDA strategies for LF and other diseases, and may be applicable in a variety of global health programs.

In order to eliminate lymphatic filariasis from a region, the World Health Organization recommends a strategy of preventative drugs delivered annually to the population. At least 65% of the population must participate for four to six consecutive years for this approach to be effective. In urban Port-au-Prince, Haiti, the number of people taking the drugs has been declining progressively below the 65% benchmark since 2012. We used a qualitative case study to identify key factors behind the decline in coverage in Port-au-Prince and ways to address them. We found that the lymphatic filariasis elimination program lacks the necessary design and program infrastructure to ensure reliable learning about problems faced by pill distribution teams on the ground, and the improvisations they introduced to address these challenges. The inability to incorporate these lessons into program improvements and refinements resulted in under-performance and contributed to the decline in coverage. Furthermore, the way that people experience the program is strongly influenced by a host of contextual factors, which shape potential participants’ experience of the program and, in turn, influence their reasoning and decisions to take, or not take, the pills.

Valuing the Unpaid Contribution of Community Health Volunteers to Mass Drug Administration Programs

Community health volunteers (CHVs) are being used within a growing number of healthcare interventions, and they have become a cornerstone for the delivery of mass drug administration within many neglected tropical disease control programs. However, a greater understanding of the methods used to value the unpaid time CHVs contribute to healthcare programs is needed. We outline the two main approaches used to value CHVs’ unpaid time (the opportunity cost and the replacement cost approaches). We found that for mass drug administration programs the estimates of the economic costs relating to the CHVs’ unpaid time can be significant, with the averages of the different studies varying between US$0.05 and $0.16 per treatment. We estimated that the time donated by CHVs’ to the African Programme for Onchocerciasis Control alone would be valued between US$60 and $90 million. There is a need for greater transparency and consistency in the methods used to value CHVs’ unpaid time.

Lessons Learned in Conducting Mass Drug Administration for Schistosomiasis Control and Measuring Coverage in an Operational Research Setting

The Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) was created to conduct research that could inform programmatic decision-making related to schistosomiasis. SCORE included several large cluster randomized field studies involving mass drug administration (MDA) with praziquantel. The largest of these were studies of gaining or sustaining control of schistosomiasis, which were conducted in five African countries. To enhance relevance for routine practice, the MDA in these studies was coordinated by or closely aligned with national neglected tropical disease (NTD) control programs. The study protocol set minimum targets of at least 90% for coverage among children enrolled in schools and 75% for all school-age children. Over the 4 years of intervention, an estimated 3.5 million treatments were administered to study communities. By year 4, the median village coverage was at or above targets in all studies except that in Mozambique. However, there was often a wide variation behind these summary statistics, and all studies had several villages with very low or high coverage. In studies where coverage was estimated by comparing the number of people treated with the number eligible for treatment, denominator estimation was often problematic. The SCORE experiences in conducting these studies provide lessons for future efforts that attempt to implement strong research designs in real-world contexts. They also have potential applicability to country MDA campaigns against schistosomiasis and other NTDs, most of which are conducted with less logistical and financial support than was available for the SCORE study efforts.

Implementer and recipient perspectives of community-wide mass drug administration for soil-transmitted helminths in Kwale County, Kenya

Soil-transmitted helminthiases (STH) are one of 17 neglected tropical diseases (NTDs) earmarked for control or elimination by 2020 in the WHO’s Roadmap on NTDs. Deworming programs for STH have thus far been focused on treating pre-school and school-aged children; however, there is a growing consensus that to achieve elimination of STH transmission, programs must also target adults, potentially through community-wide mass drug administration (MDA). There is currently a gap in the literature on what components are required to deliver community-wide MDA for STH in order to achieve high intervention reach and uptake. Nested within the TUMIKIA Project, a cluster randomized trial in Kenya evaluating the effectiveness of school-based deworming versus community-wide MDA, we collected qualitative data from program implementers and recipients in eight clusters where community-wide MDA was delivered. Data collection included semi-structured in-depth interviews (n = 72) and focus group discussions (n = 32). A conceptual framework for drug distribution was constructed to help build an analysis codebook. Case memos were developed for each top-level theme. Community-wide MDA for STH was perceived as a complex intervention with key administrative and social mobilization domains. Key actionable themes included: (1) developing an efficient strategy to allocate reasonable workload for implementers to cover all targeted households; (2) maximizing community drug distributors’ motivation through promoting belief in the effectiveness of the intervention and providing sufficient financial incentives; (3) developing effective capacity building strategies for implementers; and (4) implementing a context-adapted community engagement strategy that leverages existing community structures and takes into consideration past community experiences of MDAs. Transitioning from STH control to elimination goals requires significant planning and action to ensure community-wide MDA is delivered with sufficient reach and uptake. We present findings that can inform national deworming programs to increase intervention delivery capacity.

Infections by soil-transmitted worms are common in tropical and subtropical areas. Control strategies usually involve distributing deworming drugs to children, who are most affected. However, recent evidence suggests that distributing these drugs to whole communities, including adults, might help to achieve the elimination of these worms as a public health problem. As part of a large trial in Kenya evaluating the distribution of deworming drugs to communities, we conducted a qualitative study to explore the perspectives of drug delivery among drug distributors and recipient communities. We conducted and analyzed in-depth interviews and focus group discussions. For community deworming to be implemented well, it requires distributors to be highly motivated and follow a plan that fits well with the characteristics of the target community. In order to accept the deworming drugs, communities need to know about the health problem and the intervention, and trust the delivery system. These findings should prove useful to national deworming programs planning to distribute drugs to whole communities when developing their delivery strategies.

Gender norms and mass deworming program access in Comé, Benin: A qualitative assessment of gender-associated opportunities and challenges to achieving high mass drug administration coverage

The World Health Organization’s Neglected Tropical Disease Roadmap has accelerated progress towards eliminating select neglected tropical diseases (NTDs). This momentum has catalyzed research to determine the feasibility of interrupting transmission of soil-transmitted helminths (STH) using community-wide mass drug administration (MDA). This study aims to identify potential gender-specific facilitators and barriers to accessing and participating in community-wide STH MDA, with the goal of ensuring programs are equitable and maximize the probability of interrupting STH transmission. This research was conducted prior to the launch of community-wide MDA for STH in Comé, Benin. A total of 10 focus group discussions (FGDs) were conducted separately among 40 men, 38 women, and 15 community drug distributors (CDDs). Salient themes included: both men and women believe that community-wide MDA would reduce the financial burden associated with self-treatment, particularly for low income adults. Community members believe MDA should be packaged alongside water, sanitation, and other health services. Women feel past community-wide programs have been disorganized and are concerned these distributions will be similar. Women also expressed interest in increased engagement in the implementation of future community-based public health programs. Men often did not perceive themselves to be at great risk for STH infection and did not express a high demand for treatment. Finally, the barriers discussed by CDDs generally did not align with gender-specific concerns, but rather represented concerns shared by both genders. A door-to-door distribution strategy for STH MDA is preferred by women in this study, as this platform empowers women to participate as health decision makers for their family. In addition, involving women in planning and implementation of community-wide programs may help to increase treatment coverage and compliance.

Soil-transmitted helminths (STH) affect an estimated 1.5 billion people globally. The DeWorm3 Project is investigating if it is possible to interrupt transmission of STH with community-wide deworming of individuals of all ages. We conducted focus group discussions with adult men, women, and community drug distributors (CDDs) in Comé, Benin to identify gender-specific facilitators and barriers to accessing and participating in community-wide mass drug administration (MDA) programs. Our findings suggest that door-to-door community-wide MDA may not only improve MDA treatment coverage by increasing access but may also empower women by facilitating increased decision making on behalf of their regarding who is treated and where. Additionally, women may be an untapped resource for strategically reaching missed populations and women reported seeking increased involvement within the deworming of their families. Men did not perceive themselves to be at risk and thus did not have high demand for deworming. Both genders reported that they struggle to afford deworming drugs outside of MDA and that MDA coverage would be higher if treatment was integrated with water and sanitation services. Finally, CDDs generally identified only barriers and facilitators to MDA that were shared by both genders and may require more training to ensure MDA programs are equitable and effectively engage all at risk populations.

The fight against lymphatic filariasis: perceptions of community drug distributors during mass drug administration in coastal Kenya

Background

Lymphatic filariasis (LF), a neglected tropical disease (NTD) and leading cause of global disability, is endemic in 32 countries in Africa with almost 350 million people requiring regular drug administration, and only 16 countries achieving target coverage. Community Drug Distributors (CDDs) are critical for the success of NTD programs, and the distribution of medicines during mass drug administration (MDA) in Africa; however they could also be a weak link. The primary aim of this study is to explore and describe perceptions of CDDs during MDA for LF in Mvita sub-county in Mombasa county and Kaloleni sub-county in Kilifi county, Kenya; and provide recommendations for the effective engagement of communities and CDDs in low-resource settings.

Methods

In September 2018, we conducted six focus group discussions with community members in each sub-county, three with men aged 18–30, 31–50, and 51 years and above and three with women stratified into the same age groups. In each sub-county, we also conducted semi-structured interviews with nine community health extension workers (CHEWs), the national LF focal point, the county NTD focal points, and seven community leaders. Content analysis of the data was conducted, involving a process of reading, coding, and displaying data in order to develop a codebook.

Results

We found that several barriers and facilitators impact the engagement between CDDs and community members during MDA. These barriers include poor communication and trust between CDDs and communities; community distrust of the federal government; low community knowledge and perceived risk of LF, poor timing of MDA, fragmented supervision of CDDs during MDA; and CDD bias when distributing medicines. We also found that CDD motivation was a critical factor in their ability to successfully meet MDA targets. It was acknowledged that directly observed treatment and adequate health education were often not executed by CDDs. The involvement of community leaders as informal supervisors of CDDs and community members improves MDA.

Conclusions

In order to achieve global targets around the elimination of LF, CDDs and communities must be effectively engaged by improving planning and implementation of MDA.

Gender-related factors affecting health seeking for neglected tropical diseases: findings from a qualitative study in Ethiopia

BACKGROUND

Despite known gender-specific differences in terms of prevalence, transmission and exposure to neglected tropical diseases (NTDs), there is limited discussion of the influence of gender in NTD programmes and interventions. There is a paucity of research on how gender interacts with NTD service provision and uptake. This study, part of broader implementation research in Ethiopia, applied a gender lens to health seeking for five NTDs: lymphatic filariasis, podoconiosis, schistosomiasis, soil-transmitted helminth infection and trachoma.

METHODOLOGY/PRINCIPAL FINDINGS

The study was conducted in a district of the Southern Nations, Nationalities, and Peoples' Region of Ethiopia where the five NTDs are prevalent. A qualitative methodology was adopted to explore participants' perspectives and experiences. Data generation methods included 20 interviews and four focus group discussions. Community members, volunteer Health Development Army leaders, Health Extension Workers and a range of health workers at the health post, health centre and hospital level (n = 59) were purposively sampled. Interviews and focus group discussions were audio recorded, transcribed verbatim into English then analysed through open coding, drawing on constant comparative methods. Gender related factors affected care seeking for NTDs and were described as reasons for not seeking care, delayed care seeking and treating NTDs with natural remedies. Women faced additional challenges in seeking health care due to gender inequalities and power dynamics in their domestic partnerships. Participants recommended raising community awareness about NTDs, however this remains problematic due to gender and social norms around appropriate discourse with members of the opposite gender.

CONCLUSIONS/SIGNIFICANCE

The findings from this study provide crucial insights into how gender interacts with accessing health services, at different levels of the health system. If we are committed to leaving no one behind and achieving universal health coverage, it is essential to address gender disparities to access and utilisation of interventions delivered by national NTD programmes.

Community drug distributors for mass drug administration in neglected tropical disease programmes: systematic review and analysis of policy documents

Background

Mass drug administration (MDA) programmes for neglected tropical diseases (NTDs) depend on voluntary community drug distributors (CDDs) to deliver drugs, and these volunteer schemes need regular training and supervision. NTD policy now includes integration of multiple disease programmes, but we are unsure if there is clarity in what is currently expected of CDDs and how they are managed. We therefore analysed World Health Organization (WHO) policy, strategy and implementation guidance, and select national NTD programme implementation plans.

Methods

Included are a) WHO global and WHO-Regional Office for Africa guidelines, strategies, operational manuals and meeting reports published between January 2007 to February 2018 that included policy and plans for CDDs; and b) national NTD programme master plans for Cameroon, Ghana, Liberia and Nigeria. For both review components, we examined the CDD responsibilities through a framework developed iteratively against the documents and prepared a narrative synthesis.

Results

Twenty WHO policy documents met the inclusion criteria. In the twelve global and eight regional documents, the CDD role was not explicitly or comprehensively defined. Three documents mentioned CDDs will distribute drugs; some mentioned health promotion, data handling and engagement in clinical care. Four WHO documents noted a need for CDD training or management, eight detailed some aspect of this, and one regional document provided a comprehensive overview. In the national plans, additional responsibilities included case management in two countries and transmission control in two countries. Every plan included training and supervision, but this was not always explicit, and details of the purpose and frequency varied. In all national plans, CDD motivation was identified as a challenge but not comprehensively addressed, although one document mentioned provision of bicycles.

Conclusions

WHO and national policies and plans assume CDDs will implement NTD programmes. However, there is almost no clear delineation of responsibilities, nor is there up-to-date practical guidance to guide managers. This ambiguity, in relation to the lack of explicit policies or programmatic guidance, probably impairs the effectiveness of NTD programmes.

Are We on Our Way to Achieving the 2020 Goals for Schistosomiasis Morbidity Control Using Current World Health Organization Guidelines?

Background

Schistosomiasis remains an endemic parasitic disease affecting millions of people around the world. The World Health Organization (WHO) has set goals of controlling morbidity to be reached by 2020, along with elimination as a public health problem in certain regions by 2025. Mathematical models of parasite transmission and treatment impact have been developed to assist in controlling the morbidity caused by schistosomiasis. These models can inform and guide implementation policy for mass drug administration programs, and help design monitoring and evaluation activities.

Methods

We use these models to predict whether the guidelines set by the WHO are on track for achieving their 2020 goal for the control of morbidity, specifically for Schistosoma mansoni. We examine whether programmatic adaptations; namely increases in treatment coverage and/or expansion to adult inclusion in treatment, will improve the likelihood of reaching the WHO goals.

Results

We find that in low-prevalence settings, the goals are likely to be attainable under current WHO guidelines, but in moderate to high-prevalence settings, the goals are less likely to be achieved unless treatment coverage is increased and expanded to at least 85% for school-aged children and 40% for adults.

Conclusions

To improve the likelihood of reaching the WHO goals, programmatic adaptations are required, particularly for moderate- to high-prevalence settings. Furthermore, improvements in adherence to treatment, potential development of candidate vaccines, and enhanced snail control and WASH (water, sanitation, and hygiene) measures will all assist in achieving the goals.

Optimising the performance of frontline implementers engaged in the NTD programme in Nigeria: lessons for strengthening community health systems for universal health coverage

BACKGROUND

The control and elimination of Neglected Tropical Diseases (NTDs) is dependent on mass administration of medicines (MAM) in communities and schools by community drug distributers (CDDs) who are supported and supervised by health facility staff (FLHF) and teachers. Understanding how to motivate, retain and optimise their performance is essential to ensure communities accept medicines. This study aimed to capture and translate knowledge, problems and solutions, identified by implementers, to enhance NTD programme delivery at the community level in Nigeria.

METHODS

Qualitative data was collected through participatory stakeholder workshops organised around two themes: (i) identification of problems and (ii) finding solutions. Eighteen problem-focused workshops and 20 solution-focussed workshops were held with FLHF, CDDs and teachers in 12 purposively selected local government areas (LGA) across two states in Nigeria, Ogun and Kaduna States.

RESULT

The problems and solutions identified by frontline implementers were organised into three broad themes: technical support, social support and incentives. Areas identified for technical support included training, supervision, human resource management and workload, equipment and resources and timing of MAM implementation. Social support needs were for more equitable drug distributor selection processes, effective community sensitisation mechanisms and being associated with the health system. Incentives identified were both non-financial and financial including receiving positive community feedback and recognition and monetary remuneration. The results led to the development of the 'NTD frontline implementer's framework' which was adapted from the Community Health Worker (CHW) Generic Logic Model by Naimoli et al. (Hum Resour Health 12:56, 2014).

CONCLUSION

Maximising performance of frontline implementers is key to successful attainment of NTD goals and other health interventions. As NTDs are viewed as a 'litmus test' for universal health coverage, the lessons shared here could cut across programmes aiming to achieve equitable coverage. It is critical to strengthen the collaboration between health systems and communities so that together they can jointly provide the necessary support for frontline implementers to deliver health for all. This research presents additional evidence that involving frontline implementers in the planning and implementation of health interventions through regular feedback before, during and after implementation has the potential to strengthen health outcomes.

The division of labour between community medicine distributors influences the reach of mass drug administration: A cross-sectional study in rural Uganda

Background

Despite decades of community-based mass drug administration (MDA) for neglected tropical diseases, it remains an open question as to what constitutes the best combination of community medicine distributors (CMDs) for achieving high (>65%/75%) treatment rates within a village.

Methods

Routine community-based MDA was evaluated in Mayuge District, Uganda. For one month, we tracked 6,148 individuals aged 1+ years in 1,118 households from 28 villages. Praziquantel, albendazole, and ivermectin were distributed to treat Schistosoma mansoni, lymphatic filariasis, and soil-transmitted helminths. The similarity/diversity between CMDs was observed and used to predict the division of labour and overall village treatment rates. The division of labour was calculated by dividing the lowest treatment rate by the highest treatment rate achieved by two CMDs within a village. CMD similarity was measured for 16 characteristics including friendship network overlap, demographic and socioeconomic factors, methods of CMD selection, and years as CMD. Relevant variables for MDA outcomes were selected through least absolute shrinkage and selection operators with leave-one-out cross validation. Final models were run with ordinary least squares regression and robust standard errors.

Results

The percentage of individuals treated with at least one drug varied across villages from 2.79–89.74%. The only significant predictor (p-value<0.05) of village treatment rates was the division of labour. The estimated difference between a perfectly equal (a 50–50 split of individuals treated) and unequal (one CMD treating no one) division of labour was 39.69%. A direct tie (close friendship) between CMDs was associated with a nearly twofold more equitable distribution of labour when compared to CMDs without a direct tie.

Conclusions

An equitable distribution of labour between CMDs may be essential for achieving treatment targets of 65%/75% within community-based MDA. To improve the effectiveness of CMDs, national programmes should explore interventions that seek to facilitate communication, friendship, and equal partnership between CMDs.

Community-based mass drug administration (MDA) uses volunteers within at-risk communities to distribute preventive chemotherapies en masse for neglected tropical diseases. Treatment rates achieved by community medicine distributors (CMDs) vary widely and can undermine morbidity control. We studied routine community-based MDA in 28 villages near Lake Victoria in Uganda. There were two CMDs per village who were tasked with moving from home-to-home to administer praziquantel, albendazole, and ivermectin for schistosomiasis, lymphatic filariasis, and soil-transmitted helminths. We observed treatment outcomes for 6,148 eligible individuals aged 1+ years. Here we identified the best combination of CMD characteristics for achieving high village-level treatment rates. We found that a more equal division of labour (e.g. 50–50 split between how many people each CMD treated) was associated with higher treatment rates when compared to CMDs with an unequal division of labour (e.g. one CMD treating no one). CMDs who were friends were more likely to have a division of labour that was nearly twofold more equal than CMDs who were not friends. The similarity of CMDs with respect to network, demographic, or socioeconomic characteristics did not influence village treatment rates. National programmes should explore interventions that seek to facilitate communication, friendship, and equal partnership between CMDs.

Non-communicable disease clinics in rural Ethiopia: why patients are lost to follow-up

Background

Providing medical care for non-communicable diseases (NCDs) in rural sub-Saharan Africa has proved to be difficult because of poor treatment adherence and frequent loss to follow-up (LTFU). The reasons for this are poorly understood.

Objective

To investigate LTFU among patients with two different but common NCDs who attended rural Ethiopian health centres.

Method

The study was based in five health centres in southern Ethiopia with established NCD clinics run by nurses and health officers. Patients with epilepsy or hypertension who were lost to follow-up and non-LTFU comparison patients were identified and traced; a questionnaire was administered enquiring about the reasons for LTFU.

Results

Of the 147 LTFU patients successfully located, 62 had died, moved away or were attending other medical facilities. The remaining 85 patients were compared with 211 non-LFTU patients. The major factors associated with LTFU were distance from the clinic, associated costs and a preference for traditional treatments, together with a misunderstanding of the nature of NCD management.

Conclusions

The delivery of affordable care closer to the patients' homes has the greatest potential to address the problem of LTFU. Also needed are increased levels of patient education and interaction with traditional healers to explain the nature of NCDs and the need for life-long management.

Apology and Unintended Harm in Global Health

Over the past few decades, investments in global health programs have contributed to massive advances in health for human populations. As with clinical medicine, however, global health interventions sometimes result in unintended harm, economic adversity, or social disruption. In clinical medicine, when medical error occurs, it is increasingly common for health care workers to offer apology, which involves acknowledging the error, taking responsibility for it, and expressing genuine remorse. In addition, hospitals are beginning to offer affected patients and their families reparation or compensation in an attempt to restore patients' health and repair relationships, as well as take steps to prevent similar harm in the future. By contrast, little is known about apology and reparation for unintentional harm in global health practice. Several factors, including the scale of global health programs, diffusion of responsibility across international networks of state and non-state actors, and concern that acknowledging harm could threaten otherwise successful health programs, render apology and reparation in global health more difficult than in clinical medicine. This article examines how and when individuals and global health organizations address inadvertent harm, illustrated by four case studies. It also describes ethical, legal, and human rights principles that could inform a more systematic approach. Addressing unintended harm in global health requires further attention at the individual, organizational, and global levels.

Emerging Resistance of Neglected Tropical Diseases: A Scoping Review of the Literature

Background: Antimicrobial resistance (AMR) is a global public health threat with the potential to cause millions of deaths. There has been a tremendous increase in the use of antimicrobials, stemming from preventive chemotherapy elimination and control programs addressing neglected tropical diseases (NTDs). This study aims to identify the frequency of drug resistance for 11 major NTDs and 20 treatment drugs within a specific period by systematically analyzing the study design, socio-demographic factors, resistance, and countries of relevant studies. Methods: Adhering to PRISMA guidelines, we performed systematic reviews of the major 11 NTDs to identify publications on drug resistance between 2000 and 2016. A quality assessment tool adapted for evaluating observational and experimental studies was applied to assess the quality of eligible studies. Results: One of the major findings is that six NTDs have information on drug resistance, namely human African trypanosomiasis, leishmaniasis, onchocerciasis, schistosomiasis, soil-transmitted helminths, and trachoma. Many studies recorded resistance due to diagnostic tests, and few studies indicated clinical resistance. Although most studies were performed in Africa where there is the occurrence of several NTDs, there was no link between disease burden and locations of study. Conclusions: Based on this study we deduce that monitoring and surveillance systems need to be strengthened to enable the early detection of AMR and the mitigation of its global spread.

Wuchereria bancrofti-infected individuals harbor distinct IL-10-producing regulatory B and T cell subsets which are affected by anti-filarial treatment

Despite worldwide mass drug administration, it is estimated that 68 million individuals are still infected with lymphatic filariasis with 19 million hydrocele and 17 million lymphedema reported cases. Despite the staggering number of pathology cases, the majority of LF-infected individuals do not develop clinical symptoms and present a tightly regulated immune system characterized by higher frequencies of regulatory T cells (Treg), suppressed proliferation and Th2 cytokine responses accompanied with increased secretion of IL-10, TGF-β and infection-specific IgG4. Nevertheless, the filarial-induced modulation of the host`s immune system and especially the role of regulatory immune cells like regulatory B (Breg) and Treg during an ongoing LF infection remains unknown. Thus, we analysed Breg and Treg frequencies in peripheral blood from Ghanaian uninfected endemic normals (EN), lymphedema (LE), asymptomatic patent (CFA+MF+) and latent (CFA+MF-) W. bancrofti-infected individuals as well as individuals who were previously infected with W. bancrofti (PI) but had cleared the infection due to the administration of ivermectin (IVM) and albendazole (ALB). In summary, we observed that IL-10-producing CD19⁺CD24^highCD38d^high Breg were specifically increased in patently infected (CFA+MF+) individuals. In addition, CD19⁺CD24^highCD5⁺CD1d^high and CD19⁺CD5⁺CD1d^highIL-10⁺ Breg as well as CD4⁺CD127^-FOXP3⁺ Treg frequencies were significantly increased in both W. bancrofti-infected cohorts (CFA+MF+ and CFA+MF-). Interestingly, the PI cohort presented frequency levels of all studied regulatory immune cell populations comparable with the EN group. In conclusion, the results from this study show that an ongoing W. bancrofti infection induces distinct Breg and Treg populations in peripheral blood from Ghanaian volunteers. Those regulatory immune cell populations might contribute to the regulated state of the host immune system and are probably important for the survival and fertility (microfilaria release) of the helminth.

Regulation of the host`s immune system by filarial nematodes is crucial for the fertility and survival of the nematode. Indeed, the majority of W. bancrofti-infected individuals are characterized by a regulated state including increased regulatory T cells (Treg), IL-10, TGF-β and filarial-specific IgG4 and suppressed Th2 cytokine responses. However, the functional role of Treg populations and regulatory B cells (Breg) during filarial infection remains unknown. Thus, in this study we investigated whether W. bancrofti-infected individuals from Ghana harbored distinct Breg and Treg populations which might be important for filarial-specific immunomodulation. Overall, this study shows that W. bancrofti induces distinct Breg populations, especially in patently (microfilaremic) infected individuals who presented significantly increased frequencies of IL-10-producing CD19<sup>+</sup>CD24<sup>high</sup>CD38d<sup>high</sup> Breg. Furthermore, clearance of the infection, due to anti-filarial treatment, returned these regulatory immune cells to homeostatic levels showing that an ongoing filarial infection is important for the activation of distinct Breg and Treg subsets. Those regulatory immune cell subsets are a part of a complex system which are induced by filarial nematodes to modulate the host`s immune system and maintain long-term survival.

Barriers to the National Onchocerciasis Control Programme at operational level in Cameroon: a qualitative assessment of stakeholders' views

Background

The global burden of onchocerciasis is the heaviest in sub-Saharan Africa. Studies have shown the importance of the role of Community-Directed Distributors (CDDs) and nurses in onchocerciasis control, but little is known about their experience in implementing onchocerciasis control programmes. Our aim was to document the barriers that CDDs and local health administrators face in implementing onchocerciasis control activities.

Methods

We conducted a qualitative survey consisting of 16 in-depth interviews and 8 focus group discussions (FGDs) across three health districts of Cameroon. We interviewed a total of 9 local health officials at the district and Health Area levels, and 7 CDDs. Eight FGDs were conducted with CDDs and Health Committee members.

Results

The major barriers to the implementation of Community Directed Treatment with Ivermectin that we identified were linked and interrelated. Examples of these barriers included: contextual factors (geographical and cultural background), top-to-bottom planning, insufficient human and material resources, and lack of transparency in the management of the programme’s funds.

Conclusions

The CDTI at operational level still faces many obstacles which negatively affect therapeutic coverages. This can lead to the non-adhesion of the communities to the programme, consequently jeopardizing the sustainability of the onchocerciasis elimination programme. We recommend that the national programme planners put in place a transparent management and planning system for onchocerciasis elimination activities, with better communication with local programme stakeholders.

"For how long are we going to take the tablets?" Kenyan stakeholders' views on priority investments to sustainably tackle soil-transmitted helminths

Recent global commitments to shift responsibility for Neglected Tropical Disease (NTD) control to affected countries reflect a renewed emphasis on sustainability, away from aid-dependency. This calls for a better understanding of how domestic stakeholders perceive investments in different strategies for NTD control. Soil transmitted helminths (STH) are among the NTDs targeted for elimination as a public health problem by international agencies through mass drug administration, provided periodically to at-risk population groups, often using drugs donated by pharmaceutical companies. This study was conducted in Kenya at a time when responsibilities for long running STH programmes were transitioning from external to national and sub-national agencies. Following an initial assessment in which we identified key domestic stakeholders and reviewed relevant scientific and government documents, the perspectives of stakeholders working in health, education, community engagement and sanitation were investigated through semi-structured interviews with national level policymakers, county level policymakers, and frontline implementers in one high-STH burden county, Kwale. Our conceptual framework on sustainability traced a progression in thinking, from ensuring financial stability through the technical ability to adapt to changing circumstances, and ultimately to a situation where a programme is prioritised by domestic policymakers because empowered communities demand it. It was clear from our interviews that most Kenyan stakeholders sought to be at the final stage in this progression. Interviewees criticised long-term investment in mass drug administration, the approach favoured predominantly by external agencies, for failing to address underlying causes of STH. Instead they identified three synergistic priority areas for investment: changes in institutional structures and culture to reduce working in silos; building community demand and ownership; and increased policymaker engagement on underlying socioeconomic and environmental causes of STH. Although challenging to implement, the shift in responsibility from external agencies to domestic stakeholders may lead to emergence of new strategic directions.

Profiling the best-performing community medicine distributors for mass drug administration: a comprehensive, data-driven analysis of treatment for schistosomiasis, lymphatic filariasis, and soil-transmitted helminths in Uganda

BACKGROUND

The most prevalent neglected tropical diseases are treated through blanket drug distribution that is reliant on lay community medicine distributors (CMDs). Yet, treatment rates achieved by CMDs vary widely and it is not known which CMDs treat the most people.

METHODS

In Mayuge District, Uganda, we tracked 6779 individuals (aged 1+ years) in 1238 households across 31 villages. Routine, community-based mass drug administration (MDA) was implemented for schistosomiasis, lymphatic filariasis, and soil-transmitted helminths. For each CMD, the percentage of eligible individuals treated (offered and ingested medicines) with at least one drug of praziquantel, albendazole, or ivermectin was examined. CMD attributes (more than 25) were measured, ranging from altruistic tendencies to socioeconomic characteristics to MDA-specific variables. The predictors of treatment rates achieved by CMDs were selected with least absolute shrinkage and selection operators and then analyzed in ordinary least squares regression with standard errors clustered by village. The influences of participant compliance and the ordering of drugs offered also were examined for the treatment rates achieved by CMDs.

RESULTS

Overall, only 44.89% (3043/6779) of eligible individuals were treated with at least one drug. Treatment rates varied amongst CMDs from 0% to 84.25%. Treatment rate increases were associated (p value< 0.05) with CMDs who displayed altruistic biases towards their friends (13.88%), had friends who helped with MDA (8.43%), were male (11.96%), worked as fishermen/fishmongers (14.93%), and used protected drinking water sources (13.43%). Only 0.24% (16/6779) of all eligible individuals were noncompliant by refusing to ingest all offered drugs. Distributing praziquantel first was strongly, positively correlated (p value < 0.0001) with treatment rates for albendazole and ivermectin.

CONCLUSIONS

These findings profile CMDs who treat the most people during routine MDA. Criteria currently used to select CMDs-community-wide meetings, educational attainment, age, years as a CMD, etc.-were uninformative. Participant noncompliance and the provision of praziquantel before albendazole and ivermectin did not negatively impact treatment rates achieved by CMDs. Engaging CMD friend groups with MDA, selecting CMDs who practise good preventative health behaviours, and including CMDs with high-risk occupations for endemic infections may improve MDA treatment rates. Evidence-based guidelines are needed to improve the monitoring, selection, and replacement of CMDs during MDA.

Mapping and modelling the impact of mass drug adminstration on filariasis prevalence in Myanmar

BACKGROUND

Lymphatic filariasis (LF) is endemic in Myanmar and targeted for elimination. To highlight the National Programme to Eliminate Lymphatic Filariasis (NPELF) progress between 2000 and 2014, this paper describes the geographical distribution of LF, the scale-up and impact of mass drug administration (MDA) implementation, and the first evidence of the decline in transmission in five districts.

METHODS

The LF distribution was determined by mapping historical and baseline prevalence data collected by NPELF. Data on the MDA implementation, reported coverage rates and sentinel site surveillance were summarized. A statistical model was developed from the available prevalence data to predict prevalence at township level by year of measurement. Transmission assessment survey (TAS) methods, measuring antigenemia (Ag) prevalence in children, were used to determine whether prevalence was below a level where recrudescence is unlikely to occur.

RESULTS

The highest baseline LF prevalence was found in the Central Valley region. The MDA implementation activities scaled up to cover 45 districts, representing the majority of the endemic population, with drug coverage rates ranging from 60.0% to 98.5%. Challenges related to drug supply and local conflict were reported, and interrupted MDA in some districts. Overall, significant reductions in LF prevalence were found, especially after the first 2 to 3 rounds of MDA, which was supported by the corresponding model. The TAS activities in five districts found only two Ag positive children, resulting in all districts passing the critical threshold.

CONCLUSION

Overall, the Myanmar NPELF has made positive steps forward in the elimination of LF despite several challenges, however, it needs to maintain momentum, drawing on international stakeholder support, to aim towards the national and global goals of elimination.

Assessing knowledge about lymphatic filariasis and the implementation of mass drug administration amongst drug deliverers in three districts/cities of Indonesia

Background

This research assesses knowledge amongst drug deliverers about the implementation of mass drug administration (MDA) for lymphatic filariasis (LF) in Agam District (West Sumatera Province), the City of Depok (West Java Province) and the City of Batam (Kepulauan Riau Province), Indonesia.

Methods

A cross-sectional survey was conducted from January to March 2015 at these three sites. Respondents were identified using purposive sampling (i.e. cadre, health worker or community representatives). A total of 318 questionnaires were accepted for analysis. Three outcomes were assessed: knowledge about LF; knowledge about MDA implementation; and was informed about MDA coverage. Logistic regression analyses were employed to examine factors associated with these three outcomes.

Results

Less than half of respondents were charactersised as having a high level of LF knowledge and less than half a high level of knowledge about MDA. The odds of having a high level of knowledge of LF was significantly lower in Batam City than Agam District, yet higher amongst health workers than cadres. Deliverers living in urban areas reported more feedback on MDA outcomes than in the rural district. Health workers received more feedback than cadres (P < 0.001). Deliverers perceived the difference between coverage (drug receipt) and compliance (drug ingestion) in the community.

Conclusions

There are variations in knowledge about LF and MDA as well as feedback across drug deliverers in MDA across geographical areas. Adaptation of the MDA guidelines, supportive supervision, increasing the availability of supporting materials and directly-observed therapy might be beneficial to improve coverage and compliance in all areas.