According to the World Health Organization (WHO), an estimated 873 million children are at risk of soil-transmitted helminths (STH), including roundworm, hookworm and whipworm. In children, STH infections can lead to malnutrition, anemia and stunting. In both adults and children, they can cause fatigue, intense abdominal pain and chronic diarrhea. In severe cases they can even cause bowel obstruction, rectal prolapse and appendicitis.
To improve health and development in infected communities and reduce the prevalence of neglected tropical diseases (NTDs), WHO aims to control STH and schistosomiasis by 2020. Meeting this goal requires regularly deworming at minimum 75 percent of the preschool-age and school-age children who are at risk of STH or schistosomiasis. To ensure such an ambitious global goal is met, it is paramount that ministries of health, WHO and non-governmental organizations (NGOs) coordinate and share data.
WHO operates the Preventive Chemotherapy and Transmission Control (PCT) Databank, which tracks the number of children given PCT for STH, schistosomiasis and three other NTDs. The databank is populated largely by information reported by ministries of health and helps policymakers and implementers understand where deworming programs are active and where more interventions are needed to meet the WHO target of controlling STH and schistosomiasis by 2020.
However, gaps in the PCT Databank have become apparent. The 2013 STH preschool treatment data was recently revised when supplementary data was submitted by UNICEF. This data caused a 104 percent increase in the recorded number of preschool-age children treated for STH. Clearly, better coordination is needed to ensure the global community meets 2020 goals.
To facilitate better coordination among WHO, ministries of health and NGOs, the Children Without Worms (CWW).
After the data are compiled, WHO will merge the CWW database with national program data provided by ministries of health to the PCT Databank. This effort will make deworming dollars go even further by strengthening program monitoring and leading to an efficient use of resources. Ultimately, it will be an important step in controlling STH and 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, 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.
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If you’re reading this blog post, chances are you’ve used a toilet recently. It’s also likely you’ve never really considered how fortunate you are to have access to that toilet. Could you imagine what it would be like to leave your house in the middle of the night to relieve yourself outside rather than inside the safety and privacy of a clean bathroom stall?
Today is World Toilet Day and we’re recognizing the 2.5 billion people around the world who do not have access to a toilet (that’s about 1/3 of the world’s population!). The magnitude of this problem is significant. Without a toilet, people are forced to defecate outside – an act that compromises a person’s dignity, privacy and safety, and leaves billions susceptible to neglected tropical diseases (NTDs).
Schistosomiasis and intestinal worm infections such as roundworm, hookworm and whipworm are easily spread in communities that do not have access to toilets or sanitation facilities. Schistosomiasis spreads when infected people urinate or defecate close to a water source, contaminating it with the larvae of the parasite. Without proper infrastructure (toilets and city utilities) more than 80% of sewage in developing countries is discharged untreated polluting rivers, lakes and coastal areas and promoting the spread of NTDs.
Simply walking barefoot around this polluted and contaminated water leaves people exposed to NTDs. As a result, people can be continually re-infected as they work, play, bathe or eat. Children especially have a high risk of contracting these diseases because they often play barefoot outside and put their hands in their mouths without washing them.
According to the World Health Organization, improving water, sanitation and hygiene can reduce trachoma by 27 percent, and improved sanitation could reduce schistosomiasis by as much as 77 percent.
By combining NTD treatment, hygiene education and creative solutions for the 2.5 billion people without access to toilets, we can tackle this problem. Important work is being done by several partner organizations to promote better water, sanitation and hygiene worldwide. The Global Network is also happy to work with former president of Ghana John A. Kufuor to promote long term NTD solutions by integrating mass drug administration with programs for water, sanitation and hygiene – a message the former president drove home at this year’s World Water Week in Stockholm, sweeden.
To learn more about the links between clean water, sanitation and NTDs, watch our quick video
New commentary on the PLoS Speaking of Medicine Blog from Dr. Peter Hotez, president of the Sabin Vaccine Institute, highlights exciting findings that “give us compelling reasons to recast schistosomiasis MDA as a back door AIDS prevention strategy.”
The new study, led by a team of researchers at Yale University, found that treating young girls for female genital schistosomiasis (FGS) is a highly cost-effective approach to reducing the burden of HIV in sub-Saharan Africa. In fact, the drug praziquantel not only reduces the devastating burden of FGS on young women but also has the potential to save up to 100 million US dollars in AIDS healthcare costs over a 10-year period.
Dr. Hotez, who has it can be provided as an extremely low-cost generic (often averaging around 8 cents per tablet) from Shin Poong, MedPharm and other companies through UNICEF, WHO, and the World Bank.”
Please read Peter’s full commentary here.