COUNTDOWN goes Down Under for ICTMM 2016

By Prof. Russ Stothard, COUNTDOWN

Efforts to control NTDs typically require advice, support and coordination from several international networks. Like tropical medicine in general, the need to bring scientists and clinicians together regularly and discuss their findings is crucial to ensure that the best research is disseminated internationally and eventually translated into optimal control strategies. The International Congress for Tropical Medicine and Malaria (ICTMM) provides such a forum.

This year the 19^th ICTMM took place from 18^th to 22^nd September in Brisbane, Australia. This brought together just over 1,500 delegates. The meeting was jointly organised by the Australian Society for Parasitology (ASP) and the Australasian Society for Infectious Diseases (ASID). I was especially honoured to be awarded a travelling lectureship from the ASP to present and also visit research groups in Australia to instigate future collaboration. This I did by visiting the laboratories of Robin Gasser and Don McManus at the University of Melbourne and Queens Institute of Medical Research (QIMR), Brisbane. Robin and Don each have a tremendous stature in veterinary and medical parasitology, respectively. Both seamlessly blend state-of-the-art molecular studies with field studies and have had significant research programmes advancing the health and well-being of those living in the tropics.

In Melbourne, I gave a departmental seminar and was able to discuss with Robin and his team our ongoing and future work in Ghana and Cameroon. The Gasser lab has been pioneering molecular surveillance of helminth diseases for over thirty years and one of their recent milestones was made by Dr Neil Young in publishing the genome of Schistosoma haematobium.  This Nature publication was a tremendous achievement bringing new focus to the control of urogenital schistosomiasis in Africa. Better knowledge of this genome has opened up new ways to study the population biology of this parasite, often revealing how it is able to cause such ill-health across the continent. Furthermore, a precise knowledge of this genome allows us to monitor significant evolutionary changes which may occur to mitigate our efforts to control it with preventive chemotherapy.

In Brisbane, I attended the ICTMM meeting and gave a keynote presentation on schistosomiasis, reporting our recent findings in Cameroon at Barombi Kotto and Mbo, as well as, two other presentations on treatment of pre-school-aged children with intestinal schistosomiasis and management of co-infections of schistosomiasis and giardiasis. Whilst at the conference our viewpoint article was published . It was a timely reminder of how much future work is needed to expand access of praziquantel to those children currently overlooked within control programmes.

Suzy Campbell gave a presentation on the focus of her PhD studies on WASH (Water, Sanitation and Hygiene) for Soil-Transmitted Helminthiasis (STH). It was also a great honour for me to be invited to serve on the IFTM expanded board so we can look forward to 20^th ICTMM in 2020 hosted by the Parasitology and Tropical Medicine Association of Thailand.

A particular highlight was learning from Don the steps that his group had taken to develop and evaluate public health education materials used for control of soil-transmitted helminthiasis in China. I recommend that you view the ‘Magic Glasses’ animation and its associated impact has been reported in the New England Journal of Medicine. More broadly, we do not have adequate nor sufficient health education materials presently for use in African schools for several other NTDs. My own previous research on schistosomiasis in Zanzibar has shown that innovative approaches are very much needed to addressing this aspect of influencing positive behavioural change.

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

By Deborah Sankey, Tim Day and Faye O’Hallaron

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

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

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

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

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

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

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

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

Read more

Anyone’s Disease: Ending Lymphatic Filariasis in Ghana

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

 

Onchocerciasis in Three Decades Part II: Building the Next Generation of Parasitologists

By Prof Samuel Wanji & Pamela Bongkiyung

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

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

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

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

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

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

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

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

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

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

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

Q: What legacy would you want to leave behind?

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

Thank you for those last words Prof. Wanji.

 

Onchocerciasis in Three Decades: Through the Lens of Prof. Samuel Wanji

By Prof Samuel Wanji & Pamela Bongkiyung

Prof. Samuel Wanji is Head of Department for Microbiology and Parasitology at the University of Buea, Cameroon. He is also Executive Director of the Research Foundation in Tropical Diseases and Environment, Buea. He heads the COUNTDOWN programme’s partnership with the University of Buea. He has worked extensively on Onchocerciasis control and been instrumental in its control. We caught up with him while he was on a visit to the Liverpool School of Tropical Medicine.

Pamela: Hello Prof. Wanji. Thank you for taking the time to talk to us. How long have you worked on Onchocerciasis?

Prof. Wanji:  My journey with onchocerciasis started as far back as 1988. We could be talking of almost 30 years of research in onchocerciasis. Everything started with an experimental model when I was doing my postgraduate studies in Paris, France. And later on, I remained within Filariasis/Onchocerciasis for my research and university career. So actually, it has been a very faithful relationship with research and onchocerciasis throughout my life as a student and a worker both for teaching and research.

P: In the almost three decades that you have worked on various projects in relation to onchocerciasis, what changes have you observed?

PW: Yes, there have been changes. I started almost when Ivermectin was introduced as a new tool for the control of Onchocerciasis. And we witnessed the huge impact Ivermectin has made in the control of Onchocerciasis through the African Programme for Onchocerciasis Control – APOC. We were among the researchers involved in mapping the disease across Africa for the implementation of the control. We also witnessed the decline of the disease in many of foci where the endemicity was really high.

But what has been my major contribution for the control of onchocerciasis came from another filarial parasite Loa Loa. Originally, nobody knew that Loa Loa could cause a problem for the onchocerciasis control. So, when it was established that some people taking Ivermectin could develop severe adverse events and could even die, the link was established with Loa Loa and it became a priority to know those places where the endemicity of Loa Loa that is dangerous for the intake of Ivermectin was.

We participated in those early days around 2000 to develop the rapid assessment procedure for Loa Loa which was later on extended to 15 African countries, where we coordinated the mapping exercises in those countries, to generate the first map for Loa Loa in Africa. This map was operationally very useful in saying this place is very dangerous, this place is safe. And that is how we contributed heavily to the control of onchocerciasis in those areas where there was co-endemicity with Loa Loa.

Besides that, at the level of the laboratory we developed an experimental model in baboons to understand the mechanisms of encephalopathy due to Loa Loa with the treatment we have with Ivermectin. Today we know that the microfilaria are massively killed and they block the micro capillary of the brain and that is how people almost get killed. People become withdrawn and they go into coma because of such. We know that mechanism and we even have an idea of how such things could be prevented with ivermectin and aspirin. We have worked a lot through Loa Loa to see how the control of onchocerciasis could be safe in the forested areas of Africa.

P: What are the major impediments to controlling Onchocerciasis not just in Cameroon as you seem to have worked extensively across Africa, but also how does Loa Loa add to these impediments that you might have encountered in your work?

PW: As we know Onchocerciasis is a Neglected Tropical Disease. So just by that fact, it is already an impediment in controlling such disease. Less attention was paid to it. Fortunately for the past ten years there has been a lot of momentum around Neglected Tropical Diseases and Onchocerciasis has also benefitted from that.

As you can imagine that for almost 30years, the only drug that has been used for the control of Onchocerciasis has been Ivermectin. Ivermectin does not kill adult Onchocerciasis besides of the fact that it creates problems with Loa Loa in areas where the two diseases co-exist, Ivermectin kills only Microfilaria, the children of filarial of Onchocerca Volvulus (O. Volvulus).

So you need to take the drug for longer than 15years, to expect getting rid of the disease. And that is a very long time because people can easily go into fatigue. If the resources are not properly mobilised people may not have resources to sustain such long term control.

One probable consequence of such impediment has been the suspicion (and I will call it suspicion because there has been a lot of controversy around it) of sub-optimal response of the worms to Ivermectin. That means when you have a long term pressure of the same one medication on a parasite, the parasite may develop a strategy to not be sensitive to that drug anymore. And that has been a very shortcoming of onchocerciasis control to know that instead of having two or three drugs to play with, only one drug exists.

It is only of recent that there is a lot of work going on to develop microfilaria drug that will kill the adult worm. That is why in many areas we are really doubting how the elimination will be feasible. Those areas where the transmission was very high or is very high, we are almost sure that Ivermectin alone cannot do the job. We need alternative strategies. That is why you have been hearing about Doxycycline which was developed recently. Doxycycline can kill adult Onchocerca Volvulus but it needs at least 4weeks to do that job. The four weeks treatment is far better than 15years yearly treatments because with 15yrs yearly treatment you may have fatigue effect more than 4wks continuous treatment. At the level of the public health people think it is not suitable to have a regimen of 4wks, they insist on shorter regimens.

Here at the Liverpool School of Tropical Medicine, we have the AWOL consortium which is developing a shorter regimen of Anti-Wolbachia. Doxycycline is an anti-wolbachia. It is a drug that kills the bacteria that lives in a worm. Because that bacteria is starkly associated to the worm, they exchange some functions. So if you kill the bacteria, the worm also dies. It is an indirect effect. So the AWOL consortium is developing a shorter regimen of antibiotics that can do the same job like doxycycline. We hope that doxycycline will play its own role in the elimination of onchocerciasis or anti-wolbachia drugs globally. But we are expecting contributions from other drugs like Flubendazole which is in the pipeline.

Globally to answer your question, the impediment has come from the fact that we are dealing with only one tool, for the control of onchocerciasis.

To be continued…