Building Back Better – a new hybrid approach to neglected tropical diseases in the COVID-19 era


COVID-19 established its foothold in Africa in April 2020. The World Health Organization (WHO) issued interim guidance which encouraged neglected tropical disease (NTD) elimination programs to temporarily suspend community-based activities where COVID-19 transmission had begun.

Governments responded and interventions, including population-based surveys, mass drug administration (MDA), and active case finding, were soon suspended. This was important action during a period of great uncertainty. But as time passed people began wondering when NTD activities would resume. We wondered what kind of changes would be needed to ensure the safety of health workers and communities, and to get us back on schedule in terms of working towards elimination targets for diseases such as trachoma, river blindness, lymphatic filariasis and schistosomiasis.

Early in the pandemic we began working with donors and governments to re-prioritize funding and assist their COVID-19 response plans. This included strengthening COVID-19 prevention messaging and training health workers to assist in the track and tracing and referral of suspected cases.

This ‘COVID-flex’ approach is playing a key part in the efforts to prevent local transmission from spreading in Africa, and is also helping to secure the conditions that lead to the safe resumption of community-based NTD activities. Community-based work is recognized as one of the most cost-effective ways to counter misinformation. Where risks can be mitigated, reengaging NTD community health workers and supervisors will not only help ensure NTD elimination goals are met, it will also help combat new COVID-19 infections through a new hybrid approach of mutual benefit.

This is one of the reasons that with our collaborating partners we began to investigate processes and tools that could objectively evaluate the risk of spreading COVID-19. Importantly the tools needed to facilitate discussions on the practical precautionary measures national NTD programs would need to adopt once their governments determined that activities could resume.

What we developed was an adaptation of an excel-based risk assessment tool the World Health Organization (WHO) created for mass religious gatherings, which followed the recommended framework for conducting rapid risk assessment of acute public health events. A generic version of the WHO tool can be found here. After piloting several versions, we eventually arrived at three separate excel-based tools (in French and English) for NTD program managers to use with partners. They became known as the risk assessment and mitigation action (RAMA) tools – one for treatment distributions, a second for disease specific surveys, and a third for case finding and surgical outreach for trichiasis and hydrocele.

These tools have now become part of a more comprehensive 5-step process, which includes a review of the COVID-19 epidemiologic trends and budget requirements to support the proposed mitigation strategies. The RAMA tools were designed to complement and provide a structure for government programs to adopt additional interim guidance published by WHO in July for the resumption of NTD activities in the context of COVID-19. For example, the RAMA tools help NTD program managers document and verify the command and control structure that will monitor the COVID-19 epidemiology overtime, reconfirm the risk communication strategy that will involve community leaders in the planning of NTD activities, and enable independent technical advisors to evaluate the written standard operating procedures (SOPs) for how activities will be modified.

Such an approach complements our overall aim to strengthen health systems, facilitate integration and cross sector collaboration, and “build back better”. It provides opportunities to strengthen integrated disease surveillance, improve the capacity of local supervisors to manage public health interventions, and facilitate the introduction of electronic data capture platforms to assist supervisors in ensuring what is planned is actually implemented.

Community and school-based platforms pioneered by the NTD program for the scale-up of MDA are increasingly playing an important role in integrated disease surveillance and promotion of intensified handwashing practices, sanitation and safe water provision; these are compatible health messages and activities that will help reduce transmission of both COVID-19 and NTDs.

Having initiated ‘COVID-19 Flex’ in endemic countries we are better informed about the new context within which NTD interventions will reside.  One of the principles of public health and medicine is to “do no harm” and “leave no-one behind” and these tenets are jeopardised by a failure to resume the distribution of NTD treatments and morbidity management services. Both platforms have the ability to enhance a country response to the COVID-19 pandemic.

So, as we work to help reinstate government NTD programs, the challenge is to be even more innovative. While we fight COVID-19 and aim to preserving NTD gains, there is potential to accelerate the interruption of NTDs and shorten the time frame for achieving elimination.

About the author 

Philip Downs is the Technical Director for Neglected Tropical Diseases, Sightsavers, United States.

Competing Interests

The  author is Technical Director  for the program. No other competing interests to declare


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