Tag Archives: NTDs

Eight Million Toilets and Counting

By Alice Carter

world toilet day 2015Normally, we don’t like to talk about bathrooms. That is a private space that most of us would largely like to avoid thinking about. But on World Toilet Day, we give thanks for our sanitary facilities and celebrate the invention of the toilet, which has saved countless lives as a disease control mechanism, and gives us privacy to, you know, go.

There is a Sesame Street song, a global “urgent run,” and an art show in New York. All of these types of events are celebrations for the often overlooked efficiency of the mundane technology that is a toilet, but also are opportunities to spread awareness of just how precious our access to toilets really is. One in three people around the globe don’t have access to adequate sanitary infrastructure, leaving them at increased risk for neglected tropical diseases (NTDs) that are spread through contact with fecally-contaminated soil. Half of the people who practice open defecation globally live in India, where 1.1 million liters of human excrement enter the Ganges River every minute. Recognizing the toll that open defecation takes on health, education and economic output, the government of India is trying to increase access to sanitation infrastructure and put an end to open defecation.

Prime Minister Modi has pledged that India will be open defecation free by 2019, and under his leadership the government has set up incentives for toilet construction and usage. Swachh Bharat Abhiyan — the Clean India Mission — is a sanitation campaign run by the Indian government, with the joint objectives of reducing open defecation and changing behavior to increase the use of sanitary facilities. Prime Minister Modi launched Swachh Bharat on Mahatma Gandhi’s birthday in 2014. The government also plans to raise Rs 3,800 crore (approximately 550 million USD) from the public to support this initiative, which gives subsidies for toilet construction and helps villages become certified as open defecation free. As of August 2015, 8 million toilets have been constructed as part of the campaign.

Unfortunately, it is tricky to measure the prevalence of open defecation and people’s toilet usage. Simply constructing a toilet in every home and school won’t make people start exclusively using toilets, especially if they don’t know the benefits of sanitation infrastructure and the risks of open defecation. For this, public awareness campaigns are also needed, and people need to be given plenty of reasons to use the toilet exclusively. One motivating factor for people to switch from open defecation to toilet use is awareness of the health risks of open defecation.

In communities that continue to practice open defecation, children playing outside or walking to school with no shoes can be exposed to contaminated soil, putting them at risk for infection by soil-transmitted helminths (STH). Similarly, clean drinking water sources and uncooked fruits and vegetables can be contaminated, increasing the risk of infection.

On the other hand, access to a household latrine has been found to reduce the risk of infection with STH by 40%. Nadia, a district in West Bengal, India, was the first district to be certified as open defecation free, and has since noted a decreased incidence of diarrhea and malnutrition. Reduced NTD infection is a strong indicator of the success of the Swachh Bharat campaign. Including an NTD indicator in Swachh Bharat would give the mission concrete targets to measure exclusive toilet use in communities where the campaign has built toilets, and it would help spread awareness of the negative health impacts of open defecation.

Perhaps on Gandhi’s 150th birthday, in 2019, India will have achieved its goal of ending open defecation. He would be proud, as he often stressed that a society’s approach to private and public sanitation reflects its commitment to true freedom and dignity.


Untouched: How 284 Liberian Communities Remained Ebola-Free

By Piet deVries, Senior WASH Advisor, Global Communities


A community hand washing station in Liberia. Credit: Global Communities

Everything changed with Ebola.

For four years, Global Communities had been busy creating access to safe sanitation for communities in Liberia, helping to fight the spread of disease and improve health outcomes. Utilizing Community-Led Total Sanitation, we were making consistent progress, beginning work through the USAID-funded Improved Water, Sanitation and Hygiene (IWASH) program in 2010 in the three Liberian counties of Nimba, Lofa and Bong. Our program gained the support of the national government, and we worked with them to develop their sanitation strategy to improve the health of rural communities across the country. By early 2014, we had helped 284 communities become “open defecation-free” and were working with more communities.

Suddenly we and our partners in the Liberian County Health Teams and the Ministry of Health found ourselves at the center of a maelstrom. To combat Ebola, we scaled up our community engagement work, training community leaders who were already working to prevent open-defecation in how to provide information about Ebola prevention. As the epidemic swelled, our community engagement approach shifted again, focusing on acceptance of vital services like dead body management, and eventually, health screenings. In just a few months, our work scaled up from three to all 15 Liberian counties.

It was during this time that we received reports of an astonishing statistic. All 284 open defecation-free communities were reporting that they were also Ebola-free — despite being located in some of the regions hardest hit by the virus.

Was there a link between being open defecation-free and Ebola-free? Or between our program’s process and Ebola resistance?

Earlier this year, we employed two independent public health consultants to conduct research into the informal reports we had received. They came back with extraordinary findings. Focusing their research on 551 households in Lofa County, they established with a representative sample that the communities that had reached open defecation-free status were indeed Ebola-free.

They also found that communities that had only started the Community-Led Total Sanitation process — but not reached full open defecation-free status — were 17 times less likely to experience a single case of Ebola. This suggests a statistically significant correlation between our work to become open defecation-free and being Ebola-free.

Still, it would be wrong to assume that these findings mean that simply becoming open defecation-free stops Ebola. Rather, they suggest that people who had been exposed to the program’s education were far more likely to develop healthier behaviors and practices that lead to Ebola resistance — especially when led by a member of their own community.

Perhaps most encouraging, these behavior changes don’t just defend against Ebola. By utilizing CLTS, individuals can help prevent a variety of water, insect-borne and diarrheal diseases, including many neglected tropical diseases. In addition, such methods are inexpensive; in Liberia, incentives of only $130 per community can result in far better sanitation practices. Make household latrines, hand washing facilities, garbage pits and dish racks available, and you have a safe, hygienic and resilient community.

Disease spreads at the community level, and only by engaging with the community to create sustainable change can we hope to control and eliminate many of the diseases that are so prevalent in the developing world. CLTS does just that, and any focus on water and sanitation must recognize the importance of empowering communities to make wise decisions to help improve their health.

Celebrating NTD Success Stories: Sierra Leone’s Inspiring Progress in the Face of Ebola

Community health officer Hawa Margai speaks about onchocerciasis to a group of women gathered at the Levuma community health center in the town of Levuma, Sierra Leone on Friday July 13, 2012.

Community health officer Hawa Margai speaks about onchocerciasis to a group of women at the Levuma community health center.

During the month of October, END7 student supporters are celebrating NTD Success Stories from four countries — Haiti, India, Sierra Leone and the Philippines — that have overcome incredible obstacles to make progress towards NTD control and elimination. This week’s success story comes from Sierra Leone, where inspiring efforts are being made to fight NTDs in the wake of the Ebola epidemic.

Six NTDs are found in all 14 health districts in Sierra Leone, threatening nearly the entire population of the country. Sierra Leone faces many health and development challenges, but the government has exerted strong leadership in the fight against NTDs. By 2004, the national NTD program had successfully mapped the prevalence of targeted NTDs nationwide, and in 2005 they launched a mass drug administration (MDA) campaign to treat every at-risk community with the participation of nearly 30,000 volunteer community drug distributors. Supported by the U.S. Agency for International Development (USAID), Sierra Leone’s Ministry of Health had distributed more than 57 million NTD treatments nationwide by the beginning of 2014. As a result of these efforts, the country was on track to begin the World Health Organization process of verifying the elimination of lymphatic filariasis (LF) in eight of 14 health districts in 2014. Unfortunately, when the West African Ebola epidemic reached Sierra Leone in May of that year, all public health program activities were suspended as the country raced to stop the spread of Ebola. As a result, the Sierra Leone NTD Program was unable to carry out MDA in 2014, interrupting progress towards LF elimination.

But today, the government of Sierra Leone and partner organizations are working hard make up for lost time. In May of 2015, on the heels of nationwide malaria and vaccination campaigns, MDA restarted in Sierra Leone. Just this month, from October ninth to 13th, the Ministry of Health’s NTD Program, through the District Health Management Team, ran an MDA campaign targeting 1.4 million people with drugs for LF and soil-transmitted helminths (STH).

The relaunch of MDA this year required careful preparation, including refresher training session for community drug distributors and program administrators. Extensive social mobilization campaigns, aimed at educating communities still reeling from the Ebola epidemic about the importance of participating in MDA, were conducted through community meetings and radio spots. As a result of this careful preparation, early indications are that Sierra Leone’s 2015 MDAs have been successful.

The consistent key to Sierra Leone’s inspiring success tackling NTDs before and after the Ebola epidemic has been the leadership and commitment of volunteer community drug distributors. Elected by their communities, these volunteers reach the most remote corners of the country, enabling Sierra Leone to consistently achieve treatment coverage above 75 percent in targeted communities.

Given Sierra Leone’s small geographic size, the strong political support of the government and the commitment of the volunteer community drug distributors who form the backbone of MDA programs, the country is in the unique position to become one of the first countries in Africa to control snail fever and intestinal worms and eliminate river blindness and elephantiasis. Sierra Leone’s NTD program has also successfully demonstrated that MDA can be achieved in highly populated urban settings. But additional support is needed. By integrating NTD treatment with schools and other health programs, millions of people at risk for NTDs can live free of these diseases of poverty and their devastating effects including malnutrition, disability, social stigmatization and a loss of productivity.

Sierra Leone’s progress against NTDs despite the challenges posed by the Ebola epidemic should inspire other countries to redouble their efforts to address these diseases. Now more than ever, support for robust public health efforts like Sierra Leone’s NTD Program is needed to build on this impressive progress. END7 supporters are eager to celebrate Sierra Leone’s progress and look forward to celebrating more milestones as the country moves closer to its ultimate goal of controlling and eliminating NTDs.

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.