Evaluation of mass treatment with ivermectin program reach and survey coverage for onchocerciasis elimination in selected endemic areas of Ethiopia.

Currently, national governments of onchocerciasis endemic African countries are working towards the elimination of the disease using mass drug administration (MDA) with ivermectin as a primary strategy. Attainment of this goal requires implementation of prolonged high MDA coverage in all endemic areas, and vigilant monitoring and evaluation of the program. This study was thus conducted with the purpose of i) providing estimate of ivermectin coverage, ii) validating the MDA coverage reported through community drug distributors (CDDs), iii) determining the factors associated with MDA coverage, and iv) estimating the difference between MDA program reach and survey coverage rates following MDA campaign carried out in May 2017 in Asosa and Yeki districts in Ethiopia. A community-based cross-sectional study was conducted among 2,824 study participants in Asosa and Yeki districts. A total of 50 kebeles (smallest administrative units) were randomly selected from the two districts. A systematic sampling was employed to select study households from the 50 kebeles. Then, a household member was randomly selected for the interview. Univariate and multivariate logistic regression analysis were used to determine the odds ratio and to observe the associations between the MDA survey coverage and the variables used. Eighty-seven percent (2458/2824) of the respondents from both districts responded that they were offered ivermectin during the May 2017 MDA campaign. At the district level, 1182 individuals from Yeki and 1276 from Asosa, received the drug, that indicate 88.5% and 85.8% MDA program reach in Yeki and Assosa districts, respectively. Whereas, a total of 366 individuals were not offered ivermectin in both study districts. Of these, 47(12.8%), 143(39.1%), and 176(48.1%) did not receive the drug because of program implementation-related reasons, ineligibility criteria, and personal issues, respectively. Of the 1488 and 1336 respondents in Asosa and Yeki, 1272 and 1182 participants took the drug, resulting in survey coverage rate of 85.5% (95% CI: 83.6-87.2%) and 88.5% (95% CI: 86.7-90.1%), respectively. Multivariable logistic regression analysis revealed significantly low survey coverage rate in females (AOR = 0.5, 95%CI: 0.3-0.6; p<0.001) and in those whose age ranges between 15-24 years (AOR = 0.5, 95%CI: 0.3-0.8; p = 0.007) and 25-34 years (AOR = 0.5, 95%CI: 0.3-0.9; p = 0.021) in Asosa. The researchers believe that the current study generated operational evidence on MDA program reach and coverage rates in two study districts in Ethiopia. The survey coverages were lower than the recommended 90% minimum threshold for success. Only Yeki district reached the 90% threshold survey coverage. Both districts had reported higher coverages than the survey estimates (even outside the 95% CI), thus, were not validated. The majority (60.9%) of the reasons for not receiving the drug were related to program implementation and recipients`personal issues. Efforts must therefore be directed to enhance MDA coverage in future rounds via proper MDA planning and implementation, such as allocating adequate time to the MDA activities, health education, and mobilizing of all segments of the population, including adolescents and the youth. The researchers also recommend such studies to be extended to other MDA programs for other neglected tropical diseases (NTDs).

Impact of ivermectin mass drug administration on burden of soil-transmitted helminths in onchocerciasis control and elimination programs, Yeki district, southwest Ethiopia.

Community-directed treatment with ivermectin (CDTi) is the primary strategy employed to control and eliminate human onchocerciasis in Ethiopia. After long-term mass distribution for onchocerciasis, ivermectin is expected to have additional benefits beyond the envisioned targets by reducing the burden of other co-endemic parasitic infections as to STHs. To date, studies focused on the collateral impact of CDTi on STH in Ethiopia are scanty. Two community-based cross-sectional surveys (baseline in 1997 and post-CDTi in 2017) were conducted to evaluate the impact of long-term CDTi employed to control and eliminate onchocerciasis on the burden of STH infections in Yeki district of southwest Ethiopia. Stool samples were collected and examined using Ritchie`s concentration and Kato-Katz techniques in the baseline and current study, respectively. Overall, 188(38.3%, 95% Confidence interval (CI) 34.1-42.7%) individuals were positive at least for any of the STH species from 491 study participants in the post-CDTi. The prevalence of A. lumbricoides, hookworms, and T. trichiura was 11.2% (95% CI 8.7-14.3%), 16.3% (95% CI 13.3-19.8%), and 29.9% (95% CI 26.1-34.1%), respectively. Individuals aged 5-9 years had a significantly higher prevalence of A. lumbricoides (Adjusted odds ratio (AOR) 6.5, 95% CI 1.7-25.4), T. trichuria (AOR 8, 95% CI 2.6-25.1), and any STH infection (AOR 5, 95% CI 1.7-14.7) than those of ≥ 51 years. Also, significantly higher prevalences of T. trichuria infection were observed in individuals aged 10-14 years (AOR 4.1, 95% CI 1.7-9.9), 15-20 years (AOR 3.1, 95% CI 1.2-8.1), 21-30 years (AOR 2.4, 95% CI 1.1-5.5), and 31-40 years (AOR 3.2, 95% CI 1.3-7.5) compared with those of ≥ 51 years. The prevalence of A. lumbricoides was significantly higher in males (AOR 0.5, 95% CI 0.3-0.9). Of the 491 study participants, only data from 400 individuals who had not been involved in a mass drug administration (MDA) with other STH anthelmintics were considered in the comparative analysis. Before CDTi, the prevalence of A. lumbricoides, T. trichiura, hookworm, and any STH infection was 47.1% (95% CI 41.6-52.7%), 3.3% (95% CI 1.8-5.9%), 37.9% (95% CI 32.7-43.5%), and 58.8% (95% CI 53.2-64.1%), respectively. Long-term CDTi considerably reduced the prevalences of A. lumbricoides and hookworm by 76.2% and 56.9%, respectively (p < 0.001). Nonetheless, CDTi did not affect the prevalence of T. trichiura infection and, in contrast, it was significantly higher in the current study (P < 0.001). Overall post-CDTi prevalence of any STH infection was considerably lower than reported in the baseline (p < 0.001). It is evidenced that long-term CDTi for onchocerciasis control and elimination had additional benefits by reducing the prevalence of STH infections specifically of A. lumbricoides and hookworm, but had no impact on infections with T. trichuria. Our finding of additional health benefits of large-scale ivermectin administration taking it will aid to increase positive engagement and sustain participation of communities during MDA campaigns, and strengthen governmental and non-governmental organizations (NGOs) support for the undergoing national onchocerciasis elimination program.

Status of parasitological indicators and morbidity burden of onchocerciasis after years of successive implementation of mass distribution of ivermectin in selected communities of Yeki and Asosa districts, Ethiopia.

BACKGROUND: Control and elimination of onchocerciasis requires regular follow-up and evaluation of community directed treatment with ivermectin (CDTi) program implementation. This research was aimed to assess the epidemiological status of onchocerciasis in disease endemic communities of Asosa and Yeki districts of Ethiopia after 5 and 15 years of successive CDTi respectively, and to evaluate the decline in infection and morbidity burden. METHODS: A community-based cross-sectional study was conducted from August 2017 to January 2018 (i.e. within 2-7 months since the last treatment) using interview, physical and parasitological examinations. Pre-CDTi epidemiological data were obtained from studies conducted prior to the launch of CDTi. RESULTS: A total of 3002 individuals (1567 from Asosa and 1435 from Yeki) were included. No infection was detected from Yeki. In Asosa, the prevalence of infection was 1.6%. The geometric mean intensity of infection was 0.02 mf/mg of skin snip. The prevalence rates of dermatitis, depigmentation, nodule, and atrophy in Yeki were 33(2.3%), 57(4%), 37(2.6%) and 11(0.7%), respectively. The prevalence rates of papular dermatitis, depigmentation, palpable nodule, atrophy, and blindness in Asosa were 94(6%), 38(2.4%), 30(1.9%), 28(1.8%) and 2(0.1%), respectively. Five years of CDTi had significantly reduced prevalence and intensity of infection by 91.8% (p < 0.001) and 99.7% (p < 0.001), respectively. Moreover, CDTi reduced prevalence of papular dermatitis by 95.9% (p < 0.001), palpable nodule by 90.5% (p < 0.001), and atrophy by 30% (p = 0.6) in Yeki. Similarly, CDTi reduced prevalence of papular dermatitis by 88.6% (p < 0.001), depigmentation by 90.3% (p < 0.001), atrophy by 89.5% (p < 0.001), and blindness by 90% (p < 0.001) in Asosa. CONCLUSIONS: Fifteen years of successive CDTi had brought the infection from high to zero in Yeki. However, thorough entomological and serological data need to be generated to ascertain whether complete interruption of parasite transmission has been attained, and for considerations of an evidence-based CDTi cessation. Five years of CDTi in Asosa has significantly reduced the infection and morbidity of onchocerciasis to very low level. We, hereby, recommend biannual CDTi to continue in Asosa and its surroundings until the infection transmission is fully interrupted.

Reaching the last mile: main challenges relating to and recommendations to accelerate onchocerciasis elimination in Africa.

BACKGROUND: Onchocerciasis (river blindness), caused by the filarial worm species Onchocerca volvulus, is a serious vector-borne neglected tropical disease (NTD) of public health and socioeconomic concern. It is transmitted through the bite of black flies of the genus Simulium, and manifested in dermal and ocular lesions. Ninety-nine percent of the total global risk and burden of onchocerciasis is in Africa. This scoping review examines the key challenges related to the elimination of onchocerciasis by 2020-2025 in Africa, and proposes recommendations to overcome the challenges and accelerate disease elimination. To find relevant articles published in peer-reviewed journals, a search of PubMed and Google Scholar databases was carried out. MAIN TEXT: Rigorous regional interventions carried out to control and eliminate onchocerciasis in the past four decades in Africa have been effective in bringing the disease burden under control; it is currently not a public health problem in most endemic areas. Notably, transmission of the parasite is interrupted in some hyperendemic localities. Recently, there has been a policy shift from control to complete disease elimination by 2020 in selected countries and by 2025 in the majority of endemic African countries. The WHO has published guidelines for stopping mass drug administration (MDA) and verifying the interruption of transmission and elimination of human onchocerciasis. Therefore, countries have revised their plans, established a goal of disease elimination in line with an evidence based decision to stop MDA and verify elimination, and incorporated it into their NTDs national master plans. Nevertheless, challenges remain pertaining to the elimination of onchocerciasis in Africa. The challenge we review in this paper are: incomplete elimination mapping of all transmission zones, co-endemicity of onchocerciasis and loiasis, possible emergence of ivermectin resistance, uncoordinated cross-border elimination efforts, conflict and civil unrest, suboptimal program implementation, and technical and financial challenges. This paper also proposes recommendations to overcome the challenges and accelerate disease elimination. These are: a need for complete disease elimination mapping, a need for collaborative elimination activities between national programs, a need for a different drug distribution approach in conflict-affected areas, a need for routine monitoring and evaluation of MDA programs, a need for implementing alternative treatment strategies (ATSs) in areas with elimination anticipated beyond 2025, and a need for strong partnerships and continued funding. CONCLUSIONS: National programs need to regularly monitor and evaluate the performance and progress of their interventions, while envisaging the complete elimination of onchocerciasis from their territory. Factors hindering the targeted goal of interruption of parasite transmission need to be identified and remedial actions should be taken. If possible and appropriate, ATSs need to be implemented to accelerate disease elimination by 2025.

Treatment Outcome of Tuberculosis Patients under Directly Observed Treatment Short Course and Factors Affecting Outcome in Southern Ethiopia: A Five-Year Retrospective Study.

Tuberculosis (TB) is one of the major public health and socio-economic issues in the 21st century globally. Assessment of TB treatment outcomes, and monitoring and evaluation of its risk factors in Directly Observed Treatment Short Course (DOTS) are among the major indicators of the performance of a national TB control program. Hence, this institution-based retrospective study was conducted to determine the treatment outcome of TB patients and investigate factors associated with unsuccessful outcome at Dilla University Referral Hospital, southern Ethiopia. Five years (2008 to 2013) TB record of TB clinic of the hospital was reviewed. A total 1537 registered TB patients with complete information were included. Of these, 942 (61.3%) were male, 1015 (66%) were from rural areas, 544 (35.4%) were smear positive pulmonary TB (PTB+), 816 (53.1%) were smear negative pulmonary TB (PTB-) and 177(11.5%) were extra pulmonary TB (EPTB) patients. Records of the 1537 TB patients showed that 181 (11.8%) were cured, 1129(73.5%) completed treatment, 171 (11.1%) defaulted, 52 (3.4%) died and 4 (0.3%) had treatment failure. The overall mean treatment success rate of the TB patients was 85.2%. The treatment success rate of the TB patients increased from 80.5% in September 2008-August 2009 to 84.8% in September 2012-May 2013. Tuberculosis type, age, residence and year of treatment were significantly associated with unsuccessful treatment outcome. The risk of unsuccessful outcome was significantly higher among TB patients from rural areas (AOR = 1.63, 95% CI: 1.21-2.20) compared to their urban counterparts. Unsuccessful treatment outcome was also observed in PTB- patients (AOR = 1.77, 95% CI: 1.26-2.50) and EPTB (AOR = 2.07, 95% CI: 1.28-3.37) compared to the PTB+ patients. In conclusion, it appears that DOTS have improved treatment success in the hospital during five years. Regular follow-up of patients with poor treatment outcome and provision of health information on TB treatment to patients from rural area is recommended.