Impact assessment of onchocerciasis through lymphatic filariasis transmission assessment surveys using Ov-16 rapid diagnostic tests in Sierra Leone.

BACKGROUND: Onchocerciasis is endemic in 14 of Sierra Leone's 16 districts with high prevalence (47-88.5%) according to skin snips at baseline. After 11 rounds of mass treatment with ivermectin with good coverage, an impact assessment was conducted in 2017 to assess the progress towards eliminating onchocerciasis in the country. METHODS: A cluster survey was conducted, either integrated with lymphatic filariasis (LF) transmission assessment survey (TAS) or standalone with the LF TAS sampling strategy in 12 (now 14) endemic districts. Finger prick blood samples of randomly selected children in Grades 1-4 were tested in the field using SD Bioline Onchocerciasis IgG4 rapid tests. RESULTS: In total, 17,402 children aged 4-19 years in 177 schools were tested, and data from 17,364 children aged 4-14 years (14,230 children aged 5-9 years) were analyzed. Three hundred forty-six children were confirmed positive for Ov-16 IgG4 antibodies, a prevalence of 2.0% (95% CI 1.8-2.2%) in children aged 4-14 years with prevalence increasing with age. Prevalence in boys (2.4%; 95% CI 2.1-2.7%) was higher than in girls (1.6%; 95% CI 1.4-1.9%). There was a trend of continued reduction from baseline to 2010. Using data from children aged 5-9 years, overall prevalence was 1.7% (95% CI 1.5-1.9%). The site prevalence ranged from 0 to 33.3% (median prevalence = 0.0%): < 2% in 127 schools, 2 to < 5% in 34 schools and ≥ 5% in 16 schools. There was a significant difference in average prevalence between districts. Using spatial analysis, the Ov-16 IgG4 antibody prevalence was predicted to be < 2% in coastal areas and in large parts of Koinadugu, Bombali and Tonkolili Districts, while high prevalence (> 5%) was predicted in some focal areas, centered in Karene, Kailahun and Moyamba/Tonkolili. CONCLUSIONS: Low Ov-16 IgG4 antibody prevalence was shown in most areas across Sierra Leone. In particular, low seroprevalence in children aged 5-9 years suggests that the infection was reduced to a low level after 11 rounds of treatment intervention. Sierra Leone has made major progress towards elimination of onchocerciasis. However, attention must be paid to those high prevalence focal areas.

Achievements and challenges of lymphatic filariasis elimination in Sierra Leone.

BACKGROUND: Lymphatic filariasis (LF) is targeted for elimination in Sierra Leone. Epidemiological coverage of mass drug administration (MDA) with ivermectin and albendazole had been reported >65% in all 12 districts annually. Eight districts qualified to implement transmission assessment survey (TAS) in 2013 but were deferred until 2017 due to the Ebola outbreak (2014-2016). In 2017, four districts qualified for conducting a repeat pre-TAS after completing three more rounds of MDA and the final two districts were also eligible to implement a pre-TAS. METHODOLOGY/PRINCIPAL FINDINGS: For TAS, eight districts were surveyed as four evaluation units (EU). A school-based survey was conducted in children aged 6-7 years from 30 clusters per EU. For pre-TAS, one sentinel and one spot check site per district (with 2 spot check sites in Bombali) were selected and 300-350 persons aged 5 years and above were selected. For both surveys, finger prick blood samples were tested using the Filariasis Test Strips (FTS). For TAS, 7,143 children aged 6-7 years were surveyed across four EUs, and positives were found in three EUs, all below the critical cut-off value for each EU. For the repeat pre-TAS/pre-TAS, 3,994 persons over five years of age were surveyed. The Western Area Urban had FTS prevalence of 0.7% in two sites and qualified for TAS, while other five districts had sites with antigenemia prevalence >2%: 9.1-25.9% in Bombali, 7.5-19.4% in Koinadugu, 6.1-2.9% in Kailahun, 1.3-2.3% in Kenema and 1.7% - 3.7% in Western Area Rural. CONCLUSIONS/SIGNIFICANCE: Eight districts in Sierra Leone have successfully passed TAS1 and stopped MDA, with one more district qualified for conducting TAS1, a significant progress towards LF elimination. However, great challenges exist in eliminating LF from the whole country with repeated failure of pre-TAS in border districts. Effort needs to be intensified to achieve LF elimination.

Schistosomiasis in School Age Children in Sierra Leone After 6 Years of Mass Drug Administration With Praziquantel.

Historic data and baseline surveys showed schistosomiasis as highly/moderately endemic in 7 of 14 districts in Sierra Leone, justifying annual/biennial mass drug administration (MDA) with praziquantel. MDA commenced in 2009 and reported treatment coverage had been above the World Health Organization recommended 75% of target population. Assessment in 2012 showed significant reduction in infection. In 2016, another national school-based survey was conducted to evaluate the progress. Two schools from each category (high, moderate or low) of endemic communities in each MDA district and five schools in non-MDA districts were selected. Fifty children (25 boys and 25 girls) aged 9-14 years were randomly selected per school. Parasitological examination of 1,980 stool and 1,382 urine samples were conducted. Overall Schistosoma mansoni prevalence in the seven MDA districts decreased to 20.4% (95% CI: 18.7-22.3%) in 2016 from 42.2% (95% CI: 39.8-44.5%) at baseline (p < 0.0001). Mean overall S. mansoni intensity of infection reduced to 52.8 epg (95% CI: 43.2-62.4 epg) in 2016 from 100.5 epg (95% CI: 88.7-112.3 epg) at baseline (p < 0.001). The prevalence of Schistosoma haematobium in the five MDA districts that had baseline prevalence data decreased to 2.2% (95% CI: 1.5-3.1%) in 2016 from 18.3% (95% CI: 16.3-20.5%) at baseline (p < 0.0001). Mean overall intensity of infection increased to 1.12 e/10 ml (95% CI: 0.55-0.1.70 e/10 ml) in 2016 compared to 0.47 e/10 ml (95% CI: 0.16-0.78 e/10 ml) in 2012 (p < 0.05) (no baseline data). No district was highly endemic in 2016 compared to three at baseline and there was no significant difference in prevalence or intensity of infection by sex for both species. This survey illustrated the significant progress made in controlling schistosomiasis in Sierra Leone. The fact that prevalence and intensity of infection showed an increase from the 2010 level suggested a detrimental effect of missing MDA due to the Ebola toward schistosomiasis control. The national program needs to continue the treatment and adopt a comprehensive approach including water, hygiene, and sanitation measures to achieve control and elimination of schistosomiasis.

Soil-transmitted helminth infection in school age children in Sierra Leone after a decade of preventive chemotherapy interventions.

BACKGROUND: Baseline mapping of soil-transmitted helminth (STH) infections among school age children (SAC) in 2008-2009 found high or moderate prevalence in 13 of the 14 districts in Sierra Leone. Following these surveys, mass drug administration (MDA) of mebendazole/albendazole was conducted biannually at national level targeting pre-school children (PSC) aged 12-59 months and intermittently at sub-national level targeting SAC. In addition, MDA with ivermectin and albendazole for eliminating lymphatic filariasis (LF) has been conducted nationwide since 2010 targeting individuals over 5 years of age. Each MDA achieved high coverage, except in 2014 when all but one round of MDA for PSC was cancelled due to the Ebola emergency. The objective of the current study was to determine the prevalence and intensity of STH infections among SAC after a decade of these deworming campaigns. METHODS: Seventy-three schools in 14 districts were purposefully selected, including 39 schools from the baseline surveys, with approximately two sites from each of low, moderate and high prevalence categories at baseline per district. Fresh stool samples were collected from 3632 children aged 9-14 years (male 51%, female 49%) and examined using the Kato Katz technique. RESULTS: The prevalence of STH infections in Sierra Leone decreased in 2016 compared to 2008: Ascaris lumbricoides 4.4% (95% confidence interval [CI]: 3.7-5.1%) versus 6.6% (95% CI: 0-25%), Trichuris trichiura 0.7% (95% CI: 0.5-1.1%) versus 1.8% (95% CI: 0-30.2%), hookworm 14.9% (95% CI: 13.8-16.1) versus 38.5% (95% CI: 5.4-95.1%), and any STH 18.3% (95% CI:17.0-19.5%) versus 48.3% (CI: 5.4-96.3%), respectively. In 2016, no district had high hookworm prevalence and four districts had moderate prevalence, compared with eight and four districts respectively in 2008. In 2016, the arithmetic mean hookworm egg count in all children examined was light: 45.5 eggs per gram (EPG) of faeces, (95% CI:\ 35.96-55.07 EPG); three (0.08%) children had heavy infections and nine (0.25%) children had moderate infections. CONCLUSIONS: Sierra Leone has made considerable progress toward controlling STH as a public health problem among SAC. As LF MDA phases out (between 2017 and 2021), transition of deworming to other platforms and water and sanitation strategies need to be strengthened to maintain STH control and ultimately interrupt transmission.