Open Access

Community based interventions for the prevention and control of Non-Helmintic NTD

  • Jai K Das1,
  • Rehana A Salam1,
  • Ahmed Arshad1,
  • Hasina Maredia2 and
  • Zulfiqar A Bhutta3, 4Email author
Infectious Diseases of Poverty20143:24

DOI: 10.1186/2049-9957-3-24

Received: 5 January 2014

Accepted: 23 June 2014

Published: 31 July 2014

Abstract

In this paper, we aim to systematically analyze the effectiveness of community based interventions (CBI) for the prevention and control of non-helminthic diseases including dengue, trypanosomiasis, chagas, leishmaniasis, buruli ulcer, leprosy and trachoma. We systematically reviewed literature published up to May 2013 and included 62 studies in this review.

Findings from our review suggest that CBI including insecticide spraying; insecticide treated bednets and curtains; community education and cleanliness campaigns; chemoprophylaxis through mass drug administration; and treatment have the potential to reduce the incidence and burden of non-helminthic diseases. Lack of data limited the subgroup analysis for integrated and non-integrated delivery strategies however, qualitative synthesis suggest that integrated delivery is more effective when compared to vertical interventions; however, such integration was possible only because of the existing vertical vector control programs.

Community delivered interventions have the potential to achieve wider coverage and sustained community acceptance. Eradicating these diseases will require a multipronged approach including drug administration, health education, vector control and clean water and sanitation facilities. This would require high level governmental commitment along with strong partnerships among major stakeholders.

Keywords

NTDs Non-helminthic Community based interventions

Introduction

As discussed in paper 1 of this series [1], non-helminthic infections are a group of viral (dengue fever), protozoal (African trypanosomiasis, chagas and leishmaniasis) and bacterial (buruli ulcer, leprosy and trachoma) diseases endemic amongst the poorest population in the tropical and sub-tropical regions. These infections can lead to burdensome health consequences accountable for severe economic costs including blindness due to trachoma and disfigurement from leishmaniasis, leprosy and buruli ulcer. Some of these neglected tropical diseases (NTD) like African trypanosomiasis, chagas and dengue fever can even become fatal at the later stages of the disease [2]. For a more thorough discussion on the epidemiology and burden of each of these diseases, please refer to Paper 1 of this series [1].

The World Health Organization (WHO) recommends widespread vector control and environmental management to prevent the spread of vector borne diseases including dengue, trypanosomiasis, chagas, leishmaniasis and trachoma. These should be coupled with mass and selective chemotherapy, community participation, active diseases surveillance, health education, capacity building and training of community health workers (CHW), provision of drugs, surgical treatment and rehabilitation for deformities [3]. For trachoma, WHO recommends SAFE strategy for prevention and management of trachoma, which includes lid surgery (S), antibiotics (A), facial cleanliness (F), and environmental improvement (E). In this paper, we aim to systematically analyze the effectiveness of community based interventions (CBI) for the prevention and control of non-helminthic NTD including dengue, trypanosomiasis, chagas, leishmaniasis, buruli ulcer, leprosy and trachoma.

Methods

We systematically reviewed literature published up to May 2013 to identify studies on the effectiveness of CBI for the outlined non-helminthic diseases. Our priority was to select existing randomized, quasi-randomized and before/after studies, in which the intervention was delivered within community settings and the reported outcomes were relevant to the diseases under review. A separate search strategy was developed for each disease using appropriate key words, medical subject heading (MeSH) and free text terms. Search was conducted in the PubMed, Cochrane Libraries, Embase, and WHO Regional Databases. Studies that met the inclusion criteria were selected and double data abstracted on a standardized abstraction sheet. Quality assessment of the included randomized controlled trials (RCT) was done according to the Cochrane risk of bias assessment tool [4]. The outcomes of interest for each of the above diseases are outlined in Table 1. We conducted a meta-analysis for individual studies using the software Review Manager 5.1. Pooled statistics were reported as the relative risk (RR) for categorical variables and standard mean difference (SMD) for continuous variables between the experimental and control groups with 95% confidence intervals (CI). We also attempted to qualitatively synthesize the findings reported in the included studies for other pragmatic parameters identified in our conceptual framework including intervention coverage, challenges/barriers, enabling factors, aspects related to integrated delivery, monitoring and evaluations and equity. The detailed methodology is described in paper 2 of the series [5].
Table 1

Outcomes analyzed

Diseases

Outcomes analyzed

Chagas

Peri-domiciliary Infestation Rate

 

Domiciliary Infestation Rate

 

Chagas serology Rate

Dengue

Dengue Positive Serostatus

 

House Index

 

Mean Bretreau Index

 

Ovitrap Index

Trachoma

Active Trachoma in All Age Groups

 

Active Trachoma in Children

 

Chlamydia Trachomatis Infection in All Age Groups

 

Chlamydia Trachomatis Infection in Children

Leishmaniasis

Incidence of Cutaneous Leishmaniasis

 

Incidence of Visceral Leishmaniasis

 

Cure Rate for Cutaneous Leishmaniasis

Leprosy

Incidence of Leprosy

 

Leprosy Detection Rate

Review

We identified 3452 titles from search conducted in all databases. After screening titles and abstracts, 348 full texts were reviewed, of which 62 studies; 21 RCT and 41 before after studies, were included in the review (Figure 1). The characteristics of the included studies are summarized in Table 2. Of these 62 studies, 17 studies were on dengue, 4 on chagas, 12 on leishmaniasis, 6 on leprosy and 23 on trachoma prevention and control. We did not find any quantifiable data from studies on trypanosomiasis and buruli ulcer to be included in the review. For the 21 RCT included in this review; randomization was adequate in all 21 studies, allocation was concealed in 7, adequate sequence generation was done in 10 while studies provided insufficient information on selective reporting which limited us from making any judgment (Table 3).
Figure 1

Search flow diagram.

Table 2

Characteristics of included studies

Study

Study design

Country

Intervention

Target population

Integrated/Non-Integrated

Dengue

Gurtler 2009

Pre-post

Argentina

Preventivelarvicides and insecticide spraying

General population

Non-integrated

Seng 2008

Pre-post

Cambodia

Preventive guppies reared in household water tanks

General population

Non-integrated

Bang 1972

Pre-post

Thailand

Preventive spraying

General population

Non-integrated

Kittayapong 2008

Pre-post

Thailand

Preventive vector control

General population

Non-integrated

Madarieta 1999

Pre-post

Philippines

Preventive Permethrin treated curtains

General population

Non-integrated

Nathan 1982

Pre-post

West Indies

Preventive insecticide spraying

General population

Non-integrated

Neng 1987

Pre-post

China

Preventive growing of Chinese cat fish to consume larvae

General population

Non-integrated

Pant 1971

Pre-post

Bangkok

Preventive Malathion aerosols

General population

Non-integrated

Pai 2006

Pre-post

Taiwan

Preventive cleanliness campaign

General population

Non-integrated

Nam 1997

Pre-post

Vietnam

Preventive community education and cleanliness campaign

General population

Non-integrated

Umniyati 2000

Pre-post

Indonesia

Preventive cleanliness campaign

General population

Non-integrated

Uribe 1984

Pre-post

Columbia

Preventive aerosol applications of Malathion

General population

Non-integrated

Winch 2002

Pre-post

Puerto Rico

Preventive community education program through televised public service announcements and posters

General population

Non-integrated

Kroeger 2006

RCT

Mexico & Venezuela

Preventive insecticide treated curtains

General population

Non-integrated

Vanlerberghe 2009

RCT

Cuba

Preventive insecticide treatments of household items

General population

Non-integrated

Espinoza-Gomez 2002

RCT

Mexico

Preventive spraying and educational campaign

General population

Non-integrated

Lenhart 2008

RCT

Haiti

Preventive insecticide treated bed nets

General population

Non-integrated

Chagas

Arias 1999

Pre-post

Paraguay

Preventivespraying, housing improvement, and a combination of spraying plus housing improvement

General population

Non-integrated

Ferro 1995

Pre-post

Paraguay

Preventive insecticide spraying with lambdacyhalothrin

General population

Non-integrated

Gurtler 2007

Pre-post

Argentina

Preventive community wide spraying with unspecified insecticide

General population

Non-integrated

Gurtler 2004

RCT

Argentina

Preventiveinsecticide spraying

General population

Non-integrated

Leishmaniasis

Alten 2002

Pre-post

Turkey

Preventive Deltamethrin impregnated bed nets

General population

Non-integrated

Dietze 1997

Pre-post

Brazil

Affected dogs were eliminated

General population

Non-integrated

Jalouk 2007

Pre-post

Syria

Preventive ITNs vs. non-treated bed nets

General population

Non-integrated

Yaghoobi-Ershadi 2006

Pre-post

Iran

ITNs, curtains and health education

General population

Non-integrated

Mohebali 2010

Pre-post

Iran

Surveillance followed by treatment of detected cases

Children <12 years

PHC

Safi 2012

Pre-post

Afghanistan

Thermotherapy for Cutaneous Leishmaniasis

General population

Non-integrated

Velasco-Casrejon 1997

Pre-post

Mexico

Therapeutic localized current radio frequency ablation

General population

Non-integrated

Emami 2009

RCT

Iran

ITNs

General population

Non-integrated

Gavgani 2002

RCT

Iran

Community wide application of dog collars

Children

Non-integrated

Picado 2010

RCT

India and Nepal

ITNs

General population

Non-integrated

Reyburn 2000

RCT

Afghanistan

ITNs and Treated chaddars

General population

Non-integrated

Rojas 2006

RCT

Columbia

Deltamethrin bed nets and health education

General population

Non-integrated

Leprosy

Namadi 2002

Pre-post

Nigeria

Integration of services for leprosy detection and elimination through multi-drug therapy

General population

General health systems

Bakker 2005

Pre-post

Indonesia

Preventive Rifampicin chemoprophylaxis

General population

Non-integrated

Rahim 2004

Pre-post

Yemen

Leprosy control program through field searches for cases, clinics, referral centers

General population

Non-integrated

Schuring 2009

Pre-post

Bangladesh

Chemoprophylaxis with Rifampicin and BCG

General population

Non-integrated

Cunha 2008

RCT

Brazil

BCG revaccination of schoolchildren

7-14 years old children

Non-integrated

Moet 2008

RCT

Bangladesh

Rifampicin chemoprophylaxis for close contacts of cases

General population

Non-integrated

Trachoma

Hagan 2009

Pre-post

Ghana

Treatment according to SAFE strategy with Azithromycin

General population

Non-integrated

Alemayehu 2007

Pre-post

Ethiopia

Mass preventive treatment with Azithromycin

General population >1 years

Non-integrated

Astle 2006

Pre-post

Zambia

Treatment of Trachoma through SAFE strategy

General population

Non-integrated

Atik 2006

Pre-post

Vietnam

Treatment through SAFE, SA and S only strategy

Children aged 5–15 years

Non-integrated

Biebesheimer 2009

Pre-post

Eithopia

Preventive annual or biannual mass distribution of azithromycin

General population

Non-integrated

Broman 2006

Pre-post

Tanzania

Preventive mass treatment with azithromycin

General population

Non-integrated

Chidambaram 2006

Pre-post

Ethiopia

Single mass preventive administration of Azithromycin

General population >1 years

Non-integrated

Ewald 2003

Pre-post

Central Australia

Treatment according to SAFE strategy

Children <13 years of age and their households

Non-integrated

Gaynor 2003

Pre-post

Nepal

Single treatment with Azithromycin

Children 1–10 years with their households

Non-integrated

Huguet 2009

Pre-post

Cameroon

Mass preventive administration of Azithromycin drops

General population

Non-integrated

Khandekar 2006

Pre-post

Vietnam

Preventive interventions including improved water andsanitation facilities and increased awareness about active trachoma in the community

General population

Non-integrated

Kumaresan 2003

Pre-post

Multi-country

SAFE strategy

General population

Non-integrated

Lakew 2009

Pre-post

Ethiopia

Mass preventive administration of oral azithromycin

General population

Non-integrated

Schemann 2007

Pre-post

Mali

Mass community-based treatment of all residents, treatment of all children under 11 years of age and of women between 15 and 50 and treatment targeted to inhabitantsof households where at least one child had clinically active trachoma diagnosed with azithromycin

General population

Non-integrated

Edwards 2006

RCT

Ethiopia

Radio messaging, IEC materials, and video van activities along with the SAFE strategy

General population

Non-integrated

Emerson 2004

RCT

Gambia

Preventive intervention group that received regular insecticide spraying or provision of pit latrines (without additional health education) to each household

General population

Non-integrated

Abdou 2010

RCT

Niger

Preventive building of clean water wells and health education

General population

Non-integrated

Fraser-Hurt 2001

RCT

Gambia

Mass administration of Azithromycin vs Topical Tetracycline

General population

Non-integrated

Gebre 2011

RCT

Ethiopia

Preventive mass annual versus twice-yearly azithromycin

General population

Non-integrated

House 2009

RCT

Ethiopia

Preventive mass treatment four times per year vs. treatment delayed until after 1 year vs. routine annual mass administration of azithromycin

children aged between 1 and 10 years

Non-integrated

Melese 2008

RCT

Ethiopia

Biannualvs. annual mass azithromycin administrations

General population

Non-integrated

Schacter 1999

RCT

Egypt, Gambia and Tanzania

Community-wide oral azithromycin treatment or treatment with 1% topicaltetracycline

General population

Non-integrated

West 2007

RCT

Tanzania

Mass treatment with topical tetracycline ointmentplus the face-washing programor treatment only

Children 1–7 years

Non-integrated

Table 3

Quality assessment of the included RCTs

Study

Randomization

Sequence generation

Allocation concealment

Blinding of participants

Blinding of assessors

Selective reporting

Chagas

Gurtler 2004

Done

Not computerized but done

Not clear

Done

Done

Not clear

Dengue

Kroeger 2006

Done

Not done

Done

Not done

Not clear

Yes

Vanlerberghe 2009

Done

Not computerized but done

Not clear

Not clear

Not clear

Not clear

Espinoza-Gomez 2002

Done

Not computerized but done

Not clear

Not clear

Not clear

No

Lenhart 2008

Done

Not done

Done

Not clear

Not clear

Not clear

Trachoma

Edwards 2006

Done

Not clear

Not clear

Not clear

Not clear

Not clear

Emerson 2004

Done

Not clear

Not clear

Not clear

Done

No

Abdou 2010

Done

Not clear

Not clear

Not clear

Not clear

Not clear

Fraser-Hurt 2001

Done

Not clear

Not clear

Not clear

Not clear

Yes

Gebre 2011

Done

Done

Done

Not clear

Done

Not clear

House 2009

Done

Done

Done

Not clear

Done

Not clear

Melese 2008

Done

Done

Done

Not clear

Done

No

Schacter 1999

Done

Done

Not clear

Not clear

Not clear

Yes

West 2007

Done

Not clear

Not clear

Not done

Done

No

Leishmaniasis

Emami 2009

Done

Done

Not clear

Not clear

Not clear

No

Gavgani 2002

Done

Not done

Not clear

Not clear

Not clear

No

Picado 2010

Done

Not clear

Not clear

Not clear

Not clear

Not clear

Reyburn 2000

Done

Not clear

Not clear

Not clear

Done

No

Rojas 2006

Done

Not clear

Not clear

Not clear

Done

Yes

Leprosy

Cunha 2008

Done

Done

Done

Not done

Not done

Not clear

Moet 2008

Done

Done

Done

Done

Done

No

Included studies mainly focused on community based vector control measures like insecticide spraying and insecticide treated nets (ITN) for dengue, chagas and leishmaniasis; mass drug administration (MDA) for the prevention and treatment of leprosy and trachoma and SAFE strategy for trachoma. Two of the studies focused on removing affected dogs and using insecticide treated dog collars for preventing leishmaniasis [6, 7]. All the studies for dengue and chagas targeted general population, while two studies for leishmaniasis [6, 8], one for leprosy [9] and five from trachoma [1014] targeted children less than 15 years of age. Delivery mechanism in most of the studies was non-integrated except for two studies [8, 15] in which the intervention was integrated with primary health care (PHC). The primary comparison was between the CBI and routine facility based care or no intervention while, we also attempted to conduct subgroup analysis for the relative effectiveness of preventive and therapeutic drug administration and for the evidences from RCT and pre-post studies, where possible, and reported the results accordingly. Due to limited data we could not conduct an integrated versus non-integrated sub-group analysis. The results are summarized in Table 4.
Table 4

Results for overall and sub-group analysis according to type of study and treatment

Outcomes

Estimates (95% CI)

 
 

Combined

RCTs

Pre-post studies

Preventive

Therapeutic

Chagas

Peri-domiciliary Infestation Rate

0.77 [0.53, 1.14]

0.94 [0.67, 1.32]

0.17 [0.06, 0.48]

0.77 [0.53, 1.14]

No studies

8 datasets, 3 studies

4 datasets, 1 study

4 datasets, 2 studies

8 datasets, 3 studies

Domiciliary Infestation Rate

0.32 [0.19, 0.55]

No studies

0.32 [0.19, 0.55]

0.32 [0.19, 0.55]

No studies

4 datasets, 2 studies

 

4 datasets, 2 studies

4 datasets, 2 studies

Chagas Serology Rate (RR)

0.78 [0.61, 0.98]

No studies

0.78 [0.61, 0.98]

0.78 [0.61, 0.98]

No studies

4 datasets, 2 studies

4 datasets, 2 studies

4 datasets, 2 studies

Dengue

House Index

0.84 [0.81, 0.88]

No studies

0.84 [0.81, 0.88]

0.84 [0.81, 0.88]

No studies

9 datasets, 9 studies

9 datasets, 9 studies

9 datasets, 9 studies

Ovitrap Index

0.77 [0.64, 0.92]

No studies

0.77 [0.64, 0.92]

0.77 [0.64, 0.92]

No studies

5 datasets, 3 studies

5 datasets, 3 studies

5 datasets, 3 studies

Mean Bretreau Index (SMD)

−0.04 [−0.28, 0.19]

−0.04 [−0.28, 0.19]

No studies

−0.04 [−0.28, 0.19]

No studies

5 datasets, 2 studies

5 datasets, 2 studies

5 datasets, 2 studies

Dengue Positive Serostatus

0.31 [0.18, 0.53]

0.33 [0.18, 0.60]

0.14 [0.01, 1.62]

0.31 [0.18, 0.53]

No studies

4 datasets, 4 studies

2 datasets, 2 studies

2 datasets, 2 studies

4 datasets, 4 studies

Trachoma

Active Trachoma All Age Groups

0.24 [0.21, 0.26]

0.72 [0.59, 0.88]

0.15 [0.14, 0.17]

0.72 [0.59, 0.88]

0.15 [0.14, 0.17]

6 datasets, 3 studies

2 datasets, 1 study

4 datasets, 2 studies

2 datasets, 1 study

4 datasets, 2 studies

Active Trachoma in Children

0.67 [0.64, 0.69]

0.86 [0.83, 0.90]

0.38 [0.36, 0.40]

0.77 [0.74, 0.79]

0.32 [0.29, 0.35]

20 datasets, 14 studies

6 datasets, 4 studies

14 datasets, 9 studies

13 datasets, 8 studies

7 datasets, 6 studies

Chlamydia Trachomatic infection- All Age Groups

0.29 [0.27, 0.32]

0.28 [0.25, 0.31]

0.32 [0.27, 0.37]

0.28 [0.25, 0.31]

0.36 [0.29, 0.46]

10 datasets, 6 studies

5 datasets, 3 studies

5 datasets, 3 studies

7 datasets from 5 studies

3 datasets, 1 studies

Chlamydia Trachomatic infection in Children

0.21 [0.18, 0.24]

0.15 [0.13, 0.19]

0.42 [0.31, 0.55]

0.21 [0.18, 0.24]

No studies

9 datasets, 7 studies

6 datasets, 4 studies

3 datasets, 3 studies

9 datasets, 7 studies

Leishmaniasis

Incidence Cutaneous Leishmaniasis

0.42 [0.36, 0.49]

0.40 [0.32, 0.51]

0.43 [0.35, 0.53]

0.42 [0.36, 0.49]

No studies

9 datasets, 5 studies

5 datasets, 3 studies

4 datasets, 2 studies

9 datasets, 5 studies

Incidence of Visceral Leishmaniasis

0.93 [0.83, 1.04]

0.97 [0.84, 1.12]

0.87 [0.73, 1.04]

0.93 [0.83, 1.04]

No studies

4 datasets, 4 studies

2 datasets, 2 studies

2 datasets, 2 studies

4 datasets, 4 studies

Cure Rate for Cutaneous Leishmaniasis (RR)

0.92 [0.88, 0.96]

No studies

0.92 [0.88, 0.96]

No studies

0.92 [0.88, 0.96]

2 datasets, 2 studies

2 datasets, 2 studies

2 datasets, 2 studies

Leprosy

Leprosy Incidence

0.32 [0.30, 0.34]

0.67 [0.49, 0.92]

0.31 [0.29, 0.33]

0.32 [0.30, 0.34]

No studies

8 datasets, 5 studies

1 datasets, 1 studies

7 datasets, 4 studies

8 datasets, 5 studies

Leprosy detection rate

1.11 [1.02, 1.21]

No studies

1.11 [1.02, 1.21]

1.11 [1.02, 1.21]

No studies

 

2 datasets, 2 studies

 

2 datasets, 2 studies

2 datasets, 2 studies

 

Estimates in bold represents statistical significance.

Quantitative synthesis

CBI for dengue preventive measures including use of ITN and curtains significantly reduced dengue positive serostatus by 70% (RR: 0.30, 95% CI: 0.23, 0.38) while community education alone did not have a significant impact (Figure 2). Preventive community based education and cleanliness campaigns reduced ovitrap index by 25% (RR: 0.75, 95% CI: 0.62, 0.91). Insecticide spraying and aerosols significantly reduced house index by 10% (RR: 0.90, 95% CI: 0.86, 0.95) while preventive strategies utilizing guppies in water tank and growth of Chinese cat fish to consume larvae also had significant impact on reducing house index. Bednets and curtains had a non-significant impact however the studies reported spillover effects and non-suitable controls. Community education alone also did not have any impact.

For chagas disease, CBI including preventive insecticide spraying with housing improvement (ensure smooth, flat, and crack-free walls and ceiling surfaces and improving openings for ventilation and illumination) had a significant impact with a 68% reduction in domiciliary infestation rate (RR: 0.32, 95% CI: 0.19, 0.55) and a 22% reduction in serology (RR: 0.78, 95% CI: 0.61, 0.98) while it did not show any significant impact on peri-domiciliary infestation rate (Figure 3).

For leishmaniasis, CBI including ITN and curtains with education significantly reduced the incidence of cutaneous leishmaniasis by 58% (RR: 0.42, 95% CI: 0.36, 0.49) (Figure 4). Treatment with thermotherapy and radiofrequency resulted in significant 8% (RR: 0.92, 95% CI: 0.88, 0.96) reduction in cure rates of cutaneous leishmaniasis while interventions including surveillance, elimination of dogs, dog collars and ITN had non-significant impact on the incidence of visceral leishmaniasis.

For leprosy, treatment with MDA or rifampicin with community education resulted in a 68% reduction in the incidence of leprosy (RR: 0.32, 95% CI: 0.30, 0.34) (Figure 5) and 11% improvement in detection rate (RR: 1.11, 95% CI: 1.02, 1.21). One study evaluating the effect of revaccination of school children with BCG showed no impact on the incidence of leprosy.

CBI for trachoma treatment with SAFE strategy and Azithromycin along with community education on hygiene had significant reduction of 76% (RR: 0.24, 95% CI: 0.21, 0.26) (Figure 6) and 33% (RR: 0.67, 95% CI: 0.64, 0.69) in active trachoma among all age groups and children respectively. Chlamydia trachomatic infections also reduced by 71% (RR: 0.29, 95% CI: 0.27, 0.32) and 79% (RR: 0.21, 95% CI: 0.18, 0.24) among all age groups and children respectively. Subgroup analysis for the relative effectiveness of preventive and therapeutic drug administration and for the evidences from RCT and pre-post studies did not show any major differences.
Figure 2

Forest plot for the impact of CBI on dengue seropositive status.

Figure 3

Forest plot for the impact of CBI on chagas domiciliairy infestation rate and serology. a and b.

Figure 4

Forest plot for the impact of CBI on incidence of cutaneous leishmaniasis.

Figure 5

Forest plot for the impact of CBI on incidence of leprosy.

Figure 6

Forest plot for the impact of CBI on active trachoma (all ages).

Qualitative synthesis

Majority of the studies support that community delivered interventions have the potential to achieve wider coverage and sustained community acceptance [1619] with the combination approach having a more rapid and sustainable effect compared to individual interventions [14, 16]. The house-to-house strategy used for the distribution of drugs and commodities also assisted in improving coverage and consequently reducing active disease [14]. Studies also suggest that integrated delivery is more effective when compared to vertical interventions as vertical delivery covers a limited, high-risk population group [1618]. These integrated programs required strengthened communication and health education components along with broad social participation [17]. However, such integration was reported to be possible only because of the existing vertical vector control programs along with simultaneous strategic development of the infrastructure for improved water and sanitation [17, 19].

One of the major reported enabling factor in community directed programs included intersectoral cooperation involving close coordination between external organization, local municipality and the Ministry of Health [10, 17]. Another important aspect highlighted in the included studies was the fact that most of the vector control personnel were women from the same community accounting for very low refusals to enter the household premises [17]. To ensure sustainability and preventing future outbreaks, the programs trained a significant number of local human resources along with motivational tools for the continuation of control activities even after the study finished [17, 18]. Community involvement, knowledge and education were also highlighted as keys components associated with future sustainability as it encourages the community to continue the use of preventive measures [16, 1820]. It has been reported that conducting an educational campaign is an effective control measure compared to insecticide spraying because in the absence of education, sustainability cannot be ensured. School education has also been found to be an effective strategy [20, 21] as school children communicate with their parents about infection prevention measures and increase parental involvement in infection control., More specific messages about the change in behavior and environment need to be directed towards parents [20]. Involvement of children is postulated to promote behavior change in parents, as well as to introduce the children to the concepts of infection prevention at an early age [20]. Mass media and community-wide events should provide appropriate cues to practice specific behaviors on a routine basis and not just during epidemics, while constant positive feedback should be provided to those who are performing the target behaviors [20]. Community delivered programs could turn out to be more cost effective if all vector control tools were locally produced using locally available materials [16]. The low cost and simplicity of impregnated bed nets and curtains ensures their sustainable use in rural communities, given that local people recognize the dangers of vectors, and are amenable to the use of these commodities [22]. Some broader influencing factors included favorable political and sociocultural context that supports discussion of issues affecting health and wellbeing of individuals and community, acquisition of knowledge, and active community involvement in implementation of the program [19].

A few of the barriers reported to hinder effective program implementation and coverage included incomplete surveillance coverage, climatic conditions favorable to the vectors and lack of adequate and sustained community participation [17]. House-to-house larval surveys are typically plagued by difficulties of access, issues of acceptability, coverage and delivery, which frequently compromise the effectiveness of the available vector control tools [17]. For sustainability, surveillance for reintroduction of infectious diseases is necessary to ensure complete eradication [23, 24]. There is lack of new, more effective insecticide products that last longer along with the water coverage and storage issues [17]. Certain components of infection control programs require a change in the behaviors of all those at risk as well as the provision of clean water and sanitation. This area has been particularly challenging as change in behavior is slow and provision of water and latrines involves several other sectors and may be costly in resource limiting settings [14]. Maintenance of the hardware and certain health behaviors are also needed to derive health benefits from new housing initiatives [12]. Another important barrier to successful program implementation is the identification of neighborhoods at increased risk of infestation and transmission for developing more cost-effective, targeted control strategies [17]. Effective surveillance coverage of closed or vacant houses also remains to be addressed [18, 25].

Discussion

Findings from our review suggest that CBI including insecticide spraying; ITN and curtains; community education and cleanliness campaigns; chemoprophylaxis through MDA; and treatment have the potential to reduce the incidence and burden of non-helminthic NTDs. Figure 7 depicts the summary of evidence suggesting areas of benefit by disease. A range of CBI are effective in reducing positive serostatus, house index and ovitrap index for dengue, domiciliary infestation rates and serology for chagas, incidence and cure rates of cutaneous leishmaniasis, incidence and detection of leprosy, active trachoma and chlamydia trachomatic infections. Although some studies did not report significant impacts on Breteau index and peridomiciliary infestation rates but both indices have limitations when used to assess the quantitative impact of control interventions, partly because they are based on presence/absence of immature stages of the larval cycle and it is often difficult to show significant intervention effects on larval indices [17].
Figure 7

Summary of evidence suggesting areas of benefit according to disease.

Lack of data limited the subgroup analysis for integrated and non-integrated delivery strategies however, qualitative synthesis suggest that community delivered interventions with a combination approach have the potential to achieve wider coverage and sustained community acceptance. It also suggests that integrated delivery is more effective when compared to vertical interventions; however such integration requires pre-existing vertical vector control programs. We did not find any quantifiable data for buruli ulcer and African trypanosomiasis. These two diseases continue to pose great economic burden as the treatment costs for buruli ulcer often exceed per capita government spending on health [26]. Similarly for human African trypanosomiasis, approximately 300,000 cases are reported globally, with approximately 48,000 resulting deaths annually [27].

In January 2012, WHO published a roadmap setting targets for the prevention, control, elimination and eradication of all the NTDs; setting 6 targets for the elimination of 5 NTDs by 2015, and a further 10 targets by 2020, either globally or in selected geographical areas, for 9 NTDs. Since then progress has been made to increase coverage for the MDA. Essential preventive and control measures including community-based early detection, health education and MDA can be achieved through CHW training and capacity building [3]. These programs have been successful in increasing coverage by reaching larger populations without access to healthcare. An example is the control of African trypanosomiasis through active community screening coupled with passive screening at health-care facilities for infections. Much has been done since 2010, however still only 37% of the population in need is being provided with the desired treatment annually while 399 million school age children still in need of treatment [28, 29]. This calls for increased scale up of the mass drug campaigns utilizing community platforms to increase coverage. Although CBI are effective in reducing disease burden and improving coverage, there is a major gap in evidence for the effectiveness of integrated community delivered interventions. The major challenges faced include conflict, population growth, vector control, resistance to pesticides and medicines, lack of scale up capacity, lack of research and climate change.

Conclusion

Eradicating NTDs will require a multipronged approach and our review findings suggest that a range of CBI including drug administration, health education, cleanliness campaigns, vector control and clean water and sanitation facilities have the potential to prevent and control this set of diseases. This would require efforts to overcome the barriers to sustainable implementation including improved surveillance, access and coverage. High level governmental commitment along with strong partnerships among major stakeholders with continuous support by the WHO, United Nations Children’s Fund, World Food Programme and the World Bank, relevant national and international non-governmental organizations and key donors to mobilize resources. A major component of CBI should always be the community itself as success of existing NTD programs depends on community structures, customs, beliefs and values that keep community health worker proud and motivated.

Abbreviations

CBI: 

Community based interventions

CHW: 

Community health workers

HAT: 

Human African trypanosomiasis

IDoP: 

Infectious Diseases of Poverty

ITN: 

Insecticide Treated Nets

MDA: 

Mass drug administration

MeSH: 

Medical subject heading

NTD: 

Neglected tropical diseases

PHC: 

Primary health care

RCT: 

Randomized Controlled Trials

WHO: 

World health organization.

Declarations

Acknowledgements

The collection of scoping reviews in this special issue of Infectious Diseases of Poverty was commissioned by the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) in the context of a Contribution Agreement with the European Union for “Promoting research for improved community access to health interventions in Africa”.

Authors’ Affiliations

(1)
Division of Women & Child Health, The Aga Khan University
(2)
Brown University
(3)
Center of Excellence in Women & Child Health, The Aga Khan University
(4)
Center for Global Child Health, Hospital for Sick Children

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