COUNTDOWN in South Africa – new friendships, thoughts and directions

By Russell Stothard, Liverpool School of Tropical Medicine

Returning from Magaliesburg in South Africa and sitting here early on a Saturday morning in Heathrow waiting for a flight to a snowy Manchester, I am really proud of what COUNTDOWN has achieved this past week. As both co-organiser and participant in the International Workshop on NTDs and importance of Female Genital Schistosomiasis (FGS) and its impact on HIV/AIDS, I represented both the Liverpool School of Tropical Medicine and our research consortium. Moreover, I was joined by Kate Hawkins our communications expert and by colleagues from Ghana, Benjamin Marfo who was representing Nana Biritwum, and Margaret Gyapong. We were also expecting Louis-Albert Tchuem-Tchuente from Cameroon to join us but he was called away last minute to Nigeria to represent WHO-AFRO in revision of their national Neglected Tropical Disease (NTD) plan but very fortunate given our future there.

Once in Magaliesburg and as co-organiser with Myra Taylor (The University of KwaZulu-Natal), Eryun Kejtland (The Oslo University Hospital), Jutta Reinhard-Rupp and Claudia Cecalupo (Merck-Serono), we finalised on-site arrangements. This included tailoring the agenda with the final list of participants who were set to arrive the next day, 75 in total and collectively coming from USA, Europe and Sub-Saharan Africa. We then performed a detailed cross-check and walk-through of all on-site logistics whilst being made aware of frequent power outages and their contingencies. Our Monday evening review meeting, for example, was held by candle-light owing to a particularly impressive electrical storm disrupting local supplies that night. Of course, there were surprises and for me it was being nominated by my co-organisers to give the Tuesday evening welcome dinner speech, a well set ambush perhaps despite our prior weekly teleconference calls from November!

So with microphone in hand and overcoming my nerves in front of such a very distinguished audience inclusive of WHO-Geneva and international donors, I gave my personal expectations for the following days. This was to be a very good thing for I find the most important beginning point of any small conference is to develop a friendly and social dialogue with its participants. This is crucial if you want to see the fruits of frank and open discussions evolve as often first undertaken by people who have never before met and also come to the agenda with very divergent experiences. Thus to do so from the onset people must be made to feel comfortable within such a larger group, and that their own opinion and contribution was to be valued and considered evenly with our own expectations.

Indeed the fruits of informed conversation grew and at the end of the workshop, it was evident that this was a key achievement of this meeting for all became increasingly animated and excited by this new cross-talk between NTDs and HIV. We discovered shared ground and addressed several issues ranging from access to diagnostics and treatment, gender and age-related inequities, primary health care services and better clinical management to future steps and studies to be taken and turned into best policies and optimal practices.

Kate, Margaret, Benjamin and I felt very motivated with the outcomes from this meeting and how it will be turned into tangible research and future policy repositioning within Ghana, starting this coming week (so my thanks to Margaret and Benjamin for being so quick to take action)! Indeed, we look forward to supporting this research uptake with targeted studies to be undertaken on the ground when deemed appropriate. This will be further discussed and developed across our partners within our inception workshop during the second week of March in the Liverpool School of Tropical Medicine, so you will hear more in due course.

So key highlights for me this past week? I had the good fortune to arrive at the airport with Barbara Mukasa from Mildmay and with it the opportunity to chat about our experiences in Uganda while waiting for transportation. As I have conducted many field surveys in the remoter areas of her country for NTDs, I have always been impressed by the community outreach that Mildmay has had in facilitating access to health services for HIV and AIDS. I have only met Barbara a couple of times before and only discussed with her intestinal schistosomiasis which is more prevalent in Uganda but in this conference with the focus on urogenital schistosomiasis she really grasped the importance of FGS in the context of her own work both in children and in adults.

Moreover, Barbara gave a really touching presentation highlighting the holistic view Mildmay has in supporting children as well as their carers, with real honesty by appreciating the often shortcomings of human behaviour which can range from the darker side of deception and violence to the lighter side of compassion and love. In the context of safe childhood, with a gynaecological disease such as FGS we should also remain vigilant to often cryptic signs of sexual abuse and coercion as well as the unfortunate stigmatisation and low self-esteem that this disease can induce with its signs and symptoms. This made me think more deeply about the pressing need for social science studies and assessment of burden of disease at the psycho-social level.

Other personal highlights included: seeing Kate very busy blogging and Tweeting about the issues being raised and helping me to get to grips with the newer side of social media; reading Alan Fenwick’s blog about our workshop after the first day from his perspective as Director of the Schistosomiasis Control Initiative; meeting with Refilwe Sello a HIV/reproductive health specialist from the FHI360 South African office and seeing her become enthused about NTDs; meeting again Peter Leutcher who I had last seen in 1997 in Madagascar while working with the Institut Pasteur Antananarivo and listening to his really authoritative keynote address on Male Genital Schistosomiasis and its implications; and finally helping my colleagues Myra, Eryun and Jutta draw attention to the need and use of donated praziquantel in South Africa by supporting direct engagement with stakeholders from the local Ministry and local HIV-action groups.

But what did I learn? In line with my own research on techniques and tools for diagnosis of schistosomiasis, there is an unmet need for new diagnostics for female genital schistosomiasis, especially in girls younger that their first sexual debut where a gynaecological examination cannot be performed for obvious reasons. Better access to praziquantel treatment in both pre-school-age and school-age is crucial if we are to prevent the later occurrence of FGS where it can be measured albeit with rather cumbersome invasive methods, i.e. by colposcopy. To that end, my colleague Amaya Bustinduy drew attention to the common plight of pre-school-aged children and that we must consider higher praziquantel dosing than the present 40 mg/kg and at shorter intervals, biannual or more for example, rather than the annual treatment regime. All this to be also set within access to Anti Retroviral Therapies in children with schistosomiasis-HIV co-infections, and we will revise our syllabus within our joint Diploma of Tropical Medicine and Hygiene teaching at Liverpool and London.

Arriving now in Manchester and taken as a whole, COUNTDOWN is well set to address these issues by fostering the scale-up of NTD control by focused implementation research tapping into newly formed research networks, which is something I am very privileged to lead and will promote this coming week in WHO-Geneva at a technical advisory group on diagnostics for schistosomiasis.

Female Genital Schistosomiasis and its impact on HIV: Round up of Day One

By Kate Hawkins, COUNTDOWN

COUNTDOWN is happy to support and be a part of the International Scientific Workshop on Neglected Tropical Diseases (NTDs) which is currently taking place in South Africa. The theme of the meeting is how schistosomiasis, in particular Female Genital Schistosomiasis, impacts on HIV. On day one we were joined by some brilliant speakers who provided six keynote addresses to help provide  context for discussions in subsequent breakout sessions for each topic.

Tsakani Furumele, Director, Communicable Disease Control, National Department of Health, South Africa gave an overview of combined control policies. She outlined how NTDs effect the poorest of the poor. But because they do not often kill people they are often marginalised in broader conversations on health. However, they impair physical and intellectual capacities perpetuating the cycle of poverty. At least 79% of endemic countries are co-endemic for at least 5 of the NTDs. Africa bears half of the global burden. She argued that,

Stimulating financing for NTDs requires an evidence base and if we cannot provide it the chances of us getting support are very, very slim.”

There are a number of regional and global policies to guide action in this area such as the WHA Resolution 66.12 and the WHO strategic plan for NTDs in the Africa region as well as the London Declaration. Whilst in South Africa the various HIV guidance policies stress that integration is necessary and that there is no one size fits all approach there are still barriers that effect the integration of NTDs into this portfolio and would affect action on Female Genital Schistosomiasis. These barriers include that: not all stakeholders are involved in the process of policy formulation; there are financial constraints related to the potential costs of integrated programmes; logistical and organisational limitations mean that cross policy and sectoral action is extremely difficult; and demographic heterogeneity is also an issue. To overcome these barriers we need advocacy and information sharing so that all have access to the evidence and we need facilitate joint programming and partnership and this will mobilise political will for action on NTDs.

Gita Ramjee, Director, HIV prevention Research Unit, South African Medical Research Council/London School of Hygiene and Tropical Medicine presented on Women and HIV. She outlined how there are 35.3 million people living with HIV and every hour 50 young women are newly infected. There are various overlaps of a number of factors related to Female Genital Schistosomiasis and HIV for example, their impact on vaginal mucosa, that they both effect the poorest, the relation with gender inequality, and that they effect reproductive functions.

Gita suggested that there are a range of sexually transmitted infections (STIs) which effect the genitals and there are similarities between what STIs do and what Female Genital Schistosomiasis does. Several cross sectional studies reported association between Female Genital Schistosomiasis and HIV. In addition to increasing susceptibility to infection it may also increase progression of disease by raising viral load in individuals who are infected. Further research is required to determine the contributing role of Female Genital Schistosomiasis and other NTDs on HIV incidence in Sub-Saharan Africa.

Eyrun Kjetland, Research Fellow, Norwegian Centre for Imported and Tropical Diseases, Oslo University Hospital was our third speaker and presented on Female Genital Schistosomiasis. Eyrun explained that the pertinent symptoms of Female Genital Schistosomiasis are malodorous discharge, secondary infertility and spot bleeding and that even children have symptoms. Taken together these symptoms can be confusing for the child and initiate low self-esteem, especially at a sensitive period before their first sexual debut.  Whilst these symptoms can resolve with treatment with praziquantel this does not affect lesions in the vagina and cervix that have already formed which stay even if the S. haematobium eggs are dead. Also people can test negative when given a urine test but still be affected by the disease. Old, calcified S. haematobium eggs in genital tissue have been found to increase the density of HIV-receptive CD4 cells. Female Genital Schistosomiasis may be a cofactor for HIV transmission in endemic areas, and the association between schistosomiasis and HIV has been corroborated by several scientific groups. However the evidence base that can be drawn on for the association between HIV and Female Genital Schistosomiasis is small and still limited to a group of key experts.

This led one audience member to comment:

“Do we need to keep proving the links beyond doubt? Or should we just say that the effects of schisto and HIV are enough to treat. The fact that there could be an association is reason enough to start and continue with the collaborative effort of evidence gathering. For me, for now, I need to have started yesterday!”

Peter Leutsher, who is based at the Department of Infectious Diseases, Aarhus University Hospital, Denmark, gave a fascinating overview of  Male Genital Schistosomiasis.  He explained that most of what we know is from post-mortem studies from the 1970s which were then acceptable but today are not. It appears, however, that the seminal vesicles, prostate and vans deferens are most effected by Male Genital Schistosomiasis. Male Genital Schistosomiasis causes pelvic pain, dysuria, painful erection and ejaculation and haematospermia.  There has been a study that found that the quality of sperm in men with genital schistosomiasis was poorer.

The chronic inflammation and recruitment of lymphocytes and eosinophils to the male genital tract in men with genital shistosomiasis may increase the HIV viral load in semen as well as the associated inflammatory cytokines which may also influence the immunology of the mucosal surface of the receiving partner. This may increase the likelihood of transmission of HIV from the man to his female partner (but also in men who have sex with men who were alluded to but not specifically mentioned). Peter is currently involved in an exciting Randomised Control Trial with men living with HIV and schistosomiasis in Zimbabwe to study whether praziquantel effects the viral load of semen.

Lester Chitsulo, formerly from the WHO, public health consultant from Malawi led us through the challenges in reaching women of child bearing age (15-29 years) with schistosomiasis because of medicine regulations and recommendations and the way that programmes are currently implemented. In Malawi women of childbearing age make up 21% of the total population. 81% live in rural areas and 15% have never been to school. At any one time up to 30% of these women could be pregnant or breastfeeding children. There is some confusion among government agencies and clinicians about how safe it is to give praziquantel to women who are pregnant or breastfeeding. Because you can’t always determine whether women are pregnant or not they are often routinely excluded from large-scale treatment campaigns. Furthermore mass drug administration usually takes place through programmes with children of school age. There are often operational advantages to integrating different programmes for NTDs. However programmes that target lymphatic filariasis, onchocerciasis and soil transmitted helminths cannot include pregnant women.

Lester suggested that praziquantel is safe for use in pregnant and breastfeeding women and that there is a need to do better collection of epidemiological data to see who among women of childbearing age actually need treating. If women who are pregnant are left out then they should be followed up in the maternal and child health services that the women routinely attend following delivery.

Many of the open questions and loose ends were picked up in the breakout sessions which were reported back to the audience via rapporteurs. We look forward to a similarly enlightening round of presentations on the second and final day of the conference.

Photo by Albert González Farran, UNAMID, you can find more of his photos online here…

Tailoring Mass Drug Administration to at risk communities

By Alan Fenwick (Schistosomiasis Control Initiative (SCI) Imperial College London)

In terms of schistosomiasis control with Mass Drug Administration (MDA) of the drug praziquantel there is a need to target those who are most vulnerable to infection – those people who come into the greatest contact with infested water. The profile of treatment should be driven by its health consequences which can include: malnutrition and anemia; growth retardation; cognitive impairment; increased susceptibility to other infections; chronic health problems such as inflammation and fibrosis of the bladder wall, colon, liver, spleen, lungs; and life threatening consequences such as bladder cancer, portal hypertension, and hematemesis. In the case of some of these life threatening consequences it can be quite challenging to trace the cause back to swimming in a pond 20 years ago, especially in communities that have an incomplete understanding of the disease.

In 2000 there were no MDA programmes for schistosomiasis, now look at where we are!

We currently target our programmes in the manner which is simplest – by administering drugs to children in schools. Children tend to be responsive to their teachers who deliver treatments against schistosomiasis and intestinal helminths in settings where governments don’t stipulate that medical attendance is mandatory. Administering the medicine is fairly simple as they are taken orally – although praziquantel tastes quite bitter and children sometimes vomit if they chew the tablet when they take it. With sufficient training MDA is easy to establish as the front line method of control in resource poor areas, but we need to ensure that the delivery of drugs is best targeted and sustained  within at risk populations.

We know that pre-school children are often bathed in infected water and are therefore also vulnerable. But as a rule we don’t treat them, because of the large bitter tablet. But emerging research shows that more and more younger children are getting infected, and because of the small size of their bodies immense damage can be done by the worms and their eggs to the children’s internal organs, and some may never recover from it. Expanding treatment coverage to younger children is becoming more feasible with the development of paediatric formulations by Merck so there is now good reason to expect change for the better

In 2012 only 14.4% of the people worldwide who needed praziquantel treatment actually received the drug. That amounts to 42.1 million people. However, until quite recently one of the barriers to scale up was the accessibility of treatment. That argument no longer holds as we estimate that by 2016 we will have enough donated drugs from Merck, DFID, USAID and World Vision to treat 165 million people.  Now we have a new problem, we face financial constraints to fund delivery – the UK and the US are currently the only bilateral donors that are funding the delivery of drugs and the main financing burden falls on the governments of low- and middle-income countries who don’t always prioritise NTDs. That being said we are in a better position than ever before and are optimistic in future expansion of our operations

Scaling-up control to those who need treatment, however, will depend on a number of factors: on improving country political will and resources; on praziquantel availability; and on accurate geographical and epidemiological mapping that enables the development of evidence based national plans. To make this a reality advocacy needs to occur at the national and district level, and this work needs to be done well in advance. It can take up to six months for WHO to fulfil requests for drug donations, but creating systems and the training of those who will deliver the programmes takes time, so these tasks need to go in parallel. Other tasks may include ensuring that there is ethical clearance from the parents and caregivers of those who will be treated and we need to be ready in case there are any adverse events, however mild, with sufficient supporting community dialogue and assurance.Today we are poised to expand coverage of praziquantel treatments and improve the present and future quality of life of hundreds of millions of children in Africa, but we have only a small window of opportunity to get it right so we have to rise to the challenge.

Calling time on urogenital schistosomiasis

Sally Theobald, COUNTDOWN Consortium & Research in Gender and Ethics: Building stronger health systems (RinGs)

I spent many of my teenage years living in Malawi, enjoying swimming in beautiful Lake Malawi. Wind on to age 30, and I was struggling to get pregnant. Eventually, following illness, I was diagnosed with schistosomiasis by a consultant and colleague at the Liverpool School of Tropical Medicine. I was told that I had probably been infected for a while and that it might be affecting my fertility. So I took praziquantel, the only available drug against the parasite, and soon after I was pregnant. Today my first born daughter is 10 years old.  Whilst the links between urogenital schistosomiasis, sub-fertility and HIV have become increasingly well-established over my first born daughter’s life time, a combined and robust health systems action that brings together neglected tropical disease, sexual and reproductive health and HIV communities to address and scale up treatment for urogenital schistosomiasis is sadly lacking.

It is 20 years since the Beijing Women’s Conference and the International Conference Population and Development and the sexual and reproductive community have been taking stock on progress, challenges and future priorities. I attended a research agenda setting meeting on sexual and reproductive health, rights and gender at the WHO on 12th and 13th of January, where we discussed how to best decide priorities for action. Scaling up treatment for urogenital schistosomiasis is arguably a win-win.

The global burden of disease

Schistosomiasis is wide spread and there are two forms of disease, intestinal and urogenital. An estimated 600 million people are at risk of being infected and approximately 200-220 million people are living with schistosomiasis in Africa. Of the people infected with urogenital schistosomiasis it is thought that between about 100 and 120 million suffer from urinary and reproductive tract damage, which also impacts directly with HIV co-infection and sub-fertility in general. Typically many adolescent girls and women exhibit several symptoms in their lower genital tract where overt bleeding and unpleasant discharge, general discomfort and pain during sex can lead to low self-esteem, depression and stigma.

Peter Hotez estimates that globally there are between 67-200 million cases of urogenital schistosomiasis among girls and women. Hotez argues that between 20 million and 150 million girls are affected, possibly making it one of the most common gynaecological conditions in sub-Saharan Africa but unfortunately much under-reported. Urogenital schistosomiasis, as in my experience, also affects fertility and it is estimated to reduce a woman’s reproductive health capacity by up to 75%.

The links between urogenital schistosomiasis in women (female genital schistosomiasis) and HIV are well established. Writing in the Lancet, Stoever and colleagues argue that up to 75% of girls and women infected with female genital schistosomiasis develop often irreversible lesions in the vulva, vagina, cervix, and uterus, creating a lasting entry point for HIV and discuss how research in Zimbabwe showed that women with female genital schistosomiasis had a threefold increased risk of having HIV. In a recent review of the evidence Pamela Mbabazi and colleagues argue that “Studies support the hypothesis that urogenital schistosomiasis in women and men constitutes a significant risk factor for HIV acquisition due both to local genital tract and global immunological effects”.

 Gender, equity and rights

There is remarkable overlap between the maps showing high HIV prevalence in Africa (particularly amongst women and adolescents girls) and those showing cases of female genital schistosomiasis. A complex interplay of biological, social and cultural factors means that young women are particularly vulnerable to HIV in sub-Saharan Africa. Gender norms also shape exposure to urogenital schistosomiasis, with women being particularly responsible for activities involving water in many communities (washing, cleaning, collecting water etc). Drawing on work from Ghana, Vlassoff and Manderson have shown that women interact with water significantly more often than men.

What to do?

Several tens of millions of praziquantel tablets are now donated each year by Merck-KGaA for mass drug administration campaigns as a cost-effective method to protect people from the urogenital schistosomiasis. Hotez argues that by preventing female genital schistosomiasis in sexually active women we have an innovative and timely opportunity to reduce and likely much reduce HIV transmission throughout many rural areas of sub-Saharan Africa.

But in infected communities treatment also needs to start early.

Stoever and colleagues argue that periodic and regular treatment with praziquantel from when children are first infected should prevent the development of genital lesions, which increase HIV risk and cause gynaecological problems. Treatment, however, may need to be started even earlier as the extent and burden of schistosomiasis in pre-school-aged children is being more fully described.

To make progress in this area we need joint action between the HIV, sexual and reproductive health and neglected tropical disease communities. Health workers and communities need more information on the multiple impacts of urogenital schistosomiasis and how it can be treated.

The lack of action to date on urogenital schistosomiasis clearly illustrates the importance of new partnerships and new approaches to scaling up strategies to address neglected tropical diseases. COUNTDOWN, a new initiative in Cameroon, Ghana and Liberia, will be paying close attention to the potential role of close-to-community providers such as drug distributors in providing an interface between communities and health systems.   We will also evaluate how to deliver equitable drug delivery for schistosomiasis through the inclusion of preschool-aged-children, out-of-school-children and adults. The Director of COUNTDOWN is helping to co-organise a meeting in South Africa later in the month where several members of COUNTDOWN will also attend. It brings together world leaders in the field of schistosomiasis, HIV and paediatrics to present on the current state and future direction of research on female genital schistosomiasis.

COUNTDOWN is set to foster and to stimulate others in thinking of innovative ways of prompting a synergistic approach to neglected tropical diseases which crosses sectors and builds strength in national health systems.

If you would like to find out more follow us on Twitter or email Rachael Thompson.

Photo courtesy of Andrew Whalley. Children at Dusk.

Neglected Tropical Diseases: Time for a fresh approach

By Sally Theobald, Liverpool School of Tropical Medicine

A pre-Inca piece of pottery featuring a patient with leishmaniasis, an ancient Japanese water colour painting depicting a man with elephantiasis, and a 14th century manuscript of someone with leprosy with a warning bell. LSTM’s newly appointed Senior Professorial Fellow Prof Lorenzo Savioli used these images in his a keynote address to remind us of the long-lived links between poverty and Neglected Tropical Diseases (NTDs).

Sadly the vicious cycle of poverty, social marginalisation and NTDs is still alive and well in 2014. NTDs are among the most common infections of the “bottom billion” – people who live on less than $2 a day. They affect some of the poorest and most marginalized communities in the world.

NTDs can cause chronic, debilitating, disabling, stigmatizing and disfiguring conditions that further exacerbate poverty by limiting the options and livelihoods of infected individuals and their families. Lorenzo explained that the broader social and physical environment shapes risk and vulnerability to NTDs.

Setting goals and meeting targets

Lorenzo outlined the processes and alliances that were behind the Roadmap for implementation on NTDs, which was launched in January 2012. He argued that this has transformed the focus on NTDs from romantic diseases embedded in the post-colonial era to health issues whose elimination requires clear systematic and accountable goals and milestone for action.

There is momentum for change.

The London Declaration (2013) pledged to control or eliminate at least ten of these devastating diseases by the end of the decade. Later in 2013 the 66th World Health Assembly endorsed the Declaration and it was signed by all member states.

NTDs are on the political agenda. It is time to build the relationships, systems, and infrastructure to promote universal health coverage to preventive chemotherapy, diagnosis, and vector management and control.

New alliances and partnerships to tackle NTDs

Movement towards universal health coverage for multiple NTDs requires new alliances and partnerships. It must be underpinned by careful health systems strengthening and an in-depth analysis of the opportunities, challenges and possible unintended consequences from a health systems perspective. It will be important to capture the voices and perspectives of front line health workers and understand the challenges they face in their critical role in addressing NTDs.

Lorenzo is part of the newly formed COUNTDOWN Consortium, which is funded by the UK Department for International Development.

In COUNTDOWN we will use implementation research to produce evidence from multiple contexts on the links between NTDs and poverty and we will work in partnership to promote pro-poor and gender equitable responses. The project provides an opportunity to conduct a health systems analysis that will enable us to better understand the most effective strategies to work with Community Drug Distributers (CDDs) and Community Health Workers. These workers are vital if we are to extend the scaling up of Mass Drug Administration to hard to reach communities and build the resilience of vulnerable and marginalized people affected by NTDs. Multi-sectoral action is necessary to tackle NTDs and in COUNTDOWN we will foster cross sector working, for example with  sanitation, water and agricultural sectors.

Lorenzo was speaking at the Health in Humanitarian Settings Research Symposium. The symposium is run by current and previous Masters students and is supported by ReBUILD.

COUNTDOWN partners include: the Liverpool School of Tropical Medicine (lead), the Cameroon Ministry of Public Health; the Centre for Schistosomiasis and Parasitology (Cameroon); the Liverpool School of Tropical Medicine; Ghana Ministry of Health; FHI 360; Liberia Ministry of Health and Social Welfare; and Pamoja Communications.

To find out more about COUNTDOWN contact Rachael Thomson – Rachael.Thomson@lstmed.ac.uk

COUNTDOWN Research Consortium calls ‘time’ on Neglected Tropical Diseases (NTDs)

The COUNTDOWN research consortium has been launched today following a £7 million grant allocation from the UK Department for International Development (DFID) earlier in the year.

As part of the push towards universal access to health services, there is international consensus that NTDs such as onchocerciasis, lymphatic filariasis, soil-transmitted helminthiasis, schistosomiasis and trachoma, must be tackled more effectively and NTD control programmes need more assistance.

Where some of these diseases can be treated with a combination of antihelminthics and antibiotics they continue to cause ill-health and disability on a massive scale.

Pharmaceutical companies provide much of the needed medicines for free and Mass Drug Administration (MDA) programmes have managed to deliver these drugs to millions of people living in need.

COUNTDOWN will trial and evaluate new approaches to drug distribution, which target those who are currently overlooked and excluded. It will also examine how NTD programmes can be better integrated into broader health system responses.

COUNTDOWN Director, Professor Russell Stothard, said: “I would like to thank the UK Department for International Development for financing COUNTDOWN. Through a multi-disciplinary partnership which brings together researchers from Cameroon, Ghana, Liberia and Nigeria, the UK, and USA, we hope to create new knowledge which will kick-start other countries’ responses to NTDs and provide practical health systems guidance on how to speed-up and scale-up action.”

The partners in the COUNTDOWN consortium bring a substantive network of contacts in the NTD community including funders, academic and research institutions, drug companies, Ministries of Health, non-governmental organisations (NGOs) and policy stakeholders such as the World Health Organisation. This will ensure that COUNTDOWN benefits from the best research intelligence from within the NTD community and stays well informed.

NTD Programme Manager Nana-Kwadwo Biritwum said: “Ghana’s NTD Programme has made good progress over many years of programme implementation with its control and elimination strategies. The challenge now is to ensure elimination of lymphatic filariasis, onchocerciasis and trachoma. This end game stage poses technical challenges and can best be addressed by projects or initiatives such as COUNTDOWN 2020”

COUNTDOWN is working to support the achievement of the 2020 targets set out in the London Declaration on NTDs.

Partners in the COUNTDOWN Consortium include: the Cameroon Ministry of Public Health; the Centre for Schistosomiasis and Parasitology in Cameroon; Ghana Health Service; FHI 360; Liberia Ministry of Health and Social Welfare; Pamoja Communications and Liverpool School of Tropical Medicine (LSTM) which also acts as host and administrative hub of the Consortium.

The consortium’s Twitter handle is @NTDCOUNTDOWN and its website will go live early 2015.