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What about Male Genital Schistosomiasis: Developing a research perspective from the shoreline of Lake Malawi

By Dr Sekeleghe Kayuni (Liverpool School of Tropical Medicine PhD student)

Prof. Sally Theobald has used her personal experience to highlight the importance of reporting female genital schistosomiasis (FGS) and its long term consequences, from Lake Malawi. What about male genital schistosomiasis (MGS) and its current situation within local fishermen?

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Described as “the jewel in the crown of the country’s tourist attractions”, this third largest lake in Africa is a renowned destination for tourists and water sport supporting the country’s economy.  Its beautiful fresh waters also offer local communities a place for household chores and income generation through fishing. However, the lake harbours various aquatic snail species which are intermediate hosts for the Schistosoma parasite, a causative agent of schistosomiasis in humans.

Schistosomiasis is also known as Bilharzia or snail fever and its lifecycle was elucidated some a hundred years ago. Chronic schistosomiasis is a debilitating disease causing severe damage to many internal organs and tissues and if untreated can result in death.  As the second-most prevalent parasitic disease in the world after malaria, World Health Organisation (WHO) estimates that over 700 million people are at risk of the disease globally, with 200 million infected of which 85% live in sub-Saharan Africa (SSA), and 20 million suffer severe consequences.

In Lake Malawi and surrounding water bodies, two major species of the Schistosoma parasite are present; S. haematobium which causes urogenital disease and S. mansoni which causes intestinal diseases.  The parasite’s distribution and thus risk of infection is highly focal around these water bodies, with S. haematobium common in the southern areas of Lake Malawi and Shire valley, and S. mansoni in the Central plains and Northern areas.

Part of my future PhD research based at the Liverpool School of Tropical Medicine (LSTM); is to determine the local importance of MGS. I visited Malawi in December 2016 to start planning for my fieldwork later this year and appreciate the current situation of control measures within fishing communities along southern shores of Lake Malawi, especially within Mangochi district. These communities are associated with higher prevalence of S. haematobium infection, average of 23.7%, some reaching as much as 94% and also having episodes of re-infection.

Local health services are provided by the District Health Office (DHO) and complemented by Faith-based and private clinics. Most facilities have basic Outpatient departments, laboratories and dispensaries, with limited diagnostic resources resulting in limited clinical diagnosis of diseases like schistosomiasis. Preventive services are community-directed and provided by Health Surveillance Assistants (HSAs), who are a valuable multi-tasking human resource for health, supervised by the District Environmental Health Officer (DEHO).

Much emphasis of urogenital schistosomiasis in endemic areas is on urinary pathology, with less attention on its genital consequences despite its  first description by Madden in vaginal tissue of a female Egyptian woman in 1899 and a young man’s spermatic cord in 1911. This was echoed by health centre staff and people in fishing communities in the district.

FGS is now receiving at least some much-deserved focus in research and treatment, compared to MGS. This is despite the several reports and research studies describing Schistosoma eggs in male genital organs, its impact on reproductive health and possibility of increased susceptibility to HIV infection, and transmission among infected males and females in schistosomiasis-endemic regions.

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In preparation for my future PhD research with Professor Russell Stothard and Dr James LaCourse, I will be hoping to bring together a multidisciplinary study to determine and describe the prevalence and morbidity of MGS in the fishing communities of southern Lake Malawi, including assessing the co-morbidity of MGS with HIV infection. The aim is to raise the much-needed awareness and understanding of MGS, expand access to regular treatment and holistic disease control interventions, by national control programmes to entire populations. So watch this space for further reports in future.

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Intestinal Schistosomiasis on the shoreline of Lake Albert – Uganda: Through the prism of tropical medicine students

*Guest Bloggers from the East African Diploma of Tropical Medicine & Hygiene class of 2016: Rodgers Rodriguez, Felicity Cooksey, Tina Kindole, Angelika Masao, Anita Baine, Bonnie Mpondo, Shireen McVicker, Max Kelen, Tendai Marimwe) 

There is a field camp at Bugoigo village on the Lake Albert shoreline that is overseen by Vector Control Division, Ministry of Health, Uganda. Extensive work conducted by Dr Amaya Bustinduy and  Prof. Russ Stothard used this camp for applied research on schistosomiasis over the years. Several studies conducted there have helped change national and international policies on disease control. Less well-known is that the camp at Bugoigo also hosts students for teaching purposes and provides them with first-hand experiences of the local reality of Schistosomiasis.

As part of the East African Diploma in Tropical Medicine and Hygiene (Class of 2016), we were under the supervision of Dr Bustinduy and travelled to Bugoigo. Our intention was to learn about the ongoing battle for control of schistosomiasis and discover why the area continues to be hyper-endemic for this disease despite ongoing control interventions. Being taught previously in Uganda’s capital city Kampala, we prepared ourselves for the field camp with no electricity or running water.

After a five-hour drive from Kampala, we arrived at the lakeside location and experienced its vibrant community. It quickly became apparent that Lake Albert was of major importance to everyone; as a source of income, for drinking water, place to catch fish or bathe, as well as a children’s playground. It was also clear that ‘not going in the lake’ was impossible. Even with a local bore hole, nearly all locals and ourselves included, depended on the lake for domestic water. We were told that the local borehole water was considered ‘too salty’ for daily use. We were lucky in our camp to be able to put in place simple water hygiene measures, resting water and use of disinfectants.

Our second observation was that the community, especially the school children were familiar with Praziquantel, the current and only drug of choice for treatment of Schistosomiasis. In line with the national control campaign, the Ugandan government endorses a programme of Mass Drug Administration (MDA) with this drug. MDA takes place in all primary schools where the disease is endemic. Despite Praziquantel being an effective treatment, it is known locally as ‘mbaya’ which translated from Swahili means ‘bad.’ This is due to the side effects suffered considering disease burdens here are tremendously high and children frequently experience pain after taking treatment as the worms react. Further education is often needed to better explain this. We put on an outdoor play for the local school children, re-enforced with a song and a dance proving that their enjoyment is universal no matter where you are in the world.

Our main task at Bugoigo was to gain an appreciation of the clinical burden of schistosomiasis. This we gained in our survey of two schools and two communities nearby. The most startling result, novel to us was that pre-school children were heavily infected but are not targeted within the MDA campaigns. Sadly, many had already developed complications with negative consequences for their growth and development, 18% of young children, under the age of five, had features of liver fibrosis on ultrasound. The average egg count on stool testing (Kato-Katz) was 500 eggs/gram and 80% had a positive urine sample using Circulating Cathodic Antigen (CCA) test. We also found complications in school children with 80% of the sampled school children having anaemia.

For us as doctors in the tropics where our daily practice is hospital-centric (battling malaria, HIV and helping mothers deliver); going out into the community was an eye-opener. To find a whole generation of children already weighed down by the burden of schistosomiasis; not forgetting the frequent sights of children with pot-bellies due to environmental enteropathy and chronic malnutrition made us appreciate the vital role of research and community health especially in hard-to-reach areas. Neglected tropical diseases, in particular schistosomiasis, have become a reality to us.

We had been informed there were concerns regarding giving young children Praziquantel tablets due to fears of choking as there is no suitable paediatric formulation available. However, at the end of the testing we offered treatment to all and for the young; we crushed the tablets and mixed them with a small amount of water to make a suspension. Although younger children were initially apprehensive, they swallowed the medicine with minimal difficulty.

Despite how much we learnt during the week, we were left with more questions: What is the right drug dose for pre-school children? How frequently should mass drug administrations be done?

While there might be challenges in gaining ethical approval for a paediatric formulation, is it ethical to continue MDA with existing tools when young children from the same area are left out? The research COUNTDOWN is carrying out could provide possible answers and wait to see if it will provide answers to these questions.

We left Lake Albert feeling inspired by the local teams who are striving to improve the health of these communities and were empowered to join in this battle.

By not adequately controlling schistosomiasis here or elsewhere in sub-Saharan Africa, we are depriving children of their health and therefore communities of their future!

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Neglected tropical diseases: Getting “lost in the WASH” no longer!

By Dr Suzy Campbell & Dr Nana-Kwadwo Biritwum

There is a very important research agenda gaining momentum at present, and it is attracting extensive stakeholder buy-in. This is the importance of water, sanitation and hygiene (WASH) in augmenting preventive chemotherapy for neglected tropical disease (NTD) control. We chaired a breakout session at COR-NTD, the annual operational research meeting for NTDs, held in Atlanta in November. We highlighted the important strategic agenda for strengthening evidence on how to deliver effective WASH interventions for schistosomiasis and soil-transmitted helminthiases (STH), and embedding these findings in guidance and practice. In this blog we share why this is such an important integration priority!

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Figure 3: Dr Suzy Campbell presenting at COR-NTD (Photo: L. Hamill)

Since the early 2000s, preventive chemotherapy (“PC”, being provision of deworming tablets) has been the cornerstone morbidity-control strategy for Lymphatic Filariasis, Onchocerciasis, Schistosomiasis, STH, and Trachoma. PC is most often provided by repeated mass drug administration (MDA) campaigns, usually targeting treatment to school-aged (and school-attending) children. This approach has rightly, had strong World Health Organization (WHO) advocacy, and is considered the largest-scale repeated public health programme in the world.

However, for schistosomiasis and STH, it has been known from the outset that PC alone does not reduce the rapid cycle of reinfections. People continue to be exposed to these parasites from their environments. For schistosomiasis in particular, transmission can be continued from just one or two individuals who contaminate the environment subsequently infecting intermediate snail hosts. For these two diseases, the approach has been one of “morbidity control” rather than disease control.

MDA has been conducted for up to a decade in many endemic regions of the world, and whilst coverage of school-aged children is progressing towards WHO targets, there are multitude reasons for strengthening additional strategies, such as provision of WASH. Continuation of this is still crucially important, but additionally there is increasing focus towards other strategies that will augment PC. Since 2012, there has been much discussion on moving beyond “morbidity control” to “interruption of transmission” and “elimination as a public health problem”.

 

So what is WASH and why is it important?

WASH is the provision of access to a safe water supply, appropriately constructed sanitation infrastructure ensuring safe disposal of human excreta, and health education and promotion of hygiene (being personal and household practices aimed at preserving cleanliness and health).

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Figure 1: Integration challenges: these brand new toilets remain locked (Photo: S. Campbell)

For disease control purposes, WASH needs to be viewed both according to the individual components of water, sanitation, and hygiene (including health education as a main conduit of hygiene promotion), and additionally, as an integrated system. This is because the components are complementary: infrastructural components such as provision of public taps or household latrines are unlikely to be beneficial investments without accompanying behavioural change (or vice versa). Just as PC can be seen as the cornerstone of morbidity control, WASH can be viewed as the cornerstone of prevention of infections. From a position of biological plausibility, WASH is the key mechanism that can be implemented to reduce environmental contamination and then, quite possibly, transmission.

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Figure 2: A drain where people wash their clothes (Photo: S. Campbell)

Despite this, the evidence base for WASH activities for STH or schistosomiasis control is fairly weak and it is a growing research priority. We crucially need more information as to the elements of WASH programmes that are most beneficial for STH and schistosomiasis control. This needs to encompass not only the more commonly-discussed water collection and/or toileting habits, but also extend to other potential elements such as grey water disposal and contribution of animal faeces (given zoonotic potential for some helminths).

What is happening right now?

In 2012 the WHO released the NTD Roadmap, which set NTD coverage targets to 2020 and fostered unprecedented anthelmintic and financial donations. This led to major international momentum, strongly supported by WHO, for countries to develop strategic NTD master plans tailored to national NTD control and elimination priorities. To a very large extent these actions have redefined the international STH and schistosomiasis agenda, being a major push to assist some countries to achieve STH coverage targets.

In late 2015, the WHO published the first WASH for NTDs Global Strategy 2015-2020, providing four strategic objectives to accelerate progress on addressing NTD Roadmap targets through increased intersectoral WASH-NTD collaboration and integration of approaches. This much-awaited document provides international impetus to countries to prioritise WASH in conjunction with other NTD control strategies. The intention is that WASH activities be developed and built into country NTD programmatic planning.

However, in order to do this, we need to strengthen the evidence for delivery of effective WASH interventions for NTDs. Additionally, we need to embed these evidence findings in guidance and practice. This is the clearly stated objective, and call for assistance, of one of the Strategic Objectives in the WASH for NTDs Strategy. In this, the WHO is calling for research evidence, and programmatic examples to be shared.

Considering schistosomiasis and STH, this is a fundamentally important requirement. We know we can’t control these diseases without primary prevention strategies. This important distinction for these two NTDs needs to be explicitly made, compared to many other NTDs: WASH for schistosomiasis and STH control needs to be seen as a major determinant of disease prevention. This is radically different from NTDs such as lymphatic filariasis, where WASH can be used as a treatment strategy (for example, washing of hydroceles for morbidity management). For STH and schistosomiasis, WASH is not to treat, it is to prevent.

WASH for schistosomiasis and STH control at COR-NTD

What we focused on for COR-NTD in our discussion workshop was the importance of this prevention agenda for schistosomiasis and STH. With a strong introduction to the WHO WASH for NTD Strategy from Dr Amadou Garba (WHO), several country-specific research and NTD programme case studies were presented, as follows: Ghana (Dr Nana-Kwadwo Biritwum, National NTD Programme Coordinator, Ghana), Cameroon (Prof Louis-Albert Tchuem-Tchuenté, National NTD Programme Coordinator, Cameroon), Tanzania (Dr Steffi Knopp, Natural History Museum, UK), Ethiopia (Dr Jack Grimes, World Vision, UK), Timor-Leste (Dr Suzy Campbell, LSTM, UK), with current WASH evidence for schistosomiasis and STH summarised (Jack Grimes and Suzy Campbell). Dr Lorenzo Savioli (Chair of Executive Group, Global Schistosomiasis Alliance) then gave a compelling historical perspective of more than 30 years of PC-based control in Zanzibar (Tanzania), clearly highlighting shortcomings of STH and schistosomiasis control strategies in the absence of sufficient WASH investment. The audience of expert NTD attendees then participated in a lively discussion about evidence requirements, WASH indicators for NTDs, schistosomiasis hot-spots, more use of mathematical modelling and advanced diagnostic tests, integration challenges, and learning from other disease programmes. Key discussion points, knowledge gaps, and important next steps are summarised in the session report.

Our session integrates closely with another important WASH for NTDs session held at the NTD Non-Government Development Organisation (NGDO) Network Meeting in Washington DC in September (chaired by our collaborator Dr Fiona Fleming at the Schistosomiasis Control Initiative, as the first two major stakeholder pushes to investigate country examples and share learning in light of the WHO Strategy. We believe these are important, but preliminary, indications of the need for an investment case for WASH for NTDs. Much needs to be done to develop this; in the meantime, it is clear that integrated, multi-stakeholder support will be a critical factor for the WHO Strategy’s success. We should all contribute to this.

Please read the summary report of the session on the COR-NTD website, and our Storify.

 

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Indigenous knowledge and Intersectionality: “Incremental radicalism” and Front Line Health Workers.

By Sally Theobald, RinGS, REACHOUT, ReBUILD and COUNTDOWN

Health Systems Global 2016 was opened by leaders of the Canadian First Nation community through song and dance and a discussion of how health has four components: physical, mental, emotional, and spiritual. The First Nations Perspective on Health and Wellness stress the need for a balance between these aspects of wellness and that they are all nurtured together to create a holistic level of well-being. 

It struck me that this conceptualisation, together with intersectionality, is a good way to think creatively about ways forward in health systems, and in particular the experiences of frontline health workers.

Physical health: In the conference opening plenary Karsor Kollie, head of the Liberian NTD programme, discussed the impact of Ebola on front line health workers: death, injury and morbidity. Later in the conference video extracts of him interviewing community based drug distributors demonstrated the risks they faced as their roles expanded to include community action on Ebola and the burial of the deceased. Zara Trafford from University of Cape Town, also brought video insights from community health workers (CHW) in South Africa. One exhausted female CHW had an accidental needle stick injury; unlike formal paid cadres, such as nurses, she was not entitled to post exposure prophylaxis. This led to physical risk of infection, extreme stress, and a strong sense of being undervalued. The physical health impacts on front line health workers on CHWs working in contexts affected by conflict and epidemics is acute. Clearly CHWs deserve the same levels of protection as health workers in other cadres.

Mental Health: Work on promoting a resilient health workforce in conflict affected areas highlighted the many mental health impacts on front-line health workers including post-traumatic stress disorder, insecurity and fear, and the risk and reality of abduction. Haja Wurie from ReBUILD explained how health workers were a specific target for abductions during the northern Ugandan conflict, and had to disguise themselves in order to get to work. A skills building session on life histories, used participatory approaches to understand health workers’ experiences during and post-conflict to explore how individual experiences are shaped by broader contextual changes with many mental health implications stemming from violence, trauma and fear. Close-to-community providers deal with a wide range of issues with implications for their own mental health: domestic and sexual and gender based violence, abuse, alcoholism. Polly Walker, explained how World Vision incorporated Psychological First Aid training in their core CHW model in response to increasing need. Observation of implementation in over ten countries shows immense need here on the importance of skills-building for both mental health and psychosocial support of CHWs working in a wide range of circumstances not only to serve their client better, but also to better cope with their own experiences. World Vision are currently working on a more in-depth model for support.

Emotional Health: Despite the multiple challenges for mental and physical health, front line health workers, demonstrate “reservoirs of resilience”. New technologies can also play a role here: in Sierra Leone, in the face of Ebola, health workers used WhatsApp groups to support each other, and share vital safety information. Sophie Witter shared how coping strategies for conflict were gendered and shaped by poverty and household structure. Families, sense of nationhood and patriotism were all strategies deployed by health workers to build emotional health in these contexts. REACHOUT research within complex adaptive systems brought insights by highlighting the importance of the software of health systems (relationships, reciprocity, and trust) alongside the hardware (training, supervision and policy). When strong, respectful and trusting relationships are in place for CHWs – both with supervisors and communities – emotional health is likely to be enhanced. 

Spiritual Health: The First nations community explained that “Nurturing spirit is the aspect in your life that makes you smile! This is about what makes you feel good and connected. This builds your self-esteem, self-confidence and allows you to be connected to others, mother nature and yourself.” With strong links to emotional health and social capital, religious faith can help build the spiritual health of frontline health workers. Studies on health workers’ experience in Sierra Leone, N.Uganda, Zimbabwe and Cambodia showed that religion is a key motivator to join the profession and also a strong factor supporting staying in service during tough times.

So where do we go from here?

The brilliant plenary on intersectionality, showed how we need to consider multiple axes of inequity (race/poverty/gender/(dis)ability/sexuality etc.) to address power and privilege. These play out in different ways at different moments in time and in different contexts. Social justice is key, as is reflexivity and critically thinking through our own roles as researchers within health systems. There are parallels here too with the First Nations’ concept of “cultural humility” as a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Olena Havinsky, from Simon Fraser University in Vancouver, referred to the idea of “incremental radicalism”, small steps to build mutual understanding and alliances for change and to promote social justice. We need to draw on these concepts and put in place strategies to further support the holistic health and well-being of front line health workers who are the key to both responsive and resilient health systems and universal health coverage.

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How to Involve Key Stakeholders and Adapt to the Local Rhythm: Lessons from the Western Region, Ghana

By Irene Tsey

[on behalf of Contextualising Lymphatic Filariasis(LF) Hotspots Research Team, DHRC.  Irene Honam Tsey is a Research Officer & Institutional Review Board Administrator at DHRC]

“This was my second time to the Western Region as well as on the field for data collection. Interestingly, I cannot believe the depth of information and knowledge gained from this trip when some years back at the same place I could not even dream of putting together this piece. I am so grateful for my experience in DHRC”

It was a long trip of about 320km and we got to our final destination almost at midnight after setting off late in the morning of that same day from Dodowa. Although very tired and not knowing exactly where to spend the night we encouraged ourselves with humour. We made jokes from previous experiences.  We spent ten days in the field and learnt first-hand the importance of involving community leaders or gatekeepers through the support of other key stakeholders and the need to sometimes adjust to uncomfortable situations for successful Community Entry and data collection.

WHAT LESSONS DID WE LEARN?

The Need to Identify Key Stakeholders

It is very important to know the relevant stakeholders needed for your study to avoid unnecessary delays. Upon arriving in the first district the team’s first point of call was the District Health Administration. The team met the officer acting on behalf of the director and upon briefing him and others about the study the team was handed over to the officer involved which in this case was the Disease Control Officer. This officer had the data on all the communities involved in the MDAs which she willingly handed over to the team. She was also able to delegate a field technician (FT) involved with the MDA programmes and working with the Community Drug Distributers (CDDs) to assist us in reaching the CDDs.  The FT further led us to the various community leaders and also introduced us to some available and hardworking CDDs in the communities. Having support from the relevant stakeholders on the ground who are already known in the communities through their various engagements; made it easy to reach the other stakeholders who in this case are the community leaders. The team was warmly received and granted permission to go ahead with data collection.

Need to Understand and Respect the Cultural/Social Context of your Research Community

Our first community was Muslim and the FT in the person of Jonathan advised us to dress appropriately. Based on this piece of advice, some of the team covered their heads and did not wear make-up. We also wore clothes similar to those of local women to bridge the cultural gap and make them feel comfortable in our presence. We left this community better and stronger than we came and ever ready to continue on our journey of conducting sometimes rigorous research.

Need to Adjust to the Context in which Data is going to be Collected

The team was excited to have successfully entered some communities and conducted some Focus Group Discussions (FGDs) and In-Depth Interviews (IDIs). Aunt Rose, a very active and enthusiastic CDD gladly accepted to help organise the prospective research participants and inform the chief and elders about our study and intention. The team, Aunt Rose and the Field Technician (FT) involved in the MDAs decided to seek permission from the community leaders before commencing interviews. It is an undisputed fact that final consent to participate in a study is to be given by the prospective participant nevertheless it is important to get permission of community gatekeepers which helps with community engagement. The team learnt that seeking permission from the gatekeepers made them feel appreciated as their authority and roles as custodians of their people were respected. The benefits for us on the research team, was that it made us feel comfortable and at home in these communities.

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Most of these leaders expressed their support for our work and encouraged us. They highlighted that in the future providing prior notice before arriving communities would enable them adequately prepare to receive us and to also know more about our research. This demonstrated that it is not just about seeking their permission but also keeping them in on progress.

About the study:

Contextualising LF Hotspots Research is part of COUNTDOWN’s efforts to explore and identify strategies, for more effective mass drug administration to eliminate Lymphatic Filariasis, in the remaining districts with persistent transmission in Ghana.

You can see more of our work on Lymphatic Filariasis in Ghana below:

WHAT DOES IT TAKE TO CONTROL NEGLECTED TROPICAL DISEASES? PART THREE: ELIMINATING LYMPHATIC FILARIASIS by Linda Waldman
ANYONE’S DISEASE: ENDING LYMPHATIC FILARIASIS IN GHANA by Adriana Opong
A BED NET TO RULE THEM ALL: ACCELERATING LYMPHATIC FILARIASIS ELIMINATION THROUGH MALARIA CONTROL PROGRAMMES by Corrado Minetti.

 

 

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MOLECULAR TOOLS FOR HELMINTH CONTROL AND ELIMINATION: TIME TO GET THEM OUT OF THE LABORATORY AND INTO PROGRAMS AND POLICIES?

By Corrado Minetti

On my way back from Ghana, where we have been testing the molecular protocols for the detection of filarial parasites in mosquitoes, in the laboratory of Mike Osei-Atweneboana at the Council for Scientific and Industrial Research (CSIR) in Accra; I had some thoughts about how far molecular diagnostics has come but also questioned how can we make it a sustainable reality to assist effectively in disease control and elimination.

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DNA extraction from pooled mosquitoes for the detection of filarial worms (on the left) and an example of amplification of parasite DNA (+) with the LAMP method (on the right) (Photo: Corrado Minetti)

In order to achieve the goals of the London Declaration on Neglected Tropical Diseases for the effective and sustainable control and long term elimination of Lymphatic Filariasis, onchocerciasis, soil-transmitted helminthiasis and schistosomiasis; the deployment of appropriate diagnostic tools is crucial at every stage of these disease control and elimination programmes from initial mapping to post-elimination surveillance. With the rapidly changing epidemiological scenario of these diseases due to the scaling up of mass drug administration, and the push towards more sustainable and cost-effective multi-disease interventions, the implementation of more sensitive and cost-effective diagnostic tools is a priority well recognized and advocated by the World Health organization.

Molecular diagnostics tools, including (multiplex) real-time polymerase chain reaction and more recent isothermal amplification assays such as loop-mediated isothermal amplification and recombinase polymerase amplification do offer increased sensitivity compared to traditional approaches but they are yet to be used in control and elimination programmes due to their cost and technical requirements. There are various gaps that need to be highlighted and solved in order to allow these approaches to become potentially embedded into disease control programmes & policies, and to inform decision-making.

In order to identify these much-needed gaps, we have recently published a review paper where we compared the features of published real-time PCR and isothermal amplification assays for the detection of Lymphatic Filariasis, onchocerciasis, soil-transmitted helminthiasis and schistosomiasis in clinical and vector/intermediate host samples. Despite the availability of a wide range of assays for both patient diagnosis and xenomonitoring (parasite detection in insect vectors or snails), little or no research has been devoted to estimate the real costs and logistics of implementing these approaches on a wider scale for control and elimination. We highlight the need for a major focus on the implementation aspects of these tools in developing countries, and how barriers for their full adoption in resource-poor settings could be overcome. Key issues are the technical requirements and the related need for capacity building, the abatement of costs and the economic sustainability of molecular screening over time. For example, diagnosing multiple parasites from the same clinical sample can heavily reduce the number of samples that a community may need to provide, resulting in a far less invasive procedure for the communities, as well as reducing significantly the cost of processing. A multi-disease approach to diagnostics will certainly benefit the health system as well, both logistically and economically.

Writing this review paper has been extremely valuable to get a clearer picture of the progress in the field so far and to identify the best and most cost-effective diagnostic approaches for our project. In a broader sense and within the COUNTDOWN research consortium, we hope this review could serve as a starting point of discussion in the NTDs control and elimination community, leading to a more comprehensive analysis of what molecular diagnostics can offer and how we can make sure these tools can finally get out from the laboratory becoming embedded into policy, to strengthen disease control and elimination programmes and the health system itself.

Find more information on COUNTDOWN’s activities visit us here.

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Empowering the NTD Workforce – Highlighting Community Drug Distributors

By Pamela Bongkiyung & Prof. Sally Theobald

Mass Drug Administration (MDA) remains a fundamental part of approaches to address several Neglected Tropical Diseases. However, the people who make this process happen at the community level – Community Drug Distributors (CDDs),  are sometimes not given enough attention or  sufficient acknowledgement  for their contributions and how best to motivate with some form of remuneration and reward this critical cadre is subject to much debate

Most CDDs come from the communities in which they work, and are chosen through community processes. Training and supervision is varied and often not given enough resources or attention. Their selection, supervision and training remain a community effort. For a very long time, they have not been sufficiently considered as an essential part of the health system around the world. This in turn has meant that in some contexts they are considered by governments as voluntary workers who don’t always need formal payment. Though there have been promises to include some payments for CDDs in national budgets, this frequently doesn’t materialise in practice. The issue of paying CDDs is embedded in controversy – who should pay?

The idea to start using CDDs was created during the Bamako Initiative in 1987 and then enacted in the Community Directed Treatment with Ivermectin (CDTi), rolled out by APOC (African Programme for Onchocerciasis Control). This process was designed from the onset to be owned by the community but challenges such as support, sustainability and remuneration remain.

Given that these communities were too poor to pay for drug distribution themselves, CDD work was viewed as serving one’s community and therefore a reward in itself. It was not envisaged that serving your village or clan should be met with monetary rewards. There remains a great difficulty in putting monetary value to the high esteem given to these individuals within communities.

The work of CDDs is also relevant in the detection of diseases, but they are often not mobilised to fulfil a monitoring role. The situation is further complicated when gender is inserted into the mix.  In the analysis of Community health worker programmes, men are more likely to be paid then women; and also more likely to be in senior roles. Little is known about how gender shapes the experience of being a CDD; the relationships that are built at community level and the implications for equitable and gender transformative processes.

Although CDDs have been central for over three decades, there is very little recent literature making an appraisal of their inputs and how best to support them. . It is imperative that their work is better acknowledged as a key interface for NTD elimination. So, we ask, how can we help sustain CDDs in health systems?
This is why COUNTDOWN has taken the initiative to bring the issues and experiences of CDDs to the limelight in the Coalition for Operational Research of Neglected Tropical Diseases (COR-NTD) from 10 – 11 November 2016. We will host a specific-session exploring evidence and evidence gaps. Panellists from Ghana, Nigeria and Cameroon will discuss the experience of CDDs in different contexts, how gender, poverty and relationships shape this and priorities for action.

COUNTDOWN will also be well represented at the Health Systems Global (#HSG2016) Conference in Vancouver, Canada from 14 – 18 November 2016. The Liberia COUNTDOWN Country Director – Karsor Kollie is presenting on the experience of Community Health Workers in the Ebola response in Liberia; and we have a panel on intersectionality which explores the interplay between different axes of inequalities.

COME AND JOIN OUR DISCUSSION IN THE SESSIONS BELOW:

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COUTNDOWN Launched at 9th Mano River Union Meeting on Neglected Tropical Diseases

19th-21st October 2016, Monrovia, Liberia

Prof. Russ Stothard

Originally created in 1973, the Manu River Union (MRU) is an intergovernmental institution comprising of Sierra Leone, Liberia, Guinea and Cote d’Ivoire. Primarily, the MRU was formed to promote local trade and economic development. Since 2006 its scope has expanded. Today this includes issues related to health policies and practices, specifically in the harmonization of ongoing interventions against neglected tropical diseases (NTDs) as several NTDs cross-borders. A very pertinent example of when cross-border collaboration was crucial was evidenced by management of the Ebola Virus Disease (EVD) epidemic. Without a cross-country response in Liberia, Sierra Leone and Guinea the epidemic would not have been curtailed. Nonetheless, the EVD crisis severely shocked the health system and suspended many ongoing interventions against NTDs. Thus for Liberia to host the 9th MRU on NTDs is a testimony to reinstatement of routine activities.

In Liberia, the COUNTDOWN team is a collaboration between the Ministry of Health and University of Liberia-Pacific Institute of Research and Evaluation (UL-PIRE). Each partner was very busy this week in preparations to host the 9th MRU meeting. This brought together just over 90 Anglophone and Francophone delegates, inclusive of the MRU secretariat and many representatives of those practicing NTD control in West Africa and elsewhere beyond. We were delighted to represent COUNTDOWN as part of the international partners and were well-placed to assist the Liberian team. In addition to the standing MRU agenda, this 9th MRU meeting was especially significant for it marked the formal launches of the Liberian COUNTDOWN programme and the Integrated NTDs Case Management Programme as well as the inauguration of the first Liberian NTD Ambassador Dr Everlyn Kandakai.

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Prof. Russell Stothard – COUNTDOWN Director & Dr Evelyn Kandakai – Liberia NTD Ambassador

The strategic plan for integrated case management of NTDs is the first of its kind in sub-Saharan Africa. Clearly Liberia is forging ahead and should be much congratulated in its efforts. Alongside patient management of Buruli ulcer, leprosy and yaws, detection and surgical-interventions against hydrocele, a complication of lymphatic filariasis, were reported. Over the years the LSTM-FPSU, as supported by DFID-UK, has played a major role in assisting Liberia to develop an action plan for management of hydrocele. This was reported at the meeting by Brent Thomas.

At the start of the MRU meeting we were all very touched by a personal testimony given to us by Annie Toweh, a young girl who had had a very extensive Buruli ulcer lesion. She much benefited from the closer attention to this condition and had undergone treatment with skin-grafting; we were happy to see that she was well on the road to recovery and gaining a normal life.

The role of the NTD ambassador is primarily to promote activities of the NTD programme, especially in supporting the interface between ministries and promoting appropriate communications and messaging to and from disease-endemic communities. Dr Kandakai has had an outstanding career in shaping education in Liberia from tertiary to primary levels and wished to bring her skills to ensure that the education sector fully embraces the activities of the NTD programme.

A key channel of communication is the weekly 45-minutes health promotion slot on national radio. This is broadcast across the nation on 99.9 FM and on Tuesday, I took part in a radio interview with Karsor Kollie (MoH COUNTDOWN) and Miatta Sonkarlay Sonkarley, (Map International). During discussions I was able to highlight Laura Dean’s recent work with UL-PIRE which is now ready to start fieldwork this coming month in Bong and Maryland Counties, respectively and we look forward to their findings.

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R-L: Prof. Stothard, Karsor Kollie – COUNTDOWN Liberia Country Director, Miatta Sonkarley – Liberia Programme Manager MAPs International (Medical Assistance Programmes), Talk Show Host – Sabbah

As Kate Hawkins once told us, in COUNTDOWN communications should be everyone’s business. Team Liberia has now established a twitter account @COUNTDOWNLR and was active throughout the MRU meeting tweeting and taking notes. This helped to provide two recap sessions at the start of each day as well as drafting the 12 formal recommendations forthcoming the deliberations from the meeting. With regards to the recommendation of establishing an effective communication strategy to address NTDs implementation programme, it is therefore very fitting that COUNTDOWN is helping Liberia to develop an inclusive strategy. This will also be adopted in due course by other MRU countries so we have a lot to expect from the 10th MRU meeting to be held in Guinea.

 

 

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Spaces of Evidence: Evidence and Organisations in Development

6 -7th October, University of Edinburgh

By Prof. Russ Stothard

Funded by the Economic & Social Research Council (ESRC), Spaces of Evidence is a global network of scholars, practitioners and activists exploring the intersections of politics, measurement and evidence-based policy in health, development, economics, medicine and beyond. The network organises regular discussion meetings. This symposium took place at Edinburgh University, being the last in its series of events, and focused on five topics: Institutional responses to demand for evidence, neglected tropical data, evidence shaping policy, performing evidence generation and the politics of evidence generation. I thank the organisers Drs Ian Harper and James Smith for hosting such a stimulating meeting.

Being the only biomedical parasitologist there, it was a good forum for me to learn and exchange concepts and ideas in a wider audience. Each topic was assessed across the two days by a combination of presentations and panel-led discussions often responding to questions from the floor. At first-glance, neglected tropical diseases are typically lodged within health-specific silos, so to be given a chance to present their wider socio-political context was important. A key thread throughout was, what evidence is or data are judged to be most appropriate for assessing effective development and (or) poverty-reduction activities? There is no simple answer to this I am afraid, for there is no accepted technique or protocol that can piece together the jigsaw of evidence into a picture that all can understand, or even use generically to evaluate original goals and ambitions.

The controversy behind worm wars was much debated, as it should in an academic venue such as this, including the future use of neglected tropical diseases (NTDs) as tracers of development. I was glad to present my perspective on this with examples taken within COUNTDOWN, and from my recent survey work in Uganda. In so doing, I was able to explore with Professor Tim Allen and Dr Georgina Pearson, from the London School Economics, the common ground needed to support interventions against soil-transmitted helminthiasis and schistosomiasis, highlighting the global importance of NTDs. In the end, we all agreed there is no doubt that infected children need treatment, on equity grounds alone, but the question remains how best to empower the local health system to do so and COUNTDOWN will provide sensible answers to make it happen.

During the meeting, the growing fascination with metrics and results from random controlled trials was debated. Much of the desire to do ‘good’ typically gets lost within numbers and analytical designs. The danger here is to fall victim with the love of numbers to the occlusion of the guiding principles in bioethics, autonomy, justice, beneficence and non-maleficence. The challenge should simply boil down to better measuring these in the most robust way, not forgetting voicing the experiences of those doing and receiving the intervention in a meaningful manner. I was glad to share Prof. Sally Theobald and Dr Ifeoma Anagbogu’s blog in The Lancet Global Health about the importance of Expanded Special Project for Elimination of NTDs (ESPEN), discussing the many facets of evidence we will need in future.

Those of us in COUNTDOWN know that ‘development’ and ‘poverty-reduction’ has many dimensions and location-specific facets. This makes assessing the progress of any specific-intervention, albeit framed as outputs, outcomes and(or) impact, within a broader remit difficult to dovetail. During the spaces of evidence discussions, it brought it home to me the tremendous importance of our COUNTDOWN logframe and theory of change. Critically, these two documents help us be logically consistent and able to measure our progress in a considered and step-wise manner. Without them, complex projects like COUNTDOWN which is navigating across new ground by exploring interdisciplinary methods, would get lost. Put simply, if you have no idea of where you are going then you do not know which direction to take.

All this may sound trivial, but it is easy to get lost in details for it was clear to me from open discussions that considered the list of failed projects, their doom rooted back to a common catalogue of problems: misconceived ideas, inappropriate interventions, unrealistic donor-driven demands, poorly co-ordinated teams and each with members having mismatched skills. Sadly, in the growingly commercialised landscape of implementation research, it is all too easy for large consortia to be formed, or rather malformed, primarily upon greed beset with vague intentions. This is not the case with COUNTDOWN for our long term intention is described best described within the Sustainable Development Goal 3.3 – By 2030, to end the epidemic of AIDS, tuberculosis, malaria and neglected tropical diseases. All we need to do is simply get on with it!

 

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COUNTDOWN goes Down Under for ICTMM 2016

By Prof. Russ Stothard, COUNTDOWN

Efforts to control NTDs typically require advice, support and coordination from several international networks. Like tropical medicine in general, the need to bring scientists and clinicians together regularly and discuss their findings is crucial to ensure that the best research is disseminated internationally and eventually translated into optimal control strategies. The International Congress for Tropical Medicine and Malaria (ICTMM) provides such a forum.

This year the 19th ICTMM took place from 18th to 22nd September in Brisbane, Australia. This brought together just over 1,500 delegates. The meeting was jointly organised by the Australian Society for Parasitology (ASP) and the Australasian Society for Infectious Diseases (ASID). I was especially honoured to be awarded a travelling lectureship from the ASP to present and also visit research groups in Australia to instigate future collaboration. This I did by visiting the laboratories of Robin Gasser and Don McManus at the University of Melbourne and Queens Institute of Medical Research (QIMR), Brisbane. Robin and Don each have a tremendous stature in veterinary and medical parasitology, respectively. Both seamlessly blend state-of-the-art molecular studies with field studies and have had significant research programmes advancing the health and well-being of those living in the tropics.

In Melbourne, I gave a departmental seminar and was able to discuss with Robin and his team our ongoing and future work in Ghana and Cameroon. The Gasser lab has been pioneering molecular surveillance of helminth diseases for over thirty years and one of their recent milestones was made by Dr Neil Young in publishing the genome of Schistosoma haematobium.  This Nature publication was a tremendous achievement bringing new focus to the control of urogenital schistosomiasis in Africa. Better knowledge of this genome has opened up new ways to study the population biology of this parasite, often revealing how it is able to cause such ill-health across the continent. Furthermore, a precise knowledge of this genome allows us to monitor significant evolutionary changes which may occur to mitigate our efforts to control it with preventive chemotherapy.

In Brisbane, I attended the ICTMM meeting and gave a keynote presentation on schistosomiasis, reporting our recent findings in Cameroon at Barombi Kotto and Mbo, as well as, two other presentations on treatment of pre-school-aged children with intestinal schistosomiasis and management of co-infections of schistosomiasis and giardiasis. Whilst at the conference our viewpoint article in was published which was a timely reminder of how much future work is needed to expand access of praziquantel to those children currently overlooked within control programmes.

Suzy Campbell gave a presentation on the focus of her PhD studies on WASH (Water, Sanitation and Hygiene) for Soil-Transmitted Helminthiasis (STH). It was also a great honour for me to be invited to serve on the IFTM expanded board so we can look forward to 20th ICTMM in 2020 hosted by the Parasitology and Tropical Medicine Association of Thailand.

A particular highlight was learning from Don the steps that his group had taken to develop and evaluate public health education materials used for control of soil-transmitted helminthiasis in China. I recommend that you view the ‘Magic Glasses’ animation and its associated impact has been reported in the New England Journal of Medicine. More broadly, we do not have adequate nor sufficient health education materials presently for use in African schools for several other NTDs. My own previous research on schistosomiasis in Zanzibar has shown that innovative approaches are very much needed to addressing this aspect of influencing positive behavioural change.