The Intersections of Poverty, Handwashing and Neglected Tropical Diseases

Sabha and her friends drink water and wash their hands from a village well in Ghorahuan Village, Bihar State, India

Sabha and her friends drink water and wash their hands from a village well in Ghorahuan Village, Bihar State, India

Today marks the 7th Global Handwashing Day. This year’s Global Handwashing Day is a particularly important one for neglected tropical diseases (NTDs). Just two months ago, the World Health Organization (WHO) launched a global strategy to better integrate water, sanitation and hygiene (WASH) services — including handwashing education and access to handwashing facilities — with other public health interventions to eliminate and eradicate NTDs by 2020. The strategy aims to provide evidence-based guidance on effective ways for WASH and NTDs groups to collaborate to meet common goals.

Improved WASH is one of five interventions recommended by the WHO roadmap for the fight against NTDs. Access to clean water, handwashing facilities, proper waste management and good hygiene practices are critical to preventing NTDs from spreading. This is especially important for trachoma, the world’s leading cause of preventable blindness of infectious origin.

Approximately 232 million people are at risk of trachoma, and it is estimated to be responsible for the visual impairment of about 1.8 million people. A bacterial infection of the eyelid, trachoma is a highly contagious disease that can cause blindness if left untreated. It is spread by the eye, nose or throat secretions of an infected individual. These secretions are commonly spread by hands — as well as flies and shared facial cloths or tissues. Washing and other hygiene measures are critical to the success of trachoma interventions.

WASH and NTDs are both significant challenges to global development. WHO estimates that 1.9 billion people across 149 countries are at risk of at least one NTD, with many people at risk of suffering more than one. Likewise, 2.4 billion of the world’s population lacks access to adequate sanitation, while 1 billion people practice open defecation and 663 million do not have access to improved sources of drinking water. Both impacting the most impoverished communities, there is a significant overlap in the communities where NTDs are endemic and in which WASH resources are limited.

Notably, the strategy calls on endemic countries and partners to, “include, where possible, WASH indicators to contribute to success on NTD targets, and NTD indicators to contribute to success on WASH targets within the national frameworks for reporting progress against SDGs [Sustainable Development Goals].” NTD stakeholders have also recommended an NTD indicator to monitor progress on the SDGs. Because of the close links between poverty, the prevalence of parasitic diseases and access to WASH, measuring progress against NTDs provides insight into how effectively the global community is progressing towards ensuring equitable access to clean drinking water, improved sanitation and proper hygiene — and ultimately eradicating extreme poverty.

You can join the effort by asking your country’s representative to the United Nations to support and promote the inclusion of a global NTD indicator in the SDGs.

TAKE ACTION: Make NTDs count in the SDGs, send a message.


Celebrating NTD Success Stories: India’s Historic NTD Progress

A student holds an Albendazole tablet at a mass drug administration at the Ghorahuan School in Bihar, India.

A student holds an Albendazole tablet at a mass drug administration at the Ghorahuan School in Bihar, India.

During the month of October, END7 student supporters are celebrating NTD Success Stories from Haiti, India, Sierra Leone and the Philippines. Each country we are spotlighting has overcome their own challenges, ranging from earthquakes to the Ebola epidemic, to make sure communities receive NTD treatment and progress towards disease control and elimination. The examples of these four diverse countries help communicate not just the scope of the suffering caused by NTDs, but the hope we have of ending these diseases for good. Last week, we celebrated Haiti’s inspiring progress towards the elimination of lymphatic filariasis, and this week we’re looking across the globe to India, a historic leader against that and many other NTDs.

India’s diverse population has experienced rapid economic growth over the past two decades, but the country still faces significant health challenges due to its size and high burden of disease. Almost half of the 1.2 billion people at risk of lymphatic filariasis (LF) infection globally live in India. Additionally, NTDs such as soil-transmitted helminths (STH) negatively impact hundreds of millions of children in the country, causing delays in cognitive and physical development. These NTDs take a heavy toll on economic productivity and chronic infections perpetuate the cycle of poverty. However, the Indian government has one of the largest and most successful NTD programs in the world, and treatment scale-up is paving the way towards the elimination of LF and the control of STH infections on the subcontinent.

The Indian government first launched a pilot program to tackle LF in 1949. Over the next four decades, the government supported important research and demonstration studies that became the technical backbone of the World Health Organization’s Global Programme to Eliminate LF, launched in 2000. India’s experience with LF provided the evidence for the operational and technical feasibility of mass drug administration (MDA) to eliminate LF — a strategy that has since been adopted in countries around the world.

Today, India leads the world’s largest MDA program, reaching more than 400 million people with an annual dose of preventative medicine for LF. To date, India is one of only two countries who have achieved MDA coverage at a national level, and the population at risk of LF in the country has been reduced from 600 million to 460 million as a result. The country has also successfully scaled up efforts to control STH infections at the state level, particularly through school-based deworming programs, and recently launched a National Deworming Day to coordinate multiple platforms for deworming into one cohesive push to tackle STH in children under 19. This initiative will encourage coordinated efforts, budgeting, and monitoring to improve the efficacy and reach of deworming programs.

Several districts in India are in the process of undergoing Transmission Assessment Surveys, evaluations designed to register whether LF transmission has been interrupted and annual MDA can cease. Moving forward, bi-annual MDAs will continue in districts with a high burden of LF. Continued efforts aimed at interrupting transmission of diseases, disease surveillance, early diagnosis and response, as well as continued community mobilization and education to change risk behaviors will be critical to reducing the LF burden in India. Managing the disease among existing patients, particularly those disabled by LF with elephantiasis or hydrocele, is also a high priority.

India’s Ministry of Health and Family Welfare worked with the Global Network for Neglected Tropical Diseases in November 2014 to produce a mass media campaign, Hathipaon Mukt Bharat (Filaria Free India) to raise awareness of LF and encourage people to participate in MDAs. The video created for the campaign, entitled Giant Footprints!, won silver at the Cannes Festival of Creativity in 2015. Bollywood star Abhishek Bachchan is also supporting India’s effort against NTDs as the END7 campaign’s first official ambassador in India.

These ongoing social mobilization efforts will be critical to achieving national, regional and global NTD control and elimination goals by 2020. If India’s current NTD efforts can be maintained and expanded, those at risk for NTDs can live free of these diseases of poverty and their devastating effects. And as the leader of one of the oldest and largest programs to tackle NTDs, India can be a leader in assisting other endemic countries hoping to replicate their success around the world.

There’s ample reason to hope that history will repeat itself in India as the country celebrates the elimination of polio and looks towards new goals, like the elimination of LF. The country’s example shows that directing the expertise of different agencies and organizations towards a common goal can be successful even in a country with a large and diverse population. END7 supporters are eagerly following the good news from India — the second success story we’re spreading in a month that’s already offered many reasons to celebrate — and hoping to see it replicated worldwide.

The Unseen Impacts of NTDs


Khasirimi Mkala sits in her family’s compound. She is largely immobile due to her Elephantiasis

When we talk about the effects of neglected tropical diseases (NTDs), we have a tendency to focus on the physical and economic impacts alone, ignoring a major side effect of these conditions. In recognition of World Mental Health Day on October 10, we are taking a look at the unseen consequences of one of the most devastating NTDs.

Lymphatic filariasis (LF) is a disease transmitted by mosquitoes that leads to painful, debilitating swelling of the limbs or genitalia, inspiring the disease’s other name, elephantiasis. Though LF is easily prevented with medication, if left untreated, the severe swelling is irreversible. Individuals suffering from advanced LF are often unable to work and can suffer social stigma as a result of the disfiguring disease. Many are ostracized or even shunned by their communities.

The connection between LF and mental health has not received much attention in the scientific literature. A new paper released this summer by David H. Molyneux, Charles Mackenzie and Thanh G.N. Ton is the first to estimate the global psychological burden caused by the disease. Based on the few studies that exist on the topic, they estimate that 50 percent of clinical LF patients suffer from depression – roughly 18.1 million people. This is a conservative estimate, given that a study in India, which bears the largest burden of LF in the world, found that 97 percent of LF patients suffer from depressive illness.

When calculating the true burden of LF, Molyneux and his colleagues argue that the psychological effects on caregivers, which have not previously been quantified, need to be factored in as well. Based on a study of caregivers of blind individuals, which found that 48 percent had depression, they estimate 25 percent of caregivers of individuals with severe LF to be depressed, for an estimated total of 1.25 million people. That brings the total number of individuals suffering from depression as a result of LF to 19.35 million.

In 2013, the Global Network’s Emily Conron traveled to Lèogâne, Haiti, to interview patients with advanced LF. “These individuals told me over and over again that the hardest part of their condition was their isolation from family and friends and the shame they felt when they went out in public, where strangers would stare at their affected limb and make cruel comments,” Emily writes. In a country with one psychiatrist for every 200,000 people, access to traditional mental health care in Haiti is a near impossibility.

The feelings of social isolation have medical implications as well as psychological. A 2007 study conducted in Sri Lanka found that those suffering with severe LF avoided clinical treatment due to the embarrassment of being seen in public with the condition.

When it comes to tackling NTDs, treatment must address psychological challenges as well as physical symptoms. Though the World Health Organization began testing support programs for LF patients in 1998, such programs are still not widespread. Morbidity management – a basic package of services aimed at preventing disability in individuals already infected with advanced LF, ideally including measures to prevent disability from the mental health implications of LF – has not been scaled up to meet the needs of patients. Despite the fact that WHO’s Global Programme to Eliminate Lymphatic Filariasis, launched in 2000, includes LF morbidity management as a twin strategic goal of preventive chemotherapy to prevent new LF cases, only about one-third of national LF programs have established morbidity management measures.

Patients with advanced LF are, sadly, some of the most neglected patients of all those affected by neglected tropical diseases. Much more should be done to ensure that patients for whom the goal of eliminating LF transmission will be realized too late receive the healthcare they need for the physical and psychosocial effects of LF.

Celebrating NTD Success Stories: Good News from Haiti

Emily Conron speaks with patients in Haiti suffering from chronic filarial lymphedema.

Emily Conron speaks with patients suffering from lymphatic filariasis in Haiti

During the month of October, END7 student supporters are celebrating NTD Success Stories — spreading the exciting news that many countries around the world have already made incredible progress towards the control and elimination of some NTDs. In recent weeks, there have been many new successes to celebrate, like the announcement two weeks ago that Mexico has become the third country to officially eliminate river blindness, and the exciting news Monday that William Campbell and Satoshi Omura were awarded the Nobel Prize in medicine for their discovery of ivermectin, a drug used to treat and prevent onchocerciasis and lymphatic filariasis. This month, in addition to these exciting announcements, we want to highlight four countries — Haiti, India, Sierra Leone and the Philippines — that have achieved success fighting NTDs. Each country has overcome their own challenges, ranging from earthquakes to the Ebola epidemic, to make sure communities receive the medicine they need. We think these stories help communicate not just the scope of the suffering caused by NTDs, but the hope we have of ending these diseases for good.

The poorest country in the Western hemisphere, with the highest infant mortality and lowest life expectancy, Haiti is a country with many challenges. But the story of Haiti’s success against NTDs is a powerful reason for hope. Nearly the entire population is at risk of contracting lymphatic filariasis (LF), a mosquito-borne NTD. Caused by thread-like filarial worms that live in the lymphatic system, LF causes painful swelling of the extremities (a condition known as elephantiasis) and genitals (a condition known as hydrocele). The high prevalence of NTDs like LF persists, in large part, because of poor access to water and sanitation. About nine out of ten Haitians in rural areas do not have access to clean, safe water, and almost half lack access to adequate sanitation facilities. These circumstances were compounded in the wake of the 2010 earthquake that killed at least 200,000 people and destroyed much of the nation’s infrastructure. Despite these challenges, Haiti is making incredible progress against NTDs and expanding its national NTD control program with the goal of eliminating LF for good.

Under the leadership of the Haitian government, a range of partners have assisted with the annual distribution of drugs to help prevent the spread of four NTDs: LF, whipworm, hookworm and roundworm. A critical aspect of the success of these efforts has been the training of more than 30,000 local community leaders to organize, promote and carry out mass drug administration (MDA), distributing medicine to everyone in at-risk communities.

Until the 2010 earthquake, Haiti’s Neglected Tropical Disease Control Program conducted MDAs only in the areas of the country where LF was most prevalent. The crowded capital city of Port-au-Prince, with relatively low levels of LF infection, was thought to be too difficult a setting to carry out MDA. But after two million people were left homeless following the earthquake, internal migration threatened to redistribute the disease. The Haitian government then decided to focus on national MDA coverage, with the aim of completely eliminating the disease and preventing redistribution.

By late 2011, at least one round of MDA had been conducted in all endemic areas of Haiti except the capital, Port-au-Prince. From November 2011 to February 2012, an MDA was conducted for the first time in the crowded metropolitan area. More than 80% of the population has now been reached with NTD medications, a tremendous accomplishment in a country facing many health and development challenges. In May of 2014, the U.S. Agency for International Development (USAID), a major partner of the Haitian government’s NTD program, delivered its one billionth treatment worldwide at a ceremony in Saint-Louis-du-Sud, Haiti, a testament to the country’s commitment and progress in the fight against NTDs.

Haiti is also an example of an integrated approach to combating NTDs, having successfully integrated its LF and soil-transmitted helminth (STH) control programs, which previously operated in separate units at the Ministry of Health. To supplement expanded MDA efforts, the country is also scaling up efforts to address the needs of Haitians already incapacitated by LF and to fortify table salt with medicine to prevent LF, an approach that has helped countries like China eliminate the disease. These efforts are supported by dedicated partners including the Pan American Health Organization, the Inter-American Development Bank, the U.S. Centers for Disease Control (CDC), USAID, the University of Notre Dame Haiti Program, IMA World Health and CBM.

Haiti is one of just four countries in the Americas where LF remains endemic, accounting for 80% of people at risk of the disease in the region. If the country can succeed in their effort to eliminate LF by 2020, it would be a major milestone in global efforts to end the disease. As Dr. Patrick Lammie, an immunologist with the CDC, told NPR, “If a country like Haiti, with all of the challenges that they’ve faced over the last few years, is able to achieve full national coverage, I think that is an important example for other countries, which are struggling to scale up their programs as well.”

Certainly, a country that has not just maintained, but expanded efforts against NTDs in the face of political instability and crippling natural disasters is a powerful example to the rest of the world. Haiti’s success demonstrates the power of country ownership, government leadership, partnerships and integrated and holistic public health programs in the fight against NTDs.

END7 supporters are excited to celebrate Haiti’s unfolding success story, a narrative of perseverance in the face of challenges — and the first of four inspiring NTD Success Stories in a month that’s already offered many reasons to celebrate!