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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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 published a paper 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

Partner Website: http://countdowncameroon.org/

 

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 partner website: http://countdowncameroon.org/

Follow our activities via our Twitter accounts:

@NTDCOUNTDOWN  @NTDGHCOUNTDOWN  @COUNTDOWNNTDCAM  @COUNTDOWNLR  @COUNTDOWNNG

 

China and Africa Join Forces in fight to Eliminate Schistosomiasis

by Professor Louis-Albert Tchuem Tchuenté, Pamela Bongkiyung, Professor Russell Stothard

In the fight against Neglected Tropical Diseases (NTDs), it has become obvious that learning from other countries’ successes will help many others to control and eliminate these diseases. This is how the China-Africa meeting and collaboration came about in 2012.

Whilst on a visit to the Liverpool School of Tropical Medicine, we caught up with Prof. Louis-Albert Tchuem Tchuenté regarding the China-Africa Meeting on Schistosomiasis Elimination and Training Course on Malacology, organised in Cameroon from the 24 – 28 October 2016.

Prof. Louis-Albert Tchuem-Tchuenté is an NTD Ambassador for Liverpool School of Tropical Medicine. He also heads the Centre for Schistosomiasis & Parasitology in Cameroon and is a professor of parasitology. He lectures at the University of Yaoundé I and is Country Director for the COUNTDOWN project in Cameroon. His expertise in Schistosomiasis and Soil-Transmitted Helminthiasis spans over 30 years. He is Cameroon’s National Coordinator for the control of Schistosomiasis and Intestinal Worms.

Discussions with Prof. Louis-Albert revealed that this China-Africa meeting started a long time ago. Given that China has a vast amount of experience in Schisto control and has successfully eliminated Schisto in many of their provinces; many African countries still struggling with schisto can learn from the Chinese experience. Very few areas have Schisto in China and Schisto has been eliminated as a public health problem there. The highest prevalence is probably 1-2 percent and the plan now is to interrupt the transmission everywhere.

According to Prof. Louis-Albert, China invested a lot on their elimination agenda including treatment, environmental modification and snail control. Most of the schistosomiasis cases in China are zoonotic because they have a lot of animals who act as reservoir hosts. That is why they have invested a lot of money to modify the environment so that the animals do not maintain the parasite life-cycle.

One of the highest components of this is the snail control. Schistosomiasis has two main hosts: vertebrate hosts (including human beings and animals) and the snails. In the transmission, you have both factors that make this happen. The snails are in the water and if you don’t change the environment, the snails remain present. Even if you reduce the transmission, then at some stage it just needs one person who is infected to defecate or urinate into the environment, to rebuild the transmission cycle. That is why it is very important to control the snails. The Chinese have done so successfully and have vast experience in snail control.

Based on this, it became important for African countries to benefit from the Chinese experience. That is why the World Health Organisation(WHO), together with the Chinese government, decided to have this China-Africa cooperation, for the elimination of schistosomiasis in Africa.

This began at the governmental level between China, WHO and the governments in Africa. The agenda was further discussed at the China-Health Ministerial Forum that reviews valuable health development issues. During the 2013 Minister’s Forum held in Beijing, an agreement was reached on this partnership and the initiative approved. This move was necessary to progress granted things take time at the government level. That is why the China team, WHO and African governments decided to start an institutional-based cooperation. This initiative was developed to sustain a China – Africa Cooperation for Schistosomiasis Elimination.

China has several provinces that are endemic for schistosomiasis and it was important to link these provinces to different African countries depending on the relationship they have. That is why in the first phase, ten countries were selected in Africa and were linked with different provinces in China.

The first meeting to set-up the institution-based cooperation was launched in 2015, in Malawi. The meeting launched the initiative and the memorandum of understanding between the partners. The memorandum was signed between different African institutions and Chinese institutions for research. The meeting in Cameroon was the second meeting and it was focused on snail and malacology training. Another component of the training was using mollusciciding to control the snails. The Chinese team and ten countries participated in the meeting in Cameroon.

The rationale for collaboration is clear as it fosters relationships between various actors and allows in-depth knowledge of what works in practice. This knowledge gets refined for better use through creating more cost-effective solutions which are sustainable in the long term for NTD control and elimination.

To continue this cross-sharing of knowledge, COUNTDOWN will be at the upcoming British Society of Parasitology Autumn Symposium taking place on 28th September 2017 taking place at The Linnean Society in London. This session will focus on ‘The Multidisciplinarity of Parasitology: Host-Parasite Evolution and Control in an Ever-Changing World’.