PerspectivesPerspectives

Maintaining neglected tropical disease programmes during Jared M Alswang,a Alexis L Gutierrez,a Samantha J Sadlera & Ole F Norheimb

Neglected tropical diseases comprise 20 once again becoming neglected. A par- neglected tropical disease and/or .4 communicable diseases of different patho- ticularly salient example of this occurred Aware of the threat to existing health genic origins to tropical and during the 2013–2016 virus disease programmes that the outbreak posed, subtropical regions. These diseases dispro- outbreak in West , demonstrating WHO released guidelines for temporary portionately affect the world’s poorest and how emerging diseases threaten the sub- recommendations to allocate resources most marginalized populations.1 The global stantial progress made towards eliminating to continue to combat malaria. WHO burden of neglected tropical diseases is dev- neglected tropical diseases. based its reasoning on the notion that astating, as it affects the lives and economies fewer hospital admissions from diseases of over 1.6 billion people.2 Ebola virus disease other than Ebola would limit the spread Fortunately, in the last decade, ne- of the virus within the health-care system glected tropical diseases have begun In 2014, the Ebola virus disease and minimize the volume of patients, al- receiving global attention. sparked unprecedented media coverage lowing more resources for those infected Two movements prioritizing treatment around the world. The high case fatality with the Ebola virus.7 However, no explicit for such diseases were launched in 2012: rate, in conjunction with the symptoms recommendations were made to continue the London Declaration on Neglected of the virus, fed a media-driven sense of neglected tropical disease prevention Tropical Diseases and the World Health urgency that turned the attention of the programmes during the outbreak.4 As a Organization’s (WHO) Accelerating work world to West Africa. The outbreak hit result, many national neglected tropical to overcome the global impact of neglected Guinea, Liberia and Sierra Leone the hard- disease programmes froze operations for tropical diseases: a roadmap for implementa- est, all of which were already substantially up to two full years.5 tion.2 These two international agreements burdened by neglected tropical diseases.4 Once the Ebola outbreak appeared have helped shift the global perception of Given the relatively low mortality, yet high adequately contained, neglected tropi- such diseases from irremediable casualties morbidity of neglected tropical diseases, cal diseases and other public health of poverty to unacceptable manifestations the Ebola virus outbreak impeded the programmes were permitted to resume of global inequalities. The ’s mitigation efforts of these diseases. their respective programming. However, Disease control priorities in developing coun- As international attention and global the partial to complete cessation of these tries identifies mass drug administration, health efforts shifted to Ebola virus disease programmes during the outbreak reintro- management and early detection containment, neglected tropical disease duced, and in some cases worsened, past and treatment programmes as having high programmes, which took years to effectively implementation challenges of treatment economic impact, and therefore as priority implement, were halted in the areas where and prevention programmes for neglected approaches to attenuating neglected tropi- Ebola virus disease was most prevalent.5 tropical diseases.5 Notable challenges cal disease burden in low-resource settings.3 Expansion of endemic neglected tropical included heightened mistrust of health The signatories of the London Dec- disease treatment and prevention hinges on workers, reestablishment of logistics and laration on Neglected Tropical Diseases few resources that are delicate and difficult retraining of staff.5,6 The fragile social and have made substantial progress towards to establish, namely: trust in the health political structures for integrated mass reaching the ambitious targets of neglected system, efficient transport of medications drug administration programmes needed tropical disease management outlined in and supplies and trained health-care per- to be rebuilt, prolonging and compound- 2012. In 2018 alone, 1.12 billion people sonnel.5,6 With this outwardly more press- ing the suffering as a result of untreated received treatment for these diseases ing outbreak occurring, nearly all existing neglected tropical diseases in the interim. and 1.75 billion individuals at risk were health resources and infrastructure were Ultimately, the temporary yet dramatic identified through mapping efforts.1 These reallocated to combat the spread of Ebola. displacement of health resources during the efforts have translated into a reduction in The actions taken to combat the outbreak outbreak not only permitted regression in caseloads, with some nations even achiev- in these countries undoubtedly saved lives, neglected tropical disease control, but may ing the elimination of certain neglected but the prioritization of Ebola virus disease have also exacerbated the overall burden on tropical diseases, therefore decreasing the came at the detriment of endemic disease already resource-constrained health-care burden of disease on vulnerable popula- management. systems during the epidemic.4,6 tions worldwide.2 The concurrent burden of disease However, changes in the geopolitical from neglected tropical disease is an im- Epidemic to climate and fluctuations in funding fre- portant consideration during outbreaks. quently threaten to derail the momentum. A study estimates that almost half of the Holistic guidelines to adapt and maintain Unexpected shifts in health priorities leave total population of the three countries neglected tropical disease treatment and neglected tropical diseases vulnerable to hardest hit by the outbreak has at least one prevention are needed to prepare for the

a Harvard Medical School, 25 Shattuck St, Boston, MA 02115, United States of America. b Department of and Primary Care, University of Bergen, Bergen, Norway. Correspondence to Jared M Alswang (email: jared​_alswang@hms​ ​.harvard​.edu). (Submitted: 6 June 2020 – Revised version received: 21 December 2020 – Accepted: 21 January 2021 – Published online: 1 April 2021 )

Bull World Health Organ 2021;99:473–474 | doi: http://dx.doi.org/10.2471/BLT.20.269464 473 Perspectives Maintaining neglected tropical disease programmes during pandemics Jared M Alswang et al. next inevitable epidemic – or pandemic. not directly related to their management, the progress made thus far in mitigating However, historically, efforts to synthe- neglected tropical disease management is the disproportionate neglected tropical size guidelines from best practices during under an even greater threat than before. disease burden on low- and middle- specific epidemic (or pandemic) responses Therefore, having robust guidelines on income countries, efforts must be made have been inadequate. A recent study securing and efficiently using programme for resource allocation to allow evidence- found the methodological and reporting resources and infrastructure is critical to based programmes to be prioritized and quality of general governing guidelines optimize neglected tropical disease opera- not compromised in the wake of other for the severe acute respiratory syndrome tions during pandemics. pandemic responses. coronavirus 2 (SARS-CoV-2) pandemic The regression of neglected tropi- are insufficient to manage the public Local vs global cal disease management seen during the health crisis; the same happened during Ebola outbreak foreshadows what may the Ebola virus disease, and As our knowledge of SARS-CoV-2 contin- happen on a global scale if we fail to other outbreaks.8 ues to evolve, so does our understanding learn from past outbreaks. As the SARS- Programme management for ne- of fundamental practices key to contain- CoV-2 pandemic continues to unfold, glected tropical disease is no exception. ing the virus. Importantly, differences studies are needed to: (i) clarify why and For example, in June 2020, WHO advised in context and culture between affected how neglected tropical disease resources that community-based neglected tropi- communities often inform their respec- shift; (ii) understand the impact of these cal disease interventions, including mass tive approaches to implementing resource shifts on neglected tropical treatment, community-based surveys and control practices.11 Local stakeholders disease burden; and (iii) understand the active case-finding, be postponed until should be involved when determining perspectives of local stakeholders who further notice in the wake of the SARS- the most effective interventions for a control and/or receive these resources in CoV-2 outbreak.9 The decision to pause given local setting,12 including how to ap- preparation for inevitable future pandem- these programmes also contrasts with propriately tailor resource allocation for ics. Moreover, integrating these findings WHO’s recommendations in 2017 fol- neglected tropical diseases as part of the with lessons learnt from current practice lowing the Ebola virus disease outbreak, larger conversation around SARS-CoV-2. is critical to inform unified guidelines for where maintenance of neglected tropical International guidelines for management optimal resource allocation to neglected disease treatment, surveillance and multi- of such diseases in pandemic settings tropical disease management during disciplinary programmes was described as should therefore include frameworks for novel disease outbreaks. An improved critical to disease management.10 effective local adaptation of core prin- understanding of how management of These conflicting recommendations ciples and recommendations. Moreover, these diseases might be best leveraged highlight both the inefficiency with which prioritizing locally informed approaches during a pandemic to optimize resources we have tackled in the past and will help secure the involvement of lo- and minimize loss of life is imperative the lack of progress since. The health com- cal stakeholders, reinforcing the care for to overcoming the current SARS-CoV-2 munity should recognize and learn from people with neglected tropical diseases. pandemic and informing our approach to these shortcomings during the current Historical precedent and increasing the next outbreak. ■ pandemic, for both present and future globalization make us predict that SARS- practices. With the heightened propensity CoV-2 will not be the last pandemic to Competing interests: None declared. for pandemics to affect operations that are uproot global health infrastructure. Given

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