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OBJECTIVES: The study assessed associations between Schistosoma haematobium infection (presence of parasite eggs in urine or hematuria) and self-reported metrics (macrohematuria, fetching surface water, or swimming) to evaluate their performance as proxies of infection in presence of regular preventive chemotherapy. It also examined community water characteristics (safe water access, surface water access, and groundwater quality) to provide context for schistosomiasis transmission in different types of communities and propose interventions. METHODS: Logistic regression was used to assess the associations between the various measured and self-reported metrics in a sample of 897 primary school children in 30 rural Ghanaian communities. Logistic regression was also used to assess associations between community water characteristics, self-reported water-related behaviors and S. haematobium infection. Communities were subsequently categorized as candidates for three types of interventions: additional safe water sources, water treatment, and education about water-related disease risk, depending on their water profile. RESULTS: Microhematuria presence measured with a reagent strip was a good proxy of eggs in urine at individual (Kendall’s τ(b) = 0.88, p

Background Lymphatic filariasis (LF) is endemic in Ghana, and the country has implemented the GPELF strategy since 2000 with significant progress made in the control of the disease. However, after several years of mass drug administration (MDA) implementation, there is persistent transmission in 17 of the 98 endemic districts in the country. Current approaches to surveillance are clearly unable to target untreated individuals and new strategies are required to address the endgame challenges to enhance LF elimination as a public health problem in endemic countries. Community registers are used during MDAs to enumerate community members, their age, gender, house numbers, and records of their participation in MDAs. These MDA registers represent an untapped opportunity to identify and characterize non-compliance and inform appropriate programmatic actions. In this study, we analyzed the data presented in the registers to assess the coverage and individuals’ compliance in MDA. Methods The information in the MDA registers were assessed to verify the reported coverages obtained from the district. The community registers were obtained from the district health offices and the data from each individual record was entered into a database. A simple questionnaire was used to cross-check the participation of study participants in the 2017 MDA. The questionnaire solicited data on: participation in the 2017 MDA, reasons for not taking part in the MDA, adverse events experienced, what was done for the adverse events, and willingness to participate in subsequent MDAs. Results We found that 40.1% of the population in the registers missed at least one MDA in 3 years (2016–2018) and the majority of them were between 10–30 years of age. The results of the questionnaire assessment indicated that 13.8% of the respondents did not receive treatment in 2017 for various reasons, the most prominent among them being “absence/travel” (37.1%). Data in the registers were used to verify the treatment coverage for the years 2017 and 2018, and reviewed against the reported coverage obtained from the district. Significant differences between the reported and verified coverages were only observed in four communities. However, the assessment also revealed that the reported coverage was only accurate in 33.3% of cases. Conclusions The MDA registers allow for the identification of eligible individuals who were not reached during any MDA round. Thus, the MDA registers could be utilized at the community and programme levels to identify missing and untreated individuals, appropriately address their non-compliance to MDA, and thereby improve MDA coverage in each implementation unit and monitor the progress towards elimination of LF. The challenges observed through the review of the registers also offer opportunities to improve the training given to the community drug distributors., Author summary Elephantiasis is a disease that is common in Ghana. Since the year 2000 the country has implemented a control programme aimed at eliminating the disease as a public health problem, through the yearly treatment of entire communities in districts where the disease is found. Achievements have been made, and treatment has stopped in many districts; however, some districts have received many years of treatment without successfully reducing the infections below the targeted levels. Many individuals go untreated every year, as can be observed from the low reported treatment coverage after MDA. This untreated population may explain why some districts have failed to achieve the criteria for stopping treatment. Fortunately, the treatments are recorded in community registers, which contain the details of all community members, as well as their treatment participation. These registers can therefore be used to identify people who have not received treatment and design appropriate interventions to reach them. Through these registers, we were able to identify and characterize individuals who were not treated between 2016 and 2018 in 10 communities. We found that 4 out of 10 people missed at least one treatment between 2016 and 2018, and the majority of them were 10–30 years of age. Using the information from the registers we were also able to verify the proportion of people who took part in the treatments in 2017 and 2018, and compared this to what was reported. This comparison revealed that the reporting was only accurate in 33% of cases. A questionnaire was also used to cross-check the participation of study participants in the 2017 MDA, with results indicating that 13.8% of the respondents did not receive treatment for various reasons, the most prominent among them being “absence/travel” (37.1%). Although these registers are seldom used by the Lymphatic Filariasis Control Programme for anything other than recording and reporting treatment information, this study shows that the registers provide an opportunity to identify individuals who have not received treatment, develop a plan to appropriately address their reasons for not taking part in the treatments, target these untreated individuals to improve the overall proportion of people taking part in MDA, and assess the accuracy of reported coverage information. These activities will allow the programme to better monitor the progress towards, and ultimately achieve, elimination of lymphatic filariasis as a public health problem.

Background Despite the progress achieved in scaling-up mass drug administration (MDA) for lymphatic filariasis (LF) in Ghana, communities with persistent LF still exist even after 10 years of community treatment. To understand the reasons for persistence, we conducted a study to assess the status of disease elimination and understand the adherence to interventions including MDA and insecticide treated nets. Methodology and principal findings We conducted a parasitological and epidemiological cross-sectional study in adults from eight villages still under MDA in the Northern Region savannah and the coastal Western Region of the country. Prevalence of filarial antigen ranged 0 to 32.4% and in five villages the prevalence of night blood microfilaria (mf) was above 1%, ranging from 0 to 5.7%. Median mf density was 67 mf/ml (range: 10–3,560). LF antigen positivity was positively associated with male sex but negatively associated with participating in MDA the previous year. Male sex was also associated with a decreased probability of participating in MDA. A stochastic model (TRANSFIL) was used to assess the expected microfilaria prevalence under different MDA coverage scenarios using historical data on one community in the Western Region. In this example, the model simulations suggested that the slow decline in mf prevalence is what we would expect given high baseline prevalence and a high correlation between MDA adherence from year to year, despite high MDA coverage. Conclusions There is a need for an integrated quantitative and qualitative research approach to identify the variations in prevalence, associated risk factors and intervention coverage and use levels between and within regions and districts. Such knowledge will help target resources and enhance surveillance to the communities most at risk and to reach the 2020 LF elimination goals in Ghana., Author summary Lymphatic filariasis (LF) is a mosquito-borne disease and a leading cause of disability and chronic morbidity worldwide. Despite the progress achieved so far in stopping LF transmission by treating the affected communities with specific drugs over several years, areas where lymphatic filariasis persists still exist. Understanding the reasons behind this is pivotal to both reach and sustain elimination. We investigated the factors associated with filariasis persistence in various communities still under drug treatment from two regions of Ghana. We reported high variability in disease burden, adherence to drug treatment and mosquito net use between regions and communities. LF infection was associated with men and not taking the drugs, and men were also less likely to take treatment. Using mathematical modelling, we showed that slight increases in treatment coverage will accelerate elimination. Our findings highlight the reasons for LF persistence and provide guidance on how to successfully achieve elimination by refining drug treatment distribution and mosquito control interventions more tailored to individuals and communities. We also demonstrated the value of using field-collected data in mathematical models to assess the current status of disease elimination and to identify the gaps in control interventions.

Background Ghana started its national programme to eliminate lymphatic filariasis (LF) in 2000, with mass drug administration (MDA) with ivermectin and albendazole as main strategy. We review the progress towards elimination that was made by 2016 for all endemic districts of Ghana and analyze microfilaria (mf) prevalence from sentinel and spot-check sites in endemic districts. Methods We reviewed district level data on the history of MDA and outcomes of transmission assessment surveys (TAS). We further collated and analyzed mf prevalence data from sentinel and spot-check sites. Results MDA was initiated in 2001–2006 in all 98 endemic districts; by the end of 2016, 81 had stopped MDA after passing TAS and after an average of 11 rounds of treatment (range 8–14 rounds). The median reported coverage for the communities was 77–80%. Mf prevalence survey data were available for 430 communities from 78/98 endemic districts. Baseline mf prevalence data were available for 53 communities, with an average mf prevalence of 8.7% (0–45.7%). Repeated measurements were available for 78 communities, showing a steep decrease in mean mf prevalence in the first few years of MDA, followed by a gradual further decline. In the 2013 and 2014 surveys, 7 and 10 communities respectively were identified with mf prevalence still above 1% (maximum 5.6%). Fifteen of the communities above threshold are all within districts where MDA was still ongoing by 2016. Conclusions The MDA programme of the Ghana Health Services has reduced mf prevalence in sentinel sites below the 1% threshold in 81/98 endemic districts in Ghana, yet 15 communities within 13 districts (MDA ongoing by 2016) had higher prevalence than this threshold during the surveys in 2013 and 2014. These districts may need to intensify interventions to achieve the WHO 2020 target., Author summary Lymphatic filariasis (LF) control in Ghana has relied on ivermectin and albendazole since the year 2000 when the Ghana Filariasis Elimination Programme started. We analyzed trends in microfilaraemia prevalence during MDA, reported coverage, and transmission assessment survey using data obtained from the Ghana Health Services (GHS). The median reported treatment coverage varied between 77–80% over the years. Our results show that the treatment in Ghana made a significant impact in reducing infections

Schistosoma haematobium transmission is influenced by environmental conditions that determine the suitability of the parasite and intermediate host snail habitats, as well as by socioeconomic conditions, access to water and sanitation infrastructure, and human behaviors. Remote sensing is a demonstrated valuable tool to characterize environmental conditions that support schistosomiasis transmission. Socioeconomic and behavioral conditions that propagate repeated domestic and recreational surface water contact are more difficult to quantify at large spatial scales. We present a mixed-methods approach that builds on the remotely sensed ecological variables by exploring water and sanitation related community characteristics as independent risk factors of schistosomiasis transmission.

The first 3 years of biannual ivermectin distribution in Ghana have substantially reduced Onchocerca volvulus infection levels in 10 sentinel communities, but longitudinal analysis indicates that some communities are still consistently responding suboptimally to treatment, with implications for onchocerciasis elimination., Background. Several African countries have adopted a biannual ivermectin distribution strategy in some foci to control and eliminate onchocerciasis. In 2010, the Ghana Health Service started biannual distribution to combat transmission hotspots and suboptimal responses to treatment. We assessed the epidemiological impact of the first 3 years of this strategy and quantified responses to ivermectin over 2 consecutive rounds of treatment in 10 sentinel communities. Methods. We evaluated Onchocerca volvulus community microfilarial intensity and prevalence in persons aged ≥20 years before the first, second, and fifth (or sixth) biannual treatment rounds using skin snip data from 956 participants. We used longitudinal regression modeling to estimate rates of microfilarial repopulation of the skin in a cohort of 217 participants who were followed up over the first 2 rounds of biannual treatment. Results. Biannual treatment has had a positive impact, with substantial reductions in infection intensity after 4 or 5 rounds in most communities. We identified 3 communities—all having been previously recognized as responding suboptimally to ivermectin—with statistically significantly high microfilarial repopulation rates. We did not find any clear association between microfilarial repopulation rate and the number of years of prior intervention, coverage, or the community level of infection. Conclusions. The strategy of biannual ivermectin treatment in Ghana has reduced O. volvulus microfilarial intensity and prevalence, but suboptimal responses to treatment remain evident in a number of previously and consistently implicated communities. Whether increasing the frequency of treatment will be sufficient to meet the World Health Organization's 2020 elimination goals remains uncertain.

Ghana has been implementing mass drug administration (MDA) of ivermectin and albendazole for the elimination of lymphatic filariasis (LF) since the year 2000, as part of the Global Programme to Eliminate Lymphatic Filariasis (GPELF). It was estimated that 5&ndash, 6 years of treatment would be sufficient to eliminate the disease. Tremendous progress has been made over the years, and treatment has stopped in many disease endemic districts. However, despite the successful implementation of MDA, there are districts with persistent transmission. In this study we assessed the epidemiology of LF in three adjoining districts that have received at least 16 years of MDA. The assessments were undertaken one year after the last MDA. 1234 adults and 182 children below the age of 10 years were assessed. The overall prevalence of circulating filarial antigen in the study participants was 8.3% (95% CI: 6.9&ndash, 9.9), with an estimated microfilaria prevalence of 1.2%. The microfilarial intensity in positive individuals ranged from 1 to 57 microfilariae/mL of blood. Higher antigen prevalence was detected in males (13.0%, 95% CI: 10.3&ndash, 16.2) compared to females (5.5%, 95% CI: 4.1&ndash, 7.2). The presence of infection was also highest in individuals involved in outdoor commercial activities, with the risks of infection being four- to five-fold higher among farmers, fishermen, drivers and artisans, compared to all other occupations. Using bednets or participating in MDA did not significantly influence the risk of infection. No children below the age of 10 years were found with infection. Detection of Wb123 antibodies for current infections indicated a prevalence of 14.4% (95% CI: 8.1&ndash, 23.0) in antigen-positive individuals above 10 years of age. No antibodies were detected in children 10 years or below. Assessment of infection within the An. gambiae vectors of LF indicated an infection rate of 0.9% (95% CI: 0.3&ndash, 2.1) and infectivity rate of 0.5% (95% CI: 0.1&ndash, 1.6). These results indicate low-level transmission within the districts, and suggest that it will require targeted interventions in order to eliminate the infection.

Background: There is a high burden of morbidity due to neglected tropical diseases. To help address this, the World Health Organization recommends integration of case management (CM). Here, we present a practical framework designed to identify areas that could benefit from an integrated CM strategy in Ghana. We also investigated the accessibility of primary health care (PHC) to CM cases, and the impact of this on morbidity at diagnosis. Methods: Routinely detected cases of Buruli ulcer (BU) and leprosy, and suspected lymphedema identified through morbidity surveys during mass drug administration campaigns in Ghana in 2014 were remotely georeferenced. We estimated distances from cases’ home communities to the nearest primary healthcare facility (PHC), and compared rates of reported disease, completeness of clinical information, and risk of more severe morbidity, relative to PHC accessibility. Results: We georeferenced communities of 295/350 reported leprosy cases, 240/333 BU cases, and 1,557/2383 instances of lymphedema. Overlap of these diseases was predominantly around Accra and in the Upper East Region. Rates of reported disease appeared higher in populations with higher accessibility to PHC, and leprosy cases living further from PHC had a higher risk of disability at diagnosis. Conclusions: This investigation demonstrates the feasibility and value of using routinely collected data to map CM-NTDs at low cost. The maps presented are intended to provide a resource for planning the implementation of integrated CM for NTDs in Ghana. This approach could be easily implemented by national health services in other endemic countries in the future.

Schistosomiasis affects over 200 million people worldwide [1] and accounts for an estimated 1.9 million disability-adjusted life years (DALYs) annually [2], with 90% of the burden currently concentrated in Africa. The last decade has witnessed an extraordinary surge of advocacy and funding for neglected tropical diseases (NTDs), including schistosomiasis. Large-scale schistosomiasis control is now implemented in 30 countries in Africa [1], funded primarily through support from the United States Agency for International Development (USAID) and the Department for International Development (DFID), private philanthropic funds from the END Fund and through GiveWell recommendations, and leveraging praziquantel donations from Merck KGaA. However, the number of people still requiring treatment remains daunting [1]. The aim of current public health strategies for schistosomiasis is to decrease morbidity through preventive chemotherapy (PC) (Fig 1) [3]. Periodic large-scale administration of the drug praziquantel focusing on the school-aged population and high-risk adults aims to reduce the prevalence and intensity of infection [4].

(1) Background: Current international policy for schistosomiasis and soil-transmitted helminthiasis (STH) control emphasises mass administration of deworming drugs in school-based programmes. However, this approach is insufficient to control the transmission of these diseases, and their burden in non-school cohorts is recognised, albeit under-researched. This research will investigate the feasibility and acceptability of expanding access to praziquantel (PZQ) against schistosomiasis, and albendazole (ALB) against STH, to communities in selected transmission settings in Ghana. (2) Methods: A three-site longitudinal study will be implemented to investigate the effectiveness of expanding treatment strategies for PZQ and ALB to community members. In the context of community mass drug administration (to preschool children, school non-attending children, and adults, including pregnant women), the intervention will be assessed in a random sample of community members, at baseline with follow-up at 6, 12, and 18 months. In each community, 658 participants will be enrolled, and 314 followed up at each time point. The primary outcome measure is the prevalence of infection of Schistosoma haematobium and/or S. mansoni at study endpoint, as assessed by longitudinal surveys. Secondary outcomes are to quantify the infection of schistosomiasis and STH infections in non-treated cohorts, reductions in prevalence of STH, and intensity of schistosomiasis and STH, and treatment coverage. Nested within this study will be qualitative, cost-benefit, and cost-effectiveness evaluations that will explore accessibility, feasibility, and economic impact of expanded treatment from different complementary perspectives. (3) Discussion: Using a multidisciplinary approach, this study will generate evidence for improved availability, acceptability, affordability, and accessibility to deworming drugs against schistosomiasis and STH to individuals and communities in Ghana. This is likely to have considerable research, programmatic, and political value to contribute evidence for national programme policy development within Ghana, and, more broadly, World Health Organization policy development.

Background The Global Programme for the Elimination of Lymphatic Filariasis (GPELF) has been in operation since the year 2000, with the aim of eliminating the disease by the year 2020, following five to six rounds of effective annual mass drug administration (MDA). The treatment regimen is ivermectin (IVM) in combination with diethylcarbamazine (DEC) or albendazole (ALB). In Ghana, MDA has been undertaken since 2001. While the disease has been eliminated in many areas, transmission has persisted in some implementation units that had experienced 15 or more rounds of MDA. Thus, new intervention strategies could eliminate residual infection in areas of persistent transmission and speed up the lymphatic filariasis (LF)-elimination process. This study, therefore, seeks to test the hypothesis that biannual treatment of LF-endemic communities will accelerate the interruption of LF in areas of persistent transmission. Methods A cluster randomised trial will be implemented in LF-endemic communities in Ghana. The interventions will be yearly or twice-yearly MDA delivered to entire endemic communities. Allocation to study group will be by clusters identified using the prevalence of LF. Clusters will be randomised to one of two groups: receiving either (1) annual treatment with IVM + ALB or (2) annual MDA with IVM + ALB, followed by an additional MDA 6 months later. The primary outcome measure is the prevalence of LF infection, assessed by four cross-sectional surveys. Entomological assessments will also be undertaken to evaluate the transmission intensity of the disease in the study clusters. Costs and cost-effectiveness will be evaluated. Among a random subsample of participants, microfilaria prevalence will be assessed longitudinally. A nested process evaluation, using semi-structured interviews, focus group discussions and a stakeholder analysis, will investigate the community acceptability, feasibility and scale-up of each delivery system. Discussion It is expected that this study will add to the existing evidence on the need for alternative intervention strategies for the elimination of LF in Ghana and in other African countries that are facing similar challenges or are at the beginning of their LF-elimination programmes. Trial registration ClinicalTrials.gov, ID: NCT03036059. Registered on 26 January 2017. Pan African Clinical Trials Registry, ID: PACTR201702002012425. Registered on 23 February 2017. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-2196-9) contains supplementary material, which is available to authorized users.

Objective Mass drug Administration (MDA) for the control of Lymphatic filariasis (LF), in Ghana, started in the year 2000. While this had great success in many implementation units, there remain areas with persistent transmission, after more than 10 years of treatment. A closer examination of the parasite populations could help understand the reasons for persistent infections, and formulatingn appropriate strategies to control LF in these areas of persistent transmission. Materials and Methods In a longitudinal study, we assessed the prevalence of microfilaraemia (mf) in two communities with 12 years of MDA in Ghana. In baseline surveys 6 months after the National MDA in 2014, 370 consenting individuals were tested for antigenaemia using immunochromatographic test (ICT) cards, and had their mf count determined through night blood surveys. 48 ICT positives, of whom 17 were positive for mf, were treated with 400 μg/kg ivermectin + 400 mg albendazole and subsequently followed for parasitological assessment at 3-month intervals for 1 year. This overlapped with the National MDA in 2015. Results There was a 68% parasite clearance 3 months after treatment. The pre-treatment mf count differed significantly from the post-treatment mf counts at 3 months (p = 0.0023), 6 months (p = 0.0051), 9 months (p = 0.0113) and 12 months (p = 0.0008). Conclusion In these settings with persistent LF transmission, twice-yearly treatment may help accelerate LF elimination. Further large-scale evaluations are required to ascertain these findings. This article is protected by copyright. All rights reserved.

The World Health Organization's (WHO) 2015-2020 Global Strategy on water, sanitation, and hygiene (WASH) and neglected tropical diseases (NTDs) encourages integration, whilst maintaining existing structured NTD investments, and acceleration towards Sustainable Development Goal (SDG) targets. Accordingly, SDG-associated and WASH-NTD indicators have been developed, commencing important intersectoral dialogue, alongside opportunities for future disease-specific refinements. The rationale for soil-transmitted helminthiasis (STH)- and schistosomiasis-specific WASH considerations, and a traffic-light figure, are presented here to indicate where current international definitions may, or may not, suffice. Certain unique aspects in control dynamics and parasitic lifecycles, however, necessitate additional implementation research with more appropriate measurement indicators developed to record programmatic interventions and to define strategic priorities more effectively.

Background: In order to achieve elimination of blinding trachoma, a country needs to demonstrate that the elimination prevalence thresholds have been surpassed and then sustained for a three year period. Ghana achieved the thresholds in 2008, and since 2011 have been implementing their trachoma surveillance strategy, which includes community and school screening for signs of follicular trachoma and trichiasis, in each trachoma-endemic district. In 2015, the country plans to conduct a number of district level population based survey to verify elimination of blinding trachoma. This decision is currently made based on prevalence of clinical evaluation of “trachomatous trichiasis” and “trachomatous inflammation – follicular” (TF), the second of which has been shown to be a problematic indicator in low prevalence settings. Further evidence is required to determine the optimal surveillance strategy and indicators for trachoma. Objectives: This study will determine if Ghana has sustained the elimination prevalence thresholds. Additionally, the study will review the trachoma surveillance strategy employed in Ghana and if it was able to identify any potential resurgence of infection. It will also assess the relationships between the prevalence of the clinical sign TF, compared to prevalence of infection and antibody levels, after completion of what most observers believe to have been a successful programme. This will help to determine whether it may be appropriate to consider one or more alternative indicators for validating elimination of blinding trachoma. Surveillance for other infections (including yaws and other NTDs) will also be integrated into the pre-validation trachoma survey. Methods: The standard World Health Organization (WHO)-recommended population-based prevalence survey will be conducted in areas already scheduled to conduct validation surveys in 2015, but with the addition of eye swabbing to test for infection and finger pricking to collect bloodspots for antibody testing. Villages identified with a TF prevalence ≥5%, either retrospectively, during the on-going surveillance or during the district level survey (index village), will result in focal screening of children in neighbouring villages (and the ‘index’ village), including a clinical assessment and tests for trachoma infection and antibody levels. Surveillance for additional infections will also be included through antibody testing using the same sera collected for trachoma. Finally, document analysis and qualitative methodologies will be employed to review the operationalization of the trachoma surveillance system in Ghana. Impact: Results from this study will provide the Ghana Health Service with evidence, as to whether the country has sustained their elimination targets for trachoma. It will also inform the WHO-led Alliance for the Global Elimination of Trachoma by 2020 (GET2020) on the appropriateness of alternative indicators and surveillance methodologies for verification of blinding trachoma.

The Global Program to Eliminate Lymphatic Filariasis (GPELF) advocates for the treatment of entire endemic communities, in order to achieve its elimination targets. LF is predominantly a rural disease, and achieving the required treatment coverage in these areas is much easier compared to urban areas that are more complex. In Ghana, parts of the Greater Accra Region with Accra as the capital city are also endemic for LF. Mass Drug Administration (MDA) in Accra started in 2006. However, after four years of treatment, the coverage has always been far below the 65% epidemiologic coverage for interrupting transmission. As such, there was a need to identify the reasons for poor treatment coverage and design specific strategies to improve the delivery of MDA. This study therefore set out to identify the opportunities and barriers for implementing MDA in urban settings, and to develop appropriate strategies for MDA in these settings. An experimental, exploratory study was undertaken in three districts in the Greater Accra region. The study identified various types of non-rural settings, the social structures, stakeholders and resources that could be employed for MDA. Qualitative assessment such as in-depth interviews (IDIs) and focus group discussions (FGDs) with community leaders, community members, health providers, NGOs and other stakeholders in the community was undertaken. The study was carried out in three phases: pre-intervention, intervention and post-intervention phases, to assess the profile of the urban areas and identify reasons for poor treatment coverage using both qualitative and quantitative research methods. The outcomes from the study revealed that, knowledge, attitudes and practices of community members to MDA improved slightly from the pre-intervention phase to the post-intervention phase, in the districts where the interventions were readily implemented by health workers. Many factors such as adequate leadership, funding, planning and community involvement, were identified as being important in improving implementation and coverage of MDA in the study districts. Implementing MDA in urban areas therefore needs to be given significant consideration and planning, if the required coverage rates are to be achieved. This paper, presents the recommendations and strategies for undertaking MDA in urban areas., Author summary The control of lymphatic filariasis depends on the treatment of entire endemic communities, ensuring that a greater proportion of the population is treated. In urban areas, this can be very difficult to achieve. In Ghana, parts of the Greater Accra Region, where the capital city is located, are also endemic for lymphatic filariasis. Treatment in these areas started in 2006, but the proportion of people treated has continuously been below the required programmatic coverage levels. To understand the reasons behind this, a study was undertaken in three endemic districts. The study was carried out in three stages; pre-treatment, treatment and post-treatment. Individuals and groups of people were interviewed in the pre-treatment phase, following which their concerns were used to plan and execute treatment activities. After treatment, some individuals were again interviewed to assess the effectiveness of the interventions. The results showed that the knowledge and behavior of community members towards the disease and treatment activities improved from the pre-treatment to the post-treatment reviews. Many factors were identified including, financial, management and leadership issues that should be considered when planning treatment activities in urban areas.

Summary Lymphatic filariasis in Africa is caused by the parasite Wuchereria bancrofti and remains a major cause of morbidity and disability in 74 countries globally. A key strategy of the Global Programme for the Elimination of Lymphatic Filariasis, which has a target elimination date of 2020, is the treatment of entire endemic communities through mass drug administration of albendazole in combination with either ivermectin or diethylcarbamazine. Although the strategy of mass drug administration in combination with other interventions, such as vector control, has led to elimination of the infection and its transmission in many rural communities, urban areas in west Africa present specific challenges to achieving the 2020 targets. In this Personal View, we examine these challenges and the relevance of mass drug administration in urban areas, exploring the rationale for a reassessment of policy in these settings. The community-based mass treatment approach is best suited to rural areas, is challenging and costly in urban areas, and cannot easily achieve the 65% consistent coverage required for elimination of transmission. In our view, the implementation of mass drug administration might not be essential to interrupt transmission of lymphatic filariasis in urban areas in west Africa. Evidence shows that transmission levels are low and that effective mass drug distribution is difficult to implement, with assessments suggesting that specific control measures against filariasis in such dynamic settings is not an effective use of limited resources. Instead, we recommend that individuals who have clinical disease or who test positive for W bancrofti infection in surveillance activities should be offered antifilarial drugs through a passive surveillance approach, as well as morbidity management for their needs. We also recommend that more precise studies are done, so that mass drug administration in urban areas is considered if sustainable transmission is found to be ongoing. Otherwise, the limited resources should be directed towards other elements of the lymphatic filariasis programme.

Among the 216 districts in Ghana, 98 were declared endemic for lymphatic filariasis in 1999 after mapping. Pursuing the goal of elimination, WHO recommends annual treatment using mass drugs administration (MDA) for at least 5 years. MDA was started in the country in 2001 and reached national coverage in 2006. By 2014, 69 districts had 'stopped-MDA' (after passing the transmission assessment survey) while 29 others remained with persistent microfilaraemia (mf) prevalence (≥1%) despite more than 11 years of MDA and were classified as 'hotspots'. An ecological study was carried out to compare baseline mf prevalence and anti-microfilaria interventions between hotspot and stopped-MDA districts. Baseline mf prevalence was significantly higher in hotspots than stopped-MDA districts (p

Schistosomiasis is a waterborne parasitic disease in sub-Saharan Africa, particularly common in rural populations living in impoverished conditions. With the scale-up of preventive chemotherapy, national campaigns will transition from morbidity- to transmission-focused interventions thus formal investigation of actual or expected declines in environmental transmission is needed as ‘end game’ scenarios arise. Surprisingly, there are no international or national guidelines to do so in sub-Saharan Africa. Our article therefore provides an introduction to key practicalities and pitfalls in the development of an appropriate environmental surveillance framework. In this context, we discuss how strategies need to be adapted and tailored to the local level to better guide and support future interventions through this transition. As detection of egg-patent infection in people becomes rare, careful sampling of schistosome larvae in freshwater and in aquatic snails with robust species-specific DNA assays will be required. Appropriate metrics, derived from observed prevalence(s) as compared with predetermined thresholds, could each provide a clearer insight into contamination- and exposure-related dynamics. Application could be twofold, first to certify areas currently free from schistosomiasis transmission or second to red-flag recalcitrant locations where extra effort or alternative interventions are needed. Electronic supplementary material The online version of this article (doi:10.1186/s40249-016-0215-9) contains supplementary material, which is available to authorized users.

Background The activities of the Global Programme for the Elimination of Lymphatic Filariasis have been in operation since the year 2000, with Mass Drug Administration (MDA) undertaken yearly in disease endemic communities. Information collected during MDA–such as population demographics, age, sex, drugs used and remaining, and therapeutic and geographic coverage–can be used to assess the quality of the data reported. To assist country programmes in evaluating the information reported, the WHO, in collaboration with NTD partners, including ENVISION/RTI, developed an NTD Data Quality Assessment (DQA) tool, for use by programmes. This study was undertaken to evaluate the tool and assess the quality of data reported in some endemic communities in Ghana. Methods A cross sectional study, involving review of data registers and interview of drug distributors, disease control officers, and health information officers using the NTD DQA tool, was carried out in selected communities in three LF endemic Districts in Ghana. Data registers for service delivery points were obtained from District health office for assessment. The assessment verified reported results in comparison with recounted values for five indicators: number of tablets received, number of tablets used, number of tablets remaining, MDA coverage, and population treated. Furthermore, drug distributors, disease control officers, and health information officers (at the first data aggregation level), were interviewed, using the DQA tool, to determine the performance of the functional areas of the data management system. Findings The results showed that over 60% of the data reported were inaccurate, and exposed the challenges and limitations of the data management system. The DQA tool is a very useful monitoring and evaluation (M&E) tool that can be used to elucidate and address data quality issues in various NTD control programmes., Author Summary The Global Programme for the Elimination of Lymphatic Filariasis has been conducting yearly treatment of entire communities in endemic countries since the year 2000. During the treatments various information is collected on the populations, number of medicine tablets distributed and remaining, the number of people treated, etc. that can be used to evaluate the performance of the lymphatic filariasis control programme. For example, information on the number of people treated in a District gives an indication of the success of the programme. In line with this, the World Health Organization in collaboration with other agencies developed a tool for Neglected Tropical Diseases (NTD) to help national control programmes assemble and analyse their data. This study was undertaken to evaluate this tool and the information collected from some endemic communities in Ghana. Community registers were reviewed and personnel involved in drug distribution in the communities were interviewed to collect the necessary information. The results showed that more than half of the data reported in the endemic communities surveyed were inaccurate. It also revealed some weaknesses in the data management and reporting system. The tool, however, is good for identifying and quantifying the magnitude of the challenges encountered in the information management for NTD programmes, especially at peripheral levels.

OBJECTIVES Situational analysis of lymphatic filariasis (LF) morbidity and its management in Ahanta West, Ghana, to identify potential barrier to healthcare for LF patients. METHODS Lymphoedema and hydrocoele patients were identified by community health workers from a subset of villages, and were interviewed and participated in focus group discussions to determine their attitudes and practices towards managing their morbidity, and their perceived barriers to accessing care. Local health professionals were also interviewed to obtain their views on the availability of morbidity management services in the district. RESULTS Sixty-two patients (34 lymphoedema and 28 hydrocoeles) and 13 local health professionals were included in the study. Lymphoedema patients predominantly self-managed their conditions, which included washing with soap and water (61.8%), and exercising the affected area (52.9%). Almost 65% of patients had sought medical assistance at some stage, but support was generally limited to receiving tablets (91%). Local health professionals reported rarely seeing lymphoedema patients, citing stigma and lack of provisions to assist patients as a reason for this. Almost half of hydrocoele patients (44%) chose not to seek medical assistance despite the negative impact it had on their lives. Whilst surgery itself is free with national health insurance, 63% those who had not sought treatment stated that indirect costs of surgery (travel costs, loss of earnings, etc.) were the most prohibitive factor to seeking treatment. CONCLUSIONS The information obtained from this study should now be used to guide future morbidity strategies in building a stronger relationship between the local health services and LF patients, to ultimately improve patients' physical, psychological and economic wellbeing.

Background Lymphoedema and hydrocoele are the two most common clinical manifestations of lymphatic filariasis (LF). In order to effectively target morbidity management strategies, more information is rapidly needed on morbidity burden across all endemic countries. The purpose of this study was to develop and test an SMS tool (MeasureSMS) which enables trained community-based health workers to report basic information on all cases they identified. Methods The tool was trialled in Chikwawa district, Malawi and Ahanta West district, Ghana in 2014. Salaried health surveillance assistants (HSAs) identified and reported cases in Malawi whereas volunteer community health workers (CHWs) were used in Ghana. Health workers were trained in recognising lymphoedema and hydrocoeles and submitting individual case data using MeasureSMS, after which they undertook a LF morbidity survey. After the reporting period, a random sample of reported cases was visited by a physician to verify the health workers’ diagnoses. The proportion of correctly diagnosed cases i.e. the positive predictive value (PPV) was then calculated. Results HSAs in Malawi successfully reported 256 unique cases by SMS from 107 communities (166 hydrocoele, 88 lymphoedema, 2 with both), resulting in an estimated adult prevalence of 17.7 per 10,000 and 33.0 per 10,000 for lymphoedema and hydrocoele respectively. In Ghana, despite being less experienced in using SMS, CHWs successfully reported 360 unique cases by SMS from 33 communities (169 hydrocoele, 185 lymphoedema, 6 with both), resulting in an estimated adult prevalence of 76.9 per 10,000 and 70.5 per 10,000 adults for lymphoedema and hydrocoele respectively. The verification exercise resulted in a PPV for lymphoedema and hydrocoele diagnosis of 90 % (n = 42, 95 % CI 76.5 – 96.9) and 92 % (n = 49, 95 % CI 79.5 – 97.4) in Malawi and 94 % (n = 34, 95 % CI 78.9 %–99.0 %) and 47 % (n = 59, 35.1 %–61.7 %) in Ghana, indicating that non-invasive methods for diagnosing hydrocoeles needed to be further emphasised. Conclusions The study concludes that given the appropriate education and tools, community-based health workers are exceptionally well-placed to participate in quantifying LF morbidity burden, and other NTDs with observable symptoms. This concept has the potential to enable national programmes to more effectively monitor their community impact in an efficient, timely and cost-effective way. Electronic supplementary material The online version of this article (doi:10.1186/s12879-015-0946-4) contains supplementary material, which is available to authorized users.

Background The prevalence of Wuchereria bancrofti, which causes lymphatic filariasis (LF) in The Gambia was among the highest in Africa in the 1950s. However, surveys conducted in 1975 and 1976 revealed a dramatic decline in LF endemicity in the absence of mass drug administration (MDA). The decline in prevalence was partly attributed to a significant reduction in mosquito density through the widespread use of insecticidal nets. Based on findings elsewhere that vector control alone can interrupt LF, we asked the question in 2013 whether the rapid scale up in the use of insecticidal nets in The Gambia had interrupted LF transmission. Methodology/Principal Finding We present here the results of three independently designed filariasis surveys conducted over a period of 17 years (1997–2013), and involving over 6000 subjects in 21 districts across all administrative divisions in The Gambia. An immunochromatographic (ICT) test was used to detect W. bancrofti antigen during all three surveys. In 2001, tests performed on stored samples collected between 1997 and 2000, in three divisions, failed to show positive individuals from two divisions that were previously highly endemic for LF, suggesting a decline towards extinction in some areas. Results of the second survey conducted in 2003 showed that LF was no longer endemic in 16 of 21 districts surveyed. The 2013 survey used a WHO recommended LF transmission verification tool involving 3180 6–7 year-olds attending 60 schools across the country. We demonstrated that transmission of W. bancrofti has been interrupted in all 21 districts. Conclusions We conclude that LF transmission may have been interrupted in The Gambia through the extensive use of insecticidal nets for malaria control for decades. The growing evidence for the impact of malaria vector control activities on parasite transmission has been endorsed by WHO through a position statement in 2011 on integrated vector management to control malaria and LF., Author Summary The prevalence of lymphatic filariasis (LF), in The Gambia was among the highest in Africa in the 1950s when about 50% of the adult population was positive for microfilaraemia. However, surveys conducted in 1975 and 1976 revealed a dramatic decline in LF endemicity in the absence of systematic treatment with anti-filaria medicines. This decline in LF prevalence in all villages was partly attributed to a significant drop in human-mosquito contact through a sustained reduction in rainfall in the 1960s and 1970s and the widespread use of insecticidal nets to protect against malaria. We asked the question in 2013 whether the rapid scale up in the use of insecticidal nets for malaria control in Gambia had resulted in the interruption of LF transmission. In this paper we present the results of three independently designed filariasis surveys conducted over a period of 17 years (1997–2013), and involving over 6000 subjects in 21 districts across all administrative divisions in the country. In 2001, tests performed to detect circulating filarial antigens (CFA) in serum samples collected between 1997 and 2000, in three divisions, failed to show positive individuals from two that were previously highly endemic for the LF. Results of the second survey conducted in 2003 indicated that five of the 21 districts were slightly endemic for LF with CFA rates of 1% or 2% but MDA was never implemented in The Gambia. The results of our final survey conducted in 2013 were unequivocal in confirming the absence of transmission of LF in all 21 districts surveyed using WHO recommended statistically robust and validated tool known as transmission assessment survey (TAS). The Gambia achieving a non-endemic status for LF represents a significant step in the efforts to shrink the filariasis endemicity map and demonstrates the value of cross sector approaches in disease control.

Background It has been proposed that switching from annual to biannual (twice yearly) mass community-directed treatment with ivermectin (CDTI) might improve the chances of onchocerciasis elimination in some African foci. However, historically, relatively few communities have received biannual treatments in Africa, and there are no cost data associated with increasing ivermectin treatment frequency at a large scale. Collecting cost data is essential for conducting economic evaluations of control programmes. Some countries, such as Ghana, have adopted a biannual treatment strategy in selected districts. We undertook a study to estimate the costs associated with annual and biannual CDTI in Ghana. Methodology The study was conducted in the Brong-Ahafo and Northern regions of Ghana. Data collection was organized at the national, regional, district, sub-district and community levels, and involved interviewing key personnel and scrutinizing national records. Data were collected in four districts; one in which treatment is delivered annually, two in which it is delivered biannually, and one where treatment takes place biannually in some communities and annually in others. Both financial and economic costs were collected from the health care provider's perspective. Principal Findings The estimated cost of treating annually was US Dollars (USD) 0.45 per person including the value of time donated by the community drug distributors (which was estimated at USD 0.05 per person per treatment round). The cost of CDTI was approximately 50–60% higher in those districts where treatment was biannual than in those where it was annual. Large-scale mass biannual treatment was reported as being well received and considered sustainable. Conclusions/Significance This study provides rigorous evidence of the different costs associated with annual and biannual CDTI in Ghana which can be used to inform an economic evaluation of the debate on the optimal treatment frequency required to control (or eliminate) onchocerciasis in Africa., Author Summary The African Programme for Onchocerciasis Control (APOC) has recently been extended until 2025, with renewed commitment towards onchocerciasis elimination. This aim is aligned with the goals stated by the World Health Organization and the London Declaration on Neglected Tropical Diseases in January 2012. Switching from annual to biannual (twice yearly) ivermectin distribution might increase the feasibility of onchocerciasis elimination in some African foci. However, relatively few communities have received biannual treatments in Africa, and there are no cost data associated with increasing ivermectin treatment frequency at a large scale, essential pre-requisites to provide reliable information for evidence-based decision making regarding adoption of a biannual treatment strategy. Therefore, we undertook a study to estimate costs associated with biannual compared to annual ivermectin delivery in Ghana, which since 2009 has implemented a biannual treatment strategy in selected priority areas. Our results indicate that the cost of biannual ivermectin treatment per year is approximately 60% higher than the cost of annual treatment. This study provides tangible evidence of the different costs associated with annual and biannual ivermectin treatment, which can be used to inform economic evaluations and policy decisions regarding the optimal treatment frequency required to eliminate onchocerciasis in Africa.

Background Lymphatic filariasis (LF) is targeted for global elimination through treatment of entire at-risk populations with repeated annual mass drug administration (MDA). Essential for program success is defining and confirming the appropriate endpoint for MDA when transmission is presumed to have reached a level low enough that it cannot be sustained even in the absence of drug intervention. Guidelines advanced by WHO call for a transmission assessment survey (TAS) to determine if MDA can be stopped within an LF evaluation unit (EU) after at least five effective rounds of annual treatment. To test the value and practicality of these guidelines, a multicenter operational research trial was undertaken in 11 countries covering various geographic and epidemiological settings. Methodology The TAS was conducted twice in each EU with TAS-1 and TAS-2 approximately 24 months apart. Lot quality assurance sampling (LQAS) formed the basis of the TAS survey design but specific EU characteristics defined the survey site (school or community), eligible population (6–7 year olds or 1st–2nd graders), survey type (systematic or cluster-sampling), target sample size, and critical cutoff (a statistically powered threshold below which transmission is expected to be no longer sustainable). The primary diagnostic tools were the immunochromatographic (ICT) test for W. bancrofti EUs and the BmR1 test (Brugia Rapid or PanLF) for Brugia spp. EUs. Principal Findings/Conclusions In 10 of 11 EUs, the number of TAS-1 positive cases was below the critical cutoff, indicating that MDA could be stopped. The same results were found in the follow-up TAS-2, therefore, confirming the previous decision outcome. Sample sizes were highly sex and age-representative and closely matched the target value after factoring in estimates of non-participation. The TAS was determined to be a practical and effective evaluation tool for stopping MDA although its validity for longer-term post-MDA surveillance requires further investigation., Author Summary Lymphatic filariasis (LF) is targeted for global elimination through a strategy of repeated annual mass drug administration (MDA) to entire at-risk populations. A transmission assessment survey (TAS) is designed to evaluate whether transmission of LF is presumed to have reached a level low enough that it cannot be sustained in the absence of drug intervention and, therefore, MDA can be stopped. This multicenter operational research trial examines the value and practicality of the TAS guidelines through its implementation in 11 countries of diverse geographical and epidemiologic profiles. The field experiences support the TAS survey design methodology with particular respect to school and cluster-based sampling strategies. We found that sample sizes were age and sex representative and met the target values after factoring in estimates of non-participation rates. In 10 of 11 countries, the TAS found the number of positive cases in the evaluation unit to be no more than the statistically powered critical threshold. These results were corroborated in a follow-up TAS approximately 24 months later. We conclude the TAS is a valuable and effective tool for stopping MDA but its utility for longer-term post-MDA surveillance needs further empirical evidence and may be best supported with complementary tools and methods.

Background Mapping the distribution of schistosomiasis is essential to determine where control programs should operate, but because it is impractical to assess infection prevalence in every potentially endemic community, model-based geostatistics (MBG) is increasingly being used to predict prevalence and determine intervention strategies. Methodology/Principal Findings To assess the accuracy of MBG predictions for Schistosoma haematobium infection in Ghana, school surveys were evaluated at 79 sites to yield empiric prevalence values that could be compared with values derived from recently published MBG predictions. Based on these findings schools were categorized according to WHO guidelines so that practical implications of any differences could be determined. Using the mean predicted values alone, 21 of the 25 empirically determined ‘high-risk’ schools requiring yearly praziquantel would have been undertreated and almost 20% of the remaining schools would have been treated despite empirically-determined absence of infection – translating into 28% of the children in the 79 schools being undertreated and 12% receiving treatment in the absence of any demonstrated need. Conclusions/Significance Using the current predictive map for Ghana as a spatial decision support tool by aggregating prevalence estimates to the district level was clearly not adequate for guiding the national program, but the alternative of assessing each school in potentially endemic areas of Ghana or elsewhere is not at all feasible; modelling must be a tool complementary to empiric assessments. Thus for practical usefulness, predictive risk mapping should not be thought of as a one-time exercise but must, as in the current study, be an iterative process that incorporates empiric testing and model refining to create updated versions that meet the needs of disease control operational managers., Author Summary The challenge of accurately mapping schistosomiasis is a daunting one – particularly because of the highly focal distribution of the disease. Ideally, of course, each specific treatment area would be assessed for infection prevalence and then treated appropriately based on guidelines of the World Health Organization. In practice, however, this is not possible, and a variety of short-cutting techniques have been developed to meet these mapping needs, including geospatial predictive mapping. This paper assesses the accuracy of model-based geostatistics (MBG) predictions for determining treatments projections in Ghana by comparing previously published data using MBG predictions with empirically derived prevalence values for schistosomiasis from school surveys completed at 79 sites. We found that using predictive mapping alone would not have provided reliable information for mass drug administration (MDA) planning – resulting in overtreatment in some areas and most importantly under-treatment in areas that needed it most. Based on our findings, predictive risk mapping cannot be a one-time exercise but must instead be a process that incorporates empiric testing and model refining to create optimised spatial decision support tools that meet the needs of disease control operational managers.

Since 1987 onchocerciasis control has relied on the donation of ivermectin (Mectizan®, Merck & Co., Inc.) through the Mectizan Donation Programme. Recently, concern has been raised over the appearance of suboptimal responses to ivermectin in Ghana – highlighting the potential threat of the development of resistance to ivermectin. This report summarises a meeting held in Ghana to set the research agenda for future onchocerciasis control. The aim of this workshop was to define the research priorities for alternative drug and treatment regimes and control strategies to treat populations with existing evidence of suboptimal responsiveness and define research priorities for future control strategies in the event of the development of widespread ivermectin resistance.