Module 2. NTD Strategies - World Health Organization · Module 2. NTD Strategies Session 2. Preventive Chemotherapy Strategy What Is Preventive Chemotherapy (PC)? • Preventive chemotherapy

PROGRAMME MANAGERS’ TRAINING COURSE FOR NTDS TARGETED FOR CONTROL OR ELIMINATION BY PREVENTIVE CHEMOTHERAPY INTERVENTIONS


Module 2. NTD Strategies

Session 2. Preventive Chemotherapy Strategy


Module 2. NTD StrategiesSession 2. Preventive Chemotherapy Strategy

Overview

• What is preventive chemotherapy (PC)?

• Why PC is important?

• Where more than 1 disease is prevalent, how can we optimize resource use for PC delivery?

• Stepwise approach for decision-making in PC

• What could be challenges of PC?

• Key messages

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What is preventive chemotherapy (PC)?

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What Is Preventive Chemotherapy (PC)?

• Preventive chemotherapy (PC) is a public health intervention based on the large-scale administration of safe drugs, either alone or in combination, against selected Neglected Tropical Diseases.

• PC is recommended by WHO as one of the key public health interventions for:

*Clonorchiasis and opisthorchiasis

LF FBT* Schisto STH Trachoma Oncho

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What Is Preventive Chemotherapy (PC)?

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Medicine

Target age group

*Clonorchiasis and opistorchiasis

LF FBT* Schisto STH Trachoma Oncho

ALB + IVE or DEC

PZQ PZQALBor

MBDAZM IVE

Entire population

Entire population

SAC and at-risk adults

PRE SAC and SAC

Entire population

Entire population



Why is PC important?

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When PC is delivered with effective medicines, with high coverage at regular interval, it can reduce overall parasite/bacterial load and reduce/interrupttransmission of the targeted NTDs in entire communities.

When PC is given early in life, it can prevent development of chronic consequences of morbidity related to these infections and improve health, education, economic status and social well being of affected communities.

This PC approach is an essential component of the strategy for sustained reduction of transmission and ultimately elimination of LF, onchocerciasis, schistosomiasis and trachoma.

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Where more than 1 disease is prevalent, how can we optimize resource use for PC delivery?

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Integrating Treatment For Multiple Diseases as a PackageBecause target age groups overlap among different diseases, medicines can be delivered as a package together to the same target population.

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NTD MedicinePre-SAC

(2 - 5 yr old)SAC

(5 - 14 year old)Adults

(>15 yr old)

LF DEC + ALB X X X

Oncho IVE X X

STH ALB or MBD X X

Schistosomiasis PZQ X X (only at-risk adults)

Clonorchiasis,Opistorchiasis

PZQ X X

Trachoma AZM X X X



Integrating PC-related Activities Across Different Disease ProgrammesBecause most of activities are common among different disease programmes, they can be delivered together for multiple diseases.

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Activities LF STH SCH FBT TRA

Advocacy √ √ √ √ √

Mapping √ √ √ √ √

Training √ √ √ √ √

Social mobilization √ √ √ √ √

Drug logistics √ √ √ √ √

Drug distribution Pre-SAC √ √ √

SAC √ √ √ √ √

Adults √ (√) √ √ √

M&E √ √ √ √ √

Coordination for other

interventions

Vector control √ √ √

Water and sanitation √ √ √ √ √

Case management √ √ √ √



Stepwise Approach For Decision-making in PC

1. Define distribution of NTDs and their overlap.

2. Review the WHO treatment threshold for PC by disease.

3. Apply PC algorithm.

4. Review target population and exclusion criteria.

5. Consider potential distribution channels.

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LF and STH ++

LF and STH ++ and

SCH

Example: Cambodia data, 2008

1. Define Distribution of NTDs and Their Overlaps

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• How to use medicines in combinations

• To whom can the drug package be given

• Use in pregnancy and children

• Recommended drug dosages

• How to monitor coverage

• Include standardized village/district recording forms and dose poles as annexes

ONCHO STH SCHLF

2. Review the WHO Treatment Strategy For PC By Disease

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WHO Treatment Strategy For PC

DiseaseTreatment threshold inprevalence of infection

Targeted age group of treatment

Frequency of treatment

LF >1% Total population Once a year

STH>50%*

Pre-SAC and SACTwice a year

>20% but <50%* Once a year

Schistosomiasis

>50% *SAC and at-risk adults

Once a year

>10% but <50% * Once in 2 years

<10% * SACTwice during their primary schooling age

Clonorchiasis,Opistorchiasis

>20%SAC and adults

Once a year5-20% Once in 2 years

Trachoma >10% (TF in 1-9 yr old children) Total population Once a year

*Prevalence of infection in school-age childrenTF = trachomatous inflammation-follicular

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3. Apply PC Algorithm(where LF requires MDA in ONCHO non endemic area)

MDA2 DEC + ALB

T1 ALB/MBD + PZQ (6 months after round 1)

T2 PZQ (at least 1 week after round 1)

T3 ALB/MBD (6 months after round 1)

LF +

STH ++ STH + STH -

PC round 1

PC round 2 T1

SCH -

STH ++ STH + STH -

T2 T2 T3

MDA2 MDA2 MDA2 MDA2 MDA2 MDA2

SCH +

Add MDA with Azithromycin (at least 2 weeks before or after any round) where trachoma is also co-endemic.

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T1 ALB/MBD + PZQ (6 months after round 1)

T2 PZQ (at least 1 week after round 1)

T3 ALB/MBD (6 months after round 1)

3. Apply PC Algorithm(where LF does not require MDA)

LF -

STH ++ STH + STH -

PC round 1

PC round 2 T3

SCH -

STH ++ STH + STH -

T3

T1 T1 T2 T3 T3

SCH +

No action

required

Add MDA with Azithromycin (at least 2 weeks before or after any round) where trachoma is also co-endemic.

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LF and STH ++

LF and STH ++ and SCH


PC Strategy– Round 1

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LF and STH ++

LF and STH ++ and SCH


PC Strategy– Round 2

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PC type Medicine Target population Ineligibility

MDA2 DEC + ALBEntire population in areas of LF transmission

Pregnant women, women within a week post-partum, children <90cm tall and the severely ill/very elderly

T1PZQ + ALB/MBD

PZQ: SAC and ‘at-risk’ adultsALB/MBD: PSC, SAC, ‘at-risk’ adults, WCBA including 2nd and 3rd Trimesters

PZQ: Children <94 cm (but can be treated in medical settings)ALB/MBD: Children <1 year old, Pregnant women in 1st trimester

T2 PZQ SAC and ‘at-risk’ adultsChildren <94 cm (but can be treated in medical settings)

T3 ALB/MBDPSC, SAC, ‘at-risk’ adults, WCBA including 2nd and 3rd Trimesters

Children <1 year old, Pregnant women in 1st trimester

Cs, Ov* PZQ SAC and adults Same as above

Trachoma AzithromycinEntire population in areas of trachoma transmission

Children under 6 months of age**, the severely ill, those with history of previous severe adverse events

**For children under 6 months of age, tetracycline eye ointment should be given instead.*Cs: Clonorchiasis, Ov: opistorchiasis

4. Review Target Population and Exclusion Criteria

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Suggested PC Treatment Schedule for Multiple Diseases

Target diseases Week 1 Week 2 Week 3 Week 4 Week 5 Week 6 … 6 months

LF + STHDEC/IVM

+ ALBALB

LF + STH + SCHDEC/IVM

+ ALBPZQ ALB

LF + SCHDEC/IVM

+ ALBPZQ

STH + SCH PZQ + ALB ALB

LF + STH + TRADEC/IVM

+ ALBAZM ALB

LF + STH + SCH + TRA

DEC/IVM+ ALB

PZQ AZM ALB

LF + SCH + TRADEC/IVM

+ ALBPZQ AZM

STH + SCH + TRA PZQ + ALB AZM

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Potential programmes Pre-SAC SAC Adults

School health programme X

School feeding programme X

Child health day X X

Vaccination campaigns X

Vitamin A supplementation X X

Deworming in ante-natal clinics X X

ITN distribution X X

Is there any existing programmes/campaigns that can be integrated with PC drug distribution?

5. Consider Potential Distribution Channels

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What could be challenges of PC?

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Challenges of PC – Logistics and Cost of Drug Delivery• PC needs to cover as many people in

need as possible.

• PC should be provided free of charge to the people in need.– Medicines are donated via WHO free of

charge.

– Explore the best delivery drug packages and channels to the communities in need by integration/coordination with other programmes.

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Cost breakdown of anthelminthic treatment in 6 districts in Uganda, 2003-5



Challenges of PC - Safety Issues (Module 5)

• Adverse events (AEs)– PC drugs have excellent safety records regardless of infection status, but

– Communities must be made aware of mild AEs that may accompany PC.

• Serious Adverse Events (SAEs)– Health workers should be trained to recognize, report and manage SAEs.

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Activities need to be planned with all relevant programmes together, at the beginning of the year, district by district

Challenges of PC – Integration and Coordination With Other Programmes

Activities LF STH SCH FBT TRA

Advocacy √ √ √ √ √

Mapping √ √ √ √ √

Training √ √ √ √ √

Social mobilization √ √ √ √ √

Drug logistics √ √ √ √ √

Drug distribution Community-based √ √ √

School-based √ √ √

Child health day √ √ √

Immunization √ √

Health and nutrition day √ √ √

M&E √ √ √ √ √

Coordination for other

interventions

Vector control √ √ √

Water and sanitation √ √ √ √ √

Case management √ √ √ √

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ADVOCACY

PC Challenges – Coordination With Many Partners

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PC Challenges – Coordination With Many Partners

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Other Partnerships:

http://www.dorseyengineering.com/CDC_Logo.jpg

http://www.dorseyengineering.com/CDC_Logo.jpg



What do you think are the key messages from this session?

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Key Messages

• PC is a public health intervention aimed at controlling morbidity and transmission of targeted NTDs.

• PC focuses on regular delivery of drug packages to as many people in need.

• PC challenges NTD programme managers to i) integrate and coordinate between disease specific programmes and partners, ii) procure sufficient quantities of quality drugs, to implement drug distribution with good coverage in the most cost-effective way, iii) monitor and ensure drug safety.

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Documents

Module 2. NTD Strategies - World Health Organization · Module 2. NTD Strategies Session 2. Preventive Chemotherapy Strategy What Is Preventive Chemotherapy (PC)? • Preventive chemotherapy