Work on Neglected Tropical Diseases in Brazil provides lessons for the Africa region

By Russell Stothard Brazil has a significant burden of Neglected Tropical Diseases (NTDs) but these often differ to those in sub-Saharan Africa. For example in Brazil, there are no tsetse flies and thus there can be no transmission of human sleeping sickness. However, other blood sucking insects abound and in rural areas, triatomine bugs act as the principal vectors of Chagas disease, a major blight throughout South America and is the leading cause of heart failure. Infection with this single-celled parasite is typically chronic and drug treatment is largely ineffective when the disease progresses towards its later stages, where nearly all muscle tissues can be parasitized. Several years ago when working at the London School of Hygiene of Tropical Medicine with Professor Michael Miles, we showed that the parasite Trypanosoma cruzi underwent sexual reproduction in such tissues highlighting its capacity for  rapid evolution within the body. Of the early leading names in tropical medicine, two researchers Oswaldo Cruz and Evandro Chagas, are not as well-known in Europe as they should be, both being eclipsed perhaps by Patrick Manson and Ronald Ross. Nonetheless, Cruz and Chagas have left a truly impressive legacy in Brazil with the FIOCRUZ which is celebrating its 115 anniversary. Today FIOCRUZ employs over 11,000 staff and maintains a highly-regarded hospital and conducts an impressive portfolio of applied health research from the production of vaccines, drugs, reagents and diagnostic kits to education and training and engagement with its many social programmes focused on disease control. Within the UK we have much to learn from the approach taken by the foundation on how integrated control can proceed across a range of areas of health.

Carlos Chagas and team

Charlos Chagas with his team (Fernando’s grandfather is in the middle row on the right-hand side)

Being a speaker at ARTHROMINT 2015 meant I had the good fortune to visit the FIOCRUZ castle and see first-hand the library where Cruz and Chagas once worked. The history really does seep from its walls as I learnt from my hosting colleague Dr Fernando Monteiro, who works on the molecular systematics of Triatomines, that his grandfather was part of Chagas’s team and that his family has maintained a long connection with the institute. Having also worked on triatomine bugs before, it was a pleasure to give my research seminar at the institute and highlight more recent work on schistosomiasis and the implementation research that COUNTDOWN will conduct on several other NTDs, that often parallels similar challenges in Chagas disease control.

Speaking about schistosomiasis in Brazil is highly appropriate, for intestinal schistosomiasis is a major health hazard in rural populations where water hygiene and sanitation is poor. There is also a longstanding national control programme also focused on curative treatment with praziquantel (PZQ), however, there are key differences in approach when compared to those in Africa. Foremost, PZQ treatment is given out on a selective basis rather than in community-wide programmes. Hence, for a child to receive treatment (s)he must be shown to have evidence of infection upon the occurrence of schistosome eggs, the frontline diagnostic being the Kato-Katz stool examination in a ‘test and treat’ strategy.

Whilst this classic parasitolological method is also used in Africa, the necessary man-power and resources within the health system to provide this service to each child annually is outside the reach and resources of many Ministries of Health. Hence only community-wide application is possible or recourse is needed to more field-friendly diagnostic methods such as rapid urine antigen tests. Discussions with Octavio Pieri, the Brazilian national control programme co-ordinator, demonstrated a range of experiences in the Brazilian programme which it is important to share across the Africa region. Themes emerged such as the need for better PZQ dosing, treatment of marginalised groups (e.g. pregnant women and preschool children) and cross-talk with health education and water sanitation sectors. ARTHROMINT 2015 was a great success and I now look forward to discussing further in August how schistosomiasis control programmes can be optimised, especially in promoting access to PZQ in young children, across the transition from control to elimination settings.

New article in Open Democracy #NTDs #schisto

By Kate Hawkins

It can cause bleeding and discharge from the vagina, genital lesions, nodules in the vulva, discomfort and pain during sex, sub-fertility, miscarriage and can effect vulnerability to HIV and the Human Papilloma Virus. Yet it is completely off the radar of most people working on sexual and reproductive health and Neglected Tropical Diseases.

If you haven’t read our latest article on urogenital schistosomiasis in Open Democracy it is worth a look.

The World Health Organization’s working definition of sexual health is:

“…a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled.”

We think that between 100 and 120 million people are living with urogenital schistosomiasis which is most likely causing damage to their urinary and reproductive systems. Why isn’t it on the radar of policy makers, activists and researchers? Why hasn’t more been done to explore the causes and the consequences of this illness?

Is it to do with a squeamishness when it comes to talking about sex and sexuality?

These are some questions that urgently need to be answered if we are serious about sexual health and rights for all.

Intestinal schistosomiasis in Uganda: Taking advanced diagnostics to the lakeshore

By Hajri Al-Shehri

Neglected Tropical Diseases (NTDs) are often a symptom of poverty and challenging living conditions. Those who are most affected are the poorest people living in remote rural areas, urban slums or in conflict zones. Schistosomiasis, for example, is often found in populations with very limited access to safe water and in environments poorly served by primary health outposts as typified by out-of-stock drugs and inadequate diagnostic testing. The lack of reliable statistics reporting on treatment and disease has kept the true burden of schistosomiasis in the shadows and failed to identify the inefficiencies of control programmes that are committed to reach those most in need of treatment.

I have just returned from a three-week epidemiological study on the shores of Lake Albert, Uganda. Working with Vector Control Division (VCD), Ministry of Health, Uganda we visited five rural primary schools in Hoima and Buliisa Districts, examining just over 50 children per school with a combination of diagnostic methods.

Performance of diagnostic tools in a high prevalence settings

urine antogen testsOur basic analysis revealed that in three schools on the immediate lakeshore, prevalence of active intestinal schistosomiasis was just over 85%. With such high levels detected, it is taken for granted that these children are in regular contact with contaminated water, remaining a daily way of life and mitigates the impact of the national control programme (NCP). The Uganda NCP started in 2003 and has been providing annual treatment of school children with praziquantel (PZQ) for over several years. But despite best intentions, it is clear that annual treatment is failing on the lakeshore and needs to be strengthened. Our clinical assessments showed substantial amounts of morbidity in these unfortunate children with swollen livers, numerous schistosome eggs and blood in stool as well as enlarged tummies.

My thoughts on successful fieldwork

Fieldwork is not just an important, stimulating and often challenging part of the research process I undertake; it also offers a wonderful way of seeing the world, and a chance for personal development. The key points are to understand theory, develop skills, integrate and build tacit knowledge, develop alternative solutions for the problems in certain places, and work cooperatively with a team. Despite our best efforts in preparations, fieldwork constantly offers surprises and ad hoc solutions that may fail miserably for many reasons: a sudden rainstorm reduces time at the study site, your way back to camp is blocked by a flood and you endure water-logged muddy roads that drain your energy, as does our intermittent camp electrical supply as our portable generator fails then you are hounded by irritating lake flies that dance around your head torch while you concentrate at the microscope. Conditions in the field are often unpredictable and can affect your aims in different ways sometimes being left frustrated but when you overcome these obstacles you have good reason to be proud and satisfied.

car in UgandaSo what are the ingredients for successful fieldwork? I now realise that fieldwork should have clear vision of what you want to accomplish but be flexible within a set of integrated goals and contingency plans that can be brought rapidly into action when needed. For example, assessing each day everyone’s workload, checking in-field logistics and sampling techniques is essential to adapt to local conditions, as well as having enough in reserve to put in extra effort when required. Before leaving to Uganda, my supervisor and I had many discussions during the planning process who explained the theory but I have now the practice. The key ingredient is that there is a small window of opportunity to get the survey right where all the necessary equipment, reagents and team’s skills are brought together at the right place and at the right time, ensuring that these remote communities can be well-attended. Only by doing so can the true burden of NTDs be brought out of the shadows and highlight today’s treatment needs. I am proud to have made an important contribution to the Uganda NCP with our colleagues from VCD.  

About the author

I was born in Asser, Saudi Arabia, and have worked there for several years as a specialist in molecular diagnosis of infectious diseases in Asser Central Hospital. Being based in this busy clinical laboratory, I have developed interests in Neglected Tropical Diseases, especially schistosomiasis, and completed an MSc degree in the UK in Biomolecular and Biomedical Sciences, Faculty of Life Sciences & Medicine, at Glasgow Caledonian University. To further extend my qualifications and broaden my experience, I started my PhD in June 2014 at the Liverpool School of Tropical Medicine with Professor Russell Stothard and decided to focus on the epidemiology and control of intestinal parasites. My project hopes to compare the performance of state-of-the-art diagnostic tools in high prevalence versus low prevalence settings and understand how these tools can be applied in my own country where schistosomiasis and soil-transmitted helminthiasis are nearing elimination. Writing a science blog helps me stay motivated and by sharing my recent fieldwork in Uganda, and highlights what I have learned.