Ahorlu et al. BMC Infectious Diseases (2022) 22:106 https://doi.org/10.1186/s12879-022-07084-0 RESEARCH Open Access COVID-19 related perception among some community members and frontline healthcare providers for NTD control in Ghana Collins S. Ahorlu1*, Daniel Okyere1, Sellasie Pi‑Bansa2, Joseph Otchere2, Benjamin Marfo3, Kofi Asemanyi‑Mensah3, Joseph L. Opare3, Elizabeth F. Long4 and Dziedzom K. de Souza2 Abstract Introduction: The Coronavirus Disease 2019 (COVID‑19) pandemic has resulted in a major breakdown of health service provision in the fight against neglected tropical diseases (NTDs). COVID‑19 may impact NTDs service delivery in varied ways. As the Ghana NTD programme planned to resume MDA activities, we examined the COVID‑19 related perceptions and practices among some community members and frontline health workers for NTD control activities in the country. Methods: The study was conducted in seven communities in the Ahanta West district of Ghana. This was a qualita‑ tive study using in‑depth interviews (IDI) and focus group discussions (FGDs) for data collection. Participants were purposively selected from varied backgrounds to represent both beneficiaries and service providers directly involved in NTD programme implementation. Trained and experienced qualitative data collectors conducted the FGD and IDI sessions in the local Twi language, while health worker sessions were conducted in English. Discussions were audio‑ recorded and transcribed directly into English. Data was analysed using an iterative process. The transcripts were pre‑ coded using the broad themes, entered into a computer using Microsoft Word, and then imported into the MAXQDA software for thematic content analysis to select relevant representative narratives for presentation. Results: Participants were aware of the COVID‑19 pandemic and referred to it appropriately as ‘coronavirus’, COVID‑ 19, and often as ‘the new disease’. Though many respondents could not describe the route of transmission, most of them reported that it is transmitted through touch or sharing of common items. They reported some signs/symp‑ toms like fever, headache and difficulty breathing, and prevention methods like the use of hand sanitiser, washing of hands and sneezing appropriately. Respondents have reported that COVID‑19 has negatively affected their daily lives by limiting their movements and therefore work. It also came to light that COVID‑19 has also negatively affected the NTD programme implementation, especially mass drug administration (MDA) activities, leading to the postponement of the yearly MDA. The COVID‑19 pandemic has negatively affected clinic attendance; people are afraid that they may be tested for COVID‑19 at the clinic. *Correspondence: cahorlu@noguchi.ug.edu.gh 1 Epidemiology Department, Noguchi Memorial Institute for Medical Research, College of Health Sciences, University of Ghana, Legon, Accra, Ghana Full list of author information is available at the end of the article © The Author(s) 2022. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http:// creat ivecom mons. org/l icen ses/ by/4.0 /. The Creative Commons Public Domain Dedication waiver (http:// creat iveco mmons.o rg/ publi cdomai n/ zero/1. 0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Ahorlu et al. BMC Infectious Diseases (2022) 22:106 Page 2 of 12 Conclusion: COVID‑19 has negatively affected the NTD programme. Education and the provision of personal protective equipment will be required to build the confidence of frontline care providers including community drug distributors and community members in order to enhance quality service and participation in future MDA activities. Introduction In April 2020, the WHO issued an interim guidance on Neglected Tropical Diseases (NTDs) are communica- the conduct of NTD activities, effectively suspending all ble diseases that affect the bottom 1 billion people who NTD activities, except those requiring ongoing patient are also the most marginalised in society [1]. Lymphatic management [14]. In Ghana, the government banned filariasis (LF) is one of the neglected tropical diseases travel, gatherings, and school activities on 15th March (NTDs) targeted for elimination by the World Health 2020, followed by a partial lockdown in Accra, Kumasi, Organization (WHO) as a public health problem. In the and Kasoa, the main hotspots fuelling transmission. year 2000, the Global Programme to Eliminate Lym- However, the government started to ease restrictions phatic Filariasis (GPELF) was set up with the aim to on 31st May 2020. While the Ghana NTD programme eliminate the disease by the year 2020 by implement- planned to resume mass drug administration (MDA) ing two main strategies: (i) interrupting the transmis- activities, we looked at the perception of some commu- sion of the disease through yearly treatment of the nity members and health workers at the forefront of NTD entire endemic communities [2, 3] and (ii) alleviating control activities in Ghana. The aim is to understand the the suffering associated with LF morbidity and disabil- effect of COVID-19 on NTD interventions, especially the ity [4]. The drugs of choice for the MDA were either annual mass drug administration (MDA) for lymphatic the combination therapy of albendazole together with filariasis (LF) elimination, giving that MDA was not ivermectin and or diethylcarbamazine, depending on implemented in 2020 due the pandemic. The question the geographic setting and co-endemicity with diseases then is, how will the pandemic related restrictions and such as onchocerciasis and loa loa [5]. the availability and use of PPE affect MDA implementa- Ghana is endemic for several neglected tropical dis- tion and participation, when it resumes? Understanding eases; however, the focus of this paper is on LF, which these issues may help the program to take steps to ensure is endemic in 98/216 districts. Since 2001 the country a successful resumption of MDA activities in this hotspot has implemented the GPELF strategy, with significant district. progress made in the control of the disease [6]. There are challenges to the elimination programme, which is evident in the fact that, despite several years of MDA, Methods transmission persists in 17 of 98 endemic districts [7], Study sites a phenomenon that has given such districts the title of Data were collected in September 2020 in the Ahanta “hotspots”. It thus, appears that the country is not able West district of Ghana, an area with persistent trans- to attain optimum treatment coverage [8] and this situ- mission of lymphatic filariasis (LF) [15]. The district is ation is likely to be imparted by the COVID-19 pan- inhabited mainly by the Ahanta speaking people belong- demic, which has stalled MDA activity in 2020. ing to Ghana’s larger Twi speaking group. Farming and The Coronavirus Disease 2019 (COVID-19) pandemic fishing are the main occupations of the people. How- has resulted in a significant breakdown of health ser- ever, small scale mining and trading also employeds vice provision in the fight against NTDs [9]. The World many residents. Ghana’s budding oil industry is partly Health Organization (WHO) recently launched a new located off the shores of the district. The Ahanta West roadmap targeting the control and elimination of NTDs district started MDA implementation in 2002 and there- by 2030 [10]. The potential impact of COVID-19 on fore has received more than 16 rounds of MDA without delaying the attainment of the 2030 control and elimi- interruption of transmission [15]. For this study, a com- nation goals include shortfall in funding and political munity was randomly selected from each of the seven commitment, challenges with NTD service delivery as subdistricts forming the district. All communities with a result of the diversion of human capital, and impact of a health facility in each subdistrict were numbered, put social mobilisation and community acceptance of inter- in a bowl, and picked to represent the subdistrict. Select- ventions post-COVID-19 [11]. Other potential impacts ing a community in each subdistrict ensured that the include the resurgence of infections [12] and supply selected communities were spread across the entire dis- chain disruptions for essential diagnostics [13]. trict. The subdistricts are the local health administration units within the Ghana Health Service structure in a dis- trict, whose demarcation is usually based on promoting A horlu et al. BMC Infectious Diseases (2022) 22:106 Page 3 of 12 the geographical accessibility of health services within a Also, the CHNs were purposively selected from each of district. the six subdistrict level health facilities with the support of the facility-in-charge, taking into consideration their Study design prior involvements in MDA activities. The CDDs were This qualitative study used in-depth interviews (IDI) selected from the list of CDDs made available by the dis- and focus group discussions (FGDs) for data collection. trict health directorate using a simple random sampling This study design was chosen for this study because of technique. Using a simple random sampling technique, the need to collect quick and probing information from community members, aged 18–60  years, were selected frontline healthcare workers and community members from community-based registers of the six communities. for quick decision making to inform the resumption of The FGD participants were selected based on age and MDA activities. sex, these variables are considered to influence free and natural discussion in rural Ghana [16], hence the need Community entry to group participants into three age groups to reduce Prior to the initiation of data collection, the study team the age gaps among participant in each session. This informed regional, district, and health facility officials of promotes effective interactions among participants with the Ghana Health Service (GHS) about the study objec- very little or no age limitations. To follow the national tives, methods, and timeline. Upon arrival in each com- COVID-19 protocols, we limited FGD participants to six munity, the study team met the officials of the subdistrict per session. The FGDs allowed us to gain divergent view- health facilities, briefed them about the study and what points as well as consensus positions among participants is expected of them. The health center officials then while the IDI allowed individuals, space to share their facilitated meetings with local leaders and locally elected experiences and perceptions on COVID-19 in the context assembly members. After gaining the support of commu- of MDA activities in the district. Information solicited nity leaders, the team, assisted by community-based vol- included: knowledge on the COVID-19 pandemic, its unteers and an officer of the district health management transmission, symptoms, impact on NTD programmes, team, recruited study participants (Additional file 1). and attendance to health facilities. Other topics included the willingness to participate in NTD programmes Data collection (mainly mass drug administrations) during the COVID- All participants and data collectors were dressed in 19 pandemic, other health delivery services, community appropriate Personal Protective Equipment (PPE) and members’ perception on PPE use, and whether the NTD kept acceptable physical distancing. Trained and expe- programme should continue with its activities during and rienced qualitative data collectors conducted the FGDs post COVID-19. and IDI sessions in the local Twi language; health work- ers were interviewed in English. A moderator, note taker, Data analysis and supervisor facilitated each FGD. The moderator fol- Data were analysed using an iterative process, beginning lowed a semi-structured discussion guide, developed with the first interview, and continuing throughout data around key themes of interest. Each FGD session lasted collection via daily debriefings where data and emergent approximately 60 to 90 min while the in-depth interview themes were reviewed. The dialogues were transcribed sessions lasted 30–45  min. The discussions were audio directly into English and entered into a computer using recorded and transcribed directly into English on an on- Microsoft Word, which was then imported into MAX- going basis (the recorded audio was transcribed directly QDA software for qualitative data analysis. The thematic into English because it was established during pre-testing categories were developed based on the issues for the that transcribing directly into English was faster and con- study and were operationalized by the question guides vey the best meaning of what was said in the local Twi used for data collection. During analysis, we developed language than first transcribing into the local Twi lan- themes as attributes, descriptors, or concepts that are guage before translating it into English language). Follow- explicit for organizing a group of related ideas that enable ing each day’s work, the study teams debriefed to identify us to answer the study questions. Then, related issues that emerging themes that required further probing and to have a common point of reference were coded to gener- ensure data quality from the field. A supervisor routinely ally unify ideas regarding the subject of our investigation reviewed all English translations and provided continu- [17–21]. The coded segments or narratives were catego- ous feedback to the data collection team. rised for deductive content analysis to select a represent- Participants were selected variedly as follows: There ative and relevant responses that represented majority were only two district level disease control officers, and and minority views for presentation. Coding was carried both were purposively selected to participate in the study. out using predetermined themes based on the research Ahorlu et al. BMC Infectious Diseases (2022) 22:106 Page 4 of 12 questions and key areas of interest [20]. A codebook was in the FGD sessions with equal numbers of males and developed and refined by the first author as the analy- females. sis progressed. All transcripts were coded by the second author and reviewed by the first and last authors. Knowledge of NTD / MDA programmes The reliability of the qualitative data collected was The respondents had knowledge of MDA activities in the ensured by first pretesting the tools among similar pop- communities. Respondents mentioned drug distributions ulations. This also help to ensure that the tools were and how the heights of community members are meas- understood consistently across respondents. Findings ured before drugs are given to them. This can be seen in from the pretesting was used to refine the tool before the representative narrative below: commencement of final data collection. Secondly, the recorded audios were transcribed by the same person, “It’s very true, they usually bring drugs to share for but four audios—2 each of FGDs and IDIs were unani- all in the community (elderly and young). They use mously transcribed by a second person to ensure consist- a stick in measuring” (P2, Male, Agyambra, FGD). ency and reliability of the data. Two IDI transcripts were “They said with the drug when mosquito bites you, shared with two respondents to confirm whether their you will not get ‘Gyepim’ (Swollen feet) or ‘Otow’ views were accurately captured, they were both happy (Swollen Scrotum). So, it makes them share the drugs with the scripts and confirmed that their views were ade- step by step. They use a stick to measure. This helps quately captured. Triangulation of the data sources was us a lot” (P1, Female, Asemkor, FGD). done to ensure that data from various sources comple- As may be expected, the frontline healthcare providers ment each other, however, divergent views or positions have adequate knowledge about the MDA programmes are represented in the result. Finally, verbatim quota- for NTDs. They could describe the NTD programme as a tions from respondents’ narratives were presented in the collection of diseases that do not have enough funding for results as much as possible. their activities. They could also talk about the processes involved in MDA implementation in the communities. Some of the processes described included that: drugs Ethical approval are brought from NTD programme office in the national The study was reviewed and approved by the Nogu- capital (Accra) to the district health directorate, CDDs chi Memorial Institute for Medical Research (NMIMR are invited to a workshop at the district level, where they IRB CPN 021/19-20). All participants provided written participate in determining how to go about the distribu- informed consent prior to participation. Participants’ tion, determine the date it will start and assign supervi- participation was voluntary, and respondents reserved sors. They also mentioned that the CDDs take the heights the right to withdraw from the study at any time. Partici- of participants and then use the treatment chart as a pants were informed about the research objectives and guide to give the appropriate number of tablets and then were ensured of confidentiality of information provided. record this information in the treatment booklet. These views are represented in the following narratives: Results “I know everything about the MDA activities Socio‑demographic characteristics of study participants because I have been involved as a CDD for more In all, 91 individuals participated in the study, comprising than 12 years. […] as soon as our bosses at the dis- 19 in-depth interviews and 12 focus group discussions trict administration received the drugs, they call us as presented in Table 1. In all, there were 72 participants to a workshop for refresher training and then plan Table 1 Data collection techniques and socio‑demographic characteristics of participants Data collection Type of participants Age group (years) Sex Total technique Male Female IDI CDD 25–52 6 4 10 CHN 24–48 1 6 7 District disease control officers 26–45 1 1 2 FGD Community members 18–30 2 groups 2 groups 12 groups (6 participants in 31–50 2 groups 2 groups each group, thus, 72 partici‑ pants) 51 and above 2 groups 2 groups A horlu et al. BMC Infectious Diseases (2022) 22:106 Page 5 of 12 on how to go about the distribution. At the work- “The coronavirus is transmitted through the nose, shop, we are assigned our supervisors. They also tell mouth and the eyes. […] we know that COVID-19 is us how much will be given to us as daily allowance” transmitted when droplets from an infected person (Male CDD, Male, Bonsukrom, IDI) get into another person […] (Female Physician Assis- “I know that the NTD programme is in charge of tant, Fasin Nyamekrom, IDI). the neglected tropical diseases, which do not have enough money for their control activities […] they are neglected. As for the MDA, we have been organ- Symptoms of COVID‑19 ising for many years now and it is unfortunate that Various symptoms were reported by community mem- we could not have it in this year (2020) because of bers and among them were; headache, cough, dryness COVID-19)” (Female Community Health Nurse, in the throat, fever and painful lungs. These signs and Asemasa/Asemkor, IDI). symptoms are represented in the narratives below: “They say some of the symptoms are headache and coughs.” (P3, Female, Bonsukrom, FGD) Knowledge of COVID‑19 “Some of the signs are, the person will begin to Participants were generally aware of Coronavirus dis- cough, after a while the person will experience dry- ease and referred to it appropriately by using the medi- ness in the throat and pains in the lungs. The person cally defined names such as ‘coronavirus’ and COVID-19. will also experience some feverishness” (P1, Female, They often referred to it as ‘the new disease’ as captured Mpatase, FGD) in the responses below: Frontline healthcare workers also had vivid descrip- “We know the new disease […] The new Disease is tions of the symptoms of the novel COVID-19 disease. COVID-19” (P5, Female, Nyameyekrom, FGD). Some of the reported symptoms were coughing, fever, “As a health worker, we have all the information on breathing difficulty, dry throat, headache, bodily pains, the disease, it is call coronavirus or COVI-19, which and lung infections. These are captured in a representa- started from China (Female Physician Assistant, tive response below: Fasin Nyamekrom, IDI). “As health workers, we know the various signs and symptoms associated with the COVID-19 disease. It usu- ally starts like any febrile illness, presenting symptoms Transmission of COVID‑19 like, coughing, fever, bodily pains […]” (Male District Dis- It came to light that most of the community respondents ease Control officer, IDI). could not appropriately describe the route of transmis- sion. They typically based their responses on the current control measures being promoted in the media. Most Prevention of COVID‑19 people reported that it is transmitted through touch or Participants appropriately reported the current preven- sharing of common items as captured in the following tive measures being promoted in the media, which is narratives: an indication that information on personal hygiene and other protection protocols is reaching the people. These “What I know is that if someone gets infected and he included the use of hand sanitizer, washing of hands, and or she speaks without having a nose mask on, those sneezing appropriately as aptly represented in the follow- close by can get infected too, […]as to how the germs ing narratives: get into the person, I am not sure of it” (P1, Male, Asemkor, FGD). “We should use soap and water to regularly wash “It is transmitted through the sharing of the same our hands. We should use hand sanitizers to clean item. For example, with this plastic chair I am sit- our hands, and always keep a clean environment” ting on, if I am infected with the disease and another (P4, Female, Agyambra, FGD) person comes to touch the plastic chair, that person “If you want to sneeze, you have to sneeze into your can contract the disease” (P2, Female, Mpatase, folded elbow (showing the action) so that the drop- FGD). lets do not come out to infect other people” (P4, Male, Asemkor, FGD) The frontline healthcare workers on the other hand “COVID-19, I believe can be prevented if all of reported more correct routes of transmission of COVID- us will follow the prevention protocols, especially 19 infection. They posited that the virus is transmit- washing our hands with soap under running water ted through the nose, mouth, and eyes. This position is frequently, avoiding crowded places like churches, clearly captured in the representative narrative below. funerals, drinking spots. […] we must also wear our Ahorlu et al. BMC Infectious Diseases (2022) 22:106 Page 6 of 12 nose masks and/or face shields, use hand sanitizer cult for you to go to someone and distribute the drug, in the absence of water, and keep physical distance because both the distributor and the receiver are when dealing with other people […] sneezing into afraid of each other” (Male CDD, Nyamekrom, IDI). handkerchiefs, tissue papers or your folded elbow” (Female Physician Assistant, Fasin Nyamekrom, Health workers in the facilities also expressed concerns IDI). about the effect of COVID-19 on NTD Programmes and service delivery. Just like the CDDs, they pointed out that the pandemic has affected the arrival and distribution of Effect of COVID‑19 on daily lives/activities MDA drugs as presented in the following narratives: among community members “The lockdown that we experienced at the ear- Participants expressed worries about how COVID-19 has lier stage of the COVID-19 disease, has hindered negatively affected their daily lives and activities. Some of the arrival of the drugs for distribution. This is the the ways by which the pandemic affected the daily activi- adverse effect of COVID-19 on the programme” ties of respondent were: general slowdown of business, (Female Community Health Nurse, Asemasa/Asem- especially among traders and store operators, inability to kor, IDI). work due to restrictions in movement, fear of contract- “Even the clinicians as well as the people they are ing the infection, and the fact that children cannot attend going to administer those medications to, they are school as they used to. Below are some of the representa- scared. They have some sort of fear in them that, tive responses: “Okay, I do not know the home I am going to, I do “Business has slowed down due to this disease. not know who I am meeting, the kind of people he/ People are not buying things like they used to” (P2, she has been involved with, the past week, two or Female, Achonwa, FGD). ever since of the outbreak of the pandemic” (Female “I am not able to go for work as I used to. I am Physician Assistant, Fasin Nyamekrom, IDI). always at home now due to restrictions on move- The district health directorate also shared how the ments and the fear of contracting the disease.” (P4, NTD programme and service delivery were affected. Male, Adjumako, FGD). They maintained that COVID-19 was responsible for “First our children were going to school but now they non-implementation of the yearly MDA. Also, people are all home” (P1, Female, Nyameyekrom, FGD). were hiding suspected signs and symptoms of COVID- 19 from care providers. These positions were captured in Effect of COVID‑19 on NTD/MDA programme and service the following narrative: delivery “[…] basically, we started the year anticipating that Generally, when asked about the effects of the COVID- we will have MDA activity; thus, mass drug admin- 19 pandemic on NTD programmes, the majority of istration programme on lymphatic filariasis, but CDDs stated that there is a negative effect on NTD along the line because of COVID-19 restrictions programmes. They mentioned that the yearly MDA and the fact that we need to ensure that we go by the programme has been postponed due to the pandemic. national COVID-19 protocols coupled with uncer- Should the programme make the drugs available for dis- tainties in the air it could not come on. Basically, we tribution, some said they would be afraid to distribute were not able to do our scheduled mass drug admin- drugs because one cannot tell who is infected. The fol- istration for the year” (Male District Disease Con- lowing are some observations from respondents. trol Officer, IDI). “Okay, the programme is run yearly but look at the “People who come to the facility with cough are hid- month we are in (September), because of COVID-19 ing it from us […]. You see the person coughing and the exercise could not come on” (Male CDD, Adju- you ask “are you coughing? They would say no, only mako/Mpatase, IDI). for them to go hiding in the then you hear ‘kuhu “Okay, first and foremost, with the presence of kuhu’(coughs). So, people are trying to hide some COVID-19, when delivering drugs, there is fear of the perceived signs and symptoms of COVID-19 because you cannot determine if the receiver has it from us (care providers) because they do not want or not and therefore, you will be afraid to go round to be tested for COVID-19” (Male District Disease to distribute the drug. This will affect the work in a Control Officer, IDI). way” (Male CDD, Bonsukrom, IDI). Community volunteers expressed worry about the “We have heard that this COVID-19 is through con- changes that have occurred at the health facilities since tact or even a droplet from someone. So, it is diffi- A horlu et al. BMC Infectious Diseases (2022) 22:106 Page 7 of 12 the advent of the COVID-19 pandemic. They were wor- Malaria and you seek healthcare with your high ried that patients were no longer receiving the kinds of temperature, you can be detained for some time services they used to receive from the care providers and because of the high temperature. With situation that care providers were afraid to relate well to patients. like this it is difficult to seek treatment from the The practice of social distancing has also affected opera- health facility” (Male CDD, Bonsukrom, IDI). tions at health facilities. These positions were repre- sented in the following narratives: Key informants at the district health directorate confirmed the reduction in clinic attendance at health “The disease has made our attendance at hospi- facilities. They emphasized that the COVID-19 pan- tals very difficult, because the way and manner demic comes with some levels of stigma against those the nurses use to care for us has changed since the affected (both infected and their family members), arrival of COVID-19” (P2, Female, Agyambra, so people did not want go to the clinic and get tested FGD). for COVID-19. Respondents also explained that some “Care providers don’t want to come closer to the infections like COVID-19 could be contracted from the patients and I think the social distancing protocol hospital/clinic, so, people want to avoid going to the that is the reason why the doctors and nurses are clinic as a way of avoiding COVID-19. These positions behaving as such. The doctors are also afraid that are represented in the following narratives: maybe the patients have the disease (COVID-19) and if they don’t take the necessary precautions, they “Even I myself, at a point in time when I had may get the infection” (P3, Male, Agyambra, FGD). malaria, I felt like treating myself rather than “There have been changes at the hospital. The bench going to the hospital […] for the fear of stigma that accommodates 6 persons previously, now can associated with COVID-19” (Male District Health only accommodate 4 persons, making it difficult for Information Officer, IDI). all the patients to sit down comfortably. If you want “So, to a large extent, some people were not com- to cough you have to go somewhere else. You can’t ing to the hospitals at all, because the hospital sit on the bench and cough. If you are tested and the was even perceived to be a place where you can get result is positive you will be admitted and taken care nosocomial infections; that is Hospital Acquired of at the hospital” (P1, Female, Bonsukrom, FGD). Infections. So, we had a drastic dropped in clinic/hospital attendance” (Male, District Disease Con- trol officer, IDI). Effects of COVID‑19 on attendance to health facility All categories of respondents agreed that the COVID- 19 pandemic has negatively affected clinic attendance. Ill‑health experiences of Community members Health workers reported that they were getting worried during COVID‑19 because people with illnesses that they usually bring to Respondents shared their experiences of having fallen the clinic were staying away from health facilities because sick during this era of COVID-19. While some who of the fear of being diagnosed with COVID-19. This posi- suspected that they may be having the infection visited tion was very aptly captured in the following representa- the hospital for testing, others did not go to the hospi- tive narrative: tal, even though they were not well and needed clinical attention. These positions are well represented in the “With the presence of COVID-19, it is really wor- narratives below: rying, because people with illnesses that they may usually take to the clinic are now afraid to go to “In March 2020, I felt ill, it coincided with the com- the clinic because they are afraid that they may be ing of coronavirus into Ghana, so I thought it was tested for COVID-19. They are afraid to be diag- the virus and visited the hospital but after series of nosed to be having COVID-19, which may call for examinations. I was told it wasn’t COVID-19” (P1, hospital admission and isolation. With this, it is Male, Agyambra, FGD). difficult for people to seek healthcare. They pre- “I felt sick around March 2020, but I didn’t have fer to stay with the sickness than being diagnosed the courage to go to the hospital for testing but of having COVID-19. I have seen someone who instead, I did self-medication […] I didn’t go to the was sick and from my observation, I think it was hospital because I believed that when I go, they malaria, but because of COVID-19 the person will test me and say I am infected with COVID-19 refused to attend clinic. […] when you are sick with (P5, Male, Asemkor, FGD). Ahorlu et al. BMC Infectious Diseases (2022) 22:106 Page 8 of 12 Achieving compliance and confidence in MDA you want to say the person has COVID-19 disease” during COVID‑19 (Female Community Health Nurse, Agyambra, IDI). Various views were expressed by respondents on how to increase compliance and confidence of community mem- bers in MDA in this period of COVID-19. Respondents Usage of personal protective equipment believed that there is a need for more awareness creation With regards to the use of PPE during MDA, respondents or community education to help people understand that were divided on its potential effects on their work. While MDA could be implemented during the COVID-19 pan- some did not see it as posing a challenge to MDA activi- demic without problem. They also reported the need to ties, others think it will create some challenges. Those follow the COVID-19 protocols, especially social distanc- who think that it will not pose any challenge believed that ing and wearing of nose masks. These positions were rep- both the community members and CDDs must wear, at resented in the narratives below: minimum, nose masks to prevent stigmatization. Those who said it will present some challenges reported that, “The CDDs have responsibility to educate the com- wearing PPE, even the nose mask, will cause commu- munity to know that, though COVID-19 is there, nity members to challenge their sense of judgement; if Elephantiasis (LF) also exist. So, we should all come they know it is not safe to implement MDA, why are they together and go by the protocols such as; wearing doing it? These positions were expressed in the following our nose masks, use sanitizer, wash our hands fre- representative narratives: quently, and that when we do that, we can continue with the MDA programme” (Male CDD, Nyamek- “Not adhering rather will cause them to ask us some rom, IDI). questions like “we know we are in COVID-19 season “I think we can still go ahead with drug administra- and so why are you not adhering to the protocols?” tion but ensuring that we follow the protocols that (Male CDD, Agyambra, IDI). includes wearing of nose mask, ensuring that there is “I think that, right now due to numerous announce- physical distancing. I think we can even take advan- ment and advertisement concerning COVID-19, tage of this to give more education and assurance to people have come to accept that this is the norm the community members that COVID-19 of course of the day […] but it will be good if the community has come to stay but then when we follow the proto- members are also wearing it (face mask), so that cols, we can be able to bring it under control” (Male when they see you in face mask, they will not think District Disease Control officer, IDI). that you are stigmatizing them because of a condi- tion or something” (Female Physician Assistant, Fasin Nyamekrom, IDI). “They (community members) would not be comfort- Physical distancing able seeing us in PPE, especially when they are not Health workers, including CDDs, were concerned about wearing some. They may be afraid of us. We are physical distancing as a COVID-19 protocol. They find mostly in contentions with them on these COVID- it very challenging because by the nature of their work, 19 protocols, as most of them believe that there is no they have to get closer to their clients during MDA. Some COVID-19 in their communities” (Female Commu- of them asked rhetorically, “How can you give drugs to nity Health Nurse, Asemasa/Asemkor, IDI). people without getting close to them?” Others were con- cerned about how to take the height of people to deter- mine the number of tablets (drugs) to give them. These Community response to MDA programmes views were expressed in the following narratives: With regards to how community members will respond to MDA activities during this time, some respondents “As for social/physical distancing, it will be a chal- said that because community members are already aware lenge during MDA. Looking at how we share the of the programme, they may not respond differently. drug, we take the height of the person, so if you do Others were of the view that some community members not get close to the person, how do you take the may link the MDA activities to COVID-19, which will height? The social distancing […], we can find a way make them hesitant to participate. These views are cap- to practice it, but it will make the work a little more tured in the following narratives: difficult” (Male CDD, Adjumako/Mpatase, IDI). “The protocols have been laid down that is ensuring “We already distribute the medicines to them, and physical distancing. When you distance yourself, […] they have been taking the medicines even before they will say you are behaving someway or indirectly COVID-19. So, we will let them know that the medi- cines are not COVID-19 drugs but what they have A horlu et al. BMC Infectious Diseases (2022) 22:106 Page 9 of 12 already been taking. If we talk to them, they will those in authorities like the chiefs or the assembly- understand” (Male CDD, Asemkor, IDI). men. When they speak, the community members “I think rather that, the materials we need to pro- will listen” (P5, Female, Nyameyekrom, FGD). tect ourselves, must also be made available to them, “Showing a video on the drug for them to watch so that when they see us, they will know we are part will be useful. Most of them will come and watch it. of them and we are going to interact with them When they watch and realized what the drug and concerning the drug distribution” (Female CDD, disease is about, knowing the effect of not taking the Achonwa, IDI). drugs, knowing it is mosquitoes that cause it and mosquitoes are rampant in the communities then they will take the drug. If we do this it will help very Hindrance to MDA participation While community members believe there will be no hin- much” (Male CDD, Adjumako/Mpatase, IDI). drance to participation in the MDA, health workers think When health workers were asked about their roles in that there will be barriers to MDA implementation if social mobilization to get community members to partic- appropriate measures are not put in place. Some of the ipate in the MDA activities, they said, talking to the peo- recommended appropriate measures reported included ple about the usefulness of the drugs through community community education and awareness, as well as obser- elders, religious groups and other community durbars. vance of COVID-19 protocols. These positions were These views are represented in the following narratives: expressed in the following representative narratives: “Our duty is to properly talk to them (community mem- “We are not going to use Coronavirus as an excuse bers) about the usefulness of the drugs. If we do that, they to stop taking the drug. The drugs help me with will take the drug” (Female CDD, Agyambra, IDI). my health issues, so if you don’t continue this pro- “The CDD can go from church to church to give educa- gramme it is going to worry me” (P3, Male, Bonsuk- tion on the drugs and its usefulness. Aside the churches, rom, FGD). they can go to the local radio stations as well to give talks, “Coronavirus is different from elephantiasis; hence when they (CDDs) are supported by providing their needs we have to take elephantiasis drug in order to pre- and logistics” (Male CDD, Nyamekrom, IDI). vent it and avoid any complications” (P1, Female, “My role will be ensuring that we start social mobiliza- Adjumako, FGD). tion ahead of time. If we are to do the MDA in a month “The challenge will be that we will have to explain time, we should start social mobilization ahead of time it well enough to them and answer some questions so that the community will be able to buy into the pro- they may ask because of COVID-19. We the CDDs gramme” (Male District Disease Control officer, IDI). have to expect that and be prepared” (Male CDD, Agyambra, IDI). MDA implementation amidst COVID‑19Respondents were divided on implementing MDA amidst COVID-19. While some believed that MDA activ- Effective communication ities could be carried out without any problem provided For many respondents, effective and appropriate com- the protocols are followed, especially wearing of nose munication to create awareness and educate people was masks and keeping physical distance, others think that it the best way to get community members to actively par- will be difficult to implement MDA activities amidst the ticipate in MDA activities. They are of the view that any COVID-19 pandemic. These positions were captured in awareness creation in communities must involve the the following narratives: chiefs and elders as well as local political leaders in com- munities. This position is succinctly expressed in the fol- “Oh yeah. It should continue. As I earlier indicated, lowing representative narratives: though COVID-19 is currently available it doesn’t mean elephantiasis is not there. COVID-19 is just “First, I will suggest that we do an announcement one of the conditions that may affect us” (Male CDD, and educate them on the sickness (COVID-19), as it Nyamekrom, IDI). has come to stay with us. What we need to do is to “We have a period for the distribution of the medi- stay safe and then talk about the elephantiasis drug cines. So, if the time is up, they should bring the distribution and remind them that the drug distri- medicines for distribution and we will do it by fol- bution as is already known to them is to help us to lowing the COVID-19 protocols” (Male CDD, Asem- eliminate elephantiasis” (Male CDD, Bonsukrom, kor, IDI). IDI). “I will suggest we hold on with the distribution. “In order for people to participate, we have to involve Somewhere next year, God willing, if the spread Ahorlu et al. BMC Infectious Diseases (2022) 22:106 Page 10 of 12 is contained. Now, although COVID-19 cases are In Ghana, and elsewhere, lymphatic filariasis MDA going down, it is not completely gone. If we distribute activities are already burdened with barriers to attain- the drug now, some will take it and others will not ing optimal treatment coverage [26–29], facilitated by because of the fear of COVID-19” (Male CDD, Bon- inaccurate reported data [30–32] and socio-cultural and sukrom, IDI). health system challenges [33]. As such, more effort will be required to address the MDA challenges during the COVID-19 era. Innovative approaches to addressing the Discussions COVID-19 challenges to NTD programmes have been In preparation for MDA, the WHO issued recommen- proposed: strengthening health systems, facilitating inte- dations for safely restarting MDA for NTDs in settings gration between diseases and cross-sector collaboration, with heightened risk of COVID-19 community transmis- improving and optimizing programme interventions sion [22]. The recommendations aptly identify most of delivery [34, 35] and these cannot be overemphasised. the adaptations necessary for conducting MDA during Successful implementation of such strategies across all COVID-19. Furthermore, the recommendations also sug- NTD communities and countries will be key to attaining gested the need for field teams in MDA areas to be con- the NTD 2030 elimination targets post-COVID-19. sulted prior to restart to grasp the operational realities in In conclusion, we found that COVID-19 and its pre- field settings. The need to consult the community is what ventive protocols have led to some negative perceptions this paper aimed to address; beyond the planning, train- about restarting MDA activities among our study par- ing, logistics and funding requirements for MDA which ticipants. These negative perceptions among community by themselves will represent significant challenges to members, CDDs, and health workers must be addressed programmes in addressing the multi-faceted challenges to enhance participation in MDA activities, else the posed by COVID-19. impacts of COVID-19 may reverse the significant gains The perceptions from the CDDs, CHNs, disease con- made in reducing the NTD, especially LF, burden in the trol officers, and community members underscore the last 20 years. need to strengthen education on MDA as they saw it as a critical element to MDA during COVID-19. Participants Abbreviations expressed worry about the negative impact of COVID-19 CDD: Community‑based Drug Distributors; CHN: Community Health Nurse; on their daily lives and NTD programme activities, how- COVID‑19: Coronavirus Disease; FGD: Focus Group Discussion; FWA: Federal Wide Assurance; GPELF: Global Programme to Eliminate Lymphatic Filariasis; ever, their major concern surrounded service delivery LF: Lymphatic Filariasis; MDA: Mass Drug Administration; NMIMR‑IRB: Noguchi at the community and health facility levels. The fear of Memorial Institute for Medical Research Institutional Review Board; IDI: In‑ contracting COVID-19 and the resulting stigmatization depth Interview; NTD: Neglected Tropical Disease; PPE: Personal Protective Equipment. represent major challenges to health service provision and must be addressed, to safely restart MDA activities Supplementary Information and achieve effective coverage. Stigmatization due to The online version contains supplementary material available at https:// doi. COVID-19 [23, 24] has been reported as a major hurdle org/ 10. 1186/ s12879‑ 022‑0 7084‑0. to an effective pandemic response. This is compounded by the fact that NTDs already carry a heavy burden of Additional file 1. Table S1. Thematic categories with selected quotations social stigma [25]. from the narrative responses.. Respondents also expressed their views on how to increase compliance and confidence of community mem- Acknowledgements bers for MDA during this period. The health workers, We are grateful to the study participants for willingly participating in the study including CDDs, were concerned with physical distanc- and sharing their invaluable insights towards understanding of the impact of COVID‑19 on NTD control activities. We thank the chiefs and people of the ing as required COVID-19 protocol. They found it very study communities and the Ahanta West District health management team challenging because, by the nature of their work, they for their supports during fieldwork. may have to get closer to their clients than guidelines Authors’ contributions allow. Respondents were divided on the effect of wear- CSA and DKdS conceived the study. CSA, DKS, and EFL contributed to the ing PPE during MDA. For many respondents, effective study design. CSA, DO, JO, SP‑B, collected the data. CSA analysed the data. and appropriate communication to create awareness and DKS and CSA prepared the first draft of the manuscript. CSA, DO, SP‑B, JO, BM, KA‑M, JLO, EFL, and DKS contributed, read and approved the final draft of educate people on the need for MDA is the best way to the manuscript for publication and accept responsibility for the content. All get community members to actively participate in MDA authors read and approved the final manuscript. activities. They believed that continuing with MDA and Funding NTD programmes despite COVID-19 will not be a prob- This work received financial support from the Coalition for Operational lem provided the protocols are followed. Research on Neglected Tropical Diseases (COR‑NTD), which is funded at The A horlu et al. BMC Infectious Diseases (2022) 22:106 Page 11 of 12 Task Force for Global Health primarily by the Bill & Melinda Gates Foundation, indicators. PLOS Negl Trop Dis. 2017;11(3):e0005280. https://d oi.o rg/ 10. by UK aid from the British government, and by the United States Agency 1371/j ourna l. pntd. 000528 0. for International Development through its Neglected Tropical Diseases 7. Biritwum N‑K, Yikpotey P, Marfo BK, Odoom S, Mensah EO, Asiedu O, et al. Programme. Persistent ‘hotspots’ of lymphatic filariasis microfilaraemia despite 14 years of mass drug administration in Ghana. Trans R Soc Trop Med Hyg. Availability of data and materials 2016;110(12):690–5. https:// doi. org/ 10. 1093/ trstmh/ trx007. Qualitative data generated and analysed during this study are included in 8. Biritwum N‑K, Garshong B, Alomatu B, de Souza DK, Gyapong M, Kyelem this published article. Raw data is not available and will not be shared, as this D. Improving drug delivery strategies for lymphatic filariasis elimination in would compromise the protection of participants’ identity, however, some urban areas in Ghana. PLoS Negl Trop Dis. 2017;11(5): e0005619. https:// data could be made available upon a reasonable request from the corre‑ doi. org/ 10. 1371/j ourn al. pntd.0 00561 9. sponding author, cahorlu@noguchi.ug.edu.gh. 9. Molyneux DH, Aboe A, Isiyaku S, Bush S. COVID‑19 and neglected tropi‑ cal diseases in Africa: impacts, interactions, consequences. Int Health. 2020;12:367–72. https:// doi.o rg/ 10.1 093/i nthea lth/i haa04 0. Declarations 10. World Health Organization. Ending the neglect to attain the Sustain‑ able Development Goals: a road map for neglected tropical diseases Ethics approval and consent to participate 2021–2030. 2020 (cited 16 Feb 2021). https://w ww. who.i nt/ negle cted_ The study was carried out as part of a larger implementation research project disea ses/ Ending‑t he‑ negle ct‑t o‑ attain‑ the‑S DGs‑‑ NTD‑ Roadm ap. pdf. titled “Strategies for the endgame: Targeting Infections among Non‑compliant 11. Chaumont C, Kamara K, Baring E, Palacio K, Power A, Lancaster W. The in the Elimination of Lymphatic filariasis.” The project was reviewed and SARS‑CoV‑2 crisis and its impact on neglected tropical diseases: threat or approved by the NMIMR‑IRB and was assigned NMIMR‑IRB CPN 021/19‑20 opportunity? PLoS Negl Trop Dis. 2020;14:e0008680. https:// doi.o rg/ 10. revd. 2020 with Federal Wide Assurance Registration FWA 00001824. IRB 1371/ journa l. pntd. 00086 80. 00001276; IORG 0000908. All respondents were above 18 years of age and 12. NTD Modelling Consortium. Impact of COVID‑19 on NTD programmes signed an informed consent form. Community consent was also sought for progress. 2020 (cited 28 Jun 2020). https:// www. who. int/ neglec ted_ disea the study from the Chiefs and elders of each participating community, and ses/ news/I mpact‑ COVID‑ 19‑ NTD‑p rogra mmes.p df? ua=1. community norms were strictly observed. Study methods were performed in 13. de Souza DK, Picado A, Biéler S, Nogaro S, Ndung’u JM. Diagnosis of accordance with relevant national and international regulations and guide‑ neglected tropical diseases during and after the COVID‑19 pandemic. lines for conducting qualitative research. PLoS Negl Trop Dis. 2020;14:e0008587. https:// doi.o rg/ 10.1 371/j ourna l. pntd. 00085 87. Consent for publication 14. World Health Organization. COVID‑19: WHO issues interim guidance for Not applicable. implementation of NTD programmes. 2020 (cited 21 Feb 2021). https:// www. who.i nt/n eglec ted_ disea ses/ news/ COVID 19‑W HO‑ inter im‑ guida Competing interests nce‑ imple menta tion‑ NTD‑p rogra mmes/ en/. The authors declare that they have no competing interests. 15. Pi‑Bansa S, Osei JHN, Kartey‑Attipoe WD, Elhassan E, Agyemang D, Otoo S, et al. Assessing the pPresence of Wuchereria bancrofti infections in Author details vectors using xenomonitoring in lymphatic filariasis endemic districts 1 Epidemiology Department, Noguchi Memorial Institute for Medical Research, in Ghana. Trop Med Infect Dis. 2019. https:// doi.o rg/1 0. 3390/ tropi calme College of Health Sciences, University of Ghana, Legon, Accra, Ghana. 2 Parasi‑ d40100 49. tology Department, Noguchi Memorial Institute for Medical Research, College 16. Ahorlu Collins K, Dunyo Samuel K, Godfred A, Simonsen Paul E. Conse‑ of Health Sciences, University of Ghana, Legon, Accra, Ghana. 3 Neglected quences of hydrocele and the benefits of hydrocelectomy: a qualitative Tropical Diseases Programme, Ghana Health Service, Accra, Ghana. 4 Neglected study in lymphatic filariasis endemic communities on the coast of Ghana. Tropical Diseases Support Center, Task Force for Global Health, Decatur, GA, Acta Trop. 2001;80:215–21. USA. 17. Bradley EH, Curry LA, Devers KJ. Qualitative data analysis for health services research: developing taxonomy, themes, and theory. Health Received: 14 May 2021 Accepted: 10 January 2022 Services Res. 2007;42(4):1758–72. https:// doi. org/ 10. 1111/j. 1475‑ 6773. 2006. 00684.x. 18. Ayres L, Kavanaugh K, Knafl KA. Within‑case and across‑case approaches to qualitative data analysis. Qual Health Res. 2003;13(6):871–83. https:// doi.o rg/1 0. 1177/1 0497 32303 01300 6008. References 19. Ryan GW, Bernard HR. Techniques to identify themes. Field Methods. 1. Malecela MN. Reflections on the decade of the neglected tropical 2003;15(1):85–109. https:// doi. org/ 10. 1177/1 5258 22X02 239569. diseases. Int Health. 2019;11:338–40. https:// doi. org/1 0. 1093/ inthe alth/ 20. Buetow S. Thematic analysis and its reconceptualization as “saliency ihz048. analysis.” J Health Serv Res Policy. 2010;15(2):123–5. https:// doi.o rg/ 10. 2. Stolk WA, Swaminathan S, van Oortmarssen GJ, Das PK, Habbema JD. 1258/ jhsrp.2 009. 009081. Prospects for elimination of bancroftian filariasis by mass drug treatment 21. Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. in Pondicherry, India: a simulation study. J Infect Dis. 2003;188(9):1371–81. 2006;3(2):77–101. https:// doi. org/1 0.1 191/ 14780 88706q p063 oa. https:// doi. org/ 10.1 086/ 378354 (Epub 2003/11/01). 22. World Health Organization. Recommendations for safely restarting 3. Michael E, Malecela‑Lazaro M, Simonsen PE, Pedersen EM, Barker G, MDA for NTDs in settings with heightened risk of COVID‑19 community Kumar A, et al. Mathematical modelling and the control of lymphatic transmission. In: World Health Organization Regional Office for Africa. filariasis. Lancet. 2004;4:223–34. https:// doi. org/ 10. 1016/ S1473‑3 099(04) 2020 (cited 21 Feb 2021). https:// espen. afro. who. int/ system/fi les/ conte 00973‑9. nt/r esour ces/ ESPEN‑M DAs‑ NTDs‑i n‑t he‑ conte xt‑ of‑ COVID. pdf. 4. WHO. Lymphatic filariasis: managing morbidity and prevention disability: 23. Mostafa A, Sabry W, Mostafa NS. COVID‑19‑related stigmatization among an aide‑ memoire for national programme managers. Geneva, Switzer‑ a sample of Egyptian healthcare workers. PLoS One. 2020;15:e0244172. land: World Health Organization, 2013. http:// apps. who.i nt/i ris/b itstr eam/ https://d oi. org/ 10.1 371/j ourna l.p one.0 2441 72. 10665/ 85347/1/ 97892 415052 91_ eng. pdf. 24. Sotgiu G, Dobler CC. Social stigma in the time of Coronavirus. Eur Respir J. 5. WHO. Guideline—alternative mass drug administration regimens to 2020. https://d oi. org/1 0. 1183/ 13993 003. 02461‑ 2020. eliminate lymphatic filariasis. WHO/HTM/NTD/PCT/2017.07. Geneva: 25. Hofstraat K, van Brakel WH. Social stigma towards neglected tropical World Health Organization, 2017. diseases: a systematic review. Int Health. 2016;8(Suppl 1):i53‑70. https:// 6. Biritwum N‑K, de Souza DK, Marfo B, Odoom S, Alomatu B, Asiedu O, doi.o rg/1 0.1 093/i nthe alth/ ihv071. et al. Fifteen years of programme implementation for the elimination of 26. de Souza DK, Gass K, Otchere J, Htet YM, Asiedu O, Marfo B, et al. Review Lymphatic Filariasis in Ghana: impact of MDA on immunoparasitological of MDA registers for Lymphatic Filariasis: findings, and potential uses in Ahorlu et al. BMC Infectious Diseases (2022) 22:106 Page 12 of 12 addressing the endgame elimination challenges. PLoS Negl Trop Dis. 2020;14: e0008306. https:// doi.o rg/ 10. 1371/ journ al.p ntd. 00083 06. 27. Manyeh AK, Ibisomi L, Ramaswamy R, Baiden F, Chirwa T. Exploring fac‑ tors affecting quality implementation of lymphatic filariasis mass drug administration in Bole and Central Gonja Districts in Northern Ghana. PLoS Negl Trop Dis. 2020;14: e0007009. https:// doi. org/ 10.1 371/ journ al. pntd. 00070 09. 28. Krentel A, Fischer PU, Weil GJ. A review of factors that influence individual compliance with mass drug administration for elimination of Lymphatic Filariasis. PLoS Negl Trop Dis. 2013;7:e2447. https:// doi. org/1 0. 1371/ journ al. pntd. 00024 47. 29. Chami GF, Kontoleon AA, Bulte E, Fenwick A, Kabatereine NB, Tukahebwa EM, et al. Community‑directed mass drug administration is undermined by status seeking in friendship networks and inadequate trust in health advice networks. Soc Sci Med. 2017;183:37–47. https://d oi. org/ 10. 1016/j. socsc imed.2 017. 04. 009. 30. de Souza DK, Yirenkyi E, Otchere J, Biritwum N‑K, Ameme DK, Sackey S, et al. Assessing Lymphatic Filariasis data quality in endemic communities in ghana, using the neglected tropical diseases data quality assessment tool for preventive chemotherapy. PLoS Negl Trop Dis. 2016. https:// doi. org/ 10. 1371/ journa l. pntd. 00045 90. 31. Vroom FBC, Aryeetey R, Boateng R, Anto F, Aikins M, Gyapong M, et al. Data reporting constraints for the lymphatic filariasis mass drug adminis‑ tration activities in two districts in Ghana: a qualitative study. SAGE open Med. 2015;3:2050312115594083–2050312115594083. https:// doi. org/ 10. 1177/ 20503 12115 594083. 32. Kamara W, Zoerhoff KL, Toubali EH, Hodges MH, Bisanzio D, Chowdhury D, et al. Are census data accurate for estimating coverage of a lymphatic filariasis MDA campaign? Results of a survey in Sierra Leone. PLoS ONE. 2019;14:e0224422–e0224422. https:// doi. org/ 10. 1371/ journ al. pone. 022442 2. 33. Ahorlu CSK, Koka E, Adu‑Amankwah S, Otchere J, De Souza DK. Commu‑ nity perspectives on persistent transmission of lymphatic filariasis in three hotspot districts in Ghana after 15 rounds of mass drug administration: a qualitative assessment. BMC Public Health. 2018. https:// doi.o rg/ 10.1 186/ s12889‑ 018‑ 5157‑7. 34. Molyneux D, Bush S, Bannerman R, Downs P, Shu’aibu J, Boko‑Collins P, et al. Neglected tropical diseases activities in Africa in the COVID‑19 era: the need for a “hybrid” approach in COVID‑endemic times. Infect Dis Poverty. 2021;10:1. https:// doi. org/ 10. 1186/s 40249‑ 020‑0 0791‑3. 35. Brooker SJ, Ziumbe K, Negussu N, Crowley S, Hammami M. Neglected tropical disease control in a world with COVID‑19: an opportunity and a necessity for innovation. Trans R Soc Trop Med Hyg. 2020. https:// doi.o rg/ 10.1 093/t rstmh/ traa15 7. 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