Integration as the next step in controlling Neglected Tropical Diseases

By Dr Suzy Campbell

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

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

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

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

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

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

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

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

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

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

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

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

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

Harmonise Objectives

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

Respect of Values

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

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

 

 

 

 

 

 

 

 

 

 

Establish Coordination of Activity Timelines, and Programmatic Structures for Communication

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

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

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

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

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

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

Other reading:

FOSTERING MULTIDISCIPLINARY PARTNERSHIPS: ILLUMINATING THE “ELEPHANT IN THE DARK”

THE NEGLECTED TROPICAL DISEASE HOTSPOT PUZZLE REQUIRES MULTIDISCIPLINARY INVESTIGATION

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

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

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

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

Previous Approaches to Onchocerciasis Control

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

Alternative Approaches to Onchocerciasis Control in Cameroon

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

Strengthening Onchodermatitis Detection Capacity

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

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

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

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

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

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

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

The Bigger Picture: Research and Policy on Skin NTDs

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

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

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

Table 1: summarised from Mitja et al., 2017

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

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

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

 

The World NTD Summit Highlights & Schistosomiasis Discussions

by Prof. Russell Stothard – COUNTDOWN Director

The importance of the international activities that took place last week at the global summit on NTDs cannot be easily overstated. Hosted by the World Health Organisation (WHO), the second global partners meeting took place on the 19th April with several previous international pledges and commitments reaffirmed, alongside announcements of new ones. From a UK-perspective, the Minister of State for International Development the Rt Hon. Lord Bates stated that DFID will double its efforts on control of NTDs. This will be secured by allocation of additional funding of up to £360 million over the next five years. Bill Gates, who was in attendance welcomed this news which was later mentioned in his speech at Royal United Services Institute for Defence and Security Studies in London.

The Fourth WHO Report on NTDs was launched at the NTD summit. This recognised the achievements of the past decade on Neglected Tropical Diseases (NTDs), the need to sustain the momentum towards the 2020 WHO Roadmap Targets, and called on partners to facilitate the availability of funds and resources needed beyond the 2020 perspective. Progress being made for each NTD was listed and new vector control strategies were highlighted by discussing the draft of the WHO Global Vector Control Response 2017–2030. This argued that a “One Health” approach was much needed exploring the human–animal health interface and commonalities in water, sanitation and hygiene measures. The latter sets a broader challenge for integration within and across the current health system, especially in interpretation of what universal health coverage exactly means.

From a personal perspective, two things were particularly pleasing. First, to note was the entry of NTDs Control into the Hall of Fame of the Guinness Book of Records by achieving the “Most Medications Donated in 24 hours (multiple venues)”. Collectively this was evidence of a tremendous group effort in international goodwill where an incredible number 207,169 292 doses of donated medicines was made possible through the efforts of Bayer, Eisai, Gilead, GSK, J&J, MSD, Merck KGaA, Novartis, Pfizer, Sanofi, as well as, the Bill & Melinda Gates Foundation.

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Dr Ifeoma Anagbogu at COUNTDOWN Nigeria Launch 15.03.2017

Second, COUNTDOWN Nigeria’s lead at the Federal Ministry of Health – Dr Ifeoma Anagbogu, was one of the finalists for the Leadership Award during the Women in Focus dinner. Dr Anagbogu who worked extensively to make Nigeria Guinea-worm free, leads the NTD Division within the Nigeria Federal Ministry of Health. Other categories for the Women in Focus awards included Inspirational Award, Community Champion Award and Exceptional Service Award.

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Dr Uche Amazigo at COUNTDOWN Nigeria Launch

Prof. Uche Amazigo who is one of the main chairs of the Nigeria NTD Steering Committee was nominated for Exceptional Service, for dedicating most of her research and career to the elimination of NTDs as seen in her participation and leadership in scaling-up the innovative Community-Directed Treatment.

In a musical celebration of these awards, the NTD community was very fortunate to have the Béninoise soulstress – Angelique Kidjo, perform on stage.   

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Angelique Kidjo performing at the Women in NTDs celebration

From the 20 – 21st April, disease-specific sessions took place at the Hotel Continental. It was a delight seeing several COUNTDOWN colleagues attend and present their work. During the second session on schistosomiasis as organised by the Global Schistosomiasis Alliance (GSA), I outlined our recent work on developing a framework for environmental surveillance. This clearly sets the scene to evaluate the much-needed scale-up in, and expansion of access to praziquantel by drawing into focus the transmission dynamics within the environment.

In a further attempt to do so, the GSA created a lakeside stir by having a large inflatable worm “invade” Geneva as part of their #makeschistory initiative.  More broadly, further COUNTDOWN work was featured within brochures of the special edition of Infectious Diseases of Poverty dedicated to “Schistosomiasis research: providing the tools needed for elimination”, sponsored by the GSA.

Furthermore, copies of the report on the recent Towards Elimination of Schistosomiasis Conference in Cameroon were also available for appraisals.

During open discussions, I became aware for example that while the surveillance for Lymphatic Filariasis and STH were becoming integrated as set within the Transmission Assessment Survey (TAS), integration of intestinal schistosomiasis however, was not. This fragmentation seems counterproductive for the key diagnostic to be used. Kato-Katz faecal sampling detects both STH and Schistosoma mansoni infection. It seems a little short-sighted to ignore such synergies for there could be significant cost-savings to be made within future co-surveillance. Answers to this question might be found within the DeWorm3 initiative.

So, we now observe that space with interest, hoping that newly emerging disease-specific silos are quickly broken down.

COUNTDOWN Nigeria: A Model for Conducting Implementation Research

Dr Obiageli Nebe, Phillip Okefu Okoko, Ruth Dixon, Laura Dean

COUNTDOWN is a research consortium dedicated to investigating the cost-effective, scale up of sustainable solutions necessary to control and eliminate the seven most common Neglected Tropical Diseases by 2020. In Nigeria, the COUNTDOWN project is a collaboration between the Federal Ministry of Health (FMOH), the Kaduna & Ogun State Ministries of Health, Liverpool School of Tropical Medicine (LSTM) and Sightsavers. COUNTDOWN is supporting implementation research, the outcome of which will provide the evidence needed for policy and or programme change to enhance coordination and programme delivery. Activities began in Nigeria in September 2016.

To maintain the COUNTDOWN ethos of multidisciplinary equitable collaboration, we have ensured to build a partnership in Nigeria that focuses on the following areas:

Early Involvement of key stakeholders in a genuine and trusting partnership

It is important to secure the full commitment of the Federal and State Ministries of Health to the vision and goals of the project and buy-in into the outcomes, increasing likelihood of taking up key findings that may inform policy.

Advocacy meeting with the FMoH, Sightsavers Nigeria Office and LSTM were held before any project activity. All partners were involved in development of timelines, planning and project conceptualisation and all were on the panel during team recruitment.

The programme was launched on the 15th March 2017 receiving unanimous endorsement by the NTD Steering Committee and the COUNTDOWN Nigeria team being formally invited to the join the Research Sub-committee.

Having a multi-disciplinary and cross-sectoral team

Issues are not one dimensional; they are influenced by social, political, health, economic, operational and cultural factors. A multidisciplinary multi-sectoral team allows a holistic approach and adaptability to country’s needs.

The COUNTDOWN team is led by the Federal Ministry of Health and includes social scientists, health economists, a research uptake officer (embedded in FMoH), and a research manager/officer. The collaboration includes LSTM bringing technical guidance and Sightsavers the perspective of large scale implementing partner.

Identify research needs that will address implementation issues in the local context

Implementation research is not a “one-size fits all”; countries and contexts are different with varying challenges to NTD control and elimination programs. Research that addresses a genuine need is more useful and more likely to be taken up resulting in positive programmatic impact.

The preliminary phase of COUNTDOWN Nigeria has been a thorough and robust qualitative situation analysis of the NTD programme. It involves perspectives of Federal, State, Local Government Area (LGA), Primary Health Care (PHC) and Community Directed Distributors (CDDs)/Teachers involved in NTD programme delivery. Two States of Nigeria – Kaduna and Ogun – have been purposively selected as the focus of COUNTDOWN Nigeria and the situation analysis as they represent two very different NTD implementing environments. Key informant interviews (38) and participatory action research workshops (18) have been completed in 3 LGAs of each State. Data is currently being analysed to provide a full contextual understanding of each study area and inform research question development for the main study. Full scale research will begin late 2017.

Maintaining effective and collaborative partnership

Research questions and implementation environments evolve. Only when partnerships are truly collaborative, can teams adapt together keeping research focussed and relevant.

The Nigeria COUNTDOWN team is led by the Federal Ministry of Health who have, and continue to take an extremely active and engaged role in planning, decision making and data collection. Open dialogues and honest communication have facilitated an evolving relationship between all three partners and successful resolution of any issues. At the recent partners meeting in Yaoundé (March 2017) all partners were present including 4 participants from FMoH. Dissemination meetings for the situation analysis are planned for mid-June 2017, scheduled to allow feedback from each State to be inputted before Federal dissemination workshop. Dissemination of situational analysis will be followed by an evidence synthesis workshop and research planning meeting where questions will be formulated and planned and which all partners will attend.

Linking to the global agenda

It is important to “be informed as well as informing”. By working in tandem with the global agenda and being current on wider sectoral issues, contributions to the evidence base can be more valuable to more people and non-duplicative.

The team is working in the context of the “Leave no one behind” global agenda and the Nigerian national slogan “End the neglect of NTDs”. COUNTDOWN is a multi-country project where all country teams regularly get together for cross-country learning events. COUNTDOWN Nigeria has incorporated into the situation analysis a pilot of the new World Health Organisation (WHO) Gender, Equity and Rights Tool with results presented at the WHO Strategic and Technical Advisory Group meeting in Geneva (17th Feb 2017). Results have also been included as part of a submission for an Equity Symposium at the American Society of Tropical Medicine and Hygiene. Early findings of the situation analysis have already been discussed at international forums such as Towards Elimination of Schistosomiasis (TES) conference in Cameroon (March 2017).

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Dr Akinola Stephen – COUNTDOWN Nigeria Research Officer for Ogun State presenting at the TES Conference in Yaoundé, Cameroon

Conducting multidisciplinary implementation research can be complex, but is essential for cost effective scale up of NTD control and elimination interventions. We hope by using the guiding principles identified here that we can learn lessons to be taken forward to address some of the key bottlenecks currently faced by the NTD programme in Nigeria. Through the generation of our strong multidisciplinary team, we also hope to make recommendations for the success of cross-discipline and cross-country effective and equitable research partnerships.

Read about COUNTDOWN Nigeria’s recent launch via – https://countdownonntds.wordpress.com/2017/04/06/countdown-launched-in-nigeria/

We will also be attending the NTD Summit organised by WHO and held at their headquarters in Geneva, Switzerland from 19 – 22 April 2017.

For more information about Nigeria’s Department of health, visit – http://www.health.gov.ng/index.php/department/public-health

COUNTDOWN Launched in Nigeria!

If you want to go fast, go alone; if you want to go far, go together: Collaboration in Research

by Pamela Bongkiyung, Prof. Russell Stothard & COUNTDOWN Nigeria Team

It was an auspicious moment when the COUNTDOWN programme was launched in Lagos – Nigeria, during the 18th Neglected Tropical Diseases (NTDs) Steering Committee Meeting, which took place from the 13th – 15th March 2017.

The Steering Committee gathered experts from the academia, the Federal Ministry of Health, the State Ministries of Health, Research Triangle Institute (RTI)/ENVISION, Evidence Action, End Fund, MITOSATH (Mission to Save the Helpless), Helen Keller International, Health Partners International, Sightsavers, HANDS (Health and Development Support Programme), Amen Health Foundation, NIMR (Nigerian Institute of Medical Research), WHO (World Health Organisation), eHealth Africa and COUNTDOWN of course.

The sub-committees which presented at the main steering committee meeting, ranged from research, technical review, NTDs- WASH (water, sanitation & hygiene), elimination & verification to advocacy & resource mobilization. Discussions had in the meeting ranged from donor priorities to country’s needs. Should the country accept funders choice of disease even if the burden was heavier elsewhere; was one of the questions pondered.

With an introductory presentation from COUNTDOWN’s Nigeria Country Director, Dr Sunday Isiyaku, the Steering Committee soon understood that the project’s focus is to leave no one behind given its multidisciplinary approach and incorporation of health economics. Dr Isiyaku highlighted COUNTDOWN’s implementation research that will investigate cost-effective ways of up-scaling NTD control. Not forgetting the pertinent role played by community drug distributors (CDDs) and in this case, two CDDs from Kaduna state who have served for over 15 years; Dr Isiyaku, reminded the Steering Committee of what communities can achieve when they are committed as seen in the case of the dedicated CDDs from Kaduna.

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Community Drug Distributors (L-R): Joseph Umaru & Shittu Baba

Dr Isiyaku tendered a request for the Research Sub – Committee of the NTD Steering Committee, to play an advisory role to the COUNTDOWN Nigeria project. This was endorsed by all chairs of the NTD Steering Committee.

COUNTDOWN’s Director – Prof. Russell Stothard, in his opening speech, informed the group that COUNTDOWN is not just about one disease or partner but a multitude of partnerships working together with a major task of breaching the gap between researchers and policymakers at the federal, state and international levels.

COUNTDOWN’s priority in Nigeria is to conduct a situational analysis in the two focal states – Kaduna & Ogun, which should reveal the challenges that need to be addressed to cost-effectively scale-up NTD programmes and ease integration into the health system whilst strengthening it. In addition, gaps will be identified in line with successes that will form the basis for the next stage of the research.

The launch of COUNTDOWN Nigeria elucidated cheers but also injected an element of hope as shown in the enthusiasm expressed by Prof. Adenike Abiose, Prof. Uche Amazigo and Dr Margaret Mafe – all members of the NTD Steering Committee. COUNTDOWN Nigeria was touted as the programme that would breach the evidence research gap left by the end of APOC (African Programme for Onchocerciasis Control) as seen in its multi-partner and cross-border approach.

It soon became evident that there is a fervent desire within the Nigerian NTD community for collaboration and knowledge sharing in tackling hotspots of NTDs, an action already embodied by COUNTDOWN. In the Research Sub-Committee’s recommendations to the Steering Committee, evidence-based research is encouraged in its terms of reference. It is no longer enough to produce endless research, evidence-based research is emphasised.

Activities are already being integrated at the federal, state, local government areas (LGAs) and community levels to include advocacy and resource mobilization. There is a push for this to be reflected in state NTD Masterplans to help fund NTD activities within the country. In East Africa, advocacy has a long tradition and is entrenched in most non-governmental development organisations. Realisation is dawning on the need for advocacy to become civil society driven. The point is to encourage buy-in from communities and major stakeholders within Nigeria. For some programmes like UNITED Consortium for NTDs, engaging civil society organisations to be active participants for advocacy, provides a basis for their exit strategy.

Why advocate and mobilise for funds? We all know donors will not give forever and given the recent changing political climates and donor priorities in main funders’ countries’, the Nigerian NTD community are preparing themselves for when donor fatigue sets in.

By the time funds from advocacy and mobilisation activities in Nigeria stream in, we hope COUNTDOWN’s implementation research can provide some solutions that will put the funds raised through advocacy, to good use and move the NTDs agenda that closer to elimination.

You can access the Storify of our tweets for the launch from @NTDCOUNTDOWN and @COUNTDOWNNG from here.

 

Using Polio Samples to Assess Schistosomiasis and Soil-transmitted Helminthiasis Prevalence in Ghana

By Lucas Cunningham

With the success of the campaign to eradicate polio the questions surrounding the legacy of the Global Polio Laboratory Network (GPLN) should be asked. It is towards this end that COUNTDOWN incorporated into its objectives, an assessment of the suitability of the faecal collections generated by the GPLN for use in assessing the prevalence of Soil-Transmitted Helminths (STH) and Schistosomiasis (SCH). The polio laboratory at the Noguchi Memorial Institute for Medical Research (NMIMR) was selected to pilot this study. Members of their team attended a qPCR workshop hosted by COUNTDOWN in March 2016.

The laboratory at Noguchi had been storing faecal samples sent to it by clinicians across Ghana. These samples come from patients presenting clinical signs of polio, typically this would be acute flaccid paralysis (AFP). At the Noguchi laboratory a total of 913 samples had been collected from 2012 until 2015; and of these, a subset of ~500 samples were selected. The samples selected would undergo a DNA extraction involving a pre-treatment phase of bead beating, to break open the eggs of any helminths present. The sample would then be screened with TaqMan assays to identify the following helminth types: Strongyloides stercoralis, Necator americanus, Ancylostoma duodenale, Ascaris lumbricoides, Trichuris trichiuraI and Schistosoma.

At Noguchi, the pre-selected samples were identified and over the course of the next few weeks these samples underwent the DNA extraction described above. The samples were then screened with the TaqMan assays over the following months. The qPCR results identified a combined helminth infection prevalence of 13% with A. lumbricoides and N. americanus as the most common found in 4% of samples. The prevalence of A. duodenale, Schistosoma and S. stercoralis were like each other at 2% while T. trichuris was not found in any of the samples.

This initial investigation shows that the use of the GPLN’s faecal collections in screening for STH and SCH has potential as an alternative for assessing the prevalence of these different diseases in a country without the need to do an expensive community survey.

 

 

An African Focus at the 2017 GCID Infectious Diseases Symposium, Seoul

by Prof. Russell Stothard, Director

The Global Center for Infectious Diseases (GCID) is part of Seoul National University College of Medicine and directed by Professor Eung-Soo Hwang. Each year the GCID holds an international symposium which aims to bring together national and international researchers to discuss current health-related issues. It also seeks to initiate and solidify collaborations aligned within its two departments, The Department of Microbiology & Immunology (DMI) and The Department of Tropical Medicine & Parasitology (DTMP), respectively.

Invited by the Head of DTMP, Professor Min-Ho Choi, I was honoured to give the first keynote presentation at the 2017 GCID Infectious Diseases Symposium and discuss schistosomiasis-related work in Africa. I took the opportunity to feature the importance of female genital schistosomiasis (FGS) and our previous FGS workshop, as well as recent COUNTDOWN activities and publications.  The previous year, Professor Choi had visited the Liverpool School of Tropical Medicine (LSTM) and was keen to develop shared interests in research and teaching further. To this end, we co-supervise an LSTM-PhD student, Dr Sunghye Kim, who has been developing an island-wide STH control programme on Fiji on the back of transmission assessment surveys for lymphatic filariasis. This receives support from the Korea International Cooperation Agency (KOICA), the Korean equivalent to DFID, UK.

Established in the early 1950s, the DTMP has a long history in medical parasitology and exemplary scholarship in intestinal trematodes, describing their lifecycles and epidemiology. Several key staff, for example Professors Seo and Lee, have been seminal in developing country-wide control programmes in Korea. These have been eminently successful, for with consolidated intersectoral action, extensive diagnostic screening with bi-annual treatment and appropriate health education as well as general socioeconomic development have resulted in elimination of STH in Korea as a public health problem. This is a tremendous achievement, however, without a significant within-country burden, the DTMP has realigned itself today with bilateral efforts to control disease elsewhere, in particular in Africa.

Recent research and control undertaken by DTMP in Sudan against schistosomiasis and funded by KOICA was presented by Professor Sung-Tae Hong who had also undertaken numerous clinical assessments of bladder pathology by ultrasonography. Later in the week, we discussed at length the growing importance of FGS and I shared with him my copy of the FGS pocket atlas. The intention is to develop a better understanding of FGS and assess if a pilot gynaecological examination could be performed in adult women. Incidentally, if KOICA were to become better aware of the importance of FGS it might open up efforts within their educational and medical outreach projects to improve the health of adult women and those of child-bearing age elsewhere.

During the remainder of the 2017 GCID Infectious Diseases Symposium we discussed with colleagues within the DMI, the status of current viral influenza epidemics and the importance of preparedness for novel strains that might arise, for example H7N9. The emergence of this viral variant is of concern and orchestrates an intercontinental need for rapid molecular surveillance. On a related point of better disease surveillance, I was happy to point out that COUNTDOWN was using similar molecular DNA diagnostic tools newly embedded within the polio surveillance network and highlighted Lucas Cunningham’s and Emily Adams’ exciting results on the use of real-time PCR assays in Ghana.

After the symposium, the following morning I gave a similar presentation to the Korean Society for Parasitology then later in the afternoon a more career-focused presentation to a group of medical students. These were united by a student-action body across Seoul universities and were each interested in global health and wishing to known how best to contribute. I was impressed at their general knowledge and how one student had already volunteered to assess refugee health in Germany in light of the Syrian crisis. Later in the week I was warmly hosted by the DTMP and I took part in their laboratory meeting. There, we discussed recent efforts on developing a LAMP assay for schistosomiasis and I was able to share with them Corrado Minetti’s recent publication.

Upon leaving Korea and looking to the future, we are now thinking of ways to further our shared interest and synergise activities. It is fortunate that Professor Choi is serving on the local organising committee for the next International Congress on Parasitology, for we are aiming to organise a special session on schistosomiasis control to feature future results from the DTMP and COUNTDOWN networks. This is certainly something we should all look forward to.

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.

 

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.