Swiss TPH Winter Symposium 2107: Helminth infection – from transmission to control

By Professor Russell Stothard

Unlike the UK where there are two schools dedicated to tropical medicine, there is only one in Switzerland and located in Basel. The Swiss Tropical and Public Health Institute (Swiss TPH) is affiliated with the local university and has over 800 people from more than 70 nations working on infectious and non-communicable diseases. Internationally, the Swiss TPH has a large global foot print which has grown since its foundation in 1943.

Like the Liverpool and London Schools, the Swiss TPH has a fascinating history. Its first director – Rudolph Geigy, is widely recognised as a true pioneer of the control of vector-borne diseases. Today the institute still oversees two field stations in Côte d’Ivoire and Tanzania, originally founded as the Centre Suisse de Recherches Scientifiques (CSRS) in Adiopodoumé and the Swiss Tropical Institute Field Laboratory (STIFL) in Ifakara. The institute actively supports many interventions globally that assuage disease in low and middle-income countries.

To highlight the best of current research and control activities, each year the Swiss TPH organises a winter symposium on a topic of international interest. This year the 2-day meeting’s theme was dedicated to medical helminthology; a lot of ground was covered within a packed programme. Much of it featured implementation research that fostered interdisciplinary studies and as such, I was honoured to represent COUNTDOWN. I highlighted our research across those neglected tropical diseases amenable to preventive chemotherapy and during my keynote presentation. I discussed some of our most recent publications on gender, blogs and presentations on soil-transmitted helminthiasis and schistosomiasis as well as the growing importance of science communications in general.

With today’s changing lifestyles and needs to process information, it is critical to demonstrate how modern media tools can showcase and raise awareness of research uptake. This can be viewed as exploring a combination of new distribution channels alongside older ones that embed implementation research into adaptive health system programming and policy change. For example, I was able highlight our recent paper on WASH which was particularly opportune for our co-author Yael Vellerman was in attendance. I chaired the session where Yael presented her recent activities in WHO, whilst currently seconded from Water Aid, she discussed issues pertaining to scale-up of WASH-related interventions. I illustrated our collaborative steps, starting with platform discussions at COR-NTD, in revealing research and policy gaps. This gave better context to the need for cross-sector collaboration in development of appropriate indicators for surveillance of health and environmental change. More generally, an overview report of this meeting is featured within the Swiss TPH website likely with more detailed outputs to follow as several papers presented will later result in peer-reviewed manuscripts.

While there were many powerful examples of cross-talk and complementation of methods in implementation research, I want to highlight a few. Exciting new methods to measure children’s physical fitness and physio-social needs before and after de-worming were presented by Professor Markus Gerber; better clinical management of liver cancers alongside eco-health approaches in the environment to curtail transmission of opisthorchiasis were excellently illustrated by Professor Banchop Sripa.

From my perspective, I found this meeting a very fertile field to sow the seeds of research uptake and future collaboration which is needed to advance towards WHO 2020 targets and 2030 Sustainable Development Goals.

 

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Mind the Gap: Lessons from over two decades in Gender Mainstreaming on NTDs

by Professor Sally Theobald, Pamela Bongkiyung & Laura Dean

Gender matters in the world of Neglected Tropical Diseases (NTDs). What is gender? The World Health Organisation (WHO) defines gender as ‘socially constructed roles, behaviours, activities and attributes that a given society considers appropriate for men and women, and people of other genders.’

Following the meeting ‘Women and Girls in Focus: Ensuring NTD Programmes Achieve Gender Equality and Empower Women and Girls’ in July 2016, a group of experts and researchers from programme, donor, policy, educational institutions came together to discuss how to further the gender mainstreaming agenda within NTDs.

Because of this meeting, a paper just published in the British Medical Journal of Global Health entitled ‘20yrs of Gender Mainstreaming in Health: Lessons and Reflections for the Neglected Tropical Diseases Community’, was conceptualised. In the paper, the authors extrapolate lessons on gender mainstreaming from the past two decades; showing how addressing gender inequities can strengthen NTD programmes.

The first lesson that can help researchers, policy makers, practitioners to address gender power relations most relevant to their work is tailoring the gender framework to help make the focus on gender explicit. The authors provide an example of how gender frameworks could support the delivery of MDA.

Given that gender does not operate in isolation, the second lesson is taking on the challenge of intersectionality. Privilege, power and inequity which could be due to age, nationality, ethnicity, religion, sexuality, disability and socio-economic are the multiple axes through which gender is experienced. Some of these factors play a role in enabling or preventing access to MDA. Due to stigma and lack of perceived need, affected people stay hidden within their communities. Access is further limited or non-existent for people with disabilities.

Community drug distributors (CDDs) who are the backbone of NTD programmes. Who gets chosen as a CDD is shaped by gender power and participation; and is our third lesson. CDDs are selected by their communities as trustworthy people. The selection process appears equitable on paper but can have the unintended consequence of reinforcing gender and social hierarchies within communities.

The fourth lesson is the need to unpack gender and power dynamics at household level as this impacts delivery of NTD programmes. CDDs are embedded within the communities and possess a strategic understanding of the social and cultural norms, they are in a good position to be agents of social change for health outcomes.

The final lesson from the paper focuses on bringing a critical gender lens to data always. The authors emphasise that care be taken in how data is disaggregated, avoiding the pitfall of making certain groups invisible especially those who face multiple challenges in accessing care and treatment.

During the International Federation of Anti-Leprosy Associations meeting on 18th October 2017, some of the authors of the paper (Prof Sally Theobald & Ms Laura Dean) from the COUNTDOWN programme at Liverpool School of Tropical Medicine; delivered a keynote on gender mainstreaming as could be applicable to the leprosy programmes. They used this engagement platform to share insights on the importance of gender to the health system, given that the latter is not gender neutral and plays a key role socially in how health needs, outcomes and experiences are achieved and met. Here is the Storify of the social media interactions of the keynote.

COUNTDOWN worked with the WHO in trialling a Gender, Equity & Rights (GER) tools in Northern Nigeria with our partners Sightsavers, based in Kaduna. A presentation on the findings of this process was delivered at the WHO headquarters in February, 2017 and was well-received. It is helping to guide and inform WHO’s policy in incorporating gender into various programmes.

To read more on COUNTDOWN’s engagement on issues related to gender, equity and rights, read the below:

HOW CAN WE MAKE UNIVERSAL HEALTH COVERAGE TRULY UNIVERSAL? EQUITY, GENDER, DISABILITY, AND NTDS by Prof Russell Stothard & Kate Hawkins.

Share your experiences working in this sector in the comment section and join us on social media for further interactions.

@NTDCOUNTDOWN  @NTDGHCOUNTDOWN  @COUNTDOWNNTDCAM

@COUNTDOWNLR      @COUNTDOWNNG

http://www.countdownonntds.org/

http://countdowncameroon.org/

Impact of NTDs: Beyond the Patients

by  Maureen Tembei, Sally Theobald, Russell Stothard & Samuel Wanji

The burden of neglected tropical diseases is mainly discussed from a patient-centric perspective, however, there is a wider impact where these diseases touch the lives of those providing care and support. In this blog, we explore and expand upon broader issues of the Neglected Tropical Diseases (NTDs) burden and care drawing from experiences of work in Cameroon and the international literature.

  1. Catastrophic health expenditure for NTDs at household level

NTDs such as onchocerciasis and lymphatic filariasis (LF) lead to low economic productivity, catastrophic health expenditures, low quality of life, social stigma and isolation of affected persons and their households’ due to disabilities related to these diseases. The physical challenges associated with these conditions contribute to large productivity losses as most patients are of working age. The economic cost of managing the disability associated with these diseases are overwhelming and compounded by productivity losses (both paid and unpaid work). Household members suffer from financial losses trying to treat household members affected both directly and indirectly. Direct cost of treating these diseases (medical and non-medical costs) added to the productivity losses (economic, domestic and academic, e.g. dropping out of school leading to loss of knowledge) at household level for both patients and caretakers can be devastating.

Maureen Blog on Beyond Patients 1
Children dropping out of school to take care of affected family members.  Photo Credit: Carter Center.

 

So far, the impact of NTDs have been focused on patients, ignoring the significant impact these diseases have beyond patients to their family members. These diseases interfere with household consumption of economic and domestic (household chores and leisure) activities thereby reducing their ability to attain good health (WHO, 2009). Households of affected persons may reduce their consumption by liquidating household savings or assets thus, diminishing their opportunities to generate financial and physical capital. These household health expenses at times go beyond World Bank recommendation for catastrophic health expenditure being 10% of household income. This was evident in a leprosy economic study in India rising by up to 40% of household income (Chandler et al. 2015).

Maureen Blog on Beyond Patients 2

Buruli Ulcer  Photo Credit: Dr S Etuaful, Ghana

A study on the household cost management of another debilitating NTD; buruli ulcer at Akonolinga in Cameroon demonstrated a direct cost of €59.3 constituting 25% of household annual earnings for treatment of the disease while indirect productivity cost for both patients and family members was €64.4 (Koen et al. 2008). Also, Koen et al. reported that 63% of households cease to provide social and financial support for patients as a coping strategy.

Maureen Blog on Beyond Patients 3

Podoconiosis (Non-filarial elephantiasis) Photo Credit: Maureen Tembei

An economic study in Ethiopia on podoconiosis, an NTD with disability comparable to that of LF revealed direct treatment costs being equivalent to US$143 per patient per year excluding productivity losses and family impact. Studies in Cameroon on the household economic cost of podoconiosis (Tembei et al. Unpublished), revealed US$142 of household income being consumed annually for direct treatment of the disease constituting 40% health expenditure. Most NTDs are likely to impose catastrophic health expenses at household level.

 

2) Social Aspects of NTDs

Added to the economic burden, NTDs affect quality of life of affected households socially by reducing productivity, marginalization and causing stigma (Mousley et al. 2013) for both patients and their family members. Results from studies in Cameroon demonstrated almost equivalently low levels of quality of life and high levels of stigma, among podoconiosis and leprosy patients (Tembei et al. Unpublished).

Maureen Blog on Beyond Patients 4

Leprosy (Hansen’s Disease)  Photo Credit: Maureen Tembei

Social consequences are not only limited to isolation and exclusion from community events but also include; difficulties in finding employment, gaining education and getting married. Overcoming these consequences are vital activities for both social and economic well-being (Tora et al. 2014). Neglected Tropical Diseases are also quite stigmatizing in endemic areas and experiences are shaped by gender roles and relations (Desta et al. 2003; Kloss et al. 1997) and generation (Davey et al. 2007) in different ways both for patients and their family members. Some degree of stigma towards leprosy and podoconiosis affected households was observed in Cameroon (Tembei et al. Unpublished), implying that perceptions towards stigma related to NTDs are not limited to the patients but can also have repercussions for family members and caretakers within the household. This thwarts efforts to effectively treat and prevent NTDs as it negatively impacts health seeking behaviour of patients and act as a barrier to appropriate care from health workers and their local healers.

 

3) Sustainable Development Goals 2030: Leaving no one behind

Talking about “Leaving no one behind” means everyone should have the right to direct access to healthcare opportunities expressed in the SDGs. Narrowing down to NTD perspective, COUNTDOWN has within its portfolio, four (4) key NTDs with high prevalence and amenable to preventive chemotherapy in sub-Saharan Africa namely onchocerciasis, lymphatic filariasis, schistosomiasis and soil-transmitted helminthiasis. Among these NTDs, onchocerciasis and lymphatic filariasis have debilitating disabilities with devastating social and economic burdens not limited to the patients but extending to family members. Less well-known are the consequences of urogenital schistosomiasis, especially in women where the disease may cause infertility and sub-fertility taking away some of their more important choices in life.

Maureen Blog on Beyond Patients 5

Figure 1: A wider impact of NTDs: Economic and social impacts of NTDs extending beyond patients to family members within the household.

COUNTDOWN as a multi-disciplinary research consortium is devoted to bringing forth research-based evidence on the economic and social burdens of these NTDs to inform and influence health policy. Therefore, we are saying that as a commitment to meeting the 2030 SDGs of leaving no one behind, health strategies targeting control and elimination of NTDs should not be limited to the patients only but, should consider extending to all those affected directly or indirectly by these diseases at the household and community level.

4) Way Forward

Beyond the scope of COUNTDOWN (improved access to public health interventions for these NTDs including prevention), morbidity management and disability prevention centres are likely to result in economic returns to affected families. Another approach to this would be through subsidized health insurance for these economically vulnerable households. Affected households may benefit from such schemes so they are better financially protected. Moreover, rehabilitation and economic empowerment through skilled and unskilled labour for the disabled patients might serve as an economic relief to their family members while socially integrating them gradually into their community and society.

 

 

It is Global Handwashing Day! What does this mean for Neglected Tropical Diseases?

by Pamela Bongkiyung, Prof Russell Stothard, Prof Louis-Albert Tchuem Tchuente

Today Sunday, October 15th, we celebrate Global Handwashing Day, a day dedicated to global advocacy on increasing awareness and understanding on washing hands with soap, thereby preventing several communicable diseases. This awareness it is hoped will increase participation and save lives from preventable diseases.

Since the campaign launched in 2008, it has garnered enough support to be celebrated in over 100 countries with over 100 million people participating each year. The Global Handwashing Day aims to:

  • Foster and support a global and local culture of handwashing with soap
  • Shine a spotlight on the state of handwashing around the world
  • Raise awareness about the benefits of handwashing with soap

According to a 2014 UNICEF report on Levels & Trends in Child Mortality, diarrhoea accounts for 9 per cent of leading causes of death among children under five. Each day, nearly 1,000 children die due to preventable water and sanitation-related diarrhoeal diseases. Diarrhoea is easily transmitted where poor hygiene and sanitation are rife. Pneumonia, diarrhoea and malaria accounted for 1.3 million of under-five deaths in sub-Saharan Africa and roughly half a million in Southern Asia in 2014. Accelerating the reduction in under-five mortality rates is possible through expanding preventive and remedial interventions.

As far back as 2010, UNICEF developed an advocacy pack to inform and support planning of activities to raise the profile of WASH (Water, sanitation and hygiene) in schools around the world. This pack was created as part of its campaign ‘Raising Clean Hands: Call to Action for WASH in Schools’.

But what has all this got to do with Neglected Tropical Diseases(NTDs)? For those in the NTD world, this day is of great significance as handwashing is a good habit to develop for a sustainable and long-term control on preventing infection or re-infection with diseases such as soil-transmitted helminthiasis (STH). According to the World Health Organisation (WHO), around 1.5 billion people are infected with STH worldwide. STH are caused by infection with the roundworm (Ascaris lumbricoides), whipworm (Trichuris trichiura) and hookworms (Ancylostoma duodenale or Necator americanus). They are among the commonest infections especially those living in poverty.

These STH diseases thrive in warm, tropical environments, where sanitation is inadequate. Parasite eggs and larvae are excreted in the faeces of infected individuals which contaminate the environment, particularly the soil. People are infected through ingestion of roundworm or whipworm eggs on contaminated foods or by direct skin penetration of hookworm larvae from the ground.

When individual children harbour large numbers of these worms it can lead to bowel obstruction and iron deficiency anaemia which, over time leads to malnutrition and growth impairment.

Improving hand hygiene before eating and safe disposal of faecal material is important. The 6th goal of the Sustainable Development Goals (SDGs) which continues the legacy of the Millennium Development Goals (MDGs) states: ‘ensure clean water and sanitation for all’. WHO estimates at least 1.8 billion people around the world use a source of drinking water that is contaminated by faeces. With 2.4 billion having limited to no access to basic sanitation services such as toilets or latrines, we can see how lasting control of STH is a challenge.

SDG Banner - Health in the Global Era

Reason why handwashing and WASH in general are crucial to the elimination of NTDs. The latest Guideline: preventive Chemotherapy to control soil-transmitted helminth infections in at-risk population groups published by WHO last month, emphasises long-term solutions to STH require improvements in water, sanitation and hygiene. The Fourth WHO Report on Neglected Tropical Diseases titled ‘Integrating Neglected Tropical Diseases into Global Health and Development‘, indicates that providing safe water, sanitation and hygiene is critical for preventing and providing care for most NTDs but tends to be neglected relative to its importance. The report warns that without concerted effort to improve access to safe WASH, diseases will return to higher prevalence levels.

The COUNTDOWN programme which is multidisciplinary in its make-up has tackled this issue by participating in discussions with intersectoral partners to engage in knowledge-brokering and taking a collaborative approach to knowledge share in the process. In the current health environment where capacities are distributed, coming together to seek solutions to universal problems such as these, is paramount. The COUNTDOWN team has recently authored a paper soon to be published in Trends in Parasitology entitled “Tailoring water, sanitation and hygiene (WASH) targets for soil-transmitted helminthiasis and schistosomiasis control.

You can read more from COUNTDOWN relating to STH here.

How can you participate in the global handwashing movement? Choose from this Lazy Person’s Guide to Saving the World or share with us your experiences working in this sector in the comment section and join us on social media for further interactions.

Twitter: @NTDCOUNTDOWN  @NTDGHCOUNTDOWN  @COUNTDOWNNTDCAM

@COUNTDOWNLR      @COUNTDOWNNG

Website:  http://www.countdownonntds.org/

http://countdowncameroon.org/

BLOG: https://countdownonntds.wordpress.com/

 

Let’s Move the Agenda from Control to Elimination of NTDs

By Prof Louis Albert Tchuem Tchuenté, Pamela Bongkiyung & Prof Russell Stothard

Who has the perfect answer to controlling or eliminating a disease? It gets more difficult when simply using medication does not guarantee no re-infection. In the case of Schistosomiasis and Soil-transmitted Helminthiasis, in the agenda of elimination one wonders if what we need are more parasitologists in the affected areas or getting the current ones to be more publicly engaged in educating the population?

Prof. Louis-Albert Tchuem Tchuenté who has been working on schisto control for over three decades emphasises the control of Schisto as many other NTDs is a long-term combat. That means a lot of investment and capacity building at all levels. It also needs to have the involvement of many actors and stakeholders. It is difficult for a single organisation or a single group to interrupt the transmission of this disease. That is why intersectoral cooperation, partnership and involvement of stakeholders at all levels is very important. Policy makers, scientists, community health workers, health personnel staff, teachers and all category of the population need to be involved in this fight.

Training of parasitologists is very important because in the African setting more needs to be done. It is vital to optimise and adapt the strategy according to the different transmission setting. The same strategy cannot be deployed as it will not have the same impact. That is why for example in Cameroon, when you compare the current distribution of Schistosomiasis to what was done 25 – 30 years ago; there is a significant decrease in some areas. We have examples where transmission has been interrupted, we have many examples where prevalence has been lowered to more than 80 – 90 percent in some of the localities.

But we still have some challenges where the dynamics vary.  The disease prevalence is reducing but variances remain due to the existence of conditions that allow for the transmission cycle to continue. That is why moving from control to elimination requires integration is intensified. Part of this requires increasing capacity building by training more students, investment, health education, change in behaviour and increase awareness of the population. It is a huge challenge.

The Sustainable Development Goals (SDG) has as one of its key point a call for countries to invest more for the control and elimination of Neglected Tropical Diseases (NTDs). Therefore, for the transmission of schistosomiasis to be interrupted there is a need for countries to invest more for the elimination of this disease. When more is invested, this means that we also should invest in equipment, in sanitation, in access to water and change of the environment or that you improve the hygiene.

Prof. Tchuem Tchuenté said: “Granted, the control of schistosomiasis is very challenging, it is a long-term commitment which is feasible. At this stage, there are tools and strategies in place to interrupt the transmission of schistosomiasis; what we need now mainly in Africa is that we must change our approach to become more ambitious. We must move completely from control to elimination. This shift in paradigm should be clearly effective and endorsed by all African countries.”

He believes that when we keep the word ‘control’, we can be satisfied with morbidity control and therefore control morbidity forever. If the agenda shifts to elimination, then the momentum and the target aligns with that shift. Lymphatic Filariasis (LF) programmes have used this approach. The LF programme’s target for years has been elimination and this makes us put a lot of effort into its elimination.

There is a tendency to become complacent when you reduce a disease to the level where it no longer constitutes a health problem. This is when we need to be most careful as you could miss when the disease makes a come-back again. But if you have a target for elimination, this means additional or further efforts to interrupt the transmission and then to move to the surveillance phase. Japan is one of the good examples. In the 1960s, there were some areas in Japan where the prevalence of schistosomiasis was higher than in most parts of Africa. But they decided and launched a ‘zero parasite’ campaign. From the beginning, it was not about control but zero parasites; meaning elimination. In less than 20 years Japan has eliminated schistosomiasis. China started with control but then rapidly moved to the elimination phase. Now their objective is to eliminate everywhere in China.

The COUNTDOWN project is in a key position to contribute to this agenda. Our research aims to increase acceptability, affordability, accessibility and availability of Neglected Tropical Diseases solutions. Our multidisciplinary approach is investigating efficient methods to cost-effectively upscale mass drug administration programmes, thereby moving the agenda closer to elimination.

With this word elimination, you must put the necessary efforts and investment to interrupt transmission. In Africa, the time is right to think about this and to shift completely from control to elimination. It is not easy as this will require a lot of investment. We need to raise momentum and commitment from the government, including investment. That is what the SDG is about; as espoused in one of its goals –  for countries to invest more for the elimination of NTDs!

To find out more about our research visit our websites:

http://www.countdownonntds.org

http://countdowncameroon.org/

Follow our activities via our Twitter accounts:

@NTDCOUNTDOWN  @NTDGHCOUNTDOWN  @COUNTDOWNNTDCAM  @COUNTDOWNLR  @COUNTDOWNNG

 

 

Going with the Flow: Local learning about rivers to implement ground larviciding for community-based control of river blindness

by Prof Samuel Wanji, Dr Peter Enyong, Andrew Amuam, Relindis Ekanya, Dr Louise Hamill, Dr Joe Turner

Preparations are proceeding at pace to control the local blackfly population in the South West Region of Cameroon. This is part of an integrated control strategy against river blindness implemented by the COUNTDOWN consortium, in partnership with the University of Buea, the Cameroon Ministry of Public Health and the Liverpool School of Tropical Medicine.

River blindness, also known as onchocerciasis, is a major health problem in the South West Region of Cameroon. It is transmitted by blackflies when they bite humans to obtain a blood meal. There is an effective treatment for onchocerciasis in the form of Mectizan (ivermectin); this drug has been used successfully in many parts of sub-Saharan Africa and South America. However, in the South West Region of Cameroon, and other locations in Central Africa, Mectizan use is complicated by the presence of a second parasite; Loa loa. The latter can cause severe reactions to Mectizan in a small number of heavily infected individuals.

Onchocerciasis is currently targeted for elimination across all of Africa. For this to be achieved, different approaches that do not rely on Mectizan treatment are needed in areas where Loa loa and onchocerciasis are found together.  COUNTDOWN are trialling the co-implementation of doxycycline, a drug that is effective against onchocerciasis and does not have any cross-reactivity with Loa loa, with localised reduction of blackfly populations, to further reduce transmission.

Controlling blackfly populations involves treating the rivers where the fly larvae are found; killing them before they have the chance to mature into adult blackflies and bite humans, thereby spreading the disease. To do this safely and effectively, key characteristics of the rivers in question must be carefully measured.

The research team from the University of Buea are working in collaboration with local communities to effect blackfly control, and give local people the skills, knowledge and training needed to measure key river characteristics. Volunteers to receive training on the measurement and treatment of rivers were selected in conjunction with the health system and community leaders in each location. These people received intensive training on measuring the velocity of water within the rivers, measuring the width and depth of the rivers, determining the discharge rate at a given point, application of treatments to rivers, and safety techniques throughout.

Larviciding Training 3

Figures: volunteers receive riverside training in preparation for upcoming blackfly control activities

Training for all participants from the four different communities was very successful. Communities were enthusiastic about the training and the chance to combat onchocerciasis. As well as causing symptoms such as severe itching, dermatitis, visual impairment and blindness, blackfly biting is a real nuisance in these areas. Within the Meme River basin where this work will be conducted, one person can receive hundreds of blackfly bites every single day. Reducing this biting rate not only reduces the risk of contracting onchocerciasis, but also greatly reduces the irritation of black fly biting. This highlights the importance of this work not only in accelerating progress towards the eventual elimination of onchocerciasis, but also in improving the health and wellbeing of affected communities.

You can read more on our work relating to this intervention and the people behind it below:

Old dog, new tricks? Assessing the potential of integrating focal vector suppression with drug cure to control and eliminate river blindness

Ensuring Onchocerciasis Control is more than just “Skin Deep” by Ending the Neglect of Onchodermatitis

Onchocerciasis in three decades: Through the lens of Prof Samuel Wanji

Onchocerciasis in three decades Part II: Building the next generation of parasitologists

Tackling the Lack of Uniformity in Schistosomiasis Transmission

by Prof. Louis-Albert Tchuem Tchuente, Pamela Bongkiyung, Prof. Russell Stothard

Schistosomiasis or Bilharzia or snail fever as some call it remains one of the neglected tropical diseases (NTDs) that is ravaging many poor people around the world. They thrive in areas with poor sanitation, often inhabited by those with limited to no access to health care. It can cause liver damage or sterility in women. A major symptom is having blood in urine. Controlling this NTD remains a great challenge given that its transmission has no uniformity across countries.

In Africa, the dynamic of transmission is not uniform – it differs from one area to another even in the same country. In Cameroon for example, the transmission is not uniform because what happens in one locality is completely different from others, the dynamic of transmission is different, the snails’ species are different, the interactions between the snails and parasites are different, the re-infection rates also differ. It is important to understand all these aspects and we need more scientists working on this.

Schistosomiasis has different species which vary from Asia to those in Africa. Praziquantel is effective in all six-human species of schistosomiasis. Speaking to Prof. Louis-Albert, we learn that in Cameroon – a West Central African country; there are three species of human schistosomiasis, one specie responsible for urogenital schistosomiasis – Schistosoma haematobium and two responsible for intestinal schistosomiasis – Schistosoma mansoni and Schistosoma guineensis. schistosoma intercalatum is the fourth specie, making a total of four species in Africa. The same drug – Praziquantel is used against all four species and the two-other species prevalent only in Asia – Schistosoma japonicum and Schistosoma mekongi. Both continents use different formulations of Praziquantel.

A major challenge to schisto control and elimination has been controlling human interactions with the water snails. How can African countries extrapolate from the Chinese experience?  According to Prof. Tchuem-Tchuenté, there has to be a change in human behaviour and control of the snail. If there is no snail, there is no schisto. That is why snail control remains key for a move towards elimination.

The Problem with Snail Control 

This was a major control strategy in the 70s but because of the high cost it was abandoned. China has now developed many molluscicides and they have a vast experience on this. With all these new chemicals, it is hoped the cost of snail control will be reduced and that the snail control will make a comeback on the agenda so that it can be integrated to MDA with snail control in other activities of WASH (Water, Sanitation & Hygiene). With this integrated approach, perhaps we can move towards transmission control and elimination.

 People still live in very organic set-ups in schisto endemic areas compared to China where a lot of town planning has been done. How can we successfully implement the aspect of hygiene (WASH) or improve people’s behaviours in controlling schisto?

This is mainly linked to the economic situation in many countries postulates Prof.  Tchuem-Tchuenté. He further advances that to improve hygiene and have health education to modify people’s behaviour, it is necessary that their standards of living increase. To this end, more investment is needed.

“Within the countries, more resources need to be allocated to the control of this disease so that we shift completely from the word ‘control’ to ‘elimination’. If we keep using the word control, you find that we will stay in the same place. If we increase our ambition to elimination, the increase of resources to achieve this goal will be automatic. The country will have no choice but to increase their resources in line with the Sustainable Development Goals”, said Prof. Tchuem-Tchuenté.

The priority intervention for schistosomiasis control is preventive chemotherapy using mass drug administration as the treatment. However, treatment alone is not the solution to interrupt transmission; because reservoirs still exist with the adult population. The current focus is on school-aged children but the parasites exist in people not targeted such as pre-school children and adults. Even if there is high coverage of the school-aged children, lowering transmission and prevalence, there will be a patch of the community with some parasite reservoirs that will maintain the transmission cycle. Recently, there has been attempts to extend treatment to all population age-groups.

P1180668

Photo Courtesy of Dr Suzy Campbell

In addition to treatment, it is very important that the intervention addresses water-contact and hygiene. This explains why WASH activities have been included in control solutions. In the recent WHO NTD report titled ‘Integrating Neglected Tropical Diseases into Global Health and Development’, it was highlighted that providing safe water, sanitation and hygiene (known as WASH) is critical for preventing and providing care for most NTDs. WASH component of the NTD strategy has tended to be neglected relative to its importance. There is also environmental modification because these diseases are linked to the poverty – lack of hygiene. If there is no open defecation into the environment, we can reduce the transmission of schistosomiasis and then you can interrupt it. If open defecation continues and some part of the population still have no access to latrines, defecating or urinating into the environment will not be stopped. With treatment, this population will remain at the risk of re-infection and the disease can be re-introduced and spread anew.

Another area of schistosomiasis research that is garnering more attention these days is female genital Schistosomiasis (FGS) or urogenital schistosomiasis. COUNTDOWN has incorporated some elements of FGS into its research work in Ghana.

Read below more publications with input from COUNTDOWN researchers, engaging in knowledge cross-share with other researchers and programmes on various areas relating to schistosomiasis.

Paediatric and maternal schistosomiasis: shifting the paradigms by Amaya L Bustinduy, J Russell Stothard, Jennifer F Friedman

Female genital schistosomiasis (FGS) in Ogun State, Nigeria: a pilot survey on genital symptoms and clinical findings by U F Ekpo, O M Odeyemi, S O Sam-Wobo, O B Onunkwor, H O Mogaji, A S Oluwole, H O Abdussalam, J R Stothard

COUNTDOWN will be at the upcoming British Society of Parasitology Autumn Symposium, taking place on 28th September 2017. We will be presenting our work from Cameroon highlighting challenges relating to helminthiasis control, how  NTDs are faring amidst changing partnerships, networks and global health policies on the development agenda. There will be a presentation on the evolving needs of vector-borne diseases surveillance across the world. We hope to see you there or engage with you on social media. Tweet us @NTDCOUNTDOWN

 

Putting COUNTDOWN Vector Control Activities in the Spotlight at ISNTD Bites 2017

Dr Louise Hamill and Prof Russell Stothard

Control of mosquito and blackfly vectors of lymphatic filariasis and onchocerciasis is a well-known strategy to augment ongoing disease elimination interventions in sub-Saharan Africa. Similarly, although not strictly considered vectors, control of certain freshwater snails is again attracting considerable public health attention for targeted interventions against schistosomiasis, especially in stubborn hot-spot foci. As part of the annual meeting agenda for the International Society for Neglected Tropical Diseases (ISNTD), the importance of vector control for several NTDs, malaria and arboviruses was thrown into sharp focus at their annual ISNTD bites forum.

Each year the ISNTD has a one-day specific workshop to bring together scientists and public health practitioners to highlight the best of current cutting edge endeavours. Held on the 19th July 2017, at the Institute of Child Health, this meeting featured leading experts from UK institutions, NGOs and commercial partners to discuss vector-control solutions for NTDs and discuss global health actions. The meeting showcased the latest research on vector control as well as providing a practical platform and international network to cement implementation partnerships in vector control.

Key COUNTDOWN activities were featured to highlight our work on snail and blackfly control in South West Cameroon, and mosquito control in Ghana. The morning’s keynote speaker, Professor Gabriella Gibson from the University of Greenwich, set the scene and gave a broad overview of how knowledge of vector behaviour is key to improving control and surveillance for vector-borne NTDs. Examples from research showed how knowledge of tsetse and mosquito host-seeking behaviour led to the implementation of innovative control strategies, highlighting how vital the link between basic research and applied implementation really is. This is particularly important as development of insect traps and control methods are adapted to take advantage of weaknesses in their behaviour, leading to a better knock-down of fly populations.

Highlighting medical malacology and the importance of snail intermediate hosts, Professor Russell Stothard gave the opening talk in the first session; “Taking sensible steps in snail control in the crater lakes of Barombi Kotto and Mbo, Cameroon”. Although snails are technically reservoir hosts for schistosomiasis, they form an essential step in the environmental development of the schistosome to release copious amounts of highly motile cercariae, the infective form to people. Therefore, strategies which target this intermediate snail host can lead to effective environmental disease control and elimination. Sometimes, snail control approaches share much with vector control, especially when chemical molluscicides are used. Prof Stothard gave an overview of the current state of snail control, before revealing the recent epidemiological picture of schistosomiasis in the crater lakes of South West Cameroon. Information derived from mapping of water contact patterns at an individual level, ecological snail studies and community wide schistosomiasis prevalence studies, have helped build this detailed picture. This knowledge forms a solid foundation of evidence upon which snail control and interruption of schistosomiasis transmission can be built. See https://youtu.be/dZhx_u8h1yQ.

After talks from representatives of Merck, Natural History Museum, The London School of Tropical Medicine and Hygiene and Oxitec, Prof Stothard chaired the first panel discussion of the meeting. Key repeat themes of integration, and increased knowledge emerged from these discussions;

The more we know about vectors, the more we know about parasites and host interactions, then weird and wonderful ways to control vectors arise” – Ailie Robinson, London School of Hygiene and Tropical Medicine.

We need to collaborate, learn from each other and use a combination of approaches to beat NTDs” Theresa Maier, Merck

To facilitate interdisciplinary working, COUNTDOWN is breaking down silos between different research areas.” Russell Stothard, COUNTDOWN.

The panel discussion was recorded and can be viewed at https://youtu.be/maitrlR39IU.

These themes were further evident in the workshop on the MENTOR Initiative’s Integrated Vector Management Toolbox. In disaster and low resource areas, this workshop focused on effective, implementation ready strategies to control disease vectors in the most challenging of settings, led by Dr Richard Allan. Participants were encouraged to think outside the box, and to consider how a range of strategies could be tailored to particular settings and implemented at scale.

After lunch, there was a host of exciting talks on numerous topics, including a new drug target for tsetse control, improved performance management for NTD programs, Global Health Networks for Impact, and more fascinating discussion panels. It was also good to see other implementation research coming to the fore in the field of vector-borne NTDs, such as the digital monitoring platform Mango, presented by Greenmash; which can be easily tailored to suit specific project needs and has been used to make sure gender-disaggregated data is collected and readily available. This ties in with COUNTDOWN’s work on gender equity in NTD control.

Reflecting on the day from a COUNTDOWN perspective, it was a great opportunity to keep up to date on vector control and other NTD research at ISNTD Bites, and to make sure COUNTDOWN was a key part of the presentations and the discussions. It was particularly pleasing to note that interdisciplinary working and innovation emerged as some of the key themes in the meeting, areas where COUNTDOWN is actively providing evidence for vector borne-NTDs through implementation research on lymphatic filariasis, onchocerciasis and schistosomiasis. Participating in this meeting has ensured that COUNTDOWN keeps a firm finger on the pulse of NTD implementation research, and that the project has a loud voice at an international forum to advocate for our research and approaches.

You can access the Storify of the event here

When to Give or Not Give Incentives: A Researcher’s Reflection on Incentives in the Field

By Irene Honam Tsey

[Irene is a Research Officer & Institutional Review Board Administrator at the Dodowa Health Research Centre. She is currently a researcher on the COUNTDOWN Project].

As researchers in the field, we are very concerned with ensuring positive community relations and conducting ethical research. But my experiences from the field show how challenging this can be. We are very careful to say “thank you” to study participants for taking part in our study and being respectful of their time. For qualitative research when a participant takes part in a focus group discussion or in-depth interview, we provide an incentive as a token of our appreciation or gratitude.  In my organization, this has tended to come after we have conducted the method so participants do not feel pressure to participate. Yet, a dictionary definition of incentive is “a thing that motivates or encourages someone to do something”.

We were left with mixed feelings after the last COUNTDOWN research trip to the field.  There was a sense of guilt and disappointment following various experiences with “incentives”. Throughout our data collection experiences, timing remained an important factor. We ensure we are in the field at times that suit the community. For example, in fishing and farming communities, we would arrive very early or much later to accommodate their activities. We also try to persuade community members to participate by telling them it will not take very long. However, despite our best efforts delays happen which can be very time consuming and frustrating. If we are undertaking in-depth interviews, we try to ensure we meet participants at the right time. But if we have made a few appointments and participants are not available at the agreed time, this can have an impact on the next appointment. If people have agreed to attend a focus group discussion and then turn up late, this can mean other people who were there on time must wait. In communities where people do not have sufficient food, asking people to wait longer can leave them feeling hungry and frustrated. This frustration can spill into the interview or focus group discussions.

I have noticed a pattern with participants. In the morning participants are often hungry and unhappy to wait. Sometimes we give them snacks. However, it has been agreed those snacks (incentives) be given at the end of the interview. We make sure they are hidden from their sight until the end of a discussion. Yet, once participants get the incentives they tell you “Oh we didn’t know you were going to give us anything, or we would not have pushed you and given our best”.

News of incentives does spread and there have been instances where an entire community troops to the venue of the meeting. They then tell us: “You should have told us you would give something!” One community surprised us when its members asked why survey participants were not given incentives. This is because the norm has always been not to give them incentives.

After one such community, a thought occurred to me: why do we not use advertisements for our recruitments? For example: “12men/women needed for an FGD” and spell out what our study is about, including “incentives”. The advert could also add that admission of participants will be based on first come, first serve basis. Interestingly, advertisement is an ethically acceptable tool for recruiting research participants but we barely talk about it or consider it in the context of our research.

In my seven years at the research centre, it took my involvement on the COUNTDOWN project to realise this.  Advertisement should however be done with the best interest of participants at heart, and in a clear, transparent and accountable manner. After all, they are volunteers and must not be forced or coerced in any way.

Creating Impactful Posters: Hot Tips from the COUNTDOWN Consortium

COUNTDOWN Research Uptake Team & the COUNTDOWN Consortium

As researchers, we all understand that presenting posters is part of our publishing journey and doorway to conference participation. But it is important to take time out and reflect on what makes for a good poster. As part of our 3rd Annual Partners’ Meeting, hosted in Yaoundé, Cameroon a side workshop was held on Friday, 31st March 2017, during which participants reflected on this issue.

To begin the exercise, we had a poster walk and assessed all posters created by team members within the partner countries (Cameroon, Ghana, Liberia and Nigeria) that make-up our consortium. Discussions were had around what people liked and did not enjoy about the posters. What could have made the posters better? Responses to this question, provided these “hot tips” to creating an impactful poster, which we share below in case you find them insightful.

(Poster walk, part of poster writing session – Friday, 31st March 2017)

1) Attractive from a distance/captivating

First impressions make lasting impressions some say. It was identified that it is important for the poster to attract attention from afar. This means the images should be clearly visible and the colour coordination arresting.

2) Catchy Title

Appearances can pull the crowd and gives a good punch, but a captivating title keeps them. Ensure your title is concise, straight to the point and offers a clear message.

3) Poster Structure

We understand that posters vary depending on whether they are scientific or non-scientific. But one thing was unanimously agreed, the structure should be logical to put the policies, process and NTD programmes in context. This helps learning/generalisability across themes; whilst providing a better reading order.

Making the language and concepts easy to grasp across all the disciplines, helps the audience to understand your message. Avoid heavy use of text and keep the poster clean and less busy.

It also helps to reference your work clearly where appropriate in the same format. This should situate your body of work.

Emphasis was given to acknowledging the contributors involved in the work and their institutional affiliations.

4. Use of Images

We know that a picture speaks a thousand words and to ensure Neglected Tropical Diseases (in our context) are kept alive, we use photos from the field.

Not forgetting our ethical duties to ensure the photos are appropriately sources, with consent granted and the authors acknowledged to avoid copyright infringements. (Reference to be included)

5) Branding

It is advisable to adhere to the branding of your institution and/or the project you are working on. Ensure the logos are well-placed and in some cases, funders like to see their logos visibly displayed. Do check with them on their preferences. For COUNTDOWN, we coordinate the branding of our posters through use of colours clearly linked to our materials and project. This presents the uniformity in brand identification for our work in various publications, meetings and conferences.

We always welcome more ideas to improve those outlined above as these are not prescriptive but suggestive.

Please feel free to join the conversation in the comments section.