Patience and prior knowledge: simple requirements for schistosomiasis control

By Suzy Campbell

Schistosomiasis is challenging and complex whichever way you look at it! From its five-syllable name, to its subtle but extensive disease burden, to its lifecycle in aquatic and mammalian hosts, to its control with preventive chemotherapy and – dare we hope – to its elimination by intersectoral action.

Take for example the schistosomiasis life cycle (see below). It’s so complicated that despite many attempts it was only unravelled 100 years ago, by a parasitological pioneer, Robert T. Leiper. Before this, it was not known that there was more than one type of schistosomiasis. Added to this the snail hosts’ roles were not clear and as a result little could be done to develop control strategies in any meaningful way. This meant that schistosomiasis struck fear in the hearts of many.

There are so many interesting points to emerge from Leiper’s work. He first identified the separate African schistosome species; a contribution of tremendous value to parasitology because one (Schistosoma mansoni) is linked to intestinal schistosomiasis and the other (Schistosoma haematobium) to urogenital schistosomiasis.

Importantly, Leiper also identified and applied simple water safety measures as versatile ways to reduce schistosomiasis transmission. This included simple filtration, water boiling, use of disinfectants and resting water for 24 hours before use. In addition, his clarification of the snail intermediate hosts paved the way for attempts to remove or destroy the snails. These were all practical control strategies which were useful in schistosomiasis control, well in advance of deworming tablets being developed. All that was needed was a little patience and adequate temporary water storage.

Roll forward 100 years. Some things have changed. We are very fortunate in that we have very effective deworming tablets, although they only reach a small portion of the people who need them, and possibly not at the right frequencies to sufficiently control disease.

However, some things have not changed. The subtle morbidity of schistosomiasis is still under-recognised: for example the clinical significance of schistosomiasis in very young children and the importance of female and male genital schistosomiasis. Environmental strategies, such as water safety measures, seem to have largely been forgotten. In particular, our behaviour and perceptions of how water is used should be questioned. Water is not always safe (see below). Until we recall the prior knowledge imparted by the likes of Leiper, schistosomiasis should still strike fear in our hearts. It will not go away.

 

 

This is a village in Cameroon, showing a public tapstand as an improved water supply. But ‘run off’ water flows as an open stream, continuing through the centre of the village. Had a snail intermediate host been residing in this stream, schistosomiasis could have been prevalent despite the improved water source. (Photos: R. Stothard, S. Campbell)

A newly-released Special Issue Review in Parasitology gives an entertaining and thorough biography of Leiper’s contributions to parasitology and the developing field of ‘medical malacology’. This review covers 100 years of the history – and at times controversy – since Leiper’s elucidation of the Schistosoma life cycle and development of practical control strategies. The review goes on to illustrate how Leiper’s contributions still have relevance today, indicating a need for integrated control mechanisms, and introducing the COUNTDOWN research consortium which focuses on implementation research to provide tangible health improvements.

Globally, there is a paradigm shift for schistosomiasis, from morbidity control to transmission control, and eventual elimination as a public health problem. More than ever we are going to need to be guided by integrated and broad-based control strategies. This has been well-recognised by the World Health Organization (WHO), with their recent release of the Water, Sanitation and Hygiene (WASH) for Neglected Tropical Diseases (NTDs) Global Strategy 2015-2020. This calls for intersectoral collaboration to address NTDs by augmenting current control programmes with additional WASH activities.

Progression of a global NTD integration agenda is being increasingly recognised by NTD practitioners, researchers, and other policy makers. International consortia, such as the Schistosomiasis Control Initiative, and now COUNTDOWN, will play a part in driving this agenda. Some of the integration and WASH concepts will be elaborated upon at the annual COR-NTD meeting in November 2016. Work is also progressing within COUNTDOWN on two manuscripts to address aspects of environmental frameworks for schistosomiasis transmission control. The imperative lies with all NTD partners to ensure that Leiper’s work will continue resonating true today.

Find more information on COUNTDOWN’s activities.

Anyone’s disease: ending Lymphatic Filariasis in Ghana

By Adrianna Opong

I used to think Lymphatic Filariasis – also known as elephantiasis – was a curse from the gods and hereditary, until I started working in health research. One day in my new job, I had a chat with Mr Samuel Odoom, the senior technical officer for the Neglected tropical Diseases Programme in the Ghana health service. He explained this to me:

Lymphatic Filariasis (LF) or elephantiasis is caused by infection from the filarial worm (a thread-like worm), which is transmitted from human to human via the female mosquito. The mosquito feeds on the blood of an infected person and then when it later bites an uninfected person, the worms are able to infect a new person. The filarial worms are in their third stage of development when they penetrate the bite wound of the uninfected person. They later become adults that live in the human’s lymphatic systems. This is a problem because the lymphatic system maintains the body’s fluid balance and also fights infections.

Mr Odoom told me that although the parasites damage the lymphatic system, most LF cases do not show clinical symptoms. However, a small proportion of infected people develop complications in the acute stages. It leads to lymphedema which is fluid collection and swelling of some parts of the body such as legs, arms, breast, genitalia. Affected people also have more bacterial infections in the lymph and skin and experience hardening and thickening of the skin. Hydrocele or swelling of the scrotum is very common in men. The complications of LF such as swelling of the legs and arms can only be managed, not cured.

Lymphedema can be prevented from getting worse by:

• Carefully wash the affected/swollen areas thoroughly with soap and clean water every day
• Wash in-between folds/toes with a piece of cloth
• Dry the affected/swollen area with a clean piece of cloth
• Disinfect any wounds and sores, use antibiotic (antifungal or anti bacterial) ointment/cream if necessary
• Elevate and exercise the affected/swollen areas to move the fluid and improve the lymph flow.

Hydrocele can only be corrected through surgery. In 2002 Samuel Odoom, together with NTDP, set up a lymphedema clinic to manage the burden of LF complications. Mr Odoom said, “ NTDP trained a consultant who goes around the regions in the country and some other African countries to train physicians on how to do hydrocele surgeries”. Now in Ghana, there are 12 health facilities that conduct hydrocele surgeries.

Prevention and control

 LF is endemic in nine out of the ten regions in Ghana, so it is a serious health issue. It can of course be prevented by avoiding mosquito bites. Mosquitoes that carry the filarial worms usually bite between 5pm to 5am. The advice for people in endemic communities is to sleep under a treated mosquito net, use mosquito repellent on exposed skin and wear clothes that cover all the body. Yet for people in communities, preventing mosquito bites is not always possible.

In endemic communities, LF can be controlled or even eliminated with Mass Drug Administration of a single drug (ivermectin) through the Preventive Chemotherapy programme. The NTDP introduced the Mass Drug Administration in the year 2000, but only in a few districts. Today the programme has been able to cover all endemic districts in Ghana. But there are still some communities with a high prevalence of LF and some populations are still hard to reach.

It is with this in mind, that the COUNTDOWN research consortium is putting effort into investigating cost-effective, scale-up and sustainable solutions. In Ghana, the research is exploring how different factors within the health system hinder the scale up of the MDA and aims to integrate additional strategies to complement the MDAs in the control and elimination of LF by 2020.

I have now spent a year working with COUNTDOWN, embedded with the NTDP. I have come to the realisation that LF can affect anybody living in an endemic community, who does not or cannot protect themselves from mosquito bites. It is also very clear that we need to put more resources and research into finding sustainable solutions so that all communities in Ghana will be free from LF now and in the future.

Control of schistosomiasis in Cameroon: searching for evidence

By Russell Stothard and Louis-Albert Tchuem-Tchuenté

Schistosomiasis, also known as Bilharzia, is a disease that often doesn’t show any symptoms for several months or even years. Worms that cause schistosomiasis live in fresh water. Having been infected with these parasites that burrow through the skin, it is only after some time that people might get a high temperature, cough, diarrhoea and then progressive damage to the internal organs such as the bladder and bowel. Symptoms might disappear after a while too, but the parasite stays in the body causing serious long-term ill health, for example, infertility in women. The parasite also continues to be transmitted back into the environment, spreading further.

This neglected tropical disease needs more attention. De-worming tablets can make all the difference, and COUNTDOWN’s second integrated complementary strategy theme (ICST-2) is going to research the effectiveness and acceptability of expanded access to this deworming medication in Cameroon and Ghana.

For example, Cameroon only provides annual praziquantel (PZQ) treatment by mass drug administration to school-aged children. It’s possible to buy PZQ over the counter in local pharmacies, but the availability of this drug within the general health system is poor. Pre-school aged children and women of reproductive age are vulnerable here because without regular treatment they will continue to suffer. The parasites continue to be fed back into the environment, via stool or urine, first infecting snails then others in the community.

Over the coming years, COUNTDOWN will seek to foster the scale-up and wider access of PZQ treatment to people who are not currently targeted within national control programmes. We will also assess acceptability and find out it is both sustainable and cost-effective at the community level. In addition, expanded access to PZQ treatment could also accelerate progress towards the reduction of schistosomiasis transmission in the environment.

Water, sanitation and hygiene

The parasites that cause schistsomiasis – also known as schistosomes – live inside freshwater snails. Schistosomes are able to multiply themselves to enormous numbers each day and although the stages are short lived – they typically dying within 24 hours – a new wave of parasites are released the next day from infected snails.

While this is well known to many parasitologists, its importance and significance has been largely ignored within the water, sanitation and hygiene (WASH) community and agenda. Put simply, any aquatic habitat that people use and that contains infected freshwater snails is a high-risk location for schistosomiasis. Some very simple water hygiene measures – if used daily – can make the water safe, yet they remain out of reach for millions in rural Africa.

Furthermore, any efforts to make water safe needs to be tailored specifically to each demographic group in the population, as they each have different requirements and abilities to accept change. Mothers, for example, collect water for their domestic chores and typically bathe their children with it.

A child washing at Barombi Kotto

Eliminating schistosomiasis

How can we eliminate schistosomiasis? It’s a big question. The influential and heavily cited paper by Rollinson et al. (in which we both played a part) first outlined the need to develop a guiding framework for the surveillance of schistosomiasis in the environment. This has become ever more pressing and an issue for even closer consideration within the European health sector, given the recent focus of urogenital transmission on Corsica. Developing a strategic framework is especially important in the context of the WHO 2020 Roadmap targets. Here, certification of elimination of transmission will be needed or any reasons for its failure will need to be explored.

It is obvious that PZQ treatment should be expanded to all groups at risk of infection, as highlighted by the World Health Organization. It is less popular, however, to justify its use in reducing schistosome transmission. This year, several mathematical modelling studies suggest we should no longer overlook the significant environmental transmission of schistosomiasis from groups outside school-aged children. Moreover, as we slowly gain control of the disease, the relative roles each group plays in sustaining local transmission will also be dynamic.

With this in mind, we are looking for examples in Cameroon where COUNTDOWN activities are able to develop new coordinated intersectoral actions. This will provide a more holistic vision of how to expand access to treatment for people who need it, alongside environmental studies that measure reductions in transmission.

Cameroon: searching for evidence

In Cameroon, the communities at Barombi are at greatest risk of urogenital schistosomiasis, largely because of the presence of a key species of Bulinus, the genus of freshwater snail that are permissive hosts for Schistosoma haematobium in Africa. It is the absence of other snail species at Barombi that allows us to focus on urogenital schistosomiasis alone.

A snail distribution map of Barombi Kotto with species indicated in green and blue

Our recent field surveys undertaken in June 2016 in the crater lakes of Barombi Mbo and Barombi Kotto are starting to reveal the need to further develop a guiding strategic framework. It would measure schistosome infection alongside local environmental transmission. The sampling framework is appropriate and implementable with resources typically at hand in the sub-Saharan African region.

Since urogenital schistosomiasis also has links with female health, we can better research reasons why this parasite, which is transmitted in urine and not stool, remains a considerable health burden at Barombi Kotto and Barombi Mbo. Significant investment at Barombi Mbo has meant the building of safe water sources with piped water available to all households. However, we need to assess how current WASH interventions can be further refined to dampen local parasite transmission. For example, social science investigations could reveal why some people are unable to benefit from these interventions or continue to use unsafe water.

The two locations of Barombi are important areas for multidisciplinary studies. Here, our research will test the effectiveness and acceptability of expanded access of de-worming PZQ treatment and record any changes in environmental transmission. The research also examines biannual treatment schedules, as a way to promote equity of treatment, but also to accelerate reduction in transmission and elimination. Evidence is needed to support elimination, as there is currently no formalised WHO framework to do this. While guidelines for lymphatic filariasis with transmission assessment surveys (TAS) exist, there are none for schistosomiasis. Both national and international policies are lagging behind in this area. It is a great opportunity for our COUNTDOWN research to make an impact.

Our initial results will be presented on the 14^th and 15^th June at the meeting Global Schistosomiasis Alliance in China, so please watch this space!

What does it take to control neglected tropical diseases? Part Three: Eliminating Lymphatic filariasis

By Linda Waldman

Lymphatic filariasis or LF is, like Guinea worm, caused by a worm and transmitted by mosquitoes. The disease leads to massive swelling of the legs, other limbs, breasts, women’s vulva and men’s genitals, hence its common name elephantiasis. It causes considerable pain, severe disability, stigma and mental distress. Add financial loss to this and the disease contributes significantly to poor quality of life and poverty.

Here’s an example of how it can affect someone’s life. Kofi, a strong man, living and working in Obom is in the prime of his life and hopes to have many more children with his young wife. As a child, Kofi was bitten by mosquitoes carrying the parasite. The worms made their way to Kofi’s lymphatic system where they grew to adulthood and survived – undetected – for about eight years. During this time, they released larvae that began to circulate in Kofi’s blood, and eventually disrupted his immune system. All evidence of this damage to his lymphatic system remained hidden for many years.

Now, many years later, he experiences scrotal swelling and other signs of lymphoedema. Sitting outside his home, unable to work, Kofi continues to be bitten by mosquitoes. These mosquitoes then, in turn, suck blood from other villagers who live in Obom. As they do so, mature larvae are transferred from the mosquito and unnoticed make their way into the villagers’ bodies.

Government and community efforts

LF is endemic in 74 regions in Ghana. Ghana’s strategy for dealing with LF has focused on control and more recently elimination to ensure that the transmission of disease is stopped in particular areas. It also focuses on integrated programmes, which include treatment through mass drug administration (MDA).

The government started tackling LF in 2001 through an elimination programme. It involved MDA, using a combination of Invermectin and Albendazole/Mebendazole. These drugs have the advantage of simultaneously addressing other neglected tropical diseases such as Onchocerciasis. The programme also trained community health workers, teachers, environmental officers and others, conducted health promotion through mass and print media and held advocacy meetings to increase awareness and provide support.

By 2007-2008 some communities had reduced prevalence to less than 1%. Much of the work was done by Community Drug Distributors like Stephen Sarkodie. Stephen himself was actively involved as a key volunteer administering drugs in the elimination programme. He used charts and guidelines to determine dosages: “We measure people’s height with a colour marked stick to get the dosage… Green, red, blue provide categories for different height/dosage. If someone is categorised as blue, he or she receives a certain number of Ivermectin tablets. Everybody takes one tablet of Albendazole.”

As well as ensuring that all community residents received medication to halt transmission, Stephen and other community health workers would seek out people inflicted with LF and who may, as a result of the stigma, be isolated in their homes and be reluctant to appear in public. “We ask them to come to the clinic. We come across many men and women and we advise them to seek treatment. LF can’t be cured, so people have to know how to manage it.”

Long-term work

Human beings form the only natural reservoir for the worms, so eliminating it from humans could bring an end to LF. However, the drugs provided through MDA have only a limited effect on adult worms. They decrease the larvae density in the bloodstream and curb the parasites’ ability to be picked up by mosquitoes and transferred to other human hosts. It takes between four and six years of repeated drug administration to interrupt the transmission cycle.

This does not help people like Kofi who have already been infected with LF and have the severe form of the disease. The disease can, to a certain extent, be managed through a combination of skin care, hygiene, exercise and elevation of affected limbs and further progression can be prevented. In some extreme cases, surgical removal of excess tissue is a possibility, but this is not a World Health Organization recommendation. However, as Stephen points out, people are also sometimes too afraid of travelling long distances and being isolated in alien hospital environments, far from their family and friends, to undergo this operation.

Challenges along the way

Stephen’s work – and the success of the MDA program – was threatened by the fact that many of Obom’s residents did not wish to take the drugs. Ironically, given the effects of LF, men worried that they would become impotent and would die from the medication. Indeed, some people did suffer adverse reactions to the treatment, particularly headaches, stomach aches and itchy skin.

Stephen and his co-volunteers had to develop their own communication strategy, in parallel with the government’s official media broadcasts. They advised villagers of the side effects, recommending that anyone experiencing these symptoms should come to the clinic where they would receive free treatment from the Disease Control Officer. They were slowly able to convince people of the value of medication. “Now when we go to the village, people take the medication. Now if we go to a village, and people are not home, they later will come and find me at my home to receive the medication.”

Eliminating neglected tropical diseases

The good news is that transmission has been broken for LF in Obom. No longer do people contract this debilitating disease through mosquito bites. Today, only a couple of residents still live with the devastating swellings of LF and their conditions are carefully managed.

So, what does it take to eliminate neglected tropical diseases in Ghana? It takes commitment from a wide range of development partners – donors, NGOs, religious groups, local leaders, missions, private companies, community organisations, local volunteers and others – and an approach which focuses on control, then elimination and finally eradication. It takes many years of dedicated effort, communication and persuasion.

It takes constant vigilance, as Stephen explains, to ensure that these diseases don’t get re-introduced as people travel to other areas in Ghana and elsewhere. But most of all, it takes people like Stephen. People who derive their ‘most satisfaction’ from hearing that they have eradicated Guinea worm, who selflessly serve their communities volunteering their knowledge, time and skills.

As Stephen says ‘I became used to the work, it was a service to my people. From today, to tomorrow, then the next day, I go to the villages. There is no village in the area where people do not know me’.

Thank you Stephen for your tremendous gift to Ghana and for the legacy you have left the people of Obom.

Stephen Sarkodie

What does it take to control neglected tropical diseases? Part Two: Controlling Buruli Ulcer

         By Linda Waldman

Picture the scene: Kwame, a young boy living in swampy Obom, appears to be fine, despite his swollen arm. The swelling is painless, so he and his family do not do anything about it. Within a short period, an ulcer develops; the skin at the edges is rotting and the wound seeps pus and smells putrid.

Still Kwame does not complain and his family does nothing, in part because he and his family live in a remote rural area far from a clinic; in part because he is not in any pain, in part because there is no money for transport to a clinic or for treatment; and, in part, because now there is a stigma attached to his wound he prefers to hide inside his home. Left without treatment, massive ulcers form on Kwame’s legs, with the bone being severely affected. He is left with severe scarring and a disability which inhibits his walking.

This is the effect of Buruli Ulcer.

“To be a Community Drug Distributer and to do the job of eradicating disease,” says Mr Stephen Sarkodie, “One must take time, have heart and be restless.” Stephen’s restlessness extended beyond the eradication of Guinea worm and turned to Buruli Ulcer.

Buruli Ulcer, which is caused by bacteria, is not yet eradicated in Ghana. Rather it has the status of a ‘controlled’ disease. Controlling refers to making sure that Buruli Ulcer no longer constitutes a major public health burden. Deliberate efforts are in place to ensure that the disease remains at an acceptable level, and continued interventions are required to ensure that this level is maintained.

While Buruli Ulcer seldom leads to death, disability is high. The disease progresses rapidly, but because it has immunosuppressive properties, there is no pain or fever.   There is however loss of physical health, loss of physical movement, loss of economic productivity and loss of respect or social status.

Scientists and researchers do not know how you contract Buruli ulcer and, as a result, there is no way to prevent the disease. Early case detection and treatment with antibiotics is thus the best treatment. However, for reasons described above, this seldom happens.

Political and media pressure to address Buruli Ulcer began in 1992 and, as a result, Ghana introduced a passive surveillance system for Buruli Ulcer the following year. Over the next five to six years, about 1200 cases were reported. Case searching for Buruli Ulcer began in 1999 and covered the whole of Ghana, seeking to investigate every single known village and community. Trained national facilitators in turn trained regional teams of local people who undertook the case search. Stephen Sekodie was part of this case reporting.

As a Community Drug Distributer, Stephen was responsible for 35 villages and he began with case searching and identifying areas where the bacteria were present. Three days a week, Stephen would leave his home and walk for many hours to a neighbouring village. Like other community health workers, Stephen relied on a WHO-produced pictorial document which demonstrated the different stages of Buruli ulcer. This he showed to the villagers, asking about similar cases in the community. Because there were no treatment centres in 1999, Stephen carried a treatment box with him.

“We didn’t know where the bacteria was coming from, but we saw that the Densu River basin villages were worse. We thought it was possibly coming from the river and so we taught people how to keep their environment clean and to boil their water. We also taught them to watch out for strange boils on their skin, and, if they saw one, not to delay and to go to the clinic.”

The case search showed that Buruli Ulcer had been grossly underreported, that the disease was more widespread than conventional wisdom had allowed for, and that far more people suffered from these ulcers than had been previously believed.

The case searching revealed a prevalence of 87.7 per 100,000 people. In 2008, the Obom Health Centre (situated in Obom, a suburb of Amasaman, in the Ga West municipality) recorded 41 cases. In 2009, there were 27 cases.

Today, Stephen claims, only 1 in a hundred people in the area around Obom Health Centre experience Buruli Ulcer disease. Stephen and his fellow Community Drug Distributers have helped control it through a combination of awareness, treatment and personal hygiene.

Today, few people suffer from Buruli Ulcer and those who do should know to access treatment quickly. In 2014, only 21 cases were diagnosed. Stephen’s work is his “service to my people, to my community”. His role as a community health worker undertaking the vital legwork to help Ghana control Buruli Ulcer is, however, just another step in the work of eradicating NTDs.

What does it take to eradicate neglected tropical diseases?

By Linda Waldman, Institute of Development Studies, UK

The term Neglected Tropical Diseases, or NTDs, refers to a diverse collection of tropical infections that primarily affect people living in poverty, sometimes in high-income countries, but more frequently in low- and middle-income countries. They are caused by a variety of pathogens, including viruses, bacteria, protozoa and helminths (or worms). Not many neglected tropical diseases (NTD) can be successfully eliminated. Strategies to tackle these diseases include, in addition to elimination, seeking to control NTDs. Control does not eradicate the disease, but it does ensure that it no longer constitutes a major public health burden.

Another strategy is to eliminate the disease in a particular part of the country, rather than seeking country-wide eradication. This involves reducing disease transmission to less than 1% within the specific area and managing the area to prevent re-infection. Ghana’s management of NTDs has involved all three strategies: eradication, control and elimination. Development partners such as donors, NGOs, religious groups, local leaders, missions, private companies, community organisations, local volunteers and others all play crucial roles in tackling NTDs.

This blog, and the following two posts, explore Ghana’s experiences of dealing with three NTDs through the eyes of Mr Stephen Sarkodie, a voluntary Community Drug Distributer who lives at Obo, in the Ga West South sub municipal, close to Accra. He has helped Ghana to tackle NTDs for the past 27 years. Part one looks at the eradication of Guinea worm, Part Two at the control of Buruli Ulcer and Part Three at the elimination of Lymphatic filariasis.

Part One: Eradicating Guinea Worm

In 2014, the World Health Organization confirmed that Ghana had successfully eradicated Guinea worm disease. Guinea worm is one Neglected Tropical Disease (NTD) that no longer plagues Ghana. The disease is caused by a parasitic worm and is transmitted through drinking contaminated water. Like all other NTDs, it is endemic, disproportionately affects rural communities who live in poverty and causes significant health and economic burdens. Neglected diseases seldom kill people, but they can be severely disabling.

Imagine the scene: Adwoa a perfectly healthy woman, drinks water from a pond close by to her home. About a year later, she discovers a painful, burning blister on her ankle. This hinders her work, her ability to fetch water, cook or continue daily activities. To ease the burning, Kudjoe soaks her foot in water. While doing so, the worm protrudes from the blister, releases larvae into the water and then retreats back into her leg. The larvae are consumed by tiny water fleas, and these in turn, are swallowed by other oblivious members of Kudjoe’s community who drink from the same water sources.

To achieve certification of national level eradication, Ghana had to have zero reported cases of Guinea worm transmission, and needed to confirm this through active surveillance and investigation for at least three years. The challenges associated with doing this must, at one point in time, have appeared insurmountable. All these challenges are generic to many NTDs, as colleagues reminded us in the recent COUNTDOWN workshop in Accra.

First, these diseases are neglected; neglected by academics, neglected by donors, neglected by Ministers of Finance, neglected by health providers, and neglected by the international community. Second, national health services are constrained by funding and staff are often overworked, underpaid and inadequately trained. Third, in-country travel is difficult – or to be more accurate – very, very DIFFICULT and easily underestimated. Fourth, language is an issue. Although English is Ghana’s official language, it is not always spoken in remote rural communities where over 80 local languages are used. This too is underestimated.

Given these challenges, eradicating Guinea worm involved the work of many different actors. At international level, the World Health Assembly’s Declaration in 1986 encouraged global eradication of the disease. At national level, Ghana, having recorded 180,000 Guinea worm cases in 1988, established the Ghana Guinea Worm Eradication Program (GGWEP).

Close to the Obom Health Centre, is the home of Mr Stephen Sarkodie, a farmer in Obom and a volunteer Community Drug Distributor. His story reveals the challenges of dealing with NTDs in Ghana. Stephen became a community health worker in 1989, just as the Guinea worm eradication programme was beginning. He explains: “I was living in the community and I could see the people being infected. They can’t work or do anything for themselves. I feel (sic) for them, so I gave myself up to volunteering”.

Findings were reported to the District Health Director who then needed to ensure that the water source was treated with ABATE, a chemical that kills the Guinea work larvae.   When GGWEP was initiated in 1989, it was hoped that the worm would be eradicated by March 2007.

But eradicating a NTD like Guinea worm was never going to be easy. In 1999-2000, frustrated by the lack of progress in tackling Guinea worm, the Government created an Inter-Agency Co-ordinating Committee, and emphasised the need to provide potable water. Development partners were further mobilised to support the eradication programme in 2004.

In 2005, a major Guinea worm outbreak occurred in Ghana. In 2006, despite the work of community health workers like Stephen Sarkodie, Guinea worm was still endemic and Ghana was ranked as the world’s second worst country for the disease. Despite all the work, problems persisted. Stephen explained that some communities refused treated water. Village elders were worried that applying the ABATE would weaken the ancestral spirits and, as they had been using the water for years, didn’t make the link between the painful blisters and the water.

However, there was progress. From the mid-2000s, the numbers of Guinea worm cases began to decline: in 2008, 501 cases were reported; in 2009, 242 cases and, in the first half of 2010, only eight cases. On 11^th May 2010, the last Guinea worm case was diagnosed in Ghana. Then came the period of waiting, of hoping and of investigating, making sure that Ghana could ensure zero reporting of Guinea worm transmission for three years. Guinea worm was declared eradicated in 2014 in Ghana and was, says Stephen, “Our first success”.

Throughout the time that he was dealing with Guinea worm, Stephen was also working hard to tackle other NTDs, which we will report on in our next blog post soon.

Launch of Expanded Special Project for Elimination of NTDs (ESPEN), Geneva, 23rd May 2016

By Russ Stothard and Sally Theobald, COUNTDOWN consortium

This week the 69^th World Health Assembly (WHA) is taking place in Geneva at the Palais des Nations, where a variety of satellite meetings are also held to discuss and define the global health agenda.

The regional office of WHO in sub-Saharan Africa – WHO-AFRO – has launched a new initiative entitled ESPEN – Expanded Special Project for Elimination of NTDs. ESPEN brings fresh focus and impetus to act on the elimination of five key neglected tropical diseases (NTDs): trachoma, lymphatic filariasis, onchocerciasis, soil-transmitted helminthiasis and schistosomiasis.

Several other diseases are currently grouped within NTDs, however it is these ‘big five’ that are primarily controlled in sub-Saharan Africa with preventive chemotherapy. The backbone of preventive chemotherapy is to provide large-scale access by routine Mass-Drug Administration (MDA) of donated medications to impoverished and often marginalised populations living with, or at risk from, these NTDs.

Such MDA campaigns are endorsed by WHA resolution 66.12 and typically springboard from the various commitments and pledges made at the London Declaration on NTDs to support national control programmes. Collectively these programmes have WHO 2020 disease control targets firmly in sight with progress also to be tracked within the sustainable development goals (SDGs).

Progress in each country is tracked by national treatment coverage statistics and the use of the NTD scorecard, now in its fourth iteration. The scorecard is important because it grades progress within each disease through a traffic light system. Some disease programmes are doing well and others less so; there are barriers and bottlenecks to operationalising control for each NTD at scale. It is against this landscape, for example, that COUNTDOWN is currently conducting its multidisciplinary implementation research in Liberia, Ghana, Nigeria and Cameroon.

Common to all diseases, nonetheless, is raising and sustaining sufficient domestic funding and resources to implement control at national levels. With a three-word slogan of ‘ownership, transparency and efficiency’, ESPEN hopes to provide technical assistance, fundraising support and collaboration between country NTD programmes and partners. This is to ensure preventive chemotherapy is both cost-effective and eminently affordable for each nation. A significant achievement of ESPEN has been raising just under 10 million USD from USAID, Bill & Melinda Gates Foundation, Endfund and The Kuwait Fund for Arab Economic Development to get progress started.

The launch was packed with a variety of distinguished international and national guests with standing room only. The health stakeholders ranged from Dr Margret Chan, the WHO Director General overseeing the ESPEN launch, to several Ministers of Health, including Professor Isaac Folorunsho Adewole from Nigeria; each participated in panel-led and open-discussions facilitated by Richard Horton, Editor of the Lancet. A short video recently filmed in Accra, Ghana also helped to frame ESPEN’s cause with interviews of Drs Julie Jacobson, Johnny Gyapong and Benido Impeuma.

The WHO-AFRO Regional Director, Dr Matshidiso Moeti outlined why ESPEN was needed to frame the opinions of other panel members. “So what is new about ESPEN?” asked Richard Horton, in his worldly-wise manner having seen other initiatives come and go with success and failure in equal measure. It is true that since the African Programme for Onchoceriasis Control (APOC) came to an end last year and there is now no major NTD programme owned and led by WHO-AFRO.

Bringing together these five NTDs under one banner is a shrewd first step towards the promotion of both cost-effectiveness and health systems strengthening. For example, it encourages programmes to share funds and reduce tensions when donor supply chains are limited. Dr Mwele Malacela, Chair of the Regional Programme Review Group, also pointed out the in-kind resources available in country such as community health workers, ready to synergise with outside support.

Perhaps less new but equally important is to highlight that preventive chemotherapy is still one of the best buys in public health, as emphasized Dr Ariel Pablos-Mendez, from USAID and Ken Gustavsen, from Merck Foundation. Simply put, the investment in NTDs in WHO-AFRO will bring forward many future health dividends, especially in populations unable to afford out-of-pocket health expenditure. Indeed, it is their right to access any intervention which forms part of the basic universal health care package as Dr Dirk Engels, WHO-Geneva, pointed out with special reference to the SDGs.

The meeting was formally closed by remarks from Dr Joseph Cabore who coined the three word slogan of ‘ownership, transparency and efficiency’.

Both Sally and I felt very privileged to attend today along with LSTM colleagues, Joan Fahy and Laura Corbridge, who played significant roles to facilitate the smooth running of this meeting behind the scenes. We also welcomed the opportunity to discuss our COUNTDOWN research with our country partners attending today and our WHO colleagues.

We look forward to supporting ESPEN from within COUNTDOWN to ensure that progress can accelerate towards WHO 2020 targets and beyond.

Find further information online about ESPEN and #beatNTDs on Twitter.

Positive experiences in multisectoral engagement for NTDs – Ghana, Cameroon, Liberia, and Nigeria

By Suzy Campbell, Corrado Minetti, Margaret Gyapong (on behalf of group B)

Across the health continuum it is vitally important to engage with all relevant stakeholders from the outset. Since the inception of COUNTDOWN this has been a priority, which culminated in exemplary examples of multi-stakeholder engagement being presented at our annual partner meeting. Our first year has focussed on defining key NTD evidence gaps and developing workplans to address these. Liaising with our stakeholders at all levels has been a critical factor in ensuring that the work which we intend to achieve within COUNTDOWN is politically and practically meaningful across all components of the NTD community. Hearing from each partner country in turn, there were some amazing similarities in approaches to multi-sectoral engagement, with the following highlights:

• All countries have invested in inception meetings and stakeholder mapping to ensure that they are reaching all relevant stakeholders. Evidence gaps and subsequent research questions have then been defined in partnership with them
• Our partner countries are engaging with many government ministries, including, amongst others, departments of local government, education, finance, water resources, and agriculture
• A strong emphasis has also been placed on involvement with NTD Partners, Academic Institutions, funding agencies and Non-Government organisations at country level. These include but are not limited to World Health Organization, END, Sightsavers, the Partnership for Child Development, the Taskforce for Global Health, the media, national NTD control programmes, community drug distributors and health workers, and NTD partners in academic institutions
• Various stakeholder meetings, scientific meetings, media events, deworming campaigns and official launches have been organised by COUNTDOWN partners, providing a strong platform upon which partners will be able to disseminate our messages throughout the NTD community.

The highlight of our recently ended Partners meeting in Accra (20^th-22^nd April 2016) was the rare five minute opportunity to engage with the WHO African Regional Program Review Group for Neglected Tropical Disease, key stakeholder for COUNTDOWN.

This demonstrates the hard work that each of the COUNTDOWN countries has done, with the full spectrum from local communities, to district, national and then international levels represented, and laterally, a broad primary base beyond the traditional health sector. With this engagement from the outset, our vision of achieving a holistic integrated approach to NTD implementation research is already being realised. We look forward to continuing to work with our stakeholders, and capitalising on this momentum, as we progress with our implementation research and uptake.

 

Photo: Dr Margaret Gyapong leading an energetic discussion with COUNTDOWN partners about the importance of multi-stakeholder engagement!

Learning from the Neglected Tropical Disease NGDO Network

By Suzy Campbell,

Over the past few years it has been exciting to see momentum building to address integration and health systems strengthening beyond the traditional vertical approaches of funding and delivery of single disease strategies. A recent supplementary issue of International Health, a journal of the Royal Society of Tropical Medicine and Hygiene has a strong focus on health systems strengthening, and should be essential reading for anyone with interest in addressing NTDs.

The supplement has been largely coordinated by the Neglected Tropical Disease (NTD) Non-governmental Development Organisations Network (NNN), and is refreshingly dedicated to partnering across the entire sector to continue addressing the challenging issues pertaining to prevention, treatment and management of NTDs.

Intersectoral and transdisciplinary cooperation and learning

Of particular note is the article by Hopkins who describes the new project framework developed by the World Health Organization (WHO) Africa Region to replace the African Programme for Onchocerciasis Control (APOC). APOC ceased in 2015 yet has been widely recognised for its contributions towards health systems strengthening, as it has enabled infrastructure development and mobilisation via community health workers, thereby facilitating access to chemotherapeutic drugs by people who have otherwise been truly unable to reach them. The new framework, the Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN), will be introduced throughout 2016 and will extend beyond onchocerciasis to coordinate all NTD activities in the African region. Together with the current focus on intersectoral, transdisciplinary cooperation and learning, ESPEN will provide an unprecedented opportunity to drive impetus for integrated health system strengthening activities. This does set a new support structure for integrated NTD control and elimination, and we look forward to its further development with great interest.

NTD morbidity

Much valuable work has been done over the last 15 years to map various NTDs and enable resource prioritisation via chemotherapy. Yet the sheer scale, and varying morbidity, of NTDs means that, in addition to the important prevalence and treatment coverage statistics, it is equally important to capture data on additional morbidity measures. Having sound knowledge of the disease burden from these diseases does facilitate advocacy for their control. There are several articles in the supplement that highlight the importance of capturing data on NTD morbidity, including the importance and measurement of coverage statistics, and a research agenda for the NNN to identify common indicators that can be shared across NTDs.

Integration

Integration, as it is directly influenced by NTD control and elimination strategies, needs to be strengthened with inclusion of structural system enhancements delivered as part of the universal health coverage agenda. For many NTDs, this does require consideration beyond chemotherapy to include “multi-component integration”. However, it is clearly acknowledged that more evidence is required, that it is expensive and logistically challenging, and that it requires strong cross-sectoral collaboration. In the supplement, Waite et al. provide a comprehensive review of the progress that has been achieved in, and opportunities to prioritise, integrating water, sanitation and hygiene (WASH) with NTD programmes. Integrated WASH and NTD control contributes simultaneously to several Sustainable Development Goals and every opportunity needs to be taken to further promulgate this.

What’s next?

The international health community does need to determine what a truly integrated universal health coverage agenda should encompass. The NNN has contributed heavily to driving this agenda, as have other organisations. Looking beyond NTDs, this is in direct alignment with macro-political strategies as set by the World Bank, the WHO and other parties. By necessity, a universal health coverage agenda must be broader than NTDs, however NTDs are a major part of this (having been referred to by the WHO as a “litmus test”). As NTD practitioners and researchers we therefore have a major opportunity to collectively share knowledge and in so doing propose critical requirements of integrated health care.

We at COUNTDOWN are delighted to see this supplement published and are wholehearted in our support of its messages.

 

Practical training in molecular DNA diagnostics

Russ Stothard, Jaco Verweij, Lucas Cunningham and Mike Osei-Atweneboana

Developing our research theme on molecular diagnostics for soil-transmitted helminthiasis and schistosomiasis, COUNTDOWN organised a 1-week practical training session on real-time PCR assays within the laboratory of Mike Osei-Atweneboana.

The course was attended by 16 researchers from the Noguchi Memorial Institute for Medical Research (NMIMR), Ghana Health Services (GHS) and Council for Scientific and Industrial Research (CSIR), which aimed to consolidate and develop their existing experience and skills. The course started on the afternoon of 14^th March with formal introductions from Drs Mike Osei-Atweneboana, Nana Biritwum and Margaret Gyapong, then overview lectures by Russ and Jaco on the importance of molecular diagnostics and its application within the COUNTDOWN consortium.

The week was divided into daily lectures with ample time at-the-bench for hands on training in: genomic DNA extraction from stool, design and application of TaqMan® assays for detection of parasites and pathogens, actual data collection using duplex/multiplex assay formats on a test panel of known samples and discussion on the optimisation of TaqMan® assays. Both Jaco and Lucas were able to each provide ‘tips-and-tricks’ with general trouble shooting advice on each method used. The importance of good laboratory practice was stressed throughout. This covered how the laboratory should be organised and how each workflow should be arranged to minimise contamination; how an appropriate inventory system should be developed to track the clinical results as each assay was performed.

Typically, as each laboratory/researcher has a slightly different way of doing things adhering to best clinical practice can be problematic. Putting theory into practice in sub-Saharan Africa settings is even more challenging for there are often daily hurdles both in logistics and infrastructures to overcome. We experienced several first-hand, for example, after torrential rains on the Monday evening, downed trees on the CSIR site cut laboratory electrical grid supplies needing essential outside repairs. Throughout the morning and the following day alternative power supplies, featuring both solar and portable generators, were used.

Strengthening the collaboration between the CSIR and NMIMR after initial visit of Dr Emily Adams last summer, we made a visit to see Drs John Odoom and Jacob Barnor and discuss the Polio screening programme. By good fortune we also met with new colleagues at NMIMR who were using real-time PCR to examine cervical biopsies for Human Papilloma Virus (HPV). It came as a surprise that they were unaware of female genital schistosomiasis (FGS). This was likely due to the traditional division between virology and parasitology but by adding real-time PCR assays it would be possible to tackle FGS in routine screening of biopsy material using this DNA detection platform.

Bridging this health services gap with a newly identified solution, and using assays taught in our course, we would hope to provide a more holistic appraisal of genito-urinary tract disease in Ghana. Undoubtedly, this could give a new overview of FGS in Ghanaian women and identify their currently unmet treatment needs for schistosomiasis. On further discussions later in the week with Dr Kofi Effah, a gynaecologist working in Battor, Lake Volta Region, there is an exciting opportunity for COUNTDOWN to foster much greater concerted action on FGS across the Ghanaian health sector.