Let’s Move the Agenda from Control to Elimination of NTDs

By Prof Louis Albert Tchuem Tchuenté, Pamela Bongkiyung & Prof Russell Stothard

Who has the perfect answer to controlling or eliminating a disease? It gets more difficult when simply using medication does not guarantee no re-infection. In the case of Schistosomiasis and Soil-transmitted Helminthiasis, in the agenda of elimination one wonders if what we need are more parasitologists in the affected areas or getting the current ones to be more publicly engaged in educating the population?

Prof. Louis-Albert Tchuem Tchuenté who has been working on schisto control for over three decades emphasises the control of Schisto as many other NTDs is a long-term combat. That means a lot of investment and capacity building at all levels. It also needs to have the involvement of many actors and stakeholders. It is difficult for a single organisation or a single group to interrupt the transmission of this disease. That is why intersectoral cooperation, partnership and involvement of stakeholders at all levels is very important. Policy makers, scientists, community health workers, health personnel staff, teachers and all category of the population need to be involved in this fight.

Training of parasitologists is very important because in the African setting more needs to be done. It is vital to optimise and adapt the strategy according to the different transmission setting. The same strategy cannot be deployed as it will not have the same impact. That is why for example in Cameroon, when you compare the current distribution of Schistosomiasis to what was done 25 – 30 years ago; there is a significant decrease in some areas. We have examples where transmission has been interrupted, we have many examples where prevalence has been lowered to more than 80 – 90 percent in some of the localities.

But we still have some challenges where the dynamics vary.  The disease prevalence is reducing but variances remain due to the existence of conditions that allow for the transmission cycle to continue. That is why moving from control to elimination requires integration is intensified. Part of this requires increasing capacity building by training more students, investment, health education, change in behaviour and increase awareness of the population. It is a huge challenge.

The Sustainable Development Goals (SDG) has as one of its key point a call for countries to invest more for the control and elimination of Neglected Tropical Diseases (NTDs). Therefore, for the transmission of schistosomiasis to be interrupted there is a need for countries to invest more for the elimination of this disease. When more is invested, this means that we also should invest in equipment, in sanitation, in access to water and change of the environment or that you improve the hygiene.

Prof. Tchuem Tchuenté said: “Granted, the control of schistosomiasis is very challenging, it is a long-term commitment which is feasible. At this stage, there are tools and strategies in place to interrupt the transmission of schistosomiasis; what we need now mainly in Africa is that we must change our approach to become more ambitious. We must move completely from control to elimination. This shift in paradigm should be clearly effective and endorsed by all African countries.”

He believes that when we keep the word ‘control’, we can be satisfied with morbidity control and therefore control morbidity forever. If the agenda shifts to elimination, then the momentum and the target aligns with that shift. Lymphatic Filariasis (LF) programmes have used this approach. The LF programme’s target for years has been elimination and this makes us put a lot of effort into its elimination.

There is a tendency to become complacent when you reduce a disease to the level where it no longer constitutes a health problem. This is when we need to be most careful as you could miss when the disease makes a come-back again. But if you have a target for elimination, this means additional or further efforts to interrupt the transmission and then to move to the surveillance phase. Japan is one of the good examples. In the 1960s, there were some areas in Japan where the prevalence of schistosomiasis was higher than in most parts of Africa. But they decided and launched a ‘zero parasite’ campaign. From the beginning, it was not about control but zero parasites; meaning elimination. In less than 20 years Japan has eliminated schistosomiasis. China started with control but then rapidly moved to the elimination phase. Now their objective is to eliminate everywhere in China.

The COUNTDOWN project is in a key position to contribute to this agenda. Our research aims to increase acceptability, affordability, accessibility and availability of Neglected Tropical Diseases solutions. Our multidisciplinary approach is investigating efficient methods to cost-effectively upscale mass drug administration programmes, thereby moving the agenda closer to elimination.

With this word elimination, you must put the necessary efforts and investment to interrupt transmission. In Africa, the time is right to think about this and to shift completely from control to elimination. It is not easy as this will require a lot of investment. We need to raise momentum and commitment from the government, including investment. That is what the SDG is about; as espoused in one of its goals –  for countries to invest more for the elimination of NTDs!

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Going with the Flow: Local learning about rivers to implement ground larviciding for community-based control of river blindness

by Prof Samuel Wanji, Dr Peter Enyong, Andrew Amuam, Relindis Ekanya, Dr Louise Hamill, Dr Joe Turner

Preparations are proceeding at pace to control the local blackfly population in the South West Region of Cameroon. This is part of an integrated control strategy against river blindness implemented by the COUNTDOWN consortium, in partnership with the University of Buea, the Cameroon Ministry of Public Health and the Liverpool School of Tropical Medicine.

River blindness, also known as onchocerciasis, is a major health problem in the South West Region of Cameroon. It is transmitted by blackflies when they bite humans to obtain a blood meal. There is an effective treatment for onchocerciasis in the form of Mectizan (ivermectin); this drug has been used successfully in many parts of sub-Saharan Africa and South America. However, in the South West Region of Cameroon, and other locations in Central Africa, Mectizan use is complicated by the presence of a second parasite; Loa loa. The latter can cause severe reactions to Mectizan in a small number of heavily infected individuals.

Onchocerciasis is currently targeted for elimination across all of Africa. For this to be achieved, different approaches that do not rely on Mectizan treatment are needed in areas where Loa loa and onchocerciasis are found together.  COUNTDOWN are trialling the co-implementation of doxycycline, a drug that is effective against onchocerciasis and does not have any cross-reactivity with Loa loa, with localised reduction of blackfly populations, to further reduce transmission.

Controlling blackfly populations involves treating the rivers where the fly larvae are found; killing them before they have the chance to mature into adult blackflies and bite humans, thereby spreading the disease. To do this safely and effectively, key characteristics of the rivers in question must be carefully measured.

The research team from the University of Buea are working in collaboration with local communities to effect blackfly control, and give local people the skills, knowledge and training needed to measure key river characteristics. Volunteers to receive training on the measurement and treatment of rivers were selected in conjunction with the health system and community leaders in each location. These people received intensive training on measuring the velocity of water within the rivers, measuring the width and depth of the rivers, determining the discharge rate at a given point, application of treatments to rivers, and safety techniques throughout.

Larviciding Training 3

Figures: volunteers receive riverside training in preparation for upcoming blackfly control activities

Training for all participants from the four different communities was very successful. Communities were enthusiastic about the training and the chance to combat onchocerciasis. As well as causing symptoms such as severe itching, dermatitis, visual impairment and blindness, blackfly biting is a real nuisance in these areas. Within the Meme River basin where this work will be conducted, one person can receive hundreds of blackfly bites every single day. Reducing this biting rate not only reduces the risk of contracting onchocerciasis, but also greatly reduces the irritation of black fly biting. This highlights the importance of this work not only in accelerating progress towards the eventual elimination of onchocerciasis, but also in improving the health and wellbeing of affected communities.

You can read more on our work relating to this intervention and the people behind it below:

Old dog, new tricks? Assessing the potential of integrating focal vector suppression with drug cure to control and eliminate river blindness

Ensuring Onchocerciasis Control is more than just “Skin Deep” by Ending the Neglect of Onchodermatitis

Onchocerciasis in three decades: Through the lens of Prof Samuel Wanji

Onchocerciasis in three decades Part II: Building the next generation of parasitologists

Tackling the Lack of Uniformity in Schistosomiasis Transmission

by Prof. Louis-Albert Tchuem Tchuente, Pamela Bongkiyung, Prof. Russell Stothard

Schistosomiasis or Bilharzia or snail fever as some call it remains one of the neglected tropical diseases (NTDs) that is ravaging many poor people around the world. They thrive in areas with poor sanitation, often inhabited by those with limited to no access to health care. It can cause liver damage or sterility in women. A major symptom is having blood in urine. Controlling this NTD remains a great challenge given that its transmission has no uniformity across countries.

In Africa, the dynamic of transmission is not uniform – it differs from one area to another even in the same country. In Cameroon for example, the transmission is not uniform because what happens in one locality is completely different from others, the dynamic of transmission is different, the snails’ species are different, the interactions between the snails and parasites are different, the re-infection rates also differ. It is important to understand all these aspects and we need more scientists working on this.

Schistosomiasis has different species which vary from Asia to those in Africa. Praziquantel is effective in all six-human species of schistosomiasis. Speaking to Prof. Louis-Albert, we learn that in Cameroon – a West Central African country; there are three species of human schistosomiasis, one specie responsible for urogenital schistosomiasis – Schistosoma haematobium and two responsible for intestinal schistosomiasis – Schistosoma mansoni and Schistosoma guineensis. schistosoma intercalatum is the fourth specie, making a total of four species in Africa. The same drug – Praziquantel is used against all four species and the two-other species prevalent only in Asia – Schistosoma japonicum and Schistosoma mekongi. Both continents use different formulations of Praziquantel.

A major challenge to schisto control and elimination has been controlling human interactions with the water snails. How can African countries extrapolate from the Chinese experience?  According to Prof. Tchuem-Tchuenté, there has to be a change in human behaviour and control of the snail. If there is no snail, there is no schisto. That is why snail control remains key for a move towards elimination.

The Problem with Snail Control 

This was a major control strategy in the 70s but because of the high cost it was abandoned. China has now developed many molluscicides and they have a vast experience on this. With all these new chemicals, it is hoped the cost of snail control will be reduced and that the snail control will make a comeback on the agenda so that it can be integrated to MDA with snail control in other activities of WASH (Water, Sanitation & Hygiene). With this integrated approach, perhaps we can move towards transmission control and elimination.

 People still live in very organic set-ups in schisto endemic areas compared to China where a lot of town planning has been done. How can we successfully implement the aspect of hygiene (WASH) or improve people’s behaviours in controlling schisto?

This is mainly linked to the economic situation in many countries postulates Prof.  Tchuem-Tchuenté. He further advances that to improve hygiene and have health education to modify people’s behaviour, it is necessary that their standards of living increase. To this end, more investment is needed.

“Within the countries, more resources need to be allocated to the control of this disease so that we shift completely from the word ‘control’ to ‘elimination’. If we keep using the word control, you find that we will stay in the same place. If we increase our ambition to elimination, the increase of resources to achieve this goal will be automatic. The country will have no choice but to increase their resources in line with the Sustainable Development Goals”, said Prof. Tchuem-Tchuenté.

The priority intervention for schistosomiasis control is preventive chemotherapy using mass drug administration as the treatment. However, treatment alone is not the solution to interrupt transmission; because reservoirs still exist with the adult population. The current focus is on school-aged children but the parasites exist in people not targeted such as pre-school children and adults. Even if there is high coverage of the school-aged children, lowering transmission and prevalence, there will be a patch of the community with some parasite reservoirs that will maintain the transmission cycle. Recently, there has been attempts to extend treatment to all population age-groups.


Photo Courtesy of Dr Suzy Campbell

In addition to treatment, it is very important that the intervention addresses water-contact and hygiene. This explains why WASH activities have been included in control solutions. In the recent WHO NTD report titled ‘Integrating Neglected Tropical Diseases into Global Health and Development’, it was highlighted that providing safe water, sanitation and hygiene (known as WASH) is critical for preventing and providing care for most NTDs. WASH component of the NTD strategy has tended to be neglected relative to its importance. There is also environmental modification because these diseases are linked to the poverty – lack of hygiene. If there is no open defecation into the environment, we can reduce the transmission of schistosomiasis and then you can interrupt it. If open defecation continues and some part of the population still have no access to latrines, defecating or urinating into the environment will not be stopped. With treatment, this population will remain at the risk of re-infection and the disease can be re-introduced and spread anew.

Another area of schistosomiasis research that is garnering more attention these days is female genital Schistosomiasis (FGS) or urogenital schistosomiasis. COUNTDOWN has incorporated some elements of FGS into its research work in Ghana.

Read below more publications with input from COUNTDOWN researchers, engaging in knowledge cross-share with other researchers and programmes on various areas relating to schistosomiasis.

Paediatric and maternal schistosomiasis: shifting the paradigms by Amaya L Bustinduy, J Russell Stothard, Jennifer F Friedman

Female genital schistosomiasis (FGS) in Ogun State, Nigeria: a pilot survey on genital symptoms and clinical findings by U F Ekpo, O M Odeyemi, S O Sam-Wobo, O B Onunkwor, H O Mogaji, A S Oluwole, H O Abdussalam, J R Stothard

COUNTDOWN will be at the upcoming British Society of Parasitology Autumn Symposium, taking place on 28th September 2017. We will be presenting our work from Cameroon highlighting challenges relating to helminthiasis control, how  NTDs are faring amidst changing partnerships, networks and global health policies on the development agenda. There will be a presentation on the evolving needs of vector-borne diseases surveillance across the world. We hope to see you there or engage with you on social media. Tweet us @NTDCOUNTDOWN


China and Africa Join Forces in fight to Eliminate Schistosomiasis

by Prof Louis-Albert Tchuem Tchuenté, Pamela Bongkiyung, Prof Russell Stothard

In the fight against Neglected Tropical Diseases (NTDs), it has become obvious that learning from other countries’ successes will help many others to control and eliminate these diseases. This is how the China-Africa meeting and collaboration came about in 2012.

Whilst on a visit to the Liverpool School of Tropical Medicine, we caught up with Prof. Louis-Albert Tchuem Tchuenté regarding the China-Africa Meeting on Schistosomiasis Elimination and Training Course on Malacology, organised in Cameroon from the 24 – 28 October 2016.

Prof. Louis-Albert Tchuem-Tchuenté is an NTD Ambassador for Liverpool School of Tropical Medicine. He also heads the Centre for Schistosomiasis & Parasitology in Cameroon and is a professor of parasitology. He lectures at the University of Yaoundé I and is Country Director for the COUNTDOWN project in Cameroon. His expertise in Schistosomiasis and Soil-Transmitted Helminthiasis spans over 30 years. He is Cameroon’s National Coordinator for the control of Schistosomiasis and Intestinal Worms.

Discussions with Prof. Louis-Albert revealed that this China-Africa meeting started a long time ago. Given that China has a vast amount of experience in Schisto control and has successfully eliminated Schisto in many of their provinces; many African countries still struggling with schisto can learn from the Chinese experience. Very few areas have Schisto in China and Schisto has been eliminated as a public health problem there. The highest prevalence is probably 1-2 percent and the plan now is to interrupt the transmission everywhere.

According to Prof. Louis-Albert, China invested a lot on their elimination agenda including treatment, environmental modification and snail control. Most of the schistosomiasis cases in China are zoonotic because they have a lot of animals who act as reservoir hosts. That is why they have invested a lot of money to modify the environment so that the animals do not maintain the parasite life-cycle.

One of the highest components of this is the snail control. Schistosomiasis has two main hosts: vertebrate hosts (including human beings and animals) and the snails. In the transmission, you have both factors that make this happen. The snails are in the water and if you don’t change the environment, the snails remain present. Even if you reduce the transmission, then at some stage it just needs one person who is infected to defecate or urinate into the environment, to rebuild the transmission cycle. That is why it is very important to control the snails. The Chinese have done so successfully and have vast experience in snail control.

Based on this, it became important for African countries to benefit from the Chinese experience. That is why the World Health Organisation(WHO), together with the Chinese government, decided to have this China-Africa cooperation, for the elimination of schistosomiasis in Africa.

This began at the governmental level between China, WHO and the governments in Africa. The agenda was further discussed at the China-Health Ministerial Forum that reviews valuable health development issues. During the 2013 Minister’s Forum held in Beijing, an agreement was reached on this partnership and the initiative approved. This move was necessary to progress granted things take time at the government level. That is why the China team, WHO and African governments decided to start an institutional-based cooperation. This initiative was developed to sustain a China – Africa Cooperation for Schistosomiasis Elimination.

China has several provinces that are endemic for schistosomiasis and it was important to link these provinces to different African countries depending on the relationship they have. That is why in the first phase, ten countries were selected in Africa and were linked with different provinces in China.

The first meeting to set-up the institution-based cooperation was launched in 2015, in Malawi. The meeting launched the initiative and the memorandum of understanding between the partners. The memorandum was signed between different African institutions and Chinese institutions for research. The meeting in Cameroon was the second meeting and it was focused on snail and malacology training. Another component of the training was using mollusciciding to control the snails. The Chinese team and ten countries participated in the meeting in Cameroon.

The rationale for collaboration is clear as it fosters relationships between various actors and allows in-depth knowledge of what works in practice. This knowledge gets refined for better use through creating more cost-effective solutions which are sustainable in the long term for NTD control and elimination.

To continue this cross-sharing of knowledge, COUNTDOWN will be at the upcoming British Society of Parasitology Autumn Symposium taking place on 28th September 2017 taking place at The Linnean Society in London. This session will focus on ‘The Multidisciplinarity of Parasitology: Host-Parasite Evolution and Control in an Ever-Changing World’.



Putting COUNTDOWN Vector Control Activities in the Spotlight at ISNTD Bites 2017

Dr Louise Hamill and Prof Russell Stothard

Control of mosquito and blackfly vectors of lymphatic filariasis and onchocerciasis is a well-known strategy to augment ongoing disease elimination interventions in sub-Saharan Africa. Similarly, although not strictly considered vectors, control of certain freshwater snails is again attracting considerable public health attention for targeted interventions against schistosomiasis, especially in stubborn hot-spot foci. As part of the annual meeting agenda for the International Society for Neglected Tropical Diseases (ISNTD), the importance of vector control for several NTDs, malaria and arboviruses was thrown into sharp focus at their annual ISNTD bites forum.

Each year the ISNTD has a one-day specific workshop to bring together scientists and public health practitioners to highlight the best of current cutting edge endeavours. Held on the 19th July 2017, at the Institute of Child Health, this meeting featured leading experts from UK institutions, NGOs and commercial partners to discuss vector-control solutions for NTDs and discuss global health actions. The meeting showcased the latest research on vector control as well as providing a practical platform and international network to cement implementation partnerships in vector control.

Key COUNTDOWN activities were featured to highlight our work on snail and blackfly control in South West Cameroon, and mosquito control in Ghana. The morning’s keynote speaker, Professor Gabriella Gibson from the University of Greenwich, set the scene and gave a broad overview of how knowledge of vector behaviour is key to improving control and surveillance for vector-borne NTDs. Examples from research showed how knowledge of tsetse and mosquito host-seeking behaviour led to the implementation of innovative control strategies, highlighting how vital the link between basic research and applied implementation really is. This is particularly important as development of insect traps and control methods are adapted to take advantage of weaknesses in their behaviour, leading to a better knock-down of fly populations.

Highlighting medical malacology and the importance of snail intermediate hosts, Professor Russell Stothard gave the opening talk in the first session; “Taking sensible steps in snail control in the crater lakes of Barombi Kotto and Mbo, Cameroon”. Although snails are technically reservoir hosts for schistosomiasis, they form an essential step in the environmental development of the schistosome to release copious amounts of highly motile cercariae, the infective form to people. Therefore, strategies which target this intermediate snail host can lead to effective environmental disease control and elimination. Sometimes, snail control approaches share much with vector control, especially when chemical molluscicides are used. Prof Stothard gave an overview of the current state of snail control, before revealing the recent epidemiological picture of schistosomiasis in the crater lakes of South West Cameroon. Information derived from mapping of water contact patterns at an individual level, ecological snail studies and community wide schistosomiasis prevalence studies, have helped build this detailed picture. This knowledge forms a solid foundation of evidence upon which snail control and interruption of schistosomiasis transmission can be built. See https://youtu.be/dZhx_u8h1yQ.

After talks from representatives of Merck, Natural History Museum, The London School of Tropical Medicine and Hygiene and Oxitec, Prof Stothard chaired the first panel discussion of the meeting. Key repeat themes of integration, and increased knowledge emerged from these discussions;

The more we know about vectors, the more we know about parasites and host interactions, then weird and wonderful ways to control vectors arise” – Ailie Robinson, London School of Hygiene and Tropical Medicine.

We need to collaborate, learn from each other and use a combination of approaches to beat NTDs” Theresa Maier, Merck

To facilitate interdisciplinary working, COUNTDOWN is breaking down silos between different research areas.” Russell Stothard, COUNTDOWN.

The panel discussion was recorded and can be viewed at https://youtu.be/maitrlR39IU.

These themes were further evident in the workshop on the MENTOR Initiative’s Integrated Vector Management Toolbox. In disaster and low resource areas, this workshop focused on effective, implementation ready strategies to control disease vectors in the most challenging of settings, led by Dr Richard Allan. Participants were encouraged to think outside the box, and to consider how a range of strategies could be tailored to particular settings and implemented at scale.

After lunch, there was a host of exciting talks on numerous topics, including a new drug target for tsetse control, improved performance management for NTD programs, Global Health Networks for Impact, and more fascinating discussion panels. It was also good to see other implementation research coming to the fore in the field of vector-borne NTDs, such as the digital monitoring platform Mango, presented by Greenmash; which can be easily tailored to suit specific project needs and has been used to make sure gender-disaggregated data is collected and readily available. This ties in with COUNTDOWN’s work on gender equity in NTD control.

Reflecting on the day from a COUNTDOWN perspective, it was a great opportunity to keep up to date on vector control and other NTD research at ISNTD Bites, and to make sure COUNTDOWN was a key part of the presentations and the discussions. It was particularly pleasing to note that interdisciplinary working and innovation emerged as some of the key themes in the meeting, areas where COUNTDOWN is actively providing evidence for vector borne-NTDs through implementation research on lymphatic filariasis, onchocerciasis and schistosomiasis. Participating in this meeting has ensured that COUNTDOWN keeps a firm finger on the pulse of NTD implementation research, and that the project has a loud voice at an international forum to advocate for our research and approaches.

You can access the Storify of the event here

When to Give or Not Give Incentives: A Researcher’s Reflection on Incentives in the Field

By Irene Honam Tsey

[Irene is a Research Officer & Institutional Review Board Administrator at the Dodowa Health Research Centre. She is currently a researcher on the COUNTDOWN Project].

As researchers in the field, we are very concerned with ensuring positive community relations and conducting ethical research. But my experiences from the field show how challenging this can be. We are very careful to say “thank you” to study participants for taking part in our study and being respectful of their time. For qualitative research when a participant takes part in a focus group discussion or in-depth interview, we provide an incentive as a token of our appreciation or gratitude.  In my organization, this has tended to come after we have conducted the method so participants do not feel pressure to participate. Yet, a dictionary definition of incentive is “a thing that motivates or encourages someone to do something”.

We were left with mixed feelings after the last COUNTDOWN research trip to the field.  There was a sense of guilt and disappointment following various experiences with “incentives”. Throughout our data collection experiences, timing remained an important factor. We ensure we are in the field at times that suit the community. For example, in fishing and farming communities, we would arrive very early or much later to accommodate their activities. We also try to persuade community members to participate by telling them it will not take very long. However, despite our best efforts delays happen which can be very time consuming and frustrating. If we are undertaking in-depth interviews, we try to ensure we meet participants at the right time. But if we have made a few appointments and participants are not available at the agreed time, this can have an impact on the next appointment. If people have agreed to attend a focus group discussion and then turn up late, this can mean other people who were there on time must wait. In communities where people do not have sufficient food, asking people to wait longer can leave them feeling hungry and frustrated. This frustration can spill into the interview or focus group discussions.

I have noticed a pattern with participants. In the morning participants are often hungry and unhappy to wait. Sometimes we give them snacks. However, it has been agreed those snacks (incentives) be given at the end of the interview. We make sure they are hidden from their sight until the end of a discussion. Yet, once participants get the incentives they tell you “Oh we didn’t know you were going to give us anything, or we would not have pushed you and given our best”.

News of incentives does spread and there have been instances where an entire community troops to the venue of the meeting. They then tell us: “You should have told us you would give something!” One community surprised us when its members asked why survey participants were not given incentives. This is because the norm has always been not to give them incentives.

After one such community, a thought occurred to me: why do we not use advertisements for our recruitments? For example: “12men/women needed for an FGD” and spell out what our study is about, including “incentives”. The advert could also add that admission of participants will be based on first come, first serve basis. Interestingly, advertisement is an ethically acceptable tool for recruiting research participants but we barely talk about it or consider it in the context of our research.

In my seven years at the research centre, it took my involvement on the COUNTDOWN project to realise this.  Advertisement should however be done with the best interest of participants at heart, and in a clear, transparent and accountable manner. After all, they are volunteers and must not be forced or coerced in any way.

Creating Impactful Posters: Hot Tips from the COUNTDOWN Consortium

COUNTDOWN Research Uptake Team & the COUNTDOWN Consortium

As researchers, we all understand that presenting posters is part of our publishing journey and doorway to conference participation. But it is important to take time out and reflect on what makes for a good poster. As part of our 3rd Annual Partners’ Meeting, hosted in Yaoundé, Cameroon a side workshop was held on Friday, 31st March 2017, during which participants reflected on this issue.

To begin the exercise, we had a poster walk and assessed all posters created by team members within the partner countries (Cameroon, Ghana, Liberia and Nigeria) that make-up our consortium. Discussions were had around what people liked and did not enjoy about the posters. What could have made the posters better? Responses to this question, provided these “hot tips” to creating an impactful poster, which we share below in case you find them insightful.

(Poster walk, part of poster writing session – Friday, 31st March 2017)

1) Attractive from a distance/captivating

First impressions make lasting impressions some say. It was identified that it is important for the poster to attract attention from afar. This means the images should be clearly visible and the colour coordination arresting.

2) Catchy Title

Appearances can pull the crowd and gives a good punch, but a captivating title keeps them. Ensure your title is concise, straight to the point and offers a clear message.

3) Poster Structure

We understand that posters vary depending on whether they are scientific or non-scientific. But one thing was unanimously agreed, the structure should be logical to put the policies, process and NTD programmes in context. This helps learning/generalisability across themes; whilst providing a better reading order.

Making the language and concepts easy to grasp across all the disciplines, helps the audience to understand your message. Avoid heavy use of text and keep the poster clean and less busy.

It also helps to reference your work clearly where appropriate in the same format. This should situate your body of work.

Emphasis was given to acknowledging the contributors involved in the work and their institutional affiliations.

4. Use of Images

We know that a picture speaks a thousand words and to ensure Neglected Tropical Diseases (in our context) are kept alive, we use photos from the field.

Not forgetting our ethical duties to ensure the photos are appropriately sources, with consent granted and the authors acknowledged to avoid copyright infringements. (Reference to be included)

5) Branding

It is advisable to adhere to the branding of your institution and/or the project you are working on. Ensure the logos are well-placed and in some cases, funders like to see their logos visibly displayed. Do check with them on their preferences. For COUNTDOWN, we coordinate the branding of our posters through use of colours clearly linked to our materials and project. This presents the uniformity in brand identification for our work in various publications, meetings and conferences.

We always welcome more ideas to improve those outlined above as these are not prescriptive but suggestive.

Please feel free to join the conversation in the comments section.

Integration as the next step in controlling Neglected Tropical Diseases

By Dr Suzy Campbell

Integration is the “old/new” global development buzzword: old, because it’s certainly not new! New, because there has been an unprecedented focus on it recently in international commitments, being a key message to emerge at the Neglected Tropical Diseases (NTD) Summit in Geneva, Switzerland last week.

Suzy NTD1

What it’s all about – the 2017 World Health Organization Fourth Report on NTDs

The NTD Summit was organised in conjunction with the release of the World Health Organization (WHO) Fourth Report on NTDs, the fourth anniversary of the London Declaration pledge, and next round of global commitments by international donors, culminating in the Geneva Commitment (see picture) to reaffirm the commitments to fight NTDs that were made in the original London Declaration.

Suzy NTD2

The Geneva Commitment, signed by delegates at the NTD Summit (Photo courtesy: J Vercruysse)

For those NTDs amenable to preventive chemotherapy approaches, the success of integrated delivery of largely donated medicines to alleviate morbidity is without question. Further level of integration within and across the health system needs to continue and it is now time to augment this with tailored activities along with global advocacy. Increased cross-sectoral work is essential to integrate NTD control and elimination programmes within the broader vision of universal health coverage. But, as highlighted by Dr Dirk Engels, Director of the WHO Department of Control of NTDs, integration is extremely complex and no one yet knows enough about what this means. Without doubt, though, NTD development will improve general living conditions, and thus striving for better cross-sector working with integrated solutions is crucial.

Dr Anthony Costello, Director of the WHO Department for Maternal, Newborn, Child and Adolescent Health, gave insight into some guiding principles, namely: approaches must be country-led, have a sound evidence base, be assessable at scale, and have district-level systems. Assessment of programmes at scale is a major current epidemiological challenge – large-scale evaluations are required. Dr Costello then invited us all to join him in “LALA Land” – a novel way to encompass essential parameters of leadership, action, learning and accountability! Recognising the integration challenges, and the importance of continuing to strive to overcome them, Dr Margaret Chan (Director-General, WHO) gave a strong statement of support emphasising that “What gets measured, gets done”. In this she indicates WHO commitment to NTD indicators – if there is an indicator that programmes need to meet, NTD work will continue.

Dr Anthony Costello NTD Summit17

Dr Anthony Costello, Director of the WHO Department for Maternal, Newborn, Child and Adolescent Health

To provide a global tool to integrate, advocate and ultimately address underrepresented NTDs and control efforts (including water, sanitation and hygiene (WASH), vector control, veterinary public health, and care programmes) the BEST Framework was launched. Complementing existing WHO and UN frameworks and strategies, the BEST Framework provides a comprehensive approach for collaborative investment in NTDs for development, and for standardising measurement of these interventions to maximise benefit. Building on the four components of Behaviour, Environment, Social inclusion and Treatment, the framework emphasises the necessity of cross-sectoral work and strengthening systems to improve equity and inclusion, and maximise positive impact of development investments in NTD countries.

With this strongly supported integration theme underpinning the entire Summit, there is much optimism that significant progress will continue to be made in combatting NTDs, even as we tackle the heady issues of elimination for some of them, which already requires refinement of existing strategies. The existing progress in combatting NTDs that has already been made has provided the best possible platform for continued partnership and development.

COUNTDOWN Consortium: Sharing Learning on using a Multidisciplinary Approach to the Study of Neglected Tropical Diseases and Contributing to Policy Change for NTD Control

By Akinola Oluwole, Kabiru Salami, Luret Lar, Solomon Jacob, Ndelle, Dr Nebe Obiageli, Pamela Bongkiyung

COUNTDOWN is a consortium which is using a multidisciplinary approach to research with the aim of contributing to policy change in the implementation of Neglected Tropical Diseases (NTDs) control and elimination programmes. We are working in four countries: Nigeria, Liberia, Ghana and Cameroon.

There is an African proverb that says “If you want to go quickly, go alone. If you want to go far, go together.”  This proverb fits with the COUNTDOWN consortium’s vision to improve the control/elimination of NTDs through a “multidisciplinary research approach” to generate quality data. To achieve this, the consortium draws together experts from different disciplines. Undertaking good multidisciplinary research is an art which takes time and dedication. Reflecting on our experiences it is important to consider the following factors:

Harmonise Objectives

The first task as a multidisciplinary team in COUNTDOWN is the need for the different disciplines involved to come together and identify the main objective of the project, the different specific objectives and responsibilities of each discipline. This can be done by developing sub-objectives together which ensures complementarity and avoids duplication. COUNTDOWN has gone further in exemplifying harmonisation through its numerous workshops held to plan and streamline calendars and cross-them working. One of such workshops held in Limbe, Cameroon birth lessons highlighted in this blog – “Multidisciplinary Research at the Foothills of a Live Volcano” by Prof. Sally Theobald.

Respect of Values

To work together as a strong team and for the team to thrive, respect for each team member’s values and recognising each other’s strengths and weaknesses, is a good recipe for working together. There is a need for willingness on both sides to start from the basics and move forwards, with mutual respect for disciplines. One way of ensuring respect and collaboration is working from the central concept of a single team rather than separate ones. When you travel to the field we have one goal in mind – producing quality evidence research. There should also be a conflict resolution plan, to inform how disagreements (which inevitably happen) can be resolved.

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L-R: Prof. Uche Amazigo, Dr Oluwatosin Adekeye & Dr Akinola Oluwole








Establish Coordination of Activity Timelines, and Programmatic Structures for Communication

As a multidisciplinary group, the need to come up with deliverables, given a timeline and budget to the activities cannot be over emphasized. This is to avoid delays or setbacks to implementing time-related activities as well as preventing discord that may arise from overspending on one discipline to the detriment of another.

In addition, an effective coordination and communication structure with quality study design and purpose must be put in place. The team must agree on how data will be harmonized across the different disciplines requiring that all team members make a concerted effort to understand each other’s methodologies, decision on authorship order in publication and most important of all having equal access to data generated. This will ensure the continuous involvement of all disciplines where everyone’s voices are reflected and count equally in identifying research problems and shape teams to meet research needs. It is equally important that from concept to delivery, all country-level managers of NTD programmes need to be involved as they play a crucial role in effective implementation of the research objectives and outcome.

Physical interaction among the team members is also important as this will enable members to agree on ideas. There should be time for face to face interaction through periodic meetings so that members of the team can ask questions, resolve conflicts, clarify issues, explain and agree on different disciplinary terminologies and perspectives. During the meetings, team members are encouraged to come open-minded to learn new ideas and maintain regular communication with feedback.

This is embodied in COUNTDOWN’s Annual Partners Meeting (APM), where partners that make up the consortium, from the various countries (Cameroon, Ghana, Liberia, Nigeria, UK & USA) come together to learn about progress in each country and cross-sharing of knowledge takes place during discussions. The recent partners meeting took place in Yaoundé, Cameroon from 28 – 30 March 2017.

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Capacity Development Within COUNTDOWN, we do not use capacity development interchangeably with training. Training is one component of developing capacity, which we take seriously as seen in the PCR training in Ghana, the recent Evidence Synthesis held in Yaoundé, Cameroon from 7 – 9 February 2017, including Health Economics data analysis, basic Nvivo and qualitative analysis training at the APM. All our training has been designed to consider the local cultural, policy and organisational context. We recognise that shoring up capacity in the areas of policy research as seen in the recent situational analysis undertaken by the Nigeria COUNTDOWN team, policy immersion (our collaboration with policy making bodies) and awareness building, are essential to the capacity development of COUNTDOWN.

Overall, there is a need for an inclusive leadership where a representative from each of the collaborating institutions forms a management team with the responsibility of driving the coordination of activities in multidisciplinary projects.

Other reading:



Ensuring Onchocerciasis Control is more than just “Skin Deep” by Ending the Neglect of Onchodermatitis

Louise Hamill, Michele Murdoch, Mathias Esum, Jerome Fru, Samuel Teghen, Ernestine Wasso, Anicetus Suireng, Peter Enyong, Mark Taylor, Joseph Turner, Samuel Wanji

The COUNTDOWN team in Buea, Cameroon, are working hard to ensure that the assessment of skin disease caused by onchocerciasis is firmly embedded within the alternative onchocerciasis control strategies they are developing. The work, led by Professor Samuel Wanji, Dr Joe Turner and Professor Mark Taylor, aims to implement these alternative strategies for the control and elimination of  river blindness (onchocerciasis) in South West Cameroon. Onchocerciasis control in South West Cameroon has been sub-optimal using conventional approaches (Wanji et al., 2015), and so new, alternative strategies are urgently needed.

Onchocerciasis is a parasitic disease, caused by worms which are transmitted by the bite of infected blackflies. Untreated, onchocerciasis leads to progressive visual impairment and eventually irreversible blindness, as well as severe itching and a range of serious skin complaints, collectively known as onchodermatitis. Efforts to control this debilitating disease have used several different approaches over the past five decades.

Previous Approaches to Onchocerciasis Control

Early onchocerciasis research concentrated on blindness, and the first large-scale control programme, the Onchocerciasis Control Programme (OCP, 1974 -2002) successfully targeted the blackfly vectors in 11 West African countries with known high rates of onchocercal blindness. However this meant that, compared to blindness, there was comparatively less data available about the incidence, severity and geographic distribution of onchodermatitis. In an attempt to address this, a study was conducted across seven different rainforest sites in five African countries, all with known low rates of onchocercal blindness. The study revealed that 28% of the population aged 5 years and above had one or more forms of onchodermatitis (Murdoch et al. 2002). This work was pivotal in the decision to establish onchocerciasis control programmes in similar communities; those with a significant burden of onchodermatitis but which had previously received low attention because of low prevalence of onchocercal blindness. The African Programme for Onchocerciasis Control (APOC) was launched in 1995, and used community-directed treatment with ivermectin in 16 countries with predominantly onchocercal skin disease. Updated estimates of the health impact of APOC show that, because of the very large number of people with onchodermatitis, skin disease was, and is, more important in contributing to the overall burden of onchocerciasis than eye disease (Coffeng et al 2014). Therefore, skin disease must be central in any approach to the control of onchocerciasis going forward.

Alternative Approaches to Onchocerciasis Control in Cameroon

The main alternative control strategy that will be implemented in South West Cameroon is test and treat with doxycycline. A smaller sub-study will look at the effect of combining doxycycline with localised vector suppression. Previous work has shown doxycycline is highly effective against onchocerciasis (Turner et al., 2010). To monitor the effectiveness of these approaches, parasitological, dermatological, health economic and social science data will be gathered. Due to the lack of data around onchodermatitis generally, and particularly data on the response of onchodermatitis to doxycycline, the team identified collection of additional data on the presence of onchodermatitis as a priority.

Strengthening Onchodermatitis Detection Capacity

With this in mind, COUNTDOWN arranged a training visit from consultant dermatologist and leading expert on onchocercal skin disease; Dr Michele Murdoch. Professor Wanji and Dr Murdoch led a week long intensive programme of classroom teaching and clinical training for nurses from endemic areas, to enable them to better recognise signs of onchodermatitis.

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Dr Murdoch and some of the team who participated in the week-long training workshop

During the taught component of the workshop, the team learnt about the morphology and terminology of skin lesions, the clinical classification of onchodermatitis, and other common skin complaints. The collection of data on itching was explained and practiced through role play. In addition, there was opportunity for the team to practice form-filling for clinical signs using clinical slides of cases.

Although the severity of symptoms varies from person to person, onchodermatitis is classified into five main categories. Dr Murdoch taught the team how to recognize the characteristics of these five categories. Briefly, they are:

  • Acute papular onchodermatitis: itchy papules (small bumps) are present on the skin and some swelling, is also possible. These itchy papules can cover large areas of the body.
  • Chronic Papular Onchodermatitis: itchy papules which are larger than acute papular onchodermatitis, often around the waist and hips. Hyperpigmentation, whereby the skin takes on a much darker colour, may also occur.
  • Lichenified Onchodermatitis: hyperpigmented skin plaques, accompanied by intense itching
  • Atrophy: similar to premature aging of the skin, resulting in loss of elasticity with excessive wrinkling and dryness.
  • Depigmentation: also known as leopard skin, is when pigment (colour) is lost from entire patches of skin, with spots of normal colour around hair follicles.

Read the full description of the classification of skin disease here: (Murdoch et al., 1993).

After the taught component of the workshop concluded, the team undertook three days of practical clinical training. Consenting volunteers from communities where onchocerciasis is known to exist underwent preliminary screening for skin complaints prior to the week’s training commencing. Individuals with skin complaints were then asked for further consent to volunteer in the training. Dr Murdoch conducted examinations on these individuals, and clinical signs were demonstrated and discussed with the three nurses in a teaching setting. The nurses also conducted observed skin examinations themselves and examination techniques and observations were discussed and reviewed. The ability of the nurses to accurately detect onchodermatitis compared favourably with that of Dr Murdoch by the end of the week. When the implementation begins, these nurses will be part of the field team who travel to endemic areas and survey communities for onchocerciasis infection. The increased knowledge and capability they gained will have a lasting impact on their capacity to correctly diagnose onchodermatitis in the future.

The Bigger Picture: Research and Policy on Skin NTDs

In the past, the onchocerciasis research agenda was dominated by efforts to eliminate blindness; reprioritisation of onchodermatitis within a framework for addressing onchocerciasis morbidity in general would help redress this balance. This could be done in conjunction with other skin NTDs, such as the integrated approach to managing skin NTDS proposed by Mitja et al., 2017. As they outlined, initial assessment of individual endemic skin diseases is a crucial first step towards implementing an integrated management strategy for skin NTDS. The work of COUNTDOWN in South West Cameroon can directly feed into this initial assessment. Furthermore, as a visible, outward sign of disease, skin symptoms, associated ill health and stigma, and the impact they have on general well-being, may be more important to the patient than, say, their parasitological status. Assessment of skin symptom severity over time or in response to treatment allows better assessment of the added impact any such treatment may be having, and is less invasive than standard parasitological measurements. This should be of paramount importance when formulating or revising control strategies at the national and international level.

This work is not only important for individuals who are affected by onchodermatitis, but more broadly to raise awareness of NTDs which cause skin disease, and to provide up to date evidence on their control. Evidenced based policy and planning is becoming increasing important in all areas of health research.  Given the number of NTDs recognised by the WHO which can give rise to acute or chronic skin presentations (table 1), the assessment of skin disease in sub-Saharan Africa should be afforded higher priority on research agendas, particularly due to the lack of programmatic data surrounding their distribution, severity and management.

NTD Associated skin pathology
Onchocerciasis Severe itching, nodules, onchocerciasis related dermatitis (onchodermatitis); acute or chronic papular dermatitis, lichenified onchodermatitis, “leopard skin”/depigmentation, skin atrophy, hanging groin
Lymphatic filariasis Lymphoedema, elephantiasis, hydrocele, secondary bacterial infections
Cutaneous leishmaniasis Multiple skin ulcers, papules, nodules, plaques, scarring
Leprosy Skin patches, nodules, thickened nerves, damaged skin, permanent damage and disfigurement of eyes, nose, limbs, fingers
Buruli ulcer Skin ulcer
Yaws Ulceration, damage to skin, bone and cartilage
Mycetoma Subcutaneous mass with sinuses and discharge, destruction, deformity and loss of function in infected areas

Table 1: summarised from Mitja et al., 2017

Evidence on onchodermatitis is scarce, but not completely absent; Ozoh et al. performed two cross-sectional surveys of onchocercal skin disease at baseline and after 5 or 6 years of annual ivermectin treatment and found profound reductions in itching and all forms of onchodermatitis (Ozoh et al. 2011). An earlier study found that annual ivermectin treatment reduced skin symptom severity and prevalence, however there was no additional benefit when  3- or 6-monthly ivermectin treatment regimens were compared with annual treatment (Brieger et al. 1998). Re-analysis of pre-control data from Nigeria confirmed significant levels of itching and onchodermatitis in an area which was already known to have high rates of onchocercal blindness (Murdoch et al 2017), and demonstrated a strong correlation between parasitological indicators and risk of onchodermatitis. The burden of onchodermatitis uncovered by these studies shows why gathering evidence on the prevalence and severity of skin symptoms is so important. Otherwise, assessment of skin disease caused by onchocerciasis has been relatively neglected by control programmes. Data on skin disease before, during or after the implementation of mass drug administration programmes is not routinely reported, so this represents a real gap in our knowledge. The COUNTDOWN work in Cameroon will lead the way in bridging this gap, generating evidence to enable future research and policy agendas to prioritise assessment of NTD skin diseases appropriately.

On top of the direct and devastating physical impact of skin NTDs, recent work quantifying the mental health burden of Lymphatic Filariasis in patients with skin symptoms and their caregivers (Ton et al., 2015) showed how skin diseases have a serious impact on both a mental and physical level. COUNTDOWN has brought together parasitologists, health economists and social scientists to generate data on the overall burden, physical, mental and financial, of onchocerciasis on an individual and community level. Finally, skin presentations in onchocerciasis are a chronic presentation of the disease, they indicate a long-term infection that has progressed over the course of a lifetime. Lifelong infection with preventable infectious diseases is exactly what the targets set out by the Sustainable Development Goals and London Declaration are trying to eliminate. Tackling this “chronic pandemic” of avoidable disease and suffering caused by NTDs (Molyneux et al., 2016) is a necessity. Prioritising onchodermatitis and other skin NTDs provides an easy and effective means to do this.

COUNTDOWN is leading the way in implementing the well-established clinical grading scale to monitor the impact of doxycycline treatment, and providing a model through which onchodermatitis can be prioritised during such treatment programmes. If successful, this approach could be easily transferred to other endemic areas, and be used to monitor new drug regimens that are currently being developed. The knowledge transfer and capacity building achieved during the week-long workshop in collaboration with Dr Michele Murdoch is another important step towards increasing the profile of skin NTDs and moving towards integrated management strategies.