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

Rafenoarimalala F, Finnegan KE, Rakotonirina L, Razafinjato B, H. Bonds M, V. Evans M, Garchitorena A. Combining OpenStreetMap mapping and route optimization algorithms to inform the delivery of community health interventions at the last mile

Community health programs are gaining relevance within national health systems and becoming inherently more complex. To ensure that community health programs lead to equitable geographic access to care, the WHO recommends adapting the target population and workload of community health workers (CHWs) according to the local geographic context and population size of the communities they serve. Geographic optimization could be particularly beneficial for those activities that require CHWs to visit households door-to-door for last mile delivery of care. The goal of this study was to demonstrate how geographic optimization can be applied to inform community health programs in rural areas of the developing world. We developed a decision-making tool based on OpenStreetMap mapping and route optimization algorithms in order to inform the micro-planning and implementation of two kinds of community health interventions requiring door-to-door delivery: mass distribution campaigns and proactive community case management (proCCM) programs. We applied the Vehicle Routing Problem with Time Windows (VRPTW) algorithm to optimize the on-foot routes that CHWs take to visit households in their catchment, using a geographic dataset obtained from mapping on OpenStreetMap comprising over 100,000 buildings and 20,000 km of footpaths in the rural district of Ifanadiana, Madagascar. We found that personnel-day requirements ranged from less than 15 to over 60 per CHW catchment for mass distribution campaigns, and from less than 5 to over 20 for proCCM programs, assuming 1 visit per month. To illustrate how these VRPTW algorithms can be used by operational teams, we developed an "e-health" platform to visualize resource requirements, CHW optimal schedules and itineraries according to customizable intervention designs and hypotheses. Further development and scale-up of these tools could help optimize community health programs and other last mile delivery activities, in line with WHO recommendations, linking a new era of big data analytics with the most basic forms of frontline care in resource poor areas.

Policy and Executive Barriers in Preventing and Eradicating Neglected Tropical Diseases: A Systematic Review

Background

Tropical diseases inflict many of those living in tropical and subtropical areas each year. These populations because of these diseases suffer considerable financial and human losses. Some of these diseases are known as Neglected Tropical Diseases (NTDs) and they can be highly dangerous. Still, they have not received the attention they need. Given the necessity of eliminating these diseases, the present study is an attempt to examine the reasons for unsuccessful attempts to eliminate diseases like NTDs.

Methods

The current study was a systematic analysis of literature on neglected tropical diseases that were found in the databases of the Web of Science, PubMed, Scopus, Science Direct, Pro Quest, Cochrane, and Embase before April 2023. The Critical Appraisal Skills Program (CASP) for articles and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria were used to conduct the study.

Results

Based on the systematic search, 3193 papers were found and after the elimination of duplicates and irrelevant ones, a total of 28 articles remained to examine the challenges to eradicate neglected tropical diseases. Four themes were found for the challenges of controlling and eliminating neglected tropic diseases including drawbacks of programs for disease management policies, environmental challenges, executive challenges, and research field challenges. Thirty-six subthemes were obtained in this study, which showed cases such as the presence of immigrants and refugees, weaknesses in public health infrastructure and programs, dynamic epidemiological settings, lack of executive prioritization appropriate to endemic countries, and highly customized research infrastructures. Ending neglected tropical diseases requires an innovative roadmap and global cooperation.

Conclusions

To achieve important eradication goals, measures such as acceleration in practice are needed to plan, intensify executive and operational approaches, change application models, innovate processes, and promote culture are needed. In addition, to make possible the elimination of neglected tropical diseases, there is an undeniable need for providing financial, human, and research resources. In addition, there is a need for efficient health infrastructure management, paying attention to migrants and refugees, setting explicit targets, prioritizing based on local conditions, and paying more attention to political and social developments.

Understanding the barriers and facilitators related to never treatment during mass drug administration among mobile and migrant populations in Mali: a qualitative exploratory study

INTRODUCTION

Five of the neglected tropical diseases use a strategy of preventative chemotherapy distributed via mass drug administration (MDA) for all eligible people living in endemic areas. To be successful, high coverage must be sustained over multiple rounds. Therefore, it will be difficult to reach elimination as a public health problem using MDA if there remain clusters of people who have never been treated. The study aims to explore the reasons why people with high mobility report being never treated during MDA and to provide evidence to support the development of standardised questions for data collection using qualitative research tools.

METHODS

We conducted an exploratory study using qualitative methods among displaced people, nomads/transhumants and economic migrants who self-reported that they had never been treated during MDA in the health districts of Tominian and Kalabancoro in Mali. Data were collected through in-depth individual interviews and focus group discussions. Nvivo V.14 software was used for data management and analysis.

RESULTS

The main reasons reported for never treatment included: geographical mobility, lack of awareness/information, negative rumours, fear of side effects, conflict and insecurity and logistical difficulties faced in reaching these populations. Proposed solutions included involving communities in the MDA, increasing awareness and information campaigns, effectively managing side effects, and designing and implementing flexible and effective interventions.

CONCLUSION

This study highlights that there are people with high mobility who may never have been treated during any round of MDA. The reasons for never treatment highlight the challenges faced when reaching particular groups during MDA activities/interventions. Suggested remedies will require programmes to implement more flexible and tailored interventions. Customised approaches based on the context are essential to guarantee fair access to preventive chemotherapy. Effective interventions must consider the supply and demand side in crafting interventions. This research adds to the evidence base to understand never treatment, particularly among highly mobile population groups and in schistosomiasis elimination programmes.

Detection of Wuchereria bancrofti in human blood samples and mosquitoes in Matayos, Busia County-Kenya

Lymphatic filariasis is a mosquito borne disease which leads to abnormal painful enlarged body parts, severe disability and social stigma. We screened Wuchereria bancrofti in Matayos constituency in Busia County. Blood samples were collected from 23 villages selected purposively based on clinical case reports. Finger prick and/or venous blood sampling and mosquito collections was carried out. Antigenaemia and filarial DNA prevalence were determined. Infection rates on mosquito pools were estimated and SPSS version 26 was used for descriptive statistics analysis. A total of 262 participants were recruited, 73.3% (n = 192) of the participants had no symptoms, 14.1% (n = 5.3) had swollen legs, 5.3% (n = 14) had painful legs and 3.8% (n = 10) with scrotal swellings. Average antigenemia prevalence was 35.9% (n = 94) and DNA prevalence was at 8.0% (n = 21). A total of 1305 mosquitoes were collected and pooled into 2-20 mosquitoes of the same species and from the same village. Two pools out of 78 were positive for filarial DNA with a minimum infection rate of 0.15%. From this study, antigenaemia and infected mosquitoes are an indication of active transmission. The clinical signs are evidence that filarial infections have been in circulation for over 10 years. The global climate change phenomenon currently happening has been shown to adversely affect the transmission of vector borne diseases and is likely to increase lymphatic filariasis transmission in the area. This study therefore recommends further screening before Mass Drug Administration, morbidity management and enhanced mosquito control Programmes are recommended in the study area.

Tixagevimab and Cilgavimab Administration for Hemodialysis Patients at Community-Based Dialysis Centers in Singapore as Pre-Exposure Prophylaxis for SARS-CoV-2 Infection

INTRODUCTION

 Hemodialysis patients are deemed to be immunosuppressed and may not be able to mount an adequate response to vaccination against the SARS-CoV-2 virus. Due to the higher morbidity and mortality in this vulnerable group, pre-exposure prophylaxis with monoclonal antibodies was introduced as an additional measure for protection in selected community-based hemodialysis patients in Singapore. Tixagevimab and cilgavimab, available as Evusheld, were used for this purpose.

METHODS

 A government-sponsored clinical administration program with the provision of 200 doses of Evusheld at no cost to the patients was implemented. Patient selection criteria to further risk-stratify this vulnerable hemodialysis patient cohort was developed and 200 patients were finally selected. Evusheld administration was done over a period of two months, as two consecutive injections were given at two separate intramuscular sites, which constituted one administration. Data were collected as part of a retrospective clinical audit, as part of a routine quality monitoring process for this patient care program. Real-world evidence was generated to assess the impact on mortality, hospitalization rate, reason for hospitalization, and any associated morbidity.

RESULTS

 No adverse events from the Evusheld administration were noted. All recipients had received COVID-19 vaccinations prior to Tixa-Cilga, with a range of one to five doses. A total of 198 (99%) completed two doses and 189 (95%) completed three doses, out of which, 14 (7%) patients contracted COVID-19 infection over three months. The overall hospitalization rate was 2% (four out of 200 patients). Severe illness that required intensive care unit stay was therefore seen in only 2 (1%) out of 200 patients. None of the infected patients died.

DISCUSSION

 A significant reduction in severity of illness, hospitalization rate, and mortality was found with pre-exposure prophylaxis with tixagevimab and cilgavimab, in this real-world experience from Singapore. Evusheld administration reduced the hospitalization rate from 42.5% to 2%, which is a reduction of 95.3% (p<0.0001). Symptoms in infected patients were mild, with only 1% being admitted to the intensive care unit. The mortality rate from COVID-19 infection was reduced from 2.5% to 0% with Evusheld.  Conclusion: Mass administration of prophylactic treatments for vulnerable populations can be challenging in community-based settings and the successful implementation of such a program has been described. The findings can have health policy implications for the protection of such immunocompromised patients in the future. The combination of tixagevimab and cilgavimab, available as Evusheld in Singapore, was safe to use in hemodialysis patients, with no adverse events noted. There was a significant reduction in hospitalization rates and intensive care unit admissions with a zero-mortality rate due to COVID-19 infection, after pre-exposure prophylaxis.

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.

Finding and eliminating the reservoirs: Engage and treat, and test and treat strategies for lymphatic filariasis programs to overcome endgame challenges

Many lymphatic filariasis (LF) endemic countries, including Ghana, have successfully implemented mass drug administration (MDA) and made significant progress towards the elimination of the disease as a public health problem. Unfortunately, the existence of individuals who seldom or never take part in MDA pose a threat to this success, as they may serve as reservoirs of infection, re-infecting their communities. In this study we implemented strategies to identify and treat these individuals, while also assessing their level of infection, to inform programme actions. The study was undertaken in the Ahanta West hotspot district in Ghana, which has received more than 17 rounds of MDA. Through the community registers used in recording participation in MDAs, we identified and offered treatment to individuals who were ineligible or inadvertently missed the last MDA in April 2021 (Engage and Treat – E&amp;T), or testing using the filariasis test strip followed by treatment to community members who for various reasons chose not to participate in the last MDA (Test and Treat – T&amp;T). During the study, 23,879 individuals ranging from 5 to 98 years were reached, of whom 78% were not captured in the MDA register. Among the E&amp;T group, 75.06% willingly received and swallowed the treatment drugs. The remaining 24.94% were offered testing followed by a re-engagement to receive the drug in the T&amp;T group. Overall, 22,830 (95.61%) of participants were treated by either strategy. Of the participants in the T&amp;T group, 516 (8.66%; 95% CI= 7.96 – 9.41) were positive by the FTS. The highest antigen prevalence was detected among children 5 to 10 years, with 16.59% (95% CI= 12.02 – 22.06) and 22.54% (95% CI= 17.11 – 28.74) among females and males, respectively. Mapping of the data revealed that most infections are in a few select communities. Of the 516 FTS positives, 27.33% reportedly missed MDA once, 18.41% missed MDA twice and 54.26% missed all of the last three MDAs. The main reasons for missing MDA included absence (25.49%), travel (21.24%), being unaware of MDA (20.27%), refusals to take the drug (10.65%), illnesses (7.07%) and fear of adverse events (6.13%). This study demonstrates that greater sensitization and engagement strategies, with a test and treat strategy reserved for the most hesitant individuals, could significantly increase the number of individuals who receive treatment and therefore help districts reach their elimination targets by reducing the remaining reservoir or infection. NTD programmes require new tools to help them identify, engage and treat these individuals, as part of their overall monitoring and evaluation strategy.

Defining optimal implementation packages for delivering community-wide mass drug administration for soil-transmitted helminths with high coverage

BACKGROUND

Recent evidence suggests that community-wide mass drug administration (MDA) may interrupt the transmission of soil-transmitted helminths (STH), a group of intestinal worms that infect 1.5 billion individuals globally. Although current operational guidelines provide best practices for effective MDA delivery, they do not describe which activities are most essential for achieving high coverage or how they work together to produce effective intervention delivery. We aimed to identify the various packages of influential intervention delivery activities that result in high coverage of community-wide MDA for STH in Benin, India, and Malawi.

METHODS

We applied coincidence analysis (CNA), a novel cross-case analytical method, to process mapping data as part of the implementation science research of the DeWorm3 Project, a Hybrid Type 1 cluster randomized controlled trial assessing the feasibility of interrupting the transmission of STH using bi-annual community-wide MDA in Benin, India, and Malawi. Our analysis aimed to identify any necessary and/or sufficient combinations of intervention delivery activities (i.e., implementation pathways) that resulted in high MDA coverage. Activities were related to drug supply chain, implementer training, community sensitization strategy, intervention duration, and implementation context. We used pooled implementation data from three sites and six intervention rounds, with study clusters serving as analytical cases (N = 360). Secondary analyses assessed differences in pathways across sites and over intervention rounds.

RESULTS

Across all three sites and six intervention rounds, efficient duration of MDA delivery (within ten days) singularly emerged as a common and fundamental component for achieving high MDA coverage when combined with other particular activities, including a conducive implementation context, early arrival of albendazole before the planned start of MDA, or a flexible community sensitization strategy. No individual activity proved sufficient by itself for producing high MDA coverage. We observed four possible overall models that could explain effective MDA delivery strategies, all which included efficient duration of MDA delivery as an integral component.

CONCLUSION

Efficient duration of MDA delivery uniquely stood out as a highly influential implementation activity for producing high coverage of community-wide MDA for STH. Effective MDA delivery can be achieved with flexible implementation strategies that include various combinations of influential intervention components.

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.