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Many lymphatic filariasis (LF) endemic countries, including Ghana, have successfully implemented mass drug administration (MDA) and made significant progress towards the elimination of the disease as a public health problem. Unfortunately, the existence of individuals who seldom or never take part in MDA pose a threat to this success, as they may serve as reservoirs of infection, re-infecting their communities. In this study we implemented strategies to identify and treat these individuals, while also assessing their level of infection, to inform programme actions. The study was undertaken in the Ahanta West hotspot district in Ghana, which has received more than 17 rounds of MDA. Through the community registers used in recording participation in MDAs, we identified and offered treatment to individuals who were ineligible or inadvertently missed the last MDA in April 2021 (Engage and Treat – E&T), or testing using the filariasis test strip followed by treatment to community members who for various reasons chose not to participate in the last MDA (Test and Treat – T&T). During the study, 23,879 individuals ranging from 5 to 98 years were reached, of whom 78% were not captured in the MDA register. Among the E&T group, 75.06% willingly received and swallowed the treatment drugs. The remaining 24.94% were offered testing followed by a re-engagement to receive the drug in the T&T group. Overall, 22,830 (95.61%) of participants were treated by either strategy. Of the participants in the T&T group, 516 (8.66%; 95% CI= 7.96 – 9.41) were positive by the FTS. The highest antigen prevalence was detected among children 5 to 10 years, with 16.59% (95% CI= 12.02 – 22.06) and 22.54% (95% CI= 17.11 – 28.74) among females and males, respectively. Mapping of the data revealed that most infections are in a few select communities. Of the 516 FTS positives, 27.33% reportedly missed MDA once, 18.41% missed MDA twice and 54.26% missed all of the last three MDAs. The main reasons for missing MDA included absence (25.49%), travel (21.24%), being unaware of MDA (20.27%), refusals to take the drug (10.65%), illnesses (7.07%) and fear of adverse events (6.13%). This study demonstrates that greater sensitization and engagement strategies, with a test and treat strategy reserved for the most hesitant individuals, could significantly increase the number of individuals who receive treatment and therefore help districts reach their elimination targets by reducing the remaining reservoir or infection. NTD programmes require new tools to help them identify, engage and treat these individuals, as part of their overall monitoring and evaluation strategy.

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 Malaria remains endemic in Ghana despite several interventions. Studies have demonstrated very high levels of asymptomatic malaria parasitaemia in both under-five and school-age children. Mass testing, treatment and tracking (MTTT) of malaria in communities is being proposed for implementation with the argument that it can reduce parasite load, amplify gains from the other control interventions and consequently lead to elimination. However, challenges associated with implementing MTTT such as feasibility, levels of coverage to be achieved for effectiveness, community perceptions and cost implications need to be clearly understood. This qualitative study was therefore conducted in an area with on-going MTTT to assess community and health workers’ perceptions about feasibility of scale-up and effectiveness to guide scale-up decisions. Methods This qualitative study employed purposive sampling to select the study participants. Ten focus group discussions (FGDs) were conducted in seven communities; eight with community members (n = 80) and two with health workers (n = 14). In addition, two in-depth interviews (IDI) were conducted, one with a Physician Assistant and another with a Laboratory Technician at the health facility. All interviews were recorded, transcribed, translated and analyzed using QSR NVivo 12. Results Both health workers and community members expressed positive perceptions about the feasibility of implementation and effectiveness of MTTT as an intervention that could reduce the burden of malaria in the community. MTTT implementation was perceived to have increased sensitisation about malaria, reduced the incidence of malaria, reduced household expenditure on malaria and alleviated the need to travel long distances for healthcare. Key challenges to implementation were doubts about the expertise of trained Community-Based Health Volunteers (CBHVs) to diagnose and treat malaria appropriately, side effects of Artemisinin-based Combination Therapies (ACTs) and misconceptions that CBHVs could infect children with epilepsy. Conclusion The study demonstrated that MTTT was perceived to be effective in reducing malaria incidence and related hospital visits in participating communities. MTTT was deemed useful in breaking financial and geographical barriers to accessing healthcare. The interventions were feasible and acceptable to community members, despite observed challenges to implementation such as concerns about CBHVs’ knowledge and skills and reduced revenue from internally generated funds (IGF) of the health facility.

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.