The World NTD Summit Highlights & Schistosomiasis Discussions

by Prof. Russell Stothard – COUNTDOWN Director

The importance of the international activities that took place last week at the global summit on NTDs cannot be easily overstated. Hosted by the World Health Organisation (WHO), the second global partners meeting took place on the 19th April with several previous international pledges and commitments reaffirmed, alongside announcements of new ones. From a UK-perspective, the Minister of State for International Development the Rt Hon. Lord Bates stated that DFID will double its efforts on control of NTDs. This will be secured by allocation of additional funding of up to £360 million over the next five years. Bill Gates, who was in attendance welcomed this news which was later mentioned in his speech at Royal United Services Institute for Defence and Security Studies in London.

The Fourth WHO Report on NTDs was launched at the NTD summit. This recognised the achievements of the past decade on Neglected Tropical Diseases (NTDs), the need to sustain the momentum towards the 2020 WHO Roadmap Targets, and called on partners to facilitate the availability of funds and resources needed beyond the 2020 perspective. Progress being made for each NTD was listed and new vector control strategies were highlighted by discussing the draft of the WHO Global Vector Control Response 2017–2030. This argued that a “One Health” approach was much needed exploring the human–animal health interface and commonalities in water, sanitation and hygiene measures. The latter sets a broader challenge for integration within and across the current health system, especially in interpretation of what universal health coverage exactly means.

From a personal perspective, two things were particularly pleasing. First, to note was the entry of NTDs Control into the Hall of Fame of the Guinness Book of Records by achieving the “Most Medications Donated in 24 hours (multiple venues)”. Collectively this was evidence of a tremendous group effort in international goodwill where an incredible number 207,169 292 doses of donated medicines was made possible through the efforts of Bayer, Eisai, Gilead, GSK, J&J, MSD, Merck KGaA, Novartis, Pfizer, Sanofi, as well as, the Bill & Melinda Gates Foundation.

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Dr Ifeoma Anagbogu at COUNTDOWN Nigeria Launch 15.03.2017

Second, COUNTDOWN Nigeria’s lead at the Federal Ministry of Health – Dr Ifeoma Anagbogu, was one of the finalists for the Leadership Award during the Women in Focus dinner. Dr Anagbogu who worked extensively to make Nigeria Guinea-worm free, leads the NTD Division within the Nigeria Federal Ministry of Health. Other categories for the Women in Focus awards included Inspirational Award, Community Champion Award and Exceptional Service Award.

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Dr Uche Amazigo at COUNTDOWN Nigeria Launch

Prof. Uche Amazigo who is one of the main chairs of the Nigeria NTD Steering Committee was nominated for Exceptional Service, for dedicating most of her research and career to the elimination of NTDs as seen in her participation and leadership in scaling-up the innovative Community-Directed Treatment.

In a musical celebration of these awards, the NTD community was very fortunate to have the Béninoise soulstress – Angelique Kidjo, perform on stage.   

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Angelique Kidjo performing at the Women in NTDs celebration

From the 20 – 21st April, disease-specific sessions took place at the Hotel Continental. It was a delight seeing several COUNTDOWN colleagues attend and present their work. During the second session on schistosomiasis as organised by the Global Schistosomiasis Alliance (GSA), I outlined our recent work on developing a framework for environmental surveillance. This clearly sets the scene to evaluate the much-needed scale-up in, and expansion of access to praziquantel by drawing into focus the transmission dynamics within the environment.

In a further attempt to do so, the GSA created a lakeside stir by having a large inflatable worm “invade” Geneva as part of their #makeschistory initiative.  More broadly, further COUNTDOWN work was featured within brochures of the special edition of Infectious Diseases of Poverty dedicated to “Schistosomiasis research: providing the tools needed for elimination”, sponsored by the GSA.

Furthermore, copies of the report on the recent Towards Elimination of Schistosomiasis Conference in Cameroon were also available for appraisals.

During open discussions, I became aware for example that while the surveillance for Lymphatic Filariasis and STH were becoming integrated as set within the Transmission Assessment Survey (TAS), integration of intestinal schistosomiasis however, was not. This fragmentation seems counterproductive for the key diagnostic to be used. Kato-Katz faecal sampling detects both STH and Schistosoma mansoni infection. It seems a little short-sighted to ignore such synergies for there could be significant cost-savings to be made within future co-surveillance. Answers to this question might be found within the DeWorm3 initiative.

So, we now observe that space with interest, hoping that newly emerging disease-specific silos are quickly broken down.

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COUNTDOWN Nigeria: A Model for Conducting Implementation Research

Dr Obiageli Nebe, Phillip Okefu Okoko, Ruth Dixon, Laura Dean

COUNTDOWN is a research consortium dedicated to investigating the cost-effective, scale up of sustainable solutions necessary to control and eliminate the seven most common Neglected Tropical Diseases by 2020. In Nigeria, the COUNTDOWN project is a collaboration between the Federal Ministry of Health (FMOH), the Kaduna & Ogun State Ministries of Health, Liverpool School of Tropical Medicine (LSTM) and Sightsavers. COUNTDOWN is supporting implementation research, the outcome of which will provide the evidence needed for policy and or programme change to enhance coordination and programme delivery. Activities began in Nigeria in September 2016.

To maintain the COUNTDOWN ethos of multidisciplinary equitable collaboration, we have ensured to build a partnership in Nigeria that focuses on the following areas:

Early Involvement of key stakeholders in a genuine and trusting partnership

It is important to secure the full commitment of the Federal and State Ministries of Health to the vision and goals of the project and buy-in into the outcomes, increasing likelihood of taking up key findings that may inform policy.

Advocacy meeting with the FMoH, Sightsavers Nigeria Office and LSTM were held before any project activity. All partners were involved in development of timelines, planning and project conceptualisation and all were on the panel during team recruitment.

The programme was launched on the 15th March 2017 receiving unanimous endorsement by the NTD Steering Committee and the COUNTDOWN Nigeria team being formally invited to the join the Research Sub-committee.

Having a multi-disciplinary and cross-sectoral team

Issues are not one dimensional; they are influenced by social, political, health, economic, operational and cultural factors. A multidisciplinary multi-sectoral team allows a holistic approach and adaptability to country’s needs.

The COUNTDOWN team is led by the Federal Ministry of Health and includes social scientists, health economists, a research uptake officer (embedded in FMoH), and a research manager/officer. The collaboration includes LSTM bringing technical guidance and Sightsavers the perspective of large scale implementing partner.

Identify research needs that will address implementation issues in the local context

Implementation research is not a “one-size fits all”; countries and contexts are different with varying challenges to NTD control and elimination programs. Research that addresses a genuine need is more useful and more likely to be taken up resulting in positive programmatic impact.

The preliminary phase of COUNTDOWN Nigeria has been a thorough and robust qualitative situation analysis of the NTD programme. It involves perspectives of Federal, State, Local Government Area (LGA), Primary Health Care (PHC) and Community Directed Distributors (CDDs)/Teachers involved in NTD programme delivery. Two States of Nigeria – Kaduna and Ogun – have been purposively selected as the focus of COUNTDOWN Nigeria and the situation analysis as they represent two very different NTD implementing environments. Key informant interviews (38) and participatory action research workshops (18) have been completed in 3 LGAs of each State. Data is currently being analysed to provide a full contextual understanding of each study area and inform research question development for the main study. Full scale research will begin late 2017.

Maintaining effective and collaborative partnership

Research questions and implementation environments evolve. Only when partnerships are truly collaborative, can teams adapt together keeping research focussed and relevant.

The Nigeria COUNTDOWN team is led by the Federal Ministry of Health who have, and continue to take an extremely active and engaged role in planning, decision making and data collection. Open dialogues and honest communication have facilitated an evolving relationship between all three partners and successful resolution of any issues. At the recent partners meeting in Yaoundé (March 2017) all partners were present including 4 participants from FMoH. Dissemination meetings for the situation analysis are planned for mid-June 2017, scheduled to allow feedback from each State to be inputted before Federal dissemination workshop. Dissemination of situational analysis will be followed by an evidence synthesis workshop and research planning meeting where questions will be formulated and planned and which all partners will attend.

Linking to the global agenda

It is important to “be informed as well as informing”. By working in tandem with the global agenda and being current on wider sectoral issues, contributions to the evidence base can be more valuable to more people and non-duplicative.

The team is working in the context of the “Leave no one behind” global agenda and the Nigerian national slogan “End the neglect of NTDs”. COUNTDOWN is a multi-country project where all country teams regularly get together for cross-country learning events. COUNTDOWN Nigeria has incorporated into the situation analysis a pilot of the new World Health Organisation (WHO) Gender, Equity and Rights Tool with results presented at the WHO Strategic and Technical Advisory Group meeting in Geneva (17th Feb 2017). Results have also been included as part of a submission for an Equity Symposium at the American Society of Tropical Medicine and Hygiene. Early findings of the situation analysis have already been discussed at international forums such as Towards Elimination of Schistosomiasis (TES) conference in Cameroon (March 2017).

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Dr Akinola Stephen – COUNTDOWN Nigeria Research Officer for Ogun State presenting at the TES Conference in Yaoundé, Cameroon

Conducting multidisciplinary implementation research can be complex, but is essential for cost effective scale up of NTD control and elimination interventions. We hope by using the guiding principles identified here that we can learn lessons to be taken forward to address some of the key bottlenecks currently faced by the NTD programme in Nigeria. Through the generation of our strong multidisciplinary team, we also hope to make recommendations for the success of cross-discipline and cross-country effective and equitable research partnerships.

Read about COUNTDOWN Nigeria’s recent launch via – https://countdownonntds.wordpress.com/2017/04/06/countdown-launched-in-nigeria/

We will also be attending the NTD Summit organised by WHO and held at their headquarters in Geneva, Switzerland from 19 – 22 April 2017.

For more information about Nigeria’s Department of health, visit – http://www.health.gov.ng/index.php/department/public-health

COUNTDOWN Launched in Nigeria!

If you want to go fast, go alone; if you want to go far, go together: Collaboration in Research

by Pamela Bongkiyung, Prof. Russell Stothard & COUNTDOWN Nigeria Team

It was an auspicious moment when the COUNTDOWN programme was launched in Lagos – Nigeria, during the 18th Neglected Tropical Diseases (NTDs) Steering Committee Meeting, which took place from the 13th – 15th March 2017.

The Steering Committee gathered experts from the academia, the Federal Ministry of Health, the State Ministries of Health, Research Triangle Institute (RTI)/ENVISION, Evidence Action, End Fund, MITOSATH (Mission to Save the Helpless), Helen Keller International, Health Partners International, Sightsavers, HANDS (Health and Development Support Programme), Amen Health Foundation, NIMR (Nigerian Institute of Medical Research), WHO (World Health Organisation), eHealth Africa and COUNTDOWN of course.

The sub-committees which presented at the main steering committee meeting, ranged from research, technical review, NTDs- WASH (water, sanitation & hygiene), elimination & verification to advocacy & resource mobilization. Discussions had in the meeting ranged from donor priorities to country’s needs. Should the country accept funders choice of disease even if the burden was heavier elsewhere; was one of the questions pondered.

With an introductory presentation from COUNTDOWN’s Nigeria Country Director, Dr Sunday Isiyaku, the Steering Committee soon understood that the project’s focus is to leave no one behind given its multidisciplinary approach and incorporation of health economics. Dr Isiyaku highlighted COUNTDOWN’s implementation research that will investigate cost-effective ways of up-scaling NTD control. Not forgetting the pertinent role played by community drug distributors (CDDs) and in this case, two CDDs from Kaduna state who have served for over 15 years; Dr Isiyaku, reminded the Steering Committee of what communities can achieve when they are committed as seen in the case of the dedicated CDDs from Kaduna.

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Community Drug Distributors (L-R): Joseph Umaru & Shittu Baba

Dr Isiyaku tendered a request for the Research Sub – Committee of the NTD Steering Committee, to play an advisory role to the COUNTDOWN Nigeria project. This was endorsed by all chairs of the NTD Steering Committee.

COUNTDOWN’s Director – Prof. Russell Stothard, in his opening speech, informed the group that COUNTDOWN is not just about one disease or partner but a multitude of partnerships working together with a major task of breaching the gap between researchers and policymakers at the federal, state and international levels.

COUNTDOWN’s priority in Nigeria is to conduct a situational analysis in the two focal states – Kaduna & Ogun, which should reveal the challenges that need to be addressed to cost-effectively scale-up NTD programmes and ease integration into the health system whilst strengthening it. In addition, gaps will be identified in line with successes that will form the basis for the next stage of the research.

The launch of COUNTDOWN Nigeria elucidated cheers but also injected an element of hope as shown in the enthusiasm expressed by Prof. Adenike Abiose, Prof. Uche Amazigo and Dr Margaret Mafe – all members of the NTD Steering Committee. COUNTDOWN Nigeria was touted as the programme that would breach the evidence research gap left by the end of APOC (African Programme for Onchocerciasis Control) as seen in its multi-partner and cross-border approach.

It soon became evident that there is a fervent desire within the Nigerian NTD community for collaboration and knowledge sharing in tackling hotspots of NTDs, an action already embodied by COUNTDOWN. In the Research Sub-Committee’s recommendations to the Steering Committee, evidence-based research is encouraged in its terms of reference. It is no longer enough to produce endless research, evidence-based research is emphasised.

Activities are already being integrated at the federal, state, local government areas (LGAs) and community levels to include advocacy and resource mobilization. There is a push for this to be reflected in state NTD Masterplans to help fund NTD activities within the country. In East Africa, advocacy has a long tradition and is entrenched in most non-governmental development organisations. Realisation is dawning on the need for advocacy to become civil society driven. The point is to encourage buy-in from communities and major stakeholders within Nigeria. For some programmes like UNITED Consortium for NTDs, engaging civil society organisations to be active participants for advocacy, provides a basis for their exit strategy.

Why advocate and mobilise for funds? We all know donors will not give forever and given the recent changing political climates and donor priorities in main funders’ countries’, the Nigerian NTD community are preparing themselves for when donor fatigue sets in.

By the time funds from advocacy and mobilisation activities in Nigeria stream in, we hope COUNTDOWN’s implementation research can provide some solutions that will put the funds raised through advocacy, to good use and move the NTDs agenda that closer to elimination.

You can access the Storify of our tweets for the launch from @NTDCOUNTDOWN and @COUNTDOWNNG from here.

 

Using Polio Samples to Assess Schistosomiasis and Soil-transmitted Helminthiasis Prevalence in Ghana

By Lucas Cunningham

With the success of the campaign to eradicate polio the questions surrounding the legacy of the Global Polio Laboratory Network (GPLN) should be asked. It is towards this end that COUNTDOWN incorporated into its objectives, an assessment of the suitability of the faecal collections generated by the GPLN for use in assessing the prevalence of Soil-Transmitted Helminths (STH) and Schistosomiasis (SCH). The polio laboratory at the Noguchi Memorial Institute for Medical Research (NMIMR) was selected to pilot this study. Members of their team attended a qPCR workshop hosted by COUNTDOWN in March 2016.

The laboratory at Noguchi had been storing faecal samples sent to it by clinicians across Ghana. These samples come from patients presenting clinical signs of polio, typically this would be acute flaccid paralysis (AFP). At the Noguchi laboratory a total of 913 samples had been collected from 2012 until 2015; and of these, a subset of ~500 samples were selected. The samples selected would undergo a DNA extraction involving a pre-treatment phase of bead beating, to break open the eggs of any helminths present. The sample would then be screened with TaqMan assays to identify the following helminth types: Strongyloides stercoralis, Necator americanus, Ancylostoma duodenale, Ascaris lumbricoides, Trichuris trichiuraI and Schistosoma.

At Noguchi, the pre-selected samples were identified and over the course of the next few weeks these samples underwent the DNA extraction described above. The samples were then screened with the TaqMan assays over the following months. The qPCR results identified a combined helminth infection prevalence of 13% with A. lumbricoides and N. americanus as the most common found in 4% of samples. The prevalence of A. duodenale, Schistosoma and S. stercoralis were like each other at 2% while T. trichuris was not found in any of the samples.

This initial investigation shows that the use of the GPLN’s faecal collections in screening for STH and SCH has potential as an alternative for assessing the prevalence of these different diseases in a country without the need to do an expensive community survey.

 

 

An African Focus at the 2017 GCID Infectious Diseases Symposium, Seoul

by Prof. Russell Stothard, Director

The Global Center for Infectious Diseases (GCID) is part of Seoul National University College of Medicine and directed by Professor Eung-Soo Hwang. Each year the GCID holds an international symposium which aims to bring together national and international researchers to discuss current health-related issues. It also seeks to initiate and solidify collaborations aligned within its two departments, The Department of Microbiology & Immunology (DMI) and The Department of Tropical Medicine & Parasitology (DTMP), respectively.

Invited by the Head of DTMP, Professor Min-Ho Choi, I was honoured to give the first keynote presentation at the 2017 GCID Infectious Diseases Symposium and discuss schistosomiasis-related work in Africa. I took the opportunity to feature the importance of female genital schistosomiasis (FGS) and our previous FGS workshop, as well as recent COUNTDOWN activities and publications.  The previous year, Professor Choi had visited the Liverpool School of Tropical Medicine (LSTM) and was keen to develop shared interests in research and teaching further. To this end, we co-supervise an LSTM-PhD student, Dr Sunghye Kim, who has been developing an island-wide STH control programme on Fiji on the back of transmission assessment surveys for lymphatic filariasis. This receives support from the Korea International Cooperation Agency (KOICA), the Korean equivalent to DFID, UK.

Established in the early 1950s, the DTMP has a long history in medical parasitology and exemplary scholarship in intestinal trematodes, describing their lifecycles and epidemiology. Several key staff, for example Professors Seo and Lee, have been seminal in developing country-wide control programmes in Korea. These have been eminently successful, for with consolidated intersectoral action, extensive diagnostic screening with bi-annual treatment and appropriate health education as well as general socioeconomic development have resulted in elimination of STH in Korea as a public health problem. This is a tremendous achievement, however, without a significant within-country burden, the DTMP has realigned itself today with bilateral efforts to control disease elsewhere, in particular in Africa.

Recent research and control undertaken by DTMP in Sudan against schistosomiasis and funded by KOICA was presented by Professor Sung-Tae Hong who had also undertaken numerous clinical assessments of bladder pathology by ultrasonography. Later in the week, we discussed at length the growing importance of FGS and I shared with him my copy of the FGS pocket atlas. The intention is to develop a better understanding of FGS and assess if a pilot gynaecological examination could be performed in adult women. Incidentally, if KOICA were to become better aware of the importance of FGS it might open up efforts within their educational and medical outreach projects to improve the health of adult women and those of child-bearing age elsewhere.

During the remainder of the 2017 GCID Infectious Diseases Symposium we discussed with colleagues within the DMI, the status of current viral influenza epidemics and the importance of preparedness for novel strains that might arise, for example H7N9. The emergence of this viral variant is of concern and orchestrates an intercontinental need for rapid molecular surveillance. On a related point of better disease surveillance, I was happy to point out that COUNTDOWN was using similar molecular DNA diagnostic tools newly embedded within the polio surveillance network and highlighted Lucas Cunningham’s and Emily Adams’ exciting results on the use of real-time PCR assays in Ghana.

After the symposium, the following morning I gave a similar presentation to the Korean Society for Parasitology then later in the afternoon a more career-focused presentation to a group of medical students. These were united by a student-action body across Seoul universities and were each interested in global health and wishing to known how best to contribute. I was impressed at their general knowledge and how one student had already volunteered to assess refugee health in Germany in light of the Syrian crisis. Later in the week I was warmly hosted by the DTMP and I took part in their laboratory meeting. There, we discussed recent efforts on developing a LAMP assay for schistosomiasis and I was able to share with them Corrado Minetti’s recent publication.

Upon leaving Korea and looking to the future, we are now thinking of ways to further our shared interest and synergise activities. It is fortunate that Professor Choi is serving on the local organising committee for the next International Congress on Parasitology, for we are aiming to organise a special session on schistosomiasis control to feature future results from the DTMP and COUNTDOWN networks. This is certainly something we should all look forward to.

Neglected tropical diseases: Getting “lost in the WASH” no longer!

By Dr Suzy Campbell & Dr Nana-Kwadwo Biritwum

There is a very important research agenda gaining momentum at present, and it is attracting extensive stakeholder buy-in. This is the importance of water, sanitation and hygiene (WASH) in augmenting preventive chemotherapy for neglected tropical disease (NTD) control. We chaired a breakout session at COR-NTD, the annual operational research meeting for NTDs, held in Atlanta in November. We highlighted the important strategic agenda for strengthening evidence on how to deliver effective WASH interventions for schistosomiasis and soil-transmitted helminthiases (STH), and embedding these findings in guidance and practice. In this blog we share why this is such an important integration priority!

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Figure 3: Dr Suzy Campbell presenting at COR-NTD (Photo: L. Hamill)

Since the early 2000s, preventive chemotherapy (“PC”, being provision of deworming tablets) has been the cornerstone morbidity-control strategy for Lymphatic Filariasis, Onchocerciasis, Schistosomiasis, STH, and Trachoma. PC is most often provided by repeated mass drug administration (MDA) campaigns, usually targeting treatment to school-aged (and school-attending) children. This approach has rightly, had strong World Health Organization (WHO) advocacy, and is considered the largest-scale repeated public health programme in the world.

However, for schistosomiasis and STH, it has been known from the outset that PC alone does not reduce the rapid cycle of reinfections. People continue to be exposed to these parasites from their environments. For schistosomiasis in particular, transmission can be continued from just one or two individuals who contaminate the environment subsequently infecting intermediate snail hosts. For these two diseases, the approach has been one of “morbidity control” rather than disease control.

MDA has been conducted for up to a decade in many endemic regions of the world, and whilst coverage of school-aged children is progressing towards WHO targets, there are multitude reasons for strengthening additional strategies, such as provision of WASH. Continuation of this is still crucially important, but additionally there is increasing focus towards other strategies that will augment PC. Since 2012, there has been much discussion on moving beyond “morbidity control” to “interruption of transmission” and “elimination as a public health problem”.

 

So what is WASH and why is it important?

WASH is the provision of access to a safe water supply, appropriately constructed sanitation infrastructure ensuring safe disposal of human excreta, and health education and promotion of hygiene (being personal and household practices aimed at preserving cleanliness and health).

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Figure 1: Integration challenges: these brand new toilets remain locked (Photo: S. Campbell)

For disease control purposes, WASH needs to be viewed both according to the individual components of water, sanitation, and hygiene (including health education as a main conduit of hygiene promotion), and additionally, as an integrated system. This is because the components are complementary: infrastructural components such as provision of public taps or household latrines are unlikely to be beneficial investments without accompanying behavioural change (or vice versa). Just as PC can be seen as the cornerstone of morbidity control, WASH can be viewed as the cornerstone of prevention of infections. From a position of biological plausibility, WASH is the key mechanism that can be implemented to reduce environmental contamination and then, quite possibly, transmission.

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Figure 2: A drain where people wash their clothes (Photo: S. Campbell)

Despite this, the evidence base for WASH activities for STH or schistosomiasis control is fairly weak and it is a growing research priority. We crucially need more information as to the elements of WASH programmes that are most beneficial for STH and schistosomiasis control. This needs to encompass not only the more commonly-discussed water collection and/or toileting habits, but also extend to other potential elements such as grey water disposal and contribution of animal faeces (given zoonotic potential for some helminths).

What is happening right now?

In 2012 the WHO released the NTD Roadmap, which set NTD coverage targets to 2020 and fostered unprecedented anthelmintic and financial donations. This led to major international momentum, strongly supported by WHO, for countries to develop strategic NTD master plans tailored to national NTD control and elimination priorities. To a very large extent these actions have redefined the international STH and schistosomiasis agenda, being a major push to assist some countries to achieve STH coverage targets.

In late 2015, the WHO published the first WASH for NTDs Global Strategy 2015-2020, providing four strategic objectives to accelerate progress on addressing NTD Roadmap targets through increased intersectoral WASH-NTD collaboration and integration of approaches. This much-awaited document provides international impetus to countries to prioritise WASH in conjunction with other NTD control strategies. The intention is that WASH activities be developed and built into country NTD programmatic planning.

However, in order to do this, we need to strengthen the evidence for delivery of effective WASH interventions for NTDs. Additionally, we need to embed these evidence findings in guidance and practice. This is the clearly stated objective, and call for assistance, of one of the Strategic Objectives in the WASH for NTDs Strategy. In this, the WHO is calling for research evidence, and programmatic examples to be shared.

Considering schistosomiasis and STH, this is a fundamentally important requirement. We know we can’t control these diseases without primary prevention strategies. This important distinction for these two NTDs needs to be explicitly made, compared to many other NTDs: WASH for schistosomiasis and STH control needs to be seen as a major determinant of disease prevention. This is radically different from NTDs such as lymphatic filariasis, where WASH can be used as a treatment strategy (for example, washing of hydroceles for morbidity management). For STH and schistosomiasis, WASH is not to treat, it is to prevent.

WASH for schistosomiasis and STH control at COR-NTD

What we focused on for COR-NTD in our discussion workshop was the importance of this prevention agenda for schistosomiasis and STH. With a strong introduction to the WHO WASH for NTD Strategy from Dr Amadou Garba (WHO), several country-specific research and NTD programme case studies were presented, as follows: Ghana (Dr Nana-Kwadwo Biritwum, National NTD Programme Coordinator, Ghana), Cameroon (Prof Louis-Albert Tchuem-Tchuenté, National NTD Programme Coordinator, Cameroon), Tanzania (Dr Steffi Knopp, Natural History Museum, UK), Ethiopia (Dr Jack Grimes, World Vision, UK), Timor-Leste (Dr Suzy Campbell, LSTM, UK), with current WASH evidence for schistosomiasis and STH summarised (Jack Grimes and Suzy Campbell). Dr Lorenzo Savioli (Chair of Executive Group, Global Schistosomiasis Alliance) then gave a compelling historical perspective of more than 30 years of PC-based control in Zanzibar (Tanzania), clearly highlighting shortcomings of STH and schistosomiasis control strategies in the absence of sufficient WASH investment. The audience of expert NTD attendees then participated in a lively discussion about evidence requirements, WASH indicators for NTDs, schistosomiasis hot-spots, more use of mathematical modelling and advanced diagnostic tests, integration challenges, and learning from other disease programmes. Key discussion points, knowledge gaps, and important next steps are summarised in the session report.

Our session integrates closely with another important WASH for NTDs session held at the NTD Non-Government Development Organisation (NGDO) Network Meeting in Washington DC in September (chaired by our collaborator Dr Fiona Fleming at the Schistosomiasis Control Initiative, as the first two major stakeholder pushes to investigate country examples and share learning in light of the WHO Strategy. We believe these are important, but preliminary, indications of the need for an investment case for WASH for NTDs. Much needs to be done to develop this; in the meantime, it is clear that integrated, multi-stakeholder support will be a critical factor for the WHO Strategy’s success. We should all contribute to this.

Please read the summary report of the session on the COR-NTD website, and our Storify.

 

Indigenous knowledge and Intersectionality: “Incremental radicalism” and Front Line Health Workers.

By Sally Theobald, RinGS, REACHOUT, ReBUILD and COUNTDOWN

Health Systems Global 2016 was opened by leaders of the Canadian First Nation community through song and dance and a discussion of how health has four components: physical, mental, emotional, and spiritual. The First Nations Perspective on Health and Wellness stress the need for a balance between these aspects of wellness and that they are all nurtured together to create a holistic level of well-being. 

It struck me that this conceptualisation, together with intersectionality, is a good way to think creatively about ways forward in health systems, and in particular the experiences of frontline health workers.

Physical health: In the conference opening plenary Karsor Kollie, head of the Liberian NTD programme, discussed the impact of Ebola on front line health workers: death, injury and morbidity. Later in the conference video extracts of him interviewing community based drug distributors demonstrated the risks they faced as their roles expanded to include community action on Ebola and the burial of the deceased. Zara Trafford from University of Cape Town, also brought video insights from community health workers (CHW) in South Africa. One exhausted female CHW had an accidental needle stick injury; unlike formal paid cadres, such as nurses, she was not entitled to post exposure prophylaxis. This led to physical risk of infection, extreme stress, and a strong sense of being undervalued. The physical health impacts on front line health workers on CHWs working in contexts affected by conflict and epidemics is acute. Clearly CHWs deserve the same levels of protection as health workers in other cadres.

Mental Health: Work on promoting a resilient health workforce in conflict affected areas highlighted the many mental health impacts on front-line health workers including post-traumatic stress disorder, insecurity and fear, and the risk and reality of abduction. Haja Wurie from ReBUILD explained how health workers were a specific target for abductions during the northern Ugandan conflict, and had to disguise themselves in order to get to work. A skills building session on life histories, used participatory approaches to understand health workers’ experiences during and post-conflict to explore how individual experiences are shaped by broader contextual changes with many mental health implications stemming from violence, trauma and fear. Close-to-community providers deal with a wide range of issues with implications for their own mental health: domestic and sexual and gender based violence, abuse, alcoholism. Polly Walker, explained how World Vision incorporated Psychological First Aid training in their core CHW model in response to increasing need. Observation of implementation in over ten countries shows immense need here on the importance of skills-building for both mental health and psychosocial support of CHWs working in a wide range of circumstances not only to serve their client better, but also to better cope with their own experiences. World Vision are currently working on a more in-depth model for support.

Emotional Health: Despite the multiple challenges for mental and physical health, front line health workers, demonstrate “reservoirs of resilience”. New technologies can also play a role here: in Sierra Leone, in the face of Ebola, health workers used WhatsApp groups to support each other, and share vital safety information. Sophie Witter shared how coping strategies for conflict were gendered and shaped by poverty and household structure. Families, sense of nationhood and patriotism were all strategies deployed by health workers to build emotional health in these contexts. REACHOUT research within complex adaptive systems brought insights by highlighting the importance of the software of health systems (relationships, reciprocity, and trust) alongside the hardware (training, supervision and policy). When strong, respectful and trusting relationships are in place for CHWs – both with supervisors and communities – emotional health is likely to be enhanced. 

Spiritual Health: The First nations community explained that “Nurturing spirit is the aspect in your life that makes you smile! This is about what makes you feel good and connected. This builds your self-esteem, self-confidence and allows you to be connected to others, mother nature and yourself.” With strong links to emotional health and social capital, religious faith can help build the spiritual health of frontline health workers. Studies on health workers’ experience in Sierra Leone, N.Uganda, Zimbabwe and Cambodia showed that religion is a key motivator to join the profession and also a strong factor supporting staying in service during tough times.

So where do we go from here?

The brilliant plenary on intersectionality, showed how we need to consider multiple axes of inequity (race/poverty/gender/(dis)ability/sexuality etc.) to address power and privilege. These play out in different ways at different moments in time and in different contexts. Social justice is key, as is reflexivity and critically thinking through our own roles as researchers within health systems. There are parallels here too with the First Nations’ concept of “cultural humility” as a process of self-reflection to understand personal and systemic biases and to develop and maintain respectful processes and relationships based on mutual trust. Olena Havinsky, from Simon Fraser University in Vancouver, referred to the idea of “incremental radicalism”, small steps to build mutual understanding and alliances for change and to promote social justice. We need to draw on these concepts and put in place strategies to further support the holistic health and well-being of front line health workers who are the key to both responsive and resilient health systems and universal health coverage.

How to Involve Key Stakeholders and Adapt to the Local Rhythm: Lessons from the Western Region, Ghana

By Irene Tsey

[on behalf of Contextualising Lymphatic Filariasis(LF) Hotspots Research Team, DHRC.  Irene Honam Tsey is a Research Officer & Institutional Review Board Administrator at DHRC]

“This was my second time to the Western Region as well as on the field for data collection. Interestingly, I cannot believe the depth of information and knowledge gained from this trip when some years back at the same place I could not even dream of putting together this piece. I am so grateful for my experience in DHRC”

It was a long trip of about 320km and we got to our final destination almost at midnight after setting off late in the morning of that same day from Dodowa. Although very tired and not knowing exactly where to spend the night we encouraged ourselves with humour. We made jokes from previous experiences.  We spent ten days in the field and learnt first-hand the importance of involving community leaders or gatekeepers through the support of other key stakeholders and the need to sometimes adjust to uncomfortable situations for successful Community Entry and data collection.

WHAT LESSONS DID WE LEARN?

The Need to Identify Key Stakeholders

It is very important to know the relevant stakeholders needed for your study to avoid unnecessary delays. Upon arriving in the first district the team’s first point of call was the District Health Administration. The team met the officer acting on behalf of the director and upon briefing him and others about the study the team was handed over to the officer involved which in this case was the Disease Control Officer. This officer had the data on all the communities involved in the MDAs which she willingly handed over to the team. She was also able to delegate a field technician (FT) involved with the MDA programmes and working with the Community Drug Distributers (CDDs) to assist us in reaching the CDDs.  The FT further led us to the various community leaders and also introduced us to some available and hardworking CDDs in the communities. Having support from the relevant stakeholders on the ground who are already known in the communities through their various engagements; made it easy to reach the other stakeholders who in this case are the community leaders. The team was warmly received and granted permission to go ahead with data collection.

Need to Understand and Respect the Cultural/Social Context of your Research Community

Our first community was Muslim and the FT in the person of Jonathan advised us to dress appropriately. Based on this piece of advice, some of the team covered their heads and did not wear make-up. We also wore clothes similar to those of local women to bridge the cultural gap and make them feel comfortable in our presence. We left this community better and stronger than we came and ever ready to continue on our journey of conducting sometimes rigorous research.

Need to Adjust to the Context in which Data is going to be Collected

The team was excited to have successfully entered some communities and conducted some Focus Group Discussions (FGDs) and In-Depth Interviews (IDIs). Aunt Rose, a very active and enthusiastic CDD gladly accepted to help organise the prospective research participants and inform the chief and elders about our study and intention. The team, Aunt Rose and the Field Technician (FT) involved in the MDAs decided to seek permission from the community leaders before commencing interviews. It is an undisputed fact that final consent to participate in a study is to be given by the prospective participant nevertheless it is important to get permission of community gatekeepers which helps with community engagement. The team learnt that seeking permission from the gatekeepers made them feel appreciated as their authority and roles as custodians of their people were respected. The benefits for us on the research team, was that it made us feel comfortable and at home in these communities.

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Most of these leaders expressed their support for our work and encouraged us. They highlighted that in the future providing prior notice before arriving communities would enable them adequately prepare to receive us and to also know more about our research. This demonstrated that it is not just about seeking their permission but also keeping them in on progress.

About the study:

Contextualising LF Hotspots Research is part of COUNTDOWN’s efforts to explore and identify strategies, for more effective mass drug administration to eliminate Lymphatic Filariasis, in the remaining districts with persistent transmission in Ghana.

You can see more of our work on Lymphatic Filariasis in Ghana below:

WHAT DOES IT TAKE TO CONTROL NEGLECTED TROPICAL DISEASES? PART THREE: ELIMINATING LYMPHATIC FILARIASIS by Linda Waldman
ANYONE’S DISEASE: ENDING LYMPHATIC FILARIASIS IN GHANA by Adriana Opong
A BED NET TO RULE THEM ALL: ACCELERATING LYMPHATIC FILARIASIS ELIMINATION THROUGH MALARIA CONTROL PROGRAMMES by Corrado Minetti.

 

 

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.

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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.

Empowering the NTD Workforce – Highlighting Community Drug Distributors

By Pamela Bongkiyung & Prof. Sally Theobald

Mass Drug Administration (MDA) remains a fundamental part of approaches to address several Neglected Tropical Diseases. However, the people who make this process happen at the community level – Community Drug Distributors (CDDs),  are sometimes not given enough attention or  sufficient acknowledgement  for their contributions and how best to motivate with some form of remuneration and reward this critical cadre is subject to much debate

Most CDDs come from the communities in which they work, and are chosen through community processes. Training and supervision is varied and often not given enough resources or attention. Their selection, supervision and training remain a community effort. For a very long time, they have not been sufficiently considered as an essential part of the health system around the world. This in turn has meant that in some contexts they are considered by governments as voluntary workers who don’t always need formal payment. Though there have been promises to include some payments for CDDs in national budgets, this frequently doesn’t materialise in practice. The issue of paying CDDs is embedded in controversy – who should pay?

The idea to start using CDDs was created during the Bamako Initiative in 1987 and then enacted in the Community Directed Treatment with Ivermectin (CDTi), rolled out by APOC (African Programme for Onchocerciasis Control). This process was designed from the onset to be owned by the community but challenges such as support, sustainability and remuneration remain.

Given that these communities were too poor to pay for drug distribution themselves, CDD work was viewed as serving one’s community and therefore a reward in itself. It was not envisaged that serving your village or clan should be met with monetary rewards. There remains a great difficulty in putting monetary value to the high esteem given to these individuals within communities.

The work of CDDs is also relevant in the detection of diseases, but they are often not mobilised to fulfil a monitoring role. The situation is further complicated when gender is inserted into the mix.  In the analysis of Community health worker programmes, men are more likely to be paid then women; and also more likely to be in senior roles. Little is known about how gender shapes the experience of being a CDD; the relationships that are built at community level and the implications for equitable and gender transformative processes.

Although CDDs have been central for over three decades, there is very little recent literature making an appraisal of their inputs and how best to support them. . It is imperative that their work is better acknowledged as a key interface for NTD elimination. So, we ask, how can we help sustain CDDs in health systems?
This is why COUNTDOWN has taken the initiative to bring the issues and experiences of CDDs to the limelight in the Coalition for Operational Research of Neglected Tropical Diseases (COR-NTD) from 10 – 11 November 2016. We will host a specific-session exploring evidence and evidence gaps. Panellists from Ghana, Nigeria and Cameroon will discuss the experience of CDDs in different contexts, how gender, poverty and relationships shape this and priorities for action.

COUNTDOWN will also be well represented at the Health Systems Global (#HSG2016) Conference in Vancouver, Canada from 14 – 18 November 2016. The Liberia COUNTDOWN Country Director – Karsor Kollie is presenting on the experience of Community Health Workers in the Ebola response in Liberia; and we have a panel on intersectionality which explores the interplay between different axes of inequalities.

COME AND JOIN OUR DISCUSSION IN THE SESSIONS BELOW: