Quantifying Population Burden and Effectiveness of Decentralized Surveillance Strategies for Skin-Presenting Neglected Tropical Diseases, Liberia

Validation of routine lymphatic filariasis morbidity surveillance in the Upper West Region, Ghana

In Ghana and other countries pursuing elimination of lymphatic filariasis (LF), suspect cases of lymphoedema and hydrocele are routinely enumerated by community health workers (CHWs) during mass drug administration (MDA). These data, in addition to cases captured through the routine out-patient department are used for burden estimation and health service planning. To date there has been no systematic evaluation of the reliability of these data in Ghana. In December 2022, we conducted a cross-sectional survey of LF morbidity in two evaluation units in the Upper West Region of Ghana, including 19,180 participants. Participants with swelling affecting the scrotum or limbs were examined by clinicians to confirm whether symptoms were due to LF. Participants were asked whether their household had been visited by a CHW during the previous MDA. Suspect cases were asked whether they had reported their condition to a CHW or sought care elsewhere. We estimated the prevalence of each condition according to survey data and pre-existing routine data collected by CHWs and compared estimates. Lymphoedema prevalence rates were 87.3 and 61.2 per 10,000 in the two evaluation units, and hydrocele prevalence rates were 111.3 and 65.3 per 10,000 males. Routine enumeration underestimated lymphoedema prevalence by 81% in both cases, and underestimated hydrocele prevalence by 41%-52%. Nearly all households were visited during the previous MDA, but only 60.7% of lymphoedema and 28.3% of hydrocele cases had reported symptoms. 61.8% of lymphoedema and 42.9% of hydrocele cases had sought care from health facilities. Routine surveillance underestimates the prevalence of LF morbidity in the study area. Process modifications, including re-training of CHWs and health workers should be considered to improve data for service planning and validation of LF elimination. Anticipating cessation of MDA, continuous health service delivery, with periodic coverage evaluation, should be prioritised to strengthen passive surveillance.

Public health surveillance through community health workers: a scoping review of evidence from 25 low-income and middle-income countries

BACKGROUND

The last 3 years have witnessed global health challenges, ranging from the pandemics of COVID-19 and mpox (monkeypox) to the Ebola epidemic in Uganda. Public health surveillance is critical for preventing these outbreaks, yet surveillance systems in resource-constrained contexts struggle to provide timely disease reporting. Although community health workers (CHWs) support health systems in low-income and middle-income countries (LMICs), very little has been written about their role in supporting public health surveillance. This review identified the roles, impacts and challenges CHWs face in public health surveillance in 25 LMICs.

METHODS

We conducted a scoping review guided by Arksey and O'Malley's framework. We exported 1,156 peer-reviewed records from Embase, Global Health and PubMed databases. After multiple screenings, 29 articles were included in the final review.

RESULTS

CHWs significantly contribute to public health surveillance in LMICs including through contact tracing and patient visitation to control major infectious diseases such as HIV/AIDS, malaria, tuberculosis, Ebola, neglected tropical diseases and COVID-19. Their public health surveillance roles typically fall into four main categories including community engagement; data gathering; screening, testing and treating; and health education and promotion. The use of CHWs in public health surveillance in LMICs has been impactful and often involves incorporation of various technologies leading to improved epidemic control and disease reporting. Nonetheless, use of CHWs can come with four main challenges including lack of education and training, lack of financial and other resources, logistical and infrastructural challenges as well as community engagement challenges.

CONCLUSION

CHWs are important stakeholders in surveillance because they are closer to communities than other healthcare workers. Further integration and training of CHWs in public health surveillance would improve public health surveillance because CHWs can provide health data on 'hard-to-reach' populations. CHWs' work in public health surveillance would also be greatly enhanced by infrastructural investments.

Multimethod evaluation of health services integration for neglected tropical diseases requiring case management in Liberia

INTRODUCTION

The WHO neglected tropical disease (NTD) roadmap stresses the importance of integrating NTDs requiring case management (CM) within the health system. The NTDs programme of Liberia is among the first to implement an integrated approach and evaluate its impact.

METHODS

A retrospective study of three of five CM-NTD-endemic counties that implemented the integrated approach was compared with cluster-matched counties with non-integrated CM-NTD. We compared trends in CM-NTD integrated versus non-integrated county clusters. We conducted a pre-post comparison of WHO high-level outcomes using data collected during intervention years compared with baseline in control counties. Changes in health outcomes, effect sizes for different diseases and rate ratios with statistically significant differences were determined. Complementary qualitative research explored CM-NTD stakeholders' perceptions, analysed through the framework approach, which is a transparent, multistage approach for qualitative thematic interdisciplinary data analysis.

RESULTS

The detection rates for all diseases combined improved significantly in the intervention compared with the control clusters. Besides leprosy, detection rates improved with large effects, over fourfold increase with statistically significant effects for individual diseases (p<0.000; 95% CI 3.5 to 5.4). Access to CM-NTD services increased in integrated counties by 71 facilities, compared with three facilities in non-integrated counties. Qualitative findings highlight training and supervision as inputs underpinning increases in case detection, but challenges with refresher training, medicine supply and incentives negatively impact quality, equity and access.

CONCLUSIONS

Integrating CM-NTDs improves case detection, accessibility and availability of CM-NTD services, promoting universal health coverage. Early case detection and the quality of care need further strengthening.