Developing the Multi-disciplinarity of Parasitology, by taking three-steps at a time

COUNTDOWN at the British Society for Parasitology Autumn Symposium, 28th September 2017, with Lucas Cunningham, Louise Hamill, Zikmund Bartoníček, Lisa Reimer, Louis-Albert Tchuem-Tchuenté, David Molyneux, Mark Taylor, Russ Stothard

Parasitology BSP2017

The British Society for Parasitology Autumn Symposium is an annual event which this year took place on the 28th September 2017 in London at The Linnean Society, Burlington House. It was organised by Prof Russ Stothard and Dr Bonnie Webster, entitled “The Multidisciplinarity of Parasitology: Host-parasite evolution and control in an ever-changing world”.

The programme attempted to draw together and develop a multi-facet appraisal of the biology and control of parasites. The symposium has subsequently stimulated a meeting report and a blog on Bug Bitten on  why it is all interconnected in parasitology. Moreover, it was a convenient opportunity to feature some of COUNTDOWN’s stepwise progress in reporting our implementation research as set within the meeting’s three themes.  With just over 25 speakers and with an audience of just over one hundred, The Linnean’s auditorium was at maximum capacity; a clear evidence of the general interest in multi-disciplinarity.

Prof Stothard warmly welcomed everyone present with the simple message that ‘all living species are involved in parasitism, either as parasites or as hosts’. Indeed, this is a universal truth, for parasitism is not just a successful evolutionary strategy but is also part of a broader picture of symbiosis and part of the classification of how organisms, big or small, interact. As a metaphor, parasitism is tremendously powerful, and is regularly used in today’s language to describe significant socio-political events and processes as societies and sometimes nations negatively exploit others.

The modern agenda of parasitological research is therefore exciting, challenging and globally relevant as illustrated by Sir Roy Anderson. In the context of human disease, those parasites that typically play a detrimental role in global health are notorious, for example, malaria and the neglected tropical disease (NTD) collective are very well-known. To help guide the discussions and for convenience sake, the Autumn Symposium was split into three themes to help develop discussions in a stepwise manner.

The ‘ever changing world’ theme placed ongoing parasitological research within the new terminology of the Anthropocene and how mankind is altering global environments which may or may not favour parasitic diseases of medical, veterinary or wildlife importance. Both Prof David Molyneux and Prof Louis-Albert Tchuem-Tchuenté highlighted the challenge of NTD control against the background of planetary health, national control programmes and sustainable development goals. Both schistosomiasis and soil-transmitted helminthiasis are two of the most sensitive NTDs to human modifications of the environment and WASH infrastructures. For example, the building of water impoundment dams and expansion of freshwater irrigation schemes each has the potential to increase the parasite transmission, especially where urbanisation creates local water stress. Control of schistosomiasis is typically a long-haul endeavour and in recognition of his pioneering work on the epidemiology and control of schistosomiasis, David Rollinson was awarded a career medal by the International Federation for Tropical Medicine (IFTM) President, Santiago Mas-Coma.

COUNTDOWN BSP Twitter Blast

The ‘Multidisciplinarity of Parasitology’ encouraged synergies between molecular, ecological and social science components that link parasites and hosts into a more holistic appraisal of parasitism. COUNTDOWN molecular diagnostic work was presented by Lucas Cunningham and Zikmund Bartoníček on soil-transmitted helminthiasis and schistosomiasis as speed posters alongside surveillance and control studies on onchocerciasis control in Cameroon by Louise Hammill together with community engagement activities meshed with locally appropriate vector control strategies.

The ‘host-parasite evolution and control’ recognised that parasites are not simple self-replicating automata and are very able to respond rapidly to interventions waged against them. Lisa Reimer discussed opportunities for xenomonitoring of mosquito populations for surveillance of lymphatic filariasis.  The control of many parasitic diseases is a moving target as it is a dynamic and reactive system. It has been shown in previous control campaigns that a static strategy typically founder, therefore it is important to have in place an ability to monitor the success of any particular intervention and to ensure it is best tailored to the needs of the local populace for which it serves.

During the day, topics of discussion within the three themes often blurred, and they should, as cross-talk grew. Mark Taylor, President of the BSP closed the meeting and indicated that for a successful academic career in parasitology, a portfolio of skills and approaches is needed.  To end symposium, it was very fitting to discuss many aspects of parasite evolution in The Linnean Society where Darwin and Wallace once read their papers, nearly 160 years ago. Over this time much has changed and we hope an important milestone from this meeting will be the production of a special issue of Parasitology which will leave a longer lasting footprint of how parasitism and human health are most intimately intertwined.

Find here a link to the Storify on our participation at the meeting.

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TWITTER:  @NTDCOUNTDOWN  @NTDGHCOUNTDOWN  @COUNTDOWNNTDCAM

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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

 

 

China and Africa Join Forces in fight to Eliminate Schistosomiasis

by Prof Louis-Albert Tchuem Tchuenté, Pamela Bongkiyung, Prof 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’.

 

 

Molecular Tools for Helminth Control and Elimination: Time to Get them Out of the Laboratory and itno Programmes and Policies?

By Corrado Minetti

On my way back from Ghana, where we have been testing the molecular protocols for the detection of filarial parasites in mosquitoes, in the laboratory of Mike Osei-Atweneboana at the Council for Scientific and Industrial Research (CSIR) in Accra; I had some thoughts about how far molecular diagnostics has come but also questioned how can we make it a sustainable reality to assist effectively in disease control and elimination.

corrado-molecular-diagnostics-blog-post-08-11-2016

DNA extraction from pooled mosquitoes for the detection of filarial worms (on the left) and an example of amplification of parasite DNA (+) with the LAMP method (on the right) (Photo: Corrado Minetti)

In order to achieve the goals of the London Declaration on Neglected Tropical Diseases for the effective and sustainable control and long term elimination of Lymphatic Filariasis, onchocerciasis, soil-transmitted helminthiasis and schistosomiasis; the deployment of appropriate diagnostic tools is crucial at every stage of these disease control and elimination programmes from initial mapping to post-elimination surveillance. With the rapidly changing epidemiological scenario of these diseases due to the scaling up of mass drug administration, and the push towards more sustainable and cost-effective multi-disease interventions, the implementation of more sensitive and cost-effective diagnostic tools is a priority well recognized and advocated by the World Health organization.

Molecular diagnostics tools, including (multiplex) real-time polymerase chain reaction and more recent isothermal amplification assays such as loop-mediated isothermal amplification and recombinase polymerase amplification do offer increased sensitivity compared to traditional approaches but they are yet to be used in control and elimination programmes due to their cost and technical requirements. There are various gaps that need to be highlighted and solved in order to allow these approaches to become potentially embedded into disease control programmes & policies, and to inform decision-making.

In order to identify these much-needed gaps, we have recently published a review paper where we compared the features of published real-time PCR and isothermal amplification assays for the detection of Lymphatic Filariasis, onchocerciasis, soil-transmitted helminthiasis and schistosomiasis in clinical and vector/intermediate host samples. Despite the availability of a wide range of assays for both patient diagnosis and xenomonitoring (parasite detection in insect vectors or snails), little or no research has been devoted to estimate the real costs and logistics of implementing these approaches on a wider scale for control and elimination. We highlight the need for a major focus on the implementation aspects of these tools in developing countries, and how barriers for their full adoption in resource-poor settings could be overcome. Key issues are the technical requirements and the related need for capacity building, the abatement of costs and the economic sustainability of molecular screening over time. For example, diagnosing multiple parasites from the same clinical sample can heavily reduce the number of samples that a community may need to provide, resulting in a far less invasive procedure for the communities, as well as reducing significantly the cost of processing. A multi-disease approach to diagnostics will certainly benefit the health system as well, both logistically and economically.

Writing this review paper has been extremely valuable to get a clearer picture of the progress in the field so far and to identify the best and most cost-effective diagnostic approaches for our project. In a broader sense and within the COUNTDOWN research consortium, we hope this review could serve as a starting point of discussion in the NTDs control and elimination community, leading to a more comprehensive analysis of what molecular diagnostics can offer and how we can make sure these tools can finally get out from the laboratory becoming embedded into policy, to strengthen disease control and elimination programmes and the health system itself.

Find more information on COUNTDOWN’s activities visit us here.

COUNTDOWN goes Down Under for ICTMM 2016

By Prof. Russ Stothard, COUNTDOWN

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

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

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

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

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

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

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

By Deborah Sankey, Tim Day and Faye O’Hallaron

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

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

pic-2-with-the-whole-team

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

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

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

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

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

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

Read more

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