Assessing Lymphatic Filariasis Data Quality in Endemic Communities in Ghana, Using the Neglected Tropical Diseases Data Quality Assessment Tool for Preventive Chemotherapy

Modelling the cost of engage & treat and test & treat strategies towards the elimination of lymphatic filariasis in Ghana

BACKGROUND

Despite several years of LF-MDA implementation, Ghana still has some districts with mf prevalence >1%, partly due to poor treatment coverage levels resulting from non-participation in MDA. To address the challenges, we implemented Engage & Treat (E&T) and Test & Treat (T&T) strategies for individuals who miss or refuse MDA respectively, in a hotspot district, enabling us to reach many of those who seldom, or never, take part in MDA. This financial cost study was undertaken to analyse data on the LF-MDA, E&T and T&T implementation in 2021 and the financial cost to inform the rollout of the E&T and T&T as mop-up strategies in future LF-MDAs.

METHODS

This costing study analysed cost data from the 2021 LF-MDA implementation activities carried out by the Neglected Tropical Diseases (NTD) programme of the Ghana Health Service and the SENTINEL study, carried out in Ahanta West district for the two interventions (i.e., E&T and T&T). The 2021 Ghana Population and Housing Census data was used to estimate the LF-MDA-eligible population. The financial cost per person treated was estimated and these costs were applied to the projected population to obtain the financial cost for subsequent years.

RESULTS

Implementing MDA mop-up strategies either through the E&T or T&T to improve coverage comes at an additional cost to the elimination goals. For example, in 2024 the projected cost per person treated by the routine LF-MDA is estimated at US$0.83. The cost using the integrated LF-MDA and the E&T, T&T led by the NTD programme or T&T integrated into the health system was estimated at US$1.62, US$2.88, and US$2.33, respectively, for the same year. Despite the increased cost, the proposed combined LF-MDA and mop-up strategies will have a higher estimated population treated for 2024 (i.e., 1,392,211) compared to the routine LF-MDA approach (i.e., 988,470) for the same year.

CONCLUSION

Combining LF-MDA with E&T/T&T mop-up strategies, despite their high costs, may provide NTD Programmes with the options of improving treatment coverage and reaching the LF elimination target sooner, given that the routine LF-MDA alone approach has been implemented for many years with some districts yet to reach the elimination targets.

How well do coverage surveys and programmatically reported mass drug administration coverage match? Results from 214 mass drug administration campaigns in 15 countries, 2008-2017

INTRODUCTION

Delivering preventive chemotherapy through mass drug administration (MDA) is a central approach in controlling or eliminating several neglected tropical diseases (NTDs). Treatment coverage, a primary indicator of MDA performance, can be measured through routinely reported programmatic data or population-based coverage evaluation surveys. Reported coverage is often the easiest and least expensive way to estimate coverage; however, it is prone to inaccuracies due to errors in data compilation and imprecise denominators, and in some cases measures treatments offered as opposed to treatments swallowed.

OBJECTIVE

Analyses presented here aimed to understand (1) how often coverage calculated using routinely reported data and survey data would lead programme managers to make the same programmatic decisions; (2) the magnitude and direction of the difference between these two estimates, and (3) whether there is meaningful variation by region, age group or country.

METHODS

We analysed and compared reported and surveyed treatment coverage data from 214 MDAs implemented between 2008 and 2017 in 15 countries in Africa, Asia and the Caribbean. Routinely reported treatment coverage was compiled using data reported by national NTD programmes to donors, either directly or via NTD implementing partners, following the implementation of a district-level MDA campaign; coverage was calculated by dividing the number of individuals treated by a population value, which is typically based on national census projections and occasionally community registers. Surveyed treatment coverage came from post-MDA community-based coverage evaluation surveys, which were conducted as per standardised WHO recommended methodology.

RESULTS

Coverage estimates using routine reporting and surveys gave the same result in terms of whether the minimum coverage threshold was reached in 72% of the MDAs surveyed in the Africa region and in 52% in the Asia region. The reported coverage value was within ±10 percentage points of the surveyed coverage value in 58/124 of the surveyed MDAs in the Africa region and 19/77 in the Asia region. Concordance between routinely reported and surveyed coverage estimates was 64% for the total population and 72% for school-age children. The study data showed variation across countries in the number of surveys conducted as well as the frequency with which there was concordance between the two coverage estimates.

CONCLUSIONS

Programme managers must grapple with making decisions based on imperfect information, balancing needs for accuracy with cost and available capacity. The study shows that for many of the MDAs surveyed, based on the concordance with respect to reaching the minimum coverage thresholds, the routinely reported data were accurate enough to make programmatic decisions. Where coverage surveys do show a need to improve accuracy of routinely reported results, NTD programme managers should use various tools and approaches to strengthen data quality in order to use data for decision-making to achieve NTD control and elimination goals.

Rapid ethnography and participatory techniques increase onchocerciasis mass drug administration treatment coverage in Benin: a difference-in-differences analysis

BACKGROUND

Onchocerciasis, a neglected tropical disease (NTD) that causes blindness, is controlled via mass drug administration (MDA) where entire endemic communities are targeted with preventative chemotherapeutic treatment. However, in many settings, MDA coverage remains low. The purpose of this project was to determine if engaging communities in the development of implementation strategies improves MDA coverage.

METHODS

This study took place in an intervention and a control commune in Benin, West Africa. We conducted rapid ethnography in each commune to learn about community member perceptions of onchocerciasis, MDA, and opportunities to increase MDA coverage. Findings were shared with key stakeholders and a structured nominal group technique was used to derive implementation strategies most likely to increase treatment coverage. The implementation strategies were delivered prior to and during onchocerciasis MDA. We conducted a coverage survey within 2 weeks of MDA to determine treatment coverage in each commune. A difference-in-differences design was used to determine if the implementation package effectively increased coverage. A dissemination meeting was held with the NTD program and partners to share findings and determine the perceived acceptability, appropriateness, and feasibility of implementing rapid ethnography as part of routine program improvement.

RESULTS

During rapid ethnography, key barriers to MDA participation included trust in community drug distributors, poor penetration of MDA programs in rural or geographically isolated areas, and low demand for MDA among specific sub-populations driven by religious or socio-cultural beliefs. Stakeholders developed a five-component implementation strategy package, including making drug distributor trainings dynamic, redesigning distributor job aids, tailoring community sensitization messages, formalizing supervision, and preparing local champions. After implementing the strategy package, MDA coverage increased by 13% (95% CI: 11.0-15.9%) in the intervention commune relative to the control commune. Ministry of Health and implementing partners found the approach to be largely acceptable and appropriate; however, there was mixed feedback regarding the feasibility of future implementation of rapid ethnography.

CONCLUSIONS

Implementation research conducted in Benin, and indeed throughout sub-Saharan Africa, is often implemented in a top-down manner, with both implementation determinants and strategies derived in the global North. This project demonstrates the importance of participatory action research involving community members and implementers to optimize program delivery.

The Impact of Mass Drug Administration on Lymphatic Filariasis

Mass drug administration (MDA) has made a significant impact on the control of lymphatic filariasis (LF) since the establishment of the Global Programme to Eliminate Lymphatic Filariasis. However, its implementation is associated with several challenges, hampering interruption of parasite transmission and LF elimination in endemic areas. This study assessed the impact of MDA by comparing baseline microfilaria and antigen prevalence with those after three years (mid-term) and ≥5 years of MDA implementation and their respective prevalence reductions and identified specific challenges that may hinder its effective implementation. Three years of MDA implementation were observed to have microfilaria prevalence reductions (88.54% to 98.66%) comparable to those of studies that implemented MDA for five to 10 years (≥5 years, 79.23% to 98.26%). Inadequate community understanding of and participation in the LF MDA programme are major drawbacks to its effective implementation. The implementation of MDA that incorporates community participation, incentivisation, education, and training strategies has the potential of increasing MDA coverage and compliance, thereby interrupting parasite transmission and reducing microfilarial prevalence to levels that warrant LF elimination.

A Comparative Study of Lymphatic Filariasis-Related Perceptions among Treated and Non-Treated Individuals in the Ahanta West Municipality of Ghana

Background: Ghana joined the Global Programme to Eliminate Lymphatic Filariasis (GPELF), established in the year 2000, with the aim of eliminating the disease as a public health problem through annual mass treatment of entire endemic populations. Since 2001, the country has implemented mass drug administration (MDA) in endemic districts, with great reductions in the population at risk for infection. However, in many districts, the elimination programme is faced with the presence of hotspots, which may be due in part to individuals not taking part in MDA (either intentionally or unintentionally) who may serve as reservoirs to sustain transmission. This paper compares the LF-related perceptions among individuals who regularly take the MDA drugs and those who seldom or never take part in the MDA in the Ahanta West Municipality of Ghana to determine community acceptable ways to implement an intervention aimed to track, engage, and treat individuals who regularly miss MDA or to test individuals who intentionally refuse MDA and treat them if positive for LF. Methods: This was a mixed method study employing questionnaire surveys and focus group discussions (FDG) for data collection. Survey participants were randomly selected from the 2019 treatment register to stratify respondents into treated and non-treated groups. FGD participants were selected purposively such that there are at least two non-treated persons in each discussion session. Results: Over 90% of the respondents were aware of the disease. Poor hygiene/dirty environment was wrongly reported by most respondents (76.8%) as the causes. MDA awareness was very high among both treated (96.9%) and non-treated (98.6%) groups. A low sense of vulnerability to LF infection was evident by a reduction in the number of people presenting clinical manifestations of the disease in communities. Slightly more, 65 (29.0%) of the non-treated group compared to the 42 (19.4%) treated group reported ever experiencing adverse effects of the MDA drugs. Barriers to MDA uptake reported in both groups were poor planning and implementation of the MDA, lack of commitments on the part of drug distributors, and adverse drug reactions. About 51% of the non-treated group reported never taking the drugs even once in the last five years, while 61% among the treated group took the MDA drug consistently in the past five years. Respondents in both groups believed that, when engaged properly, most non-treated persons will accept to take the drug but insisted community drug distributors (CDDs) must be trained to effectively engage people and have time for those they will be engaging in dialogue. The chiefs emerged as the most influential people who can influence people to take MDA drugs. Conclusions: The reduction in risk perception among respondents, adverse reactions and the timing of MDA activities may be influencing MDA non-participation in the study area; however, respondents think that non-treated individuals will accept the interventions when engaged properly by the CDDs. This has been corrected and it now read “Respondents in both groups believed that, when community drug distributors (CDDs) are trained on how to engage the non-treated persons in effective dialogue, most of them will accept to take the drugs”.

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

We evaluated programmatic approaches for skin neglected tropical disease (NTD) surveillance and completed a robust estimation of the burden of skin NTDs endemic to West Africa (Buruli ulcer, leprosy, lymphatic filariasis morbidity, and yaws). In Maryland, Liberia, exhaustive case finding by community health workers of 56,285 persons across 92 clusters identified 3,241 suspected cases. A total of 236 skin NTDs (34.0 [95% CI 29.1–38.9]/10,000 persons) were confirmed by midlevel healthcare workers trained using a tailored program. Cases showed a focal and spatially heterogeneous distribution. This community health worker‒led approach showed a higher skin NTD burden than prevailing surveillance mechanisms, but also showed high (95.1%) and equitable population coverage. Specialized training and task-shifting of diagnoses to midlevel health workers led to reliable identification of skin NTDs, but reliability of individual diagnoses varied. This multifaceted evaluation of skin NTD surveillance strategies quantifies benefits and limitations of key approaches promoted by the 2030 NTD roadmap of the World Health Organization.

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&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&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&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&T group. Overall, 22,830 (95.61%) of participants were treated by either strategy. Of the participants in the T&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.

COVID-19 related perception among some community members and frontline healthcare providers for NTD control in Ghana

Introduction

The Coronavirus Disease 2019 (COVID-19) pandemic has resulted in a major breakdown of health service provision in the fight against neglected tropical diseases (NTDs). COVID-19 may impact NTDs service delivery in varied ways. As the Ghana NTD programme planned to resume MDA activities, we examined the COVID-19 related perceptions and practices among some community members and frontline health workers for NTD control activities in the country.

Methods

The study was conducted in seven communities in the Ahanta West district of Ghana. This was a qualitative study using in-depth interviews (IDI) and focus group discussions (FGDs) for data collection. Participants were purposively selected from varied backgrounds to represent both beneficiaries and service providers directly involved in NTD programme implementation. Trained and experienced qualitative data collectors conducted the FGD and IDI sessions in the local Twi language, while health worker sessions were conducted in English. Discussions were audio-recorded and transcribed directly into English. Data was analysed using an iterative process. The transcripts were pre-coded using the broad themes, entered into a computer using Microsoft Word, and then imported into the MAXQDA software for thematic content analysis to select relevant representative narratives for presentation.

Results

Participants were aware of the COVID-19 pandemic and referred to it appropriately as ‘coronavirus’, COVID-19, and often as ‘the new disease’. Though many respondents could not describe the route of transmission, most of them reported that it is transmitted through touch or sharing of common items. They reported some signs/symptoms like fever, headache and difficulty breathing, and prevention methods like the use of hand sanitiser, washing of hands and sneezing appropriately. Respondents have reported that COVID-19 has negatively affected their daily lives by limiting their movements and therefore work. It also came to light that COVID-19 has also negatively affected the NTD programme implementation, especially mass drug administration (MDA) activities, leading to the postponement of the yearly MDA. The COVID-19 pandemic has negatively affected clinic attendance; people are afraid that they may be tested for COVID-19 at the clinic.

Conclusion

COVID-19 has negatively affected the NTD programme. Education and the provision of personal protective equipment will be required to build the confidence of frontline care providers including community drug distributors and community members in order to enhance quality service and participation in future MDA activities.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-022-07084-0.

Improving data use for decision making by neglected tropical disease program teams: eight use cases

Background: The achievement of neglected tropical diseases (NTDs) program goals depends on numerous factors, including the ability of national programs to use high-quality, timely data to inform their decision-making and program delivery. This paper presents a use case analysis of the routine data used by national NTD programs targeting lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiasis, and trachoma. Methods: The use cases were developed through a combination of secondary and primary research focused on both global trends and deep dives into Burkina Faso, Ethiopia, and Tanzania. Results were refined through a stakeholder convening and the final eight use cases were determined through iteration and prioritization with stakeholders. Results: Eight use cases were developed: improve treatment register data quality, strengthen supervision of drug distributors during mass drug administration (MDA), generate accurate community-level population data for MDAs, create and manage an accurate inventory of drugs, meet district coverage targets during MDA campaigns, feedback and performance to sub-district teams, feedback on performance to sub-national teams, and national-level program use of data for evaluation and decision making. Each use case identifies key actors and their data-related needs and critical challenges, defines the current and desired state, and articulates the profile of a solution (digital and non-digital) needed to complete the use case. Conclusion: The systematic strengthening of data use for decision-making in NTD programs is key for reaching the 2030 Roadmap goals. Integrated together, the presented use cases, when translated into action using appropriate and innovative solutions, can help to ensure that accurate and timely data are present at every step of a program and empower countries to use these data to make program decisions.

Evaluation of neonatal mortality data completeness and accuracy in Ghana

Background

Cause-specific mortality data are required to set interventions to reduce neonatal mortality. However, in many developing countries, these data are either lacking or of low quality. We assessed the completeness and accuracy of cause of death (COD) data for neonates in Ghana to assess their usability for monitoring the effectiveness of health system interventions aimed at improving neonatal survival.

Methods

A lot quality assurance sampling survey was conducted in 20 hospitals in the public sector across four regions of Ghana. Institutional neonatal deaths (IND) occurring from 2014 through 2017 were divided into lots, defined as neonatal deaths occurring in a selected facility in a calendar year. A total of 52 eligible lots were selected: 10 from Ashanti region, and 14 each from Brong Ahafo, Eastern and Volta region. Nine lots were from 2014, 11 from 2015 and 16 each were from 2016 and 2017. The cause of death (COD) of 20 IND per lot were abstracted from admission and discharge (A&D) registers and validated against the COD recorded in death certificates, clinician’s notes or neonatal death audit reports for consistency. With the error threshold set at 5%, ≥ 17 correctly matched diagnoses in a sample of 20 deaths would make the lot accurate for COD diagnosis. Completeness of COD data was measured by calculating the proportion of IND that had death certificates completed.

Results

Nineteen out of 52 eligible (36.5%) lots had accurate COD diagnoses recorded in their A&D registers. The regional distribution of lots with accurate COD data is as follows: Ashanti (4, 21.2%), Brong Ahafo (7, 36.8%), Eastern (4, 21.1%) and Volta (4, 21.1%). Majority (9, 47.4%) of lots with accurate data were from 2016, followed by 2015 and 2017 with four (21.1%) lots. Two (10.5%) lots had accurate COD data in 2014. Only 22% (239/1040) of sampled IND had completed death certificates.

Conclusion

Death certificates were not reliably completed for IND in a sample of health facilities in Ghana from 2014 through 2017. The accuracy of cause-specific mortality data recorded in A&D registers was also below the desired target. Thus, recorded IND data in public sector health facilities in Ghana are not valid enough for decision-making or planning. Periodic data quality assessments can determine the magnitude of the data quality concerns and guide site-specific improvements in mortality data management.

Improving quality and use of routine health information system data in low- and middle-income countries: A scoping review

BACKGROUND

A routine health information system is one of the essential components of a health system. Interventions to improve routine health information system data quality and use for decision-making in low- and middle-income countries differ in design, methods, and scope. There have been limited efforts to synthesise the knowledge across the currently available intervention studies. Thus, this scoping review synthesised published results from interventions that aimed at improving data quality and use in routine health information systems in low- and middle-income countries.

METHOD

We included articles on intervention studies that aimed to improve data quality and use within routine health information systems in low- and middle-income countries, published in English from January 2008 to February 2020. We searched the literature in the databases Medline/PubMed, Web of Science, Embase, and Global Health. After a meticulous screening, we identified 20 articles on data quality and 16 on data use. We prepared and presented the results as a narrative.

RESULTS

Most of the studies were from Sub-Saharan Africa and designed as case studies. Interventions enhancing the quality of data targeted health facilities and staff within districts, and district health managers for improved data use. Combinations of technology enhancement along with capacity building activities, and data quality assessment and feedback system were found useful in improving data quality. Interventions facilitating data availability combined with technology enhancement increased the use of data for planning.

CONCLUSION

The studies in this scoping review showed that a combination of interventions, addressing both behavioural and technical factors, improved data quality and use. Interventions addressing organisational factors were non-existent, but these factors were reported to pose challenges to the implementation and performance of reported interventions.

Review of MDA registers for Lymphatic Filariasis: Findings, and potential uses in addressing the endgame elimination challenges

Background

Lymphatic filariasis (LF) is endemic in Ghana, and the country has implemented the GPELF strategy since 2000 with significant progress made in the control of the disease. However, after several years of mass drug administration (MDA) implementation, there is persistent transmission in 17 of the 98 endemic districts in the country. Current approaches to surveillance are clearly unable to target untreated individuals and new strategies are required to address the endgame challenges to enhance LF elimination as a public health problem in endemic countries. Community registers are used during MDAs to enumerate community members, their age, gender, house numbers, and records of their participation in MDAs. These MDA registers represent an untapped opportunity to identify and characterize non-compliance and inform appropriate programmatic actions. In this study, we analyzed the data presented in the registers to assess the coverage and individuals’ compliance in MDA.

Methods

The information in the MDA registers were assessed to verify the reported coverages obtained from the district. The community registers were obtained from the district health offices and the data from each individual record was entered into a database. A simple questionnaire was used to cross-check the participation of study participants in the 2017 MDA. The questionnaire solicited data on: participation in the 2017 MDA, reasons for not taking part in the MDA, adverse events experienced, what was done for the adverse events, and willingness to participate in subsequent MDAs.

Results

We found that 40.1% of the population in the registers missed at least one MDA in 3 years (2016–2018) and the majority of them were between 10–30 years of age. The results of the questionnaire assessment indicated that 13.8% of the respondents did not receive treatment in 2017 for various reasons, the most prominent among them being “absence/travel” (37.1%). Data in the registers were used to verify the treatment coverage for the years 2017 and 2018, and reviewed against the reported coverage obtained from the district. Significant differences between the reported and verified coverages were only observed in four communities. However, the assessment also revealed that the reported coverage was only accurate in 33.3% of cases.

Conclusions

The MDA registers allow for the identification of eligible individuals who were not reached during any MDA round. Thus, the MDA registers could be utilized at the community and programme levels to identify missing and untreated individuals, appropriately address their non-compliance to MDA, and thereby improve MDA coverage in each implementation unit and monitor the progress towards elimination of LF. The challenges observed through the review of the registers also offer opportunities to improve the training given to the community drug distributors.

Elephantiasis is a disease that is common in Ghana. Since the year 2000 the country has implemented a control programme aimed at eliminating the disease as a public health problem, through the yearly treatment of entire communities in districts where the disease is found. Achievements have been made, and treatment has stopped in many districts; however, some districts have received many years of treatment without successfully reducing the infections below the targeted levels. Many individuals go untreated every year, as can be observed from the low reported treatment coverage after MDA. This untreated population may explain why some districts have failed to achieve the criteria for stopping treatment. Fortunately, the treatments are recorded in community registers, which contain the details of all community members, as well as their treatment participation. These registers can therefore be used to identify people who have not received treatment and design appropriate interventions to reach them. Through these registers, we were able to identify and characterize individuals who were not treated between 2016 and 2018 in 10 communities. We found that 4 out of 10 people missed at least one treatment between 2016 and 2018, and the majority of them were 10–30 years of age. Using the information from the registers we were also able to verify the proportion of people who took part in the treatments in 2017 and 2018, and compared this to what was reported. This comparison revealed that the reporting was only accurate in 33% of cases. A questionnaire was also used to cross-check the participation of study participants in the 2017 MDA, with results indicating that 13.8% of the respondents did not receive treatment for various reasons, the most prominent among them being “absence/travel” (37.1%). Although these registers are seldom used by the Lymphatic Filariasis Control Programme for anything other than recording and reporting treatment information, this study shows that the registers provide an opportunity to identify individuals who have not received treatment, develop a plan to appropriately address their reasons for not taking part in the treatments, target these untreated individuals to improve the overall proportion of people taking part in MDA, and assess the accuracy of reported coverage information. These activities will allow the programme to better monitor the progress towards, and ultimately achieve, elimination of lymphatic filariasis as a public health problem.

Lessons from lymphatic filariasis elimination and the challenges of post-elimination surveillance in China

Background

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was launched in response to the call proposed at the 50th World Health Assembly. The goal of the GPELF is to ensure that all the countries where the disease is endemic would have been transmission-free or would have entered post-intervention mass drug administration (MDA) surveillance by 2020. However, several countries are still not on track to discontinue MDA as planned. Thus, issues remain regarding the achievement of stated goals and how to effectively monitor the disease in the post-control and post-elimination phases.

Main text

China was once a lymphatic filariasis (LF) endemic country with heavy disease burden. There were three milestones in the LF control phase of China, including: the proposal that the major focus of the control strategy should be on infectious sources; the three regimens of diethylcarbamazine (DEC) administration according to LF endemic extent; and the establishment of the threshold for LF transmission interruption. It has been ten years since China entered the post-elimination stage (declaration of LF elimination in China was in 2007). Two schemes and a diagnostic criterion were issued to guide all levels of disease control and prevention workers that conduct LF surveillance, as well as those caring for chronic filariasis patients. Regular training courses are held to maintain LF control skills in grass-root institutions. The Notifiable Diseases Reporting System, which included LF in 2004, plays an important role in LF post-elimination surveillance. Until now, no resurgence of LF cases has been detected, except for LF residue foci being found in Fuchuan County of the Guangxi Zhuang Autonomous Region. To confirm that transmission is no longer achievable after a decade since the declaration of LF elimination in China, it is expected within the next two years a transmission assessment survey, conducted in previous LF-endemic areas.

Conclusions

DEC-fortified salt can help accelerate the progress of GPELF before the sprite phase. Sophisticated diagnostic criteria, systematic surveillance regimes, the Direct Network Report system, and regular trainings can effectively prevent the recrudescence of LF during surveillance phases.

Electronic supplementary material

The online version of this article (10.1186/s40249-019-0578-9) contains supplementary material, which is available to authorized users.

Progress towards lymphatic filariasis elimination in Ghana from 2000-2016: Analysis of microfilaria prevalence data from 430 communities

BACKGROUND

Ghana started its national programme to eliminate lymphatic filariasis (LF) in 2000, with mass drug administration (MDA) with ivermectin and albendazole as main strategy. We review the progress towards elimination that was made by 2016 for all endemic districts of Ghana and analyze microfilaria (mf) prevalence from sentinel and spot-check sites in endemic districts.

METHODS

We reviewed district level data on the history of MDA and outcomes of transmission assessment surveys (TAS). We further collated and analyzed mf prevalence data from sentinel and spot-check sites.

RESULTS

MDA was initiated in 2001-2006 in all 98 endemic districts; by the end of 2016, 81 had stopped MDA after passing TAS and after an average of 11 rounds of treatment (range 8-14 rounds). The median reported coverage for the communities was 77-80%. Mf prevalence survey data were available for 430 communities from 78/98 endemic districts. Baseline mf prevalence data were available for 53 communities, with an average mf prevalence of 8.7% (0-45.7%). Repeated measurements were available for 78 communities, showing a steep decrease in mean mf prevalence in the first few years of MDA, followed by a gradual further decline. In the 2013 and 2014 surveys, 7 and 10 communities respectively were identified with mf prevalence still above 1% (maximum 5.6%). Fifteen of the communities above threshold are all within districts where MDA was still ongoing by 2016.

CONCLUSIONS

The MDA programme of the Ghana Health Services has reduced mf prevalence in sentinel sites below the 1% threshold in 81/98 endemic districts in Ghana, yet 15 communities within 13 districts (MDA ongoing by 2016) had higher prevalence than this threshold during the surveys in 2013 and 2014. These districts may need to intensify interventions to achieve the WHO 2020 target.

Potential factors influencing lymphatic filariasis transmission in "hotspot" and "control" areas in Ghana: the importance of vectors

BACKGROUND

Mass drug administration (MDA) programmes for the control of lymphatic filariasis in Ghana, have been ongoing in some endemic districts for 16 years. The current study aimed to assess factors that govern the success of MDA programmes for breaking transmission of lymphatic filariasis in Ghana.

METHODS

The study was undertaken in two "hotspot" districts (Ahanta West and Kassena Nankana West) and two control districts (Mpohor and Bongo) in Ghana. Mosquitoes were collected and identified using morphological and molecular tools. A proportion of the cibarial armatures of each species was examined. Dissections were performed on Anopheles gambiae for filarial worm detection. A questionnaire was administered to obtain information on MDA compliance and vector control activities. Data were compared between districts to determine factors that might explain persistent transmission of lymphatic filariasis.

RESULTS

High numbers of mosquitoes were sampled in Ahanta West district compared to Mpohor district (F = 16.09, P = 0.002). There was no significant difference between the numbers of mosquitoes collected in Kassena Nankana West and Bongo districts (F = 2.16, P = 0.185). Mansonia species were predominant in Ahanta West district. An. coluzzii mosquitoes were prevalent in all districts. An. melas with infected and infective filarial worms was found only in Ahanta West district. No differences were found in cibarial teeth numbers and shape for mosquito species in the surveyed districts. Reported MDA coverage was high in all districts. The average use of bednet and indoor residual spraying was 82.4 and 66.2%, respectively. There was high compliance in the five preceding MDA rounds in Ahanta West and Kassena Nankana West districts, both considered hotspots of lymphatic filariasis transmission.

CONCLUSIONS

The study on persistent transmission of lymphatic filariasis in the two areas in Ghana present information that shows the importance of local understanding of factors affecting control and elimination of lymphatic filariasis. Unlike Kassena Nankana West district where transmission dynamics could be explained by initial infection prevalence and low vector densities, ongoing lymphatic filariasis transmission in Ahanta West district might be explained by high biting rates of An. gambiae and initial infection prevalence, coupled with high densities of An. melas and Mansonia vector species that have low or no teeth and exhibiting limitation.

Elimination within reach: A cross-sectional study highlighting the factors that contribute to persistent lymphatic filariasis in eight communities in rural Ghana

Background

Despite the progress achieved in scaling-up mass drug administration (MDA) for lymphatic filariasis (LF) in Ghana, communities with persistent LF still exist even after 10 years of community treatment. To understand the reasons for persistence, we conducted a study to assess the status of disease elimination and understand the adherence to interventions including MDA and insecticide treated nets.

Methodology and principal findings

We conducted a parasitological and epidemiological cross-sectional study in adults from eight villages still under MDA in the Northern Region savannah and the coastal Western Region of the country. Prevalence of filarial antigen ranged 0 to 32.4% and in five villages the prevalence of night blood microfilaria (mf) was above 1%, ranging from 0 to 5.7%. Median mf density was 67 mf/ml (range: 10–3,560). LF antigen positivity was positively associated with male sex but negatively associated with participating in MDA the previous year. Male sex was also associated with a decreased probability of participating in MDA. A stochastic model (TRANSFIL) was used to assess the expected microfilaria prevalence under different MDA coverage scenarios using historical data on one community in the Western Region. In this example, the model simulations suggested that the slow decline in mf prevalence is what we would expect given high baseline prevalence and a high correlation between MDA adherence from year to year, despite high MDA coverage.

Conclusions

There is a need for an integrated quantitative and qualitative research approach to identify the variations in prevalence, associated risk factors and intervention coverage and use levels between and within regions and districts. Such knowledge will help target resources and enhance surveillance to the communities most at risk and to reach the 2020 LF elimination goals in Ghana.

Lymphatic filariasis (LF) is a mosquito-borne disease and a leading cause of disability and chronic morbidity worldwide. Despite the progress achieved so far in stopping LF transmission by treating the affected communities with specific drugs over several years, areas where lymphatic filariasis persists still exist. Understanding the reasons behind this is pivotal to both reach and sustain elimination. We investigated the factors associated with filariasis persistence in various communities still under drug treatment from two regions of Ghana. We reported high variability in disease burden, adherence to drug treatment and mosquito net use between regions and communities. LF infection was associated with men and not taking the drugs, and men were also less likely to take treatment. Using mathematical modelling, we showed that slight increases in treatment coverage will accelerate elimination. Our findings highlight the reasons for LF persistence and provide guidance on how to successfully achieve elimination by refining drug treatment distribution and mosquito control interventions more tailored to individuals and communities. We also demonstrated the value of using field-collected data in mathematical models to assess the current status of disease elimination and to identify the gaps in control interventions.

Elimination of lymphatic filariasis: current perspectives on mass drug administration

Following the London declaration on neglected tropical diseases (NTDs) in 2012 and inspired by the WHO 2020 roadmap to control or eliminate NTDs, the Global Programme to Eliminate Lymphatic Filariasis (GPELF) intensified preventive chemotherapy and management of morbidity as the two main strategies to enhance progress towards the elimination of lymphatic filariasis (LF). This paper focuses on current perspectives of mass drug administration (MDA) towards the elimination of LF. The goal of MDA is to reduce the density of parasites circulating in the blood of infected persons and the intensity of infection in communities to levels where transmission is no longer sustainable by the mosquito vector. Three drugs, diethylcarbamazine, albendazole, and ivermectin are currently available for LF treatment, and their effectiveness and relative safety have opened the possibility of treating the entire population at risk. Currently, almost all LF endemic countries rely on the single-dose two-drug regimen recommended by the GPELF to achieve elimination. The 4th WHO report on NTDs has indicated that considerable progress has been made towards elimination of LF in some countries while acknowledging some challenges. In this review, we conclude that the 2020 elimination goal can be achieved if issues pertaining to the drug distribution, health system and implementation challenges are addressed.

Community perspectives on persistent transmission of lymphatic filariasis in three hotspot districts in Ghana after 15 rounds of mass drug administration: a qualitative assessment

BACKGROUND

The Global Program for the Elimination of Lymphatic Filariasis (GPELF) started operation in 2000 and aimed at eliminating the disease by the year 2020, following 5-6 rounds of effective annual Mass Drug Administration (MDA). The MDA programme took off in Ghana in 2001 and has interrupted transmission in many areas while it has persisted in some areas after 10 or more rounds of MDA. This study was to appreciate community members' perspectives on MDA after over 15 years of implementation. Findings will inform strategies to mobilise community members to participate fully in MDA to enhance the disease elimination process.

METHODS

This was a qualitative study, employing key-informant in-depth-interviews. Respondents were selected based on their recognition by community members as opinion leaders and persons who were knowledgeable about the topic of interest in the community. A snowball sampling technique was used to select respondents.

RESULTS

Respondents were well informed about the MDA with most of them saying, it has been implemented for over 12 years. They were aware that the MDA was for the treatment/control of LF (elephantiasis). It came to light that MDA compliance was affected by five related barriers. These are; Medication, Personal, Health system, Disease and Social structure related barriers. Adverse effects of the drugs and the fact that many people perceived that they were not susceptibility to the infection have grossly affected the ingestion of the drugs.

CONCLUSION

There is a need for community mobilization and promotional activities to explain the expected adverse reactions associated with the drugs to the people. Also the importance of why every qualified person in the community must comply with MDA must be emphasized.

Persistent 'hotspots' of lymphatic filariasis microfilaraemia despite 14 years of mass drug administration in Ghana

Background

Among the 216 districts in Ghana, 98 were declared endemic for lymphatic filariasis in 1999 after mapping. Pursuing the goal of elimination, WHO recommends annual treatment using mass drugs administration (MDA) for at least 5 years. MDA was started in the country in 2001 and reached national coverage in 2006. By 2014, 69 districts had 'stopped-MDA' (after passing the transmission assessment survey) while 29 others remained with persistent microfilaraemia (mf) prevalence (≥1%) despite more than 11 years of MDA and were classified as 'hotspots'.

Methods

An ecological study was carried out to compare baseline mf prevalence and anti-microfilaria interventions between hotspot and stopped-MDA districts.

Results

Baseline mf prevalence was significantly higher in hotspots than stopped-MDA districts (p<0.001). After three years of MDA, there was a significant decrease in mf prevalence in hotspot districts, but it was still higher than in stopped-MDA districts. The number of MDA rounds was slightly higher in hotspot districts (p<0.001), but there were no differences in coverage of MDA or long-lasting-insecticide-treated nets.

Conclusions

The main difference in hotspots and stopped-MDA districts was a high baseline mf prevalence. This finding indicates that the recommended 5-6 rounds annual treatment may not achieve interruption of transmission.

Elimination of lymphatic filariasis in west African urban areas: is implementation of mass drug administration necessary?

Lymphatic filariasis in Africa is caused by the parasite Wuchereria bancrofti and remains a major cause of morbidity and disability in 74 countries globally. A key strategy of the Global Programme for the Elimination of Lymphatic Filariasis, which has a target elimination date of 2020, is the treatment of entire endemic communities through mass drug administration of albendazole in combination with either ivermectin or diethylcarbamazine. Although the strategy of mass drug administration in combination with other interventions, such as vector control, has led to elimination of the infection and its transmission in many rural communities, urban areas in west Africa present specific challenges to achieving the 2020 targets. In this Personal View, we examine these challenges and the relevance of mass drug administration in urban areas, exploring the rationale for a reassessment of policy in these settings. The community-based mass treatment approach is best suited to rural areas, is challenging and costly in urban areas, and cannot easily achieve the 65% consistent coverage required for elimination of transmission. In our view, the implementation of mass drug administration might not be essential to interrupt transmission of lymphatic filariasis in urban areas in west Africa. Evidence shows that transmission levels are low and that effective mass drug distribution is difficult to implement, with assessments suggesting that specific control measures against filariasis in such dynamic settings is not an effective use of limited resources. Instead, we recommend that individuals who have clinical disease or who test positive for W bancrofti infection in surveillance activities should be offered antifilarial drugs through a passive surveillance approach, as well as morbidity management for their needs. We also recommend that more precise studies are done, so that mass drug administration in urban areas is considered if sustainable transmission is found to be ongoing. Otherwise, the limited resources should be directed towards other elements of the lymphatic filariasis programme.

Community-based trial of annual versus biannual single-dose ivermectin plus albendazole against Wuchereria bancrofti infection in human and mosquito populations: study protocol for a cluster randomised controlled trial

BACKGROUND

The Global Programme for the Elimination of Lymphatic Filariasis (GPELF) has been in operation since the year 2000, with the aim of eliminating the disease by the year 2020, following five to six rounds of effective annual mass drug administration (MDA). The treatment regimen is ivermectin (IVM) in combination with diethylcarbamazine (DEC) or albendazole (ALB). In Ghana, MDA has been undertaken since 2001. While the disease has been eliminated in many areas, transmission has persisted in some implementation units that had experienced 15 or more rounds of MDA. Thus, new intervention strategies could eliminate residual infection in areas of persistent transmission and speed up the lymphatic filariasis (LF)-elimination process. This study, therefore, seeks to test the hypothesis that biannual treatment of LF-endemic communities will accelerate the interruption of LF in areas of persistent transmission.

METHODS

A cluster randomised trial will be implemented in LF-endemic communities in Ghana. The interventions will be yearly or twice-yearly MDA delivered to entire endemic communities. Allocation to study group will be by clusters identified using the prevalence of LF. Clusters will be randomised to one of two groups: receiving either (1) annual treatment with IVM + ALB or (2) annual MDA with IVM + ALB, followed by an additional MDA 6 months later. The primary outcome measure is the prevalence of LF infection, assessed by four cross-sectional surveys. Entomological assessments will also be undertaken to evaluate the transmission intensity of the disease in the study clusters. Costs and cost-effectiveness will be evaluated. Among a random subsample of participants, microfilaria prevalence will be assessed longitudinally. A nested process evaluation, using semi-structured interviews, focus group discussions and a stakeholder analysis, will investigate the community acceptability, feasibility and scale-up of each delivery system.

DISCUSSION

It is expected that this study will add to the existing evidence on the need for alternative intervention strategies for the elimination of LF in Ghana and in other African countries that are facing similar challenges or are at the beginning of their LF-elimination programmes.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT03036059 . Registered on 26 January 2017. Pan African Clinical Trials Registry, ID: PACTR201702002012425 . Registered on 23 February 2017.

Improving drug delivery strategies for lymphatic filariasis elimination in urban areas in Ghana

The Global Program to Eliminate Lymphatic Filariasis (GPELF) advocates for the treatment of entire endemic communities, in order to achieve its elimination targets. LF is predominantly a rural disease, and achieving the required treatment coverage in these areas is much easier compared to urban areas that are more complex. In Ghana, parts of the Greater Accra Region with Accra as the capital city are also endemic for LF. Mass Drug Administration (MDA) in Accra started in 2006. However, after four years of treatment, the coverage has always been far below the 65% epidemiologic coverage for interrupting transmission. As such, there was a need to identify the reasons for poor treatment coverage and design specific strategies to improve the delivery of MDA. This study therefore set out to identify the opportunities and barriers for implementing MDA in urban settings, and to develop appropriate strategies for MDA in these settings. An experimental, exploratory study was undertaken in three districts in the Greater Accra region. The study identified various types of non-rural settings, the social structures, stakeholders and resources that could be employed for MDA. Qualitative assessment such as in-depth interviews (IDIs) and focus group discussions (FGDs) with community leaders, community members, health providers, NGOs and other stakeholders in the community was undertaken. The study was carried out in three phases: pre-intervention, intervention and post-intervention phases, to assess the profile of the urban areas and identify reasons for poor treatment coverage using both qualitative and quantitative research methods. The outcomes from the study revealed that, knowledge, attitudes and practices of community members to MDA improved slightly from the pre-intervention phase to the post-intervention phase, in the districts where the interventions were readily implemented by health workers. Many factors such as adequate leadership, funding, planning and community involvement, were identified as being important in improving implementation and coverage of MDA in the study districts. Implementing MDA in urban areas therefore needs to be given significant consideration and planning, if the required coverage rates are to be achieved. This paper, presents the recommendations and strategies for undertaking MDA in urban areas.

The control of lymphatic filariasis depends on the treatment of entire endemic communities, ensuring that a greater proportion of the population is treated. In urban areas, this can be very difficult to achieve. In Ghana, parts of the Greater Accra Region, where the capital city is located, are also endemic for lymphatic filariasis. Treatment in these areas started in 2006, but the proportion of people treated has continuously been below the required programmatic coverage levels. To understand the reasons behind this, a study was undertaken in three endemic districts. The study was carried out in three stages; pre-treatment, treatment and post-treatment. Individuals and groups of people were interviewed in the pre-treatment phase, following which their concerns were used to plan and execute treatment activities. After treatment, some individuals were again interviewed to assess the effectiveness of the interventions. The results showed that the knowledge and behavior of community members towards the disease and treatment activities improved from the pre-treatment to the post-treatment reviews. Many factors were identified including, financial, management and leadership issues that should be considered when planning treatment activities in urban areas.

Can Lymphatic Filariasis Be Eliminated by 2020?

Interventions against neglected tropical diseases (NTD), including lymphatic filariasis (LF), scaled up dramatically after the signing of the London Declaration (LD) in 2012. LF is targeted for elimination by 2020, but some countries are considered not on track to meet the 2020 target using the recommended preventive chemotherapy and morbidity management strategies. In this Opinion article we review the prospects for achieving LF elimination by 2020 in the light of the renewed global action against NTDs and the global efforts to achieve the sustainable development goals (SDGs) by 2030. We conclude that LF can be eliminated by 2020 using cross-sectoral and integrated approaches because of the compound effect of the other SDG activities related to poverty reduction and water and sanitation.