Advocacy Brief . September 2017

Vector control : the untapped potential for neglected tropical diseases

►► control has long been an under-funded aspect of the neglected agenda, yet it has huge potential for tackling the spread of many of these diseases and supporting NTD elimination efforts

►►The WHO Global Response 2017 – 2030 provides the strategic blueprint for scaling up vector control, by endorsing the strengthening of national capacity and increasing research and innovation

►►Strong political will, sustainable and predictable financing, and inter-sectoral collaboration will be crucial for the successful scaling up and integrating of vector control strategies

populations. Mosquitoes are the most common and Vectors and neglected best known vector, with mainly Aedes, and tropical diseases Culex genera involved in disease transmission. Sand flies, fleas, ticks, black flies, triatomine bugs and some Nine of the 12 major diseases that are transmitted by freshwater snails are also responsible for transmitting vectors are classified as neglected tropical diseases some of these diseases. (NTDs) and they collectively account for nearly 300,000 deaths a year1. Despite this, vector control Some vectors are responsible for spreading multiple interventions for these diseases have often been diseases, such as the Aedes , which can an overlooked and under-funded aspect of NTD transmit chikungunya, dengue, yellow fever, Zika prevention, control and elimination strategies. The virus disease and lymphatic filariasis. In total over 80 scale up of mass drug administration has been highly percent of the world’s population now live in areas effective at driving the NTD agenda in recent years; at risk from at least one vector-borne disease, and 2 however, in order to continue making progress and over 50 percent are at risk from at least two . These tackle the challenge of rapidly spreading and newly diseases disproportionately affect low and middle- emerging diseases, now is the time to make vector income countries, which are also the countries with control a central part of NTD control approaches, fewer resources to adequately manage a high disease where it is expected to have a significant impact. burden.

Vectors are organisms that transmit Successful vector control, predominately though and parasites from one infected person (or animal) the distribution of -treated nets and to another, causing serious diseases in human indoor residual spraying, has been at the heart of the

1 WHY ARE VECTOR-BORNE successes achieved against since 2001, with outbreaks have been also increasing in refugee camps, mortality rates falling by an impressive 62 percent3. such as the recently reported outbreak of cutaneous 10 DESEASES SPREADING? Advances against and onchocerciasis leishmaniasis among Syrian refugees in Lebanon . have similarly relied upon significant investments in vector control4. With this history of success, now is In Europe, an increased number of autochthonous the time to unlock the potential of vector control for visceral leishmaniasis cases have been reported a broad range of NTDs. in Italy, and there was an outbreak of urogenital schistosomiasis in Corsica in 2013, demonstrating that high income countries too are increasingly at risk The rise of vector borne 11,12 from vector-borne diseases . This became sharply RAPID AND UNPLANNED LACK OF PROVEN, diseases apparently with the emergence of disease URBANISATION EFFECTIVE VECTOR over the last few years, which has quickly risen to being CONTROL INTERVENTIONS The last few decades have seen both the spread of seen as a major threat. Cases have been existing major vector-borne diseases as well as the reported in 67 countries, mainly across the Americas Rapid and unplanned urbanisation There is a lack of proven, effective emergence of new challenges to existing disease and South East since 2015, including the United is putting large populations at risk vector control interventions, from the emergence and expansion partly due to insufficient quality control strategies. Combined, vector-borne diseases States of America13. of certain arboviral diseases, such research on what works, why and now account for roughly 17 percent of the global as dengue and Zika virus disease, in what context communicable and cause about Why are vector-borne which are spread by mosquitoes 5 700,000 deaths a year . diseases spreading? Dengue, which is transmitted principally by the Aedes aegypti mosquito, has seen the most dramatic spread, In order to develop effective responses and invest with the number of cases exploding from just 15,000 resources responsibly, we need to know why these per year in the 1960s6, to an estimated 390 million in vector-borne diseases are spreading. Understanding 2012. In this time it has also spread from nine to 128 the complex relationship between disease, vector, countries, with cases of dengue reported on every human and/or animal host and the environment is one continent in 20127. The true burden of dengue is of the key challenges to knowing how to defeat these CHANGING LAND INCREASED GLOBAL TRAVEL hard to predict, but around 500,000 people require diseases, as well as predict where the next global threat USE PATTERNS AND TRANSPORTATION hospitalisation each year and roughly 12,500 people could come from. OF GOODS die from the disease8. The realisation that we are not well equipped to deal Changing patterns are Increased global travel and drastically altering the environment, transportation of goods is There has been an increase in the number and severity with the speed, scale and variety of threats posed modifying vector habitats and facilitating the spread of vectors of chikungunya outbreaks in recent years too, with by infectious diseases prompted Dr Margaret Chan, bringing humans into greater and humans infected with diseases, over two million suspected cases in the Americas speaking at the 69th World Health Assembly in May contact with vectors which can then be transmitted to 9 alone between 2014 and 2016 . Similarly yellow fever, 2016, to state simply that “the world is not prepared vulnerable populations also spread by the Aedes mosquito and which had all to cope”. If we are to halt and reverse the spread of but disappeared from Central and South America, diseases like dengue, as well as be prepared for the next has re-emerged as a concern. Disease threat, we urgently need to invest in vector control.

Main vector-borne neglected tropical diseases INSECTICIDE RESISTANCE

▶▶ Dengue Climate change is expected to have Insecticide resistance is a growing ▶▶ Chikungunya an impact on the environment and challenge that threatens the Lymphatic filiarisis ▶▶ ecosystems, causing changes in vector efficacy of existing vector control ▶▶ Chagas disease distribution, composition and vector interventions ▶▶ Onchocerciasis habits that could lead to greater ▶▶ Japanese encephalitis burdens of vector-borne diseases ▶▶ Human African trypanosomiasis ▶▶ Leishmaniasis ▶▶ Schistosomiasis

2 WHY ARE VECTOR-BORNE

DESEASESwhy are vector-borne diseases SPREADING? spreading

RAPID AND UNPLANNED LACK OF PROVEN, URBANISATION EFFECTIVE VECTOR CONTROL INTERVENTIONS Rapid and unplanned urbanisation There is a lack of proven, effective is putting large populations at risk vector control interventions, from the emergence and expansion partly due to insufficient quality of certain arboviral diseases, such research on what works, why and as dengue and Zika virus disease, in what context which are spread by mosquitoes

CHANGING LAND INCREASED GLOBAL TRAVEL USE PATTERNS AND TRANSPORTATION OF GOODS Changing land use patterns are Increased global travel and drastically altering the environment, transportation of goods is modifying vector habitats and facilitating the spread of vectors bringing humans into greater and humans infected with diseases, contact with vectors which can then be transmitted to vulnerable populations

CLIMATE CHANGE INSECTICIDE RESISTANCE

Climate change is expected to have Insecticide resistance is a growing an impact on the environment and challenge that threatens the ecosystems, causing changes in vector efficacy of existing vector control distribution, composition and vector interventions habits that could lead to greater burdens of vector-borne diseases

3 THE WHO RESPONSE FRAMEWORK FORTHE WHO RESPONSE VECTOR FRAMEWORK FOR VECTOR CONTROL CONTROL

REDUCE THE BURDEN AND THREAT OF VECTOR-BORNE DISEASES THAT AFFECT HUMANS

EFFECTIVE, LOCALLY-ADAPTED AND SUSTAINABLE VECTOR CONTROL

PILLARS OF ACTION

P Strengthen inter- and intra-sectoral P Enhance vector surveillance and monitoring action and collaboration and the evaluation of interventions P Engage and mobilise communitites P Scale up and integrate tools and approaches

FOUNDATION

ENHANCE VECTOR CONTROL INCREASE BASIC AND APPLIED CAPACITY AND CAPABILITY RESEARCH AND INNOVATION The capacity and capability of many endemic Research must be the foundation upon which countries to carry out effective and sustainable health interventions are based, however, there vector control is poor. The first foundation is a knowledge gap across a range of vector element is therefore to strengthen the health control areas. Research, therefore, must system and infrastructure to build national prioritise: capacity. Four stages are outlined for each P Assessment of health-system resilience country: P Better vector sampling tools P Carry out a vector control needs assessment and develop a mobilisation plan P Innovations for new tools, technologies and approaches P Appraise and enhance the entomology workforce P Improved evidence base on impact of current and new interventions P Train relevant Ministry of Health staff in entomology P Measurement of environmental changes P Establish national and regional institutional P Strengthen trans-disciplinary approaches networks for training and education ENABLING FACTORS

P Advocacy, resource mobilisation P Country leadership P Regulatory, policy and and partner coordination normative support

Adapted with permission from World Health Organization (2017), Global Vector Control Response 2017-2030

4 ►►Integration within and between sectors: The WHO Global Vector responsibility for implementing vector control lies Control Response Strategy with a wide range of stakeholders in and beyond the health sector. Coordination of activities and 2017-2030 information sharing will be essential to ensure efficient use of resources. In response to the spread and emergence of vector- borne diseases, the World Health Assembly ratified the Global Vector Control Response 2017-2030 in May Costs and benefits of investing 2017. The Global Vector Control Response builds upon in integrated vector control the integrated vector management approach, but goes further by focusing on the need to strengthen for NTDs human capacity to advocate, plan and implement vector control in an integrated manner. It provides the Implementing WHO’s Global Vector Control Response framework for the scaling up and integrating effective, will require significant financial investment. The cost locally adapted and sustainable vector control of carrying out the priority activities outlined under strategies globally, with the aim of reducing the burden the Foundation and Pillars of Action in the framework and threat of vector-borne diseases. The response (page 4) for the interim period 2017–2022 has been framework, endorsed by the WHO, comprises two estimated at US$330million per year. This amounts foundation elements, four pillars of action and three to about US$0.05 per person per year at risk from at enabling factors (see page 4). least one vector-borne disease, excluding the cost of commodities, implementation and research and What does integrating vector development14. control mean? The benefits of scaling up vector control are numerous and go beyond reducing the suffering and estimated 15 Integrating vector control across diseases will reduce 700,000 deaths they cause each year . These duplication, improve efficiency and rationalise the diseases disproportionately impact the poorest and use of limited resources, so that they can be directed most vulnerable and the costs of treatment can push where they are needed most: families further into . The illness and disabilities that they cause can inhibit the ability of people to ►►Interventions can be integrated: combining work, reducing family incomes and limiting employee vector control interventions to target every productivity that negatively impacts national vector responsible for human illnesses, as well as economies. For example, it has been estimated that integrating vector control to compliment MDA $842 million is lost in India each year to treatment and other public health strategies preventing costs and reduced work days associated with diseases. lymphatic filariasis16. The annual global cost of Chagas ►►Disease and entomological mapping can disease in 2013 was calculated to be roughly $7 billion, be integrated: by conducting an integrated while human African trypanosomiasis is estimated to situational analysis of a country’s vector species impact more than 40 percent of the annual income of and vector-borne diseases, a fuller picture of affected rural households in the Democratic Republic the national context can be gained, which will of Congo17. Making progress against these diseases strengthen our understanding of what vector is therefore an important step for tackling poverty control strategies are needed and when, and and promoting prosperity in low and middle-income therefore avoid the deployment of unnecessary countries. interventions. ►►Capacity building can be integrated: by Vector control and the Global training laboratory and entomologists to work on Goals all the relevant vectors that cause priority diseases in that country (e.g. malaria and vector-borne Tackling vector borne diseases will contribute to NTDs), in order to strengthen much-needed achieving a large number of the Global Goals for capacity and use existing resources for multi- Sustainable Development, as can be seen on page 6. vectorial approaches.

5 VECTORvector control and the global CONTROL goals AND THE GLOBAL GOALS

Vector-borne diseases By reducing the prevalence of the major disproportionately vector-borne diseases, vector control affect the poorest and contributes to defeating malaria and NTDs, most vulnerable in achieving universal health coverage, and society, trapping people reducing maternal and neonatal mortality in a cycle of illness, suffering and poverty

Some vector-borne diseases disproportionately affect women, due to either higher exposure or biological vulnerability such as pregnancy, while others predominantly affect men, as the result of occupation-related exposure

Vector-borne Water plays a crucial role in the life cycle of The construction of diseases can cause most vectors and many diseases. Therefore hydro-electric dams a significant level of cooperation and integration with the water result in complex school absenteeism and sector will be necessary for environment changes during high vector control to be successful that alter vector transmission seasons, , and seriously impacting have been linked the educational to outbreaks of opportunities of schistosomiasis and Cities need to be built children. changes to malaria in ways that reduce also cause epidemiology vector habitats underperformance at school and adversely affect the overall physical and mental development of children, with a devastating impact on Vector-borne diseases Successfully implemented vector control their future cause illness, disability will lead to cleaner, safer and more and stigma that damage sustainable cities and communities, without economic growth, the breeding grounds for vectors reduce productivity and hinder the potential of the workforce

It is expected that global warming will cause Successfully more outbreaks of vector-borne diseases, implemented vector leading to higher disease burdens across a control will require a larger number of countries. Vector control joint commitment and can therefore be considered a form of coordinated efforts climate adaptation from partners across sectors and countries

6 Recommendations

In order for vector control to be successfully ►►NATIONAL GOVERNMENTS should implemented and the Global Vector Control take action to integrate disease-specific Response achieved, programmes to ensure resources are recommends that: allocated where they are needed most. Political leaders should show strong ►►DEVELOPMENT PARTNERS should leadership including providing a positive conduct advocacy to raise awareness regulatory and policy environment, of vector borne diseases, mobilise facilitating cross-sector collaboration, stakeholders across sectors to take allocating sufficient national resources action, and work with civil society and and mobilising other domestic funding. community groups to hold governments to account on vector control progress. ►►THE WORLD HEALTH ORGANIZATION should provide ►►DONORS should work with endemic technical guidance, facilitate the efficient countries to take a more integrated uptake of proven and new vector control approach to vector control by providing tools, and coordinate capacity building long-term, predictable funding that activities at the regional and country incentivises integration. Allocation level. Local WHO offices support of funding should be based upon countries to develop disease and vector needs identified through a bottom-up surveillance capacity and a locally- approach. tailored surveillance strategy. ►►INTER-SECTORAL NATIONAL ►►ACADEMIA should conduct robust TASKFORCES should be established basic, applied and operational research to facilitate cross-sector collaboration, to the highest standard to add to the comprising ministers from all relevant evidence base that informs vector departments. The responsibility of control interventions. The applied tackling vector borne diseases is shared research agenda should be guided by by all in society. national vector-borne disease control ►►THE PRIVATE SECTOR should work programmes, and aimed at linking with donors through public-private entomological control with impact on partnership mechanisms in order disease burdens. to provide the market incentives for developing new drugs and , which would otherwise not be commercially viable. ►►COMMUNITIES in endemic countries should mobilise in order to hold their governments to account, and work with partners and institutions to develop and implement local, context-specific solutions.

7 ABOUT MALARIA CONSORTIUM

Malaria Consortium is one of the world’s leading international non-governmental organisations. Our mission is to improve lives in and Asia through sustainable, evidence-based programmes that combat targeted diseases and promote child and . We target key health burdens, including malaria, , dengue and neglected tropical diseases (NTDs), along with other factors that impact child and maternal health. We achieve our goals by:

▶▶ designing and conducting cutting-edge implementation research, surveillance and monitoring and evaluation ▶▶ selectively scaling up and delivering sustainable, evidence-based health programmes ▶▶ providing technical assistance and consulting services that shape and strengthen national and international health policies, strategies and systems and build local capacity ▶▶ Seeking to ensure our experience, thought leadership, practical findings and research results are effectively communicated and contribute to the coordinated improvement of access to and quality of healthcare

We work across Africa and Asia with communities, government and non-government agencies, academic institutions, local and international organisations, to ensure good evidence is used to improve delivery of effective services. We currently operate in , , , , , , , Sierra Leone, , and .

Notes 8. Malaria Consortium, Dengue: Falling Between the Cracks (2016) 1. World Health Organization, Global Vector Control Response 9. www.who.int/mediacentre/factsheets/fs327/en/ 2017-2030 (2017) 10. wwwnc.cdc.gov/eid/article/20/10/14-0288_article 2. World Health Organization, Global Vector Control Response 2017-2030 (2017) 11. www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20530 3. World Health Organization, World Malaria Report 2016 (2016) 12. www.ncbi.nlm.nih.gov/pubmed/27197551 4. World Health Organization, Global Vector Control Response 13. www.who.int/emergencies/zika-virus/situation-report/25- 2017-2030 (2017) august-2016/en/ 5. World Health Organization, Global Vector Control Response 14. World Health Organization, Global Vector Control Response 2017-2030 (2017) 2017-2030 (2017) 6. Anders KL and Hay S. ‘Lessons from control to help meet the 15. World Health Organization, Global Vector Control Response rising challenge of dengue’. Lancet Infectious Disease, 12(12): 977- 2017-2030 (2017) 984. (2012) www.thelancet.com/journals/lancet/article/PIIS1473- 16. Ramaiah KD, Das PK, Michael E, Guyatt HL. ‘The economic 3099(12)70246-3/ burden of lymphatic filariasis in India’. Parasitology Today. 16:251–3 7. Brady OJ, Gething PW, Bhatt S, Messina JP, Brownstein JS, (2000). Hoen AG et al. ‘Refining the global spatial limits of dengue virus 17. World Health Organization, Global Vector Control Response transmission by evidence-based consensus’. PLoS Neglected 2017-2030 (2017) Tropical Diseases, 6(8):e1760. (2012) http://journals.plos.org/ plosntds/article?id=10.1371/journal.pntd.0001760

For more information, please contact Oliver Williams, [email protected]

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