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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. Author summary: Lymphatic filariasis or elephantiasis is targeted for elimination in Sierra Leone, with annual mass treatment with ivermectin and albendazole, and required coverage was achieved in all 12 districts annually. In 2017, transmission assessment survey (TAS) was conducted in eight districts to assess whether treatment can be stopped and pre-TAS was conducted in six other districts to assess whether TAS can be conducted. Eight TAS districts were surveyed as four evaluation units (EU), and a school-based survey was conducted in 1703–1926 children aged 6–7 years from 30 clusters per EU. Six pre-TAS districts were surveyed with one sentinel and one/two spot check sites per district and 300–350 persons aged ≥5 years were tested. All tests were using the Filariasis Test Strips with finger prick blood samples. There were 0–7 positive cases in each TAS EU respectively, all below the critical cut-off value, confirming that mass treatment was no longer needed in these eight districts, a significant progress towards LF elimination. One district had prevalence of <1% in two sites and qualified for TAS, while other five districts had sites with prevalence >2%, suggesting that mass treatment needs to continue. Repeated failure of pre-TAS poses great challenge to eliminate LF in Sierra Leone.YMB is the former NTDP manager and coordinated the MDAs with AC and MS. JBK designed and oversaw the early NTDP and baseline surveys. JP, MB designed and led the TAS, pre-TAS field work data collection. MB and VRS conducted the data analysis. VRS and MH reanalysed the coverage data. YZ produced the point prevalence map. MH drafted the manuscript. MH and YZ revised the manuscript. All authors reviewed and approved the final manuscript. [ABSTRACT FROM AUTHOR]

Background: Validation of elimination of trachoma as a public health problem is based on clinical indicators, using the WHO simplified grading system. Chlamydia trachomatis (Ct) infection and anti-Ct antibody responses (anti-Pgp3) have both been evaluated as alternative indicators in settings with varying levels of trachoma. There is a need to evaluate the feasibility of using tests for Ct infection and anti-Pgp3 antibodies at scale in a trachoma-endemic country and to establish the added value of the data generated for understanding transmission dynamics in the peri-elimination setting. Methodology/Principal findings: Dried blood spots for serological testing and ocular swabs for Ct infection testing (taken from children aged 1–9 years) were integrated into the pre-validation trachoma surveys conducted in the Northern and Upper West regions of Ghana in 2015 and 2016. Ct infection was detected using the GeneXpert PCR platform and the presence of anti-Pgp3 antibodies was detected using both the ELISA assay and multiplex bead array (MBA). The overall mean cluster-summarised TF prevalence (the clinical indicator) was 0.8% (95% CI: 0.6–1.0) and Ct infection prevalence was 0.04% (95%CI: 0.00–0.12). Anti-Pgp3 seroprevalence using the ELISA was 5.5% (95% CI: 4.8–6.3) compared to 4.3% (95%CI: 3.7–4.9) using the MBA. There was strong evidence from both assays that seropositivity increased with age (p<0.001), although the seroconversion rate was estimated to be very low (between 1.2 to 1.3 yearly events per 100 children). Conclusions/Significance: Infection and serological data provide useful information to aid in understanding Ct transmission dynamics. Elimination of trachoma as a public health problem does not equate to the absence of ocular Ct infection nor cessation in acquisition of anti-Ct antibodies. [ABSTRACT FROM AUTHOR]

Background: In order to achieve elimination of trachoma, a country needs to demonstrate that the elimination prevalence thresholds have been achieved and then sustained for at least a two-year period. Ghana achieved the thresholds in 2008, and since 2011 has been implementing its trachoma surveillance strategy, which includes community and school screening for signs of follicular trachoma and trichiasis, in trachoma-endemic districts. In 2015–2016, the country conducted a district level population-based survey to validate elimination of trachoma as a public health problem. Methods: As per WHO recommendations, a cross-sectional survey, employing a two-stage cluster random sampling methodology, was used across 18 previously trachoma endemic districts (evaluation units (EUs) in the Upper West and Northern Regions of Ghana. In each EU 24 villages were selected based on probability proportional to estimated size. A minimum of 40 households were targeted per village and all eligible residents were examined for clinical signs of trachoma, using the WHO simplified grading system. The number of trichiasis cases unknown to the health system was determined. Household environmental risk factors for trachoma were also assessed. Results: Data from 45,660 individuals were examined from 11,099 households across 18 EUs, with 27,398 (60.0%) children aged 1–9 years and 16,610 (36.4%) individuals 15 years and above All EUs had shown to have maintained the WHO elimination threshold for Trachomatous inflammation-Follicular (TF) (<5.0% prevalence) in children aged 1–9 years old. The EU TF prevalence in children aged 1–9 years old ranged from between 0.09% to 1.20%. Only one EU (Yendi 0.36%; 95% CI: 0.0–1.01) failed to meet the WHO TT elimination threshold (< 0.2% prevalence in adults aged 15 and above). The EU prevalence of trichiasis (TT) unknown to the health system in adults aged ≥15 years, ranged from 0.00% to 0.36%. In this EU, the estimated TT backlog is 417 All TT patients identified in the study, as well as through on-going surveillance efforts will require further management. A total of 75.9% (95% CI 72.1–79.3, EU range 29.1–92.6) of households defecated in the open but many households had access to an improved water source 75.9% (95%CI: 71.5–79.8, EU range 47.4–90.1%), with 45.5% (95% CI 41.5–49.7%, EU range 28.4–61.8%) making a round trip of water collection < 30 minutes. Conclusion: The findings from this survey indicate elimination thresholds have been maintained in Ghana in 17 of the 18 surveyed EUs. Only one EU, Yendi, did not achieve the TT elimination threshold. A scheduled house-by-house TT case search in this EU coupled with surgery to clear the backlog of cases is necessary in order for Ghana to request validation of elimination of trachoma as a public health problem. [ABSTRACT FROM AUTHOR]

The author discusses the implementation of the Global Programme to Eliminate Lymphatic Filariasis (GPELF) by the World Health Organization (WHO) that aim to eradicate the lymphatic filariasis (LF) in Ghana. Topics discussed include the effect of mass drug administration (MDA) in the immunoparasitological indicators, the use of albendazole (ALB) and ivermectin (IVM) as a treatment for lymphatic filariasis, and the challenges encountered while implementing the national program.

Background: To reach the global goal of elimination of lymphatic filariasis as a public health problem by 2020, national programs will have to implement a series of transmission assessment surveys (TAS) to determine prevalence of the disease by evaluation unit. It is expected that 4,671 surveys will be required by 2020. Planning in advance for the costs associated with these surveys is essential to ensure that the required resources are available for this essential program activity. Methodology and Findings: Retrospective cost data was collected from reports from 13 countries which implemented a total of 105 TAS surveys following a standardized World Health Organization (WHO) protocol between 2012 and 2014. The median cost per survey was $21,170 (including the costs for rapid diagnostic tests [RDTs]) and $9,540 excluding those costs. Median cost per cluster sampled (without RDT costs) was $101. Analysis of costs (excluding RDTs) by category showed that the main cost drivers were personnel and travel. Conclusion: Transmission assessment surveys are critical to collect evidence to validate elimination of LF as a public health problem. National programs and donors can use the costing results to adequately plan and forecast the resources required to undertake the necessary activities to conduct high-quality transmission assessment surveys. [ABSTRACT FROM AUTHOR]

This article discusses the management of onchocerciasis, or river blindness, in Africa. The Onchocerciasis Control Programme in the Volta River Basin (OCP) was established in 1975 to combat the disease in seven West African countries. It later expanded to include four additional countries and changed its name to the Onchocerciasis Control Programme in West Africa (OCP). In 1995, the African Programme for Onchocerciasis Control (APOC) was launched to control the disease in all endemic countries in sub-Saharan Africa. APOC used community-directed treatment with ivermectin (CDTi) as its core strategy, leading to a significant decrease in infections and preventing millions of disability-adjusted life years (DALYs). The program also expanded its efforts to include other neglected tropical diseases (NTDs) susceptible to mass drug administration. APOC operates through a partnership between affected communities, governments, NGOs, and other stakeholders, with the World Health Organization (WHO) as the executing agency. APOC's success is attributed to its participative governance and engagement of communities through the CDTi strategy, empowering them to take responsibility for delivering treatment and expanding access to other health interventions. The document emphasizes the importance of community engagement, collaboration, and strengthening health systems at the community level in the planning, implementation, and monitoring of interventions for onchocerciasis control and other NTDs. The success [Extracted from the article]

Background: In West Africa, the principal vectors of lymphatic filariasis (LF) are Anopheles species with Culex species playing only a minor role in transmission, if any. Being a predominantly rural disease, the question remains whether conflict-related migration of rural populations into urban areas would be sufficient for active transmission of the parasite. Methodology/Principal Findings: We examined LF transmission in urban areas in post-conflict Sierra Leone and Liberia that experienced significant rural-urban migration. Mosquitoes from Freetown and Monrovia, were analyzed for infection with Wuchereria bancrofti. We also undertook a transmission assessment survey (TAS) in Bo and Pujehun districts in Sierra Leone. The majority of the mosquitoes collected were Culex species, while Anopheles species were present in low numbers. The mosquitoes were analyzed in pools, with a maximum of 20 mosquitoes per pool. In both countries, a total of 1731 An. gambiae and 14342 Culex were analyzed for W. bancrofti, using the PCR. Two pools of Culex mosquitoes and 1 pool of An. gambiae were found infected from one community in Freetown. Pool screening analysis indicated a maximum likelihood of infection of 0.004 (95% CI of 0.00012–0.021) and 0.015 (95% CI of 0.0018–0.052) for the An. gambiae and Culex respectively. The results indicate that An. gambiae is present in low numbers, with a microfilaria prevalence breaking threshold value not sufficient to maintain transmission. The results of the TAS in Bo and Pujehun also indicated an antigen prevalence of 0.19% and 0.67% in children, respectively. This is well below the recommended 2% level for stopping MDA in Anopheles transmission areas, according to WHO guidelines. Conclusions: We found no evidence for active transmission of LF in cities, where internally displaced persons from rural areas lived for many years during the more than 10 years conflict in Sierra Leone and Liberia. Author Summary: There have been many arguments regarding the implementation of Mass Drug Administration (MDA) activities for elephantiasis control in urban areas, and especially in countries where the disease is mostly found in rural settings. Blanket MDA in implementation units in big cities, may be costly and unnecessary, without evidence for active transmission in urban areas. Over 1 million people were treated in Freetown during the first MDA carried out in 2010. This represents hundreds of thousands dollars that may serve a better use in reducing the impact of elephantiasis in areas with established on-going transmission. This study was conducted to assess the evidence of transmission of elephantiasis in urban areas, as a result of rural to urban migration in West African countries that have experienced civil wars, and the displacement of people from rural to urban areas. The results showed that the main mosquitoes transmitting elephantiasis are in numbers not enough to support transmission. Testing of individuals also showed very few people to have infection. Together, the results show that elephantiasis infection in the urban areas, where the study was conducted, is not enough to justify the need for MDA in the national capitals. This study represents a strategy that can be adopted in many countries, to inform the decision for undertaking MDA activities in cities. [ABSTRACT FROM AUTHOR]

Background: 1974–2005 studies across Sierra Leone showed onchocerciasis endemicity in 12 of 14 health districts (HDs) and baseline studies 2005–2008 showed lymphatic filariasis (LF) endemicity in all 14 HDs. Three integrated annual mass drug administration (MDA) were conducted in the 12 co-endemic districts 2008–2010 with good geographic, programme and drug coverage. Midterm assessment was conducted 2011 to determine impact of these MDAs on LF in these districts. Methodology/Principal Findings: The mf prevalence and intensity in the 12 districts were determined using the thick blood film method and results compared with baseline data from 2007–2008. Overall mf prevalence fell from 2.6% (95% CI: 2.3%–3.0%) to 0.3% (95% CI: 0.19%–0.47%), a decrease of 88.5% (p = 0.000); prevalence was 0.0% (100.0% decrease) in four districts: Bo, Moyamba, Kenema and Kono (p = 0.001, 0.025, 0.085 and 0.000 respectively); and seven districts had reductions in mf prevalence of between 70.0% and 95.0% (p = 0.000, 0.060, 0.001, 0.014, 0.000, 0.000 and 0.002 for Bombali, Bonthe, Kailahun, Kambia, Koinadugu, Port Loko and Tonkolili districts respectively). Pujehun had baseline mf prevalence of 0.0%, which was maintained. Only Bombali still had an mf prevalence ≥1.0% (1.58%, 95% CI: 0.80%–3.09%)), and this is the district that had the highest baseline mf prevalence: 6.9% (95% CI: 5.3%–8.8%). Overall arithmetic mean mf density after three MDAs was 17.59 mf/ml (95% CI: 15.64 mf/ml–19.55 mf/ml) among mf positive individuals (65.4% decrease from baseline of 50.9 mf/ml (95% CI: 40.25 mf/ml–61.62 mf/ml; p = 0.001) and 0.05 mf/ml (95% CI: 0.03 mf/ml–0.08 mf/ml) for the entire population examined (96.2% decrease from baseline of 1.32 mf/ml (95% CI: 1.00 mf/ml–1.65 mf/ml; p = 0.000)). Conclusions/Significance: The results show that mf prevalence decreased to <1.0% in all but one of the 12 districts after three MDAs. Overall mf density reduced by 65.0% among mf-positive individuals, and 95.8% for the entire population. Author Summary: Onchocerciasis studies across Sierra Leone between 1974 and 2005 showed that 12 of the 14 health districts (HDs) are endemic for onchocerciasis. Baseline lymphatic filariasis (LF) studies 2005–2008 showed that all 14 HDs of Sierra Leone are LF endemic. Three annual rounds of integrated mass drug administration (MDA) with ivermectin and albendazole 2008–2010 were conducted in the 12 HDs that are co-endemic for onchocerciasis and LF with good geographic, epidemiological drug (or programme) and drug coverage. A midterm evaluation study of mf prevalence and density was conducted in the 12 HDs in 2011. The hypothesis proposed for this study is that areas previously exposed to ivermectin treatment for onchocerciasis control may require less rounds of annual MDA to eliminate LF (i.e. reduce microfilaremia (mf) prevalence to <1%). Results of the midterm evaluation study showed very significant and rapid reduction of mf prevalence and density with 11 out of the 12 districts having mf prevalence <1%. Relatively low LF baseline prevalence and effective integrated MDA for onchocerciasis and LF have led to rapid reduction in LF prevalence. [ABSTRACT FROM AUTHOR]

Background: A national mapping of Schistosoma haematobium was conducted in Sierra Leone before the mass drug administration (MDA) with praziquantel. Together with the separate mapping of S. mansoni and soil-transmitted helminths, the national control programme was able to plan the MDA strategies according to the World Health Organization guidelines for preventive chemotherapy for these diseases. Methodology/Principal Findings: A total of 52 sites/schools were selected according to prior knowledge of S. haematobium endemicity taking into account a good spatial coverage within each district, and a total of 2293 children aged 9–14 years were examined. Spatial analysis showed that S. haematobium is heterogeneously distributed in the country with significant spatial clustering in the central and eastern regions of the country, most prevalent in Bo (24.6% and 8.79 eggs/10 ml), Koinadugu (20.4% and 3.53 eggs/10 ml) and Kono (25.3% and 7.91 eggs/10 ml) districts. By combining this map with the previously reported maps on intestinal schistosomiasis using a simple probabilistic model, the combined schistosomiasis prevalence map highlights the presence of high-risk communities in an extensive area in the northeastern half of the country. By further combining the hookworm prevalence map, the at-risk population of school-age children requiring integrated schistosomiasis/soil-transmitted helminth treatment regimens according to the coendemicity was estimated. Conclusions/Significance: The first comprehensive national mapping of urogenital schistosomiasis in Sierra Leone was conducted. Using a new method for calculating the combined prevalence of schistosomiasis using estimates from two separate surveys, we provided a robust coendemicity mapping for overall urogenital and intestinal schistosomiasis. We also produced a coendemicity map of schistosomiasis and hookworm. These coendemicity maps can be used to guide the decision making for MDA strategies in combination with the local knowledge and programme needs. Author Summary: Two forms of schistosomiasis or bilharzia (intestinal and urogenital) exist in Sierra Leone. The main control strategy for this disease currently is through mass drug administration (MDA) according to the World Health Organization recommended anthelminthic chemotherapy guidelines, and others include snail control, behavior change, and safe water, sanitation and hygiene. Survey on distribution and prevalence of the disease is vital to the planning of MDA in each district. The distribution of intestinal schistosomiasis in the country has been reported previously. The current national survey showed that urogenital schistosomiasis has a specific focal distribution particularly in the central and eastern regions of the country, most prevalent in Bo (24.6%), Koinadugu (20.4%) and Kono (25.3%) districts. Using a simple probabilistic model, this map was combined with the previously reported maps on intestinal schistosomiasis and the combined schistosomiasis prevalence was estimated. The combined schistosomiasis map highlights the presence of high-risk communities in an extensive area in the northeastern half of the country, which provides a tool for planning the national MDA activities. [ABSTRACT FROM AUTHOR]

Background: A national baseline mapping of schistosomiasis and soil-transmitted helminthiasis (STH) was performed in Sierra Leone. The aim was to provide necessary tools for the Ministry of Health and Sanitation to plan the intervention strategies in the national integrated control program on neglected tropical diseases according to the World Health Organization (WHO) guidelines for preventative chemotherapy (PCT) and for future monitoring and evaluation. Methodology/Principal Findings: 53 primary schools were randomly selected through a two-staged random sampling throughout the country. Approximately one hundred children aged 5–16 years of age were systematically selected from each school and their stool samples examined in a field laboratory. A total of 5,651 samples were examined. Data were analyzed with multivariable logistic regression models using model-based geostatistics. Spatial analysis predicted that S. mansoni infection was positively associated with population density and elevation and that there was a large cluster of high risk of S. mansoni infection (prevalence >70%) in the north and most of the eastern areas of the country, in line with the observed prevalence in Kono (63.8–78.3%), Koinadugu (21.6–82.1%), Kailahun (43.5–52.6%), Kenema (6.1–68.9%) and Tonkolili (0–57.3%). Hookworm infection was negatively associated with population density and land surface temperature, and was high across Sierra Leone with a large cluster of high infection risk (prevalence >70%) in the north-eastern part of the country. Remarkably low prevalence of Ascaris lumbricoides (7.2%) and Trichuris trichiura (3.3%) was recorded when compared with results published in the 1990s. Conclusions/Significance: Results justify PCT for schistosomiasis for school age children and at-risk adults every year in high-risk communities in five districts and every two years in moderate-risk communities in one more district. The high prevalence of STH, particularly hookworm, coupled with widespread anemia according to a national report in Sierra Leone, suggests all but one district justifying biannual PCT for STH for pre-school children, school age children, and at-risk adults. PCT for STH in the remaining district, Kono is justified annually. Author Summary: The common intestinal roundworm, whipworm and hookworm (together known as soil-transmitted helminthes - STHs) together with schistosomes or bilharzia are responsible for extensive ill health, reduced life expectancy and death in sub-Saharan Africa. These diseases are transmitted in areas of poor water supply and sanitation. In order to implement an appropriate national control program, knowledge of the prevalence and geographical distribution of these diseases is required. A national survey was performed in Sierra Leone in 2008. Overall prevalence of intestinal schistosomiasis was 18.4% and that of STHs was 39.1%. Intestinal schistosomiasis was mainly prevalent in the northern and eastern regions while STH is widespread in the country. The results justify routine de-worming for pre-school children, school age children, women of childbearing age, and adults at high risk twice a year. The results also justify using anti-schistosomiasis drug (praziquantel) in school age children, all women of childbearing age, and adults at high risk annually or biennially depending upon the prevalence in the areas. [ABSTRACT FROM AUTHOR]

Background: Preventive chemotherapy was administered to 3.2 million Sierra Leoneans in 13 health districts for lymphatic filariasis, onchocerciasis, and soil transmitted helminthes from October 2008 to February 2009. This paper aims to report the findings of a coverage survey conducted in 2009, compare the coverage survey findings with two reported rates for lymphatic filariasis coverage obtained using pre-mass drug administration (MDA) registration and national census projections, and use the comparison to understand the best source of population estimates in calculating coverage for NTD programming in Sierra Leone. Methodology/Principal findings: Community drug distributors (CDDs) conducted a pre- MDA registration of the population. Two coverage rates for MDA for lymphatic filariasis were subsequently calculated using the reported number treated divided by the total population from: 1) the pre-MDA register and 2) national census projections. A survey was conducted to validate reported coverage data. 11,602 persons participated (response rate of 76.8%). Overall, reported coverage data aggregated to the national level were not significantly different from surveyed coverage (z-test >0.05). However, estimates based on pre-MDA registration have higher agreement with surveyed coverage (mean Kendall's W = 0.68) than coverage calculated with census data (mean Kendall's = 0.59), especially in districts with known large-scale migration, except in a highly urban district where it was more challenging to conduct a pre-MDA registration appropriately. There was no significant difference between coverage among males versus females when the analyses were performed excluding those women who were pregnant at the time of MDA. The surveyed coverage estimate was near or below the minimum 65% epidemiological coverage target for lymphatic filariasis MDA in all districts. Conclusion/Significance: These results from Sierra Leone illustrate the importance of choosing the right denominator for calculating treatment coverage for NTD programs. While routinely reported coverage results using national census data are often good enough for programmatic decision making, census projections can quickly become outdated where there is substantial migration, e.g. due to the impact of civil war, with changing economic opportunities, in urban settings, and where there are large migratory populations. In districts where this is known to be the case, well implemented pre-MDA registration can provide better population estimates. Pre-MDA registration should, however, be implemented correctly to reduce the risk of missing pockets of the population, especially in urban settings. [ABSTRACT FROM AUTHOR]