COUNTRY LEADERSHIP AND COLLABORATION ON NEGLECTED TROPICAL DISEASES

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COUNTRYLEADERSHIP ANDCOLLABORATIONON NEGLECTEDTROPICAL DISEASESThird progress report ofthe London Declaration


ii | Country Leadership and Collaboration on Neglected Tropical Diseases


ABOUT UNITING TO COMBAT NTDSAND THIS REPORTIn January 2012, the World Health Organization (WHO) publishedan ambitious “Roadmap for Implementation”, outlining bold targetsfor the control, elimination or eradication of 17 Neglected TropicalDiseases (NTDs) by 2020.Inspired by this initiative, a coalition of diverse partners cametogether under the banner of Uniting to Combat NTDs, pledging theircommitment in a document called the London Declaration on NTDsto provide support towards attaining the WHO Roadmap targetsfor 10 of these NTDs (Chagas disease, Guinea worm disease,human African trypanosomiasis, leprosy, lymphatic filariasis,onchocerciasis, schistosomiasis, soil-transmitted helminths,trachoma, and visceral leishmaniasis).This report has been prepared in line with the London Declarationcommitment of all Uniting to Combat NTDs partners to provideregular updates on the state of progress towards reaching the WHORoadmap targets, and to highlight priorities which, if addressed,will help ensure that delivery of those targets remains on track.CONTENTSThe London Declaration and Uniting to Combat NTDs Stakeholders 2Executive Summary 4Scorecard6Country Leadership and Collaboration on NTDs 10Momentum in the Fight against NTDs on the Rise 12The Addis Ababa NTD Commitment, 2014 13Stepping up Domestic Financing for NTDs 14World Bank Facility Offers Potential NTD Financing Route for Poorer Nations 16New Leadership in Africa 17The Compelling Case for Financing London Declaration NTD Efforts 18The Largest Public Health Drug Donation Program in the World 20London Declaration NTDs: Progress by Disease 23Innovative Program Collaboration 44Research and Development 49Advocacy and Priorities for Action 54Country Leadership and Collaboration on Neglected Tropical Diseases | 1


THE LONDON DECLARATION AND UNITINGTO COMBAT NTDS STAKEHOLDERSA quick guide to the London Declaration on NTDsThe World Health Organization’s January 2012publication, “Accelerating Work to Overcome theGlobal Impact of Neglected Tropical Diseases”, setout implementation targets for the control, elimination,or eradication of 17 Neglected Tropical Diseases(NTDs) by 2020. This is commonly referred to asthe WHO Roadmap.Drawing inspiration from this Roadmap, leaders ofseveral prominent global health and developmentorganizations, together with industry partners, met inLondon in 2012 where they pledged to unite in theirefforts to support the achievement of the WHO 2020targets in respect to 5 NTDs manageable largelythrough mass administration of safe and effectivedrugs (known as preventive chemotherapy treatment orPCT), and 5 NTDs requiring innovative and intensifieddisease management (IDM).These collective promises of support were formalizedinto the London Declaration on NTDs, and it is aroundthis Declaration that the coalition of partners calledUniting to Combat NTDs was created.The key pillars of the London Declaration on NTDs andUniting to Combat NTDs were initial pledges to:• jointly support the control, elimination, or eradicationof the 10 NTDs listed at the bottom of this page;• enhance collaboration and coordination on NTDsat national and international levels through publicand private multilateral organizations in the NTDcommunity and other relevant sectors, such as water,sanitation, and hygiene, and education; and• report regularly on the fulfillment of commitments bypartners, as well as tracking key milestones towardsthe WHO 2020 targets.These pledges are backed with commitments tosustain or expand existing drug donation initiatives,provide an initial investment of more than $785million to support NTD programs, strengthen drugdistribution, and increase research and development(R&D) efforts, including sharing expertise andcompounds to accelerate R&D of new drugs.LONDONDECLARATION:A PARTNERSHIPFOR 2020WHO ROADMAP ON NTDSNATIONAL NTDPROGRAMMESAdvocacyFunding andtechnical supportDrugdonationand supplychainLONDON DECLARATIONPARTNERSAdvocacy and ResourceMobilization Working GroupResearchDiseaseSpecificWorkingGroupExtendedDonors’WorkingGroupSTAKEHOLDERSWORKING GROUP2 | Country Leadership and Collaboration on Neglected Tropical Diseases


The Uniting to Combat NTDs Stakeholders Working GroupWho we areThe Stakeholders Working Group (SWG) is tasked withsetting the overall strategy for Uniting to Combat NTDs,in addition to overseeing the delivery of the LondonDeclaration commitments. It includes representativesfrom all stakeholder groups as follows:Donors• the United States Agency for InternationalDevelopment (USAID)• the United Kingdom’s Department for InternationalDevelopment (DFID)• the World Bank• the Bill & Melinda Gates FoundationIndustry partners• the Partnership for Disease Control Initiatives (PDCI)• drug donating industry partnersAdvocacy• the Global Network for Neglected Tropical Diseases(GNNTD)NTD research• the Coalition for Operational Research on NTDs(COR-NTDs)• the Drugs for Neglected Diseases initiative (DNDi)Civil Society• the Neglected Tropical Disease Non-GovernmentalDevelopment Organizations Network (NNN)Observers• The WHO NTD DepartmentWhat we doUniting to Combat NTDs is dedicated to achieving theWHO 2020 targets, and promote a shared and strategicapproach to NTD programs. This work is in supportof the overall leadership and technical direction thatWHO provides to guide the efforts of Ministries ofHealth and implementing partners to deploy effectivestrategies for combating these diseases. Through thecollaborative efforts of a wide group of partners thatare facilitated by the SWG, Uniting to Combat NTDsthereby complements the role of WHO.On behalf of the coalition partners, the SWG has alsocompiled a scorecard that is designed to: (i) trackprogress and form the basis of an annual report on theinroads made towards achieving the WHO 2020 targetsand London Declaration commitments; (ii) serve asarecord for shared accountability; and (iii) facilitateongoing problem-solving. The SWG is supported in its role by the Uniting toCombat NTDs Support Center (hosted jointly bySightsavers and the Task Force for Global Health)as well as by the following three working groups:The Disease-specific Working Group, which bringstogether representatives of the 10 London DeclarationNTDs, provides a crucial forum for technical andexperiential input from implementing partners. Alongwith identifying challenges faced in meeting the WHO2020 targets, the group’s members also contribute andhelp coordinate access to information that drives theScorecard and progress reporting process.The Advocacy and Resource Mobilization WorkingGroup is responsible for identifying and developingopportunities for NTD advocacy and potentialresources that may be available to fill funding gapspreventing successful achievement of the WHO2020 targets.The Extended Donors’ Working Group unites donorsof all sizes and areas of interest that are dedicated tosupporting the efforts of the global NTD communitytowards reaching the WHO 2020 targets. The workinggroup enables contributors to share where and howthey are investing resources, with the aim of creatingsynergies that can address identified gaps inresources needs.Preventive Chemotherapy (PCT) NTDsLymphatic filariasis (LF or elephantiasis)Onchocerciasis (river blindness)Schistosomiasis (snail fever or bilharzia)Soil-transmitted helminths(STH or intestinal worms)TrachomaIntensive Disease Management (IDM) NTDsChagas disease Guinea worm disease (GWD)Human African trypanosomiasis(HAT or sleeping sickness)LeprosyVisceral leishmaniasis (VL or kala-azar)Country Leadership and Collaboration on Neglected Tropical Diseases | 3


EXECUTIVE SUMMARYIn the course of human history, few public health efforts can match the scale and ambition of theendeavor to rid the world of 10 Neglected Tropical Diseases (NTDs). These efforts have acceleratedover the last three years, as a diverse group of players have come together in one of the largest everpublic-private partnerships to deliver the funding, drugs, and technical assistance required.Number of countriesThe good news is that we are beginning to seepositive results from this collaboration: a growingnumber of endemic countries are achieving eliminationgoals, more people are being reached, and there isincreasing national ownership of NTD programs.The political and economic gains from NTD investmentsmake a compelling case for further investment bothdomestically and from donors.Nonetheless there are challenges that threaten ourability to meet the WHO NTD Roadmap targets.Currently the supply of donated drugs exceeds ourability to reach communities and more needs to bedone to scale up programs. If, as a global consortium ofpartners, we cannot marshal the resources required todeliver donated drugs to the communities in need, morethan a billion people will remain at-risk of harm by NTDs.50We need to redouble our efforts.45This 40 third report on progress since the 201236London 35 Declaration on NTDs highlights importantaccomplishments and learnings, and identifies areas30that warrant greater attention.25Five 20 principal themes have emerged within the report:15LF45OnchoTrachoma24151111 104 31Control 10and elimination of NTDsprovide one of the5strongest returns52on investment in public health 10Mapping Pharmaceutical MDA companies MDA-stoppeddonate Eliminated drugsworth nearly US$3.8 billion(Surveillance)every year, underpinningthe cost effectiveness of NTD programs. The on-goinghealth benefits from 2011 through 2030 if NTD goalsare reached will be equivalent to nearly 600 milliondisability adjusted-life years (DALYs 1 ) averted.Nearly 1 in 6 people worldwide requires treatment forat least one NTD. Aside from the health and economicbenefits of tackling NTDs for the endemic countries, theprograms offer political benefits for leaders in endemiccountries as well as donor countries, who can showcasehigh impact, ‘best buy’ foreign assistance programs.However, the wealth of donated drugs is not enoughto defeat NTDs if we fall short of the funding to ensuredelivery of those drugs to communities. Currently, itis estimated that there is an annual funding gap ofUS$200-300 million through 2020.The WHO has set a target for investment by endemiccountries of 0.1% of their domestic expenditure onhealth. A recent study (described on page 18) suggeststhat would lead to US$623 billion in productivity gainsamong affected individuals between 2011 and 2030.2Leadership4among endemic countries15has shown a substantial increaseThe past year saw significant increases incountry ownership of NTD programs. One183key milestone was the creation of the Addis AbabaCommitment on NTDs, initiated by African Ministers ofHealth to outline Countries, their areas commitments and territories certified to achieving free of theGuinea-worm diseaseWHO Roadmap. To date, 26 countries have signed andother countries are encouraged to join this movement.Number of formerly endemic countries which are now certifiedNumber of endemic countriesCountries such Number as of Bangladesh formerly endemic and countries the Philippines which interrupted aretransmission and are yet to be certifiedleading the way in securing domestic resources tosupport significantNumber ofportionscountries withofnotheirrecentNTDhistoryprogramsof GWD or(85%notknown to have GWD and yet to be certifiedand 94% respectively). Honduras became the first LatinAmerican country to launch a national NTD plan fullysupported by the government.902 2 20131. DALYs are a measure of life years lost from disease, adjusted for assumptionsabout disability as well as the impact of age and future time.Global status of preventive chemotherapy in 2013Coverage (%)8070605040302012201120102009200820100Lymphatic Filariasis Onchocerciasis Soil-transmittedHelminthiasisSchistosomiasisTrachomaPC4 | Country Leadership and Collaboration on Neglected Tropical Diseases


Country progress towards elimination in NTDsGuinea Worm Disease: Country program statusNumber of countries50454035Number of countries30252015105050LFLF454545OnchoOncho104 53 4 553 2 1 2 140353036TrachomaTrachoma3625242420151515 11111111 10100(Surveillance)(Surveillance)MappingMappingMDA MDA-stoppedMDA MDA-stoppedEliminatedEliminated42 2 20134152 2 201315183183Countries, areas and territories certified free ofCountries, areas and territories certified free ofGuinea-worm diseaseGuinea-worm diseaseNumber of formerly endemic countries which are now certifiedNumber of formerly endemic countries which are now certifiedNumber of endemic countriesNumber of endemic countriesNumber of formerly endemic countries which interruptedNumber of formerly endemic countries which interruptedtransmission and are yet to be certifiedtransmission and are yet to be certifiedNumber of countries with no recent history of GWD or notNumber of countries with no recent history of GWD or notknown to have GWD and yet to be certifiedknown to have GWD and yet to be certifiedCoverage (%)90807060Coverage (%)50403020100The World Bank indicates that there are 77 poorcountries worldwide that are eligible to receiveinvestment project financing (IPF) resources from theInternational Development Association (IDA). Some ofthese resources can support NTD projects if endemiccountries integrate NTD programming into their nationaldevelopment plan.908070 Despite managing endemic disease burdens of60 their own, both Nigeria and Brazil have demonstrated50 leadership by contributing to the success of others.40 In 2015, Brazil joined Nigeria as a donor by30 providing support to other Latin American countries20 through Pan American Health Organization (PAHO).100Lymphatic Filariasis Onchocerciasis Soil-transmittedLymphatic Filariasis Onchocerciasis Soil-transmittedSchistosomiasisSchistosomiasis3The largest public health drugdonation program Helminthiasis in the Helminthiasis worldcontinues to growTogether the NTD drug donation programsare the largest of their kind in public health, withpharmaceutical companies pledging drugs valued atUS$17.8 billion from 2014 to 2020.Over 5.5 billion tablets have been donated providing3.5 billion treatments since the launch of the LondonDeclaration in 2012. In 2014 1.45 billion treatments weremade available to endemic countries, representing a36% increase since 2011.4Coverage is increasing, but the paceis too slow to meet key milestonesGlobal coverage is increasing with 43.3% of thepopulation requiring treatment with preventivechemotherapy (PCT) receiving treatment for at least onedisease, compared to a rate of 35.5% in 2008. In 2013,there were 114 countries endemic for the four preventivechemotherapy diseases with a total at risk-populationof nearly 1.8 billion. Of these, 74 countries reporteddistributions to more than 784 million people altogether.However, coverage is not increasing rapidly enough toachieve targets. The average annual increase of 1.6%is too low to achieve and sustain impact; increasing thepace is imperative.5National NTD programs areachieving elimination goalsAchievements of the Guinea Worm Eradication20122012Program are a testament to what is possible in2011NTDs. Since 1983, the global program has successfully20112010eliminated GWD in 81% of all formerly endemic 2010 countries2009(17/21). Cases in 2015 are at an all-time low of 2009 5 as at the2008end of May. Eight countries remain to be certified: 2008 Chad,Ethiopia, Mali and South Sudan remain endemic; Kenyaand Sudan are at pre-certification stage; and DemocraticRepublic of Congo and Angola (not known to be endemic),but still Trachoma have to be certified PC by WHO.Onchocerciasis was eliminated in Colombia and Ecuadorand trachoma was eliminated in Oman. Some countrieshave also made progress in stopping treatment in all orsome foci. These include Mexico, Guatemala, Uganda,Sudan, Mali and Senegal. Of the remaining 73 countriesendemic for LF, 16 countries (22%) are no longer inneed of mass drug administration (MDA). Malawi hasjust announced that they have reached a stage wheretreatment is no longer needed, increasing that numberto 17 countries. These amazing accomplishments showthat the ambitious goals set are achievable with effortand resources.ConclusionTrachomaAs noted in the 2015 G7 Summit communique, “2015is a milestone year for international cooperation andsustainable development issues”—and, the fight againstNTDs is no different. We have the opportunity now, together,to reach many of the goals laid out in the WHO roadmap onNTDs and position the future elimination of these 10 NTDsas an achievable objective for this generation. Those livingin extreme poverty around the world are counting on ourhelp. Let’s not keeping them waiting.PCCountry Leadership and Collaboration on Neglected Tropical Diseases | 5


SCORECARDWhat is the scorecard and how does it work?The scorecard is a collection of indicators andmilestones compiled from the NTD specificcommunity and WHO. Coverage milestones arebased on the WHO Roadmap and subsequentguidelines and recommendations for lead focalpersons. Additional program support milestones wereset by the implementing partners to follow progresstowards the WHO Roadmap targets. Indicatorsand milestones vary across diseases; some arestrong and others are less robust, but across alldiseases these indicators are improving throughimportant discussions generated by the productionand publication of the scorecard. Indicators arestrongest where there is an organized community ofpartners supporting a disease area, like trachoma orLF. The development of indicators and milestones insupport of WHO and endemic countries are weakestin disease areas without an organized communityof partners. Progress towards achieving the goalsis followed by relying on WHO data where possibleand with additional input from partners as needed.Disease specific communities e.g. InternationalCoalition for Trachoma Control (ICTC) and the GlobalAlliance to Eliminate Lymphatic Filariasis (GAELF)first review progress and assess if they believe theyare on target using the most current data available.The Stakeholders Working Group, comprised ofrepresentatives from all stakeholder groups, thenreview the progress and make a determination of afinal scoring (red, yellow, or green) for each diseaseaccording to set criteria and note why the decisionwas made. Yellow and red indications are not ajudgment of the program itself but rather a call toaction that additional course correction and resourcesmay be required to achieve program goals.6 | Country Leadership and Collaboration on Neglected Tropical Diseases


RESULTSIn the past year the collective NTD community has continuedto make significant progress towards the WHO Roadmap targets.The most significant progress was made in human Africantrypanosomiasis where cases hit a 75 year low with 3,796 casesfound after similar numbers of people were screened. This combinedwith two new tools (one vector control and one point-of-carediagnostic) make continued progress likely towards the 2020 goal.However, as we approach the middle of 2015 it is already clear thatmany of this year’s critical milestones will not be met. We will notachieve full scale up of the delivery of PCT for LF in all endemiccountries, nor is it likely that transmission of GWD will be broken/interrupted by the end of 2015. The scorecard is an attempt to followthis progress across diseases included in the London Declaration sothat partners can react and appropriately adjust support to ensurethe achievement of the goals.Country Leadership and Collaboration on Neglected Tropical Diseases | 7


ANNUAL SCORECARDLondon DeclarationNTDsCoverageand ImpactMilestonesProgramSupportMilestonesDrugRequestsFilledResearch1stProgressReport2ndProgressReportCurrentProgressLymphatic Filariasis2 1 1 1 2 2 2PREVENTIVE CHEMOTHERAPYOnchocerciasisSchistosomiasisSoil-TransmittedHelminths1 2 1 2 1 2 23 2 1 2 2 3 31 1 1 3 2 2 1Trachoma2 1 2 1 2 1 1Chagas Disease1 2 1 4 1 1 2INTENSIFIED DISEASE MANAGEMENTGuinea WormDiseaseHuman AfricanTrypanosomiasis(HAT)LeprosyVisceralLeishmaniasis2 2 5 1 2 2 21 4 1 1 1 1 12 2 1 2 2 1 21 4 2 2 1 1 2Key1Achieved or minordelay; or 90–100percent of requestedtreatments shipped2Delayed butachievementanticipated; or 80–89percent of requestedtreatments shipped3Delayed, additionalaction required;or 0–79 percentof requestedtreatments shipped4Globalmilestones indevelopment5Notapplicable8 | Country Leadership and Collaboration on Neglected Tropical Diseases


Summaries of the scores and rationale are as follows:Lymphatic Filariasis2 2 2LF remains yellow. Despite significantprogress, the rate of scale up remainsbelow the target. Mapping of prevalencecontinues. The target of full geographicscale up in all endemic countries isunlikely to be achieved in time to allow5 years of treatment prior to 2020.If mapping reveals a lower populationin need of treatment, and if resources(financial and human) are available,significant progress could be madein the next year to fill the gap.Onchocerciasis1 2 2Oncho remains yellow, as the programis now targeting elimination not justcontrol, which means more people needto be reached as hypo-endemic areasare included. The number of peoplereached with MDA increased in 2013,although overall coverage decreased,as the inclusion of hypo-endemic areasincreased the number needing treatment.The closure of the African Programfor Onchocerciasis Control (APOC) inDecember 2015 leaves support for theprogram uncertain, though efforts areunderway to put in place a regional entityto support country programmes.Schistosomiasis2 3 3Schistosomiasis remains red as ithas the lowest coverage of all PCTdiseases at 14.4% in 2012 and 15.6%in 2013. In addition, new mapping ofschisto in AFRO countries is increasingthe number of identified endemicdistricts. Twenty-six countries (50%) of52 endemic countries reported MDAin 2013. Significant improvementscould be made in the next cycle asdrug supply is expected to increaseand the launching of the new GlobalSchistosomiasis Alliance will increasecollaboration within this diseasecommunity to help countries scale up.Soil-Transmitted Helminths(STH)2 2 1STH moved from yellow to green.Improved coordination between UNICEFand WHO has led to an improvementin reporting of coverage for pre-schoolchildren which now exceeds 50%.Coverage in school-age children is39%, which is on track for a 75% targetin 2020. Coordination of partners asa result of the STH Coalition and theimprovement in resources and coverage,are the main drivers for moving to green.However, increases in coverage of preschool-agedchildren were primarily dueto improved reporting and STH is highlydependent on LF coverage. STH-specificimplementation efforts need to increaseto maintain a green status.Trachoma2 1 1Trachoma remains green due to itsstrong partnerships, available resources,and momentum. Trachoma has madetremendous strides in the ambitiousmapping efforts. In order for progressto be maintained, drug supply issues,coverage of the F and E componentsof the SAFE strategy, as well asimplementation in the growing numberof new districts being identified throughthe mapping exercise, will need tobe addressed.Chagas1 1 2Chagas changed from green to yellowas only 14% of endemic Latin Americancountries have verified interruption ofintra-domiciliary vectoral transmissioncompared to a target of 30%. Progressmeasurement has been hampered bya lack of availability of data and lack ofpartner coordination. However, a newlyforming coalition is expected to help, byimproving indicators for the partners’contributions, which may encourageincreased investments in Chagas. Thisand better access to annual treatmentdata may move this back to green in thenext cycle.Guinea Worm Disease (GWD)2 2 2GWD remains yellow due to the fact thatthe 2015 target to end transmission willnot be reached. There are also concernsover filling the new funding gap upto the new target of 2020. There hasnonetheless been good progress suchas Ghana being certified GWD-free inJanuary 2015 and a 48% decrease inthe number of villages reporting casesbetween 2013 and 2014. Four countriesare awaiting certification as GWD-free(DRC, Angola, Kenya, and Sudan). Ifcases are found in any pre-certificationcountry, if cases do not significantlydecrease, and if the funding gap is notresolved this would likely be red in thefollowing cycle. Initial data for 2015shows a decrease in cases and somefunding is coming in so we remaincautiously optimistic.Human AfricanTrypanosomiasis (HAT)1 1 1HAT stays green with cases at a 75year low with 3,796 cases in 2014.The marked success of the controlstrategies applied, along with theintroduction of a new rapid diagnostictest and new vector control tools suchas the “tiny targets”, gives hope forsteady progress in the following cycle.The HAT community needs to ensurethat program support is maintainedat a high level, because reaching themilestone of lowest disease incidencewill require reinforced surveillance innear-elimination foci.Leprosy2 1 2Leprosy moved from green to yellow,partly due to greater rigor of indicators.Additionally, there was poor reportingof data from endemic countries,with only 7 of 25 endemic countriesreporting national data, making progressassessment difficult. We remainoptimistic that the strong leprosycommunity and leadership may returnleprosy to green in the next cycle.Visceral Leishmaniasis (VL)1 1 2VL moved from green to yellow dueto temporary drug delay and poorlydefined indicators. Approximately915 treatments of AmBisome ® due in2014 were not distributed until March2015, though this delay did not impactprogramming needs. Currently, 9 of 11VL endemic countries in the Americashave provided updated epidemiologicaldata. South-East Asia is reporting areduction in incidence and case fatalityrates as well as progress towardselimination, with a reduction in reportedVL incidence and case fatality rate by60% and 81% respectively in 2014.80% of health facilities in East Africahave diagnostic and treatment capacitycompared to less than 60% in 2010.With improved milestones and a refinedresearch strategy plan, progress wouldbe easier to measure and likely movetowards green in the next cycle.Country Leadership and Collaboration on Neglected Tropical Diseases | 9


COUNTRY LEADERSHIP ANDCOLLABORATION ON NTDS10 | Country Leadership and Collaboration on Neglected Tropical Diseases


MOMENTUM IN THE FIGHTAGAINST NTDS ON THE RISEThe global development community witnessed a pivotal moment of unprecedented politicalleadership and commitment to the elimination of NTDs at this year’s World Health Assemblymeeting (WHA68). On May 18, 2015, current G7 chair and German Federal Chancellor AngelaMerkel proclaimed combatting NTDs as one of the three health-related issues for this year’s G7agenda. “Health is a human right,” Chancellor Merkel said. “The responsibility of individual countriesand global shared responsibility are two sides of the same coin.”That same day, Ethiopia Minister of Health, Dr.Kesetebirhan Admasu, chaired an event dedicated todiscussing country level political commitment andaccomplishments on NTDs. He opened the gatheringby asserting, “NTDs are not only a health agenda, buta development agenda too, for which the poor pay thehighest price.”Joined by his fellow ministers of health from Brazil,Malawi, and Sudan, Minister Kesete introduced TheAddis Ababa Commitment on NTDs – an agreementspearheaded by Minister Kesete himself and alreadyendorsed by 26 countries. In the commitment,ministers of health promise to increase domesticinvestments to meet the WHO Roadmap targets forNTDs; promote multi-sectoral approaches; encourageadoption of data-driven, long-term strategic plans; andensure mutual support of NTD programs and overallhealth systems.“Germany has put three health-relatedissues on the G7 agenda. First, in thelight of current events, we are askingwhat lessons can be learned from theEbola epidemic. Second, what can wedo to better combat poverty-relatedneglected tropical diseases? And third,what can we do about the increasingresistance to antibiotics? This is anissue for industrialized and developingcountries alike.”Chancellor Angela Merkel, G7 Chair, WHA68,May 18, 2015Minister Kesete further emphasized the need forgovernment-wide, cross-sectoral commitment in orderfor any NTD elimination effort to succeed.Joining the ministers’ commitment, the Uniting toCombat NTDs and the Stakeholders Working Groupcalls upon:• Countries which have not yet signed on to officiallyjoin the effort and dedicate their NTD resources“Commitment and ownership at thehighest level of government are thefirst prerequisite for success. Theengagement of women is the second.”Dr. Margaret Chan, Director General WHO, WHA68,May 18, 2015to the priorities outlined in The Addis AbabaCommitment on NTDs;• All ministers of finance and development partnerswho are meeting in Addis Ababa in July 2015 toactively support and redouble their engagementtoward increasing domestic financing for nationalNTD programs against these diseases of poverty;• Governments to both fulfill the funding commitmentsmade by their ministers of health and to diligentlycarry out the necessary actions required to implementintegrated NTD elimination programs; and• G7 to collectively echo Chancellor Merkel’s callfor universally compulsory International HealthRegulations and individually match Germany’sfinancial commitment of €200 million as seedmoney to help affected countries build functioninghealth systems.It will take a variety of sectors – health, transport, andwater and sanitation to name but a few – workingcollaboratively to ensure all people have equalopportunities to achieve the highest levels of health. AsChancellor Merkel said at WHA68, “Every single personis vitally needed to fight for the human right to health.Let us work together in a spirit of cooperation, and notseek to undermine each other’s deeds. The task is soimmense and the endeavour so important that everyhelping hand is needed.”“The development arena talks about‘value for money’ with NTDs, I like tothink about ‘value for many’.”Ethiopia Minister of Health, Dr. KesetebirhanAdmasu12 | Country Leadership and Collaboration on Neglected Tropical Diseases


THE ADDIS ABABA NTD COMMITMENT, 2014Minister Kesete of Ethiopiasigning the Addis Ababa NTDsCommitment at WHA68December 8-12, 2014 marked the first occasion whenAPOC, JAF and GAELF, together with the first GlobalSTH Coalition and Global Schistosomiasis Alliance allconvened in Addis Ababa, Ethiopia for the first time. Tocommemorate this global coordination, the assembledMinisters of Health and Heads of Delegations wouldlike to use our unique voice to buttress the efforts ofmany others who have committed to fighting NTDs andcombating global poverty.Whereas the Ministers of endemic countries havealready endorsed and committed to achieving theWHO Roadmap goals through passage of the WHA66.12, we, the undersigned (e.g., Ministers attendingthe Minister NTD Health Forum on December 9th,2014), further commit to:1. Work to increase our domestic contribution tothe implementation of NTD programs through theexpansion of government, community and privatesector commitments;2. Promote a multi-sectorial approach to theimplementation of NTD program goals thatimproves national coordination, facilitates partnercollaboration, and improves the management oftechnical and financial contributions;3. Ensure the adoption of both long-range strategicand annual implementation plans which aregrounded by appropriate goals and detailed coststhat drive and support NTD programs to achieveglobal targets;4. Report and use program data in a timely fashionto follow progress against program goals and toinform program planning and execution; and5. Ensure that the implementation of NTD programscontribute to the strengthening of the overall healthsystem and vice versa.As we move toward 2020, we promise to maximizethe use of our voices and of our offices to enact thesecommitments and to continue our leadership roles inmaking the world a healthier place where families andcommunities can thrive. In addition, we will continueto welcome the support endemic countries receivethrough the World Health Organization which providesguidelines and technical support via the WHO NTDRoadmap to control, eliminate and eradicate 17 NTDs.We also acknowledge the continuing support andengagement provided by donors and the internationalcommunity.Current list of endorsers: Burkina Faso, Burundi, Brazil,Cameroon, Central African Republic, Chad, Congo, Côted’Ivoire, Democratic Republic of the Congo, Ethiopia,Gabon, The Gambia, Ghana, Guinée Conakry, GuinéeBissau, Kenya, Liberia, Mali, Malawi, Niger, Nigeria,South Sudan, Sudan, Tanzania, Togo, and UgandaCountry Leadership and Collaboration on Neglected Tropical Diseases | 13


STEPPING UP DOMESTIC FINANCING FOR NTDSA leadership imperative with far-reaching human and economic benefitsSeveral countries are showing great initiative ondomestic financing for NTD programs, in manyinstances exhibiting remarkable leadership andforesight in the face of challenging conditions.Countries in Latin America and Asia in particular wererecognized in the recently published Third WHO Reporton NTDs (2015) for their new levels of political andfinancial commitment to achieving NTD control andelimination. These regions were acknowledged fortheir success in moving toward integrating NTD planswith treatment strategy implementation as a way ofenhancing and growing national healthcare systems.In Africa too, there has been progress in this direction,with 43 (of 47) endemic countries now operatingintegrated NTD programs.An assessment in 2014 estimated that there remainsan additional need of US$1.4 billion between 2014-2020 to meet the WHO roadmap targets for the 10London Declaration NTDs, or approximately US$200-$300 million per year, assuming that current resourcesavailable continue (donor, bilateral and domesticspending). Although this gap is relatively small fora global health program at this scale, it remains asignificant challenge when put into the context of ashifting economic climate for both traditional donorcountries and several endemic countries.The investment case for NTDs laid out in WHO’s thirdreport on NTDs, Investing to Overcome the GlobalImpact of Neglected Tropical Disease, is still verystrong. To demonstrate this, the WHO set targets fordomestic investment in universal coverage againstNTDs, which, given they represent less than 0.1%of domestic expenditure on health across endemiccountries, attests to the affordability of NTD programseven in endemic country settings. The increasingemergence of innovative financing mechanisms shouldalso help to fill the US$200-300 million annual gap andensure these targets are achieved.The following pages showcase an illustrative selectionof NTD-endemic low-and middle-income countriesshowing exemplary leadership in domestic investmentfor NTD programs, both as a tribute to what can beachieved even in the face of adversity, and to urge allendemic countries to respond to WHO’s call for animmediate major scale-up in domestic financing tocombat these diseases. These illustrative countriesvary widely in economic status, population and politicalsecurity, yet have prioritized the control and eliminationof their NTDs and have put their resources to work increative ways, through cross-sector collaboration, diseaseintegration, and targeted funding and technical assistancerequests from global donors. These countries modelwhat is achievable across all low-and middle-incomeendemic countries with the political will and commitmentto create sustainable NTD programs. The Addis AbabaNTD Commitment called for just such political will andcommitment, and is described on page 13.A number of low-/middle-incomecountries have risen to the challengeof funding NTD effortsSome countries not yet self-financing are puttingplans in motion through the development of financestrategies for NTD sustainability, linked to their NTDmaster plans. As mentioned on page 11, one suchstrategy 1 is helping national NTD programs to allocateresources effectively, mobilize additional resourcesto fill financing gaps, reduce dependence on donors,increase national commitment to the NTD program,and diversify resources: critical components tosustainability. Strategies such as these and otherinnovative financing mechanisms emerging globally,such as low/no interest IDA loans, outlined onpage 16, are powerful resources to help endemiccountries ensure the achievability of these domesticinvestment targets.The considerable and tangible human and economicbenefits of NTD investments for the countries affectedare examined in more detail in “The compelling casefor financing the London Declaration NTDs: a pro-poorstrategy and a development best buy” on page 18 ofthis report and provides further compelling reasons fora step change in commitment. This point was perhapsmost succinctly made by Dr. Margaret Chan, Directorof the WHO, who noted that “when countries and theirpartners invest in these diseases, they get a windfall ofbenefits in return”. 21. http://endinafrica.org/news/finance-strategy-a-must-for-ntd-program-sustainability/2. Foreword of Third WHO Report on Neglected Tropical Diseases (2015), World HealthOrganization.14 | Country Leadership and Collaboration on Neglected Tropical Diseases


LATIN AMERICABRAZILInnovating nationallyand supporting wider NTDefforts in Latin AmericaTotal population:200.4 million**2013HONDURASCentral Americatrailblazer with 1stnational NTD planTotal population:8.1 million**2013NTDs targeted: LF, leprosy,onchocerciasis, trachoma,schistosomiasis and STHWorld Bank 2015classification:Upper-middleincomecountryNTDs targeted: STH, Chagas,VL and Leprosy + 5 nonLondon Declaration NTDsWorld Bank 2015classification:Lower-middleincomecountryDemonstrated leadership on NTDsDemonstrated leadership on NTDs~$1.5million p.aspent on integratingleprosy/trachoma/STHschool-age treatment• Was 2nd country inthe region to launchintegrated national plan,targeting 5 NTDs• $15 million investedin 796 prioritizedmunicipalities in plan’s1st year (2012), inaddition to in-kindcontributions byregional and localgovernments of healthinfrastructure andhuman resources• Through PAHO/WHOis providing other LatinAmerican countrieswith financial andtechnical support tocombat NTDs~$20million (2012-17)of domestic funds beinginvested to combat NTDsin the most at-risk areas• Became the 1st LatinAmerican country tolaunch a national NTDplan (in 2012), coveringthe entire cost andhealth infrastructureburden itself (exceptfor donated drugs andseed funds from PAHO/WHO and other donors)• In 2013, beganintegrating dewormingwithin nationalvaccination program(absorbing the entirecost of ~$77,000),with two dewormingcampaigns carried outfor preschool-age andschool-age children in2014SOUTH-EAST ASIABANGLADESHCross-sector efforts endtreatment need in manyendemic areasNTDs targeted:LF and STHTotal population:156.6 million*World Bank 2015classification:Low-incomecountryPHILIPPINESLocal synergies helpreach widely-dispersedat-risk childrenNTDs targeted:LF, schistosomiasisand STHTotal population:98.4 million**2013 *2013World Bank 2015classification:Lower-middleincomecountry*2013Demonstrated leadership on NTDs85%of NTD coststotaling ~US$1 millioncovered by variousgovernment ministries• Ministry of Health NTDcontrol and eliminationplan (focused on massdrug administration-MDA)and expanded:- from 1 district in 2001 tocover all MDA costs for all19 LF-endemic districtswithin 7 years; and- From 2005, inconjunction withthe Directorate ofPrimary Education(DPE), covering nearlyall MDA expensesfor STH (apart fromdonated drugs) inthe 64 districts of thecountry within 3 years,resulting in 18 of theendemic districtsstopping treatment• Some funds from theCentre for NeglectedTropical Diseases-CNTD/DFID andUSAID are providedfor surveillance,supervision, and certainsuppliesDemonstrated leadership on NTDs94%of budgetsfor 3 NTD programsbeing met through jointdepartmental efforts• The Departments ofHealth and Educationhave collaborated sincearound 2000 on dewormingchildren up to 12 yearsoldscattered across thecountry’s thousandsof islands• For STH (endemiccountrywide), dewormingtreating nearly 30million children twice ayear with donated drugsat community healthclinics, with effortscoordinated betweenthe 2 departments andfunded by the HealthDepartment’s regionaloffices (at a cost of overUS$1.3 million)• MDA for LF (endemicin 44 of 80 provinces)began in 2001 withlimited funding, butis now covered 100%by government (overUS$5 million), with 27endemic provinces nowready to stop treatment(2009-2014)Country Leadership and Collaboration on Neglected Tropical Diseases | 15


WORLD BANK FACILITY OFFERS POTENTIALNTD FINANCING ROUTE FOR POORER NATIONSIf NTDs are prioritized by low-income countries in theirhealth-sector strategies, International DevelopmentAssistance (IDA) funds can provide a reliable source ofdomestic funding for NTDs.According to the World Bank, low-income countries,including those endemic for NTDs – are eligible forsupport from IDA funds depending on their relativepoverty, which is defined as the Gross National Income(GNI) per capita. 77 of the poorest countries in theworld qualify for support from this facility, 39 of whichare in Africa (see www.worldbank.org/ida/borrowingcountries.html).IDA lends money on concessional terms, that is, at littleor no interest with long periods for repayment, and alsoprovides grants to countries at risk of debt distress.During the 2014 financial year, lending to 74 lowincome countries, 36 of them in Africa, amounted toUS$22.2 billion, and for 2015, lending was extended to61 countries, (32 in Africa), amounting to US$19 billion.Of the 2015 lending, US$2.2 billion went to health,nutrition and population whilst education receivedUS$1.8 billion. Part of these resources could have beenused for NTD interventions.Evidence shows NTDs have a negative impact onthe economic stability of families, communitiesand countries and those countries that apply forIDA resources should be encouraged to includesupport for NTD programs within their developmentplans, including their national health and educationstrategies/policies/plans.Two regional World Bank programs are specificallytargeting NTD and cross-border issues withdevelopment funds. The Senegal River basin watermanagement and Malaria and NTD Sahel projects bothprovide opportunities for a group of countries to accessIDA resources for NTDs and malaria. The Senegal RiverBasin water management project allocated US$40million for NTD interventions and Malaria, and the Sahelproject budget for NTD and Malaria in Burkina Faso,Mali and Niger is US$121 million. Another multi-sectorproject in Madagascar has allocated US$5 million forNTD interventions.YEMENUncertain politicalclimate threatensprogress on NTDsAt the time of writing, thecurrent situation in Yemen isconcerning and unpredictable,with a social, political andhumanitarian situationthreatening the country’sTotal population:24.4 million*World Bank 2015classification:Lower-middleincomecountrystability. Yet just prior to the onset of this spring’sunrest, Yemen was on course to eliminatingschistosomiasis by 2017.In 2010, the Yemen Ministry of Public Healthand Population (MPHP) launched a nationwideschistosomiasis control program (also coveringsoil-transmitted helminths – STH) with a US$25million IDA grant from the World Bank andpartnerships established with the WHO and theSchistosomiasis Control Initiative (SCI). TheMPHP’s strategy was to combine schisto andSTH control with health, education, via schoolsand outreach, and the concerted engagement ofmultiple sectors, such as agriculture, education,and water and sanitation.*2013Since 2010, more than 24.8 million praziquanteltablets for schistosomiasis have been delivered,in combination with albendazole for STH in coendemicareas. In 2014, disease remappingefforts showed that the number of highly-infecteddistricts was down from 51 in 2010 to 3 anddistricts with low infection rates increased from 41to 189, translating into low-infected districts nowaccounting for more than 87% of the country, upfrom 15% just five years ago.Recent events prevented the national programfrom conducting assessments to determinehow many districts had reached the targeted 1%infection rate. 1 On reaching the WHO target, Yemenwill be among the few countries to have eliminatedthe public health burden of schistosomiasis, havingalready achieved this for Guinea worm diseaseand lymphatic filariasis – a remarkable feat for theregion’s poorest nation.With events on hold, Yemen awaits theopportunity to resume assessment activities anddetermine its schistosomiasis elimination status.Yemen serves as a stark example of howeven impressive gains made in combating NTDsdecrease in an uncertain political environment.1. WHO’s recommended metric of elimination of schistosomiasis as a publichealth problem: Helminth Control in School-Aged Children: A Guide for Managersof Control Programs, World Health Organization (2011). The 2014 assessmentshowed that two-thirds of the sentinel sites had reached this target.16 | Country Leadership and Collaboration on Neglected Tropical Diseases


NEW LEADERSHIP IN AFRICAFor the first time in its66-year history, WHOAfrica Regional Office(AFRO) has a woman atits helm. Earlier this year,Dr. Matshidiso Moeti wasappointed as the RegionalDirector for AFRO by theWHO’s Executive Board inGeneva in January 2015.Coming into this role, Dr. Moeti intends to build aneffective, responsive, results-driven WHO in Africa. Thisis no small feat given Dr. Moeti began her five-year termin the midst of the most recent Ebola disaster.Originally from South Africa, Dr. Moeti’s inspiringcareer trajectory began with medical and public healthdegrees from University of London and London Schoolof Hygiene and Tropical Medicine respectively. Fromthere she returned home and eventually led Botswana’sMinistry of Health’s epidemiology unit and its HIV/AIDSprogram. After that, she joined UNICEF in Zambia as ahealth and nutrition program officer and then went toUNAIDS as a regional team leader for Africa and theMiddle East. It was after this that Dr. Moeti first joinedthe WHO’s Africa Regional Office, where she held variousroles such as Deputy Regional Director, AssistantRegional Director, Director of Non-communicableDiseases, WHO Representative for Malawi, andCoordinator of the Inter-Country Support Team for theSouth and East African countries.Uniting to Combat NTDs caught up with Dr.Moeti during WHA68 in Geneva for an interview:In what ways does being the first female AFRO RDmatter to you? What does it mean to you – personallyand professionally?It’s an honor bestowed on me to serve my continentand Member States as the first woman WHO RegionalDirector and more importantly to join my predecessors,the men and women in the Region and indeed aroundthe world, to help reduce the burden of poor health onthe people. The role of women is changing and witheducation and hard work, there is no limit to what anywoman can achieve in her personal and professional life.Your first meeting as Regional Director was onNeglected Tropical Diseases in Brazzaville, was this ahappy coincidence for the NTDs community?As a Regional Director of WHO in the African Region, aregion that is currently experiencing the highest burdenof NTDs, I made a commitment to the Ministers ofHealth that tackling NTDs will be one of my top priorities.As you may be aware, these diseases anchor a largeproportion of African people into poverty and must becontrolled, eliminated and eradicated so as to contributeto the reduction of poverty and attainment of theSustainable Development Goals.As an immediate follow-up to my commitment anddetermination to tackle NTDs, I convened a meetingof the Regional Program Review Group, a technicaladvisory group that reviews the status of NTDprograms in the region and guides countries oncritical interventions to be taken to achieve the NTDgoals and targets.What do you think is the single biggest issue that weneed to tackle in NTDs?Addressing the burden of NTDs in the region requires amulti-sectorial approach and combination of strategiesthat includes, among others, preventive chemotherapy,intensified case management, vector control andprovision of safe water, sanitation and hygiene.One of our biggest challenges in the region is scalingup mass drug administration so as to reach the highestnumber of people and thus control, prevent, andhopefully eliminate these diseases with the supportof our partners. We must take every advantage of thedonations of medicines that pharmaceutical companiesare providing and ensure that they get to all the peoplethat need them until the diseases are eliminatedor eradicated.What gets you out of bed every morning?The knowledge that every effort during the daycontributes towards making someone in the Regionhealthy. To see that people have access to basichealthcare; to see the last Guinea worm patient andother successes in health is encouraging. I was thrilledto meet the last Guinea worm patient from Ghana and Iwant that experience about other endemic diseases.What excites you most about your new role?The fact that we’ve turned a new page and upped ourgame and are on course to tackle the health challengesfacing the African region.We know you are a lover of Jazz – which isyour favorite?It’s impossible for me to name one; but listening to MilesDavis, Sarah Vaughan, John Coltrane, and Ella Fitzgeraldhave both inspired and soothed me since my teens.Thank you Dr. Moeti, and all of us at Uniting to CombatNTDs wish you a very successful tenure in your role asRegional Director and very much look forward to workingwith you in ending these diseases of poverty in Africa.Country Leadership and Collaboration on Neglected Tropical Diseases | 17


THE COMPELLING CASE FOR FINANCINGLONDON DECLARATION NTD EFFORTS 1A pro-poor strategy and a development best buy$0.2$21.3$53.2$30.1$8.7Work completed this year by Erasmus indicates thatNTD programs have a high return on investment andby targeting NTDs, the poor are reached globally andnationally. This makes NTD programs a pro-poor best buy.Systematic studies of peer-reviewed literature showevidence $7.9 that:• a disproportionate share of the overall NTD burden iscarried by low- and lower-middle income countries,and $20.4 within countries NTDs tend to impact poorercommunities;• NTDs affect the economic livelihoods of individualsand thus households, countries, and regions – to asignificant degree; andVisceral LeishmaniasisChagas DiseaseLeprosyHuman African Trypanosomiasis• controlling, eliminating, or eradicating NTDs willmeaningfully benefit the poorest of the world’s poor.Using data from the Institute for Health Metrics andEvaluation’s 2010 Global Burden of Disease (GBD) study,researchers from Erasmus created mathematical modelsto forecast the health and economic impact of meeting theWHO 2020 targets.Health impact• Between 2011 and 2030, an anticipated 600 millionDALYs 2 would be averted as a result of meeting the WHO2020 targets (see Figure 1). Amongst the preventivechemotherapy treatment (PCT) NTDs, 96% of the healthgains would be attributed to averted disability, and withinthe intensified disease management (IDM) NTDs, 95% ofthe impact would be realized from averted deaths.$90.7• Included in these gains are approximately 150 millionaverted irreversible 3 disease manifestations, such aschronic heart disease resulting from Chagas disease,and swelling of the scrotum (hydrocele) and of the lowerlimbs (lymphedema) due to lymphatic filariasis.$259.6Hookworm anaemiaAscariasis (roundworm) infestationHookworm infestationTrichuriasis (whipworm) infestationAscariasis (roundworm) deaths• Additionally, 5 million deaths could be averted, mainlyfrom visceral leishmaniasis (VL) and human Africantrypanosomiasis.Economic impact• For PCT-NTDs, meeting the WHO Roadmap targetscould mean that, between 2011 and 2030, US$565billion could be gained in productivity alone (seeFigure 2). The lion’s share of this gain (US$434 billion)Figure 1: Global health benefit of reaching WHO 2020 targetsfor all London Declaration NTDs. DALYs averted (millions) asYears Lost to Disability (YLD) and Years of Life Lost (YLL) forthe period 2011-2030Averted DALYs (millions)2001501005002011-2020 2021-2030119PCT111IDMPCTIDMYLD (disability)YLL (deaths)would come directly from the alleviation of fiveSTH-related conditions (see Figure 3), the majority ofwhich would be realized in China. Achieving results likethese requires scale-up that is effective and equitable.The projected return on investment 4 (ROI) in the kindof scale-up needed to achieve this is US$51 for2015-2020, and US$184 for 2021-2030. Even the mostconservative estimate in 2011-2030 would still be be aproductivity gain of US$421 billion, corresponding to anROI of US$30 for 2015-20203, and US$114 for 2021-2030.• For IDM-NTDs, 2011-2030 models show a productivitygain of US$58 billion, over half of which can beattributed to averting VL and chronic heart diseasecaused by Chagas disease (see Figure 4). Avertedout-of-pocket payments would total US$35 billion.If only gains in productivity are considered, the ROI fromthe necessary investments is anticipated to range fromUS$1 (worst-case scenario in the period 2015-2020) toUS$9 (best-case scenario in the period 2021-2030) andthese values would further increase due to unspent outof-pocketcosts. Perhaps more importantly, these ROIs donot even include the significant health gain that could beexpected from achieving the WHO 2020 targets.209154The main findings from this modeling, includingimpact at country level, can be viewed online atwww.unitingtocombatntds.orgSource: De Vlaset al. Concertedefforts to controlor eliminateneglected tropicaldiseases: howmuch healthwill be gained?(Submitted toPLoS NTDs)$7.112.4$39.8$71.91. Findings of the study “Health and socioeconomic impact of achieving the WHOtargets for London Declaration NTDs” by Erasmus MC and Erasmus UniversityRotterdam (Netherlands), to be published as a collection in PLoS NTDs.2. DALYs are a measure of life years lost from disease, adjusted for assumptionsabout disability as well as the impact of age and future time.3. Surgery can be helpful for hydrocele cases, as well as pacemakers and hearttransplantation for chronic heart disease due to Chagas. Still, for most people indeveloping countries these interventions are normally not available.4. The investment costs for the calculation of the ROI came from recent WHOestimates published in the Third Report on Neglected Tropical Diseases. Theinvestment costs calculated by the WHO combined targets for the number of peoplerequiring interventions with benchmarks for the cost per person of delivering thoseinterventions, for the period 2015-2020 and 2021-2030. Therefore, the first periodfor which the ROI was calculated starts in 2015 instead of 2011.$433.818 | Country Leadership and Collaboration on Neglected Tropical Diseases


Impact (US$ international, billions)Ascariasis (roundworm) deathsFrequency (%) Frequency (%)6Figure 2. Global economic Point benefit estimate: of reaching WHO 2020 targets for 5 PCT-NTDs, lower andupper estimates from sensitivity $58 billion analysis, for the period 2011-2030 (billions US$ $8.7 international) $7.952.5th percentile:7$40 billionSource: Redekop et al. ThePoint estimate:socioeconomic benefit to4$565 billion$7.197.5th percentile:$20.4 individuals of achieving6 2.5th percentile:$12.4 $21.3the 2020 targets for five$84 billion$421 billionpreventive chemotherapy3$39.8597.5th percentile:neglected tropical diseases.$781 billion(Submitted to PLoS NTDs)$71.942Visceral Leishmaniasis$433.83Chagas Disease1Leprosy20STH Human African Trypanosomiasis20 30 40 50 60 70 80 90 100 110 120Lymphatic Filiarisis1Impact (US$, billions)Schistosomiasis0Trachoma400 500 600 700 800 900OnchocerciasisImpact (US$ international, billions)Figure 3. Global economic benefit of reaching WHO 2020 targets for STH, lower and upper estimates from sensitivityanalysis, and point estimates per STH-related condition for the period 2011-2030 (billions US$ international)Frequency (%)876543212.5th percentile:$302 billionPoint estimate:$434 billion97.5th percentile:$647 billion0200 300 400 500 600 700 800Impact (US$ international, billions)$0.2$53.2$30.1$90.7$259.6Hookworm anaemiaAscariasis (roundworm) infestationHookworm infestationTrichuriasis (whipworm) infestationAscariasis (roundworm) deathsSource: Redekop et al. Thesocioeconomic benefit toindividuals of achieving the2020 targets for five preventivechemotherapy neglectedtropical diseases. (Submittedto PLoS NTDs)Figure 4. Global economic benefit of reaching WHO 2020 targets for 4 IDM-NTDs, lower andupper estimates from sensitivity analysis, for the period 2011-2030 (billions US$ international)Frequency (%)Frequency (%)6Point estimate:$58 billion75Point estimate:2.5th percentile:$565 billion$40 billion64 2.5th percentile:$421 billion534231297.5th percentile:97.5th $84 billion percentile:$781 billion1020 30 40 50 60 70 80 90 100 110 1200Impact (US$, billions)400 500 600 700 800 900Impact (US$ international, billions)Taken together, the London Declaration NTDs constitutea disability and mortality burden of the same orderof magnitude as HIV/AIDS, tuberculosis, or malaria.However, the costs associated with reaching theWHO 2020 targets are relatively modest when compared$7.1$12.4$39.8 $21.3$71.9$8.7$7.9$20.4$433.8Visceral LeishmaniasisChagas DiseaseSTHLeprosyLymphatic FiliarisisHuman African TrypanosomiasisSchistosomiasisTrachomaOnchocerciasisSource: Lenk et al. Thesocioeconomic benefit toindividuals of achieving the 2020targets for neglected tropicaldiseases controlled or eliminatedby innovative and intensifieddisease management. (Submittedto PLoS NTDs)to these “big three”, while the benefits are enormous,providing a compelling case that the WHO Roadmapmakes a highly cost-effective initiative, with far-reachingglobal health, societal, and economic impacts.872.5th percentile:Point estimate:$434 billionCountry Leadership and Collaboration on Neglected Tropical Diseases | 19$90.7


THE LARGEST PUBLIC HEALTH DRUGDONATION PROGRAM IN THE WORLDIndustry leadership on NTDsDrug donation updateA cornerstone of both the global NTD program andthe London Declaration is the generous contributionof donated drugs from ten pharma partners (Bayer,Eisai, Gilead, GSK, Johnson & Johnson, Merck KGaA,Darmstadt, Germany, Merck& Co., Inc., Kenilworth, NJ,USA, Novartis, Pfizer, andSanofi). The commitment>5.5billiontabletsin pharma donationssince the LondonDeclarationto provide drugs neededfor nine 1 of the ten NTDsoutlined in the LondonDeclaration through to2020 is valued at morethan $17.8 billion.Since the LondonDeclaration, industry partners have donated just over 5.5billion tablets for over 3.5 billion treatments, representingan increase of 36%. Treatments in 2014 alone were up8.5% from the previous year, with more than US$1.45billion treatments made available to countries in needin 2014 – making this the largest public health drugdonation program in the world.Drugs needed to treat communities endemic for PCTNTDs account for the overwhelming majority (99.9%) ofdonations. In 2014, GSK increased its annual donation ofalbendazole by 12%, in part to meet the needs of 11 newcountries beginning treatment for lymphatic filariasis (LF)and/or soil-transmitted helminths (STH). These consistedof 3 new MDA efforts for LF in Angola, DemocraticRepublic of the Congo, and Micronesia, along with 10 forSTH in Angola, Benin, Colombia, El Salvador, Guatemala,Honduras, Kyrgyzstan, Malawi, Micronesia and Vietnam.The most impressive increase in drug donations was fromEisai, which scaled up2014 PCT-NTDstreatment donationsup8.5%from 2013over 80-fold its supplyof diethylcarbamazine(DEC) for use intreating LF (in areasnot also endemic foronchocerciasis) from1 million treatments in2013 to over 81 millionshipped in 2014. In2014, Merck producedmore than 75 millionpraziquantel (Cesol600) tablets. As ofthe end of 2014,the company hadsupplied more than72 million tabletsto the recipientcountries in Africain coordination withWHO, representingan increase of 44%over 2013.While treatment donations for IDM NTDs constituteda smaller volume of drugs, industry partners Novartis,Bayer and Sanofi were steadfast in their commitmenttowards supplying valuable medicines to combat thesediseases, providing nearly 25% more treatments in 2014than in 2013.As drug manufacturing has increased to meet nationalprogram needs for both PCT and IDM NTDs, supplychallenges have been experienced in certain instances,with 2014 delivery of some drugs (Zithromax ® fortrachoma and AmBisome ® for VL) were delayed until early2015. Pharma partners have, however, worked quickly toovercome these issues and ensure supply is provided tomeet the demand.2014 IDM-NTDstreatment donationsup27%from 2013>$17.8billionvalue of drug donationspledged for LondonDeclaration NTDs to 2020The robustness ofthe commitment ofthese pharma partnersrepresents a key assetthat has enabled NTDprograms to build amulti-pronged approachto combating NTDsthat is continuallystrengthening.Priority for progress: One acknowledged limiting factoris the availability of resources to scale up distribution ofthese donated drugs to reach endemic communities.An analysis conducted by Abt Associates has estimatedthat the global program requires around US$1.4 billion tocompletely leverage the US$17.8 billion in donated drugsthrough 2020.1. Guinea worm disease does not have an associated drug that addresses infection.20 | Country Leadership and Collaboration on Neglected Tropical Diseases


The drug donation program continues to grow1,400,000,0001,200,000,0001,000,000,000800,000,000600,000,000Human African TrypanosomiasisChagas DiseaseVisceral LeishmaniasisLeprosySchistosomiasisSoil-transmitted HelminthiasisTrachomaOnchocerciasisLF & OnchoLymphatic Filariasis400,000,000200,000,000200920102011201220132014NTD drug supply-chain progressGetting drugs to the countries:First-mile delivery improvementsEfficient and effective supply-chain managementplays a critical role in ensuring that NTD medicines aredelivered to the people who need them. Aimed in partat streamlining and coordinating this process, the NTDSupply Chain Forum (the “Forum”) was established in2012, bringing together the WHO, pharmaceutical donorpartners (GSK, Johnson & Johnson, Pfizer, Merck & Co,Inc., Merck, and Eisai), the Gates Foundation, logisticspartner DHL, and nongovernmental organizations(Children Without Worms, the Mectizan ® DonationProgram, the International Trachoma Initiative and RTIInternational).As NTD programs scale up around the world, the Forumworks to identify gaps and challenges within the “firstmile” of the NTD drug supply chain, which encompassesplanning and forecasting, manufacture, packaging,shipment, and final delivery of NTD medicines to endemiccountries – a carefully coordinated global endeavor. Theefforts of the Forum over this past year have resulted inprogress in improving drug production timelines, changesin national drug application mechanisms, and betterdistribution and delivery to the destination countries.Some highlights of the Forum’s work include:• Dedicated DHL “Control Tower” for coordinationof NTD shipmentsWith its extensive global reach, DHL is a commonlogistics provider for several donation programs.As such, an initial output of the Forum was to bringseveral donations under the humanitarian side of DHL’slogistics services, thereby enabling NTD drug donationsto benefit from DHL’s special distribution channels andexpertise in efficiently clearing medicines for countryentry.• The creation of a dedicated NTD DHL Control Towerenables the DHL to oversee the clearance of severalNTD medicines through customs and ensures deliveryto national warehouses. GSK, Johnson & Johnson,and Merck have also extended their delivery past theport of entry through to medical stores, warehousesand beyond. This means that these pharmaceuticaldonors are now fully responsible for all steps involvedin shipping customs clearance and delivery of NTDmedicines to the central medical stores or nationalwarehouse in each country. This includes coveringall associated costs. In the past, the delivery wasmade to the port of entry, leaving the local WHO/WRoffices to clear the goods and deliver these medicinesto their final destination. DHL now provides door todoor service to the government warehouse for thesepharmaceutical donors in over 98% of cases, resultingin a more controlled and efficient approach to deliveringNTD medicines.• NTD forecasting and planning tool developmentWith a view to creating one centralized data source forintegrated PCT supply-chain decision making, the WHOand the Forum are collaborating to further develop thePCT-NTD Supply Chain Management tool, enabling thesharing of planning and forecasting information with allrelevant stakeholders (such as program managers, theWHO, and donors) involved in MDA.Country Leadership and Collaboration on Neglected Tropical Diseases | 21


Drug Donation for 5 PCTs (2011-2014): TreatmentsEstimated numberof treatments900800700600500Treatments in millions40030020010002,359,696,627 225,008,727 132,837,612 154,018,386 634,154,000 59,714,560 3,566,293,633LymphaticFilariasisOnchocerciasisLF and OnchoTrachomaSoil-transmittedHelminthiasisSchistosomiasis2014201320122011• Supply-Chain ModelingThe Forum is using statistical modeling systemsand expertise to map supply chains of several NTDmedicines so as to streamline delivery of coadministeredsupplies. The data from the modelingwork will be used to better furnish business casesfor potential supply-chain improvements, and providea platform for future scenario analysis includingdiagnostic supply.Getting drugs to people:Last-mile delivery improvementsSince the LondonDeclaration there havebeen just over3.5billiontreatmentsEnsuring thatNTD medicineseffectively travelfrom manufacturersto reach endemiccountries is only partof the supply-chainprocess. There are anumber of potentialchallenges countryprograms face inreaching communitiesand individuals, oftenreferred to as the “last mile”. With support from theGates Foundation, John Snow, Inc. recently completeda three-country assessment (of Ghana, Malawi, andTanzania) to identify challenges and propose solutionsto strengthen theNTD last-mile supplychain. Multiple areasand opportunities forimproving programswere identified,including:The amount of donatedtreatmentsup36%• creating concisetraining andreference materialswith key supplychainmessagingfor frontlinehealth workers and community drug distributors,for incorporation into national NTD control programtraining systems;• developing guidelines and reference materials on NTDdrug management, and on planning and budgeting forthe delivery of drugs for MDA;• strengthening NTD program district-to-central-levelaccountability to improve feedback and performancefor MDA success• improving performance motivation at the communityand health-facility levels.The Gates Foundation is now reaching out to partnersand stakeholders to explore ways of collaborating on theopportunities presented.Total supply chain visibilitySupply Dispatch Shipping Customs Delivery Receipt22 | Country Leadership and Collaboration on Neglected Tropical Diseases


LONDONDECLARATION NTDS:PROGRESS BY DISEASECountry Leadership and Collaboration on Neglected Tropical Diseases | 23


LYMPHATIC FILARIASIS (LF)SCORECARDPROGRESS2WHO ROADMAP TARGETGlobal elimination as a public health problem by 2020Distribution and status of preventive chemotherapy for lymphaticfilariasis, worldwide, 2013 (WHO)Endemic countries and territories implementing preventive chemotherapyEndemic countries and territories where the target was achieved andimplementation stoppedEndemic countries and territories not started implementing preventivechemotherapyNot applicableNon-endemic countries and territoriesLymphatic filariasis (LF) is a mosquito-transmitted disease caused by parasitic wormsthat damage the human lymph system. It can cause severe and sometimes very extensiveswelling of the lower limbs (lymphedema), which can be accompanied by painful episodesof fever. People with lymphedema are prone to bacterial infections that can lead to a mobility-limitingcondition where the skin thickens and hardens (elephantiasis). In men, LF can also result in swellingof the scrotum (hydrocele). LF afflicts the poorest communities, preventing affected individuals fromliving a productive working and social life, further trapping them in the cycle of poverty.How many people areaffected and where?1.23 billion people in 58 countriesthroughout tropical regions inAfrica, the Americas, Asia, and thePacific are at risk of contracting LF.~120people infectedGlobal estimates for LF-infectedpersons currently stand at 120million, more than 40 millionof whom are incapacitated ordisfigured as a result. 80% ofpeople at risk live in 10 countries.India alone accounts for over halfa billion of the at-risk population,followed (in order of magnitude)by Bangladesh, the DemocraticRepublic of the Congo (DRC),Ethiopia, Indonesia, Myanmar,Nepal, Nigeria, the Philippines,and Tanzania.millionCan it be preventedand/or treated?Mass drug administration (MDA)with a combination of twodonated medicines, Mectizan ordiethylcarbamazine (DEC) andalbendazole 1 , can safely andeffectively reduce the number oflarvae (microfilariae) in an infectedperson’s blood to a level where thetransmission cycle is broken evenonce drug treatment is stopped.Additional evidence indicates thatMDA may also prevent the diseasefrom progressing to lymphedema,elephantiasis, and hydrocele, butit cannot reverse LF-associateddisabilities that have alreadyemerged. Additional methods canbe used to block transmissionusing vector control like bed nets.1. Generously donated as follows: Mectizan ® by Merck& Co., Inc., Kenilworth, NJ, USA; DEC by EISAI andSanofi; and albendazole by GSK.What strategies are in placeto achieve the WHO Roadmaptarget for LF?A two-pronged strategy is used byprograms in endemic countries:1. stopping the spread of LF throughannual MDA aimed at breaking thetransmission cycle. This includesdisease mapping to assess theneed for MDA, and surveillanceonce transmission has beeninterrupted to ensure the cycledoes not restart; and2. alleviating the suffering of thoseaffected through comprehensivecare for clinical problems andhydrocele surgery, in order toprevent and manage LF-associateddisabilities.Did you know?1 in 6 of the global populationis at risk of LF, one of theworld’s most disabling diseasesRead more about LF atwww.unitingtocombatntds.org24 | Country Leadership and Collaboration on Neglected Tropical Diseases


With crucial groundwork laid, mobilizing vitalresources is now a pressing prioritySignificant progress has been madein global efforts to combat LF, withLF programs now in place in mostcountries where the disease is apublic health concern. Even so, anumber of key challenges threatenthe achievement of the WHORoadmap target for LF, and thereforeneed to be urgently addressed.Disease mapping80%of high-risk countriesfully mapped for LFCompleting mapping for diseaseprevalence is a crucial step forachieving the WHO Roadmap target.Of the 10 most high-risk countries,the DRC completed countrywidemapping in early 2015, leaving onlyEthiopia and Nigeria, both of whichare expected to complete mappingin 2015.Key challenges: The incompletenessof mapping in Africa has proved amajor obstacle to starting and scalingup MDA. While funding to addressthis is now available, and the AFROMapping Project plans to completeLF mapping on the continent in 2015,a concerted effort is needed to finishthe task.Mass drug administration493.5million people treatedworldwide in 2013Since 2000, a cumulative total ofover 5 billion doses of medicineshave been delivered to 1 billionpeople. In 2013 alone, 493.5individuals were treated across allaffected regions.100% geographical coverage wasachieved in 22 of the 58 countriesrequiring MDA in 2013, and anadditional 23 countries are scalingup MDA. In Africa, a new regionalNTD support program that will offertechnical assistance on all aspectsof MDA should be in place by 2016.Key challenges: At the currentrate of progress, scale-up to fullgeographic coverage in all endemiccountries is unlikely to be achievedrapidly enough to allow 5 yearsof treatment before 2020, unlessmapping reveals a lower populationneeding treatment, and thenecessary resources are available.Globally, geographic coverage is only40%, and 13 endemic countries havenot started MDA. Of the 10 countriesmost at risk, only India and thePhilippines have achieved full MDAcoverage of their national territory,Indonesia and Nigeria need to scaleup quickly, and the DRC needs tostart. While, increasing politicalcommitment is leading to moredomestic funding for implementationof MDA, and resources are availablethrough bilateral agreements, thereare still “orphan countries” that havefew resources and no partners.Preventing andmanaging disability59%drop in LF-linked disability(2000-2013)Current estimates for 2013 indicatea 59% reduction in LF-associateddisability since 2000, with 16.68million suffering from lymphedemaand 19.43 million suffering fromhydrocele.Key challenges: Promotingskincare is important both forrestoring mobility and reducingepisodes of fever, and this aspectof LF programs needs to bestrengthened. Surgery for scrotalswelling has been more effective, butthere are still many patients waitingfor the procedure.Post-MDA surveillance15countriesnow in surveillance phasePost-MDA surveillance is critical toensuring the LF transmission cyclehas been truly interrupted and willnot restart once MDA stops. In animportant milestone for Africa, in2014 Malawi became the secondcountry in the region to stop MDAand move into surveillance, bringingthe global total to 15 countries. Afurther 40 at-risk nations worldwideare ready to stop MDA in some partsof their country.Key challenges: More cost-effectiveand sensitive post-MDA surveillancemethodologies, such as diagnostictools like the soon-to-be-availableFilariasis Test Strips, are needed tofacilitate making decisions on whento stop MDA.Priorities for progress:• In Africa, with mappingdue to be completed inDecember 2015, it isessential that human andfinancial resources bemobilized immediately toscale up treatment for theWHO Roadmap target to beachieved.• In other parts of the world,where country efforts areunder-resourced and lackstrategic partners, urgentfunding is needed to fillthe gap and contribute tokeeping global progresson track.Country Leadership and Collaboration on Neglected Tropical Diseases | 25


ONCHOCERCIASIS (River Blindness)SCORECARDPROGRESS2WHO ROADMAP TARGETSElimination:by 2015: in Latin America and Yemenby 2020: in selected countries in AfricaDistribution of onchocerciasis, worldwide, 2013 (WHO)Meso- or hyper-endemic (prevalence ≥ 20%)Hypo-endemic (prevalence < 20%)Endemic countries (former OCP countries)Not applicableNon-endemic countriesOnchocerciasis (or river blindness) is a disease caused by infection with a parasiticworm transmitted by blackflies, which breed in fast-flowing streams and rivers.Adult worms produce larvae (microfilariae) that migrate to the skin, eyes, andother organs, and can cause debilitating itching, disfiguring skin conditions, andvisual loss (including irreversible blindness) over time. Onchocerciasis can therefore impactenormously on the lives of those infected, reducing their ability to work and learn.How many people areaffected and where?Onchocerciasis occurs in 31countries in tropical sub–SaharanAfrica, in pockets in Yemen, andwas or remains present in 6countries in Central and SouthAmerica.~169people at riskmillionOf the approximately 169 millionpeople living in onchocerciasisendemicareas in Africa, anestimated 37 million are infected,representing 99% of the globalburden of the disease. Of these, 4million have skin manifestations,and 2 million are blind or severelyvisually impaired.Can it be preventedand/or treated?There is no vaccine to preventonchocerciasis infection, but massadministration of an oral drugcalled Mectizan ®1 to communitiesin endemic areas can reduce theprevalence of the disease and theparasite load in infected people,and can eventually interrupttransmission. Skin-snip biopsiescontinue to be used to confirmpositive cases, but new improveddiagnostic methods are also beingintroduced.What strategies are in placeto achieve the WHO Roadmaptargets for onchocerciasis?Since donations of ivermectin byMerck & Co., Inc. began in 1987,mass drug administration (MDA)programs have commenced inmany areas of the world. Startingfrom 1995, the partnership aroundthe African Programme for1. Mectizan ® is generously donated by Merck &Co., Inc., Kenilworth, NJ, USA (“Merck & Co., Inc.”).Onchocerciasis Control (APOC) hasprovided treatment to all countriesin Africa needing MDA throughan innovative delivery strategy inwhich individuals are trained to givetreatments to fellow communitymembers. This strategy – calledCommunity-Directed Treatmentwith Ivermectin (CDTI) – hasbeen enormously successfulin controlling onchocerciasis inAfrica. In Yemen, clinical cases ofonchocerciasis are treated withivermectin, while MDA and blackflycontrols will hopefully soon belaunched. In Latin America, theregional elimination strategy iscentered on twice-yearly MDAwith ivermectin to eliminatetransmission.Did you know?Onchocerciasis, the secondleading infectious cause ofblindness worldwide, is spreadby repeated bites from infectedtropical blackfliesRead more about onchocerciasis atwww.unitingtocombatntds.org26 | Country Leadership and Collaboration on Neglected Tropical Diseases


As Latin America nears its target, Africamust rally crucial resources to follow suitWhile new cross-border cooperationarrangements seem set to assistLatin America in achieving itstransmission interruption target, inmoving forward Africa will need tocontend with various constraints,including a sizeable resource gapand a transitioning onchocerciasiscontrol program, in order to ensurethat the gains made by APOCtowards elimination are not reversed.Elimination acrossLatin AmericaIn Latin America, twice-yearlytreatment with ivermectinhas interrupted or eliminatedtransmission of onchocerciasisin 11 of 13 areas in the 6 endemiccountries. 2 Blinding onchocerciasishas been considered eliminatedfrom most of the region since 1995.Of 6 endemic countries2 countriesverified as eliminatedat the national levelIn 2013, Colombia became thefirst country globally to be verifiedfree of onchocerciasis, followed byEcuador. Mexico and Guatemalaanticipate verification in 2015. Only20,495 Yanomami people living intwo endemic areas in Brazil andVenezuela still need treatment.Key Challenges: Deliveringtreatment to the Yanomami areaof the Amazon region, shared byBrazil and Venezuela, is the greatestchallenge to achieving interruptionof transmission in Latin Americaby 2015. To this end, a dedicatedborder cooperation agreementwas signed in May 2014 during theWorld Health Assembly, and the twocountries are working to make thisoperational.2. Brazil, Colombia, Ecuador, Guatemala, Mexicoand Venezuela.Elimination in YemenAlthough political considerations inYemen have hampered achievementby 2015 of the originally-envisagedelimination target, there is renewedgovernment commitment andincreased support from partners formoving forward. The country is nowrallying toward an elimination targetdate of 2020, with MDA and blackflycontrol measures anticipated tostart in 2015.Community-Directed Treatmentwith Ivermectin in AfricaIn Africa, the APOC program’s CDTIstrategy has delivered hundredsof millions of treatments to peopleliving in endemic areas.~100.7million peopletreated in 2013 3Out of a total at-risk population ofaround 169 million in 1,209 healthdistricts in Africa, around 100.7million persons received ivermectinthrough the CDTI strategy (for acoverage of 59.5%) during APOC’s2013 treatment cycle, up from99 million people in 2012 butrepresenting a drop from the 76.4%treatment coverage for that year.Onchocerciasis control efforts havenow led to elimination in focal areasin several countries in Africa. Mali,Niger, and Senegal in West Africa,and Burundi, Chad, and Malawi inCentral and Southern Africa areall ready for evaluations in 2015-16 to determine if treatment canbe stopped nationally. 12 Africancountries are expected to achievecountrywide elimination by 2020.In rural sub-Saharan areas, wherehealth systems are weak and underresourced,CDTI is proving one of3. Figure relates to APOC’s 2013 treatment cycle,spanning part of 2014.Africa’s most successful low-costdisease reduction strategies.181,000locales engaged in 2013 4In the 2013 treatment cycle, 181,000communities were mobilized and650,000 community distributors trainedin APOC’s CDTI strategy.The strategy averted a total of 8.8million DALYs 5 between 1995-2010,including 3.7 million from blindness.Another estimated 10.1 million DALYswill be averted between 2011-15.Key Challenges: It will be critical toaddress obstacles to achieving andsustaining high treatment coverage,particularly in conflict and post-conflictareas. In 2013, ivermectin distributionwas prevented in the highly-endemicCentral African Republic by civil unrest.Other areas in Central Africa where loaloa is also endemic remain untreatedbecause individuals infected withboth diseases can have serious orfatal complications from ivermectin.A strategy must be developed andimplemented for areas where deliveringtreatment is impeded by such factors.4. Figure relates to APOC’s 2013 treatment cycle,spanning part of 2014.5. DALYs are a measure of years in perfect health lostthrough disease.Priorities for progress• For Africa, urgent effortsand support are required toaddress the huge existingresource gap. Momentum willalso need to be maintainedonce APOC closes down inDecember 2015, and a newentity takes on responsibilityfor strategy coordination andtechnical support to countriesin Africa.• For Latin America, crossbordercollaboration willbe key.Country Leadership and Collaboration on Neglected Tropical Diseases | 27


SCHISTOSOMIASISSCORECARDPROGRESS3WHO ROADMAP TARGETSElimination as a public health problem:• by 2015: regionally, in the Eastern Mediterranean,Caribbean, Indonesia, and the Mekong River basin• by 2020: regionally, in the Americas and WesternPacific; and nationally, in selected countries in AfricaAnd*: 75% of school-aged children in need of preventivetreatment will be regularly treated in 100% of endemiccountries by 2020*World Health Assembly resolution targetDistribution of schistosomiasis, worldwide, 2013 (WHO)High (prevalence ≥50%)Moderate (prevalence 10% – 49%)Low (prevalence


Significant improvement in coverage required tounlock targeted treatment for Africa’s most at-riskAs momentum builds, and asmapping is completed, theimpact of efforts to combat thedisease will depend heavily onglobal coordination to achieve fullscale-up of treatment coverageby maximizing delivery of theanticipated increase in drug supply.Mass drug administration(MDA)million47.3treated worldwide in 2013Overall, global treatment numbersfor schistosomiasis are only slightlyimproving each year. In 2013, 47.3million people were treated withpraziquantel (Cesol 600), up from 42million in 2012.In contrast, donations of praziquantel(Cesol 600) are dramaticallyincreasing. In 2014, pharmaceuticaldonor Merck increased its contributionto nearly 75 million tablets, and of 41African countries requiring treatment,36 (87.8%) were reached. For 2015,Merck has increased its donation to100 million tablets, and three of themost affected countries – namely, theDemocratic Republic of the Congo,Ethiopia, and Nigeria – will expandtheir programs to dramatically scaleup treatments, particularly to schoolagechildren. For 2016, Merck hascommitted to increasing its donationof praziquantel (Cesol 600) up to 250million tablets, equivalent to 100million treatments. DFID, USAID, theWorld Bank, and World Vision alsopurchase praziquantel totaling over100 million tablets per year.Of the 52 countries around theworld where schistosomiasis isendemic and treatments are needed,39 (75%) have national programsin place to combat the diseaseand are committed to deliveringpraziquantel treatment to at-riskpopulations. In Africa, Burundiand Zanzibar (in Tanzania) havestarted projects aimed at achievingsustainable elimination through anintegrated package of strategies,including health education, improvedsanitation and water supply, andsnail control measures.75%of endemiccountriesoperate nationwideschistosomiasis programsKey challenges: Despite quantitiesof donated praziquantel (Cesol600) increasing annually, treatmentcoverage in endemic countriesremains significantly below target –particularly in Africa, the region mostaffected by schistosomiasis. Only 14African countries are treating 100%of endemic areas, and the continent’scoverage for school-age children –the group specifically prioritized bythe 2020 treatment target – remainsproblematically low. Of the 31 Africancountries that reported to WHO for2013, only 7 reached the desiredtarget of treating at least 75% ofschool-age children.Increased resources and improvedtools, as well as greater politicalcommitment for programimplementation – including trainingand monitoring and evaluation –are necessary to ensure that drugsrequired to meet treatment targetscan be effectively delivered. Theannouncement in Addis Ababain December 2014 of the GlobalSchistosomiasis Alliance, an initiativeestablished by Merck to support theWHO and partners in addressinggaps and challenges in workingtoward the elimination target, shouldprovide much-needed impetus, andlead to increased awareness andsupport for treatment with availablepraziquantel stocks.Disease mapping52%of endemiccountriesfully mapped forschistosomiasisBy the end of 2014, of the 52endemic countries, 27 had beenentirely – and 15 partially – mappedfor prevalence of schistosomiasis.Through the AFRO Mapping Project,it is anticipated that all Africancountries will be fully mapped forschistosomiasis by the end of 2015.This will be a decisive achievement,as completion of the diseaseprevalence map in Africa will allow forthe scheduled scale-up of treatmentsto be targeted where most needed.Key challenge: With mapping for allAfrican countries nearing completion,the number of endemic districts isincreasing, which can be expected tocompound the necessity for scale-upof treatment coverage. Coordinationwith STH school based programsoffers an opportunity for scale up.Priorities for progress:• Increased treatmentcoverage in Africa.• Better tools and resources toensure effective drug deliveryand treatment coverageat country level, as well assupport for further researchinto solutions to deliveryrelatedlogistical obstacles,especially in Africa.Country Leadership and Collaboration on Neglected Tropical Diseases | 29


SCORECARDPROGRESSSOIL-TRANSMITTED HELMINTHIASIS (STH)1WHO ROADMAP TARGETSBy 2015: 50% and by 2020: 75%of preschool-age and school-age children in need ofpreventive treatment will be regularly treated in 100%of endemic countriesProportion of children (1-14 years of age) in the country requiringpreventive chemotherapy for STH, worldwide 2013High (>2/3)Moderate (1/3-2/3)Low (876at-risk children worldwidemillionOf those at risk of STH, over876 million are children, who aremore susceptible due to theirfrequent exposure to contaminatedenvironments, such as during play.More than 65% of the childrenneeding treatment live in the 10highest-burden countries, in Africaand Asia.Can it be preventedand/or treated?STH can be effectively treatedwith the drugs albendazole ormebendazole. 1 As reinfectionoccurs frequently in settings whereaccess to water and sanitation islimited, these deworming drugsmust be provided regularly toat-risk populations, particularlypreschool-age and school-agechildren. Preventive measures in atriskcommunities include improvingaccess to sanitation facilities andclean water, as well as educatingpeople in personal hygiene (knowncollectively as Water, Sanitation,and Hygiene, or WASH).1. Generously donated for deworming of schoolagechildren as follows: albendazole by GSK, andmebendazole (under the brand name Vermox ® ) byJohnson & Johnson.What strategies are in placeto achieve the WHO Roadmaptargets for STH?Regular mass drug administration(MDA) to children of donated orpurchased mebendazole andalbendazole is a key componentof STH control programs. Since2013, global efforts have increasedto begin MDA, and – where it hasalready commenced – to expandits scope, especially in the 10highest-burden countries, in aneffort to reach the 75% coveragetarget by 2020.Did you know?STH is the most commonparasitic disease affectinghumans worldwide, and is oneof the leading global causes ofstunted growth in childrenRead more about STH atwww.unitingtocombatntds.org30 | Country Leadership and Collaboration on Neglected Tropical Diseases


Global MDA coverage on track to meet 2015 WHO Roadmap targetThe achievements in combating STH globally have been enormous, with increases in drug suppliesand delivery – along with improved collaboration amongst partners – ensuring that efforts are ontarget to reach 50% treatment coverage for all at-risk children by 2015. In the coming years, STHprograms will need to focus on building on this momentum and boosting coordination to scale uptreatments even further, in order for the 2020 target of 75% coverage to be met.Mass drug administrationDrug treatments are thecornerstone of STH programs,and the number of treatmentssupplied and delivered annuallyhas increased rapidly in recentyears. Since 2010, pharmaceuticaldonors have donated nearly 700million treatments of albendazoleand mebendazole to supportdeworming of school-age children,and are committed to continuingto provide a significant proportionof the drugs needed to help meetglobal targets.396at-risk children treatedworldwide in 2013From 2008 to 2013, the numberof children treated annually forSTH nearly doubled. In 2013, 396million children were treated. Ofthese, 254.3 million were school-agechildren, for a coverage of nearly40% in this age group.Based on this achievement, globalMDA efforts are on track to meetthe WHO Roadmap target of regulartreatment of 50% of the world’s atriskschool-age children by 2015.In terms of preschool-age children,improved collaboration andreporting between UNICEF and theWHO saw an impressive increase intreatment coverage.~50%of at-risk preschool-agechildren treated in 2013millionIn 2013, 141.7 million preschoolagechildren were reported tohave been treated, representingaround 50% of the world’s at-riskpopulation in this age bracket –a significant increase from 2012,when only 28% were reportedtreated, bringing coverage in linewith the WHO Roadmap targetfor 2015.As at 2013, nearly three-quartersof all countries where treatmentis needed, including 7 of the 10highest-burden countries, wereactively carrying out dewormingprograms.Key challenges: Despite thesuccess in reaching greaternumbers of at-risk childrenworldwide, MDA needs to be scaledup in the coming years to meet theWHO Roadmap target of regularlytreating 75% of all at-risk childrenin 100% of endemic countries by2020, with only 27% of endemiccountries currently reaching thislevel of coverage. More coordinatedprocesses for reporting drugcoverage across different drugdelivery platforms are also requiredto support monitoring of progresstowards these targets.Global coordinationof partners38for concerted globalpush on STHpartnersunitedin 2014In 2014, the STH Coalition –a group of 38 national andinternational public-health,donor, WASH, education, andnutrition organizations – wasestablished as a coordinatingentity. This coalition has generatedmuch-needed momentumtowards advancing STH controlin preschool-age and school-agechildren, improving monitoringand evaluation of STH programsand operational research, andpromoting advocacy and enhancedcollaboration with the WASHsector. The partnership hasalso contributed directly to theadvances made in STH treatmentsreaching children.Key challenges: Maintaining andbuilding coordinated collaborativeefforts will be essential in thenecessary push for treatment scaleup.Increased collaboration withthe WASH, agriculture, nutrition,maternal-health, and educationsectors can help ensure that thecomplementary environmentalimprovements needed to sustaintreatment gains in the long run arein place.Priority for progress• MDA for at-risk childrenneeds to be significantly andurgently scaled up.• The impact achievedby MDA needs to besustained through WASHinterventions.• Scale-up of all STH controlactivities requires increasedcollaboration with relevantsectors to harness theresources, commitment,goodwill, and skills of allpartners.Country Leadership and Collaboration on Neglected Tropical Diseases | 31


TRACHOMASCORECARDPROGRESS1WHO ROADMAP TARGETSGlobal elimination as a public health problem by 2020Distribution of trachoma, worldwide, 2013 (WHO)Countries and territories endemic for blinding trachomaCountries that have eliminated blinding trachoma as a public healthproblem or which are under surveillanceNot applicableCountries and territories non-endemic for blinding trachomaTrachoma is a disease caused by a contagious bacterial infection of the eye commonlyspread through contact with contaminated hands or items such as clothing, andby flies coming into contact with a person’s eyes or nose. Trachoma often beginsin early childhood, progressing over the years as episodes of reinfection causeinflammation and scarring of the inner eyelid. In some people, repeated infection damages theeyelids (compromising the eye surface’s normal defenses), and the eyelashes turn inwards,painfully rubbing against the eye’s surface (a condition known as trichiasis). If left untreated, aseries of complications can lead to irreversible blindness. Trachoma is directly linked to poverty,and communities without access to clean water or effective sanitation are the most vulnerable to it.The disease has a devastating impact on livelihoods, as it limits access to education and preventsindividuals from being able to work or care for themselves or their families.How many people areaffected and where?232at riskmillionAn estimated 232 million people livingin 51 countries across Africa, Asia,Central and South America, Australia,and the Middle East are at risk oftrachoma, with 77% living in Africa.More than 21 million people haveactive trachoma, with 2.2 millionpeople visually impaired, out of whom1.2 million are irreversibly blind.The majority of trachoma occurs inchildren, while women are almosttwice as likely as men to developtrichiasis.Can it be preventedand/or treated?Trachoma is treatable andpreventable with a multifacetedpublic health approach knownas SAFE. The SAFE strategycomprises eyelid Surgery to correcttrichiasis, Antibiotics 1 to clearinfection, Facial cleanliness toprevent disease transmission, andEnvironmental improvement suchas the construction and use oflatrines. For maximum impact, it isessential that the full SAFE strategybe implemented in endemiccommunities. Even after trachomais eliminated, surgery is necessaryfor people already affected withtrichiasis.1. Azithromycin (generously donated to manycountries by Pfizer under the brand nameZithromax ® ), or tetracycline eye ointment.What strategies are in placeto achieve the WHO Roadmaptarget for trachoma?The key approach employed is theSAFE strategy described above,which integrates a package ofessential measures at an individualand community level. As well ashelping to combat trachoma, thisfull strategy improves sanitationand health in general.Did you know?Trachoma – one of the oldestknown infectious diseases –is the leading infectious causeof blindness worldwideRead more about trachoma atwww.unitingtocombatntds.org32 | Country Leadership and Collaboration on Neglected Tropical Diseases


Successful global trachoma mapping isenabling scale-up of sight-saving treatmentsStrong partnership and amazingstrides in mapping have sustainedthe momentum of global trachomaefforts, even in the face of variouschallenges encountered.Disease mappingThe Global Trachoma MappingProject (GTMP) aims to find outwhere trachoma is prevalent at levelsindicating a public health problem, sothat treatment can be focused whereit is needed most.2.0assessed for trachomain 23 countriesBy the end of 2014, GTMP hadexamined 2 million people in1,371 districts of 23 countriesfor trachoma. By the end of2015, GTMP will have completedmapping all suspected trachomaendemicdistricts worldwide wheresecurity is adequate to permitfieldwork to be undertaken safely.This enormous achievementwill allow trachoma programsto dramatically scale up SAFEinterventions to the level needed toreach the WHO Roadmap target.Key challenges: The increasednumber of districts revealed asneeding intervention by the newmapping data will necessarilyplace pressure on existing drugsupplies and other implementationresources.Full SAFE strategymillionAll targets for the provision ofinterventions under the S, A, and Fcomponents of the SAFE strategywere exceeded in 2013 by nationaltrachoma programs in endemiccountries. In 2014, program planningfor large-scale full SAFE initiativestook place in 15 African countries,Pakistan, and throughout the Pacific.Key challenges: 30% of endemiccountries still need to implementSAFE to ensure that trachoma canbe eliminated as a public healthproblem. Even in countries thathave adopted SAFE, the F and Ecomponents of the strategy arecurrently not sufficiently funded andrequire stronger measurements ofimpact and progress.Antibiotic treatment(the ‘A’ in SAFE)54.7received antibioticsin 2014millionThe number of known endemicdistricts needing mass drugadministration (MDA) withantibiotics increased from 907 in2013 to 1,429 in 2014. Of these, 596were approved to receive donatedZithromax ® , and 54.7 million peoplein 465 districts were reached,compared with 54.9 million peoplein 427 districts in 2013.As the global program scales up,notable progress is also being madein areas already under treatment.In 2014, 128 districts conductedimpact assessments. Of these,77 (60%) achieved a decline of TF 2among children aged 1-9 yearsof at least 50% from baseline. 47districts (37%) achieved TF amongchildren aged 1-9 years of lessthan 5%, meaning they no longerwarrant antibiotic distribution. Thisrepresents a population of 12.6million people living in areas nolonger requiring MDA.2. Trachomatous inflammation, follicular (TF): definedas the presence of five or more follicles of >0.5 mm onthe inner surface of the upper eyelid.Key challenges: In 2014, the primarychallenges related to in-countrycapacity to deliver product, andavailability of less Zithromax ®than requested. Encouragingly,stakeholders pulled together to utilizeavailable drugs in the most efficientway to maintain momentum.Surgical treatment(the ‘S’ in SAFE)An estimated 7.3 million peopleaffected by trachoma suffer frompainful trichiasis. Eyelid surgeryreduces the risk of progression ofvisual impairment from trachoma,with 138,533 procedures carriedout in 2014.Surgery carried out in43%of endemic districtsIn 2014, surgery was delivered in43% of districts worldwide wheretrachoma-associated trichiasis wasa public health problem. In 2015,the target is 50% of districts, andnew tools for national programmanagers and health workers willhelp them reach this goal.Key challenges: Moving forward,the surgical component of SAFEwill need to focus on achievingquality and scale of surgery toaddress the global backlog ofpeople waiting for the procedure.Priority for progress• Crucial further resourcesare needed to support therequired treatment scale-up.• Adoption of the SAFE strategyby the 30% of endemiccountries yet to do so.Country Leadership and Collaboration on Neglected Tropical Diseases | 33


SCORECARDPROGRESS2CHAGAS DISEASEWHO ROADMAP TARGETS• by 2015: transmission within the home viaChagas-carrying insects in Latin America, andthrough blood transfusions in Latin America, Europeand the Western Pacific, will have been interruptedDistribution of Chagas disease, based on official estimates, 2006-2010• by 2020: infestations of Chagas-carrying insects inareas surrounding homes will have been eliminatedin Latin AmericaEstimated number of T.cruzi infected cases≥900,000


Control efforts being bolsteredby improved collaborationThe multipronged strategicapproach to Chagas control hasbeen effective in reducing diseasetransmission in many areas,but more concerted efforts areneeded to improve diagnosis andtreatment and to reach interruptionof transmission targets. Whilemeasuring progress has beenhampered by lack of available dataand partner coordination, revisedpriorities for action formulatedby Chagas disease experts in2014 have resulted in increasedcollaboration among partners,which is reinvigorating controlefforts in affected countries.Interruption of transmissionBrazil, Chile, and the CentralAmerican countries haveeliminated the main vehicleof transmission – householdinfestations of Chagas-carryinginsects – through sustained controlmeasures. This success has led allendemic countries in the region tostep up efforts in this direction. SixArgentinean provinces have verifiedthat transmission through homeinfestations has been interrupted,with corresponding advancesmade in the southern macro-regionof Peru. All these endeavors havealso directly resulted in a reducedincidence of the disease in children.95%of at-risk Latin Americancountries screen blooddonations20 out of the 21 endemic countriesin Latin America also currentlyscreen blood used for transfusions.Screening in the remaining country(Mexico) covers 80% of thenational territory.Various measures to controltransmission at birth have alsobeen adopted in several countries.Treatment scale-up20,000treated in endemiccountries in 2013Increased coverage in anti-parasiticdrug treatment for infected personssaw more than 20,000 peopletreated in Latin America in 2013. Anew centralized drug distributionsystem for Latin America hasbeen implemented in Panama withsupport from the Pan AmericanHealth Organization (PAHO).However, current treatmentsproduce a high rate of sideeffectsin patients, with the longtreatment periods involved (60-90days) also making it difficult fordrug donations to keep pace withdemand. These factors are drivingongoing industry and academicresearch efforts to find safer andmore effective drugs with improvedtolerability.Capacity strengthening ofnational health systemsAmong the initiatives adopted tobolster the capacity of affectedhealth systems to comprehensivelyaddress Chagas disease, somemajor recent highlights include:• the establishment of a newWHO collaborating center in theGran Chaco region, focused onproviding Chagas-related trainingfor healthcare professionals;• the development of a global opensourceinformation system formonitoring cases, transmissionroutes, and other key informationfor the control of Chagas disease;• the launch of the BeatChagaswebsite, a new online resourcein support of the WHO Roadmaptargets for Chagas;• the website infochagas.org,launched by the Global ChagasCoalition as a repository ofevidence, data and generalinformation to support scalingup access to diagnostics andtreatment; and• the Chagas Clinical ResearchPlatform (CCRP) web forum,bringing together more than300 institutional representativesfrom over 22 countries inregular debate led by Ministriesof Health, the WHO, the PAHO,the International Federationof People Affected by Chagas(FindeChagas), and medicalorganizations such as the MundoSano Foundation and MédecinsSans Frontières.Priorities for progress:• Urgent support to coverthe additional resourcerequirement arising fromthe widely-endorsed2014 revised priorities forcombating Chagas disease.• Assessment of thefeasibility of scalingup access to diagnosisand treatment, throughpilot projects in selectedcountries with diverseepidemiological profiles,to arrive at strategiesreplicable across differentendemic areas whilstidentifying the mostappropriate context-specificdelivery model.• Improved partnercoordination through aglobal Chagas diseasenetwork.Country Leadership and Collaboration on Neglected Tropical Diseases | 35


GUINEA WORM DISEASE (GWD)SCORECARDPROGRESS2WHO ROADMAP TARGETGlobal eradication by 2015*Distribution of guinea worm disease, worldwide, 2013 (WHO)*Revised to 2020Countries currently endemic for dracunculiasisCountries at precertification stagePreviously endemic countries certified free of dracunculiasisNot applicableCountries and territories not known to have dracunculiasis but yetto be certifiedCountries with a known or possible history of dracunculiasis endemicbefore 1980Other countries certified free of dracunculiasisGuinea worm disease (GWD, or dracunculiasis) is an incapacitating parasitic illnesscaught by drinking from water containing water fleas infected with Guinea worm larvae.Once in the body, these larvae reproduce. Over 10-14 months, female larvae can growto meter-long worms, which then begin to emerge from the skin through intenselypainful blisters, usually on the legs or feet, accompanied by fever, nausea and vomiting. Once aworm has started to emerge, it must be carefully and completely removed over a period of weeks.Often, the wound caused develops a secondary infection, increasing the time it takes for an infectedperson to resume normal activities. Failure to remove the worm can result in additional bacterialinfection, as well as infection of the whole body (septicemia) and permanent disability.How many people areaffected and where?GWD affects poor communitiesin remote parts of sub-SaharanAfrica, especially those thatdepend on stagnant surface watersources for drinking. Today, GWDis on the verge of being eradicated,with less than 130 cases reportedin 2014 in only four countries:Chad, Ethiopia, Mali, andSouth Sudan.Can it be preventedand/or treated?There are no existing diagnostictools to detect current or previousinfection with GWD, but regularlyfiltering 1 and treating 2 drinkingwater potentially infested withwater fleas are effective preventive1. Using finely-meshed cloth filters, generouslydonated by Vestergaard.2. With ABATE ® larvicide, generously donated byBASF Corporation.measures. In addition, healtheducation is used to encourageaffected communities to adopthealthy drinking water practices.For people already infected withGWD, health professionals canhelp break the transmission cycleby ensuring that emerging wormsare removed completely, safely,and do not contaminate drinkingwater sources with larvae.What strategies are inplace to achieve the WHORoadmap target for GWD?In 1980, the global campaignto eradicate GWD began at theUS Centers for Disease Control(CDC). Since 1986, The CarterCenter, in collaboration with theWHO, the CDC, and UNICEF, hasassisted Ministries of Health tointerrupt GWD transmission andcoordinate efforts towards globaleradication. The strategy of theglobal program focuses on:• preventing infection by filteringand treating potentiallycontaminated drinking water;• surveillance to detect allcases within 24 hours of wormemergence and to containcases; and• maintaining politicalcommitment to reach zerocases of new infection.Did you know?Guinea worm is set to becomethe second human disease inhistory – after smallpox – to beeradicated, and the first to beso without the use of vaccinesor medicineRead more about GWD atwww.unitingtocombatntds.org36 | Country Leadership and Collaboration on Neglected Tropical Diseases


With global eradication now targeted for 2020,sustaining engagement is key to securing gains madeIn the three decades since theGWD global program commenced,its tremendously successfulintegrated strategy of preventionand surveillance has brought thedisease to the brink of becomingthe second human disease ever tobe eradicated worldwide. Sustainedcommitment and impetus in theremaining endemic areas will be keyin the final push required to reachthat target.Effective preventionand surveillance126 cases in 2014≈99worldwide since 1986.99%dropIn the 1980s, 21 countries in Africa,the Eastern Mediterranean, andSouth-East Asia were endemic.From the estimated 3.5 millioncases registered at the start of theglobal eradication program in 1986,as few as 126 cases of GWD – thelowest number ever – were reportedin 2014 in the four remainingendemic countries: Chad, Ethiopia,Mali, and South Sudan. Thisrepresents a staggering 99.99%decrease between 1986-2014.These cases are being carefullymanaged to prevent contaminationof drinking sources, and activesurveillance in nearly 7,000 villagesin endemic areas in these fourcountries is ongoing to ensure thatany new cases are immediatelydetected, contained, and treated.As part of the surveillance strategy,a monetary reward scheme hasbeen instituted to encourage peopleto come forward and report thatthey have GWD, and awarenessof this incentive remains high inendemic countries (83-98%).~80GWD casesaverted globallysince 1986Since global eradication effortswere begun in earnest in 1986, it isestimated that the highly effectivefiltering and treatment of drinkingwater in endemic areas, as well asthe provision of health informationto at-risk communities, hasprevented an estimated 80 millionindividuals from becoming infectedwith devastating GWD.198certified by WHOas GWD-freemillioncountriesIn January 2015, Ghana becamethe latest country confirmed ashaving eradicated Guinea wormdisease. To date, 15 formerlyendemic countries and 183 othercountries and territories have beencertified by WHO as free of thedisease. 2 of 4 formerly endemicAfrican countries, Kenya andSudan, are in the pre-certificationphase, while two others whichhave had no recent history ofthe disease – Angola and theDemocratic Republic of the Congo– remain uncertified.Key challenges: Although 13of the past 14 years have beenmarked by an annual decrease inthe number of reported cases ofGWD, the original WHO Roadmaptarget of global eradication by2015 will not be met and has beenrevised to 2020. In this regard,although community and politicalcommitment in some affectedcountries, such as South Sudan,have enabled major reductions inthe face of immense challenges,political insecurity in other endemicareas has impeded the healthworker access needed to ensureprompt detection and containmentof GWD cases. Inconsistentlocal community and politicalengagement has also hamperedefforts. In Chad, potentiallysustained infection amongdomestic dogs could additionallypose a further threat to eradication.Priorities for progress:• Filling the fundinggap generated by theextension from 2015 to2020 to achieve the globaleradication target.• Sustained politicalcommitment at all levelsin the remaining endemicpockets of Chad, Ethiopia,Mali, and South Sudan willbe crucial to reaching theeradication target.• National programs willneed to remain vigilant foropportunities to accessareas of insecurity in orderto locate, contain, and reportany cases of GWD.• Further research is requiredinto other potential routes oftransmission of the disease.Country Leadership and Collaboration on Neglected Tropical Diseases | 37


SCORECARDPROGRESSHUMAN AFRICAN TRYPANOSOMIASIS (HAT)1WHO ROADMAP TARGETS• by 2015: country elimination in 80% of foci• by 2020: global elimination as a public health problemDistribution of human African trypanosomiasisreported cases worldwide 2014>1000100-1000


More robust control and surveillance effortsproduce record reduction in casesProgress over the past decade inreducing the global burden, advancesin new tool development, sustainedlevels of partner commitment, andincreased global coordination, haveall made the elimination of g-HATas a public health problem by 2020a realistic prospect. Nevertheless, anumber of challenges will need to beaddressed to ensure that progresstowards the WHO Roadmap targetsremains on track.Interruption of transmission~40 %dropin new reported casesfrom 2013-14In 2014, the number of new cases ofHAT reported to the WHO droppedsignificantly to 3,796 (down from6,314 in 2013), reaching the lowestlevel in 75 years. The target for2020 is fewer than 2,000 detectedcases (and elimination in 95% ofknown high-infection areas), themarked reduction in 2014 representsreassuring progress towardsachieving this.Reduction in newcases in 2014 marks75in HAT transmissionyear lowCrucial to this success has beenthe support of mobile health unitsin endemic countries, improvedsurveillance (through strengthenedclinics), movement of populationsfrom rural areas to urban outskirtsless at risk, and investment in bettercommunity-level management ofpatient-reported cases.Key challenges: As HAT is endemicin remote areas with weak healthinfrastructure, there is evidencethat not all cases are found. Toensure more effective interruptionof transmission, national programswill therefore need to improve activecase-finding and optimize casedetection in clinics in an effort todetect all cases of HAT. Endemiccountries must also take ownershipof programs while engagingmeaningfully with partners.Advances in diagnostics,treatment, and news toolsdevelopmentIn 2013, the WHO Expert Committeeon HAT control and surveillancereviewed current disease patterns,new diagnostic approaches, andtreatments that will invigorateelimination efforts moving forward.One is a new oral drug currently inpivotal Phase II/III trials, which woulddecentralize and simplify treatmentof the disease in both stages of thedisease. Additionally, incorporationof HAT rapid diagnostic tests intonew “light” mobile motorcycle-basedteams has been demonstrated atscale, and has shown better valuefor-moneyand increased coverageper unit time in the DemocraticRepublic of the Congo (DRC).A recent major advance in the spatialanalysis of the disease through theHAT Atlas and efforts to improvedata access and projections in DRCwill also be essential for endemiccountries as they prepare andimplement strategies for elimination.New drug in PhaseII/IIIKey challenges: Pendingdevelopment of new drugs, thediverse treatments currentlyused for the different forms andstages of disease are complex,making it difficult to integratetrialsvertical HAT programs into healthsystems. National programs alsostill require support to identify andtreat remaining cases to guaranteereaching the 2020 elimination target.Multi-stakeholder coordinationIn 2014, the WHO convened its firstmeeting of stakeholders on theelimination of g-HAT. This meetingresulted in the formation of a WHOled network of endemic countries,private companies, internationalorganizations, and donors,developing new tools to combat HATaimed at ensuring a coordinated,strengthened and sustained effortsto eliminate g-HAT. This coalition willbe critical to maintaining the politicalsupport needed to secure vitalmedium-term funding, not only forprogram implementation, but alsofor tool development and operationalresearch.Key challenges: With a decliningdisease burden, it will be crucial inthe near future to sustain countryvigilance and donor support, aswell as maintained communityawareness, in the face of thepotential for donor fatigue andcommunity apathy as witnessedin other disease elimination/eradication programs.Priorities for progress:• Donor engagement toguarantee adequate impactof case detection andtreatment activities.• Development of new drugsthat are safer, affordable,less complex to administer,and active against bothforms of the disease.• Development of well-definedmeasureable targets andmilestones for monitoringprogress in program support,incorporating new tools.Country Leadership and Collaboration on Neglected Tropical Diseases | 39


LEPROSYSCORECARDPROGRESS2WHO ROADMAP TARGETGlobal elimination as a public health problem by 2020New cases detection rates of leprosy per 100,000 population.2013 (WHO)>101.0-10.0


With elimination in reach, focus must shift to improvedearly detection and post-exposure preventionWhile successes in reducing newcase numbers and pioneeringwork on combating social stigmarepresent significant advances,lower than anticipated reductions inthe share of new cases with Grade2 disability – an indicator of delayin case detection – point to furtherscope for strategic improvements.Stopping disease transmission100%take-upof WHO-endorsed strategiesThe adoption of the WHOrecommendedstrategies (earlydetection and MDT) by all endemiccountries has led to an appreciabledecline in the annual number ofnew cases in the five years to 2013,down~12from 244,796 in 2009.%dropin new cases (2009-13)A promising new preventiveinnovation 3 has been shown toreduce the risk of contractingthe disease by 50-60% whenadministered to people who arein close contact with untreatedcases of leprosy. Pilot studies inIndonesia have successfully usedthis preventive measure underroutine program conditions, and itis now being introduced in a further5 endemic countries.Key challenges: Despite thedecreasing trend in the annualnumber of new cases, the rate ofnew cases with Grade 2 disabilityin 2013 was 1.86 per million,3. Consisting of a single post-exposure preventivedose of the antibiotic drug rifampicin, purchased byrespective government leprosy programs.representing a decrease of only3.6% since 2010. At this currentrate of decline, endemic countrieswill not meet the desired milestoneof a 35% reduction in Grade 2disability in new cases per millionpeople by 2015, nor will the globalmilestone of a reduction of Grade 2disability cases to less than 1 newcase per million people by 2020be achieved. Efforts are thereforeneeded to improve early casedetection and prompt treatment inall endemic countries.Combating social stigma32%of top at-riskcountriessupport organizationsof affected persons8 of the top 25 endemic countrieshave established and supportorganizations for people affectedby leprosy and their families, withdemonstrable evidence that peopleare accessing their services. Theseorganizations help leprosy patientsovercome the stigma associatedwith the disease that often severelyaffects patients’ mental health,causes social exclusion of affectedpersons and their families, aswell as posing a real barrier tocase detection and adherenceto treatment.In Indonesia, new ways oftackling social exclusion havebeen successfully trialed andhave shown that, by targetingstigma strategically, a measurablereduction in the level of communitystigma was achievable within atwo-year period. These programshave adopted successfulparticipatory approaches thatseek to actively involve personsaffected by leprosy and theirfamilies, and include counseling,contact-based communityawareness-raising activities, as wellas business training and facilitatedmicrofinance aimed at socioeconomicempowerment.Key Challenges: Despite somesuccess at breaking downleprosy stigma, greater strategicfocus is needed to overcomethe devastating social exclusionoften resulting from prejudicessurrounding the disease. Inendemic countries, increasedpolitical commitment to promotesocial inclusion measures isrequired. Civil society effortsthat can help prevent leprosyassociateddisabilities as well asprovide support to people livingwith such disabilities will also becritical. The organization of selfcaregroups for leprosy patientsis one way of assisting peopleto manage and prevent furtherimpairments, especially to existingGrade 2 disabilities.Priorities for progress:There is an urgent need for:• a more field-friendlydiagnostic test for leprosy.Research focused ondeveloping such tests willhelp answer many crucialremaining questionsregarding the transmissionof leprosy;• wide application of existingtechniques to preventdisabilities, in combination,where possible, with otherNTDs and conditions causingwounds and nerve damage(such as diabetes); and• strategically targetedpolitical and civil societyefforts to combat leprosyassociatedstigma, so as toremove this major obstacleto early detection and timelytreatment.Country Leadership and Collaboration on Neglected Tropical Diseases | 41


VISCERAL LEISHMANIASIS (VL)SCORECARDPROGRESS2WHO ROADMAP TARGETSBy 2020:• elimination as a public health problem inSouth-East Asia• significant reduction in associated morbidityand mortality in other endemic regionsVL endemicity, worldwide, 2013 (WHO)>1000500-999100-499


Recent multi-country MoU is reenergizingelimination efforts in South-East AsiaIn working towards the eliminationtarget in South-East Asia, countriesare harnessing new financialresources and drug donationsto build their health systems’capacity to provide treatment andmanage cases, as well as to carryout preventive measures such assandfly control.Integrated infection reductionmeasures: South-East AsiaReported cases59 %downacross 3 highest-burdencountries (2011-2013)In the 3-year period from 2011 to2013, significant progress wasmade in reducing the numbersof infections in Bangladesh, Indiaand Nepal, the three countriesthat account for the majority ofVL cases worldwide. The numberof reported cases declined from38,007 in 2011 to 15,609 in 2013 asa result of improved case detection,health systems more equipped totreat VL patients, better accessto medicines, enhanced diseasesurveillance, and targeted sprayingto control sandflies. A renewedMemorandum of Understanding(signed in 2014) 2 between thesethree and other countries in South-East Asia, together with newdrug donations and funding fromthe UK government, are helpingto reinvigorate efforts towardsachieving the WHO Roadmap targetof regional elimination by 2020.Key Challenges: Several challengesremain, such as the need toaddress sandfly resistance to theinsecticide DDT, scale up preventivescreening and patient testing,increase community awareness,2. The MoU signatories are Bangladesh,Bhutan, India, Nepal, and Thailand.prevent treatment delays, andensure political commitment issustained.Surveillance and controlefforts: East Africa andLatin Americacountriesin East Africanow monitoringfor VL 5Most endemic countries in EastAfrica have revised their nationaltreatment guidelines and initiatedcombination drug therapy that hasreduced the length and cost of – aswell as improved patient adherenceto – treatment. Five East Africannations – Ethiopia, Kenya, SouthSudan, Sudan, and Uganda – havealso adopted ongoing surveillanceto ensure all cases of infection aredetected and treated.In Latin America,82%of endemiccountriessupplying updateddisease stats11 countries in Latin America areendemic for VL, 9 of which are nowproviding up-to-date informationon the proportion and distributionof the population infected, togetherwith the rate of new cases intheir countries. This data will beinvaluable in guiding future VLcontrol efforts in the region.Key Challenges: Despite the widelydifferent factors at play in EastAfrica and Latin America, effortsto control VL in both these regionsface remarkably similar challenges.Although there have been somesuccesses in East Africa, overall,the number of VL cases in boththis region and Latin America is notsignificantly decreasing.In East Africa, poor socio-economicconditions, malnutrition, combinedinfection with other diseases, andcontinued conflicts and populationdisplacements are hamperingendeavors to combat the disease.In Brazil, the Latin American countrymost affected by VL, domestic dogsare the major host carriers andcontrol efforts to date have failed tosubstantially reduce the number ofnew cases, which continues to risein urban areas. In each of the tworegions, these context-specific factorsare being further compounded by thelower efficacy of existing therapeutics,inefficient sandfly control measures,and poor diagnostics.Priorities for progress• In South-East Asia, top-levelpolitical momentum, earlycase detection, improvedaccess to diagnosis, promptand effective treatmentservices, efficacious sandflycontrol, together with crucialfinancial and medicalresource levels, must allbe sustained. Capacity inBangladesh, India, and Nepalfor improved surveillanceand response will also needbolstering.• In East Africa and LatinAmerica, scale-up ofdiagnostic and treatmentservices, increasedcapacity to improve access,uninterrupted supply ofmedicines, strengthenedearly case detection, andepidemic preparedness andresponse capacity, alongwith support for researchinto improved knowledgeand tools for controlling VLtransmission vehicles andinto enhanced diagnosticsand therapeutics, are allrequired.Country Leadership and Collaboration on Neglected Tropical Diseases | 43


INNOVATIVEPROGRAMCOLLABORATION44 | Country Leadership and Collaboration on Neglected Tropical Diseases


The Global Trachoma Mapping Project (GTMP)THE LARGEST INFECTIOUS DISEASEMAPPING EXERCISE IN HISTORYThe aim of GTMP is to accurately map the prevalenceof trachoma, the world’s leading infectious cause ofblindness. In under two and a half years, GTMP partnershave worked with 23 ministries of health, 1 usingpopulation based survey methods to capture evidenceof disease prevalence covering a suspected endemicpopulation of 212 million people.Over 2.2 million people have been examined byinternationally standardized, GTMP-certified ophthalmichealth workers using World Health Organization (WHO)grading standards; results have been instantly capturedusing Android smartphone technology; the datacleaned, quality assured and automatically analyzed;then reviewed and approved by ministries of healthusing a secure web-based portal. In total, GTMP hastrained over 1,221 people, representing approximately500 mapping teams. These teams have demonstratedincredible stamina and dedication, often working inextreme conditions in remote and geographically hostileenvironments. We anticipate that by the end of 2015, thissignificant global endeavor will result in 27 additionalcountries being able and ready to establish evidencebasedtrachoma action plans to eliminate the diseaseusing the WHO-recommended SAFE strategy.2.2M people examined to date: anaverage of 2,400 people per day orroughly one person per minute overGTMP’s mapping life span.GTMP has exceeded all expectations. Over the lifetimeof the project 1,494 health districts have been mapped,leaving approximately 100 2 accessible, suspectedendemichealth districts still to be mapped in 2015. TheGTMP population based survey methods have beenrecognized by WHO and the International TrachomaInitiative (ITI) as gold standard epidemiological surveysfor trachoma. Ministries of health use GTMP trachomabaseline data to apply for donations of the antibioticZithromax ® from Pfizer.The scale and reach of GTMP has been accomplishedbecause of a collective will to succeed shared amongst48 collaborative partners 3 (including international nongovernmentalorganizations, regional health bureaus andministries of health). This monumental and successfulproject to determine the global public health requirementfor trachoma elimination has been made possible byfunding and support from both the U.K. government’sDepartment for International Development (DFID) 4and the U.S. government’s Agency for InternationalDevelopment (USAID), 5 who have together contributedapproximately £17 million.GTMP has changed the game for trachoma elimination,providing a clear blueprint for elimination activity andaligning the complex network of stakeholders needed toreach that goal within a newly energized Alliance. Thereis now no doubt that if sufficient resources can be madeavailable to national programs, GET2020 is achievable.1. 23 ministries of health include: Benin, Cambodia, Chad, Cote d’Ivoire, DRC, Egypt,Eritrea, Ethiopia, Fiji, Guinea, Laos, Malawi, Mozambique, Nigeria, Senegal, SolomonIslands, Sudan, Tanzania, Uganda, Vanuatu, Zambia, Zimbabwe, Yemen. (In additionministries of health in Cameroon and Nepal conducted baseline mapping projectsduring the life of GTMP without the use of GTMP methods.)2. Please note countries such as Brazil, China and India that have internalgovernment funds to support the mapping of trachoma in suspected endemicdistricts have not been included in this figure, nor have those districts wheretrachoma is suspected to be endemic but significant security concerns restrict theability of GTMP and its partners to operate.3. INGOs include: AMREF, BICO, The Carter Center, Fred Hollows Foundation, FHI 360,Helen Keller International, International Coalition for Trachoma Control, InternationalTrachoma Initiative (The Task Force for Global Health), Johns Hopkins University,Kilimanjaro Centre for Community Ophthalmology International, Light for the World(Austria), Light for the World (Netherlands), London School of Hygiene & TropicalMedicine, Magrabi Foundation, Mitosath, ORBIS, Organisation for the Prevention ofBlindness (OPC), Organizacion Panamericana de la Salud (PAHO), RTI, Sightsaversand the World Health Organization. Regional Health Bureaus include: Amhara, Somali,Tigray and Southern Nations Nationalities and Peoples Regional Health Bereaus, all inEthiopia. 23 ministries of health are listed in footnote 1 above.4. DFID provided the original grant for GTMP (£10.6 million)5. USAID funded GTMP by approximately £0.6 million through the Envision grantmanaged by RTI, in addition to directly funding RTI and FHI 360 by approximately £6million to conduct trachoma baseline projects (the majority of the surveys used GTMPmethods and systems).Country Leadership and Collaboration on Neglected Tropical Diseases | 45


INCREASED COLLABORATION ON TRACKINGSTH SHOWS PROMISE ON PROGRESSSoil-transmitted helminthiases (STH) infect over one billion people globally and are related to ahigh public health burden. WHO recommends the use of preventive chemotherapy (PCT) of highrisk groups to control STH-related morbidities. Preschool-age children (pre-SAC) are an importanttarget group for STH control with PCT in the WHO strategic plan on ‘Eliminating Soil-TransmittedHelminthiases as a Public Health Problem in Children.’ This plan defines the future global pre-SACand school-age coverage targets of 40% by 2013, 50% by 2015 and 75% by 2020.WHO tracks progress to global coverage targets throughits Preventative Chemotherapy and TransmissionControl databank that combines coverage informationfrom numerous partners and delivery mechanisms.According to this databank, global pre-SAC PCT coverageprogressively declined from 37% in 2010 to 31% in 2011and 25% in 2012. Initial coverage estimates for 2013indicated that 24% of children requiring PCT for STH werereached. WHO and its partners recognize that not allcountries requiring preventative chemotherapy for STHreported data to the databank. In particular, data fromChild Health Days, which are biannual events deliveringa package of child health interventions to pre-SAC,appeared to be incompletely captured. In these events,vitamin A supplementation and deworming are amongthe most common interventions.To address the reporting gap for deworming deliveredthrough Child Health Days, UNICEF launched a globalreporting exercise linked to UNICEF’s well establishedreporting system for global vitamin A coverage. Thedeworming coverage data obtained through this reportingmechanism was subsequently checked to avoid doublecounting and then merged with 2013 data alreadyreported in the PCT databank.With this additional data, the global 2013 pre-SACreported coverage increased from 24% to 49%, thussurpassing the 2013 coverage milestone and showingthat the coverage target for 2015 (50%) is achievable.Additional data from 8 countries are presently underevaluation, and the global coverage may therefore furtherincrease. South-East Asia exhibited the highest regionalpre-SAC PCT coverage in 2013 with 60%, followed byAfrica (49%) and East Mediterranean (37%). Pre-SACPCT coverage in Europe (12%) was the lowest. Coveragedata are available from 80% of total pre-SAC population;however, there are still 57 countries where PCT isrecommended but where no coverage data are reported.Given that Child Health Days (CHDs) delivered nearly halfof all pre-SAC treatments in 2013, the strategic importanceof this delivery mechanism for reaching this age groupis clear. UNICEF plans to repeat and further extend thePCT coverage reporting for CHDs in subsequent years.With its partners, UNICEF also continues its support togovernments to strengthen drug procurement and supplymanagement, improve data systems, and reach theunderserved. With the phase out of national poliomyelitisimmunization days, efforts to institutionalize CHDs willrequire particular attention to maintain and further expandglobal pre-SAC PCT coverage levels.This work was supported by grants from the GatesFoundation and the Canadian Department of Foreign Aid,Trade and Development.For further information please contact Roland Kupka atUNICEF rkupka@unicef.orgFigure 1: Global coverage of preventive chemotherapy among preschool-age children for soil-transmitted helminthiasesand population covered in global preventive chemotherapy and transmission control databank, 2010-2013Global Pre-SAC PC Coverage (%)10090807060504030201002010201120122013Population of pre-SAC requiring PCT for STHGlobalpreschool-agechildren PCCoveragePopulation ofpreschool-agechildren requiringPC for STHPCT DataPCT Data withChild HealthDay Data46 | Country Leadership and Collaboration on Neglected Tropical Diseases


Unprecedented collaboration by Non-GovernmentalDevelopment Organizations (NGDOs) in the fight against NTDsNGDOs support global and national NTDs programs bycatalyzing action towards national ownership; connectingformal health systems with communities; undertakingand disseminating research; building technical capacity;brokering relationships across sectors; and supportingeffective program delivery models at the community levelthat can be scaled up.The Neglected Tropical Disease NGDO Network (NNN) isa forum for non-governmental development organizations(NGDOs) working to control or eliminate NTDs atthe community level. The forum provided by NNNpromotes coordination and collaboration for successfulimplementation of all the NTDs’ activities.Scale-up of MDA campaigns is vital to achievingelimination and control targets. Just as important isprevention (e.g., provision of water and sanitation facilitiesand hygiene education) to break the cycle of transmission.Equally important is morbidity management to mitigatethe consequences of diseases that affect the poorest ofthe poor.Recognizing that treatment, prevention, and morbiditymanagement are all core components of successful NTDprograms, NGDO members established the followingcross-cutting working groups at the 2014 NNN annualmeeting, where a record number of 70 organizationscame together and as result, set up the following groups:• Morbidity management and disability Working Group.This working group will collaborate with WHO onpreparing comprehensive guidance on these issuesand how to incorporate them as part of overallprogram strategies.• Water, Sanitation, and Hygiene (WASH) WorkingGroup. This working group will promote the inclusionof WASH activities in NTD programs and advocateto policy makers, planners and funding partners, theimportance and impact of WASH on NTD outcomes.At the 2015 annual meeting in September, the NNNwill consider additional crosscutting issues: identifyingstrategies for effective vector control and measuringthe impact of elimination and control of NTDs on theSustainable Development Goals.Morbidity Management and Disability:Ensuring no one is left behindNew tools are now available to ensure that those whosuffer from the effects of NTDs can be reached withcompassionate care. Millions of people live with thephysical, psychological and social implications ofNeglected Tropical Diseases and for many, disabilityis an everyday reality. Morbidity management anddisability (MMD) interventions can have a clear andoften immediate impact on the lives of the peopleaffected by these diseases of poverty.A central pillar of the post-2015 discussions has beenthe call to “leave no one behind”. This means that nointernational target or goal, including those linked toNTDs, can be considered met unless it is met for allsocial groups, including people with disabilities. NTDprograms are a way to translate the leave no one behindprinciple into practice.Global collaborative efforts to eliminate NTDs havehad a strong focus on preventive chemotherapy throughmass drug administration. From the perspective of aperson affected by NTDs however, a comprehensiveresponse does not merely mean the absence of diseasebut functional recovery that allows a person to performtheir everyday activities and ensures they can participatefully in their community. Effective NTD managementof MMD preserves vision, promotes mobility andempowers, while assuring health, education, work,community life, water and sanitation are availableand accessible.Scaling up interventions for NTD-related morbidity andAn empowering approachAmerican Leprosy Mission developed a teachingguide and summary cards to address 10 crosscuttingissues common to many NTDs and otherhealth conditions. The updated version is expectedto be available in September 2015 and can be foundat www.leprosy.org. Some module topics coveredinclude: suspecting and treating disease and healthconditions early; practicing good personal andhousehold cleanliness, using footwear, caring foreyes, care to prevent movement limitations andadequate management of edema and wounds.As basic care at the community level is strikinglysimilar across diseases, these modules will enablepeople affected, communities and health workersto identify and address common problems early,know when and where to refer, and understandhow to monitor results. It encourages ownershipand a person-centered, problem-based approachto learning where the trainer/facilitator becomesa “coach”.disability will reduce the burden of many NTDs and fillcritical gaps in disease management.For the NTD community, the outcome of the post-2015dialogues on what will replace the MDGs when they expireis critical. The NTD community hopes not only to see NTDsrecognized as a health and development priority alongsideother infectious diseases, but also to see increasedrecognition of disability within a new framework.Country Leadership and Collaboration on Neglected Tropical Diseases | 47


NTDS AND WASH: INNOVATING TOGETHERPrimary prevention for the control of NTDs reliesheavily on improved water, sanitation, and hygiene(WASH). There are numerous NTD transmissionroutes that can be interrupted with improved WASH. Inaddition to preventing disease, improved WASH is vitalto NTD-related wound and morbidity management anddisability prevention.To date, NTD control initiatives have reliedpredominantly on mass drug administration (MDA).While MDA includes the treatment of disease, as wellas delivery of drugs as preventive chemotherapy (PCT),studies have shown continued re-infection post-PCTwhere WASH interventions are not part of the strategy. 1Water, sanitation and hygiene (WASH) play a criticalrole in the prevention of and care for 5 of the 10London Declaration NTDs. While the evidence base ofwhich WASH improvements most efficiently leveragethe most effective and sustainable NTD control orelimination, there are multiple areas ripe for informed,active collaboration:• developing in-country connections in nations with botha strong capacity for MDA and explicit commitmentsto universal access to water and sanitation;• creating effective ways for the NTD and WASHsectors to exchange information, and harmonize andamplify behavior-changing messages;• sharing and/or coordinating mapping and datacollection, given both the common geographicand demographic targets, and goal of disease-freecommunities;• informing the bi-lateral gaps, barriers, and technicalobstacles to NTD and WASH partnering efforts; and• examining cross-cutting opportunities such as fullyintegrating the school-based platform of NTD MDA,WASH, and nutrition interventions, which could leadto high-impact health benefits, increased donorcommitment, and service-delivery efficiency andcost-effectiveness.We welcome the new WHO strategy (see box thispage), which can only serve to strengthen thecollaboration between the NTD and WASH sectors,towards the common goal of meeting the WHORoadmap targets for NTDs.1. Jia T-W, Melville S, Utzinger J, King CH, Zhou X-N (2012) Soil-transmitted helminthreinfection after drug treatment: A systematic review and meta-analysis. PLoS NeglTrop Dis 6: e1621. doi: 10.1371/journal.pntd.0001621A new WHO effort – collaboration on water, sanitation, hygiene and NTDsA new strategy has been developed to guidenational programs and partners in implementingNTD programs, in collaboration with water, sanitationand hygiene (WASH). WASH plays a critical role inthe prevention of, and care of 16 of the 17 neglectedtropical diseases (NTDs), scheduled for intensifiedcontrol or elimination by 2020. However, how theseimportant complementary health interventions areimplemented, need to be defined to ensuremaximum impact.The vision of the new strategy is accelerated andsustained achievement of the NTD roadmap targets,particularly among the poorest and most vulnerable,through better-targeted WASH and NTDs efforts.The strategy informs WHO’s actions and those ofendemic countries and partners, aiming for mutualreference and embedding of WASH and NTDsaspects in sector plans and programs, with fullintegration of programs where appropriate. Itincludes four strategic objectives, enhancedawareness and experience sharing, monitoring,increasing evidence for improved practice, and jointplanning and delivery.Collaboration between WASH and NTDs stakeholdersis essential to meet many of the NTD roadmap targets,and offers important co-benefits to both communities.Opportunities for joint work include; the developmentof comprehensive disease control plans, improving thetargeting and effectiveness of WASH interventions fordisease-control purposes, and improving the qualityof facility-based care and self-care aspects of NTDprograms.The new development of a solid path forward, withattention to doing and learning, will guide futurework and collaboration. Carrying out this strategy,will not only improve the NTD effort, but will alsocontribute to the vision expressed in the SustainableDevelopment Goals, of shared prosperity,strengthened health systems, universal healthcoverage, and equitable access to resources andservices that underpin human development.48 | Country Leadership and Collaboration on Neglected Tropical Diseases


RESEARCH ANDDEVELOPMENTCountry Leadership and Collaboration on Neglected Tropical Diseases | 49


INNOVATION TO DRIVE GREATER IMPACTResearch and development (R&D)Great progress has been made over the past year in pursuing research aimed at facilitating theefforts of national NTD programs to combat the diseases included in the London Declaration, andmeet the WHO Roadmap targets. To further these advances, and to perhaps shorten the length oftime and investment needed, numerous donors, institutions and collaborators have been partneringto identify, support and carry out research across three principal categories: drugs, diagnostic tools,and operational research.For the purposes of this report, an initial attempt hasbeen made to capture any research that is ongoing orrecently completed for each of these three categorieswith respect to the 10 London Declaration NTDs.Research institutions, universities and consortiums,along with disease community networking groups,were contacted to contribute to and comment on agrowing list of research efforts. Although far fromcomprehensive, the preliminary list contains morethan 150 unique investigations underway to developmuch-needed drugs to treat affected communitiesand individuals, tools that will help programs scale upand scale down safely to achieve program targets, andimproved methods for implementing program strategies.New DrugsCurrently there are more than 40 active studies workingto identify or develop new drugs to combat NTDs. Somehighlights include:• a new pediatric formulation of praziquantel 1 willenable national programs to treat an estimated 10-15 million preschool-age children who are infectedor at risk for schistosomiasis. Pediatric studiesare planned starting in 2016 to show that this newformulation of praziquantel, which is made palatablefor small children, is safe, well-tolerated, and effectivein the treatment of this age group. Phase I clinicaldevelopment in healthy adults began in October 2014,with the intent being to have the new formulationready for registration by 2018, and• the oral drug fexinidazole, in co-develoment by DNDi,WHO and Sanofi, is set to be a game changer inreaching communities endemic for human Africantrypanosomiasis (HAT). The current standard oftreatment requires patients to travel to well-equippedhealth centers to receive a combined treatment thatincludes intravenous drug administration (14 infusionsover 7 days). Fexinidazole, currently in Phase II/IIItrials, promises to be a single oral treatment over10 days that can be delivered at community level orwhere point-of-care services are provided. This willdecrease costs, complexity, and time required to treatpatients suffering from HAT, and hopefully speedprogress towards elimination. Regulatory approvaland pre-qualification are anticipated in 2018Diagnostic ToolsAs NTD programs move forward, improved tools areneeded to measure impact and achieve program goals.This area has not received sufficient attention, andalthough significant progress has been made, manygaps remain. Effective, reliable and sensitive diagnostictools remain key to ensuring that national programsare able to judiciously deliver and safeguard highlyvaluabledonated drugs, as well as determining whereadditional interventions may be required. Among the50-plus research investments in this area, some recentprogress in new and refined diagnostic tools for NTDsincludes:• a new test offers a less expensive and more sensitivealternative to the diagnostic Kato-Katz standard formapping and monitoring of schistosomiasis, whilealso requiring less technical oversight. The WHO hasrecently endorsed the use of the urine circulatingcathodic antigen (CCA) test for Schistosomamansoni in schistosomiasis control programs.The Schistosomiasis Consortium for OperationalResearch and Evaluation (SCORE) is coordinatingthe evaluation efforts with multiple partners andresearchers. The savings in time and costs will bekey to the global schistosomiasis program as itattempts to complete mapping of the disease inpreparation to deliver the increased donation 2 ofpraziquantel (Cesol 600) from 100 million tablets in2015 and up to 250 million in 2016; and• in 2014, the Ov16 rapid diagnostic test 3 foronchocerciasis was launched by StandardDiagnostics with support from the nonprofit globalhealth innovator PATH. Now a second-generationtool is under development that adds the Wb123antigen for lymphatic filariasis (LF) to the same teststrip, allowing programs to test and follow impact onboth onchocerciasis and LF. This will be invaluablefor regions where both are endemic and programdecisions on the two diseases are linked. The Ov16/Wb123 biplex rapid test is anticipated to be launchedaround late 2015, early 2016.1. Produced by Merck KGaA, Darmstadt, Germany.2. Generously donated by Merck KGaA, Darmstadt, Germany.3. Known commercially as the SD BIOLINE Onchocerciasis IgG4 rapid test.50 | Country Leadership and Collaboration on Neglected Tropical Diseases


Operational ResearchThere are over 60 operational research activitiesidentified as engaged in answering questions that willhelp to improve the implementation of NTD programs,and increase the likelihood of achieving control,elimination and eradication goals by 2020. The types ofoperational research efforts underway run the gamutfrom validating the use of new tools, to identifyingmore effective treatment regimes, or leveraging MDAplatforms for better program integration, mapping andimpact measurement.Some examples include:• the work being done by Washington University, inconjunction with the Côte d’Ivoire Ministry of Health,exploring the impact and cost implications of annualversus semi-annual treatment with ivermectinand albendazole in an area where both LF andonchocerciasis are endemic. It is proposed that themore intensified twice-yearly treatment schedulefor LF will accelerate the elimination of LF and mayhave a similar impact on onchocerciasis. Together,these benefits could reduce the total number ofyears required for MDA, thereby creating savings ondelivery costs and decreasing the need for donateddrugs. The final results of this study, anticipated bythe end of 2017, will likely inform the refinement ofWHO treatment guidelines; and• research carried out to test the benefits ofsimultaneously assessing soil-transmitted helminths(STH) levels using Transmission AssessmentSurveys (TAS). The TAS was designed to determineif MDA for LF can be stopped. Including theassessment of STH allows countries to decide howSTH treatment continues following LF scale down.This work was conducted through a partnershipbetween the WHO, the Task Force for Global Health,GlaxoSmithKline, and several Ministries of Healthincluding those from Benin and Tonga. This approachwas recently endorsed by the WHO as operationallyfeasible, programmatically relevant, and potentiallycost-effective.Despite the demands on countries to achievemore ambitious targets, research dollars have notincreased to help in reaching these goals. Diseasespecificresearch plans are needed, focused on criticalgaps and accelerating progress towards eliminationand control targets. Established plans would enablethe larger NTD community to be aware of prioritizedresearch topics, know what is currently being funded orstill needs resourcing, and understand how to measureprogress. This should be a priority in the next year.Funding for NTD ResearchBetween 2007-2013, approximately US$1.6 billion wasinvested in R&D for NTDs. The level of funding in thisarea has remained constant without any significantincrease since 2010. More than 44% (US$700 million)of these resources has been available to researcherssince the launching of the London Declaration in 2012,the vast majority (73%) being dedicated towards theIntensified Disease Management (IDM) NTDs, reflectingthe particular challenges posed by these diseases, whichare not easily managed through MDA campaigns anddonated drugs. Innovation will be required to accelerateprogress with new tools and strategies in support ofendemic country programs and their targets.Distribution of funding for NTD research by disease (US$1.6 billion between 2007-2013)$300,000,000$250,000,000$200,000,000$150,000,000$100,000,000Lymphatic FilariasisOnchocerciasisSoil-transmitted Helminthiasis (total)Multiple HelminthsSchistosomiasisTrachomaChagas DiseaseMultiple KinetoplastidsHuman African TrypanosomiasisLeishmaniasisLeprosy$50,000,000$0FY2007FY2008FY2009FY2010FY2011FY2012FY2013Country Leadership and Collaboration on Neglected Tropical Diseases | 51


CAN WE REACH THE 2020 GOALSUSING CURRENT STRATEGIES?As control programs scale-up their efforts to control NTDs and new tools are being developed indiagnostics, treatments, vector control and surveillance, there is a growing body of evidence anddata on which we can base more refined public health strategies.Epidemiological modelling 1 has become an essentialtool in developing public health policy for the controlof infectious diseases.An NTD modelling consortium 2 has been formedwith funding from the Gates Foundation, the Children’sInvestment Fund Foundation and the Novartis Foundationto develop models across the diseases in the LondonDeclaration (except Guinea worm disease) to supportstrategy development on the most effective controlstrategies to achieve the goals in particular settings.For PCT NTDs, the models will be informed by thegrowing body of data from routine monitoring andevaluation of treatment programs across a rangeof different countries and epidemiological settingsto assess how effective the current strategies areat reducing the level of infection. They will also beconsidering the potential impact of new drugs or drugcombinations as the results of ongoing studies andtrials become available. Validating the models againstthese data will increase their reliability and usefulnessat the programmatic level.The role of modelling in assisting inonchocerciasis control in AfricaGreat progress has been made towards the eliminationof onchocerciasis in Africa by annual mass treatmentwith ivermectin. In some areas, ivermectin masstreatment has been going for over 15 years andmany of these areas may be close to the completeinterruption of transmission. For these countries, thereis the prospect of true local elimination and haltingof transmission if no new cases arise between thenand 2025. In contrast, other countries are laggingbehind due to late starts, implementation problems orcontraindications for the implementation of ivermectinmass treatment. To eliminate onchocerciasis in thesecountries by 2025, control activities must be intensifiedor alternative treatment strategies be implemented.Using the established ONCHOSIM 3 simulationmodel, developed by Erasmus MC (Rotterdam, theNetherlands) in collaboration with the OnchocerciasisControl Program in West Africa (1974-2002), it waspossible to estimate the final year of treatment for allonchocerciasis endemic areas under the assumptionthat the current strategies are continued (mostlyannual ivermectin mass treatment, in some areasbiannual treatment). The modelers identified 47 areasin 12 countries where interventions likely need tocontinue beyond 2022. This included areas in bothcurrently targeted regions where treatment is alreadyongoing or has not yet started and potential new areaswhich are not yet targeted. The analysis highlightedthat the Democratic Republic of Congo is likely topose a particular challenge, with 24/47 problem areaslocated in this country.Given this observation, the question then becomeswhat strategies should be used in those areas whichare not Loa loa co-endemic. Possible strategiesinclude increased coverage of treatment or morefrequent treatment. The modelling analyses suggestthat measures to improve treatment coverage wherethe achieved levels are


For preventive chemotherapy (PCT)NTDs, the modelers are addressingquestions on how frequently treatmentshould be given, to which age groups,using which drug combinations, and atwhat coverage to reach the goals morequickly in communities with differentprevalence of disease.For IDM diseases, incidence of diagnosed cases isdependent on the accessibility of the health system,as well as the level of active case detection, in eachparticular setting. This makes interpretation of thesedata particularly challenging, but by working with theresearchers and control programs to gain a betterunderstanding of the routes to diagnosis and theresponse to detection of cases, these teams aregiving new insights on the underlying dynamics oftransmission which will be crucial in controlling theseinfections. The development of new diagnosticsand drug treatments for these diseases are alsoproviding data which have the potential to change ourunderstanding of the epidemiology of these infections,and the modelers are supporting efforts to link datausing older and newer diagnostics so that they can beanalyzed alongside each other to improve programsand outcomes.The consortium’s results for this year will be publishedin early November 2015. Further information on theresearch group, their activities, and other modellingpublications will be posted on www.ntdmodelling.orgFor Intensive Disease Management(IDM) diseases, such as sleepingsickness or leprosy, the modelersare developing better quantitativeestimates, e.g. the time from infectionto symptoms, the proportion of thepopulation asymptomatically affected,or the importance of particular vectorbehaviors.Prevalence of onchocerciasis (%) based on microfilariae in the skinSimulated trends in the prevalence of onchocerciasis (based on presence of microfilariae in the skin) for a high endemic community. The figure shows theimpact of increasing the frequency of mass treatment from annual (dashed and lighter lines) to biannual (solid and darker lines). In the scenario with annualtreatment, the first treatment is given at time=0 and 14 treatment rounds are provided in total (last treatment at time = 13). In the alternative scenario, treatmentagain starts annually at time 0, but from the 4th treatment round onward treatment is given biannually with 19 treatment rounds in total (last treatment attime 10.5). In both scenarios, 70% of the total population is treated per round, excluding children under 5, and pregnant or lactating women. Simulations weredone with the established ONCHOSIM simulation model (Coffeng et al 2014). The presented trends are based on yearly surveys carried out at time 0 with yearlyintervals before and after this timepoint, with surveys always just preceding treatment in case the two coincide. The thick lines shows the average predictedtrends of 125 simulations per scenario, the thin lines show the results of each of the 125 individual simulation runs per scenario.Country Leadership and Collaboration on Neglected Tropical Diseases | 53


ADVOCACYAND PRIORITIESFOR ACTION54 | Country Leadership and Collaboration on Neglected Tropical Diseases


G7 LEADERSHIP ON NEGLECTEDTROPICAL DISEASESThe conclusion of the 2015 Group of 7 (G7) Summit, held June 7-8 in Schloss Elmau, Germany,offers promising news for people around the world who continue to endure the crushing burden ofNTDs. Under Chancellor Angela Merkel’s leadership, NTDs remained a priority on the 2015 agenda,devoting much needed attention and dialogue to an issue that affects the most vulnerable andneglected populations across the world.Leaders of G7 nations – Canada, France, Germany,Italy, Japan, the United Kingdom, and the UnitedStates – made a firm commitment to advance thefight against NTDs by investing in prevention andcontrol efforts as well as by supporting priorityareas in research and development. The G7 Leaders’Declaration also emphasized the importance of equalaccess to health services as part of their broadereffort to strengthen health systems, including throughcommunity-based mechanisms – an approach thathas proven to be highly successful in expanding accessto NTD treatments.Equally important, the G7 issued an additionalstatement, promising to engage the health; water,sanitation and hygiene; and education communities toboost efforts to end malnutrition. We urge the G7 toinvest in comprehensive approaches to help expandaccess to treatments for intestinal worms, anevidence-based, nutrition-specific interventionthat improves pregnancy outcomes and childhooddevelopment.This year’s commitment builds on the G7’s longstandingpledge to fight NTDs, dating as far back asthe 1998 Birmingham Summit that established theJapanese-led historic Hashimoto Initiative – the firstinternational parasitic disease control initiative.Uniting to Combat NTD partners stand ready tomarshal the very best talent, resources, knowledgeand experience, to work side by side with the G7 to endthese diseases once and for all. This year, 2015, offersa pivotal moment for the G7 to wrap up the unfinishedNTD agenda and have an immediate, meaningful andsustainable impact, setting the stage for successas the world looks ahead to the new sustainabledevelopment goals.The G7 Leaders’ DeclarationNeglected Tropical DiseasesWe commit ourselves to the fight against neglectedtropical diseases (NTDs). We are convinced thatresearch plays a vital role in the development andimplementation of new means of tackling NTDs. Wewill work collaboratively with key partners, includingthe WHO Global Observatory on Health Researchand Development. In this regard we will contributeto coordinating research and development (R&D)efforts and make our data available. We will build onefforts to map current R&D activities, which will helpfacilitate improved coordination in R&D and contributeto better addressing the issue of NTDs. We committo supporting NTD-related research, focusing notablyon areas of most urgent need. We acknowledge therole of the G7-Academies of Science in identifyingsuch areas. In particular, we will stimulate bothbasic research on prevention, control, treatment, andresearch focused on faster and targeted developmentof easily usable and affordable drugs, vaccines, andpoint-of-care technologies.As part of our health system strengthening effortswe will continue to advocate accessible, affordable,quality, and essential health services for all. Wesupport community-based response mechanisms todistribute therapies, and otherwise prevent, control andultimately eliminate these diseases. We will invest inthe prevention and control of NTDs in order to achieve2020 elimination goals.Annex to the G7 Leaders’ DeclarationWe commit to following an integrated multi-sectoralapproach to improving food security and nutrition…We will pursue nutrition specific interventions thathave proven to be effective in addressing undernutritionand micronutrient deficiencies. We will alsostrengthen our nutrition sensitive interventions inkey sectors, such as agriculture, social protection,water, sanitation and hygiene, health, education, andimproving food systems.Country Leadership and Collaboration on Neglected Tropical Diseases | 55


NTDS AND SUSTAINABLE DEVELOPMENT GOALSWhile tremendous progress has been made on the WHO Roadmap targets; gaps still exist. Later thisyear, the UN General Assembly (UNGA) will meet in New York to adopt 17 Sustainable DevelopmentGoals (SDGs) that will carry forward the momentum of the Millennium Development Goals (MDGs)as the sun begins to set on the MDGs timeline. Like the MDGs, the SDGs have a 15-year agenda.Recognizing that the momentum behind the LondonDeclaration’s NTD commitments must continue beyond2015, Uniting to Combat NTDs stakeholders met inFebruary 2015 to contemplate how NTDs, the LondonDeclaration, and the WHO Roadmap on NTDs will alignwithin the SDG context.While the eight MDGs did not include specific mentionof NTDs, a number of the current SDGs are particularlypertinent to the multi-pronged and multi-sectoredefforts to control, eliminate, and eradicate NTDs.Specifically, SDG 3 – Ensure healthy lives and promotewell-being for all at all ages, references NTDs undersub-goal or target 3.3:SDG 3:“By 2030, end the epidemics of AIDS,tuberculosis, malaria, and neglectedtropical diseases and combat hepatitis,water-borne diseases, and othercommunicable diseases.”Given that target 3.3 explicitly mentions “the end ofNTDs”, it is imperative that this NTD target includesa global indicator. The NTDs Department at WHOhas been leading the process of defining an indicatorfor NTDs and achieved consensus for the followingindicator from broader NTD community:Proposed SDG indicator for NTDs:“90% reduction in the number ofpeople requiring interventions againstNTDs by 2030.”Specific actions that the NTDs community can take tosupport this are:• contact the Inter-agency and Expert Group onSustainable Development Goal Indicators (IAEG-SDGs) established by the UN Statistical Commissionto develop an indicator framework for the monitoringof targets at the global level and urge the inclusion ofthis NTD indicator;• work with national government officials involvedin the post-2015 development agenda and SDGprocess and urge for the inclusion of a global NTDindicator.• contact your UN permanent representative in NewYork and urge for the inclusion of an NTD indicator.“Political Commitment andAccomplishment on NTDs”WHA68 Side Event, May 201556 | Country Leadership and Collaboration on Neglected Tropical Diseases


Design by Positive2Photography creditsCover, page 6 and 7, 24, 30, 49, 54: © GSK/Marcus PerkinsPage 10, 13, 56: © UTC-NTDs/Marcus PerkinsPage 23: © RTI/Louise GubbPage 26: © Dr Adrian Hopkins, MBEPage 28: © WHOPage 32: © The Fred Hollows Foundation/Antonio FiorentePage 34: © Programe Nacional de Chagas de BoliviaPage 36: © The Carter Center/L.GubbPage 38: © DNDi/Simon TshiamalaPage 40: © Netherlands Leprosy ReliefPage 42: © Bill & Melinda Gates Foundation/Prashant PanjiarPage 44: © WaterAid/Dieter TelemansPage 45: © SightsaversCountry Leadership and Collaboration on Neglected Tropical Diseases | 57


58 | Country Leadership and Collaboration on Neglected Tropical DiseasesWebsite: www.unitingtocombatntds.orgEmail: info@unitingtocombatntds.orgFollow us on twitter: @CombatNTDs

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