Neglecting the effect of COVID-19 on neglected tropical diseases: the Ethiopian perspective.

Countries around the world are facing an enormous challenge due to the COVID-19 pandemic. The pressure that the pandemic inflicts on health systems could certainly impact on the care, control, and elimination of neglected tropical diseases (NTDs). From mid-January 2020, Ethiopia started to prepare for the prevention and treatment of COVID-19. The Federal Ministry of Health pledged to continue essential healthcare, including NTD care, during this pandemic. However, some hospitals have been closed for other healthcare services and have been turned into isolation and treatment centers for COVID-19. In addition to the healthcare facility measures, all community-based health promotion and disease prevention services have been stopped. The current shift in attention towards COVID-19 is expected to have a negative impact on NTD prevention and care.

Introduction

The world is facing the huge and unexpected challenge of the coronavirus disease 2019 (COVID-19) pandemic. Countries around the world have had to quickly adjust and respond to curb transmission of the virus and to deliver care for those infected. The stress that the pandemic is placing on health systems could certainly have an impact on the control, care, and elimination of neglected tropical diseases (NTDs), especially in resource-limited settings where health systems already struggle to meet the demand of their population. Additionally, NTD control and care can also be affected by public anxiety, misinformation, and restrictions on the movement of people. On the healthcare side, NTD care will be affected by a shortage of supplies, involvement of healthcare workers in the pandemic, and economic slowdowns.

The Ethiopian response to the COVID-19 pandemic

As of May 22, 2020, Ethiopia had recorded 399 cases, 123 recoveries, and five deaths from COVID-19. From mid-January 2020, the country started to prepare for the prevention and treatment of COVID-19. Different preventive measures including physical distancing were introduced from the last two weeks of March 2020, followed by the declaration of a state of emergency. The measures include reducing the number of passengers on public transport by half and closing religious sites and schools. Some hospitals are completely closed for the purpose of COVID-19 treatment and prevention. In addition, awareness-raising is underway, and members of the public are being urged by the government to contribute towards the national COVID-19 resource mobilization. The Federal Ministry of Health has pledged to continue essential healthcare service, including for NTDs, during this pandemic. Seven interventions targeting lymphatic filariasis elimination, three targeting onchocerciasis elimination, four for trachoma elimination, four for schistosomiasis control, four for control of soil-transmitted helminths, two for scabies control, two for leishmaniosis control, three for Guinea worm disease case control, and six for podoconiosis elimination are incorporated into the essential healthcare package of Ethiopia.

Implications for NTD prevention, care, control, and elimination efforts

Ethiopia has a high burden of NTDs. The morbidity management and disability prevention of some NTDs like cutaneous leishmaniasis, leprosy, and deep fungal infections are available only in specialized centers. Most hospitals have had a significant decrease in their patient load since the second week of March. For example, the only leprosy center in the Amhara region and center of care for a range of skin NTDs was closed to serve as a dedicated COVID-19 treatment center. In this center, more than 25,000 patients with skin disorders are seen annually, and nearly one fifth are patients with skin NTDs. Leprosy, cutaneous leishmaniasis, and scabies are the most common disorders. For more than a month, the hospital was empty waiting for the first COVID-19 case. This was at the expense of thousands of critically ill patients who were in need of hospital care. More than 75% of patients with cutaneous leishmaniasis in the Amhara region used to access treatment from this center. In addition, several leprosy rehabilitation services including the orthopedic workshop are closed, making life difficult for disabled leprosy patients.

In addition to the healthcare facility measures, all community-based disease prevention and health promotion services have been stopped. At the national level, monitoring and supervision of key NTD programs have been halted. At the regional level also, preparation for mass drug administration programs and a treatment coverage validation survey have been severely affected (Table 1). Moreover, the health extension program, which delivers the core activities of the NTD prevention, control, and elimination programs, is being compromised by the pandemic.

Table 1.

Effect of COVID-19 pandemic on NTD interventions in Ethiopia, 2020

NTD intervention	Disease	Planned	Conducted
School based mass drug administration	Soil-transmitted helminthiasis	Round 2 treatment in 347 districts	Suspended due to COVID-19
	Schistosomiasis	178 districts	100% of the planned districts already completed before COVID-19
Districts report on community-based mass drug administration	Trachoma	300 districts	All suspended due to COVID-19
	Onchocerciasis	Round 2 MDA in 220 districts	Suspended due to COVID-19
	Lymphatic filariasis	54 districts	100% of the planned districts already completed before COVID-19
Districts report on coverage validation survey	All PC-NTD	15 districts to be surveyed	Suspended due to COVID-19

MDA = Mass drug administration; PC-NTD = Preventive chemotherapy for neglected tropical diseases.

The World Health Organization (WHO) recommends suspending community-based surveys, mass treatment, and active case finding during the COVID-19 pandemic, but it is not clear how long the suspension should last. This guideline recommends contextualization, as the necessity for delaying these activities should be based on the stage of the COVID-19 outbreak and an assessment of each country's health system.

The WHO guidance recommends the continuation of NTD care regardless of the extent of the COVID-19 pandemic. The care of some NTDs like lymphatic filariasis and podoconiosis needs regular training of healthcare workers. However, face-to-face training is not advisable in this context. The adoption of technology to support virtual meetings is therefore necessary. The difficulty of setting up and conducting virtual meetings in countries like Ethiopia is compounded by poor internet connectivity.

Conclusion

Collectively, NTDs affect a sizable number of Ethiopian populations, leading to disability and complications. NTD-related complications range from heart and kidney failure and visual impairment to seizures and in several cases death. COVID-19 has diverted attention from NTDs, and this will certainly have a negative impact on the health system, including the NTD program. NTD services need to be considered as essential services in health facilities, even in areas where there is evidence of community transmission of COVID-19. The regular NTD preventive measures and care have to continue and to be integrated with vigilant COVID-19 prevention efforts. This can be done by leveraging and strengthening the health extension program to address NTD services while protecting health workers and communities through infection prevention and control (IPC) measures. Otherwise, compromising the already underprivileged NTD care may have an enduring consequence.