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International Health 3 (2011) 69– 74

Contents lists available at ScienceDirect

International Health

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eglected tropical disease control in post-war Sierra Leone using thenchocerciasis Control Programme as a platform

ary E. Hodgesa,∗, Joseph B. Koromab,c, Mustapha Sonniea, Ngozi Kennedyd,mily Cottere, Chad MacArthur f

Helen Keller International, 35 Nelson Lane, Tengbeh Town, Freetown, Sierra LeoneNational Neglected Tropical Diseases Control Program, New England, Freetown, Sierra LeoneWorld Health Organization, P.O. Box 529, Freetown, Sierra LeoneNational School and Adolescent Health Program, Youyi Building, Freetown, Sierra LeoneGeorge Washington University, School of Medicine and Health Sciences, Washington DC, USAHelen Keller International, 352 Park Avenue South, 12th Floor, New York, NY 10010, USA

r t i c l e i n f o

rticle history:eceived 21 June 2010eceived in revised form 7 September 2010ccepted 14 March 2011vailable online 26 May 2011

eywords:eglected tropical diseasesnchocerciasisymphatic filariasischistosomiasisoil-transmitted helminthsrachoma

a b s t r a c t

Strategic investments in the control of neglected tropical diseases (NTD) spearheaded by theUS Government, the British Government and other bilateral donors such as foundations andkey pharmaceutical partners have enabled the treatment of millions of people for the fivetargeted debilitating diseases (lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted helminthiasis and trachoma), paving the way for the potential elimination aspublic health problems of some of these diseases. Like many other countries, Sierra Leonehas a high burden of these major NTDs. Despite the fragile infrastructure of a health systememerging from a devastating 10-year civil war, the country has successfully implementedthe National NTD Control Programme, reaching national coverage in 2010. The NTD ControlProgramme uses the existing Onchocerciasis Control Programme as a platform and involvesprimary health workers. The programme has provided extensive training opportunities tohealth workers at national, district and community levels. The country currently has 31 161

trained community volunteers treating a population of five million people. It is shown thatthe investments in NTD control are not only to control NTDs but also to strengthen healthsystems, particularly at the primary level, through extensive capacity building of frontlinehealth workers and community-directed distributors.

yal Soc

© 2011 Ro

. Introduction

Sierra Leone went through a devastating civil waretween 1991 and 2002. Already ranked as one of the

east developed countries in the world, it suffered fur-her loss of infrastructure.1 Two-thirds of the population

ives on less than US$1 per day, infant and child mortalityates are among the highest in the world, and malnutri-ion and anaemia are widespread.2 Of the 1087 primary

∗ Corresponding author. Tel.: +232 76 859 625.E-mail address: mhodges@hki.org (M.E. Hodges).

876-3413/$ – see front matter © 2011 Royal Society of Tropical Medicine and Hoi:10.1016/j.inhe.2011.03.003

iety of Tropical Medicine and Hygiene. Published by Elsevier Ltd. All rights reserved.

health facilities that existed pre-war, only 79 were fullyfunctional (undamaged and appropriately staffed) in 2002as others had been looted or wantonly destroyed (R. Shoo,UNICEF, personal communication). Human resource capac-ity in government and the private sector was shattered,with personnel evacuated, internally displaced and/ortraumatised.

Post-war Sierra Leone received investment from manyinternational agencies to rehabilitate its infrastructure

and to increase human resource capacities. Decentral-isation of administration and formation of 13 DistrictHealth Management Teams (DHMT) lead by District Medi-cal Officers (DMO) developed greater accountability. These

ygiene. Published by Elsevier Ltd. All rights reserved.

national

70 M.E. Hodges et al. / Inter

teams comprise ‘Focal Persons’ to co-ordinate hospitals andcommunity health services, including reproductive andchild health, school health, nutrition, malaria, HIV/AIDSand neglected tropical diseases (NTD). Many organisationshave been involved in reconciliation, integration of ex-combatants, and strengthening of good governance at alllevels of society. By 2009, 1040 primary health facilitieshad become functioning under the supervision of Commu-nity Health Officers at chiefdom level, reporting directly toDMOs3 and from there onwards to the national Ministry ofHealth and Sanitation (MoH&S).

Like other countries in the subregion, Guinea, Liberiaand Sierra Leone are endemic for many of the major NTDs4

that afflict the poorest populations in the world and canlead to blindness, disfigurement, social stigma, marginal-isation, anaemia, malnutrition, stunting, cognitive delays,increased mortality rates and huge socioeconomic losses.5

Greater access to preventative chemotherapy for NTDsis thought by some to contribute to national security bypoverty alleviation.6

2. Evolution of the national Onchocerciasis ControlProgramme (OCP)

In Sierra Leone, endemicity of onchocerciasis wasknown as early as 1926 when Blacklock first describedthe transmission of onchocerciasis through the black fliesSimulium damnosum in Kono District.7 Onchocerciasis isthe second most common cause of blindness after cataractin the country.8,9 Considerable work on epidemiologicalaspects of the disease was carried out in the early dayswith the prevalence of onchocerciasis found to be 30–50%along the main rivers,7,10–12 and black flies were found toexist in the entire country except areas around Freetownand the southern coastal plain.11 In 1974, the distributionof onchocerciasis was mapped using skin snips for detect-ing Onchocerca volvulus microfilariae (mf) and all districtswere found to be endemic except the Western Area.13 Thecontrol effort started as early as 1957 with insecticide treat-ments along the Tonkolili River that was found to be themost severely affected.11 In 1988, the former OCP expandedits coverage to include Sierra Leone, along with other coun-tries, and vector control by spraying insecticides continuedalong rivers in hyperendemic areas, but the activity wassuspended during the war owing to insecurity.14–16 Withsupport from the African Programme for OnchocerciasisControl (APOC), the national OCP resumed in 2002 afterthe war. Community-directed treatment with ivermectin(CDTI) was implemented nationwide in mesoendemic (mfprevalence 20% to <40%) and hyperendemic (mf preva-lence ≥40%) communities (Special Intervention Zones).17

In 2007, with support from the APOC and the WHO AfricanRegional Office, the national OCP started to distributealbendazole together with ivermectin (CDTI+) in six dis-tricts along the borders with Guinea and Liberia to beginthe lymphatic filariasis (LF) elimination programme.

With international effort in the past few years, inte-

grated control of NTDs using a rapid impact packagefor LF, onchocerciasis, schistosomiasis, soil-transmittedhelminthiasis (STH) and trachoma has gained momentum.4

With the successful experience in integrating control of LF

Health 3 (2011) 69– 74

into the existing CDTI activities, the government of SierraLeone decided to take the opportunity to expand the exist-ing CDTI+ further and to use it as a platform to control otherNTDs in the country. With technical assistance from andthrough Helen Keller International, Sierra Leone success-fully received funding for the integrated control of NTDsfrom the United States Agency for International Develop-ment (USAID) through RTI International in 2008, and thenational OCP was used as a platform to form the newNational NTD Control Programme.

3. Preparing for integrated control of neglectedtropical diseases

3.1. Political commitment and leadership

The MoH&S led the early planning and involvement ofstakeholders and established the NTD Task Force Group,including two universities, the College of Medicine and theSchool of Community Health and Clinical Sciences, non-governmental organisations (NGO) and external experts.A 5-year national strategic plan was formulated and bud-geted.

3.2. Mapping of neglected tropical diseases

Before NTD control was implemented, mapping of thedistribution and prevalence of the target diseases through-out the country was completed and intervention strategieswere justified according to WHO guidelines.18 Collabora-tion on mapping between the health sector and universitieshelped to rebuild capacity amongst undergraduates, grad-uates and employees in field techniques, laboratory skillsand statistical analysis.

Onchocerciasis was mapped prior to CDTI implementa-tion. With the exception of the Western Area, 12 villagesin each district, close to fast-flowing rivers, were selectedand villagers were examined by skin snips for O. volvulusmf. All districts surveyed were found to be endemic exceptfor Bonthe Island;16 Pujehun District had the highest mfprevalence (87%).

LF was mapped in 2005 by immunochromatographictest (ICT) cards19,20 funded by APOC/WHO African RegionalOffice. This was performed in randomly selected communi-ties in each district. Every district was found to be endemic(positive ICT >1%).21 The overall prevalence of positive ICTwas 21%, with the highest in Bombali (52%).

Schistosomiasis mapping was performed in 2008.Results showed that Schistosoma mansoni is prevalentthroughout the country, with the highest prevalence inthe northeast districts, e.g. 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%).22 Schistosoma haematobium alsoexists in some parts of the country (M.E. Hodges et al.,unpublished data). These findings concur with previousfindings.23

Soil-transmitted helminths were known to be endemic

nationwide.24–27 National mapping in 2008 and valida-tion in 2009 found that the STH prevalence was moderate,particularly, hookworm (M.E. Hodges et al., unpublisheddata).

national Health 3 (2011) 69– 74 71

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Trachoma was mapped in five northern districts consid-red to be at risk in 2008. The prevalence of trachomatousrichiasis in persons ≥15 years of age was 0.26% in Portoko and 0.21% in Bombali (J.B. Koroma et al., unpublishedata), but trachomatous inflammation–follicular in chil-ren aged 1–9 years was below levels of public healthignificance (<5%). Therefore, no preventative treatmentith azithromycin was warranted within the country.

. Scaling-up to integrated national neglectedropical diseases control

Based on the mapping results and funding from USAID,POC and Sightsavers International, the National NTDontrol Programme was able to plan a scale-up to imple-ent an integrated national control programme for LF,

nchocerciasis, schistosomiasis and STH. Phased expansionf community drug distributors (CDD) to new geographicalreas enabled a fragile post-war primary health service thepportunity to acquire the human resources for training,mplementation, monitoring and supervision. The increasen programme activities, villages reached, geographic areasf implementation and CDDs trained from 2005 to 2010 ishown in Table 1.

.1. Community ownership of the NTD Controlrogramme

Community ownership of the programme is critical touccessful implementation and long-term sustainability.his was in part achieved by launching the NTD Controlrogramme at national level before the 5-year nationaltrategic plan was finalised to allow discussion and debatey all stakeholders, including traditional and religious lead-rs. Political commitment and dynamic national leadershipeveloped a flexible but strong management system withinhe MoH&S. This provided training and guidance but gavewnership of NTD control to each level of the health admin-stration and advocacy at all levels of society (Figure 1).

.2. Cascade training

Cascade training of health personnel from nationalo district, district to chiefdom and chiefdom to villageas adopted. Primary health service workers received

raining in mapping, budgeting, planning, stock control,evelopment, production and dissemination of informa-ion, education and communication materials, monitoring,valuation and reporting. CDDs received training in NTDecognition, census-taking, distribution of drugs, ‘directlybserved treatment’, record keeping, recognition andesponse to serious adverse events after treatment.

.3. Social mobilisation

Social mobilisation to establish and maintain stronginks with traditional authorities and civil societies was

onsidered key to success. Social mobilisation meetings,here the diseases and treatments were explained, were

ollowed by the selection of CDDs by village health com-ittees. These CDDs were then trained by the local primary Ta

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72 M.E. Hodges et al. / International Health 3 (2011) 69– 74

Ministry of Heal th a nd Sanita� on: Directorat e of Dise ase Preven�on a nd

Control

UN a gencies a nd NGOs: par �cipated in technical task

force

Param ount C hiefs tradi�onal : authority for chiefdoms, par �cipat ed in na� onal and district

planning

Na� onal NTD C ontrol Programm e: res ponsible f or na� onal plann ing, t raining of

trai ners (DHM Ts), monitorin g, superv ision a nd

repor�ng t o donors

Parliame ntar ians: par �cipated in stak eholders

mee�ng

DHMTs: res ponsible f or district planning, t rai ning of

CHOs, m onitorin g, sup erv ision and r epor�ng t o NTD C ontrol

Programme

CDDs: responsible f or v ill age census, im plementa� on of

CDTI+, rep or�ng and recogni�on of SAEs

Sec�on C hiefs : par �cipated in

district planning

PHWs: res ponsible f or tra ining of CDD s, sup erv ision,

repor�ng a nd m anagement of SAEs i n cat chment a reas

CHOs: responsible f or chiefdom planning, t rai ning of PHWs, m onitorin g, sup erv ision

and r epor�ng Reli gious leaders:

Imams, p ries ts par �cipat ed in district plann ing f or

schoo l-based schistosomia sis a nd STH

control

Dis trict coun cill ors: par �cipated in district

planning f or schoo l-based schistosomia sis a nd STH

control planning

Dis trict D irecto rs of Edu ca� on: par �cipat ed in

na� onal plann ing f or schoo l-based schistosomia sis a nd

STH control planning

Town coun cill ors: par �cipated in urban

planning f or schoo l-based schistosomia sis a nd STH

control

Comm unity T eacher Ass ocia� ons: par �cipated

in plann ing f or schoo l-based schistosomia sis a nd

STH control

Vill age headmen

Vill age Heal th Commi�ees: selec�on of

CDDs

Training , supplies , monitoring and evalua �on Repor�ng

Advocacy

Figure 1. Organisational chart of the National Neglected Tropical Diseases (NTD) Control Program illustrating cascade training, reporting channels, mon-itoring and evaluation, multilayered social mobilisation and advocacy activities mobilisation. NGOs: non-governmental organisations; DHMTs: DistrictHealth Management Teams; STH: soil-transmitted helminthiasis; CHOs: Community Health Officers; PHWs: primary health workers; CDDs: communitydrug distributors; SAEs: severe adverse effects; CDTI+: community-directed treatment with ivermectin plus albendazole.

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ealth service workers but were held responsible by theirocal communities. Community radio networks were usedo disseminate information regarding diseases and pro-ramme activities by multiple methods: jingles, sportessages, panel discussions and phone-in programmes.

.4. Extending the coverage for lymphatic filariasisontrol

LF elimination involves the distribution of ivermectinnd albendazole to ≥80% of the eligible at-risk popula-ion in endemic areas annually for at least 5 years.28,29

dditional benefits are that persons in onchocerciasisypoendemic areas (<20% mf prevalence) receive iver-ectin. Second, eligible persons >5 years of age receive

vermectin and albendazole annually to treat STHs.30

In 2008, community distribution of treatment withDTI+ took place in all communities except the Urbanestern Area. Overall, the epidemiological coverage (thoseho received treatment with both ivermectin and alben-azole among eligible, at-risk population targeted) was0%.31 This was a remarkable achievement considering thathe conflict had only ended 6 years previously. However,he CDTI+ strategy performed in the Rural Western Area,he outskirts of the capital city Freetown, was low althoughhe national surveyed coverage was 66% (W. Kamara et al.,npublished data) and a National Immunization Day strat-gy was adopted for the entire Western Area in 2009–2010ith great success of 86% surveyed coverage of an esti-ated population of 1.68 million people.32 Greater socialobilisation was deployed, including multimedia advo-

acy, newspaper articles, television reporting, Internet asell as structured meetings with town councillors and tra-itional and religious leaders.

.5. Scaling-up to schistosomiasis control

Schistosomiasis control started in 2009 with a school-ased deworming programme in districts highly andoderately endemic for schistosomiasis. Praziquantel andebendazole (donated by Medical Research Centre–Sierra

eone) were administered. Only school-going childrenere targeted in this first round. Advocacy meetingsere held with Directors of Education, Paramount Chiefs,istrict Councillors and senior religious leaders in eachistrict, who jointly signed a letter declaring their sup-ort for the programme and taking ‘ownership’. Healthtaff were trained in the appropriate dosing of prazi-uantel using height poles and were given posters andactsheets to disseminate information to their commu-ities and schools. Radio discussions, spot messages and

ingles were aired over the community radio networks.he side effects of praziquantel include vomiting, stom-ch pain and diarrhoea,33 especially if taken on an emptytomach in heavily parasitised individuals. Many childreno to school without eating in Sierra Leone, so funds wereistributed to all head teachers to prepare a meal on the

greed date so that children could be fed before treat-ent. The health staff implemented this in an average of

ve schools each within their catchment areas. Monitor-ng was performed in unannounced, random site visits in

Health 3 (2011) 69– 74 73

75% of chiefdoms by teams from National School and Ado-lescent Health, National NTD Control Programme, HelenKeller International and the Pharmacy Board to ensure thatchildren were fed, height poles were appropriately utilisedand data were correctly recorded.

After the anarchy of the war years, it was remarkableto see the health service functioning so effectively, withsupplies and funds successfully distributed to 544 pri-mary health facilities often in very isolated locations. Usingenrolment figures, 94% of school-going children in 2436schools received praziquantel. Stomach aches were fre-quent but were appropriately managed and tolerated bycommunities as they had been well informed previously.

In 2010, all school-aged children and ‘at-risk adults’ inhighly and moderately endemic communities were tar-geted. All adults in these rural communities are consideredto be ‘at-risk’ as they fish, wash or mine in fresh waterwhere the intermediate snail hosts proliferate. The targetpopulation was 1.8 million individuals in 2010.

4.6. Soil-transmitted helminthiasis control

STH control became integrated into the NTD ControlProgramme in 2009. Previously, deworming of primaryschool children had been performed by NGOs andUnited Nations agencies. The St Andrew’s Clinics forChildren–Sierra Leone (STACC-SL), a non-governmentaldevelopment organisation based in Scotland, had usedalbendazole in district-wide distribution to school-goingchildren since 2002, and the World Food Programme hadtreated children receiving school food aid twice yearly withmebendazole supplied by UNICEF since 2004.

A Memorandum of Understanding with the Ministryof Education and Youth Services is being developed toextend the school-based deworming coverage to districtshypoendemic for schistosomiasis where teachers will beresponsible for mebendazole administration. As only 66%of school-aged children attend school,2 out-of-school chil-dren will receive mebendazole from the health services.

4.7. Monitoring and evaluation of the programme

Significant progress has been made in the National NTDControl Programme. Whilst the programme is progressing,monitoring and evaluation procedures were carried outto ensure the coverage and quality of the programme. Anindependent nationwide validation survey was performedin 2009. Overall consumption of Mectizan (ivermectin) andalbendazole reported from 2200 randomly sampled house-holds was 67% and 66%, respectively (W. Kamara et al.,unpublished data). Independent monitoring of the recentpreventative chemotherapy and transmission control forLF in the Western Area reported coverage of 86%.32

5. Conclusion

Onchocerciasis, LF, schistosomiasis and STH are widely

endemic in Sierra Leone and the scaling-up to nationalcoverage has involved all sectors of society from nationalplanners, DHMTs, primary health workers, religious lead-ers, traditional leaders and CDDs in every community. The

national

74 M.E. Hodges et al. / Inter

success of these recent interventions demonstrates theprogress made in strengthening the health service, collab-oration with civil society, and increasing human resourcessince the war. The National NTD Control Programme hascontributed significantly to this progress. The reduction inNTD-related morbidity will also make a significant contri-bution to reducing poverty.

Authors’ contributions: MEH and JBK conceived thereview; MEH and EC drafted the manuscript; JBK, MS, NKand CM critically reviewed and revised the paper for intel-lectual content. All authors read and approved the finalmanuscript. MEH is guarantor of the paper.

Acknowledgements: Mectizan (ivermectin) and albenda-zole for the lymphatic filariasis elimination programme aredonated by Merck Co. Inc. and GlaxoSmithKline, respec-tively. Mebendazole and albendazole for soil-transmittedhelminthiasis control are donated by the World Food Pro-gramme, Medical Research Centre–Sierra Leone and StAndrew’s Clinics for Children–Sierra Leone (STACC-SL).Support with the data from A. Conteh, F. MacCarthy (NTDControl Programme), M. Tucker (UNICEF) and E. Nyorkor(STACC-SL) is appreciated. The NTD Control Programme hasalso been supported by funding from the World Bank andthe Mectizan Donation Programme. Editorial support andrevision of the paper by Y. Zhang (HKI) is also appreciated.

Funding: The National Neglected Tropical Diseases (NTD)Control Programme was made possible by the Govern-ment of Sierra Leone, Helen Keller International andthe United States Agency for International Development(USAID) through RTI International. The contents of thispaper are the responsibility of Helen Keller Internationaland do not necessarily reflect the views of USAID or the USGovernment. The programme also received support fromthe African Programme for Onchocerciasis Control (APOC),Sightsavers International and the Mectizan Donation Pro-gramme.

Conflicts of interest: None declared.

Ethical approval: Control of neglected tropical diseases inSierra Leone is a national programme managed and imple-mented by the Government of Sierra Leone. Mass drugadministration for these diseases is a national strategy thatdoes not require formal ethical approval. There are no datafrom individuals involved in this paper and therefore noethical approval is required.

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