Religious practices and Neglected Tropical Diseases: What is the connection?

Baptism Weija

By Dr Samuel Armoo

 

On a warm and humid Sunday afternoon during a COUNTDOWN field trip on schistosomiasis related to our implementation research on expanding the mass drug administration treatment against schistosomiasis and soil-transmitted helminthiasis,  I observed 20 individuals performing the Christian practice of baptism by full-water-immersion in Manheam – a community along the Weija dam where schistosomiasis remains highly endemic.

My interaction and discussions with the people revealed that participants were not local to the community but had travelled from afar to baptise or be baptised in the dam. I also found out that this was a common practise among many churches in Accra, as Weija dam was within easy commute. So how could I ignore this observation as my COUNTDOWN team had revealed active on-going transmission of schistosomiasis, a parasitic disease also known as bilharzia, being highly endemic in the local community. This meant that many of these unsuspecting individuals, living in areas further away with no risk of infection, could now be exposed to a disease in the process of practising this religious act. The Weija dam is within a day’s trip to millions of Ghanaian Christians, so the significance of this observation should not be overlooked. Moreover, Ghana is a deeply religious country, with about 70% of the population being Christians.

Infection occurs when the larval forms of the parasite are deposited by freshwater snails which can penetrate the skin when it comes into contact with the infested water. The parasitic worms that cause schistosomiasis can live up to 40 years within the system of an infected individual if left untreated. As a result of a single water baptism in an infested water source, this can lead to contracting this disease, with unfortunate life changing experiences.

S Armoo Blog

Figure 1: Several activities at Manheam that bring people in contact with schistosomiasis- infected water.

The World Health Organisation estimates that over 200 million people around the world are infected with the Schistosoma parasites, with most of the burden of prevalence in sub-Saharan Africa. Ghana is one of the top five countries (Nigeria, Tanzania, Ghana, the Democratic Republic of Congo, Mozambique) on the continent with high prevalence rates of schistosomiasis.

In sub-Saharan Africa the disease presents in two forms: intestinal schistosomiasis, which is caused by S. mansoni, and urinary schistosomiasis, which is caused by S. haematobium. Urinary schistosomiasis known as urogenital schistosomiasis also affects women’s reproductive health leading to infertility, social stigma and an increased rate of abortion. The lesions associated with retained S. haematobium eggs in the female urogenital tract have been associated with an increased risk of HIV infection. For male genital schistosomiasis, the most common symptoms include blood in semen, inflammation of one or both testicles, and prostate inflammation. Both intestinal and urinary schistosomiasis results in anaemia and impaired childhood development, with the risk of reduced intellectual function.

The current control strategies for schistosomiasis is mainly based in identified endemic communities, who usually have close proximity to dams, lakes and other still water bodies. Despite the many successes against the disease in Ghana, it still remains a public health threat. Many areas in Accra are not within the control radar for the national control programme with regards to schistosomiasis. The frequent water baptism in the infested Weija dam area could mean a large cohort of infected individuals living outside the targeted intervention communities. And the most concerning issue is that many of these individuals may not be aware of their infection status and may relate the symptoms of schistosomiasis to other diseases, and wrongly treat them. This calls for an urgent need to inform, communicate and ultimately educate those largely oblivious to the risks of schistosomiasis, in a professional manner allowing them to seek better alternatives.

My suggested way forward is for the churches to create safer places for water baptism, without losing its religious significance and connection or to educate about the risks of infected water sources. The national or district disease control programmes could help advise and collaborate with churches to set up safer ponds with treated water, since people should not be prevented from exercising their Christian faith. Environmental control of schistosomiasis has a long history of local water engineering schemes but is sadly often forgotten. Despite the dangers of drowning in the lake during baptism activities – like was reported a few weeks after my observation, the risks of contracting schistosomiasis during baptism needs to be mitigated and addressed as part of the national NTD control programme.

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Dr Samuel Armoo is the Head of the Biomedical and Public Health Research Unit at the Council for Scientific and Industrial Research – Water Research Institute (CSIR-WRI) in Accra, Ghana. You can reach him via his email: Samuel.k.armoo@gmail.com

Research to Practice: COUNTDOWN Findings lead to improved Community Awareness for Neglected Tropical Diseases in Nigeria

Ogun Sensitisation - radio interview

Discussants after a radio programme on NTDs in a local radio station in Abeokuta, Ogun State.  
From Left to Right: Mr. Ayo Ayowojolu (Coordinator FUNAAB radio), Ms. Chienye Egwuonwu (Programme anchor/ presenter), Prof. Sammy Sam- Wobo (Chairman, State Advisory Committee on NTDs- SACON), Dr. Soneye Islamiat (Ogun State NTDs Programme Coordinator), Prof. Uwem Ekpo (A professor of parasitology and epidemiology, from Federal University of Agriculture, Abeokuta) and Dr. Olabanji Surakat (Ph.D Parasitology).Photo credit: Ogun NTD Programme

By James Nuphi Yashiyi (Social Scientist, COUNTDOWN Ogun State), Victoria Lebrun, COUNTDOWN Consortium

 

COUNTDOWN research conducted in Ogun State, Nigeria indicates that understanding in relation to Neglected Tropical Diseases (NTDs) and associated awareness campaigns is limited in some areas. Consequently, the NTDs programme unit in the state recently organized an NTD awareness creation campaign across the 20 Local Government Areas (LGAs) of the State. The goal of such campaigns is to increase participation in the distribution of medicines to control diseases like onchocerciasis, schistosomiasis, and lymphatic filariasis and help people manage side effects if they encounter any after taking the medicine. Ogun State is one of two states in Nigeria where COUNTDOWN has been working to understand how the NTD programme is functioning and how to accelerate progress against NTDs.

In the state capital – Abeokuta, staff of the NTD Control Unit and other public servants from the Ministry of Health and the Ministry of Information walked through the streets, calling out messages, distributing handbills, and holding illustrative posters that explained the drugs used in the mass administration of medicines (MAM).

Ogun sensitisation

A poster in the local Yoruba language displaying the four NTDs prevalent in the state and their treatment  Photo credit: James Yashiyi (Social scientist, COUNTDOWN Nigeria)

As part of the awareness creation, the NTDs Control Unit staff were joined by parasitology experts from the University on a FUNAAB Radio show (89.5FM) based at the Federal University of Agriculture, Abeokuta in Ogun State. They shared with the public the signs and symptoms of several NTDs and explained how to prevent them. They also debunked the myth that preventive chemotherapy (PC) drugs can be harmful and encouraged parents to set a good example of hygiene for their children like regular washing of hands and keeping their environments clean.

This campaign featured evidence-based approaches informed by COUNTDOWN’s situational analysis and ongoing research. Here are a few ways that this campaign reflects the findings of COUNTDOWN research.

  1. Getting to the heart of End-user Needs

The project’s situational analysis brought attention to the perspectives and needs of communities. In the development of the awareness campaign, COUNTDOWN’s Participatory Action Research(link is external) approach brought all health system actors together whilst focusing on the community perspective. To learn about the programme COUNTDOWN used qualitative methods such as interviews, participatory workshops, and focus groups. The volunteer community directed distributors (CDDs) and school teachers, who carry out the essential task of giving people PC drugs, were engaged in mock trainings using existing information, education, and communication materials. Feedback sessions from teachers, children, community members and CDDs revealed opportunities to improve these materials, which were updated to use the local language and have clearer, more appealing visual aids. COUNTDOWN held regional and national dissemination meetings, which informed the decision of the Ogun State NTD programme to make raising public awareness a priority.

2. Use of Strategic Points in Awareness Creation

One of the activities completed during COUNTDOWN’s participatory action research cycle were several transect walks in various study communities, including those in urban and rural areas. This involved community leaders walking through their communities with researchers and pointing out strategic places where people gather, such as to do business, socialize, or worship. Discussions with female and male community members also revealed important locations and communication channels where men and women can get information. To maximize the impact of the campaign, the NTD programme used research findings to select popular communication channels, like the radio, and strategic locations to distribute PC drugs, such as the large Kuto Market in the state capital, Abeokuta.

3. Adapting to changes over time

A key theme highlighted in the situational analysis is that new challenges have emerged over time. MAM’s success has reduced morbidity due to NTDs, leading some to think that taking PC drugs is not necessary. Volunteers and school teachers reported having to address rumours that PC is harmful. The radio show addressed these issues head on: it explained the need to take the medicine over several years and as a preventive measure and advised against believing “fake news” about the medicines killing children or the government having ulterior motives. Engaging influential community members and leaders such as members of the Parents Teachers Association (PTA), religious leaders etc. was critical to supporting the programme to address rumours about the need for the medicines and their side effects. COUNTDOWN’s community mapping activities supported the programme to identify which individuals could be targeted to support programme delivery in this way.

The global health community is always looking for ways in which the move from evidence to practice can be accelerated and made smoother. It is exciting to see how COUNTDOWN’s holistic approach to research uptake is helping the NTD programme in Ogun, Nigeria. We can see how participatory methods in research allow for the voices of communities to be heard by programme leads, facilitating better community ownership which in turn leads to greater acceptance of medicines.

Highlighting New Paradigms for fighting Neglected Tropical Diseases

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Several COUNTDOWN members attended the Coalition for Operational Research on Neglected Tropical Diseases (COR-NTD) meeting in October 2018. COR-NTD is an alliance of researchers, programme implementers, donors, and advocates with the shared goal of optimizing NTD control and elimination. The meeting highlighted many urgent topics related to how and when to shift strategies to tackle NTDs with more precision and better treatment/intervention coverage, despite implementation challenges.

In Africa, several national NTD programmes are achieving scale-up of preventive chemotherapy (PC) with better access to medications and annual treatment coverage. However, progress against each NTD can be uneven. For example, certain populations remain vulnerable, overlooked, and left behind. Part of COUNTDOWN’s mission is to find out why this is happening, how to ensure better access to treatment, through making the most of limited resources. To improve programme implementation and turn the tide against NTDs in some of the remaining strongholds of NTDs, COUNTDOWN researchers presented new evidence from ongoing research.

Embedding social science methods into a national NTD programme

The first step in improving NTD programme coverage is to ask, ‘who is being left behind, and why?’ For example, mass drug administration (MDA) with a combination of deworming medications, aims to kill the parasites that cause schistosomiasis, onchocerciasis, lymphatic filariasis, and soil-transmitted helminthiasis. The delivery of effective medications is a pro-poor intervention often linked to the third Global Goal, universal health coverage. Laura Dean delivered a presentation in the session, “Aligning NTD programmes with Universal Health Coverage: lessons from research” on the problem of increasing coverage of an intervention already at scale to reach non-covered individuals and populations.

Critical analysis

Critical analysis of programme areas. Image courtesy of Laura Dean   

NTD programmes need to make the focus on equity explicit and plan their activities with the goal of reaching the most marginalized. Participatory Action Research (PAR) cycles are an approach COUNTDOWN used in Liberia and Nigeria to leverage community knowledge to find out who is missing MDA and how to be more inclusive. Getting community members to help tailor programme delivery according to local needs and desires can overcome contextual disadvantages like working with a hard-to-reach population. The approach is particularly well suited for devising strategies for overcoming misconceptions and fears about MDA. If this approach is sustained, the NTD programme will become increasingly agile and adaptable. Researchers are working to establish champions of the method who will ensure it is included in MDA planning and activities.

Send out letters to the LGA Chairman, community leaders, religious leaders like the Pastors and Imams, and influential people like youth leaders. Letters indicate date and time of advocacy visits.
Advocacy visit to these leaders on schistosomiasis and STH.
Sensitising owners/operators/leads and placing posters in worship centres, football viewing centres, boreholes, schools, motor parks, suya and waina joints, bus stops, and grinding mills.
Road shows and practical mobilisation of the communities before and during mobilisation using the IEC materials, radio jingles and television adverts.

Examples of activities using the PAR approach.

Re-thinking who needs PC treatment

Even with revised international guidelines being promoted by WHO from recently conducted randomised controlled trials, millions of women in Africa continue to be excluded from praziquantel treatment such that the burden of female genital schistosomiasis (FGS) goes unchecked. Reasons for this are multifaceted: from shortages in praziquantel supplies to exposing knowledge gaps in the peripheral health system. These latter include insufficient medical education and training of primary health care providers who remain oblivious to FGS etiology as well as confusion within afflicted communities. For example, many mistakenly interpret blood in urine, a cardinal sign of FGS, with that of sexually transmitted diseases. Detailed discussions and exploratory solutions to tackle FGS were guided by Professor Russell Stothard and Dr Jutta Reinhard-Rupp within the session organized by Dr Goylette Chami delving into better behavioral interventions against NTDs. Recent COUNTDOWN research in Ghana has shown that adolescent girls with FGS are being unduly stigmatised for promiscuity.

New mapping technique helps identify where to focus intensive efforts

Professor Louis-Albert Tchuem Tchuenté chaired the session “Shrinking the map for Schistosomiasis.” Geospatial mapping has long been employed to conduct surveillance and plan NTD programme activities. However, schistosomiasis control through treating school-aged children with PC is usually planned by surveying a limited number of schools in a region or district and then either treating, or not treating, all the schools in that geographic area. New evidence from COUNTDOWN demonstrates that mapping NTD prevalence at a more granular level would result in more efficient resource allocation by targeting only schools and/or communities that have an infection prevalence in the 10% threshold. This methodology is called precision mapping.

Precision map

Precision mapping of schistosomiasis gives high-resolution information at the local level and allows for a better and rational utilization of praziquantel and available resources

In a recent study in Cameroon (pictured above), this method would reduce the overall number of treatments even if more ambitious targets for schistosomiasis elimination are adopted. In the session, participants discussed the need for new evidence-based guidance and the need for further operational research to develop it.

Fluid contexts call for partnerships with communities and experts in other disciplines

COUNTDOWN’s Dr  Rachael Thomson and Dr Sunday Isiyaku led a panel on community engagement in emergent contexts such as border regions, urban areas, and conflict zones, where NTD programmes must rely even more on the goodwill and participation of communities to conduct MDA successfully. Dr Theresa Hoke explained how a research uptake strategy can engage communities from start to finish so they experience increased ownership in the NTD programme.

Communities are a unique stakeholder in NTD research because some community members are involved at every stage of the research process, including using the research findings. Luret Lar M.D. of COUNTDOWN’s Nigeria team spoke more about how this philosophy was applied in Nigeria. Following a situational analysis that uncovered specific needs related to community engagement, several participatory methods were employed during PAR cycles, including transect walks and community mapping, a discrete choice experiment with community drug distributors, mock training cascades. Participatory approaches like this group exercise are helping communities identify solutions to sustain participation with the NTD programme. Another approach COUNTDOWN has used is to learn from other disciplines. Anthony Bettee, from COUNTDOWN Liberia, shared how they used research to develop a new communications strategy, leveraging the expertise of the National Health Promotion Department.

In conclusion, reaching programmatic targets often means extra effort in finding those who need treatment, and more precise identification of at-risk populations and geographic locations. Then, programmes must go to those communities that are most in need and work with them, using fit-for-purpose research methods. Increasing equity in NTD control means considering other paradigms besides the current methodologies for carrying out treatment and prevention activities.  A key challenge at COR-NTD arises in being a broad forum bringing together researchers and implementors spanning the major strategies for NTD control.  The meeting has done an outstanding job highlighting common issues and questions that may be answered with further research applying techniques and perspectives from a range of disciplines. The diverse COUNTDOWN Consortium is playing an important role in discussions that will guide this progression towards more equitable and sustainable control of NTDs in Africa.

Albendazole for lymphatic filariasis… direct hit or misfire? (Reposted from ‘BugBitten’)

Albendazole-tablets-620x342

For two decades albendazole has been donated for lymphatic filariasis mass treatment programs. An updated Cochrane Review investigates the effectiveness of albendazole for lymphatic filariasis.

Lymphatic filariasis

Lymphatic filariasis, a disease common in tropical and subtropical areas, is spread by mosquitoes and caused by infection with parasitic filarial worms. Once infected, larval worms grow into adult worms and mate to produce microfilariae (mf). The mf are then collected by mosquitoes during a blood meal, and the infection can be spread to another person.

Life-cycle-300x238

Life cycle of parasitic worms causing lymphatic filariasis.
CDC

Infection can be diagnosed using tests for circulating mf (microfilaremia) or parasite antigens (antigenemia), or by ultrasound imaging to detect live adult worms.

The World Health Organization (WHO) recommends annual mass treatment of entire populations for at least five years. The main treatment is a two-drug combination of albendazole and a microfilaricidal (antifilarial) drug, either diethylcarbamazine (DEC) or ivermectin.

Albendazole alone, given biannually, is recommended for areas co-endemic for loiasis, where DEC or ivermectin should not be used due to the risk of serious adverse events.

Albendazole for lymphatic filariasis

Both ivermectin and DEC rapidly clear mf infections and can suppress their reappearance. However, mf production will resume due to the limited effects on adult worms. Albendazole was considered for lymphatic filariasis after a study reported that high doses given over several weeks caused serious adverse reactions suggestive of adult worm death.

WHO informal consultation report then proposed that albendazole has a killing or sterilizing activity on adult worms. In 2000, GlaxoSmithKline began donating albendazole for lymphatic filariasis treatment programs.

Elephantiasis-300x207

Elephantiasis of leg due to filariasis.
Wikimedia Commons

Randomized clinical trials (RCTs) investigated the effectiveness and safety of albendazole alone or in combination with ivermectin or DEC. Several systematic reviews of RCT and observational data followed, but it was unclear whether albendazole was of any benefit for lymphatic filariasis.

In light of this, a Cochrane Review published in 2005 has been updated to assess the effects of albendazole in people and communities with lymphatic filariasis.

The Cochrane Review update

Cochrane Reviews are systematic reviews that aim to identify, appraise and synthesize all the empirical evidence that meets pre-specified criteria to answer a research question. Cochrane Reviews are also updated when new evidence becomes available.

Cochrane methods minimize bias in the review process. This includes using tools to assess the risks of bias in individual trials and GRADE the certainty (or quality) of evidence for each outcome.

GRADE-768x578

Use of GRADE for synthesizing evidence and developing recommendations. The upper half describes steps common to Cochrane systematic reviews.
GRADE handbook

The updated Cochrane Review, ‘albendazole alone or in combination with microfilaricidal drugs for lymphatic filariasis’, was published in January 2019 by the Cochrane Infectious Diseases Group and COUNTDOWN consortium.

The Review sought RCTs that assessed:

1) albendazole vs placebo;

2) albendazole plus DEC vs DEC; and

3) albendazole plus ivermectin vs ivermectin

Outcomes of interest included measures of transmission potential (mf prevalence and density), markers of adult worm infection (antigenemia prevalence and density, and adult worms detected by ultrasound) and adverse events.

Using electronic searches, the authors attempted to identify all relevant trials up to January 2018 regardless of language or publication status. Two authors independently assessed studies for inclusion, assessed the risks of bias, and extracted trial data.

What the research says

The Review included 13 trials with 8713 participants. To measure treatment effects, meta-analyses were used for parasite prevalence and adverse event outcomes. Tables were prepared to analyse parasite density outcomes, as poor reporting meant the data could not be pooled.

The authors found that albendazole alone or added to a microfilaricidal drug makes little or no difference to mf prevalence over two weeks to 12 months after treatment (high-certainty evidence).

They do not know if there is an effect on mf density between one to six months (very low-certainty evidence) or at 12 months (very low-certainty evidence).

Treatment with albendazole alone or added to a microfilaricidal drug makes little or no difference to antigenemia prevalence between six to 12 months (high-certainty evidence).

risk-of-bias

‘Risk of bias’ summary: authors’ judgments about each risk of bias item for each trial.
Albendazole alone or in combination with microfilaricidal drugs for lymphatic filariasis.

The authors do not know if there is an effect on antigen density over six to 12 months (very low-certainty evidence). Albendazole added to a microfilaricidal drug may make little or no difference to adult worm prevalence detected by ultrasound at 12 months (low-certainty evidence).

When given alone or as a combination, albendazole makes little or no difference to the number of people reporting an adverse event (high-certainty evidence).

Implications for practice

The Review found good evidence that albendazole alone or in combination with microfilaricidal drugs has little or no effect on completely clearing the mf or adult worms up to 12 months after treatment.

There was no convincing data across studies of an effect on mf density or adult worm viability.

Given that the drug is part of mainstream policy, and the W

HO now also recommend a triple‐drug regimen, it seems unlikely researchers will continue to evaluate albendazole in combination with DEC or ivermectin.

However, albendazole alone is recommended in areas endemic for loiasis. Therefore, this remains a priority for research to know whether the drug is effective in these communities.

A macrofilaricidal drug with a short treatment regimen could make a significant impact on filariasis elimination programs. One such drug is currently undergoing preclinical development, and has been covered in a recent BugBitten blog.