Category Archives: Africa

Measuring the District Health Sister of Kenema, Sierra Leone to determine the appropriate dosage of NTD medicine for her. Photo: FHI360

Down But Not Out: Sierra Leone’s NTD Program Restarts Activities as the Ebola Threat Subsides

It all started a year and a half ago in Guinea, West Africa, when in December 2013, the country reported several cases of the Ebola Virus Disease (EVD). By March 2014, the outbreak had spread to neighboring Liberia. In May, it reached also Sierra Leone, dealing a huge blow the country’s public health system, including its Neglected Tropical Diseases (NTD) program.

Sierra Leone is a poor West African country with poor health indicators. A decade earlier, a twelve-year civil war (1991-2002) had devastated the economy and almost brought the entire health care system to a standstill. Nevertheless, the country made progress in revamping its socio-economic situation after the war, and the outlook appeared optimistic. In the health arena, FHI 360 was in the forefront of assisting Sierra Leone in rebuilding its public health system. Through the USAID-funded END in Africa project, FHI 360 has supported a successful integrated NTD program since 2010 in Sierra Leone that targets 7 NTDs: lymphatic filariasis (LF), schistosomiasis (SCH), trachoma, onchocerciasis (oncho) and three soil-transmitted helminthes (STH).

Shortly after the EVD outbreak began in Sierra Leone, all public health program activities were suspended in the country, including those involving NTDs. Consequently, the NTD Program (NTDP) was unable to provide any mass NTD treatments in Sierra Leone in 2014, as the EVD outbreak had spread to all 14 districts in the country, bringing the country to a virtual stand-still.

Almost an entire year passed before the NTDP was able to resume mass NTD treatments. Even now, three of the country’s 14 districts (the Western Urban, Kambia and Port Loko districts) are still working toward containing the outbreak.[1] However, mass drug administration (MDA) for LF, Oncho, STH and SCH (baseline studies have shown that trachoma is not endemic in Sierra Leone) was successfully resumed in May 2015, on the heels of a recent nationwide malaria MDA and vaccination campaign.

Preparing for Sierra Leone’s 2015 NTD MDA

After a year-long interruption in mass treatment, Sierra Leone’s national NTDP and Helen Keller International (HKI), END in Africa’s sub-grantee in Sierra Leone, carefully planned and carried out many preparatory activities prior to embarking on the country’s 2015 NTD MDA campaign. These included conducting:

  • An NTD stakeholders meeting to plan the resumption of NTD activities in Sierra Leone (February 2015).
  • A national refresher training session for trainers in the Bo district (March 7, 2015).
  • A refresher training for peripheral health unit (PHU) district personnel (March 24 – April 4, 2015).
  • Social mobilization through radio discussions and community meetings in every community targeted for treatment in 12 provincial districts (April 2015).
  • Special advocacy and social mobilization meetings in the 3 districts that failed the last pre-transmission assessment surveys (pre-TAS) for LF conducted in 2013 (Koinadugu, Bombali and Kailahun districts). These meetings targeted paramount, section and village chiefs, people in the community, health workers and community volunteers such as community directed distributors (CDDs).
  • Advocacy and social mobilization meetings led by the district health management teams (DHMTs) under the supervision of the NTDP and partner organizations in all 12 provincial districts (May 2015).
  • Training for the CDDs, led by PHU staff supervised by DHMTs, the NTDP and partner organizations (May 2015).


Leading by Example to Regain Trust

As the MDA was getting underway in late May 2015, END in Africa Technical Advisor (TA) Dr. Joseph Koroma visited the community of Komende Luyama in the Kenema district, which was conducting MDA for LF, oncho and STH.

“The MDA in Komende Luyama was just getting started on the day of my visit,” Dr. Koroma said. “Only after Chief Musa Lahai, the village chief, and the village’s two community nurses took the NTD treatment, would the people in the community consent to taking the treatment themselves.” He added that three members of the district health team who had accompanied him to the village, also took the NTD treatment in front of community members to further convince people to take the treatment.

“END in Africa will continue to support HKI and the national NTDP in the process of reestablishing NTD program activities in Sierra Leone, so that the effect of the EVD on NTD control and elimination efforts will be minimal,” he said. While there’s a clear need for special social mobilization in order to convince community members to take the NTD treatment, given the country’s terrible experience with EVD, early indications are that Sierra Leone’s 2015 MDA will ultimately be considered a success.

[1]Sierra Leone cannot be declared EVD-free until every health district in the country has no new cases for at least 42 consecutive days. According to the MOH EVD situation report of June 17, 2015, 11 of Sierra Leone’s 14 health districts have not reported any new EVD cases in the past 42 days or longer. They include: Pujehun and Kailahun, with no new cases for over 6 months; Bonthe and Bo, with no new cases for over 5 months; Kenema, Kono, Tonkolili and Moyamba, with no new cases for over 3 months; and Bombali, Koinadugu and Western Rural, with no new cases in 81, 60 and 55 days, respectively. Three districts still intermittently report new EVD cases (1-3 per day): Western Urban district has gone 18 days without a new case, but Kambia and Port Loko each had 1 new confirmed case during reporting period.

Photo: Measuring the District Health Sister of Kenema, Sierra Leone to determine the appropriate dosage of NTD medicine for her. Credit: FHI360

This blog was originally published on the End Neglected Tropical Diseases in Africa blog.

Children at dusk in Malawi

Calling Time on Urogenital Schistosomiasis

I spent many of my teenage years living in Malawi, enjoying swimming in beautiful Lake Malawi. Wind on to age 30, and I was struggling to get pregnant. Eventually, following illness, I was diagnosed with schistosomiasis by a consultant and colleague at the Liverpool School of Tropical Medicine. I was told that I had probably been infected for a while and that it might be affecting my fertility. So I took praziquantel, the only available drug against the parasite, and soon after I was pregnant. Today my first born daughter is 10 years old. Whilst the links between urogenital schistosomiasis, sub-fertility and HIV have become increasingly well-established over my first born daughter’s life time, a combined and robust health systems action that brings together neglected tropical disease, sexual and reproductive health and HIV communities to address and scale up treatment for urogenital schistosomiasis is sadly lacking.

It is 20 years since the Beijing Women’s Conference and the International Conference Population and Development and the sexual and reproductive community have been taking stock on progress, challenges and future priorities. I attended a research agenda setting meeting on sexual and reproductive health, rights and gender at the WHO on 12th and 13th of January, where we discussed how to best decide priorities for action. Scaling up treatment for urogenital schistosomiasis is arguably a win-win.

The global burden of disease

Schistosomiasis is wide spread and there are two forms of disease, intestinal and urogenital. An estimated 600 million people are at risk of being infected and approximately 200-220 million people are living with schistosomiasis in Africa. Of the people infected with urogenital schistosomiasis it is thought that between about 100 and 120 million suffer from urinary and reproductive tract damage, which also impacts directly with HIV co-infection and sub-fertility in general. Typically many adolescent girls and women exhibit several symptoms in their lower genital tract where overt bleeding and unpleasant discharge, general discomfort and pain during sex can lead to low self-esteem, depression and stigma.

Peter Hotez estimates that globally there are between 67-200 million cases of urogenital schistosomiasis among girls and women. Hotez argues that between 20 million and 150 million girls are affected, possibly making it one of the most common gynaecological conditions in sub-Saharan Africa but unfortunately much under-reported. Urogenital schistosomiasis, as in my experience, also affects fertility and it is estimated to reduce a woman’s reproductive health capacity by up to 75%.

The links between urogenital schistosomiasis in women (female genital schistosomiasis) and HIV are well established. Writing in the Lancet, Stoever and colleagues argue that up to 75% of girls and women infected with female genital schistosomiasis develop often irreversible lesions in the vulva, vagina, cervix, and uterus, creating a lasting entry point for HIV and discuss how research in Zimbabwe showed that women with female genital schistosomiasis had a threefold increased risk of having HIV. In a recent review of the evidence Pamela Mbabazi and colleagues argue that “Studies support the hypothesis that urogenital schistosomiasis in women and men constitutes a significant risk factor for HIV acquisition due both to local genital tract and global immunological effects”.

Gender, equity and rights

There is remarkable overlap between the maps showing high HIV prevalence in Africa (particularly amongst women and adolescents girls) and those showing cases of female genital schistosomiasis. A complex interplay of biological, social and cultural factors means that young women are particularly vulnerable to HIV in sub-Saharan Africa. Gender norms also shape exposure to urogenital schistosomiasis, with women being particularly responsible for activities involving water in many communities (washing, cleaning, collecting water etc). Drawing on work from Ghana, Vlassoff and Manderson have shown that women interact with water significantly more often than men.

What to do?

Several tens of millions of praziquantel tablets are now donated each year by Merck-KGaA for mass drug administration campaigns as a cost-effective method to protect people from the urogenital schistosomiasis. Hotez argues that by preventing female genital schistosomiasis in sexually active women we have an innovative and timely opportunity to reduce and likely much reduce HIV transmission throughout many rural areas of sub-Saharan Africa.

But in infected communities treatment also needs to start early.

Stoever and colleagues argue that periodic and regular treatment with praziquantel from when children are first infected should prevent the development of genital lesions, which increase HIV risk and cause gynaecological problems. Treatment, however, may need to be started even earlier as the extent and burden of schistosomiasis in pre-school-aged children is being more fully described.

To make progress in this area we need joint action between the HIV, sexual and reproductive health and neglected tropical disease communities. Health workers and communities need more information on the multiple impacts of urogenital schistosomiasis and how it can be treated.

The lack of action to date on urogenital schistosomiasis clearly illustrates the importance of new partnerships and new approaches to scaling up strategies to address neglected tropical diseases. COUNTDOWN, a new initiative in Cameroon, Ghana and Liberia, will be paying close attention to the potential role of close-to-community providers such as drug distributors in providing an interface between communities and health systems.   We will also evaluate how to deliver equitable drug delivery for schistosomiasis through the inclusion of preschool-aged-children, out-of-school-children and adults. The Director of COUNTDOWN is helping to co-organise a meeting in South Africa later in the month where several members of COUNTDOWN will also attend. It brings together world leaders in the field of schistosomiasis, HIV and paediatrics to present on the current state and future direction of research on female genital schistosomiasis.

COUNTDOWN is set to foster and to stimulate others in thinking of innovative ways of prompting a synergistic approach to neglected tropical diseases which crosses sectors and builds strength in national health systems.

If you would like to find out more follow us on Twitter or email Rachael Thompson.

This blog post was writtem by Sally Theobald, COUNTDOWN Consortium & Research in Gender and Ethics: Building stronger health systems (RinGs), and was originally posted on Cross-Talk: A Place to Share New approaches to Neglected Tropical Diseases.

Photo courtesy of Andrew Whalley. Children at Dusk.

Endemic Countries Lead the Fight against NTDs



Nearly 1.8 billion people require treatment for neglected tropical diseases (NTDs). Many of these diseases can be easily prevented or treated, yet only 43 percent of people are receiving the treatment they need for the most common NTDs.

In this time of resource scarcity, our collective commitment to the poorest communities should not wane. Yet, the traditional donor-supported model is not a sustainable solution. Increasingly, the global health and development community has been promoting the concept of country ownership as a critical issue of sustainability for country programs. In order to build programs that will live on past the life of a grant or the passing interest of a donor country, affected nations need independent, self-sustaining systems that are domestically organized and funded. This is not country ownership, but rather country leadership.

This country leadership was solidified when health ministers reaffirmed their commitment to the Addis Ababa Commitment on NTDs at the World Health Assembly (WHA) in Geneva in May. Nearly two dozen African countries signed this declaration in December 2014, pledging to increase domestic investment, promote multi-sector approaches, encourage adoption of data-driven, long-term strategic plans and ensure mutual support of NTD programs and overall health systems.

This Commitment heralds a new development model, where low- and middle-income countries partner together to invest in and lead their own development with support from the global community.

The Addis Commitment exemplifies the partnership required to create a successful health system through political, financial and technical reciprocity between donor countries and endemic countries.  While financial assistance is a critical stepping stone on the road to self-sufficiency, the real value comes from building proficiencies and systems that will last long after the money has been spent.

Government of Nigeria Releases New Data on the Prevalence of Schistosomiasis and Intestinal Worms



On Thursday June 4, Nigeria’s Federal Ministry of Health released, for the first time, comprehensive data on the national distribution of two major neglected tropical diseases (NTDs) — schistosomiasis and intestinal worms. This new information, gathered by the government of Nigeria and a network of partners, found that across 19 states and the Federal Capital Territory (FCT) approximately 24 million Nigerians were at risk for schistosomiasis and 21 million were at risk for intestinal worms. Children between the ages of 5 – 10 had the highest prevalence of infection. The results also showed that men were more likely than females to have one of the diseases.

Nigeria is said to have the highest burden of NTDs in sub-Saharan Africa. While the government and NGO partners have already taken several steps to address the burden of disease, comprehensive epidemiological mapping had not been available until recently. Moving forward, the data gathered from this mapping project will aid the Federal Ministry of Health in planning effective intervention measures for both schistosomiasis and intestinal worms.

People infected with NTDs like schistosomiasis and intestinal worms are often unable to work or attend school – resulting in an endless cycle of economic hardship. Treating these diseases is critical to reducing poverty and boosting economic prosperity. Given the strong association between NTDs and economic development, NTD control and elimination should be considered an important factor in achieving the Sustainable Development Goals (SDGs) in Nigeria. Nigeria’s quest to be one of the 20 major economic players globally by 2020 as captured in it Vision 20: 2020 will depend on a healthy and productive society that does not neglect the less fortunate.

The prevalence mapping survey was completed by analyzing 50 – 55 children from five randomly selected schools in the 19 states and FCT. The Federal Ministry of Health partnered with the Children’s Investment Fund Foundation, Sightsavers, Helen Keller International, DFID and RTI/ENVISION to carry out the survey. Epidemiological data on both diseases were collected using a novel technique; the LINKS system developed by the Task Force for Global Health which uses smart phones for data collection and cloud based data reporting and management.

Map of Nigeria displaying study area

Map of Nigeria displaying study area

The results showed an overall prevalence rate of 9.5 percent for schistosomiasis and 27 percent for intestinal worms.

The data gathered from the mapping survey will enable Nigeria to receive the appropriate amount of donated medicines to treat schistosomiasis and intestinal worms, so that they can deliver the medicine to where it is most needed. In addition to providing actionable data, the mapping project helped build and improve the capacity of health workers across Nigeria for the country’s NTD programme. The project also fostered a platform for cross-sector learning and skills sharing, which ultimately improved programme coordination.

Moving forward, the Federal Ministry of Health has recommended that all levels of government (Federal, State and LGAs), NTD partners and other stakeholders — with the cooperation of the communities — scale up uninterrupted provision and administration of appropriate medicines alongside other environmental improvement interventions such as clean water and sanitation provisions. Plans should also be put in place for impact assessment after the third year of consistent Mass Administration of Medicines.

While there is much work to be done, the successful completion of epidemiological mapping for schistosomiasis and intestinal worms is a promising sign. Armed with this information, Nigeria can strategically and effectively scale up their efforts to control and eliminate these debilitating diseases for a more prosperous Nigeria.  Nigeria’s new government, led by President Buhari, should take advantage of this cost effective and relatively simple intervention in order to make a tremendous impact on the country’s most vulnerable populations.

Photos provided by Nigeria’s Federal Ministry of Health.