Despite the pandemic, NTD elimination work continues as IMA World Health connects virtually for ASTMH 2020

  • Matt Hackworth
  • Nov 9, 2020

The staff and partners of IMA World Health are excited to join colleagues at the American Society of Tropical Medicine and Hygiene 2020 Annual Meeting (#TropMed20). We join colleagues from ministries of health in Tanzania and Haiti, academic researchers from Brigham Young University and others to present our shared work, moving us ever closer to ending debilitating diseases.

9:30 a.m. - 9:45 a.m., November 17, 2020

Overcoming the Deworming Cliff: Challenges in Maintaining Mass Treatment for Soil Transmitted Helminths When Lymphatic Filariasis Program Stops - LF elimination and STH control in Haiti – Success and Challenges 

Read the abstract here.

Abdel Direny 

Lymphatic Filariasis (LF) and Soil transmitted helminths (STH) are two of the most widespread neglected tropical diseases (NTDs) amenable to preventive chemotherapy. In most countries, the LF program is the largest platform for drug distribution using Albendazole (ALB) and Ivermectin (IVM) or ALB in combination with Diethylcarbamazine (DEC)- in some countries, DEC is co-administrated with ALB and IVM. Soil transmitted helminths have rarely been mapped alone at baseline prior to the starting of preventive chemotherapy. In general, STH has been treated as part of the mass drug administration (MDA) for LF - because Albendazole is also the main drug for STH control. Alternatively, STH treatments are co-implemented during Schistosomiasis (SCH) MDA in areas where the two diseases are co-endemic. Only a few countries have standalone STH control programs. In addition, impact assessments for STH programs have been very limited in most of the donors supported countries. Under the USAID funded Act to End NTD program, 468 districts from a total of 11 countries have stopped MDA for LF in 2019. Among these districts 126 are still in need for STH MDA upon evaluation (prevalence >1%). Globally, within the USAID supported countries, several programs including Togo, Mali, Cameroon and Haiti have either stopped or on track for stopping LF MDA in all their endemic districts following successful transmission assessment surveys. These countries are now facing challenges in terms of developing and implementing long-term strategies to transition their STH control programs, especially in districts where STH prevalence remains moderate to high. In fact, in areas where STH remain endemic, School health platforms, immunization outreach projects, bed nets distribution, nutrition interventions, maternal and child health campaigns have been explored or used to continue deworming programs. The session will discuss the programmatic and operational challenges in maintaining the gains of STH control especially around and after post LF MDA. The presenters will explore country specific perspectives in terms of cross sector coordination with non-health sectors (education, water, sanitation etc.) and the integration of deworming into other public health platforms and routine health care services for people at risk for STH. 

9 A.M. - 10:45 A.M., November 18, 2020

Comparing post-MDA coverage survey data for Trachoma, Onchocerciasis and Lymphatic Filariasis with reported data among 14 district councils in Tanzania

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Veronica Kabona, Denis Kailembo, Kerry Dobies, Mary Linehan, Abdel Direny

All districts of Tanzania are endemic for ≥2 preventive chemotherapy neglected tropical diseases (NTDs). Mass drug administration (MDA) interventions in Tanzania have interrupted transmission of lymphatic filariasis (LF) in 105 out of 120 district councils and Trachoma in 65 out of 71. In October 2019, the Tanzania NTD Control Program (TZNTDCP) conducted a post-MDA coverage evaluation survey (CES) in 14 councils to compare reported coverage for Trachoma, Onchocerciasis and LF data from community drug distributors (CDDs), with data collected from the survey. The purpose was to first, estimate concordance between the two datasets, and second, identify reasons for not participating in MDA. The CES was a cross-sectional survey following the World Health Organization (WHO) guidelines using probability proportional to estimated size. Councils were selected if they had failed a disease specific assessment (DSA) at least once by 2019 for LF or Trachoma, and those with the change of MDA strategy to twice MDA yearly for Onchocerciasis. In two councils (14.2%) there was higher coverage in the CES results when compared to the one reported by CDDs (81.8% vs 70.1% and 78.8% vs 71%). WHO set the minimum coverage for MDA at 65% for LF and 80% for Onchocerciasis and Trachoma. Successful MDA was found in 1 out of 4 councils (25%) for Trachoma, 1 out of 3 councils (33.3%) for Onchocerciasis and in 7 out of 7 the councils (100%) for LF when comparing the CES validated coverage with the WHO targets. This contradicts reported MDA coverage by CDDs that shows 12 out of 14 surveyed councils achieved the recommended MDA coverage. The CES also revealed that absenteeism was the main reason that people did not participate in MDA (38.1% for Trachoma and 36.3% for LF and Onchocerciasis), followed by drug distributors did not arrive (22.4% for Trachoma and 16.7% for LF and Onchocerciasis). New strategies such as strengthening advocacy and social mobilization as well as improving CDDs training, based on the CES results, will be implemented by the TZNTDCP in councils which had low MDA coverage validated by the CES, to improve coverage and subsequently eliminate NTDs in the country as a whole. 

9 A.M. - 10:45 A.M., November 18, 2020

Segmenting implementation units (IUs) during pre-TAS in Haiti to strengthen mass drug administration (MDA) in confirmed hotspots 

Read the abstract here.

Carl Fayette, Alain Javel, Paul-Emile Dalexis, Eurica Denis, Ellen Knowles, Mary Linehan, Abdel Direny 

Persistent efforts to eliminate lymphatic filariasis (LF) in Haiti over the past two decades have resulted in large reductions in prevalence nationwide. As a result, 121 out of 140 implementation units (IUs) in the country no longer require mass drug administration (MDA). Despite this progress, 19 IUs have on-going transmission after having completed at least nine rounds of MDA. These IUs have had high baseline prevalence (antigenemia: 10-45%) and are demographically diverse. The Haiti Neglected Tropical Disease Control Program (HNTDCP), with support from its partners, created an adapted approach during sentinel and spot-check site surveys. While these surveys are usually in one sentinel and one spot-check site per IU, the program segmented 4 IUs into 2-3 smaller, sub-units based on their suspected risk. The results showed an age range of antigen-positives between 25-68 years old in all 4 IUs; 1.6% of females in all 4 IUs were positive while 3.6% of males were positive. The results also revealed that, rather than complete failures in IUs when considered as a whole, 33% of the sub-units now meet the World Health Organization (WHO) criteria for eligibility to implement a transmission assessment survey (TAS) to determine if MDA can be stopped (Ag<2% in sentinel and spot-check sites). With limited resources, segmenting IUs in Haiti can be a solution for tailoring MDA strategies for hard-to-reach and non-compliant populations, and to apply resources efficiently, where needed. With this approach, the HNTDCP will be on track with the new WHO roadmap, which aims to eliminate LF as a public health problem by 2030.

1:45 P.M. - 3:30 P.M., November 18, 2020

Follow Up of Children Antigen-Positive for Lymphatic Filariasis identified during a Transmission Assessment Survey in Haiti 

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Alain Javel, Eurica Denis

The transmission assessment survey (TAS) is a standardized WHO decision-making tool to determine when the prevalence of lymphatic filariasis (LF) has reached low enough levels that mass drug administration (MDA) can be stopped. In Haiti, the threshold to stop MDA is when LF antigenemia falls below 2% among children aged 6-7 years old. A challenge facing LF programs is how to respond to antigen-positive children identified during TAS that passed this threshold. Haiti’s Nippes Department passed TAS 1 and stopped MDA in 2015. Nippes passed TAS 2 in 2017; however, the number of antigen-positive children increased from 2 to 8, and 4 of these were in a single administrative commune. In 2019, a household survey was conducted in Nippes using two sampling strategies to help provide guidance for post-TAS surveillance. First, the 50 closest households to each LF antigen-positive child (index case) were selected purposively for inclusion in the survey. Twenty households were then randomly selected from each index case’s census enumeration area (EA). All consenting household members ≥ 2 years old were administered a survey and asked to provide 75μl of blood by finger stick for rapid antigen testing. Overall, 29 of 1,936 (1.5%) survey participants from 794 households were antigen-positive. Higher positivity rates were identified in participants >10 years old, however two sampled children <10 years old were antigen-positive, suggesting recent transmission. Positivity rates were similar between males and females. Households selected using random sampling identified a smaller number of cases but a higher positivity rate (n=9, 2.5%) compared to households selected using purposive sampling (n=17, 1.4%). Antigen positivity was higher in the commune with 4 index cases (2.4%) than in the other participating communes (0-1.8%) (P=0.002). Overall, a substantial number of LF cases were identified through both sampling methods indicating potential ongoing transmission in this area despite passing TAS. These results demonstrate the need for systematic post-MDA surveillance and policy guidelines for responding to antigen-positive children identified in TAS. 

3 P.M. - 4:45 P.M., November 19, 2020

Using mobile data collection technology to help overcome challenges during mass drug administration (MDA) in Port-de-Paix, Haiti 

Read the abstract here.

Alain Javel, Eurica Denis, Carl Fayette, Paul-Emile Dalexis, Ellen Knowles, Abdel Direny 

Since 2000, much progress has been made in Haiti to eliminate lymphatic filiaraisis (LF) as a public health threat. Port-de-Paix is one of the communes that have twice failed the pre-transmission assessment survey (pre-TAS) and continues to implement mass drug administration campaigns. In 2019, the Haiti Neglected Tropical Disease Control Program (HNTDCP) used Open Data Kit (ODK), a real time data collection tool, to improve data quality and collect additional information related to MDA in Port-de-Paix. Eighteen community health workers (CHWs) were trained to use ODK on smartphones and then collected data during MDA supervision. Each CHW was assigned at least two distribution posts to collect data on GPS coordinates, supervision checklists, and disaggregated treatment by sex, age and subdistrict, which were then sent to a central server for analysis and quick decision making. The CHWs sent 1889 forms for all 199 distribution posts. Results showed that at least 6 localities were not covered while 26% of the distribution posts were located at less than 50 meters from each other in some areas. The data also revealed that some distribution posts were located outside the commune boundaries. With this information, community leaders were able to follow up during MDA to facilitate real-time program adaptation and to reach uncovered areas. By using this tool, CHWs were able to identify 20% of distribution posts that were without a functional megaphone, which is important for social mobilization during MDA. The CHWs also found that in 12% of the distribution posts, registration forms were not completed properly on the first day of MDA. By the last day of the campaign, the rate was reduced to 1.6% thanks to on-site training of the community drug distributors (CDDs). Because the data were analyzed daily, the HNTDCP provided appropriate recommendations to supervisors and CDDs to resolve issues. The experience of Port de Paix showed how real-time mobile data collection with ODK can improve the MDA coverage and quality reporting. The HNTDCP plans to extend the use of this tool in other communes in order to decrease LF transmission and to reach its elimination goal by 2030. 

5 P.M. - 6:45 P.M., November 19, 2020

Efforts towards strengthening the integration of Supply Chain of Neglected Tropical Disease medicines into the electronic Logistics Management Information System in Tanzania 

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Frank Komakoma, Kerry Dobies, Katie Crowley

Tanzania’s supply chain management (SCM) of neglected tropical disease (NTD) medicines has gone through stages of improvement to achieve goals of effective mass drug administration (MDA). Initial assessment of the supply chain in 2014 revealed these challenges: poor inventory leading to shortages during MDA; large quantities of medicines remaining after MDA; medicines expiring before next MDA; and poor storage conditions compromising quality of medicines. In 2014, the NTD program together with partners developed supply chain guidelines for community drug distributors, frontline health workers and district pharmacists. Guidelines aimed to support NTD teams to better manage inventory, quantify medicines accurately, improve adverse effects reporting, and conduct reverse logistics. Following implementation of the guidelines, the program saw improvements in management of medicines whereby districts reported having fewer drugs in stock after MDA. After the 2014 MDA for example, a total of 3,419 bottles of Zithromax tabs and 84,256 bottles of Zithromax oral solution remained at district level. In 2018, this was down to 504 bottles of Zithromax tabs and 28,533 bottles of Zithromax oral, representing a combined 66% reduction in four years. The second improvement started in 2018 and aimed at streamlining inventory management among various stakeholders including the NTD program, Medical Stores Department (MSD), Pharmaceutical Services Unit, district and health facilities. This involved inclusion of NTD medicines at all levels (national, zonal, district and health facility) into the electronic Logistics Management Information System (eLMIS) which collects and provides logistics data in real time. As a result, the streamlined eLMIS will enable health facilities to order NTD drugs directly at MSD and strengthen ownership at the community level; MSD to plan efficient distribution of NTD medicines to health facilities; and NTD program to view quantities of medicines available at all levels after MDA and correctly quantify amounts required. It also allows for more efficient planning of reverse logistics, more accurate data, and better monitoring of expired medicines. 

Poster Session Presentations

1:30 P.M. - 3 P.M., November 16, 2020

Strategies toward meeting the Lymphatic Filariasis (LF) elimination goal in Tanzania 

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Denis Kailembo, Gerald Robi, Veronica Kabona, Kerry Dobies, Mary Linehan, Abdel Direny  

Lymphatic Filariasis (LF) is endemic across 120 districts in Tanzania. Tanzania’s Neglected Tropical Diseases Control Program (TZNTDCP) is using the drug-package of Ivermectin+Albendazole (IVM+ALB) during mass drug administration (MDA) as the primary strategy for achieving LF elimination. Among the 120 LF endemic districts, 105 districts have passed transmission assessment survey (TAS), reaching the criteria to stop MDA. While the TZNTDCP continues surveillance in districts which passed TAS, the focus is now on the remaining 15 districts with persistent LF transmission. TZNTDCP added extra clusters that were positive in TAS1 and TAS2 during TAS2 and TAS3 conducted in 2019. No positive cases were reported in the extra clusters. Of the 15 districts still requiring MDA, 14 were scheduled for re-pre-TAS in 2020 (to determine eligibility for conducting TAS) after successfully achieving sufficient coverage in the last two rounds of MDA. During this re-pre-TAS, three to five sites within each district were selected. The sites included both sentinel and spot check sites from previous assessments with a history of failure (Ag >2%), as well as new sites selected from those with reported cases of LF and a history of low MDA coverage. About 300 individuals aged 5 years and older were tested per site with Filarial Test Kits (FTS). Preliminary results showed that 8 of the 14 districts did not pass re-pre-TAS, highlighting ongoing transmission. TZNTDCP will develop and implement new strategies to strengthen MDA and to reach all populations (including migrant populations) before the next disease specific assessment (DSA). The strategies include allocation of community drug distributors (CDDs) according to level of effort (applying the CDD ratio), implement micro-plans at the sub-district level, and enhance supportive supervision. Moreover, DSA failure investigation will be conducted to critically analyze and provide recommendations to address why the districts did not pass the assessment. These strategies will help TZNTDCP move towards LF elimination in line with the WHO proposed target of eliminating LF as a public health problem by 2030. 

Integrating community health workers in Mass Drug Administration (MDA) supervision to improve MDA implementation

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Eurica Denis, Alain Javel, Carl Renand Fayette, Paul-Emile Dalexis, Ellen Knowles, Mary Linehan, Abdel Direny 

To achieve global goals to eliminate lymphatic filariasis (LF), the Haiti NTD Control Program (HNTDCP) follows WHO’s recommendations to implement rounds of annual mass drug administration (MDA) of diethylcarbamazine and albendazole for at least five consecutive years among at risk populations to halt LF transmission. In Haiti, MDA has always been supervised by the Ministry of Health (MOH) staff and its partners. The MDA strategy employs school- and community-based distribution posts to distribute the drugs to the targeted population. Due to a lack of resources and accessibility, some distribution posts have not been adequately supervised during MDA, resulting in poor reporting and low epidemiological coverage (<65%) by community drug distributors (CDDs). In 2019, the Haiti Neglected Tropical Disease Control Program (HNTDCP) developed a multi-level supervision plan to improve MDA supervision. The first level included a platform of 157 community health workers (CHWs) in 12 communes to ensure each distribution post is visited daily. The second level of supervision was comprised of MOH representatives and implementing partners, providing technical and logistical support to the first level supervisors, or directly to the distribution posts. With this new strategy, each distribution post is supervised every day using an electronic supervision checklist. The electronic forms are completed by each CHW using Open Data Kit through mobile phone, in which data is sent to an online server. A total of 1400 out of 1501 distribution posts (93%) are now supervised daily and geo-localized. Geo-localization is important to avoid uncovered areas during MDA. In addition, partial MDA results from every distribution post is collected daily and other information such as cleanliness of the distribution post and directly observed treatment strategy were also reported. With the information collected, HNTDCP was able to evaluate coverage daily and provide necessary assistance where needed, as well as inform program adaption in real-time to ensure effective coverage was reached. MDA supervision and reporting quality have improved while maintaining low costs. 

Lessons learned from a 24/7 hotline experience during urban MDA in Haiti 

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Paul-Emile Dalexis, Carl Renand Fayette, Eurica Denis, Alain Javel, Ellen Knowles, Abdel Direny, Mary Linehan 

Reaching the minimum goal of mass drug administration (MDA) coverage (≥65%) for lymphatic filariasis (LF) in urban setting remains a challenge worldwide. The Haiti Neglected Tropical Disease Control Program (HNTDCP) first achieved this goal in the metropolitan area of Port-au-Prince with the first MDA launching in 2012. However, coverage has declined in the following rounds and by 2017, HNTDCP reported one of the lowest coverage rates since the initiative began, 41%. In 2018, the Ministry of Health and partners developed a new strategy to improve MDA coverage. This strategy included: improving social mobilization, increasing drug access, increasing volunteers’ visibility, and increasing knowledge of drugs and reducing fears of adverse effects, including implementing a 24/7 hotline to facilitate communication between the HNTDCP and the target population. The purpose of this abstract is to provide details about the 24/7 hotline. Three medical doctors and one nurse were recruited to field incoming calls and answer questions. The hotline was free of charge and began 2 days prior to the launch of MDA, continued through one post-MDA. It was advertised on radio and television. An average of 40 calls were received per day, totaling 3,457 calls. Nearly half (44%) of the calls originated from the metropolitan area; 32% of the callers inquired about the location of the distribution posts, 5% had questions on adverse events, 14% declared they had participated in the actual MDA, and 60% asked general questions. By the conclusion of the 2018 MDA, the coverage rate reached 80%. While the hotline was just one component of the revised strategy, it alone cannot be attributed to the increase in MDA coverage. Nevertheless, it appears the hotline was an important factor in the revamped MDA strategy. The HNTCP is considering extending the hotline for MDA in other communes to improve coverage in order to reduce persistent LF transmission in areas which have continuously failed disease specific assessments.

11:45 A.M. - 1:15 P.M., November 18, 2020

What to do differently to enhance elimination of trachoma in Tanzania: lessons learned from districts with persistent TF prevalence of more than 5% 

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Gerald Robi, Denis Kailembo, Veronica Kabona, Kerry Dobies, Mary Linehan, Abdel Direny

Tanzania has reduced the number of districts requiring mass drug administration (MDA) for Trachoma by over 90% (71 to 6). These districts have successfully passed the trachoma impact survey indicating continuing transmission cannot be sustained. Despite this progress, the Tanzania neglected tropical diseases (NTD) program must still address districts where Trachoma transmission persists. Four districts failed TIS in 2014, 2016, and 2019 while two districts failed Trachoma surveillance survey in 2019, two years after stopping MDA. After failures in 2019, the NTD program conducted key informant interviews and reviewed MDA coverage history, health-facility MDA coverage, and coverage evaluation surveys (CES) to identify possible reasons for failures and to explore appropriate actions to improve program effectiveness. The program further conducted a desk review to identify key reasons and factors that have contributed to failure. The MDA historical data from 2004 revealed that all districts have trachoma follicular (TF) baseline prevalence >20% in children of 1-9 years of age, and had at least 8 rounds of MDA though all districts reported MDA coverage ≥80% at least in two rounds (ranging 2-5). In addition, the data showed low access to water (6-28%) and sanitation (4-29%) in these areas. The four main reasons for low MDA coverage are absenteeism, wrong perception of MDA, lack of information on MDA, and lack of drug inventory. The data allows to identify some challenges during MDA implementation such as insufficient number of community drug distributors (CDDs) and MDA supervisors, and tetracycline not used in MDA for those ineligible for Zithromax. Based on desk review results, recommendations have been made to Tanzania NTD programs to promote increased access and advocate with WASH partners to improve access to facial cleanliness and environmental improvement (F&E) component of the SAFE strategy to decrease trachoma infection in these four districts. Also, the program will implement MDA, coverage supervisor tool (CST) and mop-up if needed at proper times, and will consider introducing tetracycline in MDA for those ineligible for Zithromax. 

Onchocerciasis vectors and transmission status of Onchocerca Volvulus after 17 years of mass drug administration with ivermectin in Muheza district, Tanga focus in Tanzania 

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Andreas Nshala, Denis Kailembo

After over 17 years of annual mass drug administration (MDA) with average therapeutic coverage around 80% through community directed treatment with ivermectin (CDTI), it was envisaged that transmission would be interrupted to allow progress toward elimination of onchocerciasis in Tanzania. A cross-sectional study was conducted in six villages distributed in six wards each in Muheza district in Tanga focus to evaluate the entomological status to understand the impact of CDTI on elimination of Onchocerca volvulus infection in the vectors. Black flies were captured using a standard method of human landing collection from June 2017 through August 2017, a peak period for biting activity and transmission of the parasite. Biting rate was calculated by dividing total flies collected by number of capture days. Collected flies were morphologically identified macroscopically, confirmed microscopically and preserved in absolute ethanol in pools of 100 flies by catching point. Polymerase chain reaction (PCR) using O-150 pool-screening method was performed in 2019 to detect O. volvulus infection in black flies. A total of 5,119 adult female black flies were collected at six catching points for 24 days. Simulium woodi were the main vector collected in the study area with daily biting rate of 213 flies/day. A total of 54 pools of heads and bodies of black flies were analyzed and 3 (5.6%) pools tested positive for O. volvulus which is over 0.1%, the current threshold for stopping MDA. Each positive pool came from a separate catching point in the study area, hence 3 of 6 (50%) sites had a positive signal. These findings suggest that despite long term MDA with ivermectin in Muheza district, transmission of O. volvulus is ongoing in vectors and humans. 

About IMA’s NTD Work

With RTI International as the prime recipient, IMA has implemented the USAID Act to End NTDs | East project since 2019, building on our existing work through the previous project, USAID ENVISION (2011-2019). Through these projects, IMA provides assistance to national programs to control and eliminate five targeted NTDs: lymphatic filariasis, trachoma, onchocerciasis, schistosomiasis and soil-transmitted helminthiasis (from roundworm, hookworm and whipworm).