Mass treatment of endemic communities aims to break the chain of infection in Ghana
"It's often said that yaws is found where the road ends," says Dr Nana Konama Kotey, Programme Manager at the National Buruli Ulcer Control and Yaws Eradication Programme, Ghana Health Service, adding: "It primarily affects people in poor communities where access to basic health care is limited."
Yaws, a chronic infection of the endemic treponematosis bacteria, is a disfiguring and debilitating disease that targets the skin, cartilage and bones. The disease mainly affects children under the age of 15 years and those in remote communities.
Once widely found in humid tropical countries around the world, it is now only still endemic in about 15 countries — one of which is the West African nation of Ghana.
Neglected tropical diseases such as yaws affect more than 1 billion people around the world. In 2007, yaws was added to the WHO's list of neglected tropical diseases targeted for eradication.
"I had a small boil last month and it became big this month. It is sometimes painful and distracts me in school, so I got some medicines from the drug store. But is not going away," says Godfrey Tamate, a 14-year old student at Topease Methodist School in West Akim Municipal.
"It is common in children who play a lot and have direct skin contact with each other," says Dr Kotey. "A few untreated cases — about 10 percent –will end up with disfiguring late yaws, which is permanent."
"What's important is that the complications of yaws are easily preventable. It is a disease that can be easily taken care of," she adds.
In the 1950s, yaws was among the first diseases targeted for global eradication. Initial efforts were successful in reducing global disease burden from 50 million people to just 2.5 million by 1964, before surging back in recent decades as health care authorities redirected their funds and attention to other priorities.
In 2012, a new and easy-to-administer treatment was discovered, which has the potential to transform the yaws eradication landscape. With just a single oral dose of the antibiotic azithromycin, yaws can be cured within 2–4 weeks. Orally administering azithromycin tablets is more appropriate for large-scale treatment of affected communities compared to injectable penicillin, which was used in previous eradication programmes. The discovery spawned the development of a new eradication strategy by the WHO, and renewed national efforts to eradicate the disease.
Efforts are now underway by the Ghana Health Service to eradicate yaws from the country through mass drug administrations, which are community campaigns that widely distribute medicine among affected populations. The main objective of mass drug administration is to prevent the occurrence of yaws, as well as to treat, cure and stop ongoing transmission.
"What we need is a combination of political commitment, leadership, and resources — both financial and logistical. And we now have that in place for the project districts," says Dr Kotey. "Eradication of yaws will have a significant impact on the lives of the people of Ghana — it has the potential to be transformational and will definitely improve public health."
Mass drug administration campaigns will be rolled-out initially in 18 districts across the country in 2020.
"Yes, we have an effective treatment for yaws, but for eradication to be effective, and to stop transmission, mass treatment covering all the affected communities must be carried out," points out Dr Samuel Agyeman Boateng, West Akim Municipal Director of Health Services. "We have not done that since the 1950s eradication campaigns."
An aerial view of a rural community in West Akim Municipal.
In December 2019 to January 2020, a 30-day long endemicity mapping survey (also referred to as 'case search') was conducted in West Akim to collect relevant information from affected communities that will help in planning for the upcoming mass drug administration campaigns. The survey established a baseline by identifying and mapping endemic and non-endemic communities in the municipality and helping to target interventions down to the sub-district level. Interviews of local leaders and community members were also carried out to identify potential operational challenges, including the level of public knowledge of the disease.
Students at a school in West Akim line up to be screened for skin lesions and tested for yaws. West Akim has a population of about 130,000 and consists of 10 sub-municipalities, 7 of which are considered yaws endemic.
"The different components of the mass drug administration are attended to one after the other," says Dr Boateng. "We are training health workers in identification and testing, and volunteers in surveillance and reporting of suspected yaws, followed by social mobilization to create awareness of the exercise. All these come together systematically to ensure the success of the programme."
"The first step is to map out the endemic communities. Once we have the results, we will then plan the mass drug administration using azithromycin. If everybody is treated at least once, there is no chance that the disease will continue to spread," says Dr Boateng.
Mass drug administration requires extensive planning and multiple phases of activities. As part of the preparatory phase, the Access and Delivery Partnership is providing support to build the capacity of frontline and community-based health workers. These activities also aim to identify and address operational challenges that could impede the optimal delivery of azithromycin.
Health workers from the National Yaws Programme and regional neglected tropical diseases focal persons received training on case identification and reporting, as well as on monitoring any adverse effects of the medicine.
"A single mass drug administration round of oral azithromycin could reduce prevalence of yaws by 90 percent in the community within 12 months, provided the treatment coverage is almost 100%," explains Dr Boateng.
Solomon Antwi Brefo, Public Health Officer (Disease Control) at the West Akim Municipal Health Directorate, describes the case-finding field work being done at a local school in West Akim: "We first give small talks to share basic information about yaws, and then we do a physical screening of the children to identify who has lesions, ulcers and other skin diseases, and separate them from the others who do not."
"The team checks whether the skin lesions are yaws-like or not. We bring those with suspected yaws lesions to join a queue for a rapid diagnostic test (RDT). When the RDT is positive it tells us that the person has a high probability of having yaws. After that we do a dual path platform test to confirm that the person does in fact have the active disease," he says.
Health workers, including Solomon Antwi Brefo (pink shirt) from the West Akim Municipal Health Directorate test students as part of endemicity mapping activities.
Once the team identifies a confirmed case of yaws, it administers the azithromycin medicine.
"I have had the sore for more than two years now. I use hot water and an ointment from the drug store but it's still there. I wasn't taken to the hospital," Samuel Achia, 16 years old, laments.
Samuel Achia receives treatment for yaws.
In addition to visiting schools, other teams go from house-to-house trying to identify cases to ensure no one is missed. There are also community volunteers who carry out sensitization activities.
"As volunteers, we go around educating people, especially children, on how to keep their body clean by bathing and cleaning themselves at least once a day," says Oku Asare Joshua, a teacher, farmer and community-based surveillance volunteer from Anuma Kojo community. "We also tell people they should report any wounds at the nearest health facility for testing."
Following the mass drug administration campaign, community surveillance will be strengthened to monitor any appearance of new cases, with the help of community-based surveillance volunteers and community health nurses.
The success of mass drug administration campaigns relies on building partnerships with a range of stakeholders. Political and community support must be mobilized using appropriate advocacy and health education materials, and collaboration is essential with sectors and other programmes, such as education, water and sanitation, immunization, nutrition, health promotion and community development organizations.
"We try to bring in lessons learnt from mass drug administrations conducted by other programmes," says Dr Kotey. "Mass drug administration is a health issue that needs a multisectoral approach to be successful. Social mobilization is also key and buy-in from the communities is crucial."
As part of the next steps, the Access and Delivery Partnership will continue to support the Ghana Health Service in building the capacity of health workers and conducting case search activities. These activities are contributing significantly to the health system readiness to deliver mass drug administration and eradicate this neglected tropical disease in Ghana.
Once completed, the chain of infection will at last be broken, for good.
Cover photo: Students gather outside their school during a yaws case search activity in West Akim Municipal, Ghana. Photos by Nii Armah Solomon.
Authored by Ian Mungall, UNDP, Praise Nutakor, UNDP Ghana, and Yoko Reikan, UNDP Ghana.
This news story was originally published by Medium