Quick viewing(Text Mode)

The Neglected Tropical Diseases: a Challenge We Could Rise to – Will We?

The Neglected Tropical Diseases: a Challenge We Could Rise to – Will We?

The Neglected Tropical : A challenge we could rise to – will we?

Report for the All-Party Parliamentary Group on and Neglected Tropical Diseases (APPMG)

Using presentations made to the APPMG 2008/9

Chairman: Stephen O’Brien MP Vice-Chairmen: Dr Evan Harris MP, Lord Rea, David Drew MP Treasurer: Ashok Kumar MP Secretary: Eleanor Laing MP Coordinator: Susan Dykes Website: www.appmg-malaria.org.uk Contents Chairman’s Foreword

House Of Commons Chairman’s Foreword iii The All-Party Parliamentary Group on Malaria and Neglected Tropical Diseases Acknowledgments v

1 Introduction: The Neglected Tropical Diseases 1 I am pleased to introduce and endorse the latest in our describing the suffering caused, and quantifying the 2 Group One – controlled by 2 2 series of authoritative and influential reports: the All- burden of , which remarkably has been shown 3 Group Two – Case finding and treatment 3 7 Party Parliamentary Group on Malaria and Neglected to be as high as Malaria and TB in terms of “ 4 Group Three – Zoonotic Diseases 4 9 Tropical Diseases (APPMG’s) Fifth Report entitled: Life Years” lost. They have described the complex 5 Lessons learnt from the Speakers 10 The Neglected Tropical Diseases: life cycles of the parasites which infect and sometimes their . They have stressed how 6 Conclusions and Recommendations of the APPMG 11 A challenge we could rise to – will we? these diseases affect the poorest of the poor who For the first time since the APPMG was established, cannot afford treatment, and they have described Annex 1 Summary of presentations 12 we focus our report outside the Malaria field. how the have come to the During the last two years our meetings have been of these vulnerable populations by providing attended by more and more biomedical scientists, Bibliography 15 drugs free of charge. There is still a funding gap and particularly parasitologists, interested in the wider money is needed for new drug development for tropical spectrum beyond Malaria. In particular some diseases. For other diseases funds are required Figures presentations by Sir Roy Anderson, Professor David for advocacy, for training, for drug distribution Molyneux, Dr. Lorenzo Savioli and Professor Alan Figure 1 Child with intestinal helminths 2 from the ports to the points of delivery, for health Fenwick convinced us to turn our attention to these Figure 2 Successful early deworming of children stimulates growth 2 education, for delivery through schools, health Neglected Tropical Diseases (NTDs), in addition to Figure 3 Coverage leaves a lot to be achieved 3 centres or selected drug distributors, all our continuing work on Malaria. Figure 4 from a child 3 and finally for monitoring and evaluation. Figure 5 Bloody urine caused by haematobium 3 The case for more investment in the control of However, the funding gap for all these activities is Figure 6 Advanced Schistosoma mansoni causes ascites 3 the NTDs has been promoted by a group of relatively smaller than the amounts required for Figure 7 Sighted children lead blind adults 4 international scientists who have each worked HIV/AIDs, TB and Malaria. Despite that smaller Figure 8 Lymphatic causes swelling of limbs 4 on individual diseases for many years, developing demand, filling that gap is still proving to be Figure 9 causes swelling of the scrotum 5 and validating tools for their control. Armed with problematic despite calls from the Commission Figure 10 Central African countries still need LF elimination programmes 5 proven strategies they have now combined their for , the G8, the UN Secretary General and Figure 11 cause chlamidia infection leading to 6 efforts to advocate how (not whether) we the WHO Secretary General and contributions Figure 12 Trachoma causes eye damage 6 the world of some of the NTDs, and how we from USAID and DFID. put in place control measures for other NTDs. Figure 13 infection 6 The massive numbers of people infected with NTDs As you read this report, you will be taken aback Figure 14 Man with 7 live mainly in sub-Saharan Africa, although there are at the unbelievably complicated life cycles and Figure 15 Cutaneous 7 still infected populations in , the Pacific, Central and the horrific and tragic consequences of these . Because NTDs are not necessarily mostly unknown in the Western world perceived as being responsible for the major burdens Tables – in children and stunting of growth, of disease as they are not serious causes of , Table 1 The NTDs 1 and later in life blindness, deformity, urinary tract they are nonetheless an integral cause of Table 2 The Pharmaceutical company donations 10 and intestinal damage, swellings of limbs to gross preventing progress on the Millennium Development proportions, anaemia, and . Goals. To achieve the MDGs, NTDs will need to The APPMG meetings during 2008 and 2009 have be controlled, and that control to be sustainable. If on several occasions been dedicated to NTDs. this can be achieved, a heavy burden on vulnerable Speakers have professionally presented the evidence economies will be removed.

Chairman: Stephen O’Brien MP Vice-Chairmen: Dr Evan Harris MP, Lord Rea, David Drew MP Treasurer: Ashok Kumar MP Secretary: Eleanor Laing MP Coordinator: Susan Dykes Website: www.appmg-malaria.org.uk

III Chairman’s Foreword Acknowledgements

The APPMG would like to express its deep gratitude to Professor Alan Fenwick, Director of the Control, Initiative (SCI) Imperial College London, who has prepared the Report for the Group. Our grateful thanks go to all those who made presentations to the Group since the last report: House Of Commons The Group would also like to express its grateful thanks to GlaxoSmithKline which has kindly sponsored The All-Party Parliamentary Group on Malaria and Neglected Tropical Diseases the printing of this Report. Presentations on Neglected Tropical Diseases during 2008-09 • Professor Sir Roy Anderson, Rector, Imperial College, London The APPMG has played a major role in raising the In addition to all the contributors, the Officers • Professor Alan Fenwick, Director SCI, Imperial College, London awareness of NTDs. It has been heartening to see and Members of the APPMG are deeply grateful • Professor David Molyneux, Liverpool School of the group expand not only in its remit, but also in to Professor Alan Fenwick of the Schistosomiasis addressing a wider number of attendees as well as Control Initiative (SCI, Imperial College) for his • Professor Peter Piot, Director, Institute for at Imperial College London the variety of speakers and subjects. expertise and hard work in producing this report. • Professor Chris Whitty, Director of Research, DFID So the Group is now called the All-Party I commend this report and its recommendations • Chris Gilbert, Crown Agents Parliamentary Group on Malaria and Neglected to all those who, with us, are willing to learn about • John ‘Luc’ Lucas and Adam Flynn, Sumitomo Global Control Tropical Diseases (retaining its abbreviation – infections which are common in the developing • Dr Jan Kolaczinski, NTD and Malaria Specialist, the APPMG). It remains a lively forum where, at world but which are often new to us. They infect • Dr John P Rumanu, MPH, MB.BS, Director General, Preventative Medicine, Ministry of Health, least monthly, new ideas, technologies, methods a high percentage of the world’s poor keeping Government of Southern Sudan and field work can be explained and debated them in poverty and making their lives a misery. • Dr Lorenzo Savioli, Director, NTDs WHO, Geneva, Switzerland from across the spectrum of all those involved For less than 50 pence per person per year it is • Dr Egon Weinmuller, Head of Corporate Affairs, BASF in the battle against Malaria and the NTDs. The awe-inspiring what could be achieved in treating all • Andy Wright, Director of the Lymphatic Filariasis Programme, GSK plc UK Government and the Opposition Parties are the people with these Neglected Tropical Diseases now all equally committed to Malaria control and – almost invariably the very poorest people on our • Ivan Lewis MP (previously) Parliamentary Under-Secretary at the Department of International Development) DFID has become one of the leading government planet and often hardest to reach too, across sub- departments in helping to bring tools to Saharan Africa, as well as across other equatorial • Prof. Michel Kazatchkine, Executive Director, the Global Fund communities who need them. We still maintain that continents. I urge all readers of this Report to use Many other organisations gave presentations during this period. They will all be acknowledged in the next we must control Malaria in the highest it to join in the advocacy and campaign to alleviate Group’s Report on Malaria Control. areas of sub-Saharan Africa and eliminate the NTDs – it is do-able. Let us decide to act! disease country by country, as we all work together In addition, the Group would like to express its gratitude for the financial support it receives from The Malaria to ‘shrink the map’ of Malaria. It is vital that this Consortium and Medicines for Malaria Venture. political will is maintained to sustain the long term commitment required. However while this is being done our presenters have also shown that with a smaller and cost effective intervention of just 50 pence or less per person per year, many less lethal Stephen O’Brien MP tropical diseases could be eliminated or reduced in Chairman of the All-Party Parliamentary Group and intensity of infection. We must not on Malaria and Neglected Tropical Diseases forget them because their control would alleviate the suffering on many millions, improve their quality of life, and to school-aged children give them a healthier start to life. Additionally, NTD infections may make children more susceptible to Malaria and HIV, and less likely to respond positively to against a range of diseases.

Chairman: Stephen O’Brien MP Chairman: Stephen O’Brien MP Vice-Chairmen: Dr Evan Harris MP, Lord Rea, David Drew MP Vice-Chairmen: Dr Evan Harris MP, Lord Rea, David Drew MP Treasurer: Ashok Kumar MP Secretary: Eleanor Laing MP Treasurer: Ashok Kumar MP Secretary: Eleanor Laing MP Coordinator: Susan Dykes Coordinator: Susan Dykes Website: www.appmg-malaria.org.uk Website: www.appmg-malaria.org.uk

IV V 1. Introduction 2. Group One

The Neglected Tropical Diseases Group One: Those susceptible to annual MDA (Fenwick, Molyneux et al. 2005) The various speakers described some of the major NTDs which are listed below and a small description of each of these diseases is offered – along with some graphic photographs of serious cases taken from their presentations. a. The Soil transmitted NTD Status Control Strategy (Hotez, Fenwick et al. 2009) Diseases controllable by Mass Drug MDA control Administration (MDA) When individuals have massive infections, anaemia is Soil transmitted helminths (STH) Over 1 billion infected globally Annual treatment with or the major result, and of course anaemia is the major Schistosomiasis (Bilharzia) 200 million infected – mostly in Africa Treatment with , from water contact improved water supplies cause of poor birth outcomes, and maternal Lymphatic filariasis () 120 million infected in Africa and the Indian sub Elimination strategy by six annual Mass Drug mortality. Thus hookworms are particularly serious continent, but elimination is possible Administrations with albendazole + Mectizan for pregnant women, while in children hookworm (in Africa) or albendazole + DEC (elsewhere) infections can cause stunting and retardation. Trachoma (preventable blindness) 80 million infected, 8 million visually impaired – Annual treatment with Zithromax, eliminated from Morocco as part of a “SAFE” strategy Whipworm and round worms are acquired (River blindness) 50 million infections in Africa Control of symptoms by annual treatment when the eggs or larvae are ingested. Again heavy with Mectizan Provision of filtered water infections occur in poor areas and these can lead Guinea worm Close to eradication Individual case finding and case containment, to malnutrition and stunting in children. clean water provision and filtration, These three worms used to be common in (abate), Regular surveillance of villages Diseases requiring individual treatment Case control and USA, but with widespread hygienic conditions, Leprosy Close to elimination Case finding followed by multi drug therapy () they have been eliminated from developed Buruli Endemic in 30 countries in the , Early diagnosis, treatment with countries, but over a billion people are infected Africa and SE Asia or surgery with one or more worms in developing countries. Limited distribution in South America – Control of the Bed bugs which carry a disease of poor housing the disease Yet the worms can be expelled from the body African Narrow distribution in Africa dictated Case finding and treatment; with a single 500mg tablet of a drug called by Tsetse distribution vector control where appropriate albendazole (an alternative drug is mebendazole), 1.5 million new cases for CL are considered to Early diagnosis and prompt treatment; occur annually, with an estimated 12 million people control of populations through residual which can cost as little as one penny per tablet presently infected worldwide. 90% of cutaneous spraying of houses and through the from a generic manufacturer. In practice an annual leishmaniasis cases occur in Afghanistan, , use of insecticide-impregnated bednets; , , and Syria. dose of deworming tablets throughout a child’s 500,000 cases per year. 90% of all visceral Case finding and treatment with meglumine life will have an amazing positive effect on their leishmaniasis cases occur in Bangladesh, antimoniate (Glucantime) or sodium growth and nutritional status. Brazil, , Nepal and Sudan; fatal if untreated. stibogluconate (Pentostam). Dengue 250 million at risk and 50 million cases Effective clinical management. per year in over 100 countries Fluids and possibly transfusions Vector control Percentile 17 Animal 97 Neuro-Cysticercosis Up to 20% infections in rural Africa and South America Tape worm control and strict meat inspection 16 90 Echinococcus Unknown numbers with cysts in Tape worm control in dogs and careful surgery 15 plus albendazole to remove unbroken cysts 75 Animal reservoir 14 50 Pasteurisation of milk 13 25 Rabies Transmitted by dog bites Figure 1: Child with intestinal helminths 10 12 Table 1: The NTDs 3 Three species of worms infect the “bottom 11 Weight (Kg) The extent of the problem caused by Neglected Tropical Diseases billion” who are those people who live in poverty 10 in the poorest areas of the poorest countries The NTDs have several things in common. They affect the poorest of the poor, but they rarely affect the well off, 9 because usually poor is a high risk factor (Hotez, Ottesen et al. 2006). They are neglected in terms of the of the world. They are hookworm (Necator and research and control funding allocated to them both by ‘developing world’ governments and other donors. Less Ancylostoma spp), whipworm (Trichuris species) 8 than 10% of research funds are received for NTDs compared with Malaria, HIV/Aids and TB. Some of the NTDs and the round worm (). These 7 (eg intestinal worms and schistosomiasis) infect many people but are chronic infections and so cause few , worms inhabit the human gut, and their eggs are while others (sleeping sickness and visceral leishmaniasis) infect relatively few people and are quickly fatal. passed out in the faeces. They have no intermediate 6 For illustrative purposes, the individual NTDs above have been divided into three groups; hosts but hookworm undergo a free living stage 5 1. those for which we have inexpensive, safe and effective drugs, which need to be administered just once before reinvading a human . Thiabenazole for 2 days 4 a year (annual MDA)(Hotez, Raff et al. 2007); is acquired when the larvae of 3 2. those for which improved drugs are needed, but for which there is no profitable market because those hookworm which have hatched from the eggs and 2 needing the drugs cannot pay; and lie in wait in the grass, attach themselves to the feet 0 3 6 9 12 15 18 21 24 27 and ankles of passers-by. They then penetrate the 3. the “zoonotic” diseases, which are NTDs where human infections are derived from animals and Age (Months) predominantly infect those who work with livestock. , migrate around the body, and end up finally in the gut where they attach and gorge on . Figure 2: Successful early deworming of children stimulates growth

1 2 2. Group One

than 10%. It is clearly unacceptable that children in food production. Subsequently, the ecological STH/Schisto 10% 90% Series 1 The other forms of schistosomiasis (bilharzia) rural Africa are left with these infections when it is caused by this chemical control became Series 2 treatable at a cost of 20 pence. As with intestinal unacceptable. Fortunately, in 1986 the drug Mectizan Series 3 cause intestinal schistosomiasis because the adult Lymphatic 38% 63% worms, an annual treatment reaching out to school was discovered, and its killing effect on the circulating Filariasis worms live in blood vessels around the intestine and the eggs get trapped in the liver causing aged children would have a massive effect on larvae proved to be the saviour of sight. Merck and improving the quality of life of children, and protect Co., recognising the fact that poor people in Africa Onchocerciasis 44% 56% chronic liver damage and eventually liver fibrosis. Deaths in young African adults from due them from the serious consequences of their would never be able to afford to buy even an annual 0% 20% 40% 60% 80% 100% to high blood pressure may well be due to liver infections in later life (Lammie, Fenwick et al. 2006). dose of this drug, offered to donate the drug to all who live in endemic areas “for as long as needed”. Figure 3: Coverage leaves a lot to be achieved damage caused by schistosomiasis during childhood. Are there are other methods to rid the world Infections are usually acquired when children swim, of schistosomiasis? Yes: improved water supply, Over 20 years later this donation continues. bathe or have contact with fresh water which improved and snail control. Sadly snail There is a bizarre to what seems to be harbours aquatic snails. These snails (intermediate control has not proven to be effective, because a simple control programme using annual Mass Drug hosts) become infected when human excreta chemicals which will kill snails are expensive, and Administration (MDA), and that is a parasite called (which is the route for the eggs to leave the body) environmentally unacceptable. However, economic Loa Loa which is another worm with live larvae is deposited in fresh water. The eggs hatch and development which will lead to improved water circulating in the body. Mectizan also kills these larvae larvae emerge and invade the snail, where they supplies and effective sanitation could eventually rid but sometimes with disastrous consequences [such multiply before re-emerging to infect a human. The the world of this disease. It has already happened in as………]. Thus in parts of Central Africa where Loa schistosomiasis larvae in water penetrate unbroken Japan and Puerto Rico (Fenwick 2006). Loa is endemic it is not safe to control onchocerciasis skin and migrate around the body until they reach because of the possible dangerous complications. This the liver where they grow to over a centimetre in is a matter still to be resolved. length before they pair up and start to lay eggs. c. Onchocerciasis (river blindness) d. Lymphatic filariasis (LF – elephantiasis) Figure 4: Worms from a child Another family of worms cause LF, and the deformity and misery caused by this disease are horrific. The b. Schistosomiasis (bilharzia) worms are transmitted to humans during a bite, and the larvae injected from the mosquito Three major species of schistosome worms infect develop into adult worms which migrate and invade man: one is found only in and the Far East the lymph system which they can block, causing long and it is estimated that less than a million humans, term pathology. The lymph does not drain, which but many domestic animals, carry that infection causes swelling of lower limbs, secondary infections today. Another is found in Africa, South America and, in the case of some men, the scrotum becomes and the Caribbean. The third species is found only grotesquely swollen. Meanwhile, as the pathology in Africa and the . The worms of all Figure 7: Sighted children lead blind adults is being caused by the adult worms, the millions of species live in the blood vessels of the human host larvae which the females produce circulate in the and the major symptoms are caused by the eggs A scourge of Africa and totally neglected until the blood stream to be picked up by a mosquito for the laid by the female worm. The “African species” 1970s, this worm causes blindness because the transmission cycle to be completed. causes blood in the urine in children and severe larvae produced by the adult worms in the human damage to the urinary tract, as well as bladder body migrate across the eye. The most serious effect cancer in later life (urinary schistosomiasis). Girls of the parasite larvae is irreversible blindness but infected with these worms can develop lesions in infected individuals also suffer from severe itching their genital organs making them more susceptible and skin irritation. As recently as 1970, up to 50% of to HIV infection (Stoever, Molyneux et al. 2009). populations living on the banks of fast moving rivers suffered impaired vision. Why fast moving rivers? - because the vector of this worm is the – a small biting fly that breeds in fast moving water. Figure 6: Advanced Schistosoma mansoni infection causes ascites River blindness was the first disease to be tackled 200 million people are infected globally with on a large scale in Africa in the last 4 decades. In schistosomiasis but almost 90% of those infected 1974 the Onchocerciasis Control Programme are found in Africa (Fenwick 2006). Can infected (OCP) controlled river blindness by spraying be treated? Yes - there is a generic drug using planes and helicopters into West called praziquantel which costs about 20 pence Africa’s major rivers where the Black Flies breed. for the tablets needed to treat an adult and kill This approach controlled transmission over an area the worms. How many of the 200 million infected the size of western Europe and freed up previously received treatment in 2008 ? The answer is less uninhabitable land for development - some 25 Figure 5: Bloody urine caused by Schistosoma haematobium million hectares in 10 countries significantly increasing Figure 8: Lymphatic filariasis causes swelling of limbs

3 4 2. Group One

endemic area should lead to elimination because e. Trachoma f. Guinea Worm – a worm on its own transmission will be stopped and eventually existing adult worms will die out. Of course to reach elimination it is vital that a high coverage with the annual drug regime is achieved; this is a challenge when only a small percentage of the population are infected. People are often reluctant to take drugs when they do not feel they need to. This leads to the need for effective advocacy. To aid that advocacy, it is publicized that the LF drugs also bring additional benefits by killing intestinal worms and other parasites. Figure 13: Guinea worm infection The elimination programme is being underpinned by the donation pledges of GSK (for albendazole) Imagine having a worm a metre in length crawling and Merck and Co. (Mectizan) as a result of which around your body just under your skin. This is approximately 500 million people are currently guinea worm. Infection is acquired from swallowing being treated annually with free drugs or with Figure 11: Flies cause chlamidia infection leading to trachoma infected water fleas, and this is the only way one the extremely the cheap drug, DEC (1 US cent can get infected. Thus, improved water supplies will per treatment). Sadly many people in Africa who Blindness due to Trachoma is caused by the after- prevent infection, and indeed in areas where people need the treatments are not yet receiving the effects of conjunctivitis caused by infections drink from ponds, simple filtering of this dirty water drugs as some of the key endemic countries have carried by flies. Trachoma is simply a disease of poor through muslin cloth is enough to prevent infection. yet to embrace the value that the LF programme hygiene, plus dry and dusty conditions, and poverty. In the unfortunate people who have acquired the brings. Civil unrest in many parts of Africa also After severe infections around the eyes, eyelids infection, the adult female worm, when she is ready Figure 9: Lymphatic filariasis causes swelling of the scrotum contributes to the poor coverage in some areas. become affected by scarring, and eyelashes are turned to lay her eggs, emerges through the skin usually These infections could be eliminated cheaply and Merck & Co. extended their donation of into the eye and destroy the cornea over time. around the ankle. This and so the natural effectively because scientists have shown that an Mectizan to include LF in Africa following the Early treatment is effective - an for active reaction is for the victim to run to the nearest annual dose of albendazole plus either mectizan GSK commitment to donate albendazole. This infection (Zithromax which is currently donated by water to cool the leg down – and out into the (in Africa) or DEC (elsewhere) will prevent the emphasises the capacity of global pharmaceutical Pfizer) taken annually. For existing trichiasis cases, water come millions of eggs which are ingested by worms producing larvae. Although the adult interests to work together on a major global simple surgery can correct the problem. Face-washing water fleas where they develop and wait to infect worms are not killed, no larvae can be picked up health problem: the Global LF elimination and improved water and sanitation are essential humans when ingested. The only way to remove by mosquitoes and so transmission is stopped. An programme (GAELF) is an alliance which components in a trachoma elimination strategy. the worm from the human is to catch it when it ambitious effort is being made to eliminate this represents an important operational model of The International Trachoma Initiative (ITI) promotes emerges, wrap one end around a match stick and disease: the theory is that since the worms live an effective public private partnership beyond an integrated approach named the SAFE strategy – S slowly tease it out – taking up to a week to achieve for an estimated 4-6 years, then six consecutive the target disease but focussing on elimination for surgery, A for Antibiotics, F for face-washing and this so as not to snap the worm and cause further annual treatments given to everyone in an of a global problem. E for environmental improvements to reduce the suffering from internal infection. infestation of flies. The World Health Organisation Thanks to a massive campaign by the WHO and promotion “GET 2020” and a number of NGOs this worm is almost eradicated from are very active in promoting eye care and control of Africa where less than 10,000 cases are thought both onchocerciasis and trachoma. Excellent progress to remain compared to 3 million just 20 years ago. has been made in some countries, and ITI’s flagship Most African countries have been declared free of programme has eliminated trachoma from Morocco. transmission with the disease confined to a small number of conflict zones such as Southern Sudan. Guinea worm will hopefully be the next human infection to be eradicated.

15 Pacific Island countries

LF Endemic countries

Countries using albendazole for LF elimination

Figure 10: Central African countries still need LF elimination programmes Figure 12: Trachoma damages the eye

5 6 3. Group Two

Group Two: Case finding and treatment – b. Visceral Leishmaniasis d. Chagas disease and the need for better This is the serious consequence of Another – a trypanosome – causes data, this has recently been arrested. The potential infection from a sandfly bite, and the resulting Chagas disease in the Americas and Sleeping for remain: Sleeping Sickness is a disease disease is called kala-azar or visceral leishmaniasis. Sickness in Africa. It is very similar to leishmaniasis which requires constant surveillance by national a. Leprosy The parasite invades internal organs, causing , when viewed under the microscope. It has been health authorities. Recently developed innovative anaemia, and an enlarged . It is distributed estimated that as many as 8 to 11 million people methods for the control of tsetse flies by insecticide in the tropical belt across the world and is caused in Mexico, , and South America based methods appear to work, and should be by a single cell animal (protozoa) transmitted have Chagas disease, but most of these do not deployed to reduce transmission. by . If this parasite invades the viscera know they are infected. Chagas disease in South and internal organs death is inevitable unless America is a disease of poor quality housing a correct treatment with or because it is transmitted by Triatomine bugs (bed f. (Glucantime) or sodium bugs). When a person is infected from a bed bug Buruli ulcer has been reported to WHO from stibogluconate (Pentostam) can be administered bite, the organism invades and damages the heart 30 countries largely in Africa, but the geographical quickly. Drugs are not readily available in rural and other organs, although the pathology takes distribution of the disease is not fully known due to areas, diagnosis is difficult and even if the drugs many years to develop. under-reporting and insufficient knowledge among are available they have to be paid for. Since most and improved housing and hygiene would eliminate both health workers and the public. It is caused by infected people are unable to afford them, the this disease. A is currently being tested, a mycobacterium, Mycobacterium Ulcerans, similar death rate is high. A new safe and effective drug and the antifungal agent amphotericin B has been to the organsisms which cause TB. The costs of is needed to treat this disease, and Drugs for proposed as a second-line treatment, but the high treatment if available are high as patients may require Neglected Diseases Initiative are working with cost and relatively high of the drug have extensive surgery and such cases place a huge One World Health on . An effective limited its use. Domestic transmission of the on the health facilities in hospitals Buruli drug, ambisome, exists but it is not donated hence has been controlled in 5 countries (the southern ulcer is a disease of people who live in remote, rural areas having little contact with any health Figure 14: Man with Lerosy the problems of affordability. cone in South America) by indoor house spraying with insecticide. The remaining countries in South system. Infection with the bacterium often starts as Everyone has heard of leprosy, and many probably a painless, mobile swelling in the skin but over time c. Cutaneous Leishmaniasis America have similar control plans. However, the think it no longer exists. Yes there are now many urgent need is for a new drug as the currently this leads to extensive destruction of skin and soft fewer cases of leprosy than before, and the site of used drugs have many drawbacks. A complication tissue with the formation of large ulcers usually on disfigurement is now relatively rare compared to is that Chagas Disease is also spread through blood the legs or arms. Early stage diagnosis and treatment last century but cases do still occur and must be transfusion and because of increased migration with antibiotics can prove successful, but if untreated treated. This requires a multi drug therapy package from endemic areas to USA and Europe and the the consequences can be irreversible deformity, which is donated through WHO by Novartis. donation of blood by migrants, the disease is being extensive skin lesions and sometimes life-threatening The difficulty is the early diagnosis, and beating found in non-South Americans through transfusion. secondary infections. The epidemiology of the the stigma attached to leprosy. The number of disease and how people become infected remains countries where leprosy remains a significant to be clarified although there appears to be some problem has been reduced remarkably through e. Human (HAT) association with water bodies multidrug therapy from over a hundred to nine, African Sleeping Sickness is also caused by a but in these nine (, Brazil, Central African trypanosome, but this one is transmitted by the Republic, Democratic Republic of Congo, India, that breeds in savanna and riverine g. Dengue & dengue hemorrhagic fever , , Nepal, and the United woodland in a belt across Africa. When humans (DHF) Republic of ), the prevalence remains Figure 15: Cutaneous leishmaniasis become infected from the bite of the fly, the and dengue hemorrhagic fever unacceptably and unnecessarily high. parasites first invade the blood and later invade the (DHF) are acute febrile diseases, found in the The same organism as in (b) above if it remains central nervous system with fatal consequences if , and caused by four closely related virus in the skin at the site of the sandfly bite causes untreated. There is no satisfactory treatment for HAT serotypes, transmitted by the mosquito an unsightly and expanding ulcer which does not as we remain dependent on arsenical based drugs which bites during the day. The distribution is respond well to any known treatment. At least this which are themselves dangerous, although some from northern Australia and northern , form of the disease is not fatal. Fortunately the recent progress on has been across the entirety of SE Asia, sub Saharan Africa, suppurating ulcer does not usually spread far from reported. Further research funding is needed to the Caribbean, and parts of South America. the site of the bite, and is self-curing after about discover better drugs and treatment regimes. Early Dengue is transmitted to humans by the Aedes six months. Many animals act as reservoir hosts of diagnosis is vital but methods need to be improved. aegypti daytime feeding mosquitoes. Early cutaneous leishmania - often in Asia, the Effective approaches to control have been based on treatment with therapy to tackle due to Middle East and in the Americas. mobile teams actively making microscopic diagnoses haemoconcentration and bleeding is important. and giving early treatment to those found positive. Increased oral fluid intake is recommended to Unfortunately, the reduced resources for the “mobile prevent dehydration. Internal gastrointestinal team approach” to control, and civil conflict in tsetse bleeding may occur requiring a transfusion. areas, led to a rise in Sleeping Sickness cases in the 1980’s and 1990’s. However, according to WHO

7 8 4. Group Three 5. Lessons Learnt

Group Three: animal zoonoses – b. Echinococcosis Lessons learned from the speakers on the NTDs the even more neglected tropical diseases Echinococcus is another tapeworm which normally lives in dogs with cysts in sheep. In this case the Professor Sir Roy Anderson and Professor David Molyneux presented on one day as a double act and cysts can develop in man if the eggs in dog’s faeces a. Neuro-Cysticercosis proposed a convincing argument for the APPMG to widen its remit from just malaria and embrace NTDs. are swallowed. It seems unlikely to us but it does Between them they described the life cycles of these NTDs and demonstrated graphically the horrific Cysts in the human brain cause severe , happen where young children live with their dogs cost in terms of human suffering and economic losses. Professor Molyneux emphasised the advantage of and death. But what causes these cysts in unhygienic conditions. With the adult tapeworm controlling NTDs as a means of tackling poverty and addressing the MDGs. It was also emphasised that and what is inside them? In fact, humans are living in dogs, the eggs are normally transmitted NTD control can be of great value in malaria control programmes and in reducing the spread of HIV. The accidental hosts to these cysts which really belong from dogs to sheep who ingest the eggs from importance of taking a holistic approach to the interventions available which are some of the cheapest and in the pig. The pig is the normal intermediate host dogs faeces while grazing. The cysts develop in the most effective available was emphasised. Some months later Professor Alan Fenwick and Dr Lorenzo Savioli of a tapeworm which lives in the gut of man, and liver of sheep, and tapeworms get back to the dog each gave a different slant to the NTDs, again covering aspects of their life cycles (described above), their become infected by eating the eggs which when offal is eaten by or fed to dogs. If children burden globally, numbers infected in different countries and regions, and describing attempts and progress are passed out in human faeces. When ingested have intimate contact with an infected dog and do towards elimination or control of these diseases. The efforts of a few dedicated individuals were first of all the eggs hatch and the larvae of the tapeworm not regularly, eggs can transfer into the targeted against each of the individual diseases, but more recently the speakers explained how integration of develop into a cyst full of fluid and new tapeworm child’s mouth and then cysts will grow in their liver NTD control had become the norm. WHO has established an NTD department, and countries were being heads, waiting for a human to eat the pig meat. or other organs. These cysts can cause encouraged to integrate their efforts to control NTDs. So humans get infected accidentally by somehow and can be mistaken for tumours. swallowing the tapeworms eggs in their excreta. The APPMG learned which drugs can be used to control the various diseases, and the costs of delivery have

Under conditions of poor hygiene, man can infect been calculated at approximately 50 pence per person treated per year. himself – not washing hands after defacting, for c. Anthrax Other presentations from Dr John Rumanu, Director Preventative Medicine, MInistry of Health, Government example. If a person does ingest the eggs then This disease of cows which is a killer if man gets of Southern Sudan, and Dr Jan Kolaczinski, NTDs and Malaria Specialist with the Malaria Consortium they will develop into the cysts, but in humans they infected is spread by fungal spores and these spores focussed on the distribution and burden of NTDs in Southern Sudan and a plan was presented for their develop in the brain. Humans get infected with the can lie dormant for decades. control after the recent ending of a very long civil war which had disrupted the health services in the region. adult worms by eating infected and poorly cooked These presentations emphasised the need for country commitment and NGO implementing partners pork, so meat inspection is important – but non- The following table demonstrates the contribution that pharmaceutical companies are making towards NTD control. existent in rural village settings. d. Brucellosis The tapeworm that causes cysticercosis is endemic This disease is contracted from drinking unpasteurised milk and the consequences to Merck & Co Inc – donates Mectizan for as long as needed for to many parts of the world including China, onchocerciasis and lymphatic filariasis control in Africa , India, sub-Saharan Africa, and Latin women are serious because infection tends to cause abortion or other complications during birth. America. The prevalence of cysticercosis in Mexico GlaxoSmithKline – donates albendazole for lymphatic is reported to be 3 to 4 percent, and in Guatemala, filariasis globally at least to 2020 Bolivia, and Peru rates as high as 20 percent in e. Rabies humans, and 37 percent in pigs have been reported. Pfizer – has commited to donate up to 120 million doses Although the UK is rabies-free, this disease which is In , and the Democratic Republic of of for trachoma mainly associated with dogs and foxes is prevalent Congo around 10% of the population is infected, elsewhere in the world wherever dogs exist, and the in Madagascar 16%. The frequency has decreased Novartis has a continuing commitment to bite from a rabid dog is fatal unless a vaccination is in developed countries owing to stricter meat Multi-Drug-Therapy for leprosy given almost immediately. There is now a pre-exposure inspection, better hygiene and better sanitary facilities. vaccine for humans which is expensive but a post- Johnson & Johnson – donates mebendazole for In , an estimated 75 million persons exposure vaccine should be available in hospitals and removal of intestinal worms live in endemic areas and 400,000 people have clinics in case of bites from suspect animals. symptomatic disease. Medpharm (generic manufacturer) – has donated praziquantel and deworming drugs via Canadian donations

E. Merck has committed to donate through WHO up to 200 million praziquantel tablets over 10 years

Table 2: The Pharmaceutical company donations The process of establishing a control programme and the possible strategies were also described by several speakers. In summary there are seven NTDs which are extremely prevalent globally, but which today are almost never found in the developed world. These seven (Group One above) are now known to be controllable at minimal cost using an annual dose of what has been termed a “rapid impact package” of four drugs. However the process for control was shown to be a complicated exercise in funding, advocacy and planning, with the first obstacle to be overcome being that most governments, even the Ministries of Health in endemic countries, do not encompass these diseases in their plans.

9 10 6. Conclusions & Recommendations Annex 1

Conclusions & Recommendations of the APPMG List of Presentations made to the APPMG on Neglected Tropical Diseases in 2008-09 A Summary of presentations The messages from the speakers which have been endorsed by those who have attended the APPMG are as follows: Professor Sir Roy Anderson, Rector, Imperial College, Department of Infectious Disease Epidemology, Faculty of Medicine Sir Roy presented a strong case for the control of Neglected Tropical Diseases (NTDs), he pointed out that at present control • NTDs are a diverse group of infections which tend to affect the poorest of the poor was disjointed: there were many NGOs, and many diseases but there was little co-ordination between them. Disease control was separated as for malaria, HIV and TB in the Global Fund. • Without something being done for the NTDs, the MDGs will not be attainable There was a need for co-ordinated logistics, delivery and management for all these diseases, including NTDs. The disease burden • For the first group of NTDs a cheap rapid impact package of drugs can be delivered annually at minimal was high but much of this was preventable with simple low cost but effective interventions. Governments needed to focus on cost and could easily control or eliminate the suffering of up to a billion individuals (the estimated cost is keeping structures simple. about $200 million per annum for 5-7 years) Amongst the UN Millennium Development Goals combating HIV/AIDs, TB, Malaria, and other diseases, NTDs were included in “other diseases”, he said. • A number of global pharmaceutical companies have been generous in donating their products which An estimated 500 million people in Africa infected with one or more infections which constitute the Neglected Tropical Diseases (NTDs), raise revenue in the west but are unaffordable to those who need them in the poorer countries the burden as measured by DALY’s was as great as malaria and TB. But unlike many diseases, safe and effective drugs existed for at least • Post-conflict countries and countries still in conflict probably have the greatest need for support. seven of these diseases which should make morbidity unnecessary. Sadly, those who needed them could not afford them. The pharmaceutical industry had helped in this respect with drug donations from GSK (Albendazole), Merck (Mectizan), Pfizer (Zithromax), • For some diseases new drugs are needed so further R & D should be funded Johnson and Johnson (Mebendazole) and smaller donations from MedPharm and Merck (Praziquantel to SCI and WHO respectively). • Greater attention needs to be focussed on Zoonotic In conclusion, Professor Anderson said that advocacy, mapping, training and drug delivery were needed to complete the treatments. • Endemic and neighbouring countries should increase awareness about Buruli ulcer and put up effective They were relatively inexpensive when conducted at scale. Treatment could do so much good at an extremely low cost. surveillance and reporting systems. Professor David Molyneux, Liverpool School of Tropical Medicine • Efforts to eradicate guinea worm from the last few affected countries should be supported NTDs Malaria: Realities and Operational Opportunities Professor Molyneux, who has had experience in both onchocerciasis and lymphatic filariasis, reminded the meeting that the Blair Commission for Africa Report recognized the gap in funding for NTDs with the statement: “Donors should ensure that there is adequate funding for the treatment and prevention of parasitic diseases and micronutrient deficiency.” He said that the targets of the Millennium Development Goals also needed NTD control, because this would have a significant effect on: MDG 1: Eliminate extreme poverty and ; on MDG 4: Reduce ; MDG 5: Reduce maternal mortality; MDG 6: Combat HIV/AIDS, TB and Malaria and other diseases and MDG 8: Develop a global partnership for development. Professor Molyneux stressed that NTDs affected the poorest people. “They live in areas where there are no roads, no doctors, and no drugs. Hunger and are the greatest threats; incomes are very low and the communities are in greatest need”. There have been successes: in China 350 million are now free of threat of Lymphatic Filariasis disease, because transmission has been arrested. In sub Saharan Africa, in 10 countries, Onchocerciasis (river blindness) was no longer a problem. In South America, domestic transmission of Chagas disease had been eliminated in 5 countries and transfusion transmission eliminated. In China and in , Schistosomiasis had been controlled – though not yet eliminated. In Morocco, active trachoma prevalence in under 10’s had been reduced by over 90%. In , soil transmitted helminths control had reached the target of 75% children under regular treatment at an estimated cost of US$0.02. Leprosy had been eliminated as a public health problem through Multi Drug Therapy, prevalence had been reduced by 90%; and only 6 countries out of 122 remained at risk. The Guinea Worm Eradication Programme had reduced global infections from circa 900,000 in 1990 to 25,500 in 2006. It cost around $US.50 per person per year for treatment, often much less, he said.

Andy Wright, Director of the Lymphatic Filariasis Programme, GlaxoSmithKline Mr Wright said that private sector companies had a role to play in Malaria and NTD control. GSK cared for their staff in endemic countries; cared for communities in which the company operated (mining, oil companies) and GSK believed in local and international corporate responsibility. GlaxoSmithKline in particular was one of the world’s largest pharmaceutical companies with 100,000 employees in over 100 countries. Their expertise was to develop medicines and for medical needs globally, as required. GSK was heavily involved in the development of anti-malarial drugs, development of a , and developing and using community partnership programmes. The GSK CEO, Andrew Witty, made commitments in a speech delivered at Harvard, where he stressed GSK’s flexible approach to Intellectual Property for Less Developed Countries (patent pool for medicines for NTDs). He committed GSK to reduce prices for patented medicines in the Less Developed Countries (LDCs), greater collaboration in R&D for developing world diseases, and a move to being a partner in delivering solutions (GSK would reinvest 20% back into the field). GSK had a portfolio of anti-malarials (, Malarone, LapDap, CDA), and a drug discovery unit at Tres Cantos, Spain. GSK continued to support research into Malaria, TB and other NTDs. There were 100 scientists, who were in partnership with MMV and the Alliance for TB Drug Development. The Malaria Vaccine Development Programme was run by GSK Biologicals, one of the largest vaccine companies, where the malaria vaccine candidate RTS,S had been in development for 20 years. GSK in partnership with the Gates PATH Malaria Vaccine Initiative

11 12 Annex 1

had completed Phase II trials and was entering Phase III in 7 countries. The hope was for proven 50-60% efficacy, and if successful Dr Savioli stressed the lack of funding for these diseases, both for the delivery of existing drugs, and for much needed new drugs for a vaccine should be available by 2012 he said. leishmaniasis and HAT. For Lymphatic filariasis, Leprosy, Onchocerciasis, Schistosomiasis, Helminthiasis, Trachoma and , it was a The GSK Community Partnership programmes included “Credit with Education” - (teaching village women simply a question of getting drugs distributed to those who needed them. For Human African trypanosomiasis, Chagas disease, Buruli about malaria prevention and treatment in 6 countries); “Ugandan Malaria Partnership” - AMREF (training workers ulcer, Leishmaniasis, and Dengue, case management in the field was essential. Meanwhile new drugs were required. to deliver home based treatment to children and pregnant women) and “Malaria prevention and Treatment” - Plan International For NTD control the need was for simple efficient and inexpensive diagnostic tools, oral, inexpensive drugs that did not have side- (behaviour promotion to prevent Malaria and treatment programme in Sudan). effects and integration within existing health structures if possible. This would lead to sustainable control and eventual elimination. The GSK contribution to NTD control was through their major contribution to LF control. It had been their commitment, since Dr Savioli stressed that mass drug administration was the way forward, not individual diagnosis, nor the use of delivery through the 1998, to provide albendazole to all who needed it until LF was eliminated. GSK had already donated over 5 billion treatments and community. He showed that there was a template produced by WHO that would determine the best timetable for interventions given $1 million per year in grants. It had established a factory in South Africa dedicated to albendazole production, and the potential according to the overlapping distribution of the NTDs. output from this factory was approximately 1 billion tablets per year. They were donated through WHO, in conjunction with the WHO’s recipe for success was a focus on populations to improve access to essential interventions; They would look to: Mectizan Donation Programme (MDP) to those countries embarking on an LF elimination programme. • Integrate “strategies” to improve effectiveness Sub Saharan Africa was a major recipient, 20 of 38 countries were currently under control by regular annual MDA with albendazole and either Mectizan or DEC. As it was inexpensive, in Asia, albendazole and DEC was the drug combination of choice. Since there • Improve education, environment, and local empowerment as a core for success was no onchocerciasis it could be used without needing to use Mectizan. • Encourage all-round care GSK’s mission was to improve the quality of human life, not just for the wealthy countries but wherever there was medical need. • Deliver preventive chemotherapy on large scale Malaria and lymphatic filariasis were priorities for world health and a priority for GSK. As outlined by CEO Andrew Witty at • Reinforce Primary Health Care Harvard, GSK was making new commitments and a call for other partners to join in. • Deliver focused interventions and innovation • Empower peripheral systems through training and equipment Dr. Jan Kolaczinski , Malaria Consortium, Kampala, Uganda. • Advocate access to care and mainstream society for the neglected communities NTDs in : Where could we be in 2015 and how do we get there? • Measure diseases and development indicators Presenting his overview of NTD control, Dr Kolaczinski suggested that the integration of NTD control was intuitively appealing, because of the large areas of co-endemicity; the safe and free or cheap treatments available, and treatments could be co-administered using mass drug administration (MDA). Professor Alan Fenwick, Director of the Schistosomiasis Control Initiative, Imperial College London. He estimated that the potential cost savings could be up to 46% compared to stand alone programmes, but warned that integration The Burden of the Diseases and their Impact. should not become the goal, although it could provide the means to achieve them. This presentation complemented Dr Savioli’s. Professor Fenwick described in more detail some of the life cycles, the consequences He proposed that in Africa, success could be achieved by complete LF mapping, using an integrated mapping approach (i.e. including of long term infections and attempted to describe the burden of the diseases. He also costed the control measures taking into schistsomiasis & soil-transmitted helminths (STH) and by strengthening community-based delivery. He said he would use the consideration the value of the drug donations, and suggested that control of NTDs, at least the seven that could be controlled by community-based delivery networks, and the guinea worm network to deliver drugs and complementary interventions for other NTDs. mass drug administration, was the best buy for public health. He also pointed out that there were other NTDs for which we did not have adequate diagnostic techniques, nor safe and effective chemotherapy. Dr Kolaczinski suggested that Lymphatic filariasis (LF) elimination was the ideal driver for integrated NTD control because it provided clear goals which were achievable within 5-7 years. There was little prospect of further investment once elimination has Professor Fenwick described the financial resources needed to control the seven NTDs in sub Saharan Africa, approximately $1 billion been achieved. Meanwhile the treatment of LF with mectizan and albendazole also controlled onchocerciasis, STH, lice and , over 5 years. He pointed out how little was spent on NTDs in contrast to the funding available for HIV control. He described how and strengthened health systems in the process. this could be used, and which donors had so far provided funding. The three major donors were the American people through USAID, the British people through DFID, and a private donor, Legatum, who had donated to SCI and the GNNTDC. The coverage of each disease was shown on maps, and the various organisations involved, the WHO, APOC for Onchocerciasis, Dr. John P. Rumunu (MPH, MB.BS), Director General, Preventive Medicine, MoH-GoSS, discussed the local challenges. GAELF for Lymphatic filariasis, ITI for trachoma and SCI for Schistosomiasis and intestinal helminths. They were credited for their Focussing on Southern Sudan, Dr Rumunu said that Southern Sudan covered a large area (640,000 sq. km) and dispersed population efforts. The Global Network partners were now moving towards integration of NTD control, as were the grantees supported by (10 million). In this area, there was a prolonged rainy and flooding, but more important, the Southern Sudan was emerging the USAID and funding through the contractor RTI. They were now expanding control in 10 countries with, in time, more to be from a conflict situation. For many years there had been disruption of the health infrastructure, health human resources and health added as funding was increased. care delivery system and massive population movement which had an impact on disease distribution including NTDs. The private donor Legatum supported the integrated control of NTDs in and Burundi he said. The Government of Southern Sudan did have a mission to ensure equitable sector-wide, accelerated and expanded quality health Despite all this progress, in 2008 the WHO believed that schistosomiasis and intestinal helminth treatment reached less than 10% of care for all the people in Southern Sudan, especially women and children he said. The goal of the Interim (2006-2011) was those who needed to be reached. to improve the health of the people through strengthening the at all levels. In particular, there must be a commitment to increase and strengthen the coverage of the primary health care system and services, including the referral system. In order to achieve this, the Ministry of Health would need resources both in terms of man power, funding, partnerships with international Professor Peter Piot, Director of the new Global Health Institute, Imperial College, London. agencies, NGO’s and effective planning and training. Professor Piot presented a wide ranging over view of the concept of global health as perceived today. He cited the progress that has been made The Ministry of Health (MoH) had prioritized the control or elimination of some diseases e.g. Onchocerciasis, Guinea worm and in the expansion of the coverage with ARVs in Africa to several million, at a cost reduced in 10 years from $1,000 per person to less than $100 Trachoma, while expanding resources to affect the control of Human African Trypanosomiasis (HAT) and Visceral Leishmaniasis. per person. He cited how quickly the WHO responded to the SARS threat and how a similar threat (swine flu) was being tackled in 2009. Funding from USAID would enable the MoH to move towards the integrated control of NTDs using preventive chemotherapy (PCT) Professor Piot cited the “unfinished business” in global health which is again an evolving scenario because of . However, there and complementary approaches, as recommended by the World Health Organisation. The target diseases would be Soil-transmitted was a need to focus on seven major categories if the world was to become a better place for those in the bottom billion in terms of wealth. helminths (causing , and hookworm disease), Schistosomiasis, Lymphatic filariasisTrachoma and Onchocerciasis. • Infectious diseases (,TB, Malaria and NTDs) He concluded that there was a high burden of NTDs in Southern Sudan. However, as the strategic plan and structures for NTDs control • Maternal mortality and elimination were being put into practice, this demonstrated that there was political will and a commitment. Unfortunately, current • Child health funding would only provide mapping and small scale control through MDA in limited areas, so there was still a need for more funding to scale up PCT in all endemic areas. • Neglected tropical diseases • Dr Lorenzo Savioli, Department of Control of Neglected Tropical Diseases, World Health Organisation • Malnutrition Neglected Tropical Diseases: An Overview • Primary health care Dr Savioli listed the major Neglected Tropical Diseases, and pointed out that 10 years ago Malaria, HIV and TB were considered This was illustrated by the figures which suggested that the above conditions accounted for 70% of the burden of disease in Africa, neglected. He also said that several NTDs were diseases of animals, (zoonotic diseases) and that humans could be infected accidentally. less than 10% in Europe and the USA. He showed that the were funded mainly in developing countries with Sub Saharan Africa bearing the main The message from Professor Piot was that we needed to finalize the unfinished agenda, tackle chronic diseases, ; disease burden. He said that the death rate due to NTDs was relatively low, probably about 500,000 per year, much less than HIV, urbanisation, climate change, water and population. This could only be done if we delivered new prevention & treatment TB and malaria. However, as previous speakers had done, he stressed that taken together the burden of disease due to NTDs was as technologies and ensured people had access to more effective health systems. great as malaria and TB because of the sheer numbers infected and the length of time the people suffered with the diseases.

13 14 Bibliography

Fenwick, A. (2006). “New initiatives against Africa’s worms.” Trans R Soc Trop Med Hyg 100(3): 200-7. Since 1999, the funding available for the control of diseases of poverty (neglected diseases) has increased mainly due to leverage resulting from donations by the Bill and Melinda Gates Foundation and loans from the . Many countries have embarked on control programmes on a national scale due to drug donations by pharmaceutical companies through vertical programmes. The Schistosomiasis Control Initiative has expanded its operations to cover six countries in sub-Saharan Africa, but overlap of treatments between different vertical programmes is now a reality, and so care is needed to ensure that too many different drugs are not given together. Dialogue between programme managers has increased, and integration of some programmes may offer chances of synergy.

Fenwick, A. (2006). “Waterborne infectious diseases--could they be consigned to history?” Science 313(5790): 1077-81. The development of water resources, particularly in Africa, has changed the face of the continent, opening up land for , providing electric power, encouraging settlements adjacent to water bodies, and bringing prosperity to poor people. Unfortunately, the created or altered water bodies provide ideal conditions for the transmission of and a favourable habitat for intermediate hosts of tropical parasitic infections that cause disease and suffering. The recent progress in control of these waterborne and vector-borne diseases, such as guinea worm, schistosomiasis, lymphatic filariasis, and onchocerciasis, suggests that many of them could be controlled effectively by 2015, which is the target for reaching the Millennium Development Goals. Donations of safe and effective drugs by several pharmaceutical companies, funds for delivering these donated drugs from foundations and bilateral donors, and effective global health partnerships should make these diseases history.

Fenwick, A., D. Molyneux, et al. (2005). “Achieving the Millennium Development Goals.” Lancet 365(9464): 1029-30.

Hotez, P., E. Ottesen, et al. (2006). “The neglected tropical diseases: the ancient afflictions of stigma and poverty and the prospects for their control and elimination.” Adv Exp Med Biol 582: 23-33.

Hotez, P., S. Raff, et al. (2007). “Recent progress in integrated neglected control.” Trends Parasitol 23(11): 511-4. Three years have passed since the publication of the first of a series of policy papers, which first highlighted the under-appreciated global burden of the neglected tropical diseases (NTDs) and then outlined a rationale for linking vertical control strategies for the seven most prevalent NTDs in a cost-effective pro-poor package of preventive chemotherapy. Since then, global advocacy for these conditions has increased and, with it, new funds for scale-up of integrated NTD control in sub-Saharan Africa. Recent speeches by the Director General of the World Health Organization at regional meetings have referred to NTDs as important global health priorities (www.who.int/dg/speeches/2007). Outlined here is a summary of the recent progress in global efforts to integrate NTD control, with an emphasis on the challenges that lie ahead.

Hotez, P. J., A. Fenwick, et al. (2009). “Rescuing the bottom billion through control of neglected tropical diseases.” Lancet 373(9674): 1570-5.

Lammie, P. J., A. Fenwick, et al. (2006). “A blueprint for success: integration of neglected tropical disease control programmes.” Trends Parasitol 22(7): 313-21. The rapid expansion of chemotherapy-based control programmes for neglected tropical diseases has been catalysed by funding from the Bill and Melinda Gates Foundation, donations of several drugs from pharmaceutical manufacturers, and the reduced price of the drug praziquantel. Focussing on lymphatic filariasis, schistosomiasis and soil-transmitted helminthiasis, we review here the progress made to date with the implementation and integration of large-scale control programmes. Unresolved issues include a means for rapid identification of communities at highest risk of co-morbidity, cost-effective approaches for integrating the technical interventions into setting-specific packages, and determination of the most appropriate and sustainable delivery systems.

Stoever, K., D. Molyneux, et al. (2009). “HIV/AIDS, schistosomiasis, and girls.” Lancet 373(9680): 2025-6.

15

Top View