Day Two - Afternoon - Global Alliance to Eliminate Lymphatic Filariasis

Linking the programmes:
New partnerships with
onchocerciasis programmes
GAELF 7
World Bank
Washington DC
18-19 November 2012
Adrian D Hopkins
Mectizan Donation
Program
www.mectizan.org

• Common populations infected
• Common disease agent
• Common treatment
• Common M&E
• Common challenges

Common populations infected

Common populations
In Africa and the Yemen

Lymphatic Filariasis Current
Status

Onchocerciasis Treatment
areas

Common Disease agent

Filaria
• Both diseases are caused by filarial
species !

Common treatment

Treatment
• Both diseases use Mectizan in
Onchocerciasis endemic areas
• Albendazole is needed for LF and
may well speed up onchocerciasis
elimination

Common M&E

M & E commonalities
• Both diseases need better diagnostics for
M&E
– Parasitological investigations. Night blood and
skin snips ARE NOT POPULAR
– Existing serological test are not ideal
– Need for human and laboratory capacity
building to carry out entomological and
parasitological surveys
– Existing methods of M&E are costly

Common challenges

at risk population (million)
Common challenges 1
Scaling up
Treatment targets
Treated (million)
350.0
Source: WHO/AFRO Neglected Tropical Diseases
300.0
250.0
200.0
81% LF
Treatment
150.0
111.9
100.0
82.8
69.3
57.8
46.6
50.0
28.0
34.0
16.5
20.8
9.4
0.2 3.0
-
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Treatment targets 1.1 2.9 7.5 15.6 20.1 31.6 35.0 50.0 64.0 72.3 92.4 138.6 188.6 240.4 288.1 288.7 283.1 238.5 174.9 104.3 39.6 -
Treated (million) 0.2 3.0 9.4 16.5 20.8 28.0 34.0 46.6 57.8 69.3 82.8 111.9

18 million people in areas where
nodule prevalence is between 5
and 15%

‘Big 4’ countries account for 60%, 9
Countries account for 80% of people
not covered by LF treatment

2.
M
a
p
p
i
n
g

3.
Cross
border
issues

Common challenges 4 Loa loa
Zouré HGM, Wanji S, Noma M, Amazigo UV, Diggle PJ, et al. (2011) The Geographic Distribution of Loa loa in
Africa: Results of Large-Scale Implementation of the Rapid Assessment Procedure for Loiasis (RAPLOA). PLoS
Negl Trop Dis 5(6): e1210. doi:10.1371/journal.pntd.0001210

Where are the co-endemic
areas? RAPLOA results
PLoS Negl Trop Dis 5(6): e1210. doi:10.1371/journal.pntd.0001210

Population at risk

MEC TCC guidelines
www.mectizan.org

Conclusions
Co-implementation
Opportunities for synergy (LF/oncho)
• Integrated mapping
• Joint implementation of training
• Joint implementation of MDA (combined
treatment registers, simultaneous drug
administration
• Joint Monitoring and reporting
• Joint epidemiological evaluations

Conclusions
• I am not advocating for
exploiting the synergies in
two programmes
• I advocate for one
programme in Africa

GAELF-7
Linking the Programmes
Extending the Benefits
David Addiss
19 November, 2012
Washington, DC

Extending the Benefits
Not a new idea…

Extending the Benefits

Benefits Realized
Soil-transmitted helminthiasis (STH)
• 2 billion treatments with combination
therapy using albendazole, 2001-2011 *
• In 2010, 57% of school-age children
treated for STH were treated through
PELF
• Community-based distribution
* Courtesy of Dr. KD Ramaiah

Benefits realized
• ‘Ancillary benefits’
• Bold vision
• Advanced NTD agenda
• Platform for integrated
NTD programs

Extending the Benefits
Have the benefits been fully extended
to those with LF-related disease?

“Two Pillars” of LF Elimination-
Rationale

“Two Pillars” of LF Elimination-
Rationale

“Two Pillars” of LF Elimination-
Rationale

Morbidity Control & Disability
Prevention

Components of NTD Control
Preventive Chemotherapy
Vector
Control
Water,
Sanitation,
Hygiene
Clinical
Care

Lymphatic Filariasis Elimination
“Two Pillars”
“Interrupt transmission”
“Care for those
with disease”
Preventive Chemotherapy
Morbidity
Management
& Disability
Prevention
Vector
Control

Preventive Chemotherapy
Dominant Organizing Principle for STH Control
Preventive Chemotherapy
Water,
Sanitation,
Hygiene

Elimination of Blinding Trachoma
’SAFE’ Strategy
Antibiotics
Environmental
Improvement
Surgery
Facial
cleanliness

LF Elimination
Internally and Externally Integrated
Source: WHO

Legs to Stand On Framework
Courtesy: Dr Mary Jo Geyer

Benefits realized
• ‘Ancillary benefits’
• Bold vision
• Advanced NTD agenda
• Platform for integrated NTD programs
• “Seeing the faces”

“Willing to see faces”
“If we are to maintain the reputation this
institution now enjoys, it will be because in
everything we do, behind everything we say,
as the basis for every program decision we
make—we will be willing to see faces.”
Bill Foege, Smallpox, Gandhi, and CDC
– Fifth Annual Joseph Mountain
Lecture, Atlanta, October 26, 1984

Elements of Compassion
• Awareness of suffering (cognitive
attunement)

Awareness of Suffering

Elements of Compassion
• Empathy (emotional attunement)

Empathy
The Power of Personal Story
Courtesy:
Fr. Thomas
Streit

Elements of Compassion
• Awareness of suffering (cognitive
attunement)
• Empathy (emotional attunement)
• Action (to relieve suffering)

Compassion and Action
• “[Compassion] is not just a wish to see sentient beings
free from suffering, but an immediate need to
intervene and actively engage, to try to help.”
• “A person who has attained stability in his or her
compassion training … should now be out, running
around like a mad dog, actively
engaged in acts of compassion.”
- His Holiness the Dalai Lama
Source: Davidson RJ and Harrington A, eds. Visions of
Compassion: Western Scientists and Tibetan Buddhists Examine
Human Nature. Oxford University Press, New York, 2002

Compassionate action

Certification of Lymphatic Filariasis
Elimination in China, 2008

Challenges to Compassion
in LF Elimination
• Empathy (emotional attunement)
– Geographic distance
– How to keep seeing the ‘faces behind
the numbers’?
– Compassion for
populations

Challenges to Compassion
in LF Elimination
• Action (to relieve suffering)
– Complex systems
– Institutional agendas
– Competing motivations

GPELF: “…a mass uprising of compassion”

Extending the Benefits
The Challenge of Paradox
• Maintain focus while expanding peripheral
vision
• A united LF program with activities across
different sectors of the health system
• See the faces and the numbers at the same
time
• Compassion for individuals and action at the
population level

Thank you
Photos courtesy of Fr. Thomas Streit and Dr Patrick Lammie

Insert teshome

Lymphatic Filariasis
Partnerships with Malaria
Programs: Experience in
Nigeria
Frank Richards, Jr., MD
Director
Malaria, Lymphatic Filariasis, River
Blindness and Schistosomiasis Programs
Global Alliance for the Elimination of
Lymphatic Filariasis
19 November 2012

• WER 2011

Nigeria

Nigeria former Head of State General Dr. Yakubu Gowon

Lymphatic Filariasis
Elimination

Integrated Onchocerciasis, Lymphatic
Filariasis and Urinary Schistosomiasis
Activities in Nigeria
Published in 2002
Funded by GSK

Published in 2002

Primary Vector in Nigeria:
Anopheles gambiae

Malaria
• Plasmodium destroys red
blood cells
• Fever….also Anemia
• Mosquito transmitted
• ~1 million deaths each year
(mostly children

Malaria
Monitoring and Evaluation
Future Key Outcomes:
- Malaria death/cases/
prevalence/transmission
- Anemia
- LLIN ownership
- LLIN usage

Impact of LLIN on LF Mosquito
Infection

80,000 mosquito dissections since 1998

INFECTIVE STAGE LARVA

Average Mosquito LF Infection Rates (all larval stages) in 9
Sentinel Villages (through (Baseline September through 2010) 2011)
3.5%
3.0%
2.5%
3.1%
Mass drug administration
2.0%
1.5%
1.0%
0.5%
0.0%
1.1%
0.8%
0.5% 0.4% 0.4%
0.4% 0.3%
Baselne 2004 2005 2006 2007 2008 2009 2010
Infected
0.0%
Based on >44,000 dissections

Average Mosquito LF Infection Rates (all larval stages) in 9
Sentinel Villages 2000 – September 2011
3.5%
3.0%
2.5%
3.1%
Mass drug administration
LLIN
2.0%
1.5%
1.0%
0.5%
0.0%
1.1%
0.8%
0.5% 0.4% 0.4%
0.4% 0.3%
Infected
0.0%
Baselne 2004 2005 2006 2007 2008 2009 2010 2011
In 2011, for the first time, no infective (L3) mosquitoes were detected
Based on >46,000 dissections

MDA/LLIN versus LLIN alone
Impact on Mosquito Infection rates
Side by Side comparison
ALONE
P

NET DISTRIBUTION STATUS FOR ALL STATES
(as of 17 September 2012)
SOKOTO
* TCC-Assisted States Outlined in RED
KEBBI
ZAMFARA
KATSINA
KANO
JIGAWA
YOBE
BORNO
BAUCHI
KADUNA
GOMBE
NIGER
PLATEAU
ADAMAWA
KWARA
FCT
OYO (Phase
1 completed)
NASSARAWA
TARABA
OGUN
OSUN
EKITI
ONDO
KOGI
BENUE
LAGOS
EDO
DELTA
BAYELSA
ENUGU
EBONYI
ANAMBRA
IMO ABIA
RIVERS
Nets already distributed
TCC-assisted states where
distribution has not been completed
Non-TCC states where distribution
has not been completed

106 million Nigerians at risk based on 91% mapping
(Dec.’11)

NATIONAL LEVEL IN NIGERIA
LF Mass Drug Administration
• Out of the 541 LF endemic LGAs only
103(19%) are under MDA.
• Treatment of persons
• 3.4m in 2007
• 3.8m in 2008
• 4.7m in 2009
• 10.0m in 2010

FMOH and TCC cosponsored a national
combined LF and Malaria Program
meeting in Nigeria, March 27-28, 2012

Outcome of this Meeting
• To create awareness on benefits of integration of
malaria control and lymphatic filariasis activities
among relevant stakeholders.
• To facilitate integration and collaboration between
malaria control and lymphatic filariasis elimination
programs
• To develop areas of synergy in implementation of
activities
• To scale up interventions for malaria control and
lymphatic filariasis elimination as a result of this
synergy and integration

Synergies between the LF and
Malaria communities on a
common enemy: Anemia

Anemia in children in multifactorial and complex
Severe anemia is a manifestation of
serious malarial disease and
accounts for more than half of all
malarial deaths in African children.

Hookworm
• Blood loss up to 0.25 ml/day per worm
• Intensity of infection steadily increases during
childhood and does not plateau until
adulthood.
• LF MDA is given to adults, not just school
aged children, and is a more intensive
approach to hookworm
Tolentino and Friedman AJTMH 2007

In a study in Ghana, the mean Hgb
was lower for women coinfected
with malaria and intestinal worms
compared to women infected with
malaria alone, intestinal worms
alone, or women with neither
infection.
Yatich et al. AJTMH 2009 and 2010 (Kumasi, Ghana)

LF Community based networks
and potential Malaria synergies

Mobilizing existing networks of community
drug distributors (CDDs) for malaria control
activities
• a. LLIN distribution and mop-up
• b. Annual LLIN monitoring (ownership, use,
condition) during household census for MDA
• d. Behavioral change communication (BCC)
• e. Active case detection and referral

Focus group research
conducted in Plateau
suggests that:
-People don’t think
malaria is a serious
disease
-People are much more
afraid of getting big legs
or swollen scrotum than
they are of getting
malaria
EMPHASIZING THAT LLINs PREVENT LF MAY BE A MORE EFFECTIVE WAY TO
ENCOURAGE NET USE.

We love integrated NTD/MAL work!

Acknowledgments
•Members of the affected communities (‘CDDs’)
•Ministries of Health (Federal, State, and Local)
•Local Staff of The Carter Center
•GlaxoSmithKline
•Merck & Co., Inc/ Mectizan Donation Program
•Bill & Melinda Gates Foundation
•World Health Organization
•CDC
•Global Fund
•Clarke Mosquito Company
•Vestergaard Frandsen
•Lions Club International Foundation/Local Lions Clubs
•The thousands of donors to The Carter Center!!!

The future of GAELF post the
London Declaration
Professor David Molyneux, CNTD , Liverpool

Santiago, Spain 2000
Seoul, Korea 2010
New Delhi, India 2002
Arusha, Tanzania 2008 Cairo, Egypt 2004
Nadi, Fiji 2006

Global Alliance for the Elimination of Lymphatic Filariasis

The Journey from Santiago de Compostela to
Washington DC
The Alliance journey:
10
DESTINATION
2020
The changing environment
and adapting the game plan
2012
Washington
12 years

The Global Health Interstate-2000-2012
GLOBAL
HEALTH
• Millennium Development Goals and Poverty Reduction
• Health and MDG-MDG6 “other diseases”
• Establishment of GFATM and GAVI
• Report on Macroeconomics and Health
• Emergence of Public/Private Partnerships
• Bill and Melinda Gates Foundation establishment and
Commitment
• Pharmaceutical sector commitment and policy changepreferential
pricing, expanded donations, R&D commitment
• NTD brand emerges post Berlin meetings and advocacy
papers
• Africa Commission Report pre Gleneagles G8 mentions
NTDs 2005
• Increased reference to NTDs WHO DG, G8 Japan, USAID and
President Bush statement in Ghana; DFID 50 million GBP
• President Obama Global Health Initiative-NTDs and
LF key platform-USAID $450 million
• The London Declaration 13 Pharma, WHO Road Map, DFID
£195 million

Operational Research
DFID, GSK, MDP
BMGF, GAELF
AWOL, DOLF
GFATM
Academic
MDG’s / Poverty alleviation
Success stories
Vanuatu, Togo
NIH, WHO/TDR
Tunis
Commitment
Success stories
Egypt, Sri
Lanka
National
Commitment
Up-scaling &
financing
LF/NTD JOURNEY
International
Agencies
Macro-economic
& Health Report
Rockhopper
Production
Wellcome Trust
VW Foundation
High Impact
Journals
MDP/TD
R
Loa
Jeff Sachs
BMGF -
GNNTDC
WHO RD;
RDs
G8
Bilateral
Donors
Africa
Commission
Major Pharma
Key to lines
Global Health Line
Country Line
BMGF
PP Partnerships
Research Line
Advocacy Line

The important major routes
• Country commitment to scale up
• Bilateral interest from donors enhanced by NTD concept
and opportunity
• Maintenance of research funding streams and funders
interest
• Establishment of GAELF as a credible, representative
and viable partnership
• Involvement of NGDOs and expansion of their interest
within framework of integrated NTD control
• Maintenance and growth of advocacy
• Consistent and long term support from GSK and
Merck & Co. Inc-drugs, GAELF, MDP and beyond

The Country roads
• Historic country commitment to LF control-pre
1997-China,Korea, India, Thailand, Sri Lanka,
Suriname
• Embracing new WHO strategy and scale up in
many
other countries
• Scale up success stories-Egypt, Sri Lanka
Zanzibar,
Togo, Vanuatu and others
• Country financial commitment
• Endorsement on policy towards budget lines and
LF
as part or platform for NTD control
• Community commitment and potential of APOC
platform; Tunis Ministerial statements

The research road
• Historic support-WHO/TDR, NIH, Wellcome Trust, MDP,
GSK, European Foundations
• BMGF-Initial Grant in 2001 to Partners via the World
Bank
-Grant to GAELF in 2006 via Task Force for
Global Health (E Ottesen PI)
-AWOL grant to Mark Taylor Liverpool for
anti Wolbachia studies
-DOLF grant to Gary Weil for optimisation of
chemotherapy
• NIH; Case Western, Washington University
• DFID/ GSK to Liverpool School for operational research/
capacity building
• DBL-capacity builing
• EU Foundation Post Doctoral Fellowships include 3 LF
fellowships related grants
• Bill & Melinda Gates Foundation, European Foundations
• BMGF

The achievements GPELF and
GAELF
• 8 million annual treatments to 500 million plus per year
• $24 million in costs savings to 2008 alone
• Low unit costs
• Three pharmaceutical company donations
• Recognition as a successful but different Alliance
• 52 country programmes-Regional templates and diversity of settings
• Global programme with diverse disease epidemiology and health
systems
• Successful operational research-programme needs have focussed
research
• Platform for NTD integration concept-albendazole and ivermectin are
not just an LF project but also an oncho and STH one combined-”three
in one”
• Most rapidly expanding public health programme in history
• Seamless linkage between GPELF and Alliance

Challenges to elimination
•Mega countries
•Need for more rapid up scaling
•Country buy in for LF and NTDs as a conceptpriority
•Vector control and MDA
•Monitoring and evaluation and surveillance-costs
of TAS
•National capacity