Community-directed Distributors Research Articles

Acceptability of test and treat with doxycycline against Onchocerciasis in an area of persistent transmission in Massangam Health District, Cameroon.

The main onchocerciasis elimination strategy is annual Community-Directed Treatment with ivermectin (CDTi). However, as a response to persistent high infection prevalence in Massangam Health District in Cameroon, two rounds of alternative treatments including biannual CDTi, ground larviciding and test and treat with doxycycline (TTd) were implemented. This led to a significant prevalence reduction from 35.7% to 12.3% (p<0.001) as reported by Atekem and colleagues. Here we report on the acceptability of TTd component based on qualitative and quantitative data. The TTd involved microscopic examination for microfilaria in skin biopsy and those infected were offered doxycycline 100 mg daily for 35 days by community-directed distributors (CDDs). Participation level was significantly high with 54% of eligible population (age > 8, not pregnant, not breastfeeding, not severely ill,) participating in the test in each round, increasing to 83% over the two rounds. Factors associated with non-participation included mistrust, being female; being younger than 26 years; short stay in the community; and belonging to semi-nomadic sub population due to their remote and disperse settlement, discrimination, their non selection as CDD, and language and cultural barriers. Treatment coverage was high -71% in round 1 and 83% in round 2. People moving away between testing and treatment impacted treatment coverage. Some participants noted mismatch between symptoms and test result; and that ivermectin is better than doxycycline, while others favoured doxycycline. CDD worried about work burden with unmatching compensation. Overall, TTd participation was satisfactory. But can be improved through reinforcing sensitisation, reducing time between test and treatment; combining TTd and CDTi in one outing; augmenting CDDs compensation and/or weekly visit; exploring for frequently excluded populations and adapting strategies to reach them; and use of a sensitive less invasive test.

Household coverage of ivermectin distribution in birnin kudu local government area of Jigawa State, Nigeria.

To assess community-directed treatment coverage with Ivermectin (CDTI) in Onchocerciasis-endemic communities in Birnin Kudu local government area (LGA) Jigawa state. This was a community-based multistaged cross-sectional survey based on probability proportional to size. The study involved the administration of a questionnaire on 2021 respondents from 207 households. Also, 30 Community Leaders and Community Directed Distributors (CDDs) were purposively selected for interview from the communities visited. Overall, 2021 respondents from the 2031 sampled population took part in the study giving a response rate of 99.6%. Slightly above half, 1130 (55.9%) were males. The geographic and therapeutic coverage of mass drug administration of Ivermectin achieved in the LGA was 100% and 79.9%, respectively. The key factors affecting coverage includes the unavailability of drugs (48.8%), absenteeism of some of the household members (31%), and inadequate incentives to the CDDs by the government and poor record keeping by the CDDs. This study found that the minimum geographic and therapeutic coverage of Ivermectin distribution was achieved by CDD as recommended by the World Health Organization for the control of onchocerciasis. For this to be sustained and to achieve elimination, there must be an adequate supply of ivermectin, training of CDDs, retraining of CDDs, adequate supervision in record keeping, and health education to the community.

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

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

Reaching the unreached: effectiveness and satisfaction with community-directed distribution of sulfadoxine-pyrimethamine for preventing malaria in pregnancy in rural South-East, Nigeria

BackgroundInnovative community strategies to increase intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) coverage is advocated particularly in rural areas, where health infrastructure is weakest and malaria transmission highest. This study involved proof-of-concept implementation research to determine satisfaction with and effectiveness of community-directed distribution of IPTp-SP on uptake among pregnant women in Ebonyi State, Nigeria.MethodsThis before-and-after study was carried out in 2019 in a rural community in Ebonyi State Nigeria. The intervention involved advocacy visits, community-wide sensitizations on malaria prevention, house-to-house directly observed IPTp-SP administration, and follow-up visits by trained community-selected community-directed distributors (CDDs). Monthly IPTp-SP coverage was assessed over 5 months and data analysed using SPSS version 20.ResultsDuring the study, 229 women received the first dose of IPTp while 60 pregnant women received 5 or more doses of IPTp. The uptake of ≥ 3 IPTp doses increased from 31.4% before the community-directed distribution of IPTp to 71.6% (P < 0.001) by the fourth month post-initiation of the community-directed distribution of IPTp. Sleeping under insecticide-treated net (ITN) the night before the survey increased from 62.4 to 84.3% (P < 0.001) while reporting of fever during pregnancy decreased from 64.9 to 17.0% (P < 0.001). Although antenatal clinic utilization increased in the primary health centre serving the community, traditional birth attendants and patent medicine vendors in the community remained more patronized. Post-intervention, most mothers rated CDD services well (93.6%), were satisfied (97.6%), and preferred community IPTp administration to facility administration (92.3%).ConclusionCommunity-directed distribution of IPTp-SP improved uptake of IPTp-SP and ITN use. Mothers were satisfied with the services. The authors recommend sustained large-scale implementation of community-directed distribution of IPTp with active community engagement.

Barriers to the National Onchocerciasis Control Programme at operational level in Cameroon: a qualitative assessment of stakeholders\u2019 views

BackgroundThe global burden of onchocerciasis is the heaviest in sub-Saharan Africa. Studies have shown the importance of the role of Community-Directed Distributors (CDDs) and nurses in onchocerciasis control, but little is known about their experience in implementing onchocerciasis control programmes. Our aim was to document the barriers that CDDs and local health administrators face in implementing onchocerciasis control activities.MethodsWe conducted a qualitative survey consisting of 16 in-depth interviews and 8 focus group discussions (FGDs) across three health districts of Cameroon. We interviewed a total of 9 local health officials at the district and Health Area levels, and 7 CDDs. Eight FGDs were conducted with CDDs and Health Committee members.ResultsThe major barriers to the implementation of Community Directed Treatment with Ivermectin that we identified were linked and interrelated. Examples of these barriers included: contextual factors (geographical and cultural background), top-to-bottom planning, insufficient human and material resources, and lack of transparency in the management of the programme’s funds.ConclusionsThe CDTI at operational level still faces many obstacles which negatively affect therapeutic coverages. This can lead to the non-adhesion of the communities to the programme, consequently jeopardizing the sustainability of the onchocerciasis elimination programme. We recommend that the national programme planners put in place a transparent management and planning system for onchocerciasis elimination activities, with better communication with local programme stakeholders.

The social, physical and economic impact of lymphedema and hydrocele: a matched cross-sectional study in rural Nigeria

BackgroundLymphatic filariasis (LF) is a mosquito-borne parasitic disease and a major cause of disability worldwide. To effectively plan morbidity management programmes, it is important to estimate disease burden and evaluate the needs of patients. This study aimed to estimate patient numbers and characterise the physical, social and economic impact of LF in in rural Nigeria.MethodsThis is a matched cross-sectional study which identified lymphedema and hydrocele patients with the help of district health officers and community-directed distributors of mass drug administration programmes. A total of 52 cases were identified and matched to 52 apparently disease-free controls, selected from the same communities and matched by age and sex. Questionnaires and narrative interviews were used to characterise the physical, social and economic impact of lymphedema and hydrocele.ResultsForty-eight cases with various stages of lower limb lymphedema, and 4 with hydrocele were identified. 40% of all cases reported feeling stigma and were 36 times (95% CI: 5.18–1564.69) more likely to avoid forms of social participation. Although most cases engaged in some form of income-generating activity, these were low paid employment, and on average cases spent significantly less time than controls working. The economic effects of lower income were exacerbated by increased healthcare spending, as cases were 86 times (95% CI: 17.48–874.90) more likely to spend over US $125 on their last healthcare payment.ConclusionThis study highlights the importance of patient-search as a means of estimating the burden of LF morbidity in rural settings. Findings from this work also confirm that LF causes considerable psychosocial and economic suffering, all of which adversely affect the mental health of patients. It is therefore important to incorporate mental health care as a major component of morbidity management programmes.

Evaluation of onchocerciasis control in the Upper Denkyira East municipal in the forest area of Ghana: Responses of participants and distributors to the CDTI programme

The African Programme for Onchocerciasis Control (APOC), which focused on annual mass treatment with ivermectin, was launched in 1995 and was replaced by the Expanded Special Project for Neglected Tropical Diseases (ESPEN) by the end of 2015. In Ghana, the Community Directed Treatment with Ivermectin (CDTI) was introduced in 1999. After a decade, biannual reinforcement was introduced during which the Ghana Health Service (GHS) recorded coverage rates through routine data collection. Transmission studies conducted in the Upper Denkyira East Municipal (UDEM) of the forest zone of Ghana in 2002 and 2006 had shown that annual treatments with ivermectin had hardly any effect on the transmission of Onchocerca volvulus by the vector Simulium sanctipauli. In order to establish whether or not this was due to an insufficient compliance to the CDTI programme, an additional questionnaire survey was carried out in 2013 following those conducted in 2002 and 2006. The repeat transmission survey conducted in 2013 in the same area revealed that the vector S. sanctipauli had apparently disappeared from the rivers Ofin and Pra due to gold mining activities. In 2006 and 2013, we conducted surveys using structured questionnaires to address issues related to compliance and to compare results on the effectiveness of CDTI. A total of 692 individuals from 7 villages and 447 individuals from 9 villages were interviewed in 2006 and 2013 respectively. Questions asked included whether or not they had taken the ivermectin and reasons for not doing so when that was the case. Results were compared with the previous investigations conducted in 2002. Whereas official reported coverage rates ranged from 59 to 85% in 2006 and from 88 to 97% in 2013, compliance rates decreased from 36% in 2006 to 21% in 2013. Factors affecting compliance included fear of unpleasant side effects (pruritus and oedema), which decreased from 36% to 21% for the same period. Lack of awareness of CDTI sharply increased from 12% to 46% for the same period. Participants believed that treatments were no longer necessary due to the absence of vectors observed in 2013. There seems to be a considerable difference between coverage and compliance rates in the study communities. The difference can be attributed to the performance of the Community-Directed Distributors (CDDs) and the absence of the vector population observed in 2013. Discussions with CDDs suggested that factors that led to non-compliance were mostly side effects, unawareness of the disease by immigrants and lack of financial motivation for the CDDs. Also included was the fact that they needed to complete distribution of the drugs in the entire village, covering all households within just one week irrespective of the size of the catchment area. This, they thought was too much work for a short period of time. We propose to intensify the training of CDDs by the national Neglected Tropical Diseases Programme (NTDP) and to include the Community-based Health and Planning Services (CHPS) concept into onchocerciasis control efforts for awareness creation while the vector population and the transmission should be further monitored. The population should be made aware that the side effects they experienced from previous treatments or had heard about had reduced significantly. They also should be in the known that vector flies may return and so the risk of transmission remains.

Assessment of the performance of community-directed treatment with ivermectin strategy for the control and elimination of onchocerciasis in Edo State, Nigeria.

Community-directed treatment with ivermectin (CDTI) was developed in the mid 1990's as a solution for the control and elimination of onchocerciasis. It requires that ivermectin be administered continuously over a period of at least 14 years with community involvement before elimination can be achieved. The objective of this study is to assess the performance of CDTI strategy for control and elimination of onchocerciasis in endemic Local Government areas of Edo State. A descriptive evaluation in a cross-sectional, descriptive study design was conducted among 720 community members selected from six communities using multistage sampling technique, 11 Community directed distributors (CDDs), and 17 health workers involved in the implementation of the CDTI strategy in Edo State. Primary data were collected using an interviewer's administered questionnaire while secondary data were obtained from the State Ministry of Health. IBM SPSS version 21 software was used for data analysis. The highest therapeutic coverage (95.5%) was observed in Aden II community while the least therapeutic coverage (56.6%) was observed in Imeke community. Regarding the performance indicators, ivermectin supply, work of CDDs, training, monitoring and supervision, finances by communities had scores ≥2.5 and were therefore considered as having satisfactory performance. However, community participation and ownership and health education and mobilization had scores <2.5 and as such considered as having unsatisfactory performance. Sustainability of the CDTI program in the study area is likely but not guaranteed as there is need for improvement in areas regarding community mobilization, participation, and ownership.

English

Improving malaria control, hygiene and sanitation in households is a challenge in the health system. Hence, several countries have used community directed distributors (CDDs) to assist in delivering health information and services. Despite their use there is little attempt to profile this group of workers. This was a cross sectional study conducted in 2014 involving 297 CDDs from 3 rural communities in Anambra Central Senatorial Zone of Anambra State. A structured questionnaire was used to obtain information from the respondents during their training in various town halls. Most (44.4%) of CDDs fell within the age range of 29 to 38 years. Only 2.0% of the respondents had no formal education.&nbsp; Major source of water to the household is from water vendors (39.1%) and it takes 87.2% of them less than 30 min to get water. Flush toilet system is mostly used (49.2%) while 9.4% have no toilet facility in the house. Almost 8% throw garbage into the street while majority either burn, bury or take the garbage to public dump site or disposal bin. About 71 and 16.5% wash hands with soap after using the toilet and before eating, respectively. Also 74% of the respondents make use of mosquito net while 64% take child for treatment outside home.&nbsp; Key household practices among CDDs on sewage and refuse disposal and personal hygiene are sub-optimal. Hence, project managers should consider the profile of those selected to be CDDs and establish training programs to improve their habits. &nbsp; Key words: Key household practices, community health workers, health promotion.

Assessment of knowledge and factors that may predict willingness to volunteerism: a pilot study of community-directed distributors in Anambra state.

Malaria as a leading cause of death in many developing countries requires urgent interventions. In order to improve access to healthcare, trained volunteers are used to distribute health commodities. The present study aims at determining knowledge and factors that may predict willingness to volunteerism in a developing country. This was a cross-sectional descriptive study carried out in 2014 among 284 community-directed distributors in three rural communities in Anambra, Southeast Nigeria using pretested semi-structured questionnaires. The age range of volunteers was 21-79 years. Most (71.8%) are females and are married (83.1). Only 5.6% of the volunteers did not have any formal education. The predominant occupation is trading (52.5). Most volunteers (78.5%) could define the term volunteerism. Less than half (40.1%) knew the resources that could be volunteered. Most (67.3%) felt that volunteerism is most needed in church activities. Many respondents (58.8%) had volunteered for one or more programs previously. The most common challenge faced was interference with other income generating activities (66.5%). Retired males were more likely to volunteer than retired females (P ≤ 0.01). However, females are more likely to volunteer if the main reason of volunteering is to help people (P ≤ 0.01). The more educated ones believe that volunteerism will help them to be selected for other community programs. Most respondents had volunteered for other programs and the motivating factors included the satisfaction derived from helping others and the hope of being used for other community programs.

Contribution and performance of female Community-Directed Distributors in the treatment of onchocerciasis with Ivermectin in Sub-Saharan Africa: a systematic review.

The African Program for Onchocerciasis Control (APOC) was launched in 1995 with the main goal being to boost the fight against onchocerciasis in Africa. In 2011, over 80 million people benefited from this intervention thanks to the contribution of 268.718 Community-Directed Distributors (CDD). These significant results obscure the role of women CDD in this fight. Indeed, the insufficient involvement of female CDD has been identified as a concern by the APOC partners early in the program. The present study aims to assess the contribution and performance of women involved in a strategy to control onchocerciasis by community-directed treatment with ivermectin in sub Saharan Africa. We searched the following electronic databases from January 1995 to July 2013: Medline, Embase (Excerpta Medica Database), CINAHL (Cumulative Index to Nursing and Allied Health Literature), LILAS (Latin American and Caribbean Literature on Health Sciences), International Bibliography of Social Sciences, Social Services s, and Sociological s. Two research team members independently conducted data extraction from the final sample of articles by using a pre-established data extraction sheet. The primary outcome was the contribution of female CDD in the control of onchocerciasis by community-directed treatment with Ivermectin. Of 25 hits, 7 papers met the inclusion criteria. For the management of onchocerciasis, female CDDs are elected by the health committee from the communities they will serve. The significant proportion of those treated (about 61%) were women, although only 24% of CDDs were women. Many community members reported that women were more committed, persuasive and more patient than men in the distribution of ivermectin. Some studies have identified underutilization of female CDD as one reason for the limited effectiveness or, in some cases, pure failure related to the distribution of Ivermectin interventions in the fight against onchocerciasis in sub-Saharan Africa. Evidence from this review suggests that female CDD contribute to the treatment of onchocerciasis with Ivermectine in sub-Saharan Africa. Large-scale rigorous studies including Randomized controlled trials (RCTs) are needed to compare Community-Directed intervention involving men and women CDDs.

Factors affecting community participation in the CDTI program in Morogoro, Tanzania.

Up to 4 million people in Tanzania are at risk for the parasitic disease onchocerciasis. A treatment program, Community-Directed Treatment with Ivermectin (CDTI), has made significant gains in prevention and treatment. Understanding factors affecting participation could help boost treatment coverage and sustain gains made in controlling onchocerciasis in endemic areas. To explore community-perceived factors related to participation in and sustainability of the CDTI program in southwest Tanzania. Multilevel triangulation design using surveys, focus group discussions (FGDs), and semistructured interviews to collect data in two villages in the Morogoro Rural District of Tanzania. In total, 456 villagers participated in the survey and 42 in FDGs. Five community-directed distributors (CDDs) and three community health workers were interviewed. High levels of awareness of onchocerciasis (90%) and methods of prevention and treatment (95%) were reported. Over 75% of participants knew how ivermectin was distributed and 74% have taken the drug. Over 90% of villagers knew that distribution of the drug was for treatment and prevention. Only 43% knew the cause of onchocerciasis. Through FGDs, villagers reported barriers to participation, including lack of comprehensive understanding of the disease, fears of medication, distrust of the method determining dose, lack of health education materials, insufficient CDD-resident communication, and inflexible drug distribution mechanisms. Sustaining programs without supporting growth of CDDs and reinforcing education of communities could lead to a decrease in treatment and an increase in the public health threat. This research uncovered a need for more effective community education and sensitization. Understanding barriers to participation in community-based programs can assist public health and community health nurses and key stakeholders including Ministries of Health and local and regional health systems in the development of education and support materials to enhance health literacy and encourage program participation.

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

To evaluate onchocerciasis control activities in the Democratic Republic of Congo (DRC) in the first 12years of community-directed treatment with ivermectin (CDTI). 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. Community-directed treatment with ivermectin expanded from 1968 communities in 2001 to 39100 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. 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.

Monitoring of Mass Distribution Interventions for Trachoma in Plateau State, Nigeria

Mass drug administration (MDA) with antibiotics is a key component of the SAFE strategy for trachoma control. Guidelines recommend that where MDA is warranted the whole population be targeted with 80% considered the minimum acceptable coverage. In other countries, MDA is usually conducted by salaried Ministry of Health personnel (MOH). In Plateau State, Nigeria, the existing network of volunteer Community Directed Distributors (CDD) was used for the first trachoma MDA. We conducted a population-based cluster random survey (CRS) of MDA participation to determine the true coverage and compared this to coverage reported from CDD registers. We surveyed 1,791 people from 352 randomly selected households in 24 clusters in three districts in Plateau State in January 2011, following the implementation of MDA. Households were enumerated and all individuals present were asked about MDA participation. Household heads were questioned about household-level characteristics and predictors of participation. Individual responses were compared with the CDD registers. MDA coverage was estimated as 60.3% (95% CI 47.9–73.8%) by the survey compared with 75.8% from administrative program reports. CDD registration books for comparison with responses were available in 19 of the 24 clusters; there was a match for 658/682 (96%) of verifiable responses. CDD registers did not list 481 (41.3%) of the individuals surveyed. Gender and age were not associated with individual participation. Overall MDA coverage was lower than the minimum 80% target. The observed discrepancy between the administrative coverage estimate from program reports and the CRS was largely due to identification of communities missed by the MDA and not reported in the registers. CRS for evaluation of MDA provides a useful additional monitoring tool to CDD registers. These data support modification of distributor training and MDA delivery to increase coverage in subsequent rounds of MDA.

Preventing malaria in pregnancy through community-directed interventions: evidence from Akwa Ibom State, Nigeria

BackgroundDespite massive anti-malaria campaigns across the subcontinent, effective access to intermittent preventive treatment (IPTp) and insecticide-treated nets (ITNs) among pregnant women remain low in large parts of sub-Saharan Africa. The slow uptake of malaria prevention products appears to reflect lack of knowledge and resistance to behavioural change, as well as poor access to resources, and limited support of programmes by local communities and authorities.MethodsA recent community-based programme in Akwa Ibom State, Nigeria, is analysed to determine the degree to which community-directed interventions can improve access to malaria prevention in pregnancy. Six local government areas in Southern Nigeria were selected for a malaria in pregnancy prevention intervention. Three of these local government areas were selected for a complementary community-directed intervention (CDI) programme. Under the CDI programme, volunteer community-directed distributors (CDDs) were appointed by each village and kindred in the treatment areas and trained to deliver ITNs and IPTp drugs as well as basic counseling services to pregnant women.FindingsRelative to women in the control area, an additional 7.4 percent of women slept under a net during pregnancy in the treatment areas (95% CI [0.035, 0.115], p-value < 0.01), and an additional 8.5 percent of women slept under an ITN after delivery and prior to the interview (95% CI [0.045, 0.122], p-value < 0.001). The effects of the CDI programme were largest for IPTp adherence, increasing the fraction of pregnant women taking at least two SP doses during pregnancy by 35.3 percentage points [95% CI: 0.280, 0.425], p-value < 0.001) relative to the control group. No effects on antenatal care attendance were found.ConclusionThe presented results suggest that the inclusion of community-based programmes can substantially increase effective access to malaria prevention, and also increase access to formal health care access in general, and antenatal care attendance in particular in combination with supply side interventions. Given the relatively modest financial commitments they require, community-directed programmes appear to be a cost-effective way to improve malaria prevention; the participatory approach underlying CDI programmes also promises to strengthen ties between the formal health sector and local communities.

Compliance with eight years of annual ivermectin treatment of onchocerciasis in Cameroon and Nigeria

BackgroundAs the African Programme for Onchocerciasis Control (APOC) matured into its 10th year of ensuring community involvement in mass annual treatment of onchocerciasis with ivermectin, there was recognition of a need to study not only annual coverage of ivermectin in villages but also the compliance of individual villagers with these annual treatments. This was based on the concern that while population coverage goals may be achieved each year, there might be segments of the population who systematically are not complying with the annual regimen, thus creating a reservoir of infection and threatening program gains.MethodsA multi-site study in five APOC sponsored projects in Nigeria and Cameroon was undertaken to identify the socio-demographic correlates of compliance with ivermectin treatment. A total of 8,480 villagers above 9 years of age selected through a systematic random sampling from 101 communities were surveyed to ascertain their levels of compliance, by adapting APOC's standard household ivermectin survey form. Community leaders, community directed distributors (CDDs) of ivermectin and health workers were interviewed with in-depth interview guides, while focus group discussions were held with community members to help explain how socio-demographic factors might affect compliance.ResultsEight-year compliance ranged from 0 to 8 times with 42.9% taking ivermectin between 6-8 times annually (high compliance). In bivariate analysis high compliance was positively associated with being male, over 24 years of age, having been married, not being Christian, having little or no formal education and being in the ethnic majority. These variables were also confirmed through regression analysis based on total times ivermectin was taken over the period. While these factors explained only 8% of the overall variation in compliance, ethnic status and education appeared to be the strongest factors. Those with higher education may be more mobile and harder to reach while neglect of ethnic minorities has also been documented in other programs.ConclusionThese findings can help managers of CDTI programmes to ensure ivermectin reaches all segments of the population equally.

Simultaneous administration of praziquantel, ivermectin and albendazole, in a community in rural northern Ghana endemic for schistosomiasis, onchocerciasis and lymphatic filariasis

To compare (i) side effects associated with the simultaneous adminstration of praziquantel, albendazole and ivermectin with side affects associated with albendazole and ivermectin only and (ii) coverage by volunteers distributing three or two drugs. Two-arm comparative study in northern Ghana integrated praziquantel distribution into an existing lymphatic filariasis and onchocerciasis control programme using Community Directed Distributors. The control arm continued to distribute only ivermectin and albendazole. Dosages of ivermectin and praziquantel were based on height. Treatment was directly observed, and all two/three drugs were co-administered. Adverse effects were recorded based on passive surveillance. Parasitological, anthropometric and haematological data were collected at baseline. Prevalence of Schistosoma haematobium infection among 1001 (boys: 47.9% girls: 52.1%) school-age children (6-15 years) [intervention: 30.0% (CI: 23.1-34.2); control: 23.0% (CI: 18.9-27.0)], mean haemoglobin, weight and age were similar among the intervention and control groups. While 1676 (99.1%) compounds in the control area were visited and 15,020 (96.58%) people were treated, only 1375 (88.5%) compounds in the intervention area were visited and 8454 (80.97%) people treated (P < 0.001). The numbers of adverse effects were similar (intervention: 50/6896; control: 130/15,020). The most reported adverse effects was headache (intervention: 14/50; control: 13/130), followed by body weakness, which was reported more from the intervention group (intervention: 13/50, 95% CI: 14.6-40.3; control: 6/130, 95% CI: 1.7-9.8]. Sixty-six per cent (6896/10,441) of the eligible population received praziquantel. Reported adverse events were mild and managed at the subdistrict level with no cases of hospitalization; intensive health education will, however, be required to improve coverage.

Neglected tropical disease control in post-war Sierra Leone using the Onchocerciasis Control Programme as a platform

Strategic investments in the control of neglected tropical diseases (NTD) spearheaded by the US Government, the British Government and other bilateral donors such as foundations and key pharmaceutical partners have enabled the treatment of millions of people for the five targeted debilitating diseases (lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiasis and trachoma), paving the way for the potential elimination as public health problems of some of these diseases. Like many other countries, Sierra Leone has a high burden of these major NTDs. Despite the fragile infrastructure of a health system emerging from a devastating 10-year civil war, the country has successfully implemented the National NTD Control Programme, reaching national coverage in 2010. The NTD Control Programme uses the existing Onchocerciasis Control Programme as a platform and involves primary health workers. The programme has provided extensive training opportunities to health workers at national, district and community levels. The country currently has 31 161 trained community volunteers treating a population of five million people. It is shown that the investments in NTD control are not only to control NTDs but also to strengthen health systems, particularly at the primary level, through extensive capacity building of frontline health workers and community-directed distributors.

Where would I be without ivermectin? Capturing the benefits of community‐directed treatment with ivermectin in Africa

To document peoples' perceptions of the benefits of taking ivermectin, as an important predictor of sustained compliance with long-term ivermectin treatment, and to identify the socio-demographic correlates of perceived benefits of ivermectin treatment. Multisite study in Cameroon, DRC, Nigeria and Uganda. A structured questionnaire was administered to 1600 persons randomly selected from household treatment records. Community leaders, community-directed drug distributors (CDDs) and health workers were interviewed using in-depth interview guides, while focus group discussions (FGDs) were held with community members to capture factors that reflected their perception of benefits of community-directed treatment with ivermectin (CDTI). Case histories of persons with special experiences with onchocerciasis were collected. In this study, 84.7% of respondents indicated that ivermectin treatment has many benefits. The social benefits of CDTI included improved ability to work, peer acceptance and improved school attendance. Other individual benefits included self-respect/esteem, election to political office and improved relationship in the homes. The health benefits included improved skin texture and less ill health. Important demographic factors that influenced perception of the benefits of taking ivermectin, include marital status (P=0.012), age (P=0.029) and length of stay in onchocerciasis-endemic communities (P<0.001). Another factor was individual perception of susceptibility to onchocerciasis infection (P<0.0001). A programmatic focus on the benefits of CDTI could provide a basis for motivating communities to comply with long-term treatment with ivermectin. The results illustrate the importance of capturing beneficiaries' perceptions towards CDTI as a resource for producing health education materials for increasing the sustainability ivermectin distribution in endemic countries.

Perceptions on onchocerciasis and ivermectin treatment in rural communities in Uganda: implications for long-term compliance

Registers of community-directed distributors of ivermectin for onchocerciasis from 2000 to 2005 were reviewed to identify people highly and poorly compliant to ivermectin treatment. Compliance was termed 'high' if a person took annual ivermectin ≥4 out of 6 times and 'poor' if it was taken <4 times. Individuals (409 and 362 highly and poorly compliant, respectively) were interviewed on knowledge of onchocerciasis, severity of the disease, benefits of ivermectin treatment and its adverse events. Those who believed onchocerciasis to be a serious disease and also believed ivermectin treatment alleviated symptoms (71.9%), were highly compliant compared with (37.7%) who believed that onchocerciasis was not a serious disease and ivermectin did not alleviate symptoms (P < 0.001). Those who believed that ivermectin caused itchiness were 6.1% and 39.5% of highly and poorly compliant respectively (P < 0.001). Given that people more highly compliant with ivermectin mass drug administration (MDA) appear to better recognize the severity of onchocerciasis and the salutary effects of ivermectin, their enthusiasm to take ivermectin should be maintained through regular health education on the benefits and importance of continued treatment, and proper management of adverse events. The conclusions drawn in this article may equally apply to other MDA programmes.