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

OBJECTIVE

To evaluate onchocerciasis control activities in the Democratic Republic of Congo (DRC) in the first 12 years of community-directed treatment with ivermectin (CDTI).

METHODS

Data from the National Programme for Onchocerciasis (NPO) provided by the National Onchocerciasis Task Force (NOTF) through the annual reports of the 21 CDTI projects for the years 2001-2012 were reviewed retrospectively. A hypothetical-inputs-process-outputs-outcomes table was constructed.

RESULTS

Community-directed treatment with ivermectin expanded from 1968 communities in 2001 to 39 100 communities by 2012 while the number of community-directed distributors (CDD) and health workers (HW) multiplied. By 2012, there were ratios of 1 CDD per 262 persons and 1 HW per 2318 persons at risk. More than 80% of the funding came from the fiduciary funds of the African Programme for Onchocerciasis Control. The cost of treatment per person treated fell from US$ 1.1 in 2001 to US$ 0.1 in 2012. The therapeutic coverage increased from 2.7% (2001) to 74.2% (2012); the geographical coverage, from 4.7% (2001) to 93.9% (2012). Geographical coverage fell in 2005 due to deaths in loiasis co-endemic areas, and the therapeutic coverage fell in 2008 due to insecurity.

CONCLUSIONS

Challenges to CDTI in DRC have been serious adverse reactions to ivermectin in loiasis co-endemic areas and political conflict. Targets for personnel or therapeutic and geographical coverages were not met. Longer term funding and renewed efforts are required to achieve control and elimination of onchocerciasis in DRC.

Factors affecting the attrition of community-directed distributors of ivermectin, in an onchocerciasis-control programme in the Imo and Abia states of south-eastern Nigeria

In areas of Nigeria where onchocerciasis is endemic, community-directed distributors (CDD) distribute ivermectin annually, as part of the effort to control the disease. Unfortunately, it has been reported that at least 35% of the distributors who have been trained in Nigeria are unwilling to participate further as CDD. The selection and training of new CDD, to replace those unwilling to continue, leads to annual expense that the national onchocerciasis-programme is finding difficult to meet, given other programme priorities and the limited resources. If the reported levels of attrition are true, they seriously threaten the sustainability of community-directed treatment with ivermectin (CDTI) in Nigeria. In 2002, interviews were held with 101 people who had been trained as CDD, including those who had stopped serving their communities, from 12 communities in south-eastern Nigeria that had high rates of CDD attrition. The results showed that, although the overall reported CDD attrition was 40.6%, the actual rate was only 10.9%. The CDD who had ceased participating in the annual rounds of ivermectin blamed a lack of incentives (65.9%), the demands of other employment (14.6%), the long distances involved in the house-to-house distribution (12.2%) or marital duties (7.3%). Analysis of the data obtained from all the interviewed CDD showed that inadequate supplies of ivermectin (P<0.01), lack of supervision (P<0.05) and a lack of monetary incentives (P<0.001) led to significant increases in attrition. Conversely, CDD retention was significantly enhanced when the distributors were selected by their community members (P<0.001), supervised (P<0.001), supplied with adequate ivermectin tablets (P<0.05), involved in educating their community members (P<0.05), and/or involved in other health programmes (P<0.001). Although CDD who were involved in other health programmes were relatively unlikely to cease participating in the distributions, they were more likely to take longer than 14 days to complete ivermectin distribution than other CDD, who only distributed ivermectin. Data obtained in interviews with present and past CDD appear vital for informing, directing, protecting and enhancing the performance of CDTI programmes, in Nigeria and elsewhere.

Community-directed interventions strategy enhances efficient and effective integration of health care delivery and development activities in rural disadvantaged communities of Uganda

The community-directed interventions (CDI) strategy achieved a desired coverage of the ultimate treatment goal (UTG) of at least 90% with ivermectin distribution for onchocerciasis control, and filled the gap between the health care services and the communities. However, it was not clear how its primary actors--the community-directed health workers (CDHW) and community-directed health supervisors (CDHS)--would perform if they were given more responsibilities for other health and development activities within their communities. A total of 429 of 636 (67.5%) of the CDHWs who were involved in other health and development activities performed better than those who were involved only in ivermectin distribution, with a drop-out rate of 2.3%. A total of 467 of 864 (54.1%) of CDHSs who were involved in other health and development activities also maintained the desired level of performance. They facilitated updating of household registers (P<0.05), trained and supervised CDHWs, and educated community members about onchocerciasis control (P<0.001). Their drop-out rate was 2.6%. The study showed that the majority of those who dropped out had not been selected by their community members. Therefore, CDI strategy promoted integration of health and development activities with a high potential for sustainability.

Implementing community-directed treatment with ivermectin for the control of onchocerciasis in Uganda (1997-2000): an evaluation

Over the period 1997-2000, an evaluation was made, in 10 districts of Uganda, of the onchocerciasis-control programme based on community-directed treatment with ivermectin (CDTI). This programme is supported by the Ministry of Health, the African Progamme for Onchocerciasis Control (APOC) and The Carter Center Global 2000 River Blindness Programme. The data analysed came from: (1) monthly and annual reports; (2) annual interviews, in randomly-selected communities in selected districts, with heads of household, community leaders and ivermectin distributors; (3) participatory evaluation meetings (PEM); (4) participant observation studies; and (5) key informants. The percentage of treated communities in the 10 study districts achieving satisfactory treatment coverage [i.e. > or = 90% of the annual treatment objective (ATO)] rose from 46.0 in 1997 to 86.8 in 2000. This improvement was largely attributable to the adoption of collective CDTI decision-making by community members, avoidance of paving monetary incentives to the ivermectin distributors, and the satisfaction with the programme of those who had been treated. Coverage improved as the numbers of community members who were involved in choosing the method of distribution and in selecting their own community-directed health workers (CDHW) increased. Health education was also critical in improving individual members' involvement in decision-making, and in mobilizing other community members to take part in CDTI. Involvement of kinship groups, as well as educated community members as supervisors of CDHW, also helped to increase coverage. In a regression model, satisfaction with the programme was revealed as a significant predictor of the achievement of the target coverage (P<0.001). Cost per person, as an indicator for sustainability, varied with the size of the population under treatment, from at least U.S. $0.40 when the district ATO was <15,000 people, to U.S. $0.26 with an ATO of 15,000-40,000 and less than U.S. $0.10 when the district ATO exceeded 40,000 people. These results cast doubt on the validity of the current APOC indicator for sustainability, of a cost of no more than U.S. $0.20/person for all CDTI projects, whatever the size of the population to be treated. Although some women were involved in decision-making, their current involvement as supervisors or CDHW was minimal. Most of the present data were obtained through monitoring and operational-research activities that have been carried out, in an integrated fashion, within the Ugandan CDTI programme since its launch. It is recommended that assessment, monitoring and evaluation be widely used within all CDTI efforts. Operational research should remain focused and appropriate and directly involve the personnel who are executing the programme.

Involvement of women in community-directed treatment with ivermectin for the control of onchocerciasis in Rukungiri district, Uganda: a knowledge, attitude and practice study

A study of knowledge, attitudes and practice was carried out in the Rukungiri district of Uganda, in order to investigate the involvement of women in community-directed treatment with ivermectin (CDTI), for the control of onchocerciasis. The data analysed came from interviews with 260 adult women (one from each of 260 randomly-selected households in 20 onchocerciasis-endemic communities), community informants, and participatory evaluation meetings (PEM) in eight communities. The women who had been treated with ivermectin in 1999 generally had more knowledge of the benefits of taking ivermectin, were more likely to have attended the relevant health-education sessions and were more involved in community decisions on the method of ivermectin distribution than the women who had not received ivermectin in that year. There were fewer female community-directed health workers (CDHW) than male CDHW in the communities investigated. The reasons for not attending health-education sessions, not participating in community meetings concerning the CDTI, and the reluctance of some women to serve as CDHW were investigated. The most common reasons given were domestic chores, a reluctance to express their views in meetings outside their own kinship group, suspicions that other women might take advantage of them, and a lack of interest. Most of the women interviewed (as well as other community members) felt that there were relatively few women CDHW. The women attributed this to a lack of interaction and trust amongst themselves, which resulted in more men than women being selected as CDHW. The rest of the community members were not against women working as CDHW. It is recommended that communities be encouraged to select women to serve as CDHW in the CDTI, and that the performances of male and female CDHW be compared.

Community-directed health (CDH) workers enhance the performance and sustainability of CDH programmes: experience from ivermectin distribution in Uganda

The performance and 'drop-out' rates of ivermectin (Mectizan) distributors in the Ugandan programme for community-directed treatment with ivermectin (CDTI) were investigated and related to the manner in which the distributors were recruited. Distributors, from randomly selected communities endemic for onchocerciasis in seven of the 10 affected districts, were interviewed. Questionnaires were initially completed for 296 communities (in which ivermectin had been distributed in 1998 but not in 1999) and then extended to another 310 communities (in which ivermectin had been distributed in both study years). Discussions were also held with some other community members, in participatory evaluation meetings (PEM) in 14 communities from four districts. Despite the CDTI being labelled as 'community-directed', the first round of interviews and questionnaires revealed that there were in fact three categories of distributors: 322 (69.4%) of those questioned had been selected by community members and were therefore truly community-directed health workers (CDHW) but 101 (22%) were community-based health workers appointed by the leaders of the local council (CBHW-LC) and 41 (9%) were self-appointed volunteers (CBHW-SA). During 1999, only the CDHW received good community support; they still helped to mobilise and educate their community members and advocate CDTI, and 98% of them agreed that they would distribute ivermectin during the following year. In contrast, many of the CBHW-LC were neither supported nor appreciated by the community members. Presumably in consequence, many of the CBHW-LC did not help to mobilise or educate their community members in 1999, nor did they advocate CDTI. Almost all (95%) of the CBHW-LC said that they would not be available to distribute in the following year, and were therefore regarded as total 'drop-outs' from the CDTI. The CBHW-SA were better supported by community members than were the CBHW-LC, they did more to advocate the CDTI, and 93% reported that they would distribute ivermectin during the following year. The 'drop-out' rates for 1999 were < 2% for the CDHW, 7% for the CBHW-SA, and 95% for the CBHW-LC. The results also indicated that the CBHW-SA were not as reliable as the CDHW. Similar results were obtained from the second round of questionnaires, in which 224 (73%) of the interviewees were CDHW, 57 (18%) were CBHW-LC and 28 (9%) were CBHW-SA. The results of the PEM showed that the CDHW, who mainly came from the same kinship groups as the people who selected them, were likely to achieve higher ivermectin coverage within a week than the other categories of distributors. It is clear that, for the optimum performance and sustainability of the CDTI, the distributors used should be CDHW selected by their own community members.

Community-directed, ivermectin-treatment programmes for onchocerciasis control in Uganda: the selection and validation of indicators for monitoring sustainability at the district level

The selection and validation of indicators for predicting and monitoring sustainment in community-directed, ivermectin-treatment programmes (CDITP) at the community level in the Kabale, Kisoro and Rukungiri districts of Uganda have already been reported. The aim of the present study was to select and validate similar indicators at the district level, in the same districts over the same 4-year period. Three dependent-variable scales of programme sustainability (PS), PS1, PS2 and PS3, were compared by district. As at the community level, Rukungiri district clearly performed better than Kabale or Kisoro. Cost variables compiled at the district level and the ratios of numbers of community-based distributors (CBD) to community members were used as input variables in regression and correlation models, with PS1, PS2, and PS3 as outcome variables. In the regression model, cost of training CBD was found to be statistically significant (P = 0.0186). This variable also scored 100% on a scale for programme-indicator sensitivity and hence was selected as a helpful indicator. In the correlation model, cost of health education of community members had a weak relationship with PS1 (P = 0.0662). Cost of training CBD had a significant negative correlation with PS2 (P = 0.0186), indicating that reducing the cost of training would facilitate sustainability. PS3 showed weak negative correlations with cost of health education of community members (P = 0.0586) and cost/person treated in the district (P = 0.0584). Sustainment of CDITP might be better, therefore, if the costs per person could be reduced. As correlation relationships may not be linear, however, they were not considered particularly useful in the selection of helpful indicators.

The selection and validation of indicators for monitoring progress towards self-sustainment in community-directed, ivermectin-treatment programmes for onchocerciasis control in Uganda

A retrospective analysis was made of quantitative data on coverage obtained over 4 years of annual ivermectin treatment of the eligible populations (approximately 56,000 individuals) of 71 communities with endemic onchocerciasis in the Kabale, Kisoro and Rukungiri districts of Uganda. The objective was to formulate methods for defining sustainability in community-directed, ivermectin-treatment programmes (CDITP). Three dependent-variable scales of programme sustainability (PS), PS1, PS2, and PS3, were tested for statistical significance by analysis of variance. The inhabitants of a random sample of 230 households drawn from 23 communities [each containing one community leader and one community-based distributor (CBD)] were then invited to answer a questionnaire covering seven independent variables. These variables were analysed in regression and correlation models, with the PS scales as dependent variables. In the regression model, only one variable, selection of CBD by community members (P = 0.038), which scored 100% on the scale of programme-indicator sensitivity, passed as a useful indicator for predicting the sustainability and monitoring the sustainment of CDITP at the community level. The same variable was also selected in the correlation model (P = 0.028). Although two other variables--involvement of CBD in other primary-health-care activities (P = 0.0594) and provision of incentives for the CBD (P = 0.0558)--showed weak negative associations with sustainability in the correlation model, they did not exhibit a linear relationship with it and cannot therefore be used as valid indicators for predicting sustainability or monitoring sustainment.