By Warren Lancaster, Senior Vice President, Program
My second blog in as many weeks – the current world situation makes you think. I have been reflecting not only on the emergency response to COVID-19 as I talked about in my last blog but also about the safe and effective delivery of neglected tropical disease (NTD) medicine as countries in Africa emerge into post-lockdown but still in a COVID-19 active transmission era.
All the medicine required to treat people for NTDs is available in each country donated by pharmaceutical companies. Countries, with support from external partners like the END Fund, distribute this medicine to millions of people infected with or at risk of infection at least once a year and in a timely way. We use a campaign strategy to do this. But the trouble in our current environment is that campaigns tend to bring people together around things like a central distribution point and that is not desirable in a COVID-19 endemic world.
Between 1996 and 2015 the African Program for Onchocerciasis Control (APOC), a division of WHO, was the partnership charged with fighting onchocerciasis (river blindness) in Africa. APOC developed an approach called Community Directed Treatment with Ivermectin (CDTI). The hallmark of the Community Directed Treatment (CDT) approach was that communities that needed and wanted this free treatment selected 2-4 community members to be trained (2-3 days is regarded as the financial optimum) to distribute the medicines. The Community Drug Distributors (CDD) worked under the overall leadership of the community and distribution was done house-to-house or at a central location.
But there was also another requirement which made the approach truly participatory, community-directed, and sustainable — the community had to commit to underwriting the opportunity cost to the CDDs, through working on their farms. CDDs were also exempted from communal responsibilities and financial contributions. Each community decided on the type of incentive/remuneration CDDs received.
Taking into consideration the rainy season, planting, harvests, and peak transmission season for river blindness, the best-suited months for treatment were agreed and established. Then APOC partners (non-governmental organizations) in countries and the Ministry of Health delivered the medicine to the nearest health posts to the communities. The CDD or community leader would collect and take responsibility for the safety of the medicine followed by the distribution of medicine to eligible people in the community. This was a hugely successful approach and millions of people were treated consistently by trained and retrained CDDs.
Research by the World Health Organization TDR showed that CDDs in 27 African countries had not only the competencies to safely and effectively administer NTD medicine, but also had the capability to deliver many other health interventions that benefited community health. This is an enormous and untapped added value to increasing universal health coverage in Africa where the health system cannot reach those living in rural remote communities. In our current pandemic environment, this evaluation by TDR could be interpreted to include COVID-19 responsiveness.
Since the end of APOC, the treatment of river blindness has passed to countries and other supporting agencies like the END Fund and our colleague organizations. It has remained effectively delivered and in fact because of this devolution, at an even greater scale. But we all use a time-constrained campaign approach, which means that all treatment should be completed within a specific short window of time to have the maximum impact on the infection transmission. However, it is a largely top-down not bottom-up approach.
By contrast, CDT is more — although not entirely — bottom-up hence “community-directed.” CDT moves away from campaigns and engages and empowers communities to treat themselves effectively. It enables people and communities to take responsibility for their treatment or even non-treatment. External partners/supporters assist communities with resources, training, and retraining of CDDs but not direction beyond technical epidemiological parameters.
As I reflect on annual treatment coverage for NTDs post-COVID-19 lock-down, I wonder if, in this new and very fragile treatment environment, CDT with treatment window guidance offers a way to ensuring high coverage of NTD medicine which is essential if NTDs are going to be eliminated.