A Knowledge, Attitudes and Practices Survey Conducted Three Years after Halting Ivermectin Mass Treatment for Onchocerciasis in Guatemala

Background: Mass drug administration (MDA) with ivermectin for onchocerciasis was provided in Guatemala’s Central Endemic Zone (CEZ) over a 24 year period (1988–2011). Elimination of Onchocerca volvulus transmission was declared in 2015 after a three year post MDA surveillance period (2012–2014) showed no evidence of recrudescence. The purpose of the present study was to evaluate the knowledge, attitudes and practices (KAP) towards onchocerciasis and ivermectin among residents in the post endemic CEZ. A major interest in this study was to determine what community residents thought about the end of the ivermectin MDA program. Methodology/Principal Findings: A total of 148 interviews were conducted in November 2014 in four formerly hyperendemic communities using a standard questionnaire on smart phones. The majority (69%) of respondents knew that the MDA program had ended because the disease was no longer present in their communities, but a slight majority (53%) was personally unsure that onchocerciasis had really been eliminated. Sixty-three percent wanted to continue to receive ivermectin because of this uncertainty, or because ivermectin is effective against intestinal worms. Eighty-nine percent of respondents said that they would seek medical attention immediately if a family member had symptoms of onchocerciasis (especially the presence of a nodule), which is a finding very important for ongoing surveillance. Conclusions/Significance: Many respondents wanted to continue receive ivermectin and more than half did not believe onchocerciasis had been eliminated. The ministry of health outreach services should be prepared to address ongoing concerns about onchocerciasis in the post endemic CEZ. Author Summary: Human onchocerciasis (also known as ‘River Blindness’) is a parasitic disease of the skin and eyes whose etiological agent (Onchocerca volvulus) is transmitted by black flies. Guatemala was the country in the Americas most afflicted by onchocerciasis, and the largest focus of onchocerciasis in Guatemala was the Central Endemic Zone (CEZ). In the late 1980’s the Guatemalan ministry of health launched an onchocerciasis transmission elimination program based on mass drug administration (MDA) with the medicine ivermectin (Mectizan) in affected communities. Health education messages based on community knowledge, attitudes and practices (KAP) surveys were designed to enhance understanding and sustain participation in the MDA program. The first KAP survey (published 1991) recommended the elements of the health education program. The second KAP survey (published 1995) identified barriers preventing the achievement of adequate treatment coverage, and recommended adjustments to program activities to improve participation. This third KAP survey was conducted in 2014, almost 3 years after cessation of the MDA program. Results indicated that many respondents wanted ivermectin MDA to continue in their community because of uncertainty about onchocerciasis elimination, or in order to treat intestinal worms. The ministry of health outreach services should be prepared to address ongoing concerns of the populations residing in post endemic, post MDA onchocerciasis Guatemala.