Sabina facilitating the seasonal calendar

The Importance of Team Work and Shared Learning in Collaborative International Health Research

By Eleanor MacPherson

Leaving my two young children in the UK and travelling for work is always tough. But spending time in the company of the Dodowa Health Service research team made being away worthwhile. I, like many qualitative researchers, know that the skill of the person collecting the data is the most important factor to ensuring good quality data. Yet, anyone who has tried conducting a qualitative interview or focus group discussions knows how challenging it can be to do it skilfully. By spending ten days with the Dodowa Health Service research team, under Dr Margaret Gyapong’s excellent leadership, I learnt so much about how to provide rigorous inclusive training in collaborative research.

Here are my *Four Take Home Messages:

You have to understand the research topic before you can begin: Neglected tropical diseases are complicated! As a social scientist who has only recently begun working on these types of tropical diseases I know how challenging it can be to understand the complex way that a mosquito, black-fly or snail can ultimately contribute to the transmission of worms to people. Further, if someone is infected it may take a number of years for them to experience ill-health. The focus of this round of data collection is lymphatic filariasis and understanding why some districts in Ghana are still facing on-going transmission despite a number of rounds of preventative chemotherapy. The training began with an introduction as to what lymphatic filariasis is and how it is transmitted. Building on this information the team then discussed the purpose of the research and the groups who could best provide insights into these questions. During the training discussions in the group frequently returned to these areas. This allowed the team members, particularly those new to the topic, the opportunity to ask clarifying questions and gain further understanding.

Translating and refining the topic guide as a team can improve the tools: Conducting research on international health often requires the researchers to work across multiple languages. Yet, the way language is used is of the utmost importance to ensuring participants understand what is being asked of them. The Dodowa team took a two-step approach to translation. They went through the topic guides together in English first, discussing as a group whether they made sense; whether they had covered all the research objectives and whether the order of the topics worked. As the team went through they re-ordered some of the questions, removed questions that didn’t make sense and refined the language. The second stage was to translate the guides into Twi and Fante. At this point the whole team contributed to the translation taking turns to read the guide and holding spirited discussions about the correct meaning of the words.

Practice, practice, practice: The team used role-play as key part of the training. This gave every single member of the team an opportunity to practice conducting a qualitative interview and a focus group discussion multiple times. Sheila Addei or Mama She as the team like to call her oversaw the role play. She has more than a decade of experience conducting qualitative research studies and together with Dr Margaret who has more than twenty years’ experience provided fascinating insights into what has worked well and what hasn’t when conducting qualitative research! Mama Shelia told the team about how during one of her first interviews the participant told her off for failing to use the topic guide correctly. The team also took turns giving difficult responses to provide the researchers with an opportunity to practice managing these challenges before they went to the field. Every team members’ role was practiced including the note taker and the observer to ensure that the person undertaking this role fully understood their duties.

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From Left: Sheila Addei (Mama She), Dr Margaret Gyapong, Sabina Asiamah, Piloting the FGD & Seasonal calendar in the field, Dr Ellie MacPherson with team, Irene & Selase practising interview and Adriana Opong

Strong leadership combined with an empowered team is a powerful combination: One of my favourite parts of my time in Ghana was feeling part of such an empowered and well-led team. It was fantastic to witness even the most junior members of the team having their voices listened to, and thoughts respected. Creating space for reflection and shared-learning is such a core component of qualitative research but doing it well when working in a team can be challenging. Respect and inclusion are fundamental to qualitative research practice and by placing these at the centre of their work, the Dodowa team did a fantastic job. I am sure this practice will continue throughout the whole of the project.

I know I have returned to the UK a better researcher thanks to the team and very excited for the next stage of the collaborative research process.

Onchocerca infective larvae

Old dog, New Tricks? Assessing the Potential of Integrating Focal Vector Suppression with Drug Cure to Control and Eliminate River Blindness

By Louise Hamill

Onchocerciasis, also known as river blindness, is one of the vector-borne neglected tropical diseases (NTDs); in this case, transmitted by many different species of black fly. The majority of infections (99%) occur in sub-Saharan Africa. The disease was previously also found in South America but is now thankfully close to total elimination; with only a few isolated, extremely remote areas still to be verified disease-free. The aim for Africa is to achieve continent-wide interruption of transmission by 2025.  Current control of river blindness in Africa, which, as well as blindness, leads to debilitating, disfiguring skin pathology, is based upon the mass delivery of ivermectin to entire populations in endemic areas. Ivermectin kills microfilariae in the skin, but has no significant effects on adult worms. This necessitates repeated rounds of ivermectin mass delivery for a period of 12 – 15 years, with sustained high coverage of the at-risk population essential for successful disease control and eventual elimination.

This approach has had notable successes in several areas, led by the efforts of the African Programme for Onchocerciasis Control (APOC). However in other areas, the impact of sustained delivery of ivermectin for fifteen years, and in some areas more than two decades, has yet to result in the predicted interruption of transmission. Furthermore, where the eye worm Loa loa and onchocerciasis occur together, mass delivery of ivermectin cannot be easily rolled out. Ivermectin causes unwanted side effects, and in rare cases death, in individuals infected with L. loa as the drug rapidly kills this parasite. L. loa is common in large swathes of West and Central Africa, allowing onchocerciasis to endure in these areas, where many people are still infected and transmission of both pathogens is actively taking place, despite ongoing control efforts. Clearly there is no one-size-fits-all approach to curtail river blindness, and there is a need to seek alternative strategies to ivermectin-based control in areas where river blindness and L. loa overlap.

In the nineteen seventies and eighties the WHO onchocerciasis control programme, OCP, ran an extremely successful vector control strategy against onchocerciasis in savannah areas of West Africa. This programme relied exclusively on aerial application of larvicide to kill black fly larval as they resided in rivers and streams. It is estimated this past use of vector control prevented 600,000 cases of blindness and prevented 40 million people being infected. The scale of this undertaking, including the huge financial cost and human resource needed, means that the use of mass vector elimination as a tool for onchocerciasis control is very much consigned to the history books. Before turning the page completely on this chapter of onchocerciasis control, are there any lessons to be learnt from this “old dog”?

The COUNTDOWN meeting on Focal black fly Control in Cameroon

This is exactly the question we set out to debate when COUNTDOWN convened a technical advisory panel at the Liverpool School of Tropical Medicine on 22nd of July 2016. Although mass vector control is out of the question, is there any way in which short-term, localised approaches can be used to augment and complement existing strategies?

Vector Meeting

Attendees at the COUNTDOWN meeting on Focal Black fly Control, from Left to Right: Professor Graham Matthews, Professor Rory Post, Dr Frank Walsh, Didier Bakajika, Dr John B. Davies, Dr Louise Hamill, Dr Hans Dobson, Dr Joseph Turner, Professor María-Gloria Basáñez, Professor Mark Taylor, Isobel Routledge, Professor Russell Stothard, Professor Robert Cheke. Not pictured; Professor Janet Hemingway, Dr Lisa Reimer.

Previous work in South West Cameroon by members of the COUNTDOWN consortium indicates that ten years of ivermectin delivery in our study area has not had the expected impact on disease prevalence. The average community-level of skin microfilaria prevalence stands at 52.7 percent, with the infection intense even in children under ten years of age. Additional work in South West Cameroon found current adherence to ivermectin mass delivery by local residents is not adequate to achieve onchocerciasis control. This is an area where alternative and complementary strategies are urgently needed.

The COUNTDOWN consortium has proposed that larvicidal treatment of vector breeding sites at the same time as testing and treating the human population with doxycycline could offer a complementary onchocerciasis control strategy. This two-pronged approach, it is hoped, will have a greater impact on disease transmission than using either technique in isolation. Doxycycline targets “friendly” bacteria living within the adult onchocerciasis worms, resulting in a significant shortening of their lifespans and giving doxycycline a very different mode of action to ivermectin. Since L. loa does not harbour the same bacteria, individuals co-infected with L. loa who take doxycycline will not suffer the same side effects as can happen with ivermectin. From the evidence above, it is clear to see ivermectin mass delivery has not had the desired impact on disease prevalence over the past ten years in this area of South West Cameroon; could targeted vector suppression jump start the path to onchocerciasis control?

At the meeting, debate revolved around the factors influencing choice of larvicide; when, how often & for how long the larvicide should be applied; the most suitable sampling methods to monitor impact of the larviciding on adult and larval black fly; and how best to undertake monitoring of the impact of insecticide application on non-target organisms. The optimal timing of any vector suppression to best amplify the impact of the community test-and-treat strategy is crucial. The way ahead is far from straight forward, highlighting the importance of rigorously assessing the evidence and our proposed strategy in this way. Although the use of localised vector control against black flies is not a new proposal, there is little information on how this could be implemented against free-living black fly larvae.

Where next?

The control and elimination of NTDs in Africa has repeatedly been in the post-millennium development goals policy spotlight, with (among others) the WHO roadmap to elimination, the London Declaration on NTDs and recently the launch of the Expanded Special Programme for Elimination of NTDS (ESPEN). Similar to the situation for lymphatic filariasis, scale-up of mass delivery of ivermectin will not be enough to achieve the London Declaration 2020 targets for onchocerciasis control and elimination. The use of both doxycycline and focal vector suppression are separately recommended by WHO and APOC as alternative onchocerciasis control strategies, to accelerate progress towards onchocerciasis control, however as relatively new control strategies evidence on their implementation is scarce and evidence on integrated, dual-strategy implementation is wholly absent. The specific contexts in which these tools could be successfully implemented together are unclear.  Going forward with our onchocerciasis work in Cameroon, COUNTDOWN’s focus is consolidation of the evidence gathered at the vector control meeting to assess the possibility of implementing localised vector suppression as an adjunct to existing and alternative control and elimination strategies. This will bridge vital evidence gaps and provide clarity on if and where these techniques can be used, and the optimal conditions in which to implement them.

 

 

 

Anopheles gambiae, the major vector of lymphatic filariasis and malaria in rural Africa (source: www.scientistsagainstmalaria.net)

A Bed Net to Rule Them All: Accelerating Lymphatic Filariasis Elimination Through Malaria Control Programmes

by Corrado Minetti

In rural areas of Africa, Lymphatic Filariasis (LF) is primarily transmitted by night-biting Anopheles mosquitoes, which also transmit malaria. Currently, the two major ways of controlling malaria vectors are the indoor residual spraying (IRS) of insecticides and the use of bed nets. It has been estimated that the combination of these two interventions, in the decade 2000-2010, has prevented  more than 200 million new cases and more than 1 million deaths due to malaria.

In areas where both LF and malaria occur and are transmitted by the same mosquitoes, should we then promote vector control alongside mass drug administration (MDA) to accelerate the elimination of LF through a better and more cost-effective integration of LF and malaria control programmes at the national level?

The answer is yes.

The importance of vector control for lymphatic filariasis elimination

Reducing mosquito numbers and preventing people being bitten has a significant impact in reducing the burden of LF and, ultimately, pushing towards its elimination. As it has been reported in various countries around the world the use of bed nets, IRS and/or reducing the mosquito breeding sites can all result in a significant reduction of LF transmission even in the absence of MDA. For example, in Papua New Guinea the deployment of insecticidal bed nets in communities where MDA was stopped 10 years before resulted in a reduction of the LF transmission potential down to zero within only 11 months following distribution.

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A long-lasting insecticidal net (LLIN) in Agyan (Ghana) (Photo: Corrado Minetti)

Mathematical models have clearly shown the strategic impact of implementing vector control alongside MDA for LF: reducing the human-mosquito exposure allows reaching the community and vector infection thresholds below which LF transmission will be interrupted faster and earlier compared with using MDA alone. As a result less rounds of MDA may be needed to reach elimination if vector control is in place, with important savings for the programme.  Furthermore, sustained vector control may avoid the resurgence of LF in treated communities in a post-elimination setting (after MDA has been stopped) due to the potential re-introduction of the disease through human movement.

The way forward: integration of lymphatic filariasis and malaria control programmes

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Mass distribution of ivermectin for LF elimination (on the left, source: www.mectizan.og) and bed nets for malaria control (on the right, source: www.usaid.org)

Given the importance of vector control for LF elimination; with LF and malaria being transmitted by the same mosquito vectors in West and rural Africa, integrated vector management (IVM) becomes crucial. There is a tremendous opportunity to effectively integrate the LF and the malaria control programmes, making both more efficient and cost-effective.

Establishing a synergy between MDA for LF and bed nets distribution/indoor insecticide spraying for malaria can have two major effects which will be extremely beneficial for the fight of both diseases. Firstly, a more efficient use of resources: the same community distributors delivering the drugs can distribute bed nets at the same time leading to important savings in terms of time and human resources. Secondly, a higher impact on the burden of both diseases: MDA campaigns can facilitate the distribution and penetration of bed nets in the community and vice-versa.

The beneficial effects of an integration of MDA and bed nets distribution has been clearly shown in Nigeria, where the concomitant delivery of nets alongside MDA resulted in a significant improvement in insecticide-treated bed net ownership and use (up to 9-fold) and it did not negatively affect the MDA coverage.

Following the above evidence, in 2014 Nigeria has been the first country in Africa to launch a Nationwide Malaria and LF elimination Co-Implementation Plan alongside specific guidelines.

We now have the tremendous opportunity to promote a better cross-talk between the vector borne disease-specific communities, stakeholders and policy-makers in order to raise awareness on the importance of a sustained and better planned vector control leading to a more cost-effective and effective use of resources across disease control programmes.

Within the COUNTDOWN research consortium, we recognize that the scale-up of MDA won’t be enough to achieve the London Declaration 2020 targets for the elimination of lymphatic filariasis. In particular, following the example of Nigeria, we are seeking opportunities in Ghana for an integration of the national LF elimination and malaria control programmes to co-ordinate MDA distribution and delivery of vector control interventions and to evaluate the impact of such synergy on service delivery, community participation and cost-effectiveness.

Find more information on COUNTDOWN’s activities here.

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Patience and prior knowledge: simple requirements for schistosomiasis control

By Suzy Campbell

Schistosomiasis is challenging and complex whichever way you look at it! From its six-syllable name, to its subtle but extensive disease burden, to its lifecycle in aquatic and mammalian hosts, to its control with preventive chemotherapy and – dare we hope – to its elimination by intersectoral action.

Take for example the schistosomiasis life cycle (see below). It’s so complicated that despite many attempts it was only unravelled 100 years ago, by a parasitological pioneer, Robert T. Leiper. Before this, it was not known that there was more than one type of schistosomiasis. Added to this the snail hosts’ roles were not clear and as a result little could be done to develop control strategies in any meaningful way. This meant that schistosomiasis struck fear in the hearts of many.

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There are so many interesting points to emerge from Leiper’s work. He first identified the separate African schistosome species; a contribution of tremendous value to parasitology because one (Schistosoma mansoni) is linked to intestinal schistosomiasis and the other (Schistosoma haematobium) to urogenital schistosomiasis.

Importantly, Leiper also identified and applied simple water safety measures as versatile ways to reduce schistosomiasis transmission. This included simple filtration, water boiling, use of disinfectants and resting water for 24 hours before use. In addition, his clarification of the snail intermediate hosts paved the way for attempts to remove or destroy the snails. These were all practical control strategies which were useful in schistosomiasis control, well in advance of deworming tablets being developed. All that was needed was a little patience and adequate temporary water storage.

Roll forward 100 years. Some things have changed. We are very fortunate in that we have very effective deworming tablets, although they only reach a small portion of the people who need them, and possibly not at the right frequencies to sufficiently control disease.

However, some things have not changed. The subtle morbidity of schistosomiasis is still under-recognised: for example the clinical significance of schistosomiasis in very young children and the importance of female and male genital schistosomiasis. Environmental strategies, such as water safety measures, seem to have largely been forgotten. In particular, our behaviour and perceptions of how water is used should be questioned. Water is not always safe (see below). Until we recall the prior knowledge imparted by the likes of Leiper, schistosomiasis should still strike fear in our hearts. It will not go away.

 

 

This is a village in Cameroon, showing a public tapstand as an improved water supply. But ‘run off’ water flows as an open stream, continuing through the centre of the village. Had a snail intermediate host been residing in this stream, schistosomiasis could have been prevalent despite the improved water source. (Photos: R. Stothard, S. Campbell)

A newly-released Special Issue Review in Parasitology gives an entertaining and thorough biography of Leiper’s contributions to parasitology and the developing field of ‘medical malacology’. This review covers 100 years of the history – and at times controversy – since Leiper’s elucidation of the Schistosoma life cycle and development of practical control strategies. The review goes on to illustrate how Leiper’s contributions still have relevance today, indicating a need for integrated control mechanisms, and introducing the COUNTDOWN research consortium which focuses on implementation research to provide tangible health improvements.

Globally, there is a paradigm shift for schistosomiasis, from morbidity control to transmission control, and eventual elimination as a public health problem. More than ever we are going to need to be guided by integrated and broad-based control strategies. This has been well-recognised by the World Health Organization (WHO), with their recent release of the Water, Sanitation and Hygiene (WASH) for Neglected Tropical Diseases (NTDs) Global Strategy 2015-2020. This calls for intersectoral collaboration to address NTDs by augmenting current control programmes with additional WASH activities.

Progression of a global NTD integration agenda is being increasingly recognised by NTD practitioners, researchers, and other policy makers. International consortia, such as the Schistosomiasis Control Initiative, and now COUNTDOWN, will play a part in driving this agenda. Some of the integration and WASH concepts will be elaborated upon at the annual COR-NTD meeting in November 2016. Work is also progressing within COUNTDOWN on two manuscripts to address aspects of environmental frameworks for schistosomiasis transmission control. The imperative lies with all NTD partners to ensure that Leiper’s work will continue resonating true today.

Find more information on COUNTDOWN’s activities.

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Anyone’s disease: ending Lymphatic Filariasis in Ghana

By Adrianna Opong

I used to think Lymphatic Filariasis – also known as elephantiasis – was a curse from the gods and hereditary, until I started working in health research. One day in my new job, I had a chat with Mr Samuel Odoom, the senior technical officer for the Neglected tropical Diseases Programme in the Ghana health service. He explained this to me:

Lymphatic Filariasis (LF) or elephantiasis is caused by infection from the filarial worm (a thread-like worm), which is transmitted from human to human via the female mosquito. The mosquito feeds on the blood of an infected person and then when it later bites an uninfected person, the worms are able to infect a new person. The filarial worms are in their third stage of development when they penetrate the bite wound of the uninfected person. They later become adults that live in the human’s lymphatic systems. This is a problem because the lymphatic system maintains the body’s fluid balance and also fights infections.

Mr Odoom told me that although the parasites damage the lymphatic system, most LF cases do not show clinical symptoms. However, a small proportion of infected people develop complications in the acute stages. It leads to lymphedema which is fluid collection and swelling of some parts of the body such as legs, arms, breast, genitalia. Affected people also have more bacterial infections in the lymph and skin and experience hardening and thickening of the skin. Hydrocele or swelling of the scrotum is very common in men. The complications of LF such as swelling of the legs and arms can only be managed, not cured.

Lymphedema can be prevented from getting worse by:

  • Carefully wash the affected/swollen areas thoroughly with soap and clean water every day
  • Wash in-between folds/toes with a piece of cloth
  • Dry the affected/swollen area with a clean piece of cloth
  • Disinfect any wounds and sores, use antibiotic (antifungal or anti bacterial) ointment/cream if necessary
  • Elevate and exercise the affected/swollen areas to move the fluid and improve the lymph flow.

Hydrocele can only be corrected through surgery. In 2002 Samuel Odoom, together with NTDP, set up a lymphedema clinic to manage the burden of LF complications. Mr Odoom said, “ NTDP trained a consultant who goes around the regions in the country and some other African countries to train physicians on how to do hydrocele surgeries”. Now in Ghana, there are 12 health facilities that conduct hydrocele surgeries.

Prevention and control

 LF is endemic in nine out of the ten regions in Ghana, so it is a serious health issue. It can of course be prevented by avoiding mosquito bites. Mosquitoes that carry the filarial worms usually bite between 5pm to 5am. The advice for people in endemic communities is to sleep under a treated mosquito net, use mosquito repellent on exposed skin and wear clothes that cover all the body. Yet for people in communities, preventing mosquito bites is not always possible.

In endemic communities, LF can be controlled or even eliminated with Mass Drug Administration of a single drug (ivermectin) through the Preventive Chemotherapy programme. The NTDP introduced the Mass Drug Administration in the year 2000, but only in a few districts. Today the programme has been able to cover all endemic districts in Ghana. But there are still some communities with a high prevalence of LF and some populations are still hard to reach.

It is with this in mind, that the COUNTDOWN research consortium is putting effort into investigating cost-effective, scale-up and sustainable solutions. In Ghana, the research is exploring how different factors within the health system hinder the scale up of the MDA and aims to integrate additional strategies to complement the MDAs in the control and elimination of LF by 2020.

I have now spent a year working with COUNTDOWN, embedded with the NTDP. I have come to the realisation that LF can affect anybody living in an endemic community, who does not or cannot protect themselves from mosquito bites. It is also very clear that we need to put more resources and research into finding sustainable solutions so that all communities in Ghana will be free from LF now and in the future.

Lake Malawi

Future directions in Neglected Tropical Diseases

By Eleanor MacPherson, Liverpool School of Tropical Medicine

On the 14th June I attended a meeting of the All-Party Parliamentary Group (APPG) on Malaria and Neglected Tropical Diseases (NTDs). It brought together a panel of four men to discuss Neglected Tropical Diseases and the Sustainable Development Goals. The panel included three members from the World Health Organisation: Dirk Engels (Director of NTDs), Christopher Fitzpatrick (Economist for NTDs), Bruce Gordon (NTD-WASH strategy) and Mr Andy Wright from GSK Uniting to Combat NTDs. The meeting was chaired by Jeremy Lefroy the MP for Stafford and coordinator for the APPG on Malaria and Neglected Tropical Diseases.

Here are five reflections on our discussions:

  1. Including women in community led mass drug administration can improve women’s standing within communities. Dirk Engles talked about the different ways that tackling NTDs could help meet the 17 Sustainable Development Goals but this one stood out. He described how including women as community drug distributors could be empowering for women because by taking a leadership role they were challenging gender norms. However, I would love to broaden this out to highlight the multiple ways gender shapes women and girls’ experiences of NTDs. These include the way social norms within communities often mean that women and girls are expected to interact with infected water sources on a near constant basis. Women can experience greater stigma from living with the clinical manifestations of NTDs. For instance, women living with swelling in their legs can lead to greater stigmatisation both within their families and in the communities more broadly. Expectations around who provides care in households can also mean that women and girls care for those living with the symptoms of NTDs. Making sure we highlight the diverse ways gender power relations shape vulnerability and experiences of living with the diseases is vital. One step to doing this would be the inclusion of women and girls voices in the design health and social programmes to ensure their needs are not overlooked.
  2. Despite free drugs being available not all countries request them: Understanding why countries do not request free drugs is important. Health systems in resource limited settings are often overburdened. Provision of free drugs is only part of a health programme. Many bottlenecks obviously exist that prevent countries from requesting and delivering these programmes. Taking a health systems approach that asks stakeholders what challenges governments face that stops them from requesting drugs could provide important insights.
  3. We need to look beyond just giving drugs: Where people live, whether they have access to safe water, whether they have access to health care, and what they do for a living can all affect their vulnerability to NTDs. Giving preventative chemotherapy has to be seen as a strategy that goes hand in hand with other interventions that aim to prevent people becoming infected in the first place. These include vector controls as well as Water, Sanitation and Hygiene (WASH).
  4. WASH is not always easy but it is necessary: WASH’s start-up and maintenance costs can be expensive but given the very real ways it can prevent illness and suffering investment should be made.
  5. Let’s not leave anyone behind: Millions of people, and their families, continue to be affected by NTDs. Making sure that these people’s health and social needs are considered and addressed within NTD programmes is of the upmost importance.

It was heartening to see the successes of NTD interventions such as the lymphatic filariasis programme from the last decade. However, it is clear that many challenges still remain if we are to live in a world free of NTDs.

Photo credit: Lake Malawi by Eleanor MacPherson

Collecting patient data.

Control of schistosomiasis in Cameroon: searching for evidence

By Russell Stothard and Louis-Albert Tchuem-Tchuenté

Schistosomiasis, also known as Bilharzia, is a disease that often doesn’t show any symptoms for several months or even years. Worms that cause schistosomiasis live in fresh water. Having been infected with these parasites that burrow through the skin, it is only after some time that people might get a high temperature, cough, diarrhoea and then progressive damage to the internal organs such as the bladder and bowel. Symptoms might disappear after a while too, but the parasite stays in the body causing serious long-term ill health, for example, infertility in women. The parasite also continues to be transmitted back into the environment, spreading further.

This neglected tropical disease needs more attention. De-worming tablets can make all the difference, and COUNTDOWN’s second integrated complementary strategy theme (ICST-2) is going to research the effectiveness and acceptability of expanded access to this deworming medication in Cameroon and Ghana.

For example, Cameroon only provides annual praziquantel (PZQ) treatment by mass drug administration to school-aged children. It’s possible to buy PZQ over the counter in local pharmacies, but the availability of this drug within the general health system is poor. Pre-school aged children and women of reproductive age are vulnerable here because without regular treatment they will continue to suffer. The parasites continue to be fed back into the environment, via stool or urine, first infecting snails then others in the community.

Over the coming years, COUNTDOWN will seek to foster the scale-up and wider access of PZQ treatment to people who are not currently targeted within national control programmes. We will also assess acceptability and find out it is both sustainable and cost-effective at the community level. In addition, expanded access to PZQ treatment could also accelerate progress towards the reduction of schistosomiasis transmission in the environment.

Water, sanitation and hygiene

The parasites that cause schistsomiasis – also known as schistosomes – live inside freshwater snails. Schistosomes are able to multiply themselves to enormous numbers each day and although the stages are short lived – they typically dying within 24 hours – a new wave of parasites are released the next day from infected snails.

While this is well known to many parasitologists, its importance and significance has been largely ignored within the water, sanitation and hygiene (WASH) community and agenda. Put simply, any aquatic habitat that people use and that contains infected freshwater snails is a high-risk location for schistosomiasis. Some very simple water hygiene measures – if used daily – can make the water safe, yet they remain out of reach for millions in rural Africa.

Furthermore, any efforts to make water safe needs to be tailored specifically to each demographic group in the population, as they each have different requirements and abilities to accept change. Mothers, for example, collect water for their domestic chores and typically bathe their children with it.

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A child washing at Barombi Kotto

Eliminating schistosomiasis

How can we eliminate schistosomiasis? It’s a big question. The influential and heavily cited paper by Rollinson et al. (in which we both played a part) first outlined the need to develop a guiding framework for the surveillance of schistosomiasis in the environment. This has become ever more pressing and an issue for even closer consideration within the European health sector, given the recent focus of urogenital transmission on Corsica. Developing a strategic framework is especially important in the context of the WHO 2020 Roadmap targets. Here, certification of elimination of transmission will be needed or any reasons for its failure will need to be explored.

It is obvious that PZQ treatment should be expanded to all groups at risk of infection, as highlighted by the World Health Organization. It is less popular, however, to justify its use in reducing schistosome transmission. This year, several mathematical modelling studies suggest we should no longer overlook the significant environmental transmission of schistosomiasis from groups outside school-aged children. Moreover, as we slowly gain control of the disease, the relative roles each group plays in sustaining local transmission will also be dynamic.

With this in mind, we are looking for examples in Cameroon where COUNTDOWN activities are able to develop new coordinated intersectoral actions. This will provide a more holistic vision of how to expand access to treatment for people who need it, alongside environmental studies that measure reductions in transmission.

Cameroon: searching for evidence

In Cameroon, the communities at Barombi are at greatest risk of urogenital schistosomiasis, largely because of the presence of a key species of Bulinus, the genus of freshwater snail that are permissive hosts for Schistosoma haematobium in Africa. It is the absence of other snail species at Barombi that allows us to focus on urogenital schistosomiasis alone.

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A snail distribution map of Barombi Kotto with species indicated in green and blue

Our recent field surveys undertaken in June 2016 in the crater lakes of Barombi Mbo and Barombi Kotto are starting to reveal the need to further develop a guiding strategic framework. It would measure schistosome infection alongside local environmental transmission. The sampling framework is appropriate and implementable with resources typically at hand in the sub-Saharan African region.

Since urogenital schistosomiasis also has links with female health, we can better research reasons why this parasite, which is transmitted in urine and not stool, remains a considerable health burden at Barombi Kotto and Barombi Mbo. Significant investment at Barombi Mbo has meant the building of safe water sources with piped water available to all households. However, we need to assess how current WASH interventions can be further refined to dampen local parasite transmission. For example, social science investigations could reveal why some people are unable to benefit from these interventions or continue to use unsafe water.

The two locations of Barombi are important areas for multidisciplinary studies. Here, our research will test the effectiveness and acceptability of expanded access of de-worming PZQ treatment and record any changes in environmental transmission. The research also examines biannual treatment schedules, as a way to promote equity of treatment, but also to accelerate reduction in transmission and elimination. Evidence is needed to support elimination, as there is currently no formalised WHO framework to do this. While guidelines for lymphatic filariasis with transmission assessment surveys (TAS) exist, there are none for schistosomiasis. Both national and international policies are lagging behind in this area. It is a great opportunity for our COUNTDOWN research to make an impact.

Our initial results will be presented on the 14th and 15th June at the meeting Global Schistosomiasis Alliance in China, so please watch this space!

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What does it take to control neglected tropical diseases? Part Three: Eliminating Lymphatic filariasis

By Linda Waldman

Lymphatic filariasis or LF is, like Guinea worm, caused by a worm and transmitted by mosquitoes. The disease leads to massive swelling of the legs, other limbs, breasts, women’s vulva and men’s genitals, hence its common name elephantiasis. It causes considerable pain, severe disability, stigma and mental distress. Add financial loss to this and the disease contributes significantly to poor quality of life and poverty.

Here’s an example of how it can affect someone’s life. Kofi, a strong man, living and working in Obom is in the prime of his life and hopes to have many more children with his young wife. As a child, Kofi was bitten by mosquitoes carrying the parasite. The worms made their way to Kofi’s lymphatic system where they grew to adulthood and survived – undetected – for about eight years. During this time, they released larvae that began to circulate in Kofi’s blood, and eventually disrupted his immune system. All evidence of this damage to his lymphatic system remained hidden for many years.

Now, many years later, he experiences scrotal swelling and other signs of lymphoedema. Sitting outside his home, unable to work, Kofi continues to be bitten by mosquitoes. These mosquitoes then, in turn, suck blood from other villagers who live in Obom. As they do so, mature larvae are transferred from the mosquito and unnoticed make their way into the villagers’ bodies.

Government and community efforts

LF is endemic in 74 regions in Ghana. Ghana’s strategy for dealing with LF has focused on control and more recently elimination to ensure that the transmission of disease is stopped in particular areas. It also focuses on integrated programmes, which include treatment through mass drug administration (MDA).

The government started tackling LF in 2001 through an elimination programme. It involved MDA, using a combination of Invermectin and Albendazole/Mebendazole. These drugs have the advantage of simultaneously addressing other neglected tropical diseases such as Onchocerciasis. The programme also trained community health workers, teachers, environmental officers and others, conducted health promotion through mass and print media and held advocacy meetings to increase awareness and provide support.

By 2007-2008 some communities had reduced prevalence to less than 1%. Much of the work was done by Community Drug Distributors like Stephen Sarkodie. Stephen himself was actively involved as a key volunteer administering drugs in the elimination programme. He used charts and guidelines to determine dosages: “We measure people’s height with a colour marked stick to get the dosage… Green, red, blue provide categories for different height/dosage. If someone is categorised as blue, he or she receives a certain number of Ivermectin tablets. Everybody takes one tablet of Albendazole.”

As well as ensuring that all community residents received medication to halt transmission, Stephen and other community health workers would seek out people inflicted with LF and who may, as a result of the stigma, be isolated in their homes and be reluctant to appear in public. “We ask them to come to the clinic. We come across many men and women and we advise them to seek treatment. LF can’t be cured, so people have to know how to manage it.”

Long-term work

Human beings form the only natural reservoir for the worms, so eliminating it from humans could bring an end to LF. However, the drugs provided through MDA have only a limited effect on adult worms. They decrease the larvae density in the bloodstream and curb the parasites’ ability to be picked up by mosquitoes and transferred to other human hosts. It takes between four and six years of repeated drug administration to interrupt the transmission cycle.

This does not help people like Kofi who have already been infected with LF and have the severe form of the disease. The disease can, to a certain extent, be managed through a combination of skin care, hygiene, exercise and elevation of affected limbs and further progression can be prevented. In some extreme cases, surgical removal of excess tissue is a possibility, but this is not a World Health Organization recommendation. However, as Stephen points out, people are also sometimes too afraid of travelling long distances and being isolated in alien hospital environments, far from their family and friends, to undergo this operation.

Challenges along the way

Stephen’s work – and the success of the MDA program – was threatened by the fact that many of Obom’s residents did not wish to take the drugs. Ironically, given the effects of LF, men worried that they would become impotent and would die from the medication. Indeed, some people did suffer adverse reactions to the treatment, particularly headaches, stomach aches and itchy skin.

Stephen and his co-volunteers had to develop their own communication strategy, in parallel with the government’s official media broadcasts. They advised villagers of the side effects, recommending that anyone experiencing these symptoms should come to the clinic where they would receive free treatment from the Disease Control Officer. They were slowly able to convince people of the value of medication. “Now when we go to the village, people take the medication. Now if we go to a village, and people are not home, they later will come and find me at my home to receive the medication.”

Eliminating neglected tropical diseases

The good news is that transmission has been broken for LF in Obom. No longer do people contract this debilitating disease through mosquito bites. Today, only a couple of residents still live with the devastating swellings of LF and their conditions are carefully managed.

So, what does it take to eliminate neglected tropical diseases in Ghana? It takes commitment from a wide range of development partners – donors, NGOs, religious groups, local leaders, missions, private companies, community organisations, local volunteers and others – and an approach which focuses on control, then elimination and finally eradication. It takes many years of dedicated effort, communication and persuasion.

It takes constant vigilance, as Stephen explains, to ensure that these diseases don’t get re-introduced as people travel to other areas in Ghana and elsewhere. But most of all, it takes people like Stephen. People who derive their ‘most satisfaction’ from hearing that they have eradicated Guinea worm, who selflessly serve their communities volunteering their knowledge, time and skills.

As Stephen says ‘I became used to the work, it was a service to my people. From today, to tomorrow, then the next day, I go to the villages. There is no village in the area where people do not know me’.

Thank you Stephen for your tremendous gift to Ghana and for the legacy you have left the people of Obom.

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Stephen Sarkodie

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What does it take to control neglected tropical diseases? Part Two: Controlling Buruli Ulcer

LW         By Linda Waldman

Picture the scene: Kwame, a young boy living in swampy Obom, appears to be fine, despite his swollen arm. The swelling is painless, so he and his family do not do anything about it. Within a short period, an ulcer develops; the skin at the edges is rotting and the wound seeps pus and smells putrid.

Still Kwame does not complain and his family does nothing, in part because he and his family live in a remote rural area far from a clinic; in part because he is not in any pain, in part because there is no money for transport to a clinic or for treatment; and, in part, because now there is a stigma attached to his wound he prefers to hide inside his home. Left without treatment, massive ulcers form on Kwame’s legs, with the bone being severely affected. He is left with severe scarring and a disability which inhibits his walking.

This is the effect of Buruli Ulcer.

“To be a Community Drug Distributer and to do the job of eradicating disease,” says Mr Stephen Sarkodie, “One must take time, have heart and be restless.” Stephen’s restlessness extended beyond the eradication of Guinea worm and turned to Buruli Ulcer.

Buruli Ulcer, which is caused by bacteria, is not yet eradicated in Ghana. Rather it has the status of a ‘controlled’ disease. Controlling refers to making sure that Buruli Ulcer no longer constitutes a major public health burden. Deliberate efforts are in place to ensure that the disease remains at an acceptable level, and continued interventions are required to ensure that this level is maintained.

While Buruli Ulcer seldom leads to death, disability is high. The disease progresses rapidly, but because it has immunosuppressive properties, there is no pain or fever.   There is however loss of physical health, loss of physical movement, loss of economic productivity and loss of respect or social status.

Scientists and researchers do not know how you contract Buruli ulcer and, as a result, there is no way to prevent the disease. Early case detection and treatment with antibiotics is thus the best treatment. However, for reasons described above, this seldom happens.

Political and media pressure to address Buruli Ulcer began in 1992 and, as a result, Ghana introduced a passive surveillance system for Buruli Ulcer the following year. Over the next five to six years, about 1200 cases were reported. Case searching for Buruli Ulcer began in 1999 and covered the whole of Ghana, seeking to investigate every single known village and community. Trained national facilitators in turn trained regional teams of local people who undertook the case search. Stephen Sekodie was part of this case reporting.

As a Community Drug Distributer, Stephen was responsible for 35 villages and he began with case searching and identifying areas where the bacteria were present. Three days a week, Stephen would leave his home and walk for many hours to a neighbouring village. Like other community health workers, Stephen relied on a WHO-produced pictorial document which demonstrated the different stages of Buruli ulcer. This he showed to the villagers, asking about similar cases in the community. Because there were no treatment centres in 1999, Stephen carried a treatment box with him.

“We didn’t know where the bacteria was coming from, but we saw that the Densu River basin villages were worse. We thought it was possibly coming from the river and so we taught people how to keep their environment clean and to boil their water. We also taught them to watch out for strange boils on their skin, and, if they saw one, not to delay and to go to the clinic.”

The case search showed that Buruli Ulcer had been grossly underreported, that the disease was more widespread than conventional wisdom had allowed for, and that far more people suffered from these ulcers than had been previously believed.

The case searching revealed a prevalence of 87.7 per 100,000 people. In 2008, the Obom Health Centre (situated in Obom, a suburb of Amasaman, in the Ga West municipality) recorded 41 cases. In 2009, there were 27 cases.

Today, Stephen claims, only 1 in a hundred people in the area around Obom Health Centre experience Buruli Ulcer disease. Stephen and his fellow Community Drug Distributers have helped control it through a combination of awareness, treatment and personal hygiene.

Today, few people suffer from Buruli Ulcer and those who do should know to access treatment quickly. In 2014, only 21 cases were diagnosed. Stephen’s work is his “service to my people, to my community”. His role as a community health worker undertaking the vital legwork to help Ghana control Buruli Ulcer is, however, just another step in the work of eradicating NTDs.

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What does it take to eradicate neglected tropical diseases?

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By Linda Waldman, Institute of Development Studies, UK

The term Neglected Tropical Diseases, or NTDs, refers to a diverse collection of tropical infections that primarily affect people living in poverty, sometimes in high-income countries, but more frequently in low- and middle-income countries. They are caused by a variety of pathogens, including viruses, bacteria, protozoa and helminths (or worms). Not many neglected tropical diseases (NTD) can be successfully eliminated. Strategies to tackle these diseases include, in addition to elimination, seeking to control NTDs. Control does not eradicate the disease, but it does ensure that it no longer constitutes a major public health burden.

Another strategy is to eliminate the disease in a particular part of the country, rather than seeking country-wide eradication. This involves reducing disease transmission to less than 1% within the specific area and managing the area to prevent re-infection. Ghana’s management of NTDs has involved all three strategies: eradication, control and elimination. Development partners such as donors, NGOs, religious groups, local leaders, missions, private companies, community organisations, local volunteers and others all play crucial roles in tackling NTDs.

This blog, and the following two posts, explore Ghana’s experiences of dealing with three NTDs through the eyes of Mr Stephen Sarkodie, a voluntary Community Drug Distributer who lives at Obo, in the Ga West South sub municipal, close to Accra. He has helped Ghana to tackle NTDs for the past 27 years. Part one looks at the eradication of Guinea worm, Part Two at the control of Buruli Ulcer and Part Three at the elimination of Lymphatic filariasis.

Part One: Eradicating Guinea Worm

In 2014, the World Health Organization confirmed that Ghana had successfully eradicated Guinea worm disease. Guinea worm is one Neglected Tropical Disease (NTD) that no longer plagues Ghana. The disease is caused by a parasitic worm and is transmitted through drinking contaminated water. Like all other NTDs, it is endemic, disproportionately affects rural communities who live in poverty and causes significant health and economic burdens. Neglected diseases seldom kill people, but they can be severely disabling.

Imagine the scene: Adwoa a perfectly healthy woman, drinks water from a pond close by to her home. About a year later, she discovers a painful, burning blister on her ankle. This hinders her work, her ability to fetch water, cook or continue daily activities. To ease the burning, Kudjoe soaks her foot in water. While doing so, the worm protrudes from the blister, releases larvae into the water and then retreats back into her leg. The larvae are consumed by tiny water fleas, and these in turn, are swallowed by other oblivious members of Kudjoe’s community who drink from the same water sources.

To achieve certification of national level eradication, Ghana had to have zero reported cases of Guinea worm transmission, and needed to confirm this through active surveillance and investigation for at least three years. The challenges associated with doing this must, at one point in time, have appeared insurmountable. All these challenges are generic to many NTDs, as colleagues reminded us in the recent COUNTDOWN workshop in Accra.

First, these diseases are neglected; neglected by academics, neglected by donors, neglected by Ministers of Finance, neglected by health providers, and neglected by the international community. Second, national health services are constrained by funding and staff are often overworked, underpaid and inadequately trained. Third, in-country travel is difficult – or to be more accurate – very, very DIFFICULT and easily underestimated. Fourth, language is an issue. Although English is Ghana’s official language, it is not always spoken in remote rural communities where over 80 local languages are used. This too is underestimated.

Given these challenges, eradicating Guinea worm involved the work of many different actors. At international level, the World Health Assembly’s Declaration in 1986 encouraged global eradication of the disease. At national level, Ghana, having recorded 180,000 Guinea worm cases in 1988, established the Ghana Guinea Worm Eradication Program (GGWEP).

Close to the Obom Health Centre, is the home of Mr Stephen Sarkodie, a farmer in Obom and a volunteer Community Drug Distributor. His story reveals the challenges of dealing with NTDs in Ghana. Stephen became a community health worker in 1989, just as the Guinea worm eradication programme was beginning. He explains: “I was living in the community and I could see the people being infected. They can’t work or do anything for themselves. I feel (sic) for them, so I gave myself up to volunteering”.

Findings were reported to the District Health Director who then needed to ensure that the water source was treated with ABATE, a chemical that kills the Guinea work larvae.   When GGWEP was initiated in 1989, it was hoped that the worm would be eradicated by March 2007.

But eradicating a NTD like Guinea worm was never going to be easy. In 1999-2000, frustrated by the lack of progress in tackling Guinea worm, the Government created an Inter-Agency Co-ordinating Committee, and emphasised the need to provide potable water. Development partners were further mobilised to support the eradication programme in 2004.

In 2005, a major Guinea worm outbreak occurred in Ghana. In 2006, despite the work of community health workers like Stephen Sarkodie, Guinea worm was still endemic and Ghana was ranked as the world’s second worst country for the disease. Despite all the work, problems persisted. Stephen explained that some communities refused treated water. Village elders were worried that applying the ABATE would weaken the ancestral spirits and, as they had been using the water for years, didn’t make the link between the painful blisters and the water.

However, there was progress. From the mid-2000s, the numbers of Guinea worm cases began to decline: in 2008, 501 cases were reported; in 2009, 242 cases and, in the first half of 2010, only eight cases. On 11th May 2010, the last Guinea worm case was diagnosed in Ghana. Then came the period of waiting, of hoping and of investigating, making sure that Ghana could ensure zero reporting of Guinea worm transmission for three years. Guinea worm was declared eradicated in 2014 in Ghana and was, says Stephen, “Our first success”.

Throughout the time that he was dealing with Guinea worm, Stephen was also working hard to tackle other NTDs, which we will report on in our next blog post soon.