Coverage of preventive measures and surveillance for neglected tropical diseases in hard-to-reach communities in Ghana.

BACKGROUND: Neglected tropical diseases (NTDs) are a major public health burden which mainly affects poor populations living in tropical environments and hard-to-reach areas. The study sought to examine coverage of preventive efforts, and case surveillance for NTDs in hard-to-reach communities in Ghana. METHODS: The study investigated treatment efforts for lymphatic filariasis (LF), and onchocerciasis and schistosomiasis/soil transmitted helminths (SCH/STH) at household level, in difficult-to-access communities in Ghana. A total of 621 households were sampled from 6 communities in the Western, Oti and Greater Accra regions. RESULTS: Over 95% of the households surveyed were covered under mass drug administration (MDA) campaigns for lymphatic filariasis (LF) and onchocerciasis. More than 80% of households had received at least two visits by community drug distributors under the MDA campaigns in the last two years preceding the study. In addition, over 90% of households in the LF and onchocerciasis endemic communities had at least one member using anthelminthic medications under the MDA campaigns in the 12 months preceding the study. However, households where no member had taken anthelminthic medications in 12 months preceding the study were over 6 times likely to have someone in the household with LF. CONCLUSIONS: This study determined that SCH/STH, LF and onchocerciasis are of serious public health concern in some communities in Ghana. There is an urgent need for holistic practical disease control plan involving both financial and community support to ensure total control of NTDs in difficult-to-access communities is achieved.

Neglected tropical diseases in Africa: a new paradigm.

Programmes to control onchocerciasis have been ongoing for over 40 years. What was once a devastating blinding and disabling disease, particularly in West Africa, has largely been eliminated at least as a public health problem. Efforts continue to eliminate the transmission of the disease. However, as the elimination agenda has developed so have efforts to control/eliminate other neglected tropical diseases (NTDs). The African Programme for Onchocerciasis Control will close at the end of 2015. There has been considerable discussion as to what should replace it and the World Health Organization Africa Region has been consulting widely during the first part of 2015 and has established a new project framework that will be presented to a wider group of stakeholders to mobilise support with the aim of the coordination of NTD activities in the region. This will be called the Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN). This will put the countries in the driving seat but offer technical advice, capacity building and financial support, where needed, to enable countries to implement their NTD Master Plans, and also to implement recommendations of the Regional Programme Review Group. An NTD forum will be held periodically to consult with stakeholders.

Impact of vectorborne parasitic neglected tropical diseases on child health.

Chagas disease, leishmaniasis, onchocerciasis and lymphatic filariasis are all vectorborne neglected tropical diseases (NTDs) that are responsible for significant disease burden in impoverished children and adults worldwide. As vectorborne parasitic diseases, they can all be targeted for elimination through vector control strategies. Examples of successful vector control programmes for these diseases over the past two decades have included the Southern Cone Initiative against Chagas disease, the Kala-azar Control Scheme against leishmaniasis, the Onchocerciasis Control Programme and the lymphatic filariasis control programme in The Gambia. A common vector control component in all of these programmes is the use of adulticides including dichlorodiphenyltrichloroethane and newer synthetic pyrethroid insecticides against the insect vectors of disease. Household spraying has been used against Chagas disease and leishmaniasis, and insecticide-treated bed nets have helped prevent leishmaniasis and lymphatic filariasis. Recent trends in vector control focus on collaborations between programmes and sectors to achieve integrated vector management that addresses the holistic vector control needs of a community rather than approaching it on a disease-by-disease basis, with the goals of increased efficacy, sustainability and cost-effectiveness. As evidence of vector resistance to currently used insecticide regimens emerges, research to develop new and improved insecticides and novel control strategies will be critical in reducing disease burden. In the quest to eliminate these vectorborne NTDs, efforts need to be made to continue existing control programmes, further implement integrated vector control strategies and stimulate research into new insecticides and control methods.

Transmission of Onchocerca volvulus continues in Nyagak-Bondo focus of northwestern Uganda after 18 years of a single dose of annual treatment with ivermectin.

The objective of the study was to determine whether annual ivermectin treatment in the Nyagak-Bondo onchocerciasis focus could safely be withdrawn. Baseline skin snip microfilariae (mf) and nodule prevalence data from six communities were compared with data collected in the 2011 follow-up in seven communities. Follow-up mf data in 607 adults and 145 children were compared with baseline (300 adults and 58 children). Flies collected in 2011 were dissected, and poolscreen analysis was applied to ascertain transmission. Nodule prevalence in adults dropped from 81.7% to 11.0% (P < 0.0001), and mf prevalence dropped from 97.0% to 23.2% (P < 0.0001). In children, mf prevalence decreased from 79.3% to 14.1% (P < 0.0001). Parous and infection rates of 401 flies that were dissected were 52.9% and 1.5%, respectively, whereas the infective rate on flies examination by polymerase chain reaction (PCR) was 1.92% and annual transmission potential was 26.9. Stopping ivermectin treatment may result in onchocerciasis recrudescence.

Extracts of Euphorbia hirta Linn. (Euphorbiaceae) and Rauvolfia vomitoria Afzel (Apocynaceae) demonstrate activities against Onchocerca volvulus microfilariae in vitro.

BACKGROUND: Onchocerciasis transmitted by Onchocerca volvulus is the second major cause of blindness in the world and it impacts negatively on the socio-economic development of the communities affected. Currently, ivermectin, a microfilaricidal drug is the only drug recommended for treating this disease. There have been speculations, of late, concerning O. volvulus resistance to ivermectin. Owing to this, it has become imperative to search for new drugs. World-wide, ethnomedicines including extracts of Euphorbia hirta and Rauvolfia vomitoria are used for treating various diseases, both infectious and non-infectious. METHOD: In this study extracts of the two plants were evaluated in vitro in order to determine their effect against O. volvulus microfilariae. The toxicity of the E. hirta extracts on monkey kidney cell (LLCMK2) lines was also determined. RESULTS: The investigations showed that extracts of both plants immobilised microfilariae at different levels in vitro and, therefore, possess antifilarial properties. It was found that all the E. hirta extracts with the exception of the hexane extracts were more effective than those of R. vomitoria. Among the extracts of E. hirta the ethyl acetate fraction was most effective, and comparable to that of dimethanesulphonate salt but higher than that of Melarsoprol (Mel B). However, the crude ethanolic extract of E. hirta was found to be the least toxic to the LLCMK2 compared to the fractionated forms. CONCLUSIONS: Extracts from both plants possess antifilarial properties; however, the crude extract of E. hirta was found to be least toxic to LLCMK2.

Efficacy of DEET and non-DEET-based insect repellents against bites of Simulium damnosum vectors of onchocerciasis.

Coping strategies including smoke screens are used against nuisance bites of Simulium damnosum Theobald (Diptera:Simuliidae) in onchocerciasis endemic communities. To find more effective alternatives, the efficacy of commercially available N,N-diethyl-3-methylbenzamide (DEET) products with active concentrations of 9.5, 13, 25, 50 and 98.1-100% and 'NO MAS,' (active component: para-menthane-3,8-diol and lemon grass oil) were tested at Bui-Agblekame, Ghana. A Latin square study design was implemented using eight groups of two vector collectors each, who used repellents (treatment), mineral oil or nothing each day until the end of the study. Flies were caught and their numbers each hour recorded using the standard methods for onchocerciasis transmission studies. T-tests were used to compare the mean duration of protection and a one-way analysis of variance controlling for catchers and repellents was performed. Tukey's test was used to compare protection by repellents and mineral oil. The highest percentage protection was 80.8% by NO MAS and the least 42.5% by the 13% DEET product. The period of absolute protection was 5 h by NO MAS and 1 h by 50% DEET product. No significant increase in protection was offered beyond 25% active DEET products and no significance was observed in terms of catcher × repellent effect (F = 1.731, d.f. = 48, P = 0.209).

Impacto de la ivermectina sobre las geohelmintiasis en el foco de oncocercosis en Colombia / The effect of ivermectin on geohelminth frequency (i.e. as used in the onchocerciasis control program in Colombia)

Objetivo: Evaluar el efecto de la ivermectina sobre la frecuencia de infección por geohelmintos en una población colombiana incluida en el Programa para la Eliminación de la Oncocercosis en las Américas. Métodos: Estudio de evaluación de impacto con enfoque longitudinal como punto referente inicial, la población de Naicioná (1996) y como control, sujetos de la misma población (2008). Para el enfoque transversal se usó como referente la población de Naicioná en 2008 y como control, sujetos de Dos Quebradas en 2008. El procesamiento de las muestras de materia fecal se hizo por Ritchie-Frick modificado. Resultados: Ascaris lumbricoides fue el parásito más frecuente 49,6 % (60/121; IC 95 %:37,8-63,8) en Naicioná y 47,4 % (36/76; IC 95 %: 33,2-65,6) en Dos Quebradas. El mayor efecto de la ivermectina en mayores de 5 años fue la disminución del riesgo de infección, para Trichiuris trichiura, de 86 % (IC95 %:74-93) en la evaluación longitudinal y 63 % (IC 95 %:24-82) en la evaluación transversal. La disminución en la frecuencia de Strongyloides stercoralis fue 93 % (IC 95 %: 45-99), en la evaluación longitudinal y 85 % (IC95 %:-031 - 99) en la evaluación transversal. Conclusiones: El uso de la ivermectina en el contexto del Programa para la Eliminación de la Oncocercosis en las Américas no es suficiente para el control de la morbilidad de todas las geohelmintiasis, se requiere de programas integrales que incluyan los componentes de educación y saneamiento básico.

Objective: Evaluating the effect of ivermectin on soil-transmitted helminthes (STH) infection frequency in a Colombian population included in the Onchocerciasis Elimination Program for the Americas (OEPA). Methods: This was an impact evaluation study which adopted a longitudinal approach using the population of Naicioná (1996) as baseline for comparison to people from the same population as controls (2008). The cross-sectional approach involved comparing the reference population of Naicioná (2008) to the population of Dos Quebradas (2008) used as controls. Fecal samples were processed by a modified Ritchie-Frick method. Results: Ascaris lumbricoides was the most frequently found parasite in Naicioná (60/121; 49.6 %: 37.8-63.895%CI) and in Dos Quebradas (36/76; 47.4 %: 33.2-65.6 95 % CI). Ivermectin’s main effect on the population aged over 5 years was a decreased risk of Trichiuris trichiura infection in both longitudinal assessment (86 % reduction: 74-93 95 % CI) and cross-sectional assessment (63 %:24-82 95 % CI). A 93 % reduction (45-99 95 % CI) in Strongyloides stercoralis frequency was found in longitudinal assessment, compared to 85 % in cross-sectional assessment (-031-99 95 % CI). Conclusions: Ivermectin use in the OEPA is not sufficient for STH morbidity control. Integrated programs including education and basic sanitation are required.

[The effect of ivermectin on geohelminth frequency (i.e. as used in the onchocerciasis control program in Colombia)]. / Impacto de la ivermectina sobre las geohelmintiasis en el foco de oncocercosis en Colombia.

OBJECTIVE: Evaluating the effect of ivermectin on soil-transmitted helminthes (STH) infection frequency in a Colombian population included in the Onchocerciasis Elimination Program for the Americas (OEPA). METHODS: This was an impact evaluation study which adopted a longitudinal approach using the population of Naicioná (1996) as baseline for comparison to people from the same population as controls (2008). The cross-sectional approach involved comparing the reference population of Naicioná (2008) to the population of Dos Quebradas (2008) used as controls. Fecal samples were processed by a modified Ritchie-Frick method. RESULTS: Ascaris lumbricoides was the most frequently found parasite in Naicioná (60/121; 49.6 %: 37.8-63.895%CI) and in Dos Quebradas (36/76; 47.4 %: 33.2-65.6 95 % CI). Ivermectin's main effect on the population aged over 5 years was a decreased risk of Trichiuris trichiura infection in both longitudinal assessment (86 % reduction: 74-93 95 % CI) and cross-sectional assessment (63 %:24-82 95 % CI). A 93 % reduction (45-99 95 % CI) in Strongyloides stercoralis frequency was found in longitudinal assessment, compared to 85 % in cross-sectional assessment (-031-99 95 % CI). CONCLUSIONS: Ivermectin use in the OEPA is not sufficient for STH morbidity control. Integrated programs including education and basic sanitation are required.

Preventive chemotherapy in human helminthiasis: theoretical and operational aspects.

Preventive chemotherapy (PC), the large-scale distribution of anthelminthic drugs to population groups at risk, is the core intervention recommended by the WHO for reducing morbidity and transmission of the four main helminth infections, namely lymphatic filariasis, onchocerciasis, schistosomiasis and soil-transmitted helminthiasis. The strategy is widely implemented worldwide but its general theoretical foundations have not been described so far in a comprehensive and cohesive manner. Starting from the information available on the biological and epidemiological characteristics of helminth infections, as well as from the experience generated by disease control and elimination interventions across the world, we extrapolate the fundamentals and synthesise the principles that regulate PC and justify its implementation as a sound and essential public health intervention. The outline of the theoretical aspects of PC contributes to a thorough understanding of the different facets of this strategy and helps comprehend opportunities and limits of control and elimination interventions directed against helminth infections.

Comparative repellent activities of some plant extracts against Simulium damnosum complex.

The root and leaf extracts of four plants, Occimum gratissimum, Azadirachta indica, Pterocarpus santalinoides, and Pistia hyptis, were studied for repellent activities against the adults of Simulium damnosum sensu lato. The leaves and roots were extracted with 95% ethanol and the stocks were diluted with paraffin. The repellent activities of the extracts were investigated using human baits along the banks of River Oyan and River Ogun in southwestern Nigeria. The results showed that the root extract of O. grattissium and leaf extract of P. hyptis had highest repellent potentials with 78% and 78.1% protection against S. damnosum sensu lato, respectively, whereas the root and leaf of P. santalinoides recorded the least. Although there were significant differences in the percentage of protection of the extracts of the plants (p < 0.05), the variations in the percentage of protection of the leaf and root extracts were not statistically significant (p > 0.05). The study concludes that there exist some repellent efficacies in the extracts of the plants, most importantly O. grattissimum and P. hyptis. The plant extracts can further be developed in the prevention of man-vector contact in onchocerciasis endemic communities.

Monitoring ivermectin distributors involved in integrated health care services through community-directed interventions--a comparison of Cameroon and Uganda experiences over a period of three years (2004-2006).

OBJECTIVES: To assess and compare the effectiveness of ivermectin distributors in attaining 90% treatment coverage of the eligible population with each additional health activity they take up. METHODS: Random sampling was applied every year to select distributors for interviews in community-directed treatment with ivermectin (CDTI) areas of Cameroon and Uganda. A total of 288 in 2004, 357 in 2005 and 348 in 2006 distributors were interviewed in Cameroon, and 706, 618 and 789 in Uganda, respectively. The questions included treatment coverage, involvement in additional activities, where and for how long these activities were provided, and whether they were supervised. RESULTS: At least 70% of the distributors in Cameroon and Uganda during the study period were involved in CDTI and additional health activities. More of the distributors involved in CDTI alone attained 90% treatment coverage than those who had CDTI with additional health activities. The more the additional activities, the less likely the distributors were to attain 90% treatment coverage. In Uganda, distributors were more likely to attain 90% coverage (P < 0.001 if they worked within 1 km of their homesteads were selected by community members, worked among kindred, and were responsible for <20 households. CONCLUSION: Additional activities could potentially undermine the performance of distributors. However, being selected by their community members, working largely among kindred and serving fewer households improved their effectiveness.

Challenges for the integration of mass drug administrations against multiple 'neglected tropical diseases'.

Simple and safe medications for some of the common, but often neglected, diseases that afflict the poor are not only available but are often donated. Other medications indicated for neglected diseases are extremely cheap and cost-effective. These drugs can be administered together and combined, when feasible, into rapid-intervention packages based on mass drug administrations. It is therefore logical to integrate mass drug administrations when possible. Integration is, however, not always as simple as it seems, and 'integration' means different things to different people. Drugs are needed at different frequencies for different lengths of time, sometimes for the whole population, sometimes only for children. Care has to be taken that parallel systems are not created that bypass primary healthcare. Much can be achieved, however, by sensible integration, whether it be in the mapping of diseases or the setting up of treatment platforms that tackle several diseases at once. As governments and international organizations seek to create policies for integration that include not only mass drug administration but also morbidity control, and as various partnerships develop for implementation, there is the possibility to scale up health interventions, which will have a very positive impact on the poorest communities globally. Nevertheless, integration should not be forced for the sake of policy. Where things fit well they should be developed, where not, coordination within the primary-healthcare system can produce an equally long-lasting impact.

Community directed approach beyond ivermectin in Tanzania: a promising mechanism for the delivery of complex health interventions.

The Community Directed Intervention (CDI) is currently used for Ivermectin distribution for the treatment of onchocerciasis in Africa. This study was carried out to determine the extent to which the CDI process can be used for the delivery of other health interventions with different degrees of complexity. The study was conducted in five districts of Kilosa, Muheza, Lushoto, Korogwe and Ulanga in Tanzania and involved communities, health facility and district healthcare providers. Implementation of CDI across these health interventions involved addressing six major processes, namely, stakeholder processes, health system dynamics, engaging communities, empowering communities, engaging CDI implementers and broader system effects. Community and health systems changes were triggered, such that the inherent value of community involvement and empowerment could be internalized by communities and health workers, leading to a more receptive health system. The CDI process was accepted at the community levels as many were willing and ready to adopt the approach. Health workers at community levels were readily available and supportive of the process. Additionally, noted were the verified willingness and ability of community implementers to deliver multiple interventions; confirmed efficiency of CDI leading to cost savings at health systems level; increasing interest of the health system in CDI; interest of health workers in the process of integrated planning. However, there were factors that may have a negative influence on the CDI process. Drug and supply policy for CDI process was lacking at the national and district levels and the presence of parallel community-based programmes that provide financial incentives for community members to run them discouraged Community-directed distributors who in most cases are volunteers. In conclusion, the results have clearly and evidently demonstrated the potential of CDI approach for effectively and efficiently control of other diseases such as malaria, tuberculosis and childhood illnesses. The study has provided unique information on the feasibility and effectiveness of integrated delivery of interventions at the community level.

Adverse reactions from community directed treatment with ivermectin (CDTI ) for onchocerciasis and loiasis in Ondo State, Nigeria

Onchocerciasis is an endemic disease in Ondo state, Nigeria. Community directed distribution of ivermectin is currently on-going in some local government areas of the state. Randomly selected persons (2 331 males and 2 469 females) were interviewed using a modified rapid assessment procedure for Loa loa (RAPLOA) to assess community directed treatment with ivermectin. The retrospective study evaluated the coverage, impacts and adverse reactions to the drug treatment. A questionnaire was administered by house-to-house visit in six local government areas, implementing community directed treatment with ivermectin (CDTI) in this bioclimatic zone. A total of 2,398 respondents were reported to have participated in the treatment. The overall ivermectin coverage of 49.96% was recorded (range 0 - 52% in different communities). Adverse reactions from ivermectin administration were experienced in 38% of individuals. Diverse adverse reactions experienced included predominantly itching (18.50%); oedema, especially of the face and the limbs (8.2%); rashes (3.4%) and body weakness (2.4%). Expulsion of intestinal worms occurred in 0.96% of the respondents. The occurrence of adverse reactions in relation to age categories was statistically significant. Neither fatal nor severe adverse reactions were reported by respondents. Significantly, despite experienced adverse reactions, continued participation, acceptability and compliance to ivermectin treatment was expressed by the various communities. This attitude is in consonance with the African Programme for Onchocerciasis Control (APOC) objectives. Rev. Biol. Trop. 56 (4): 1635-1643. Epub 2008 December 12.

La oncocercosis es endémica en el estado Ondo, Nigeria. Se seleccionaron 4 800 personas al azar para evaluar con encuesta retrospectiva la cobertura, efectos y reacciones al tratamiento farmacológico con ivermectina administrado por la misma comunidad. La cobertura global de ivermectina fue 50 % con reacciones adversas en 38 % de los individuos. Estas fueron comezón picazón (18%), edema, especialmente de la cara y las extremidades (8%), erupciones cutáneas (3%) y debilidad (2%); dependieron de la edad y no hubo reacciones más graves. La expulsión de las lombrices intestinales se produjo en 96% de los encuestados. A pesar de las reacciones adversas, hubo continuidad, aceptación y cumplimiento del tratamiento con ivermectina, en consonancia con los objetivos del Programa Africano para el Control de Oncocercosis (APOC).

The Onchocerciasis Elimination Program for the Americas (OEPA).

Human onchocerciasis (river blindness) occurs in 13 foci distributed among six countries in Latin America (Brazil, Colombia, Ecuador, Guatemala, Mexico and Venezuela), where about 500,000 people are considered at risk. An effort to eliminate the disease from the region was launched in response to a specific resolution adopted by the PanAmerican Health Organization (PAHO) in 1991: to eliminate onchocerciasis from the region, as a public-health problem, by 2007. The effort took advantage of the donation of the drug Mectizan (ivermectin) by Merck & Co., Inc. In 1992, the Onchocerciasis Elimination Program for the Americas (OEPA) was launched, with its headquarters in Guatemala, to act as a technical and co-ordinating body of a multinational, multi-agency coalition that includes the endemic countries, PAHO, The Carter Center, Lions Clubs, the United States Centers for Disease Control and Prevention, The Bill and Melinda Gates Foundation, Merck & Co., Inc., and other partners. This public-private partnership facilitated the establishment of programmes for the semi-annual mass administration of Mectizan in the six countries with onchocerciasis. The aims were to (1) provide sustained treatments, with coverage reaching at least 85% of those eligible to receive the drug (in the 1845 endemic communities that are distributed within the 13 regional foci); (2) eliminate new morbidity caused by Onchocerca volvulus infection by 2007; and (3) eliminate transmission of the parasite wherever feasible. Significant progress has already been made in all six countries, each of which has active programmes with treatment coverages exceeding the target of 85%. The progress is being documented in accordance with certification guidelines for onchocerciasis elimination established by the World Health Organization. No new cases of onchocercal blindness are being reported in the region, and ocular disease attributable to O. volvulus has been eliminated from nine of the 13 foci. Treatment is no longer needed in Santa Rosa, Guatemala, where transmission has been eliminated, and will be halted in at least three other foci in 2008, as they confirm the interruption of transmission. Treatment efforts should now be concentrated on the five foci where significant transmission remains: Central (Guatemala), Amazonas/Roraima (Brazil), North-central (Venezuela), North-east (Venezuela) and South (Venezuela). Based upon the experience gained, the well-established operations and the success achieved so far, it seems reasonable to estimate that onchocerciasis could be eliminated from most of the remaining foci in the Americas by 2012. The protocol, criteria and deadline for stopping all onchocerciasis treatment in the region should soon be addressed by OEPA's Program Co-ordinating Committee (PCC), in co-ordination with the PAHO.

The NGDO Co-ordination Group for Onchocerciasis Control.

Since the beginning of the donation of Mectizan by Merck & Co., Inc., non-governmental development organizations (NGDO) have been actively involved in the mass distribution of this drug to control onchocerciasis. In 2006, the network of NGDO involved in onchocerciasis control assisted in the treatment of over 62 million people. The current strategy that is used for distribution in Africa, community-directed treatment with ivermectin (CDTI), is very well suited for integration with other health activities. NGDO have been the pioneers in integrating comprehensive eye care, insecticide-treated nets for malaria, the control of multiple 'neglected' tropical diseases, and vitamin-A supplementation. These expanded activities bring with them new challenges, which need to be addressed by all partners and where the NGDO will play an active role.

Adverse reactions from community directed treatment with ivermectin (CDTI) for onchocerciasis and loiasis in Ondo State, Nigeria.

Onchocerciasis is an endemic disease in Ondo state, Nigeria. Community directed distribution of ivermectin is currently on-going in some local government areas of the state. Randomly selected persons (2331 males and 2469 females) were interviewed using a modified rapid assessment procedure for Loa loa (RAPLOA) to assess community directed treatment with ivermectin. The retrospective study evaluated the coverage, impacts and adverse reactions to the drug treatment. A questionnaire was administered by house-to-house visit in six local government areas, implementing community directed treatment with ivermectin (CDTI) in this bioclimatic zone. A total of 2,398 respondents were reported to have participated in the treatment. The overall ivermectin coverage of 49.96% was recorded (range 0-52% in different communities). Adverse reactions from ivermectin administration were experienced in 38% of individuals. Diverse adverse reactions experienced included predominantly itching (18.50%); oedema, especially of the face and the limbs (8.2%); rashes (3.4%) and body weakness (2.4%). Expulsion of intestinal worms occurred in 0.96% of the respondents. The occurrence of adverse reactions in relation to age categories was statistically significant. Neither fatal nor severe adverse reactions were reported by respondents. Significantly, despite experienced adverse reactions, continued participation, acceptability and compliance to ivermectin treatment was expressed by the various communities. This attitude is in consonance with the African Programme for Onchocerciasis Control (APOC) objectives. Rev. Biol.

Dracunculiasis, onchocerciasis, schistosomiasis, and trachoma.

The four diseases discussed in this chapter (dracunculiasis, onchocerciasis, schistosomiasis, and trachoma) are among the officially designated "Neglected Tropical Diseases," and each is also both the result of and a contributor to the poverty of many rural populations. To various degrees, they all have adverse effects on health, agricultural productivity, and education. The Carter Center decided to work on these health problems because of their adverse effect on the lives of poor people and the opportunity to help implement effective interventions. As a result of the global campaign spearheaded by the Carter Center since 1986, the extent of dracunculiasis has been reduced from 20 to five endemic countries and the number of cases reduced by more than 99%. We have helped administer nearly 20% of the 530 million Mectizan (ivermectin) doses for onchocerciasis, which is now being controlled throughout most of Africa, and is progressing toward elimination in the Americas. Since 1999, two Nigerian states have been using village-based health workers originally recruited to work on onchocerciasis to also deliver mass treatment and health education for schistosomiasis and lymphatic filariasis. They now also distribute vitamin A supplements and bed nets to prevent malaria and lymphatic filariasis. Ethiopia aims to eliminate blinding trachoma in the Amhara Region of that highest-endemicity country by 2012, already constructing more than 300,000 latrines and other complementary interventions. Because of the synergy between these diseases and poverty, controlling or eliminating the disease also reduces poverty and increases self-reliance.

Community-directed interventions strategy enhances efficient and effective integration of health care delivery and development activities in rural disadvantaged communities of Uganda.

The community-directed interventions (CDI) strategy achieved a desired coverage of the ultimate treatment goal (UTG) of at least 90% with ivermectin distribution for onchocerciasis control, and filled the gap between the health care services and the communities. However, it was not clear how its primary actors--the community-directed health workers (CDHW) and community-directed health supervisors (CDHS)--would perform if they were given more responsibilities for other health and development activities within their communities. A total of 429 of 636 (67.5%) of the CDHWs who were involved in other health and development activities performed better than those who were involved only in ivermectin distribution, with a drop-out rate of 2.3%. A total of 467 of 864 (54.1%) of CDHSs who were involved in other health and development activities also maintained the desired level of performance. They facilitated updating of household registers (P<0.05), trained and supervised CDHWs, and educated community members about onchocerciasis control (P<0.001). Their drop-out rate was 2.6%. The study showed that the majority of those who dropped out had not been selected by their community members. Therefore, CDI strategy promoted integration of health and development activities with a high potential for sustainability.