Evaluating the availability and quality of services for lymphatic filariasis morbidity in Ghana.

BACKGROUND AND METHODOLOGY: In districts where lymphatic filariasis (LF) is endemic, the goal is to provide 100% geographical coverage of the essential package of care. Additionally, countries seeking elimination status must document the availability of services for lymphoedema and hydrocele in all endemic areas. To do this, the WHO recommends conducting assessments of the readiness and quality of services provided to identify service delivery and quality gaps. This study used the recommended WHO Direct Inspection Protocol (DIP), which consists of 14 core indicators related to LF case management, medicine and commodities, staff knowledge and patient tracking. The survey was administered in 156 health facilities across Ghana designated and trained to provide LF morbidity management services. Patient and health provider interviews were also conducted to assess challenges and feedback. PRINCIPAL FINDINGS: The highest performing indicators across the 156 surveyed facilities were related to staff knowledge; 96.6% of health workers correctly identified two or more signs and symptoms. The lowest scoring indicators concerned medication availability, with the two lowest scoring indicators in the survey being availability of antifungals (26.28%) and antiseptics (31.41%). Hospitals performed best with an overall score of 79.9%, followed by health centers (73%), clinics (67.1%) and CHPS compounds (66.8%). The most commonly reported challenge from health worker interviews was lack of medications and supplies, followed by a lack of training or poor motivation. CONCLUSIONS AND SIGNIFICANCE: The findings from this study can help the Ghana NTD Program identify areas of improvement as they seek to achieve LF elimination targets and continue to improve access to care for those with LF-related morbidity as part of overall health systems strengthening. Key recommendations include prioritizing refresher and MMDP training for health workers, ensuring reliable patient tracking systems, and integrating lymphatic filariasis morbidity management into the routine healthcare system to ensure medicine and commodity availably.

A Comparative Study of Lymphatic Filariasis-Related Perceptions among Treated and Non-Treated Individuals in the Ahanta West Municipality of Ghana.

Background: Ghana joined the Global Programme to Eliminate Lymphatic Filariasis (GPELF), established in the year 2000, with the aim of eliminating the disease as a public health problem through annual mass treatment of entire endemic populations. Since 2001, the country has implemented mass drug administration (MDA) in endemic districts, with great reductions in the population at risk for infection. However, in many districts, the elimination programme is faced with the presence of hotspots, which may be due in part to individuals not taking part in MDA (either intentionally or unintentionally) who may serve as reservoirs to sustain transmission. This paper compares the LF-related perceptions among individuals who regularly take the MDA drugs and those who seldom or never take part in the MDA in the Ahanta West Municipality of Ghana to determine community acceptable ways to implement an intervention aimed to track, engage, and treat individuals who regularly miss MDA or to test individuals who intentionally refuse MDA and treat them if positive for LF. Methods: This was a mixed method study employing questionnaire surveys and focus group discussions (FDG) for data collection. Survey participants were randomly selected from the 2019 treatment register to stratify respondents into treated and non-treated groups. FGD participants were selected purposively such that there are at least two non-treated persons in each discussion session. Results: Over 90% of the respondents were aware of the disease. Poor hygiene/dirty environment was wrongly reported by most respondents (76.8%) as the causes. MDA awareness was very high among both treated (96.9%) and non-treated (98.6%) groups. A low sense of vulnerability to LF infection was evident by a reduction in the number of people presenting clinical manifestations of the disease in communities. Slightly more, 65 (29.0%) of the non-treated group compared to the 42 (19.4%) treated group reported ever experiencing adverse effects of the MDA drugs. Barriers to MDA uptake reported in both groups were poor planning and implementation of the MDA, lack of commitments on the part of drug distributors, and adverse drug reactions. About 51% of the non-treated group reported never taking the drugs even once in the last five years, while 61% among the treated group took the MDA drug consistently in the past five years. Respondents in both groups believed that, when engaged properly, most non-treated persons will accept to take the drug but insisted community drug distributors (CDDs) must be trained to effectively engage people and have time for those they will be engaging in dialogue. The chiefs emerged as the most influential people who can influence people to take MDA drugs. Conclusions: The reduction in risk perception among respondents, adverse reactions and the timing of MDA activities may be influencing MDA non-participation in the study area; however, respondents think that non-treated individuals will accept the interventions when engaged properly by the CDDs.

The development and roll-out of a new hydrocoele surgery facility assessment tool for the elimination of lymphatic filariasis.

A hydrocoele surgery facility assessment tool (HSFAT) was developed to assess the readiness of hydrocoele surgery services in health facilities prior to implementation of hydrocoele surgical campaigns for the elimination of lymphatic filariasis (LF). A first version of the tool was piloted in Bangladesh, Malawi and Nepal in 2019, then, following feedback from country programme managers, a second version of the tool was rolled out across countries implementing hydrocoele surgery in the Accelerating the Control of Neglected Tropical Diseases (Ascend) West and Central Africa Programme, including Benin, Burkina Faso, Ghana, Guinea, Niger and Nigeria. The HSFAT assessed facilities across 10 domains: background information, essential amenities, emergency patient transfer, laboratory capacity, surgical procedures and trained staff, infection prevention, non-disposable basic equipment, disposable basic equipment, essential medicines and current hydrocoele practices. The HSFAT results highlight key areas for improvement in different countries and can be used to develop a quality improvement plan, which may include actions with agreed deadlines to improve the readiness and quality of hydrocoele surgery services provided by the health facility, prior to implementation of surgical campaigns and assist country programmes to achieve the dossier requirements set out by the World Health Organization for the elimination of LF.

The development of a capacity-strengthening program to promote self-care practices among people with lymphatic filariasis-related lymphedema in the Upper West Region of Ghana.

BACKGROUND: The Upper West region of Ghana is mostly made up of rural communities and is highly endemic for lymphatic filariasis (LF), with a significant burden of disability due to lymphedema and hydrocele. The aim of this paper is to describe an enhanced, evidence-based cascading training program for integrated lymphedema management in this region, and to present some initial outcomes. MAIN TEXT: A baseline evaluation in the Upper West Region was carried out in 2019. A cascaded training program was designed and implemented, followed by a roll-out of self-care activities in all 72 sub-districts of the Upper West Region. A post implementation evaluation in 2020 showed that patients practiced self-care more frequently and with more correct techniques than before the training program; they were supported in this by health staff and family members. CONCLUSIONS: Self-care for lymphedema is feasible and a program of short workshops in this cascaded training program led to significant improvements. Efforts to maintain momentum and sustain what has been achieved so far, will include regular training and supervision to improve coverage, the provision of adequate resources for limb care at home, and the maintenance of district registers of lymphedema cases, which must be updated regularly.

Progress towards lymphatic filariasis elimination in Ghana from 2000-2016: Analysis of microfilaria prevalence data from 430 communities.

BACKGROUND: Ghana started its national programme to eliminate lymphatic filariasis (LF) in 2000, with mass drug administration (MDA) with ivermectin and albendazole as main strategy. We review the progress towards elimination that was made by 2016 for all endemic districts of Ghana and analyze microfilaria (mf) prevalence from sentinel and spot-check sites in endemic districts. METHODS: We reviewed district level data on the history of MDA and outcomes of transmission assessment surveys (TAS). We further collated and analyzed mf prevalence data from sentinel and spot-check sites. RESULTS: MDA was initiated in 2001-2006 in all 98 endemic districts; by the end of 2016, 81 had stopped MDA after passing TAS and after an average of 11 rounds of treatment (range 8-14 rounds). The median reported coverage for the communities was 77-80%. Mf prevalence survey data were available for 430 communities from 78/98 endemic districts. Baseline mf prevalence data were available for 53 communities, with an average mf prevalence of 8.7% (0-45.7%). Repeated measurements were available for 78 communities, showing a steep decrease in mean mf prevalence in the first few years of MDA, followed by a gradual further decline. In the 2013 and 2014 surveys, 7 and 10 communities respectively were identified with mf prevalence still above 1% (maximum 5.6%). Fifteen of the communities above threshold are all within districts where MDA was still ongoing by 2016. CONCLUSIONS: The MDA programme of the Ghana Health Services has reduced mf prevalence in sentinel sites below the 1% threshold in 81/98 endemic districts in Ghana, yet 15 communities within 13 districts (MDA ongoing by 2016) had higher prevalence than this threshold during the surveys in 2013 and 2014. These districts may need to intensify interventions to achieve the WHO 2020 target.

Improving drug delivery strategies for lymphatic filariasis elimination in urban areas in Ghana.

The Global Program to Eliminate Lymphatic Filariasis (GPELF) advocates for the treatment of entire endemic communities, in order to achieve its elimination targets. LF is predominantly a rural disease, and achieving the required treatment coverage in these areas is much easier compared to urban areas that are more complex. In Ghana, parts of the Greater Accra Region with Accra as the capital city are also endemic for LF. Mass Drug Administration (MDA) in Accra started in 2006. However, after four years of treatment, the coverage has always been far below the 65% epidemiologic coverage for interrupting transmission. As such, there was a need to identify the reasons for poor treatment coverage and design specific strategies to improve the delivery of MDA. This study therefore set out to identify the opportunities and barriers for implementing MDA in urban settings, and to develop appropriate strategies for MDA in these settings. An experimental, exploratory study was undertaken in three districts in the Greater Accra region. The study identified various types of non-rural settings, the social structures, stakeholders and resources that could be employed for MDA. Qualitative assessment such as in-depth interviews (IDIs) and focus group discussions (FGDs) with community leaders, community members, health providers, NGOs and other stakeholders in the community was undertaken. The study was carried out in three phases: pre-intervention, intervention and post-intervention phases, to assess the profile of the urban areas and identify reasons for poor treatment coverage using both qualitative and quantitative research methods. The outcomes from the study revealed that, knowledge, attitudes and practices of community members to MDA improved slightly from the pre-intervention phase to the post-intervention phase, in the districts where the interventions were readily implemented by health workers. Many factors such as adequate leadership, funding, planning and community involvement, were identified as being important in improving implementation and coverage of MDA in the study districts. Implementing MDA in urban areas therefore needs to be given significant consideration and planning, if the required coverage rates are to be achieved. This paper, presents the recommendations and strategies for undertaking MDA in urban areas.

Persistent 'hotspots' of lymphatic filariasis microfilaraemia despite 14 years of mass drug administration in Ghana.

Background: Among the 216 districts in Ghana, 98 were declared endemic for lymphatic filariasis in 1999 after mapping. Pursuing the goal of elimination, WHO recommends annual treatment using mass drugs administration (MDA) for at least 5 years. MDA was started in the country in 2001 and reached national coverage in 2006. By 2014, 69 districts had 'stopped-MDA' (after passing the transmission assessment survey) while 29 others remained with persistent microfilaraemia (mf) prevalence (≥1%) despite more than 11 years of MDA and were classified as 'hotspots'. Methods: An ecological study was carried out to compare baseline mf prevalence and anti-microfilaria interventions between hotspot and stopped-MDA districts. Results: Baseline mf prevalence was significantly higher in hotspots than stopped-MDA districts (p<0.001). After three years of MDA, there was a significant decrease in mf prevalence in hotspot districts, but it was still higher than in stopped-MDA districts. The number of MDA rounds was slightly higher in hotspot districts (p<0.001), but there were no differences in coverage of MDA or long-lasting-insecticide-treated nets. Conclusions: The main difference in hotspots and stopped-MDA districts was a high baseline mf prevalence. This finding indicates that the recommended 5-6 rounds annual treatment may not achieve interruption of transmission.