The Neglected Tropical Disease hotspot puzzle requires multidisciplinary investigation

Sally Theobald, Margaret Gyapong, Mike Osei-Atweneboano, Sheila Addei, Alexander Adjei, Adriana Opong, Samantha Page and Kate Hawkins Dr Benjamin Kofi Marfo, Deputy Director of the Neglected Tropical Disease (NTD) programme in Ghana, is fizzing with energy as he explains the NTD hotspot conundrum in Ghana. Hotspots, or areas with persistent NTD prevalence above a threshold set by the World Health Organisation, present the final hurdle to elimination of certain NTDs. The COUNTDOWN team meeting in Accra brought together the Ghana Health Service (GHS) NTD team, colleagues from Dodowa Health Research Centre, the Council for Scientific and Industrial Research, Liverpool School of Tropical Medicine and Pamoja Communications. Together we discussed the map of hotspots for Lymphatic Filariasis (LF) in Ghana – bringing to mind a detective story – we debated different explanatory possibilities:

  • Border areas: All but four of the 22 hotspot areas are either on the border or next to a border district – with the Cote D’Ivoire (West of Ghana), and Burkina Faso (North of Ghana), but intriguingly not Togo (East of Ghana). These borders, carved up by colonial powers, separate families and communities and in reality are porous with regular movement and trade across them. Could it be that people here are missing Mass Drug Administration as they move from one country to the other? Dr Marfo and his team discussed the importance and challenge of cross border NTD collaboration and the possibility of synchronising approaches to MDA to minimise losing people from the process.
  • Genetic variation in human population: Why is it that in some families people get LF and others don’t although their exposure is arguably similar. Are there some genetic factors at play which predispose certain individuals or communities to LF?
  • Genetic variation in parasite or vector population that we don’t understand: Are there some genetic changes in some population of parasites and/or vectors and some geographically specific adaptation going on that needs further investigation?
  • Context specific socio-cultural beliefs or practices: Or is there something specific about the understanding, livelihoods and socio-cultural realities of these communities that lead to additional vulnerability or challenges in accessing and adhering to drugs (or in NTD language are there more persistent non-compliers in hotspots?)
  • Health system challenges: Or could it be that there are some health systems challenges and bottle necks within the hotspots? Challenges relating to distribution or possibly community based drug distributors feeling under motivated and undervalued?

Or does the explanation lie in a mixture of some or all of the factors above? Trachoma is on the road to elimination in Ghana. However, with the exception of the Upper East Region, it is more problematic in the Northern and Upper West Regions of Ghana. Why is the Upper East Region less affected? Dr Marfo explained how this district has benefitted from different Non-Governmental Organisations conducting water, sanitation and hygiene programmes, which have supported access to fresh water and the construction of latrines. There is also an eye hospital in the Region which has enabled earlier access to treatment. The trachoma story highlights the importance of understanding the context and historical evolution of the Regions when looking at NTDs. It also illustrates the positive legacy of interventions in water and sanitation and the importance of multisectoral partnership in efforts to address the debilitating and disabling effects of NTDs. The tricky conundrum presented by hotspots demands multidisciplinary investigation and multi-sectoral engagement to understand which factors play out in different contexts to shape hotspots. COUNTDOWN brings together social scientists, health systems researchers, health communication experts, health economists, parasitologists, molecular biologists and modellers to work in partnership with NTD programmes in Ghana, Cameroon and Liberia to support NTD programmes. Watch this space as we bring different disciplines to bear to understand and address hotspots.

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