Community-directed distributors-The "foot soldiers" in the fight to control and eliminate neglected tropical diseases.

The neglected tropical diseases (NTDs) affect hundreds of millions of people, predominantly in rural, often difficult-to-access areas, poorly served by national health services. Here, we review the contributions of 4.8 million community-directed distributors (CDDs) of medicines over 2 decades in 146,000 communities in 27 sub-Saharan African countries to control or eliminate onchocerciasis and lymphatic filariasis (LF). We examine their role in the control of other NTDs, malaria, HIV/AIDS interventions, immunisation campaigns, and support to overstretched health service personnel. We are of the opinion that CDDs as community selected, trained, and experienced "foot soldiers," some of whom were involved in the Ebola outbreak responses at the community level in Liberia, if retrained, can assist community leaders and support health workers (HWs) in the ongoing Coronavirus Disease 2019 (COVID-19) crisis. The review highlights the improved treatment coverage where there are women CDDs, the benefits and lessons from the work of CDDs, their long-term engagement, and the challenges they face in healthcare delivery. It underscores the value of utilising the CDD model for strong community engagement and recommends the model, with some review, to hasten the achievement of the NTD 2030 goal and assist the health system cope with evolving epidemics and other challenges. We propose that, based on the unprecedented progress made in the control of NTDs directly linked to community engagement and contributions of CDDs "foot soldiers," they deserve regional and global recognition. We also suggest that the World Health Organization (WHO) and other international stakeholders promote policy and guidance for countries to adapt this model for the elimination of NTDs and to strengthen national health services. This will enhance the accomplishment of some Sustainable Development Goals (SDGs) by 2030 in sub-Saharan Africa.

Community-driven interventions can revolutionise control of neglected tropical diseases.

Whether global health interventions target diseases (vertical), systems (horizontal) or both (diagonal), they must address the challenge of delivering services in very remote areas of poor countries with inadequate infrastructure. The primacy of this challenge has been underscored by persistent service-delivery difficulties despite several large financial commitments - the latest, US $363 million in the January 2012 London Declaration. Community-driven approaches, pioneered in river blindness control, show that engaging communities can maximise access and performance. This experience should inform a paradigm shift in disease control whereby communities are empowered to extend health service access themselves.

Where would I be without ivermectin? Capturing the benefits of community-directed treatment with ivermectin in Africa.

OBJECTIVES: To document peoples' perceptions of the benefits of taking ivermectin, as an important predictor of sustained compliance with long-term ivermectin treatment, and to identify the socio-demographic correlates of perceived benefits of ivermectin treatment. METHODS: Multisite study in Cameroon, DRC, Nigeria and Uganda. A structured questionnaire was administered to 1600 persons randomly selected from household treatment records. Community leaders, community-directed drug distributors (CDDs) and health workers were interviewed using in-depth interview guides, while focus group discussions (FGDs) were held with community members to capture factors that reflected their perception of benefits of community-directed treatment with ivermectin (CDTI). Case histories of persons with special experiences with onchocerciasis were collected. RESULTS: In this study, 84.7% of respondents indicated that ivermectin treatment has many benefits. The social benefits of CDTI included improved ability to work, peer acceptance and improved school attendance. Other individual benefits included self-respect/esteem, election to political office and improved relationship in the homes. The health benefits included improved skin texture and less ill health. Important demographic factors that influenced perception of the benefits of taking ivermectin, include marital status (P=0.012), age (P=0.029) and length of stay in onchocerciasis-endemic communities (P<0.001). Another factor was individual perception of susceptibility to onchocerciasis infection (P<0.0001). CONCLUSION: A programmatic focus on the benefits of CDTI could provide a basis for motivating communities to comply with long-term treatment with ivermectin. The results illustrate the importance of capturing beneficiaries' perceptions towards CDTI as a resource for producing health education materials for increasing the sustainability ivermectin distribution in endemic countries.

Integrated rapid mapping of onchocerciasis and loiasis in the Democratic Republic of Congo: impact on control strategies.

BACKGROUND: Onchocerciasis can be effectively controlled by annual mass treatment with ivermectin in endemic communities. However, in communities that are endemic for loiasis there may be significant risk of severe adverse reactions after ivermectin treatment. Planning of control requires therefore mapping of these two infections using rapid assessment tools developed for each disease. These tools were initially implemented independently till the feasibility of combining them was demonstrated. This paper reports the results of integrated mapping in four epidemiological zones in the Democratic Republic of Congo and its implications on operational decision-making on ivermectin treatment. METHODS: Rapid assessment surveys were conducted between 2004 and 2005 using both rapid epidemiological mapping of onchocerciasis (REMO) and rapid assessment procedure for loiasis (RAPLOA). The survey results were subjected to a spatial analysis in order to generate for each of the two diseases maps of the estimated prevalence of infection throughout the four zones. RESULTS: Surveys were undertaken in 788 villages where 25,754 males were examined for palpable onchocercal nodules and 62,407 people were interviewed for history of eye worm. The results showed major differences in the geographic distribution of the two diseases. Loiasis was highly endemic in some areas, where special precautions were required, but not in others where routine ivermectin treatment could proceed. CONCLUSION: Integrated rapid mapping of onchocerciasis and loiasis reduces both time and cost of surveys and greatly facilitates operational decision-making on ivermectin treatment in areas where loiasis might be co-endemic.

Influence of an experimental Trypanosoma congolense infection and plane of nutrition on milk production and some biochemical parameters in West African Dwarf goats.

The interactions of trypanosomosis and plane of nutrition on health and productivity of multiparous and primiparous West African Dwarf (WAD) does were studied in a multi-factorial experiment including diet (supplementation or basal diet) and infection (infected or control). Experimental does were infected with Trypanosoma congolense at the beginning of the second week post-kidding and monitored for 16 weeks after infection. Trypanosome infection significantly reduced packed cell volume (PCV) (control: 30.1+/-0.3% versus infected: 22.2+/-0.3%; P<0.0001). Regardless of infection, the drop in PCV from the pre-infection period to the end of the experiment was more severe in animals under restricted diet (interaction dietxperiod, P<0.001). Trypanosome parasitaemia tended to be higher in the supplemented group than in the basal diet group (P>0.05) and multiparous animals had a higher parasitaemia (score: 2.6+/-0.1) than primiparous animals (score: 2.2+/-0.1) (P<0.05). Trypanosome infection as well as dietary supplement had a significant effect on lactation length. Milk off-take from trypanosome-infected does was significantly lower than that from the uninfected control group (17.5+/-3.2l versus 35.5+/-3.2l, P<0.001) and there was a positive effect of plane of nutrition (supplemented: 32.8+/-3.2l and basal diet: 20.2+/-3.5l, P=0.01). The drop in milk off-take due to trypanosome infection was more severe in the supplemented group (control: 46.7+/-4.7l versus infected: 18.9+/-4.2l) than in the group receiving a basal diet (control: 24.2+/-5.0l versus infected: 16.1+/-4.7l) (interaction infectionxdiet, P=0.04) due to the number of does from the supplemented group that were withdrawn from the experiment. The effect of trypanosome infection on doe's live-weight was only noticeable during the first 8 weeks of lactation and there was no significant effect on offspring growth rate unless the mother died. Plasma total protein (TP), albumin and cholesterol concentrations were significantly reduced by the infection but were significantly increased by supplementation. Supplemented does had a higher level of cholesterol and a tendency for a higher parasitaemia. Does of high parity also had a higher cholesterol level than primiparous does and, based on the number of animals that were withdrawn from the experiment, they showed a lower resistance to the infection.

Effects of an experimental Trypanosoma congolense infection on the reproductive performance of West African Dwarf goats.

Thirty-six West African Dwarf (WAD) goats were used to assess the effects of an experimental Trypanosoma congolense infection on their reproductive system. Estrous cycles were synchronised and when confirmed pregnant (n = 31), the does were randomly allocated into control and trypanosome-infected groups. After infection, the animals were carefully observed till parturition. Trypanosome infection caused an increase of rectal temperature, a significant drop in PCV (infected: 23.3 +/- 0.3%; control: 28.5 +/- 0.4%; P < 0.0001) and abortions in 27.8% of the infected does. Kids born from infected does had a lower birth weight than kids born from control goats (0.9 +/- 0.1 kg versus 1.6 +/- 0.1 kg; P < 0.0001). Eight out of 13 kids (61.5%) that were born alive from infected does died during their first week of life. Plasma pregnancy-associated glycoprotein (PAG) and progesterone concentrations were lower in the infected animals than in the controls. In general, PAG concentration in does which aborted dropped before abortion. Our results revealed that artificial T. congolense infection affected reproductive performance of WAD goats with abortions, premature births and perinatal losses being observed. Neither transplacental transmission of T. congolense nor histopathological lesions of the placenta could be demonstrated.

Responses of bovine chimaeras combining trypanosomosis resistant and susceptible genotypes to experimental infection with Trypanosoma congolense.

West African N'Dama cattle have developed a genetic capacity to survive, reproduce and remain productive under trypanosomosis risk. The cellular and molecular bases of this so-called trypanotolerance are not known, but the trait is manifested by the N'Dama's greater capacity to control parasitaemia and anaemia development during an infection. In order to examine the role of the haematopoietic system in trypanotolerance, we have exploited the tendency for the placentas of bovine twin embryos to fuse. Placental fusion in cattle results in bone marrow chimaerism in twins. By comparison with the N'Dama, cattle of the East African Boran breed are relatively susceptible. We evaluated the role of the haemopoietic system in trypanotolerance by comparing the performance of five Chimaeric Boran/N'Dama twin calves with that of singletons of the two breeds. Chimaeric Boran/N'Dama pairs of twins were produced in recipient Boran cows by embryo transfer, and the majority of haemopoietic cells in all twinned individuals were of Boran origin. Thus, N'Dama chimaeras differed from N'Dama singletons in that the bulk of their haemopoietic system was derived from their susceptible Boran twins, while Boran chimaeras differed little from Boran control animals. All cattle became parasitaemic and developed anaemia. The N'Dama chimaeras did not manage their anaemia and white blood cell counts effectively. However, they were able to limit parasitaemia development. These results suggest that trypanotolerance is the result of two mechanisms, one that improves parasite control and is independent of the genetic origin of the haemopoietic tissue, and another that is influenced by haemopoietic tissue genotype and which improves control over anaemia. The capacity to maintain growth during infection was similarly dependent on the genetic origin of the haemopoietic tissue.