Treating schistosomiasis and parasitic worm infections in Malawi during COVID-19

Resuming mass drug administration in Malawi

At the end of July, the Ministry of Health in Malawi delivered a treatment campaign for schistosomiasis in three districts, marking the resumption of the country’s activities for the control and elimination of neglected tropical diseases (NTDs) in the context of the COVID-19 pandemic. We spoke to Lazarus Juziwelo, the National Programme Manager for schistosomiasis and STH (soil-transmitted helminths) within the Ministry, to find out more.

Malawi, widely known as ‘the warm heart of Africa’, is a landlocked country in south-eastern Africa with a population of 17.5 million. Onchocerciasis, schistosomiasis, soil-transmitted helminths and trachoma are all prevalent in Malawi, and the World Health Organization estimates that 11,435,030 people in Malawi require treatment using tablets for at least one of these NTDs.

Schistosomiasis affects all 29 districts in the country, and with support from SCI Foundation, the Ministry of Health has been implementing national-scale annual treatment for schistosomiasis and STH since 2012. Usually, this would happen in the first half of the year, ideally before the long school holidays start in July. However, with travel restrictions and closure of schools due to the pandemic, the situation was complicated.

While recognising the seriousness of the pandemic, Lazarus Juziwelo knew that the morbidity associated with schistosomiasis does not go away. There were also concerns that, with schools closed, children may be engaging in behaviours which put them at greater risk of infection (such as swimming or playing in contaminated surface water). The team also wanted to make sure the quantity of praziquantel tablets left over from a previous mass drug administration could be distributed before they expired in July and August.

The risks of mass drug administration during COVID-19

With this in mind, the MoH undertook an assessment to fully understand the risks of undertaking MDA in the context of COVID-19, and prepared new standard operating procedures to outline mitigation measures for each stage including preparation, training, actual drug distribution, and reporting. A decision was made to implement an interim MDA in three districts, which would be an opportunity to pilot this new approach to treatment and could provide lessons for a larger MDA to take place later in the year.

Lazarus Juziwelo explained: “During the MDA, the community was able to understand the new approach, which provided a platform for HSAs and parents to discuss some challenges like adverse events following drug treatment. The community observed that most children were reacting during school based MDA because they were taking drugs on an empty stomach, having walked a long distance to school. It was also observed that it was very easy to track defaulters (those registered to receive treatment but who were deliberately absent on the day) since the event was conducted within village premises.

Importantly, the Covid-19 precautionary measures were followed beyond the expectation of the organisers. It is expected that such approaches will be scaled up to all districts as the country plans to conduct a country-wide MDA using a community based approach.”

New training for health workers, new PPE, new hygiene measures

In planning for the MDA, the National Programme worked closely with the Epidemiology and COVID-19 Response teams within the MoH, as well as with the Health Education and Logistics teams. With schools closed, the programme shifted to a fully community-based distribution platform, to be implemented by Health Surveillance Assistants (a cadre of health workers responsible for implementing community-level health interventions) and community volunteers.

It was agreed that masks and hand sanitisers needed to be made available to all personnel involved in drug distribution, and materials would be provided for hand washing stations to be set up in communities when treatment was taking place. The MDA would also be used as an opportunity for HSAs to raise awareness and disseminate messages about COVID-19 prevention in their communities.

The MDA was not without its challenges. HSAs needed to be trained on the new approach and get to grips with new tools for registration and reporting of treatment, and there was also a need for more intensified supervision. Calculating the requirements and arranging the logistics for personal protective equipment was also a new task for the programme.

Long term benefits to new ways of working

Ultimately, however, these steps helped to ensure treatments could be delivered safely. Mr Juziwelo also anticipates that there will be longer-term benefits: For example, the new approach to MDA provided an opportunity to increase community engagement on COVID-19, and as a result of the integrated training and materials provided to support the MDA, the programme believes health workers and health teams in those districts are now better equipped to respond to COVID-19 through their community interventions.