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!


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).


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.


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.


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.


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.


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.


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:






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.


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.


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.



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.


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.


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.




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!



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.


A Focus on Schistosomiasis and Soil-Transmitted Helminthiasis in Crater Lakes in Cameroon

By Deborah Sankey, Tim Day and Faye O’Hallaron

This blog describes some of the highlights and challenges of our work with Louis-Albert Tchuem-Tchuenté in Cameroon. We were privileged to learn a great deal about the day-to-day realities and practicalities of interventions against Neglected Tropical Diseases (NTD). Our experiences generated more stories than we have time to tell, but here is a brief overview about lakes Barombi Mbo and Kotto. We hope you enjoy reading this as much as we enjoyed our work with the team there.

Having attended several planning meetings and gaining local permissions in Kumba; our first day in the field involved getting ourselves and all our equipment to our first field site – the crater lake of Barombi Mbo. Getting there was challenging and our journey involved a one -hour commute each way in local hand-paddled canoes but was set within breath-taking scenery. We arrived on the other side of the lake and walked through the surrounding cocoa farms- the most valuable commodity of the region – to the village itself. After greeting several village elders, we were taken directly to the chief’s house to discuss our work. We requested their permissions and support to help us conduct our surveys and interviews.


At this point the team split, half going back to the lake in search of aquatic snails and the remainder based inside the village church hall to begin collection of samples and conduct interviews by questionnaire. As the community rushed to be involved, our workload on the first day was greater than expected. We faced challenges in French-speaking situations.  Meanwhile on the lake the malacological team were working under the full might of the African sun. Wearing their armour of waders and sporting only a simple kitchen sieve (Sainsbury’s RRP £4.99) and a pair of tweezers, the intrepid team delved into the shallows in search of the miniscule molluscs.

After both teams had completed their quota of samples for the day (the importance of applied statistics for you!), we regrouped and made our way back to Kumba setting to work analysing all our samples.

Several further days were spent in Barombi Mbo following a similar pattern of work, before moving on to our second study site Barombi Kotto. At Kotto, due to its rural location, we stayed in the vicinity of the second lake for the duration of the survey. This involved a three-hour journey along mud tracks, which was tricky even when dry and almost impassable on our return visit where two vehicles had succumbed to the mud.

We set up the lab in the local health centre, and were pleased to see a modern looking lab with clean white tiles and all the mod cons, minus however running water and electricity! Each day we collected water from the local stream and we had the foresight to bring a portable generator. Using this within the health centre meant entertainment was on hand for while we worked. The surrounding children could watch DVD films in the evening and adults charge phones in the health centre while we beavered away in the laboratory until the late hours of the evening. Deborah and Faye, being women, were lucky enough to enjoy the hospitality of a local family living within their vicinity. Tim and the male staff took up residence in the abandoned maternity ward. The family welcomed us with great kindness, cooking for us excellent meals every day, and ensuring we had everything we needed, we even joined the family for morning prayers.

The days followed a similar pattern of questionnaires, sample collection, and then analysis. The main difference was that the majority of the population lived in an isolated community on an island in the middle of the Lake Kotto. Unlike the clear waters of Mbo, the lake was smaller and much less enticing. The canoes were very rickety, made of half a hollowed-out tree patched-up with cement, making for interesting journeys across the lake. This community were less accustomed to foreign visitors and our supervisor was invited to spend a night on the island. We were lucky enough to be told stories by the community elders about the village’s history. It gave us a greater insight into the local culture and traditions and just how important the water of the lake was to their community identity and beliefs.

We faced many challenges throughout our trip and were pushed to our limit physically, mentally and digestively. With team work and perseverance we achieved our goals. We learned more than we can convey.

Read more

Anyone’s Disease: Ending Lymphatic Filariasis in Ghana

A Bed Net to Rule them all: Accelerating Lymphatic Filariasis Elimination through Malaria Control Programmes



ONCHOCERCIASIS IN THREE DECADES PART II: Building the Next Generation of Parasitologists

By Pamela Bongkiyung

This post continues the discussion with Prof. Wanji on the strides undertaken towards the control of Onchocerciasis.

In this segment, he discusses his hopes for a drug that could not only work against Onchocerciasis but also Loa Loa without causing harm to the human host. He highlights the foundation he has laid down to help the next generation of parasitologists, empowering them to seek solutions to problems endemic to their respective environments.

Question: Understanding that we have just the one tool, does it complicate matters or make it worse that there is Loa Loa in all of this to deal with?

Prof. Wanji: Of course because that tool presents a problem with Loa Loa. Just because it is one tool remains a problem but the fact that in some areas you cannot use it, makes it more difficult. It presents a double problem and sometimes people often talk of double penalty with regards to Loa Loa. That is something which was discovered recently that the area where Loa Loa exists, the tool which was being used to map Lymphatic Filariasis can have false positivity. It can be positive not because of Lymphatic Filariasis but because of Loa Loa. Loa Loa has been inflicting a double penalty for the control of lymphatic filariasis and onchocerciasis in the central African region.

Q: Is there a drug to mitigate Loa Loa as well as Onchocerciasis without causing any adverse reactions.  It appears there isn’t the one stone that can kill two birds but is there one that can kill each bird at a time?

Prof. Wanji: Unfortunately we do not have a drug that can kill Loa Loa safely for now. That is a major problem. In our laboratory, we are trying to develop experimental models but at the in vitro and nvivo that can help screening and developing drugs for Loa loa. If we can have drugs that can kill Loa Loa alone, that already will be a great achievement. If we could have a good drug that could kill Loa Loa in a safe manner for the host (the human) and also kill onchocerciasis, that will be a tremendous achievement. Actually, we were handicapped, we don’t have a solution for Loa Loa as we stand today.

Q: This problem is very endemic in the Central Africa region. At the level of education especially within the universities, are there any incentives to get students more interested in research work for diseases that affect their environment? And is there available training to enable them conduct research that could possibly bring a much needed solution in the future?

Prof. Wanji: I think the teaching of parasitology (because all of this belongs to microbiology and parasitology), is difficult because most of our African students are likely to learn computer science, business administration and Economics.

We, at the University of Buea for the past five years in the Department of Microbiology and Parasitology have created postgraduate programmes that are specifically oriented to Neglected Tropical Diseases (NTDs). We have an MSc in Molecular Parasitology and Vector Biology, MSc in Microbiology, MSc in Epidemiology and Control of Infectious Diseases, a PhD in Cellular and Molecular Parasitology and a PhD in Microbiology. And if you look at our PhD and Master degree programmes, we have two arms: we have the arm of research and development which includes the MSc in Molecular Parasitology and vector biology, PhD in Cellular and Molecular Parasitology.

They give the basis for students to be involved in developing new tools for diagnosis of parasites, new tools for understanding the immune responses and developing vaccines, new tools for developing new drugs. The thing is that our students have to understand and be part of the momentum. But we also work with epidemiology and control orientation in the programme. We want them to be ready to uptake the product of the research to the end users because the epidemiology conceives control programmes, monitors and evaluates them. We want them to be able to say, this is what we have achieved, this is where we are having difficulties or encountering bottlenecks and we can do this to change.

We have conceived a programme to address the problem of NTDs and infectious diseases at large maintaining a parasitology focus.

Q: What legacy would you want to leave behind?

Prof. Wanji: Difficult question. Legacy is difficult because it is not easy to praise yourself. I would like to be known as somebody who conscious of the dimension and width of NTDs devoted part of his life to contribute, to understand and fight those tropical diseases; by teaching students about NTDs, creating and developing research capacity that has contributed to the training of those students; by participating in research work that has contributed to change people’s lives, contributing to fight in the field of those diseases and by anticipating what the future will be in my discipline; re-orienting the teaching programme at the university to get African students to be more proactive in the solution to those problems created by  NTDs.

Thank you for those last words Prof. Wanji.