Maintaining effective mass drug administration for lymphatic filariasis through in-process monitoring in Sierra Leone

Hodges, Sonnie Mustapha, Turay Hamid, Conteh Abdulai, Maccarthy Florence, Sesay, Sesay Santigie

Description

Since 2007 Sierra Leone has conducted mass drug administration (MDA) for the elimination of lymphatic filariasis (LF) implemented by unpaid community health volunteers (CHVs). Other health campaigns such as Mother and Child Health Weeks (MCHW) pay for services to be implemented at community level and these persons are then known as community health workers (CHWs). In 2010, the LF MDA in the 12 districts of the Southern, Northern and Eastern Provinces un-expectantly coincided with universal distribution of Long Lasting Insecticide Treated Nets (LLITNs) during the MCHW. In-process monitoring of LF MDA was performed to ensure effective coverage was attained in hard to reach sites (HTR) in both urban and rural locations where vulnerable populations reside. Methods Independent monitors interviewed individuals eligible for LF MDA and tallied those who recalled having taken ivermectin and albendazole, calculated program coverage and reported results daily by phone. Monitoring of coverage in HTR sites in the 4 most rapidly urbanizing towns was performed after 4 weeks of LF MDA and again after 8 weeks throughout all 12 districts. End process monitoring was performed in randomly selected HTR sites not previously sampled throughout all 12 districts and compared to coverage calculated from the pre-MDA census and reported treatments. Results Only one town had reached effective program coverage (≥80%) after 4 weeks following which CHWs were recruited for LF MDA in all district headquarter towns. After 8 weeks only 4 of 12 districts had reached effective coverage so LF MDA was extended for a further month in all districts. By 12 weeks effective program coverage had been reached in all districts except Port Loko and there was no significant difference between those interviewed in communities versus households or by sex. Effective epidemiological coverage (≥65%) was reported in all districts and overall was significantly higher in males versus females. Conclusions The challenges to LF MDA included the late delivery in country of ivermectin, the availability and motivation of unpaid CHVs, concurrent LLITN distribution and the MCHW, remuneration for CHWs, rapid urbanization and employment seeking population migrations. 'In process' monitoring ensured modifications of LF MDA were made in a timely manner to ensure effective coverage was finally attained even in HTR locations.

Sujets

• Filariasis
• Mass drug administration
• Supply chain management
• Urbanization

Informations

• Publié par: biomed
• Publié le: 01 janvier 2012
• Nombre de lectures: 13
• Langue: English

Extrait

Hodges et al. Parasites & Vectors 2012, 5:232
http://www.parasitesandvectors.com/content/5/1/232
RESEARCH Open Access
Maintaining effective mass drug administration
for lymphatic filariasis through in-process
monitoring in Sierra Leone
1* 1 1 2 2 2Mary H Hodges , Mustapha Sonnie , Hamid Turay , Abdulai Conteh , Florence MacCarthy and Santigie Sesay
Abstract
Background: Since 2007 Sierra Leone has conducted mass drug administration (MDA) for the elimination of
lymphatic filariasis (LF) implemented by unpaid community health volunteers (CHVs). Other health campaigns such
as Mother and Child Health Weeks (MCHW) pay for services to be implemented at community level and these
persons are then known as community health workers (CHWs). In 2010, the LF MDA in the 12 districts of the
Southern, Northern and Eastern Provinces un-expectantly coincided with universal distribution of Long Lasting
Insecticide Treated Nets (LLITNs) during the MCHW. In-process monitoring of LF MDA was performed to ensure
effective coverage was attained in hard to reach sites (HTR) in both urban and rural locations where vulnerable
populations reside.
Methods: Independent monitors interviewed individuals eligible for LF MDA and tallied those who recalled having
taken ivermectin and albendazole, calculated program coverage and reported results daily by phone. Monitoring of
coverage in HTR sites in the 4 most rapidly urbanizing towns was performed after 4 weeks of LF MDA and again
after 8 weeks throughout all 12 districts. End process monitoring was performed in randomly selected HTR sites not
previously sampled throughout all 12 districts and compared to coverage calculated from the pre-MDA census and
reported treatments.
Results: Only one town had reached effective program coverage (≥80%) after 4 weeks following which CHWs were
recruited for LF MDA in all district headquarter towns. After 8 weeks only 4 of 12 districts had reached effective
coverage so LF MDA was extended for a further month in all districts. By 12 weeks effective program coverage had
been reached in all districts except Port Loko and there was no significant difference between those interviewed in
communities versus households or by sex. Effective epidemiological coverage (≥65%) was reported in all districts
and overall was significantly higher in males versus females.
Conclusions: The challenges to LF MDA included the late delivery in country of ivermectin, the availability and
motivation of unpaid CHVs, concurrent LLITN distribution and the MCHW, remuneration for CHWs, rapid
urbanization and employment seeking population migrations. 'In process' monitoring ensured modifications of LF
MDA were made in a timely manner to ensure effective coverage was finally attained even in HTR locations.
Keywords: Lymphatic filariasis, Monitoring and evaluation, Mass drug administration, Community health workers,
Supply chain management, Urbanization
* Correspondence: [e-mail]
1
Helen Keller International, Freetown, Sierra Leone, 35 Nelson Lane, Tengbeh
Town, Freetown, Sierra Leone
Full list of author information is available at the end of the article
© 2012 Hodges et al.; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative
Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and
reproduction in any medium, provided the original work is properly cited.Hodges et al. Parasites & Vectors 2012, 5:232 Page 2 of 9
http://www.parasitesandvectors.com/content/5/1/232
Background (NMCP) and/or twice annually from the Mother and
Lymphatic filariasis (LF) is a mosquito borne neglected Child Health Week (MCHW). Unpaid CHVs and tem-
tropical disease (NTD) [1]. In 1998, the World Health porary, paid CHWs are increasingly implementing health
Organization (WHO) launched a Global Program for the programs in Sierra Leone.
Elimination of LF [2]. Persons suffering from LF may The health calendar became 'over-booked' in 2010.
suffer morbidity, social marginalization and loss of Delayed LF MDA coincided with the MCHW, which in
wage-earning capacity. As LF is a disease of the most addition to mass Vitamin A supplementation (VAS), de-
vulnerable they often live in remote, under-populated, worming and polio immunization to pre-school children,
rural, hard to reach (HTR) locations, or in over-populated, undertook universal distribution of Long Lasting Insecti-
rapidly urbanizing settlements increasingly recognized as cideTreated Nets (LLITNs).
HTR by persistently underperforming in MDAs even If LF MDAs do not reach effective coverage, programs
though they are geographically accessible. Ensuring effect- may need to be continued [11,12]. The NTDCP and
ive coverage for HTR populations should be prioritized in implementing partner: Helen Keller International (HKI)
LFeliminationprograms. were aware of the negative impact that the concurrent
Mapping of LF in Sierra Leone was performed in 2005 MCHW and LLITN distribution could have on coverage
and all 14 districts were found to be endemic, justifying especially in HTR communities. The most rapidly ur-
nation-wide mass drug administration (MDA) and a banizing, largest towns with relatively large HTR popula-
baseline LF microfilaria survey was performed in 2007– tions include the 3 provincial head quarters of the
08 [3]. The goal of the National Neglected Tropical Di- North, South and East: Makeni, Bo and Kenema respect-
sease Control Program (NTDCP) is to eliminate LF by ively. These towns had grown rapidly during the war
2015, requiring 5–6 effective rounds with ivermectin and post war due internal displacement. In addition
(IVM) plus albendazole (ALB) [4]. To be effective, 65% Koidu in the heart of the Kono diamond mining district
of the national, at risk population should receive IVM has grown most rapidly post war due to employment
and ALB or 80% of the eligible, at risk population [5]. seeking migration. In-process monitoring of LF MDA
Children <90 cm in height, the sick, very elderly, preg- was performed with the specific objectives of ensuring
nant women, and women who gave birth within the last effective coverage was attained in HTR sites, enabling
week are not eligible during MDA [6]. modifications/re-enforcements to the MDA strategy be-
The National NTDCP piloted house-to-house LF fore the distribution stopped. The main objective of the
MDA by unpaid community health volunteers (CHV) in end process monitoring was to compare program cover-
6 districts in 2007 [7]. Since 2008 all 12 districts in the age in HTR locations by district and the 4 largest towns
Northern, Southern and Eastern Provinces have imple- with epidemiological coverage reported by the District
mented effective MDA using CHVs as reported by the Health Management Teams (DHMTs) to the NTDCP
NTDCP. However a post event coverage survey found calculated from the pre-MDA census and reported treat-
house-to-house LF MDA by CHVs had been ineffectual ments. The second objective was to compare coverage
in the semi-urban setting of the Rural Western Area in males versus females by both methods. This paper
(RWA) in 2009 [8]. The LF MDA strategy was changed reports on the results, discusses the challenges to effect-
to a public, fixed point and street-by-street distribution ive LF MDA and the corrective measures taken.
using temporary paid community health workers
(CHWs) in the RWA and Urban WA (UWA) in June
Methods2010 and end process independent monitoring showed
Pre-Mass Drug Administration censusthat coverage had been effective as shown in Figure 1
Preparations began 2 months before for the annual[9]. Full geographical coverage including the 2 districts
MDA in 2010 with advocacy meetings and socialin the Western Area was achieved in 2010 [9,10].
mobilization organized by the staff of the 1,080 localUnpaid CHVs are elected/re-elected annually by their
PHUs and their community health management com-communities, trained by the Peripheral Health Unit
mittees in 12 districts comprised of 149 chiefdoms and(PHU) staff and function as the drug distributors for LF
approximately 14,253 communities. Each PHU has aMDA. These CHVs perform an annual pre-MDA com-
recognized catchment population of approximately 5,000munity census, but un-controlled settlement of inter-
residents. These communities elected or re-elected ap-nally displaced persons during the war (1991–2002)
proximately 2 CHVs per 500 residents. These CHVs thenfollowed by employment seeking migrations post war
up-dated the pre-MDA community census upon whichmakes this pre-MDA census challenging in rapidly ur-
banizing settings [8]. Trained CHVs may also work for IVM and ALB requisitions from their supervisory PHUs
were based and reported epidemiological coverage wasand receive remuneration as CHWs from other pro-
finally calculated.grams such as the National Malaria Control ProgramHodges et al. Parasites & Vectors 2012, 5:232 Page 3 of 9
http://www.parasitesandvectors.com/content/5/1/232
Koinadugu
223
Kambia
310 Bombali 371+
LF MDA by CHVs piloted in rural
settings in 2007 and effective Makeni 127
since 2008
Port Loko Kono 377+·
Tonkolili480 Koidu Town 84 Effective, annual LF MDA by 412
CHVs since 2008·
LF MDA by CHVs piloted in RWA
in 2009 and effective LF MDA Bo Kenema
UWA*
by CHWs since 2010374+ 427+Moyamba1,602
Kailah