COUNTDOWN at the Royal College of Pathologists: Emerging and Neglected Tropical Infections

By Professor Russell Stothard

A dear departed colleague of mine from the London School of Hygiene & Tropical Medicine (LSHTM), Dr David Ellis, often used to tell me his favourite medical joke – 

“What’s the difference between a physician, a surgeon and a pathologist? The physician knows everything and does nothing. The surgeon knows nothing and does everything. The pathologist knows everything, but always a week too late”.

David died in 2012 aged 90 but throughout his varied career, he was a proud member of the Royal College of Pathologists.

In life, David had many colourful stories and as a young man he worked with the eminent pathologist Howard Florey during the first trials of Penicillin in Oxford during WW2. He danced ballet with Marlene Dietrich in the opening scene of Hitchock’s Stage Fright in 1950 (but that’s another story), and whilst in charge of LSHTM’S Electron Microscope Unit from 1975 made many important discoveries. David was one of the very first to characterise Ebola virus, a pathogen that many of us in COUNTDOWN now know well and was regularly seconded to Porton Down to provide biosecurity advice to the UK Forces.

With this in mind, I was very honoured to be invited to present at the Royal College of Pathologists on their emerging and neglected tropical infection day. The meeting echoed many of David’s interests, from use of antibiotics to emerging viral diseases, and I was delighted to present our recent COUNTDOWN research.

The first talk by Dr Colin Brown (Public Health England), introduced key topics in the practice of medical bacteriology in the UK: epidemiology of Mycobacterium chimaera associated with open heart surgery, the UK-rise of scarlet fevers with group A Streptococci, outbreak vaccination strategies for pertussis control and emerging antimicrobial resistance in general. Taking a more international perspective, emerging viral diseases were discussed by Professor Daniel Bausch (LSHTM), who now heads the UK Public Health Rapid Support Team, as he recounted his experiences in West Africa, providing support during the recent Ebola Virus Disease outbreak. As many of us know, this was supported by UK-AID and many staff from both UK Schools of Tropical Medicine. The theme was also expanded on by Lieutenant-Colonel Emma Hutley (Royal Army Medical Corps), who helped oversee setting up diagnostic laboratories in Sierra Leone. These provided essential services for patient blood screening, transfusion needs and pathogen detection illustrating the cornerstone role of effective pathology services in real time needs. The latter was especially important to confirm or exclude viral infection.

A later talk by Professor Mathew Fisher (Imperial College London), shed new light on the current problems of antifungal management and treatment of fungal disease either found in the blast wounds of servicemen from soil-contaminated shrapnel or in the lungs and bodies of those with opportunistic infections in London. Mat highlighted his airborne sampling apparatus for fungal spores sited on St Mary’s rooftop, a few floors above Sir Alexander Fleming’s laboratory where he first discovered mould juice to have antibacterial properties, although it was Florey et al. who pioneered its clinical implementation.     

A key but often an under-appreciated part of pathology is study of medical parasites, especially those in the tropics. In contrast to the acute nature of either bacterial or viral infections; medical parasites on the other hand are often chronic, difficult to control and inflict disease in tens of millions. I presented on recent work within COUNTDOWN and highlighted the importance of female genital schistosomiasis (FGS). A quick show of hands of revealed only 3 of the audience had heard of the condition, but one reported she had seen it several times in the UK upon referral from perplexed surgeons who had encountered suspicious cancer-like masses in the Fallopian tubes and uteri of their patients undergoing surgery, which later turned out to be schistosomiasis granulomata (neoplastic masses around trapped schistosome eggs).

The discussions, reminded me of David’s joke, so I made extra effort to feature our work in of FGS in Ghana, Cameroon  and the importance of the international workshop we organised in South Africa three years ago. All of which is starting to raise more awareness, hopefully outside of pathology to FGS; and allow NTD programmes to change tactics through more enlightened discussions and better align themselves with key sustainable development goals, leave no one behind.

Making change happen does not come quickly and there is no short route to rapid policy change but a quick review of our recent activities in Ghana reveal there is much to be hopeful for. Furthermore, this year at our annual partners meeting in Liverpool I hope to see our carefully nurtured seedlings of COUNTDOWN research start to flower, to bear fruit and to nurture lasting policy change with more equitable NTD interventions.     


Press Play for Women pushing for progress on Global Health

by Pamela Bongkiyung, Prof Sally Theobald, Julie Irving, Rachael Thomson & Eleanor MacPherson

“Only 31% of the world’s ministers of health are women, and among the chief executives of the 27 health-care companies in the 2017 global Fortune 500, only one is female.”

The Lancet, Nov. 2017[1]

With this knowledge, we are ushered into this year’s International Women’s Day, whose theme is charging us to #PressforProgress on gender parity. In the COUNTDOWN programme, we are pushing for  gender analysis to be a critical part of policy and practice to address Neglected Tropical Diseases (NTDs), to ensure their equity and effectiveness whilst promoting social justice.

#PressforProgress 2018 International Women's Day

The Department for International Development (DFID) released its strategic vision on gender equality on 7th March 2018 titled ‘A Call to Action for Her Potential, Our Future’. DFID’s vision on gender equality emphasises a need for all to challenge and change unequal power relations, build inter-linked foundations that will have a transformational impact for girls and women, protect and empower girls and women in situations such as conflict, protracted crises and humanitarian emergencies among others. Most importantly, this strategy urges that we leave no girl or woman behind by integrating gender equality across board and build an evidence base that uses data reflective of all groups. This is critical for the NTD response and in COUNTDOWN we have a strong focus on research and action to promote inclusive NTD strategies and approaches.

The COUNTDOWN programme which is multidisciplinary in nature, has been working with women who are leaders in health research and implementation. They have made it their life’s mission to spearhead access to leadership positions, representation of women in health systems research and recognition for women’s contribution to the health system; where women constitute the majority of the health workforce, but are sadly under-represented in leadership positions.

But what prevents the rise of women is bottlenecks in institutions and rules that hinder career advancement, sometimes due to gender bias and discrimination in the workplace and preconceived notions about difficulties of balancing family responsibilities with work.[2]

Regardless of the obstacles they encounter, women still strive for progress as exemplified by our Social Science lead in Ghana, Prof Margaret Gyapong. She decided a year ago to take up the mantle of leadership at a young university – University of Health and Allied Sciences in Ho, Ghana as Director for the Centre for Health Policy & Implementation Research. Prof Gyapong will give her inaugural lecture titled “From the stomach to the skies: Lay perceptions of disease causation and implications for disease control” on 15th March 2018.

Margaret Gyapong Inaugural Lecture

Globally, there has been some progress in promoting gender equity at leadership representation tables and in gender pay gaps. Early this year, we saw Iceland take the lead in enforcing gender equal pay. The UK is getting tough on the issue by asking companies to provide evidence of efforts being made to ensure this gap is bridged. The Bank of England in its Gender Pay Gap Report acknowledges more needs to be done. We need to ensure initiatives promoting gender equity in human resource for health extend to all contexts and all levels of the health systems including amongst community-based drug distributors who play a critical interface role linking NTDs programmes and communities. We need to promote gender transformative approaches in health systems strengthening across the board, and we welcome DFID’s publication highlighted above.

We encourage you to read a paper recently published in the British Medical Journal of Global Health by our colleagues and great women leaders from wonderful organisations on “20years of Gender Mainstreaming in Health: Lessons and reflections for the neglected tropical diseases’ community”.

Happy International Women’s Day and aluta continua!



Don’t be alone, don’t be afraid: Partnerships fostered between the NTD Programme and Communities in Liberia

by Karsor Kollie, Laura Dean, Anna Wickenden and Sally Theobald

This was an exciting and historic event to celebrate World Leprosy Day.  It was the first-time that people affected by these diseases came together to increase awareness of the integrated approach to morbidity management and launch the LF/Onchocerciasis MDA programme in Liberia. This created an important space for patients to meet many others for the first time, and further strengthen these exchanges with each other will have impact on many levels.

Patients in Attendance

Ma Grace, Pa Abraham and Pastor Joseph stood strong to tell their testimonies of life with either Lymphatic filariasis (big foot) or leprosy in Maryland County, Liberia. Their inspiring journeys of overcoming challenges and being part of community life meant that they were important advocates for the NTD programme, bringing much needed visibility and inclusion of people affected. Their key educational messages to their peers – others from Maryland with lymphoedema or leprosy, school children and community health volunteers and community health workers were:

  1. Don’t be alone, don’t be afraid, speak to others;
  2. Visit the health centre and
  3. Take your drugs.

Zero disability

Community health volunteers and community health workers play a critical interface role in NTD and other health programmes, linking communities and health systems. One community health support supervisor, shared her experiences of contributing to “Ending the Neglect and Stigma: to achieve zero disabilities in girls and boys affected by NTDs” (the theme of the day’s event). They also explained how they provide psychosocial and medication support. This important cadre of “foot soldiers” was appropriately celebrated. They also demonstrated how to measure clients and distribute medicine.

Karsor Kollie, director of the NTD programme and COUNTDOWN country manager, provided awareness and education on the different focus NTDs such as Buruli ulcer (everlasting sore), lymphatic filariasis (big foot/big water bag), Leprosy and Onchocerciasis. He broke down complex concepts into clear digestible chunks and the audience were really engaged. We also heard from Dr Evelyn Kandakai, ambassador for the NTD programme and former Minister of Education in Liberia. She began by thanking the audience for maintaining peace in the recent elections. She then had three key messages 1. Be a friend to people affected by NTDs, 2. Cooperate with programme work and 3. Make Liberia environmentally friendly. She asked the audience to “put their arms around the Ministry of Health and Karsor Kollie”.

Dr. David Ross, CEO – Task Force on Global health, launched the CNTD-supported, DFID-funded, Mass Drug Administration against Lymphatic Filariasis/Onchocerciasis in Maryland County. This included several participants including the NTD Director, former Deputy Chief Medical Officer (DCMO) and Director of Community Health taking part. They were measured using the height pole, given the appropriate number of pills, and swallowed the mectizan and albendazole to demonstrate that the medicines are safe, and everyone can safely take them.

Reflecting on the day, it was great to see partnerships celebrated at different levels of health systems. The emphasis on the critical role of patients, communities and Community Health Volunteers (CHVs) and the importance of their ownership and agency was refreshing and important. Strengthening these partnerships will be critical in meeting the challenges ahead.

Swiss TPH Winter Symposium 2107: Helminth infection – from transmission to control

By Professor Russell Stothard

Unlike the UK where there are two schools dedicated to tropical medicine, there is only one in Switzerland and located in Basel. The Swiss Tropical and Public Health Institute (Swiss TPH) is affiliated with the local university and has over 800 people from more than 70 nations working on infectious and non-communicable diseases. Internationally, the Swiss TPH has a large global foot print which has grown since its foundation in 1943.

Like the Liverpool and London Schools, the Swiss TPH has a fascinating history. Its first director – Rudolph Geigy, is widely recognised as a true pioneer of the control of vector-borne diseases. Today the institute still oversees two field stations in Côte d’Ivoire and Tanzania, originally founded as the Centre Suisse de Recherches Scientifiques (CSRS) in Adiopodoumé and the Swiss Tropical Institute Field Laboratory (STIFL) in Ifakara. The institute actively supports many interventions globally that assuage disease in low and middle-income countries.

To highlight the best of current research and control activities, each year the Swiss TPH organises a winter symposium on a topic of international interest. This year the 2-day meeting’s theme was dedicated to medical helminthology; a lot of ground was covered within a packed programme. Much of it featured implementation research that fostered interdisciplinary studies and as such, I was honoured to represent COUNTDOWN. I highlighted our research across those neglected tropical diseases amenable to preventive chemotherapy and during my keynote presentation. I discussed some of our most recent publications on gender, blogs and presentations on soil-transmitted helminthiasis and schistosomiasis as well as the growing importance of science communications in general.

With today’s changing lifestyles and needs to process information, it is critical to demonstrate how modern media tools can showcase and raise awareness of research uptake. This can be viewed as exploring a combination of new distribution channels alongside older ones that embed implementation research into adaptive health system programming and policy change. For example, I was able highlight our recent paper on WASH which was particularly opportune for our co-author Yael Vellerman was in attendance. I chaired the session where Yael presented her recent activities in WHO, whilst currently seconded from Water Aid, she discussed issues pertaining to scale-up of WASH-related interventions. I illustrated our collaborative steps, starting with platform discussions at COR-NTD, in revealing research and policy gaps. This gave better context to the need for cross-sector collaboration in development of appropriate indicators for surveillance of health and environmental change. More generally, an overview report of this meeting is featured within the Swiss TPH website likely with more detailed outputs to follow as several papers presented will later result in peer-reviewed manuscripts.

While there were many powerful examples of cross-talk and complementation of methods in implementation research, I want to highlight a few. Exciting new methods to measure children’s physical fitness and physio-social needs before and after de-worming were presented by Professor Markus Gerber; better clinical management of liver cancers alongside eco-health approaches in the environment to curtail transmission of opisthorchiasis were excellently illustrated by Professor Banchop Sripa.

From my perspective, I found this meeting a very fertile field to sow the seeds of research uptake and future collaboration which is needed to advance towards WHO 2020 targets and 2030 Sustainable Development Goals.


Mind the Gap: Lessons from over two decades in Gender Mainstreaming on NTDs

by Professor Sally Theobald, Pamela Bongkiyung & Laura Dean

Gender matters in the world of Neglected Tropical Diseases (NTDs). What is gender? The World Health Organisation (WHO) defines gender as ‘socially constructed roles, behaviours, activities and attributes that a given society considers appropriate for men and women, and people of other genders.’

Following the meeting ‘Women and Girls in Focus: Ensuring NTD Programmes Achieve Gender Equality and Empower Women and Girls’ in July 2016, a group of experts and researchers from programme, donor, policy, educational institutions came together to discuss how to further the gender mainstreaming agenda within NTDs.

Because of this meeting, a paper just published in the British Medical Journal of Global Health entitled ‘20yrs of Gender Mainstreaming in Health: Lessons and Reflections for the Neglected Tropical Diseases Community’, was conceptualised. In the paper, the authors extrapolate lessons on gender mainstreaming from the past two decades; showing how addressing gender inequities can strengthen NTD programmes.

The first lesson that can help researchers, policy makers, practitioners to address gender power relations most relevant to their work is tailoring the gender framework to help make the focus on gender explicit. The authors provide an example of how gender frameworks could support the delivery of MDA.

Given that gender does not operate in isolation, the second lesson is taking on the challenge of intersectionality. Privilege, power and inequity which could be due to age, nationality, ethnicity, religion, sexuality, disability and socio-economic are the multiple axes through which gender is experienced. Some of these factors play a role in enabling or preventing access to MDA. Due to stigma and lack of perceived need, affected people stay hidden within their communities. Access is further limited or non-existent for people with disabilities.

Community drug distributors (CDDs) who are the backbone of NTD programmes. Who gets chosen as a CDD is shaped by gender power and participation; and is our third lesson. CDDs are selected by their communities as trustworthy people. The selection process appears equitable on paper but can have the unintended consequence of reinforcing gender and social hierarchies within communities.

The fourth lesson is the need to unpack gender and power dynamics at household level as this impacts delivery of NTD programmes. CDDs are embedded within the communities and possess a strategic understanding of the social and cultural norms, they are in a good position to be agents of social change for health outcomes.

The final lesson from the paper focuses on bringing a critical gender lens to data always. The authors emphasise that care be taken in how data is disaggregated, avoiding the pitfall of making certain groups invisible especially those who face multiple challenges in accessing care and treatment.

During the International Federation of Anti-Leprosy Associations meeting on 18th October 2017, some of the authors of the paper (Prof Sally Theobald & Ms Laura Dean) from the COUNTDOWN programme at Liverpool School of Tropical Medicine; delivered a keynote on gender mainstreaming as could be applicable to the leprosy programmes. They used this engagement platform to share insights on the importance of gender to the health system, given that the latter is not gender neutral and plays a key role socially in how health needs, outcomes and experiences are achieved and met. Here is the Storify of the social media interactions of the keynote.

COUNTDOWN worked with the WHO in trialling a Gender, Equity & Rights (GER) tools in Northern Nigeria with our partners Sightsavers, based in Kaduna. A presentation on the findings of this process was delivered at the WHO headquarters in February, 2017 and was well-received. It is helping to guide and inform WHO’s policy in incorporating gender into various programmes.

To read more on COUNTDOWN’s engagement on issues related to gender, equity and rights, read the below:


Share your experiences working in this sector in the comment section and join us on social media for further interactions.



Impact of NTDs: Beyond the Patients

by  Maureen Tembei, Sally Theobald, Russell Stothard & Samuel Wanji

The burden of neglected tropical diseases is mainly discussed from a patient-centric perspective, however, there is a wider impact where these diseases touch the lives of those providing care and support. In this blog, we explore and expand upon broader issues of the Neglected Tropical Diseases (NTDs) burden and care drawing from experiences of work in Cameroon and the international literature.

  1. Catastrophic health expenditure for NTDs at household level

NTDs such as onchocerciasis and lymphatic filariasis (LF) lead to low economic productivity, catastrophic health expenditures, low quality of life, social stigma and isolation of affected persons and their households’ due to disabilities related to these diseases. The physical challenges associated with these conditions contribute to large productivity losses as most patients are of working age. The economic cost of managing the disability associated with these diseases are overwhelming and compounded by productivity losses (both paid and unpaid work). Household members suffer from financial losses trying to treat household members affected both directly and indirectly. Direct cost of treating these diseases (medical and non-medical costs) added to the productivity losses (economic, domestic and academic, e.g. dropping out of school leading to loss of knowledge) at household level for both patients and caretakers can be devastating.

Maureen Blog on Beyond Patients 1
Children dropping out of school to take care of affected family members.  Photo Credit: Carter Center.


So far, the impact of NTDs have been focused on patients, ignoring the significant impact these diseases have beyond patients to their family members. These diseases interfere with household consumption of economic and domestic (household chores and leisure) activities thereby reducing their ability to attain good health (WHO, 2009). Households of affected persons may reduce their consumption by liquidating household savings or assets thus, diminishing their opportunities to generate financial and physical capital. These household health expenses at times go beyond World Bank recommendation for catastrophic health expenditure being 10% of household income. This was evident in a leprosy economic study in India rising by up to 40% of household income (Chandler et al. 2015).

Maureen Blog on Beyond Patients 2

Buruli Ulcer  Photo Credit: Dr S Etuaful, Ghana

A study on the household cost management of another debilitating NTD; buruli ulcer at Akonolinga in Cameroon demonstrated a direct cost of €59.3 constituting 25% of household annual earnings for treatment of the disease while indirect productivity cost for both patients and family members was €64.4 (Koen et al. 2008). Also, Koen et al. reported that 63% of households cease to provide social and financial support for patients as a coping strategy.

Maureen Blog on Beyond Patients 3

Podoconiosis (Non-filarial elephantiasis) Photo Credit: Maureen Tembei

An economic study in Ethiopia on podoconiosis, an NTD with disability comparable to that of LF revealed direct treatment costs being equivalent to US$143 per patient per year excluding productivity losses and family impact. Studies in Cameroon on the household economic cost of podoconiosis (Tembei et al. Unpublished), revealed US$142 of household income being consumed annually for direct treatment of the disease constituting 40% health expenditure. Most NTDs are likely to impose catastrophic health expenses at household level.


2) Social Aspects of NTDs

Added to the economic burden, NTDs affect quality of life of affected households socially by reducing productivity, marginalization and causing stigma (Mousley et al. 2013) for both patients and their family members. Results from studies in Cameroon demonstrated almost equivalently low levels of quality of life and high levels of stigma, among podoconiosis and leprosy patients (Tembei et al. Unpublished).

Maureen Blog on Beyond Patients 4

Leprosy (Hansen’s Disease)  Photo Credit: Maureen Tembei

Social consequences are not only limited to isolation and exclusion from community events but also include; difficulties in finding employment, gaining education and getting married. Overcoming these consequences are vital activities for both social and economic well-being (Tora et al. 2014). Neglected Tropical Diseases are also quite stigmatizing in endemic areas and experiences are shaped by gender roles and relations (Desta et al. 2003; Kloss et al. 1997) and generation (Davey et al. 2007) in different ways both for patients and their family members. Some degree of stigma towards leprosy and podoconiosis affected households was observed in Cameroon (Tembei et al. Unpublished), implying that perceptions towards stigma related to NTDs are not limited to the patients but can also have repercussions for family members and caretakers within the household. This thwarts efforts to effectively treat and prevent NTDs as it negatively impacts health seeking behaviour of patients and act as a barrier to appropriate care from health workers and their local healers.


3) Sustainable Development Goals 2030: Leaving no one behind

Talking about “Leaving no one behind” means everyone should have the right to direct access to healthcare opportunities expressed in the SDGs. Narrowing down to NTD perspective, COUNTDOWN has within its portfolio, four (4) key NTDs with high prevalence and amenable to preventive chemotherapy in sub-Saharan Africa namely onchocerciasis, lymphatic filariasis, schistosomiasis and soil-transmitted helminthiasis. Among these NTDs, onchocerciasis and lymphatic filariasis have debilitating disabilities with devastating social and economic burdens not limited to the patients but extending to family members. Less well-known are the consequences of urogenital schistosomiasis, especially in women where the disease may cause infertility and sub-fertility taking away some of their more important choices in life.

Maureen Blog on Beyond Patients 5

Figure 1: A wider impact of NTDs: Economic and social impacts of NTDs extending beyond patients to family members within the household.

COUNTDOWN as a multi-disciplinary research consortium is devoted to bringing forth research-based evidence on the economic and social burdens of these NTDs to inform and influence health policy. Therefore, we are saying that as a commitment to meeting the 2030 SDGs of leaving no one behind, health strategies targeting control and elimination of NTDs should not be limited to the patients only but, should consider extending to all those affected directly or indirectly by these diseases at the household and community level.

4) Way Forward

Beyond the scope of COUNTDOWN (improved access to public health interventions for these NTDs including prevention), morbidity management and disability prevention centres are likely to result in economic returns to affected families. Another approach to this would be through subsidized health insurance for these economically vulnerable households. Affected households may benefit from such schemes so they are better financially protected. Moreover, rehabilitation and economic empowerment through skilled and unskilled labour for the disabled patients might serve as an economic relief to their family members while socially integrating them gradually into their community and society.



Developing the Multi-disciplinarity of Parasitology, by taking three-steps at a time

COUNTDOWN at the British Society for Parasitology Autumn Symposium, 28th September 2017, with Lucas Cunningham, Louise Hamill, Zikmund Bartoníček, Lisa Reimer, Louis-Albert Tchuem-Tchuenté, David Molyneux, Mark Taylor, Russ Stothard

Parasitology BSP2017

The British Society for Parasitology Autumn Symposium is an annual event which this year took place on the 28th September 2017 in London at The Linnean Society, Burlington House. It was organised by Prof Russ Stothard and Dr Bonnie Webster, entitled “The Multidisciplinarity of Parasitology: Host-parasite evolution and control in an ever-changing world”.

The programme attempted to draw together and develop a multi-facet appraisal of the biology and control of parasites. The symposium has subsequently stimulated a meeting report and a blog on Bug Bitten on  why it is all interconnected in parasitology. Moreover, it was a convenient opportunity to feature some of COUNTDOWN’s stepwise progress in reporting our implementation research as set within the meeting’s three themes.  With just over 25 speakers and with an audience of just over one hundred, The Linnean’s auditorium was at maximum capacity; a clear evidence of the general interest in multi-disciplinarity.

Prof Stothard warmly welcomed everyone present with the simple message that ‘all living species are involved in parasitism, either as parasites or as hosts’. Indeed, this is a universal truth, for parasitism is not just a successful evolutionary strategy but is also part of a broader picture of symbiosis and part of the classification of how organisms, big or small, interact. As a metaphor, parasitism is tremendously powerful, and is regularly used in today’s language to describe significant socio-political events and processes as societies and sometimes nations negatively exploit others.

The modern agenda of parasitological research is therefore exciting, challenging and globally relevant as illustrated by Sir Roy Anderson. In the context of human disease, those parasites that typically play a detrimental role in global health are notorious, for example, malaria and the neglected tropical disease (NTD) collective are very well-known. To help guide the discussions and for convenience sake, the Autumn Symposium was split into three themes to help develop discussions in a stepwise manner.

The ‘ever changing world’ theme placed ongoing parasitological research within the new terminology of the Anthropocene and how mankind is altering global environments which may or may not favour parasitic diseases of medical, veterinary or wildlife importance. Both Prof David Molyneux and Prof Louis-Albert Tchuem-Tchuenté highlighted the challenge of NTD control against the background of planetary health, national control programmes and sustainable development goals. Both schistosomiasis and soil-transmitted helminthiasis are two of the most sensitive NTDs to human modifications of the environment and WASH infrastructures. For example, the building of water impoundment dams and expansion of freshwater irrigation schemes each has the potential to increase the parasite transmission, especially where urbanisation creates local water stress. Control of schistosomiasis is typically a long-haul endeavour and in recognition of his pioneering work on the epidemiology and control of schistosomiasis, David Rollinson was awarded a career medal by the International Federation for Tropical Medicine (IFTM) President, Santiago Mas-Coma.


The ‘Multidisciplinarity of Parasitology’ encouraged synergies between molecular, ecological and social science components that link parasites and hosts into a more holistic appraisal of parasitism. COUNTDOWN molecular diagnostic work was presented by Lucas Cunningham and Zikmund Bartoníček on soil-transmitted helminthiasis and schistosomiasis as speed posters alongside surveillance and control studies on onchocerciasis control in Cameroon by Louise Hammill together with community engagement activities meshed with locally appropriate vector control strategies.

The ‘host-parasite evolution and control’ recognised that parasites are not simple self-replicating automata and are very able to respond rapidly to interventions waged against them. Lisa Reimer discussed opportunities for xenomonitoring of mosquito populations for surveillance of lymphatic filariasis.  The control of many parasitic diseases is a moving target as it is a dynamic and reactive system. It has been shown in previous control campaigns that a static strategy typically founder, therefore it is important to have in place an ability to monitor the success of any particular intervention and to ensure it is best tailored to the needs of the local populace for which it serves.

During the day, topics of discussion within the three themes often blurred, and they should, as cross-talk grew. Mark Taylor, President of the BSP closed the meeting and indicated that for a successful academic career in parasitology, a portfolio of skills and approaches is needed.  To end symposium, it was very fitting to discuss many aspects of parasite evolution in The Linnean Society where Darwin and Wallace once read their papers, nearly 160 years ago. Over this time much has changed and we hope an important milestone from this meeting will be the production of a special issue of Parasitology which will leave a longer lasting footprint of how parasitism and human health are most intimately intertwined.

Find here a link to the Storify on our participation at the meeting.

Join us on social media for further interactions.




It is Global Handwashing Day! What does this mean for Neglected Tropical Diseases?

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

Today Sunday, October 15th, we celebrate Global Handwashing Day, a day dedicated to global advocacy on increasing awareness and understanding on washing hands with soap, thereby preventing several communicable diseases. This awareness it is hoped will increase participation and save lives from preventable diseases.

Since the campaign launched in 2008, it has garnered enough support to be celebrated in over 100 countries with over 100 million people participating each year. The Global Handwashing Day aims to:

  • Foster and support a global and local culture of handwashing with soap
  • Shine a spotlight on the state of handwashing around the world
  • Raise awareness about the benefits of handwashing with soap

According to a 2014 UNICEF report on Levels & Trends in Child Mortality, diarrhoea accounts for 9 per cent of leading causes of death among children under five. Each day, nearly 1,000 children die due to preventable water and sanitation-related diarrhoeal diseases. Diarrhoea is easily transmitted where poor hygiene and sanitation are rife. Pneumonia, diarrhoea and malaria accounted for 1.3 million of under-five deaths in sub-Saharan Africa and roughly half a million in Southern Asia in 2014. Accelerating the reduction in under-five mortality rates is possible through expanding preventive and remedial interventions.

As far back as 2010, UNICEF developed an advocacy pack to inform and support planning of activities to raise the profile of WASH (Water, sanitation and hygiene) in schools around the world. This pack was created as part of its campaign ‘Raising Clean Hands: Call to Action for WASH in Schools’.

But what has all this got to do with Neglected Tropical Diseases(NTDs)? For those in the NTD world, this day is of great significance as handwashing is a good habit to develop for a sustainable and long-term control on preventing infection or re-infection with diseases such as soil-transmitted helminthiasis (STH). According to the World Health Organisation (WHO), around 1.5 billion people are infected with STH worldwide. STH are caused by infection with the roundworm (Ascaris lumbricoides), whipworm (Trichuris trichiura) and hookworms (Ancylostoma duodenale or Necator americanus). They are among the commonest infections especially those living in poverty.

These STH diseases thrive in warm, tropical environments, where sanitation is inadequate. Parasite eggs and larvae are excreted in the faeces of infected individuals which contaminate the environment, particularly the soil. People are infected through ingestion of roundworm or whipworm eggs on contaminated foods or by direct skin penetration of hookworm larvae from the ground.

When individual children harbour large numbers of these worms it can lead to bowel obstruction and iron deficiency anaemia which, over time leads to malnutrition and growth impairment.

Improving hand hygiene before eating and safe disposal of faecal material is important. The 6th goal of the Sustainable Development Goals (SDGs) which continues the legacy of the Millennium Development Goals (MDGs) states: ‘ensure clean water and sanitation for all’. WHO estimates at least 1.8 billion people around the world use a source of drinking water that is contaminated by faeces. With 2.4 billion having limited to no access to basic sanitation services such as toilets or latrines, we can see how lasting control of STH is a challenge.

SDG Banner - Health in the Global Era

Reason why handwashing and WASH in general are crucial to the elimination of NTDs. The latest Guideline: preventive Chemotherapy to control soil-transmitted helminth infections in at-risk population groups published by WHO last month, emphasises long-term solutions to STH require improvements in water, sanitation and hygiene. The Fourth WHO Report on Neglected Tropical Diseases titled ‘Integrating Neglected Tropical Diseases into Global Health and Development‘, indicates that providing safe water, sanitation and hygiene is critical for preventing and providing care for most NTDs but tends to be neglected relative to its importance. The report warns that without concerted effort to improve access to safe WASH, diseases will return to higher prevalence levels.

The COUNTDOWN programme which is multidisciplinary in its make-up has tackled this issue by participating in discussions with intersectoral partners to engage in knowledge-brokering and taking a collaborative approach to knowledge share in the process. In the current health environment where capacities are distributed, coming together to seek solutions to universal problems such as these, is paramount. The COUNTDOWN team has recently authored a paper soon to be published in Trends in Parasitology entitled “Tailoring water, sanitation and hygiene (WASH) targets for soil-transmitted helminthiasis and schistosomiasis control.

You can read more from COUNTDOWN relating to STH here.

How can you participate in the global handwashing movement? Choose from this Lazy Person’s Guide to Saving the World or share with us your experiences working in this sector in the comment section and join us on social media for further interactions.






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