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Public–Private Partnerships in Blindness Prevention Eye (2005) 19, 1050–1056 & 2005 Nature Publishing Group All rights reserved 0950-222X/05 $30.00 www.nature.com/eye 1 2 CAMBRIDGE OPHTHALMOLOGICAL SYMPOSIUM Public–private DH Molyneux and V Nantulya partnerships in blindness prevention: reaching beyond the eye Abstract health problems than has been hitherto recognized, thereby assisting in attaining the The control of river blindness (onchocerciasis) millennium development goal targets. has been one of the major public health Eye (2005) 19, 1050–1056. doi:10.1038/sj.eye.6701961 achievements of recent decades. Initially, vector control was used to stop transmission of Keywords: onchocerciasis; ivermectin; the parasite Onchocerca volvulus by blackflies albendazole; filariasis; malaria; millennium (Simulium) but the introduction of ivermectin development goals (Mectizan) as a means of morbidity control enabled new strategies of distribution to be developed based on community directed Introduction treatment. The donation of Mectizan by Merck & Co. Inc. for onchocerciasis control in 1987 ‘as Several reviews have been published in recent long as needed’ was a public health landmark years, which have summarised the specific to be followed by a donation from issues relating to the partnerships based around GlaxoSmithKline of albendazole in 1997 for onchocerciasis (river blindness) control as well lymphatic filariasis to which Merck also as overviews about such partnerships in the responded by agreeing to extend their donation broader area of international health.1–5 More to include the coadministration of Mectizan recent analyses have been published on various and albendazole. Both the drugs, however, aspects of the onchocerciasis control 1Lymphatic Filariasis Support have wider impacts than those specific to 1,6,7 Centre, Liverpool School of programmes (OCP). These publications Tropical Medicine, filarial parasites and are effective against a provide not only excellent summaries of the Pembroke Place, Liverpool, range of intestinal parasites, whilst ivermectin body of knowledge to date and serve as an entry UK has an important effect on ectoparasites. The point into the literature, but also cover the wider benefits of the annual public health scientific and strategic evolution of these 2 The Global Fund to fight intervention-collateral benefitsFtherefore programmes. Publications on current mass drug AIDS, Tuberculosis and include deworming, improved nutritional 8 Malaria, Centre Casai, chemotherapy, on progress of the APOC 9 10 Geneva, Switzerland status, increased growth, improved school programme the delivery of ivermectin, and performance and attendance, and improved the role of NonGovernmental Development Correspondence: DH haemoglobin status as a result of the impact of Organisations (NGDOs) in onchocerciasis Molyneux, Lymphatic albendazole on hookworm, a major cause of control11 have been summarised recently. Filariasis Support Centre, anaemia. More recently, studies suggest that This paper is intended to avoid duplication of Liverpool School of Tropical worm-free children have a significantly Medicine, Pembroke Place, content of these publications and to discuss the Liverpool L3 5 QA, UK reduced frequency of malaria specific episodes opportunities that onchocerciasis programmes Tel: þ 44 151 705 3291; of fever and Ascaris-infected children have a have and should continue to provide to enhance Fax: þ 44 151 709 0354. two-fold higher frequency of cerebral or severe the benefits of the structures, strategies, capacity E-mail: David.Molyneux@ malaria than those without Ascaris. These building, health systems, impact assessment as liverpool.ac.uk findings suggest that programmes based on well as the intervention itself on the health of annual interventions to control river blindness Received: 11 April 2005 populations, in addition to the impact of s Accepted in revised form: and lymphatic filariasis can contribute ivermectin (Mectizan ) on the morbidity and 2 May 2005 disproportionately more to a range of public mortality12 associated with river blindness. Onchocerciasis control-extended benefits DH Molyneux and V Nantulya 1051 The concept of maximising opportunity from described by earlier studies on Mectizan summarised by onchocerciasis control raises the following issues: Ottesen et al,14 later summarised in a table by Molyneux and Nantulya.15 The deworming benefits of ivermectin are often cited as the principal perceived benefit by 1. The impact of ivermectin on infectious agents other communities.16 than Onchocerca The value of ivermectin has been recently highlighted in a 2. The benefits the programme has brought to health study carried out in north-east Brazil.13 Heukelbach et al13 systems themselves after facilitating wider disease studied the effect of treatment with a generic ivermectin control issues (Revectina) on helminths and ectoparasites in a highly endemic community. The population under study was Onchocerciasis programmes have been suggested to around 600 individuals and assessment took place at 1 facilitate improvement in the health system itself. The month and 9 months after treatment. Declines in OCP contributed significantly to human resource hookworm from an initial prevalence of 28.5 to development through the provision of fellowships, over a 7.7% after 9 months were recorded; Ascaris declined from period of 28 years, which included a major contribution to 17.1 to 7.2%; Trichuris from 16.5 to 9.4%; Strongyloides from strengthening national research capacities in participating 11 to 0.7%. Similar reductions in prevalence were countries, to strengthening evaluation, monitoring, and observed in headlice, (Pediculus capitis), scabies (Sarcoptes surveillance systems, strengthening links between the scabiei), cutaneous larva migrans and tungiasis (Tunga health facilities and communities through community- penetrans). Heukelbach et al13 conclude, ‘ivermectin was based approaches, encouraging community engagement an effective safe means of reducing the prevalence of in health delivery, engaging local as well as international most of the parasitic diseases prevalent in a poor NGDOs, and improving all aspects of drug management, community’. These studies confirm the published benefits delivery, and distribution (see Figure 1). Systems benefits Increased participation by communities in health care Capacity Development Community directed treatment Possible entry points with other interventions Country Drug -Bednet distribution Distribution, Logistics - Measles vaccination Strengthening of Monitoring -Vitamin A and Evaluation Systems -Praziquantel for Schistosomiasis -Trachoma via Zithromax Reduced Hydrocoele -condom distribution Surgery After LF Control, Reduced Hospital Costs Links to other sectors Improved Research Education Capacity Environment Donated Drugs Mectizan® (Ivermectin) Albendazole 13 Malaria40,41 Ectoparasites Onchocerciasis Lymphatic Intestinal Filariasis37 Helminths38,39,42 Reduced Deworming Reduced frequency Reduced skin of fevers diseases Blindness Reduced Alleviation of Anaemia Improved Onchocercal Transmission Improved Nutritional status and Micronutrient uptake haemaglobin status skin disease Reduced Improved cognition Reduced cerebral Fevers Malaria frequency Increased school attendance, weight Productivity gain and physical output Health benefits Figure 1 Summary of benefits of donated drugs to disease-specific conditions and to the health system. Eye Onchocerciasis control-extended benefits DH Molyneux and V Nantulya 1052 3. The opportunities provided by the concept programmes.20–22 This donation, it can be argued, was of community directed treatment using ivermectin instrumental in maintaining donor commitment to a (CDTI)Fthe chosen method of drug delivery in engaging programme based on a ‘vertical’ intervention of vector communities in health-care issues control that could not readily be devolved to country programmes or their health services and which required The concept of utilising the CDTI approach to achieve a centralised management system and technical expertise sustained delivery of Mectizan as the most viable of a highly specialised nature. Mectizan as a product approach to achieving mass drug distribution at the combined the ideal qualities of being an efficacious drug coverage required has been well documented. Such an reducing microfilaria density in the skin, preventing approach also provides the prospect of long-term advancement of anterior segment eye lesions but also, as sustained annual distribution when support from central has been subsequently demonstrated, reducing the APOC funds terminates.17 Amazigo et al18 identify the onchocercal pruritus and skin disease, a feature of challenges as management, technical, and socio-political. onchocerciasis morbidity that previously had been less To sustain distribution systems, these authors identify the well studied.23 However, the donation of Mectizan ‘for as major challenges as timely drug collection, integrating long as needed’ for the control of onchocerciasis as a CDTI with existing primary health-care services, public health problem provided an important strengthening local health care infrastructure, maintaining opportunity to effectively engage national health services optimum treatment coverage, ensuring community self- of the participating countries in the OCP in a more monitoring, implementing locally relevant operational meaningful way in the process of devising what had research, ensuring performance of community been called ‘devolution’Fthe greater involvement of distributors, increasing
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