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.

Celebrating Victories, Together with a Public Health Champion

 

A pregnant woman speaks with a health worker during a vaccination session at the primary school in the town of Coyolito, Honduras on Wednesday April 24, 2013.

A pregnant woman speaks with a health worker during a vaccination session at the primary school in the town of Coyolito, Honduras.

The Latin American and Caribbean (LAC) region continues to inspire the world, showing how unwavering determination can help achieve public health elimination targets.

For example, earlier this year the Pan American Health Organization (PAHO) and other leading global health experts said goodbye to rubella in the Americas, a virus also known as German measles. This exciting accomplishment is the result of a concerted 15-year initiative to provide widespread provision of the MMR vaccine (measles, mumps and rubella).

Announced on April 30th, this historic achievement generated even more energy and excitement during Vaccination Week in the Americas (VWA), held during April 25th – May 2nd.  VWA, a regional flagship initiative of PAHO, is an extraordinary effort led by countries to vaccinate people of all ages against rubella, measles, polio, pneumonia and other diseases. These vaccination campaigns are also used to deliver a package of life-saving health interventions, including Vitamin A supplements to boost children’s immune systems, deworming treatments that rid people of intestinal worms (a type of neglected tropical disease) and distribution of insecticide-treated nets to prevent malaria. The Guardian has highlighted VWA as one of five memorable public health movements that save millions of lives.

We are especially excited to celebrate these recent victories with a public health champion from Córdoba, Argentina, Dr. Mirta Roses, who recently visited the Sabin Vaccine Institute office in Washington, D.C. Holding medical and public health degrees, serving two terms as Director of PAHO and representing the LAC region on the Global Fund Board provides only a small snapshot of her passion for equitable access to health. We are proud to have her serve as Special Envoy for the Global Network for Neglected Tropical Diseases, speaking out on behalf of the hundreds of millions of people suffering unnecessarily from preventable diseases.

Dr. Roses began working at PAHO in 1984 – and became Director 20 years later. She took action quickly as Director, spearheading the first-ever Vaccination Week in the Americas in 2003. This annual campaign was inspired by the Sucre Agreement, signed 23 April 2002 by the Andean Ministers of Health (Colombia, Bolivia, Ecuador, Peru and Venezuela) plus Chile, recommending simultaneous implementation of their national immunization weeks. Following a 2002 measles outbreak in Venezuela and Colombia, this coordinated effort was planned to prevent future outbreaks across the Andean Region.

During the final stages of polio eradication in the Americas in 1991, Dr. Roses witnessed how the power of social communication and community involvement transformed vaccination campaigns into health celebrations. Entire villages, countries, leaders and celebrities were eager to participate, injecting a vibrant, dynamic energy into the campaigns.

Building off the momentum and success of this approach, annual Vaccination Weeks in the Americas helped create an even larger health celebration by sharing educational materials, screening for communicable and chronic diseases and delivering deworming treatments. This platform also helps early detection of NTDs, disabilities and micronutrient deficiencies.

As an example, in Honduras, the Ministry of Health uses this campaign to deliver deworming treatments to children across at the country alongside vaccines and other interventions. Honduras has also integrated water, sanitation and hygiene (WASH) practices, as well as vitamin A supplementation, as part of this effort. Since poor WASH contributes to increased intestinal worm infections, and intestinal worms can worsen and intensify malnutrition, integrating these three health interventions is essential for maximizing the health of children.

This unprecedented model caught the attention of people across the world. One by one, countries from all six WHO regions started employing the same approach – beginning with countries from the Eastern Mediterranean, reaching all the way to South-East Asia. By 2011, the World Health Organization made it official: World Immunization Week will happen every year during the last week of April.

These successes demonstrate the sharp and unwavering determination of people, communities and partnerships in the LAC region. We look forward to celebrating future success with Dr. Roses, PAHO and other partners, and inspiring other countries and regions to learn from lessons learned and best practices.

Endemic Countries Lead the Fight against NTDs

 

END7_Malindi_MoScarpelli_web_16

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.