Reducing the Antigen Prevalence Target Threshold for Stopping and Restarting Mass Drug Administration for Lymphatic Filariasis Elimination: A Model-Based Cost-effectiveness Simulation in Tanzania, India and Haiti.

BACKGROUND: The Global Programme to Eliminate Lymphatic Filariasis (GPELF) aims to reduce and maintain infection levels through mass drug administration (MDA), but there is evidence of ongoing transmission after MDA in areas where Culex mosquitoes are the main transmission vector, suggesting that a more stringent criterion is required for MDA decision making in these settings. METHODS: We use a transmission model to investigate how a lower prevalence threshold (<1% antigenemia [Ag] prevalence compared with <2% Ag prevalence) for MDA decision making would affect the probability of local elimination, health outcomes, the number of MDA rounds, including restarts, and program costs associated with MDA and surveys across different scenarios. To determine the cost-effectiveness of switching to a lower threshold, we simulated 65% and 80% MDA coverage of the total population for different willingness to pay per disability-adjusted life-year averted for India ($446.07), Tanzania ($389.83), and Haiti ($219.84). RESULTS: Our results suggest that with a lower Ag threshold, there is a small proportion of simulations where extra rounds are required to reach the target, but this also reduces the need to restart MDA later in the program. For 80% coverage, the lower threshold is cost-effective across all baseline prevalences for India, Tanzania, and Haiti. For 65% MDA coverage, the lower threshold is not cost-effective due to additional MDA rounds, although it increases the probability of local elimination. Valuing the benefits of elimination to align with the GPELF goals, we find that a willingness to pay per capita government expenditure of approximately $1000-$4000 for 1% increase in the probability of local elimination would be required to make a lower threshold cost-effective. CONCLUSIONS: Lower Ag thresholds for stopping MDAs generally mean a higher probability of local elimination, reducing long-term costs and health impacts. However, they may also lead to an increased number of MDA rounds required to reach the lower threshold and, therefore, increased short-term costs. Collectively, our analyses highlight that lower target Ag thresholds have the potential to assist programs in achieving lymphatic filariasis goals.

The effects of selected neglected tropical diseases on economic performance at the macrolevel in Africa.

BACKGROUND: Neglected tropical diseases (NTDs) such as leprosy, lymphatic filariasis (LF), schistosomiasis and onchocerciasis are endemic in several African countries. These diseases can lead to severe pain and permanent disability, which can negatively affect the economic productivity of the affected person(s), and hence resulting into low economic performance at the macrolevel. Nonetheless, empirical evidence of the effects of these NTDs on economic performance at the macrolevel is sparse. This study therefore investigates the effects of the above-mentioned NTDs on economic performance at the macrolevel in Africa. METHODS: The study employs a panel design with data comprising 24 to 45 African countries depending on the NTD in question, over the period, 2002 to 2019. Gross domestic product (GDP) is used as the proxy for economic performance (Dependent variable) and the prevalence of the above-mentioned NTDs are used as the main independent variables. The random effects (RE), fixed effects (FE) and the instrumental variable fixed effects (IVFE) panel data regressions are used as estimation techniques. RESULTS: We find that, an increase in the prevalence of the selected NTDs is associated with a fall in economic performance in the selected African countries, irrespective of the estimation technique used. Specifically, using the IVFE regression estimates, we find that a percentage increase in the prevalence of leprosy, LF, schistosomiasis and onchocerciasis is associated with a reduction in economic performance by 0.43%, 0.24%, 0.28% and 0.36% respectively, at either 1% or 5% level of significance. CONCLUSION: The findings highlight the need to increase attention and bolster integrated efforts or measures towards tackling these diseases in order to curb their deleterious effects on economic performance. Such measures can include effective mass drug administration (MDA), enhancing access to basic drinking water and sanitation among others.

Cost of care and its impact on households due to lymphatic filariasis: Analysis of a national sample survey in India.

BACKGROUND AND OBJECTIVES: India is an endemic country for lymphatic filariasis (LF). There are no current estimates of the expenditure being borne by LF patients in case of outpatient care or hospitalisation and its impact on households. This study aimed to estimate the household out-of-pocket (OOP) expenditure due to hospitalization or outpatient care as a result of LF in India. METHODS: Secondary analysis of nationally representative data for India collected by the National Sample Survey Organization in 2014 was performed, reporting on health service utilization and health care related OOP expenditure by income quintiles and by type of health facility (public or private). RESULTS: The median household OOP expenditure from hospitalization and outpatient care due to LF was US$ 178 and US$ 04, respectively; and was more than two times higher among the richest group compared to the poorest. There was a significantly higher proportion of households affected by catastrophic costs among the rich (30%) compared to the poor households (18%) due to hospitalization. Median private sector OOP hospitalization expenditure was nearly four times higher than the public sector. Less than one-fourth of outpatient visits (22%) were in the public sector. The median expenditure on medicines and indirect cost were US$ 32 (IQR: 17-84) and US$ 23 (IQR: 9-59), respectively in case of hospitalization due to LF; while in case of outpatient care these were US$ 1.5 (IQR: 0-5.8) and US$ 1.5 (IQR: 0-4), respectively. INTERPRETATION & CONCLUSION: Households with LF incur huge cost of patient care, particularly those in the lowest income group and those seeking care in the private sector.

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

BACKGROUND: Lymphatic 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. METHODS: This 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. RESULTS: Forty-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. CONCLUSION: This 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.

Integrated morbidity management for lymphatic filariasis and podoconiosis, Ethiopia.

PROBLEM: Lymphatic filariasis and podoconiosis are the major causes of tropical lymphoedema in Ethiopia. The diseases require a similar provision of care, but until recently the Ethiopian health system did not integrate the morbidity management. APPROACH: To establish health-care services for integrated lymphoedema morbidity management, the health ministry and partners used existing governmental structures. Integrated disease mapping was done in 659 out of the 817 districts, to identify endemic districts. To inform resource allocation, trained health extension workers carried out integrated disease burden assessments in 56 districts with a high clinical burden. To ensure standard provision of care, the health ministry developed an integrated lymphatic filariasis and podoconiosis morbidity management guideline, containing a treatment algorithm and a defined package of care. Experienced professionals on lymphoedema management trained government-employed health workers on integrated morbidity management. To monitor the integration, an indicator on the number of lymphoedema-treated patients was included in the national health management information system. LOCAL SETTING: In 2014, only 24% (87) of the 363 health facilities surveyed provided lymphatic filariasis services, while 12% (44) provided podoconiosis services. RELEVANT CHANGES: To date, 542 health workers from 53 health centres in 24 districts have been trained on integrated morbidity management. Between July 2013 and June 2016, the national health management information system has recorded 46 487 treated patients from 189 districts. LESSONS LEARNT: In Ethiopia, an integrated approach for lymphatic filariasis and podoconiosis morbidity management was feasible. The processes used could be applicable in other settings where these diseases are co-endemic.

Disease control priorities for neglected tropical diseases: lessons from priority ranking based on the quality of evidence, cost effectiveness, severity of disease, catastrophic health expenditures, and loss of productivity.

BACKGROUND: In the context of limited health care budgets in countries where Neglected Tropical Diseases (NTDs) are endemic, scaling up disease control interventions entails the setting of priorities. However, solutions based solely on cost-effectiveness analyses may lead to biased and insufficiently justified priorities. OBJECTIVES: The objectives of this paper are to 1) demonstrate how a range of equity concerns can be used to identify feasible priority setting criteria, 2) show how these criteria can be fed into a multi-criteria decision-making matrix, and 3) discuss the conditions under which this decision-making procedure should be carried out in a real-world decision-making context. METHODS: This paper draws on elements from theories of decision analysis and ethical theories of fair resource allocation. We explore six typical NTD interventions by employing a modified multi-criteria decision analysis model with predefined criteria, drawn from a priority setting guide under development by the WHO. To identify relevant evidence for the six chosen interventions, we searched the PubMed and Cochrane databases. DISCUSSION: Our in vitro multi-criteria decision analysis suggested that case management for visceral leishmaniasis should be given a higher priority than mass campaigns to prevent soil-transmitted helminthic infections. This seems to contradict current health care priorities and recommendations in the literature. We also consider procedural conditions that should be met in a contextualised decision-making process and we stress the limitations of this study exercise. CONCLUSION: By exploring how several criteria relevant to the multi-facetted characteristics of NTDs can be taken into account simultaneously, we are able to suggest how improved priority settings among NTDs can be realised.

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

BACKGROUND: Despite several years of LF-MDA implementation, Ghana still has some districts with mf prevalence >1%, partly due to poor treatment coverage levels resulting from non-participation in MDA. To address the challenges, we implemented Engage & Treat (E&T) and Test & Treat (T&T) strategies for individuals who miss or refuse MDA respectively, in a hotspot district, enabling us to reach many of those who seldom, or never, take part in MDA. This financial cost study was undertaken to analyse data on the LF-MDA, E&T and T&T implementation in 2021 and the financial cost to inform the rollout of the E&T and T&T as mop-up strategies in future LF-MDAs. METHODS: This costing study analysed cost data from the 2021 LF-MDA implementation activities carried out by the Neglected Tropical Diseases (NTD) programme of the Ghana Health Service and the SENTINEL study, carried out in Ahanta West district for the two interventions (i.e., E&T and T&T). The 2021 Ghana Population and Housing Census data was used to estimate the LF-MDA-eligible population. The financial cost per person treated was estimated and these costs were applied to the projected population to obtain the financial cost for subsequent years. RESULTS: Implementing MDA mop-up strategies either through the E&T or T&T to improve coverage comes at an additional cost to the elimination goals. For example, in 2024 the projected cost per person treated by the routine LF-MDA is estimated at US$0.83. The cost using the integrated LF-MDA and the E&T, T&T led by the NTD programme or T&T integrated into the health system was estimated at US$1.62, US$2.88, and US$2.33, respectively, for the same year. Despite the increased cost, the proposed combined LF-MDA and mop-up strategies will have a higher estimated population treated for 2024 (i.e., 1,392,211) compared to the routine LF-MDA approach (i.e., 988,470) for the same year. CONCLUSION: Combining LF-MDA with E&T/T&T mop-up strategies, despite their high costs, may provide NTD Programmes with the options of improving treatment coverage and reaching the LF elimination target sooner, given that the routine LF-MDA alone approach has been implemented for many years with some districts yet to reach the elimination targets.

Financial hardship among patients suffering from neglected tropical diseases: A systematic review and meta-analysis of global literature.

INTRODUCTION: Neglected tropical diseases (NTDs) mainly affect underprivileged populations, potentially resulting in catastrophic health spending (CHS) and impoverishment from out-of-pocket (OOP) costs. This systematic review aimed to summarize the financial hardship caused by NTDs. METHODS: We searched PubMed, EMBASE, EconLit, OpenGrey, and EBSCO Open Dissertations, for articles reporting financial hardship caused by NTDs from database inception to January 1, 2023. We summarized the study findings and methodological characteristics. Meta-analyses were performed to pool the prevalence of CHS. Heterogeneity was evaluated using the I2 statistic. RESULTS: Ten out of 1,768 studies were included, assessing CHS (n = 10) and impoverishment (n = 1) among 2,761 patients with six NTDs (Buruli ulcer, chikungunya, dengue, visceral leishmaniasis, leprosy, and lymphatic filariasis). CHS was defined differently across studies. Prevalence of CHS due to OOP costs was relatively low among patients with leprosy (0.0-11.0%), dengue (12.5%), and lymphatic filariasis (0.0-23.0%), and relatively high among patients with Buruli ulcers (45.6%). Prevalence of CHS varied widely among patients with chikungunya (11.9-99.3%) and visceral leishmaniasis (24.6-91.8%). Meta-analysis showed that the pooled prevalence of CHS due to OOP costs of visceral leishmaniasis was 73% (95% CI; 65-80%, n = 2, I2 = 0.00%). Costs of visceral leishmaniasis impoverished 20-26% of the 61 households investigated, depending on the costs captured. The reported costs did not capture the financial burden hidden by the abandonment of seeking healthcare. CONCLUSION: NTDs lead to a substantial number of households facing financial hardship. However, financial hardship caused by NTDs was not comprehensively evaluated in the literature. To develop evidence-informed strategies to minimize the financial hardship caused by NTDs, studies should evaluate the factors contributing to financial hardship across household characteristics, disease stages, and treatment-seeking behaviors.

Socioeconomic burden of lymphatic filariasis in Georgetown, Guyana.

OBJECTIVE: To assess the socioeconomic impact of lymphatic filariasis (LF) in Guyana. METHODS: Observational, cross-sectional study of 50 persons with chronic LF attending the Filariasis Clinic who were selected as the cases; and 50 persons with chronic skin conditions but no chronic LF, attending the Skin Clinic who were selected as the controls. The two groups were assessed using semi-structured interviews. RESULTS: Socioeconomic impact was statistically significant, especially with respect to 'having to change jobs' and experiencing major emotional and financial changes (P < 0.05). Fifty-six per cent of cases reported a major change since their diagnosis, whereas only 32% of controls did. Cases were less likely to be able to dress themselves and walk inside and outside the house than controls; they were three times more likely to spend money on transportation than controls (OR, 3.04 95% CI 1.11, 8.44). CONCLUSION: Patients with chronic LF face a considerable burden, which should be addressed as part of the Elimination Programme. One way in which this can be done is to provide free transportation for patients with chronic LF to and from Filariasis Clinics.

The implementation and impact of a pilot hydrocele surgery camp for LF-endemic communities in Ethiopia.

BACKGROUND: Ethiopia aims to eliminate lymphatic filariasis by 2020, through a dual approach of mass drug administration to interrupt transmission and morbidity control which includes making hydrocele surgery available in all endemic areas. Locating patients requiring surgery, providing high quality surgeries, and following up patients are all formidable challenges for many resource-challenged or difficult-to-reach communities. To date, hydrocele surgery in Ethiopia has only occurred when a patient has the knowledge, time and resources to travel to regional hospitals. Ethiopia tested the novel approach of using a surgical camp, defined as mobilizing, transporting, providing surgery at a static site, and following up of a large cohort of hydrocele patients within a hospital's catchment area, to address delays in seeking and receiving care. METHODOLOGY AND RESULTS: Health extension workers mobilized 252 patients with scrotal swelling from a list of 385 suspected hydrocele cases from seven endemic districts in the region of Beneshangul-Gumuz. Clinical health workers and surgeons confirmed 119 as eligible for surgery. Of 70 additional patients who self-referred, 56 were eligible for surgery. Over a two-week period at a regional hospital, 175 hydrocele excision surgeries were conducted. After discharge three days after surgery, trained clinical health workers followed up with the patients on Day 5, Day 8, Day 14 and 1st-month benchmarks with a randomized follow-up of a selection of patients conducted at 9-12 months. There were no post-operative complications upon discharge at Day 3 and 22, while minor complications occurred (12.6%) between Day 3 and one month. The 9-12 month follow-up found patients self-reported an improvement in quality of life, health and economic status. CONCLUSION: A hydrocele surgery camp was effective at providing a large number of quality surgeries in a short time. Using peripheral health workers to mobilize and follow up patients helped address delays in seeking and receiving quality care. Mainstreaming patient mobilization and follow-up into a community health system could be effective in other countries. The camp's results also influenced two regions in Ethiopia to change their policies in order to offer free hydrocele surgery (including patient transport, consultation, surgery, diagnostic tests and necessary medications).

Assessing the effects of disease-specific programs on health systems: An analysis of the Bangladesh Lymphatic Filariasis Elimination Program's impacts on health service coverage and catastrophic health expenditure.

This study presents a methodology for using tracer indicators to measure the effects of disease-specific programs on national health systems. The methodology is then used to analyze the effects of Bangladesh's Lymphatic Filariasis Elimination Program, a disease-specific program, on the health system. Using difference-in-differences models and secondary data from population-based household surveys, this study compares changes over time in the utilization rates of eight essential health services and incidences of catastrophic health expenditures between individuals and households, respectively, of lymphatic filariasis hyper-endemic districts (treatment districts) and of hypo- and non-endemic districts (control districts). Utilization of all health services increased from year 2000 to year 2014 for the entire population but more so for the population living in treatment districts. However, when the services were analyzed individually, the difference-in-differences between the two populations was insignificant. Disadvantaged populations (i.e., populations that lived in rural areas, belonged to lower wealth quintiles, or did not attend school) were less likely to access essential health services. After five years of program interventions, households in control districts had a lower incidence of catastrophic health expenditures at several thresholds measured using total household expenditures and total non-food expenditures as denominators. Using essential health service coverage rates as outcome measures, the Lymphatic Filariasis Elimination Program cannot be said to have strengthened or weakened the health system. We can also say that there is a positive association between the Lymphatic Filariasis Elimination Program's interventions and lowered incidence of catastrophic health expenditures.

Economic Costs and Benefits of Community-Based Lymphedema-Management Programs for Lymphatic Filariasis in India.

Lymphatic filariasis (LF) is endemic in 72 countries; 15 million persons live with chronic filarial lymphedema. It can be a disabling condition, frequently painful, leading to reduced mobility, social exclusion, and depression. The Global Program to Eliminate Lymphatic Filariasis aims to stop new infections and care for affected persons, but morbidity management has been initiated in only 38 countries. We examine economic costs and benefits of alleviating chronic lymphedema and its effects through simple limb care. We use economic and epidemiological data from 12 Indian states in which 99% of Indians with filariasis reside. Using census data, we calculate the age distribution of filarial lymphedema and predict the burden of morbidity of infected persons. We estimate lifetime medical costs and lost earnings due to lymphedema and acute dermatolymphangioadenitis (ADLA) with and without community-based limb-care programs. Programs of community-based limb care in all Indian endemic areas would reduce costs of disability by 52%, saving a per person average of US$2,721, equivalent to 703 workdays. Per-person savings are 185 times the program's per-person cost. Chronic lymphedema and ADLA impose a substantial physical and economic burden in filariasis-endemic areas. Low-cost programs for lymphedema management based on limb washing and topical medication are effective in reducing the number of ADLA episodes and stopping progression of disabling lymphedema. With reduced disability, people can work longer hours per day, more days per year, and in more strenuous, higher paying jobs, resulting in important economic benefits to themselves, their families, and their communities.

Quantifying the socio-economic impact of leg lymphoedema on patient caregivers in a lymphatic filariasis and podoconiosis co-endemic district of Ethiopia.

BACKGROUND: Lymphoedema caused by lymphatic filariasis (LF) or podoconiosis can result in physical disability and social exclusion, which is exacerbated by painful acute dermatolymphangioadenitis (ADLA) episodes. These conditions have a significant impact on patients, however, little is known about the indirect effects on their caregivers. This study, therefore, aimed to determine the impact on caregivers for patients with leg lymphoedema in a co-endemic district of Ethiopia. METHODOLOGY/PRINCIPAL FINDINGS: A cross-sectional survey of lymphoedema patients and their caregivers was conducted using semi-structured questionnaires in the Southern Nation Nationalities Peoples Region (SNNPR) of Ethiopia. Lymphoedema patient information on clinical severity (mild, moderate, severe), frequency of ADLAs, their socio-demographic characteristics and the identity of main caregiver(s) was collected. Caregiver information on socio-demographic characteristics, types of care provided, their quality of life (QoL) measured across nine domains, and productivity was collected, with key indicators compared in the presence and absence of patients' ADLAs. A total of 73 patients and 76 caregivers were included. Patients were grouped by mild/moderate (n = 42, 57.5%) or severe (n = 31, 42.5%) lymphoedema, and reported an average of 6.1 (CI± 2.18) and 9.8 (CI± 3.17) ADLAs respectively in the last six months. A total of 48 (65.8%) female and 25 (34.2%) male patients were interviewed. Caregivers were predominately male (n = 45, 59.2%), and spouses formed the largest caregiving group for both female and male patients. In the absence of an ADLA, most caregivers (n = 42, 55.2%) did not provide care, but only one caregiver did not provide care during an ADLA. In the absence of an ADLA, the average time (hour:minute) spent by mild/moderate (00:17, CI: ± 00:08) and severe (00:10, CI: ± 00:07) patient caregiver per task was minimal. The time mild/moderate (00:47, CI: ± 00:11) and severe (00:51, CI: ± 00:16) patient caregivers spent per task significantly increased in the presence of an ADLA. In addition, caregivers' QoL was negatively impacted when patients experienced an ALDA, and they had to forfeit an average of 6 to 7 work/school days per month. CONCLUSION/SIGNIFICANCE: Lymphoedema and ADLAs impact negatively on patients' and their caregivers' lives. This emphasises the importance of increasing access to effective morbidity management and disability prevention services to reduce the burden and help to address the Sustainable Development Goal (SDG) 5, target 5.4, which seeks to recognise and value unpaid care and domestic work.

GlaxoSmithKline and Merck: private-sector collaboration for the elimination of lymphatic filariasis.

More than 1000 million people in 82 countries are at risk of contracting the tropical disease lymphatic filariasis (LF). Although the disease is wide-spread, transmission of the causative parasites can be stopped through mass drug administrations based on a combination of anti-parasitic medicines. For more than 10 years, the pharmaceutical companies GlaxoSmithKline (GSK) and Merck & Co., Inc., have participated in a unique private-sector collaboration to support the global efforts to eliminate LF, through donations of drugs to prevent the disease. GSK's albendazole and Merck's ivermectin (Mectizan) now reach hundreds of millions of people each year, through national LF-elimination programmes carried out in collaboration with Ministries of Health, the World Health Organization, non-governmental organizations and local communities. Working in support of the Global Programme to Eliminate Lymphatic Filariasis, GSK and Merck not only provide donated medicines but also offer financial, programmatic and management expertise to support LF-elimination efforts worldwide.

Eliminating lymphatic filariasis: a view from the field.

Among infections closely associated with poverty, lymphatic filariasis (LF) is a study in contrasts. It is both a consequence of and a contributor to poverty. Although rarely fatal, it is recognized as a leading global cause of lifelong disability as well as significant personal, social, and economic burdens coincident with disease. Infection is often considerably more prevalent in communities than the number of cases of overt pathology for which LF is best known (lymphedema, elephantiasis, and hydrocele). With an estimated 120 million to 130 million affected persons in 83 countries and 1.25 billion persons living in areas at risk, in some countries LF may be expanding its range, whereas in others, with economic development, it has disappeared with little if any targeted intervention. The transmission cycle is relatively inefficient, yet an association with pockets of deepest poverty remains tenacious. Thanks to scientific advances in diagnostic tools, and particularly in control strategies focused on large-scale drug donation and mass drug distribution programs, scientists and policy makers now consider LF eliminable. Together with new approaches for morbidity control, a hopeful tone surrounds a disease problem that as recently as two decades ago could easily have been categorized as among the most neglected of neglected diseases. Continued progress toward global LF elimination will require solutions to potential obstacles in the most challenging--that is, the poorest--endemic settings. This chapter reviews progress toward LF elimination and some of the remaining challenges from a perspective in Haiti, the only least developed country of the Americas.

Strengthening of mass drug administration implementation is required to eliminate lymphatic filariasis from India: an evaluation study.

BACKGROUND & OBJECTIVES: The mass drug administration (MDA) is one of the strategies to eliminate lymphatic filariasis in India. Eleven districts are endemic for the disease in Madhya Pradesh state of India, which conduct MDA activities annually. A mid-term evaluation was conducted with the objectives to review the progress of the single dose of di-ethyl-carbamazine (DEC) administration, and to understand the functioning of the programme to recommend mid-term amendments. METHODS: A qualitative cross-sectional study was conducted in three endemic districts of Madhya Pradesh between July and October 2007. The teams of faculty members from medical college visited the study districts and collected data by desk review, indepth interviews, on site observations, and from the community. RESULTS: The filaria units in these districts were understaffed. There were no night clinics in two out of the three districts. The sufficient number of trainings for MDA were conducted without any mechanism for quality assurance. There was erratic and inadequate supply of DEC tablets, leading to the postponement of MDA activity, twice. The evaluated coverage with DEC tablets was much lower than that reported by the district officials. The tablet intake was not ensured by the distributors and the compliance rate was in the range of 60-70%. The IEC activities were conducted in limited areas, and there were prevailing myths and misconceptions, contributing to low compliance rate. There was no proper recording of the data on filariasis with gross mismatch at district headquarters and peripheral health facilities. A proportion of community members developed side effects following DEC tablet intake and had to visit private health facilities for treatment. INTERPRETATION & CONCLUSION: This evaluation study noted that MDA is restricted to tablet distribution only and the major issues of implementation in compliance, health education, side effect and morbidity management, and the logistics were not being given due attention. The implementation should be strengthened immediately in the MDA programme in India to achieve the goal of LF elimination by 2015.

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

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

Health, financial, and education gains of investing in preventive chemotherapy for schistosomiasis, soil-transmitted helminthiases, and lymphatic filariasis in Madagascar: A modeling study.

BACKGROUND: Neglected tropical diseases (NTDs) account for a large disease burden in sub-Saharan Africa. While the general cost-effectiveness of NTD interventions to improve health outcomes has been assessed, few studies have also accounted for the financial and education gains of investing in NTD control. METHODS: We built on extended cost-effectiveness analysis (ECEA) methods to assess the health gains (e.g. infections, disability-adjusted life years or DALYs averted), household financial gains (out-of-pocket expenditures averted), and education gains (cases of school absenteeism averted) for five NTD interventions that the government of Madagascar aims to roll out nationally. The five NTDs considered were schistosomiasis, lymphatic filariasis, and three soil-transmitted helminthiases (Ascaris lumbricoides, Trichuris trichiura, and hookworm infections). RESULTS: The estimated incremental cost-effectiveness for the roll-out of preventive chemotherapy for all NTDs jointly was USD125 per DALY averted (95% uncertainty range: 65-231), and its benefit-cost ratio could vary between 5 and 31. Our analysis estimated that, per dollar spent, schistosomiasis preventive chemotherapy, in particular, could avert a large number of infections (176,000 infections averted per $100,000 spent), DALYs (2,000 averted per $100,000 spent), and cases of school absenteeism (27,000 school years gained per $100,000 spent). CONCLUSION: This analysis incorporates financial and education gains into the economic evaluation of health interventions, and therefore provides information about the efficiency of attainment of three Sustainable Development Goals (SDGs). Our findings reveal how the national scale-up of NTD control in Madagascar can help address health (SDG3), economic (SDG1), and education (SDG4) goals. This study further highlights the potentially large societal benefits of investing in NTD control in low-resource settings.

Implementing a community vector collection strategy using xenomonitoring for the endgame of lymphatic filariasis elimination.

BACKGROUND: The global strategy for elimination of lymphatic filariasis is by annual mass drug administration (MDA). Effective implementation of this strategy in endemic areas reduces Wuchereria bancrofti in the blood of infected individuals to very low levels. This minimises the rate at which vectors successfully pick microfilariae from infected blood, hence requiring large mosquito numbers to detect infections. The aim of this study was to assess the feasibility of using trained community vector collectors (CVCs) to sample large mosquito numbers with minimal supervision at low cost for potential scale-up of this strategy. METHODS: CVCs and supervisors were trained in mosquito sampling methods, i.e. human landing collections, pyrethrum spray collections and window exit traps. Mosquito sampling was done over a 13-month period. Validation was conducted by a research team as quality control for mosquitoes sampled by CVCs. Data were analyzed for number of mosquitoes collected and cost incurred by the research team and CVCs during the validation phase of the study. RESULTS: A total of 31,064 and 8720 mosquitoes were sampled by CVCs and the research team, respectively. We found a significant difference (F(1,13) = 27.1606, P = 0.0001) in the total number of mosquitoes collected from southern and northern communities. Validation revealed similar numbers of mosquitoes sampled by CVCs and the research team, both in the wet (F(1,4) = 1.875, P = 0.309) and dry (F(1,4) = 2.276, P = 0.258) seasons in the southern communities, but was significantly different for both wet (F(1,4) = 0.022, P = 0.005) and dry (F(1,4 ) = 0.079, P = 0.033) seasons in the north. The cost of sampling mosquitoes per season was considerably lower by CVCs compared to the research team (15.170 vs 53.739 USD). CONCLUSIONS: This study revealed the feasibility of using CVCs to sample large numbers of mosquitoes with minimal supervision from a research team at considerably lower cost than a research team for lymphatic filariasis xenomonitoring. However, evaluation of the selection and motivation of CVCs, acceptability of CVCs strategy and its epidemiological relevance for lymphatic filariasis xenomonitoring programmes need to be assessed in greater detail.

Equity and efficiency in the scaled-up implementation of integrated neglected tropical disease control: the health economics protocol of the COUNTDOWN multicountry observational study in Ghana, Cameroon and Liberia.

INTRODUCTION: Worldwide, millions of individuals are affected by neglected tropical diseases (NTDs). They are frequently the poorest and most marginalised members of society. Their living conditions, among other things, make them susceptible to such diseases. Historically, several large-scale treatment programmes providing mass drug administrations (MDAs) were carried out per single disease but over the last decade there has been an increasing trend towards co-implementation of MDA activities given the resources used for such programmes are often the same. The COUNTDOWN multicountry studies focus on scaled-up implementation of integrated control strategies against four diseases: lymphatic filariasis, onchocerciasis, schistosomiasis and soil-transmitted helminthiasis. The objective of the COUNTDOWN economic study is to assess the multicountry implementation of control interventions in terms of equity, impact and efficiency. METHODS: The health economic study uses different analytical methods to assess the relationship between NTDs and poverty and the cost-effectiveness of different large-scale intervention options. Regression analysis will be used to study the determinants of NTD occurrence, the impact of NTDs on poverty, factors that hinder access to MDAs and the effect of NTDs on quality-of-life of those affected, including disability. Cost-effectiveness analyses of various integration methods will be performed using health economic modelling to estimate the cost and programme impact of different integration options. Here, cost-effectiveness ratios will be calculated, including multivariate sensitivity analyses, using Bayesian analysis. ETHICS AND DISSEMINATION: Ethics approval has been received both at the Liverpool School of Tropical Medicine and in all participating countries. Results of the various substudies will be presented for publication in peer-reviewed journals. STUDY DATES: 1 July 2016 to 30 June-October 2019.