Although preparations had been underway for weeks, there were now just 72 hours to go before the 2020 mass drug administration (MDA) treatment campaign for two neglected tropical diseases (NTDs)—lymphatic filariasis (LF) and onchocerciasis—would begin in the four geographic areas (called communes) of Ouinhi, Covè, Zagnanado, and Za-Kpota—and the tension was almost palpable. Already, a myriad of phone calls were exchanged by stakeholders working with USAID’s Act to End NTDs | West program in Benin, which was assisting thee campaign. Although the national NTD program (NTDP) had plenty of experience running MDA campaigns successfully, this one was different. The country was kicking it off just as the Ministry of Health (MOH) was launching a national response to the novel COVID-19 pandemic, after six people in the country had tested positive for the virus.
Already, Benin had begun to put restrictions in place, including prohibitions against gatherings of more than 50 people, recommending physical distancing, and restricting public movement into and out of 12 communes (districts) considered to be most at risk for coronavirus spread. Although the latter measure was meant to isolate people in at-risk districts from the rest of the country and thus, minimize disease spread, it complicated the ability of the NTD campaign supervisory and monitoring teams to travel to and from Ouinhi.
The sudden government restrictions were unsettling for certain segments of the population. Rumors began spreading through social media and elsewhere, exacerbating pandemic-related fears and feeding public mistrust. The most viral and dangerous of these, from an MDA perspective, was a rumor that other countries were supposedly sending anti-coronavirus vaccines and medicines to Africa that, instead of protecting people, were actually intended to wipe out entire populations or render them sterile.
It was clear that carrying out a mass treatment campaign was going to be a challenge. Even though they intended to distribute the NTD medicines free of charge to populations still at risk for LF (following a surveillance survey that showed transmission was ongoing), the NTDP would need to convince people to let go of their mistrust and take the medicines. Equally important, they would need to ensure the safety of both the public and their staff during an MDA conducted under extraordinary circumstances.
Four pillars of mass treatment for NTDs in the COVID-19 context
The NTDP and its partners consulted with other units in the MOH as well as medical professionals, public health experts and stakeholders before making the decision to go ahead with the MDA in March 2020. They identified four strategic pillars necessary for MDA in the COVID-19 context: comprehensive coordination, training adaptations, social mobilization with rumor management, and enhanced supervision.
Coordination and leadership
Effective coordination and leadership are crucial to the success of any NTD mass treatment campaign. The NTDP team and partners needed to consider so many additional unfamiliar factors as they adapted to the changing situation, making many critical decisions in the process. Through daily virtual meetings between FHI 360’s Act to End NTDs | West (Act | West) program in Benin and Washington, DC, the national NTDP coordinator, and the director of public health of Zou Department, the team successfully complied with COVID-19 pandemic requirements and decrees from the Government of Benin.
After extensive consultations with the MOH and community leaders and implementing special safety and precautionary measures to protect field staff, supervisors, and community members, the NTDP team and partners went ahead with the MDA. Three important considerations that contributed to the decision to go ahead were:
- This particular MDA would be localized to just four contiguous districts that had shown evidence of ongoing transmission of lymphatic filariasis.
- The four targeted communes were located outside the restricted access zone (known as the cordon sanitaire) that the MOH had put in place in response to the COVID-19 pandemic; the risk of transmission was considered to be relatively low in those communes.
- The NTD medicines would be delivered door-to-door during this MDA; thus, the campaign would not require public gatherings.
The team quickly adapted both the physical training environment and the curriculum content to fully address the new challenges. In the past, training was “cascaded” from national level trainers to head nurses to community distributors at the health district and municipality levels, which used to mean delivering training to relatively large groups of people simultaneously. However, new physical distancing procedures brought by COVID-19 weren’t compatible with classroom-style training settings; instead, the team divided the trainees into smaller groups in multiple rooms and installed handwashing devices at each site to enable the trainers and trainees to practice safe hygiene.
The training curriculum was also revised to address topics related to COVID-19 and include key messages to help health workers address confusing pandemic-related rumors that threatened to interfere with the MDA. Community drug distributor (CDD)-trainees roleplayed various situations and incidents and practiced well-constructed arguments to convince the community that taking the NTD medicines was safe, necessary, and in their best interest.
CDDs were trained to strictly follow prescribed hygiene measures (e.g., using handwashing kits at each household and using the lid of the bottle or a clean spoon to provide the NTD medicines) and to practice safe physical distancing (e.g., avoiding handshakes and maintaining 1 meter of distance between themselves and others) throughout the MDA.
In all, 32 head nurses and over 500 CDDs were trained for the March 2020 NTD mass treatment using the revised curriculum and adapted COVID-19-related safety and hygiene measures.
Sensitization meetings were held with 384 village chiefs and town criers to reassure them about the safety of the NTD drugs, address their concerns, learn about the rumors that were circulating in each community, devise strategies to manage those rumors, and discuss roles and responsibilities for the upcoming MDA.
Town criers were given announcements and messages about the MDA to disseminate in each community. The NTDP team also recruited 64 Red Cross volunteers to go door-to-door in the communities before the start of the campaign, reinforcing the town criers’ and chiefs’ social mobilization efforts. For three days, volunteers travelled through the villages in pairs, providing information on the targeted diseases, including how they spread, how to prevent them, and how to treat and minimize complications in people who have the diseases.
The home visits by the Red Cross volunteers helped to reassure people about the safety of the NTD medicines and provided an opportunity to address their questions. They also helped to prepare families for the CDDs’ visits and dispel any confusion by reminding people that the medicines that would be provided were the very same ones they took every year to prevent NTDs. The volunteers were careful to clarify that NTD medicines were totally unrelated to the new coronavirus—they would neither make people more likely to get COVID-19 (one of the false rumors that had been circulating) nor would they prevent or cure it.
In addition to all the face-to-face efforts, local health teams also used radio programs to underscore the message that NTD mass treatment was completely unrelated to COVID-19. Local doctors were interviewed and each repeated this same basic message to further reassure people living in their communes about the safety of taking NTD medicines. Informative public service announcements were also aired in local languages on local radio and television channels to help further prepare the communities for the upcoming MDA.
Due to government travel restrictions, the NTDP devised a new supervision strategy for the mass treatment campaign, reducing traditional three-person teams to single supervisors. These supervisors were supplemented by the presence of local head nurses and doctors ready to respond quickly if any COVID-19 cases were detected. These nurses and doctors were also available to monitor the work of the CDDs during the MDA.
The plainly visible, close supervision by local doctors and nurses helped curb fears among the community members, as they were able to answer questions, reinforce the messaging, and provide additional reassurance.
Mass treatment results
The NTDP launched Benin’s March 2020 MDA in the four communes, which lasted 12 days and without incident. The recruitment of the Red Cross volunteers, local nurses and doctors and the use of additional media coverage had positive impacts. In Ouinhi, in particular, community members who were influenced by rumors and fiercely opposed health interventions reported feeling reassured when they saw the medicines and realized that they were indeed the same ones they had received during previous MDAs.
Thanks to the coordinated planning and preparation on the part of the national NTDP and partners, preliminary results show that Benin’s 2020 MDA achieved a range of 84% to 88% of treatment targets across the four communes, despite the very unique circumstances and challenges. Because the NTDP was able to adapt to the unique circumstances and deliver NTD medicines on schedule to most of the people who needed them, Benin remains on track to eliminate LF nationally by 2025.