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Reaching the unreached Fourth progress report of the London Declaration
Welcome to the fourth report and scorecard on the progress of the London Declaration on neglected tropical diseases (NTDs). When the London Declaration was signed in January 2012, the partners committed themselves to achieving the targets for 10 of the 17 diseases in the World Health Organization’s (WHO’s) Roadmap for Implementation for the control, elimination, or eradication of NTDs. The 10 diseases were chosen on the basis that the essential ingredients were present for providing immediate, targeted assistance.
This report describes the efforts and contributions of many stakeholders, which include endemic countries, WHO, non-governmental development organizations, researchers, academics, funders, and industry partners who have supported countries and communities in reaching the WHO targets in various ways.
If you are new to the world of NTDs, we hope you will be inspired to join this unique, powerful global health community, which is working hard to consign these diseases to history. If you are already an invested partner, we thank you for your partnership and look forward to continuing to work with you through to the end!
Although NTDs are preventable and treatable, they continue to be a heavy burden on over 1 billion of the most vulnerable, disadvantaged people in the world.
This fourth report on progress of the London Declaration demonstrates that we are in a strong position to reach the global goals
This fourth report on progress of the London Declaration demonstrates that we are in a strong position to reach the global goals and thus achieve a better quality of life for the people at risk and affected by 10 NTDs. Four factors contribute to achievement of the goals:
- We have a strong, unique partnership in global health.
- We have better data and tools to target programs in order to reach the remaining communities.
- We benefit from generous drug donations by industry partners to treat and prevent these debilitating diseases.
- Country programs are making significant progress in attaining program goals in hard-to-reach areas, ensuring success upon which programs can build.
A diverse, open partnership in global health focused on diseases of inequity
In January 2012, a coalition of global health institutions, pharmaceutical companies, philanthropic organizations, donor countries and the governments of countries in which these diseases are endemic signed the London Declaration, which commits them to control, eliminate, or eradicate 10 NTDs – a turning-point in fighting these diseases. As we approach the Declaration’s five-year anniversary in 2017, harnessing and strengthening these partnerships will be crucial to continued success.
If NTDs are not addressed, over one billion of the world’s most vulnerable, most disadvantaged people will be left behind from development progress over the next 15 years
In September 2015, with the support and commitment of these partners, the fight against NTDs gained new momentum when world leaders adopted the United Nations’ new Sustainable Development Goals (SDGs). For the first time, NTDs are cited specifically in the global development framework (SDG 3) as an issue of global importance.
The SDGs, unlike their predecessors, the Millennium Development Goals (MDGs), are reinforced by the commitment of global leaders to ensure that “no one is left behind” from development progress over the next 15 years. Equity and justice underpin the new global goals, inherently supporting the place of NTDs on the agenda. If NTDs are not addressed, over 1 billion of the world’s most vulnerable, most disadvantaged people will be left behind – the poorest of the poor, who live in the remotest, hardest to reach parts of the world.
As the NTD program has grown, it has also become smarter – gathering data and developing new technologies to reach the unreached
As the name implies, NTDs occur in some of the most remote, inaccessible parts of the world. Without accurate data, we simply cannot know where to provide treatment. By mapping where NTDs are prevalent, we can accurately determine who is at risk, who isn’t, and where at-risk populations live, thereby increasing program efficiency to reach the world’s most marginalized communities. Better data on disease distribution and program progress allow partners to set targets and direct resources more strategically to the areas of greatest need.
Better data on disease distribution and program progress allow partners to set targets and direct resources more strategically to the areas of greatest need
An example is the recently concluded Global Trachoma Mapping Project (GTMP), which has identified that public-health level interventions are required to eliminate trachoma for 100 million people living in areas that were previously categorized only as “suspected endemic”. These data doubled the population already known to require interventions against trachoma, with the global at-risk population now totalling 200 million people, and completed the global baseline trachoma map of secure suspected-endemic districts. Approximately 38% of the people at risk live in Ethiopia, which has one of the highest prevalence rates of trachoma in the world. Survey results from countries such as Cambodia and the Democratic Lao People’s Republic, which were previously endemic, showed that trachoma was no longer a public health problem and will therefore not require widespread treatment.
Accurate maps showing where NTDs are found and which communities are affected give ministries of health in endemic countries the evidence base to tackle the appropriate diseases and to use their resources and donated medicines more efficiently
New tools are rapidly becoming available to identify communities at risk and to provide preventive and curative treatment for the control and eventually the elimination of NTDs. One example of the use of new tools to better plan control strategies is new, improved diagnostics for lymphatic filariasis (LF). The effectiveness of the LF elimination program was threatened by the presence of a second parasitic infection, loiasis. Patients with both infections could not receive the conventional community treatment with ivermectin because the high burden of infection made it unsafe. Existing diagnostic tools had limited ability to differentiate between the two types of infection, and patients therefore did not receive appropriate treatment. New, improved diagnostic tools are moving the global community closer to more accurate diagnosis, ensuring that 40 million more people will have access to safe, effective treatment.
The largest public–private partnership provides over 1 billion treatments annually
The global effort to control and eliminate NTDs is one of the largest public health initiatives ever seen. In 2015 alone, pharmaceutical companies donated an estimated 2.4 billion tablets, enough for 1.5 billion treatments to prevent and treat NTDs – an increase of 11.7% from 2014. Thus, one of the largest public health programs in the world owes its success to a drug donation program on a truly global scale. The generous contributions of pharmaceutical partners ensure that preventive chemotherapy programs for NTDs are highly cost-effective, ranking them as one of the best buys in global development.
In 2015 alone, pharmaceutical companies donated an estimated 2.4 billion tablets, enough for 1.5 billion treatments to prevent and treat NTDs
Countries are already making significant progress, achieving impressive public health milestones
Thanks to the catalytic impact of the London Declaration, a growing number of endemic countries have achieved their elimination goals since 2012, and more people than ever are being reached with the treatments they need. An unprecedented 1.1 billion treatments were delivered in 2014, reaching 858 million individuals. All programs involving large-scale drug distribution increased their activities in 2014, bringing the global coverage rate to just over 50% for the first time. Treatment of LF made the biggest leap, from 40.2% to 50.7% coverage in a single year. Not only are programs reaching more people, they are also reaching program goals.
The number of people who needed treatment decreased by 230 million between 2012 and 2014, largely because the criteria for stopping mass drug administration for trachoma and LF were met.
1.1 billion treatments were delivered in 2014, reaching 858 million individuals
The number of people who needed treatment decreased by 230 million between 2012 and 2014, largely because the criteria for stopping mass drug administration for trachoma and LF were met.
18 of 73 countries endemic for LF and 8 of 58 countries endemic for trachoma have stopped mass drug administration (MDA) and are under post-MDA surveillance; an additional 22 countries are on track to achieve elimination of LF as a public health problem by 2020. Four of six endemic countries in the Americas have met the 2015 target of elimination of onchocerciasis, the disease remaining only in hard-to-reach Yanomami communities on the border between Brazil and Venezuela. The program in Africa is the only program to successfully achieve its coverage target.
Progress in intensive disease management
Great progress is also being made for diseases that require case management. The numbers of cases of sleeping sickness and visceral leishmaniasis continue to fall as the programs pursue the remaining cases, and the prevalence of Guinea worm disease is at a historic low.
- Fewer than 3000 new cases of human African trypanosomiasis occurred in 2015 – the lowest number recorded in 70 years; the approach to the disease moved from control to elimination as a public health problem in 2012.
- An average reduction of 75% in the number of cases of visceral leishmaniasis was seen in Bangladesh, India and Nepal, down to 10,209 cases, the lowest number of recorded cases since the target of elimination as a public health problem was launched. In Africa, much lower incidence has been reported, as no major outbreaks have occurred.
- The prevalence of Guinea worm disease is at a historic low of 22 cases in 2015, bringing us closer than ever to the first successful eradication of a parasitic disease.
PRIORITIES FOR PROGRESS
The global NTD community continues to make impressive progress towards the Roadmap goals; however, with more ambitious milestones, we have to accelerate to stay on track. At the same time, we have learned from the challenges that have arisen and developed tools to better target programs to reach the unreached. We are committed to ambitious goals for achieving the vision of the NTD Roadmap, and the drug donation program alone will not solve the problem: the coverage and reach of programs must increase for all the diseases.
Scale up work in the countries with the greatest burden
Close the treatment coverage gap
The impressive reach of the NTD program is inspiring and has extended steadily since 2012. 2014 saw acceleration and raised the slope of the line above what it was in 2013.
However, to achieve the global goals, we will need to adjust the trajectory and accelerate progress.
To meet the 2020 targets, 75% coverage would have had to be reached by the end of 2015. Although data for 2015 are not yet fully available, this target is unlikely to have been met. As a community, we must identify the key barriers to progress and find solutions. We must address issues such as domestic resources, widening the donor base, greater efficiency as well as new approaches where they are needed.
As we look toward the fifth anniversary of the London Declaration, we remain committed to scaling up programs to ensure no one is left behind. To do that, our partnership will have to grow, to bring in new innovations, new partners, and new resources.
Shrinking the NTD map
With more than 1 billion people targeted by mass drug administration (MDA) to eliminate NTDs, programs in endemic countries are faced with practical difficulties in getting the work done. Challenges associated with the vast scope of the efforts include knowing when to start or stop MDA, whom to test and treat, and how to measure program success.
On average, one person was examined every 40 seconds during the three-year period of the GTMP project
Whom to treat?
NTD programs are finding new ways to reach the unreached. Thorough disease mapping systems are helping to determine accurately who is at risk for these diseases, who is not, and where they live. Without accurate mapping data, it is difficult to target interventions. Two key mapping initiatives are providing critical data for reaching the communities that require treatment and for achieving the NTD roadmap goals: the Global Trachoma Mapping Project (GTMP) and the WHO Regional Office for Africa project ‘Shrinking the Map on NTDs in Africa‘.
The Global Trachoma Mapping Project
The ground-breaking, three-year GTMP, which is funded in large part by the United Kingdom Government (DFID) with additional funding from the US Government (USAID), pioneered the use of mobile technology for NTD data collection on a large scale.
The GTMP ended in December 2015, having mapped a total of 1627 districts. More than 2.6 million people were examined in each of 29 countries (16 in sub-Saharan Africa, 3 in the Middle East and North Africa, 8 in Asia and the Pacific, and 2 in the Americas), representing a total of 224 million people. Over 60 million data items were processed. On average, one person was examined every 40 seconds during the three-year period. A key to the success of this program was use of the same standardized method and system in 95% (1546) districts in the 29 countries.
The GTMP team worked with ministries of health and non-governmental development organizations to prepare sampling protocols and provided training materials and expert advice for workshops. Additionally, the team processed and cleaned data and provided technical oversight (supported by WHO) and troubleshooting support during the mapping. All GTMP data are owned by ministries of health, and already available to support programmatic decision making.
GTMP has identified that 100 million people are at risk from trachoma blindness, doubling the population already known to require interventions against trachoma, with the global at-risk population now totalling 200 million people. Approximately half of the people at risk live in Ethiopia, which has one of the highest prevalence rates of the disease in the world.
Although the GTMP has now ended, the system lives on and will continue to be a platform for baseline mapping, impact surveys, and surveillance surveys until a new system, “Tropical Data”, is up and running – in 2016. The new system has already supported trachoma prevalence surveys in the Democratic Republic of the Congo, Guinea, and Zambia.
Shrinking the Map on NTDs in Africa
The NTD mapping project of the WHO Regional Office for Africa is the largest project in Africa for assessing the prevalence of NTDs that can be treated by preventive chemotherapy. Between the GTMP and the NTD mapping project, a complete picture of need for preventive chemotherapy will be available by the end of 2016.
One of the innovations of the Regional Office for Africa was use of new, highly sensitive diagnostic tools that can detect low levels of infection. Over 1.2 million diagnostic kits were supplied to countries for mapping; these tools require minimal training and limited resources, overcoming major challenges in the Region.
Remarkable progress has been made toward achieving zero unmapped NTDs in the WHO African Region. Mapping has been completed in 41 (87%) countries for LF, schistosomiasis, and soil-transmitted helminths and is on track to completion in the remaining 6 (13%) countries in 2016. Since the start of the project, 3267 surveys have been conducted in 29 countries for LF, schistosomiasis, soil-transmitted helminths and onchocerciasis. As of December 2015, 531 surveys remained to be conducted for LF, schistosomiasis and soil-transmitted helminths.
The progress made since the start of the project translates into a more than a 90% reduction in the number of countries with mapping gaps for LF, an 80% reduction for schistosomiasis and soil-transmitted helminths and an about 50% reduction for onchocerciasis.
Currently, the WHO Regional Office for Africa is developing a robust NTD mapping database and portal, to be rolled out in 2016. The mapping portal will provide access to mapping survey results through an interactive platform, allowing national programs and other stakeholders to access high-quality data for improved program decision-making and NTD interventions.
The huge amount of data collected with the new diagnostics and future collaboration will allow refinement of these tools to make them more useful for surveillance and provide guidance to program managers on scaling up MDA and changing program policy and strategies.
Status before and after initiation of the WHO AFRO NTD MAPPING PROJECT
Completed mapping 17 Mapping gap 30
*Targeted NTDs refer to Lymphatic Filariasis, Schistosomiasis and Soil-Transmitted Helminths
Completed mapping 41 Ongoing mapping 2 Preparing to start mapping 4
January 30, 2016
*Targeted NTDs refer to Lymphatic Filariasis, Schistosomiasis and Soil-Transmitted Helminths
Ensuring elimination with targeted tools
Refined diagnostic tests and techniques allow programs to achieve success. Diagnostic testing for lymphatic filariasis (LF) is now more sensitive and cost-efficient, thanks to a partnership among academic, philanthropic, pharmaceutical, governmental, and nongovernmental organizations.
Using new tools, the NTD team of the Ministry of Health in Tanzania determined that the population requiring MDA had decreased by 19 million people, representing potential savings of millions of dollars in donated drugs and program costs
Accurate testing is especially important as programs in endemic countries navigate the stages recommended by the Global Program to Eliminate Lymphatic Filariasis: starting mass drug administration (MDA); stopping MDA; and surveillance to ensure that transmission has been interrupted.
The current diagnostic test presented issues of cost, shelf life, and reliability. With the development of a new diagnostic test, programs can now detect parasite antigens for LF in the blood with greater confidence and at lower cost. The filariasis test strip was endorsed in 2015 by WHO’s Scientific and Technical Advisory Group for use in national programs. Training materials to support its use have been made available to country programs in English, French, Portuguese, and Bahasa.
Although operational research has also led to improvements in mapping, uncertain results are sometimes obtained, indicating that new tools are required to delineate disease transmission. In response, a ‘confirmation mapping’ strategy has shown promising results in reducing the cost, time, drug supply, and human resources associated with starting MDA. The new survey strategy indicated that fewer people than initially expected required treatment in Bangladesh, the Democratic Republic of the Congo, Ethiopia, Eritrea and the United Republic of Tanzania.1
In the last country, for example, the NTD team of the Ministry of Health determined that the population requiring MDA had decreased by 19 million people, representing potential savings of millions of dollars in drug and program costs.
These developments are some of many operational research advances, which demonstrate the power of a coordinated response among partners to address issues in country programs. With the right tools, endemic countries are empowered to conduct their programs accurately and efficiently as they progress towards their goals for NTD elimination.
- Weekly Epidemiological Record 2015;80:489–504. Geneva: World Health Organization; 2015 (http://www.who.int/wer/2015/wer9038/en/ accessed 21 April 2016).
Against all odds, South Sudan is on the verge of eliminating Guinea worm disease
A case study in reaching the unreached from the National Program Manager in South Sudan, Dr Makoy Yibi logora
Population Density: Average of only 13 people per square kilometer
South Sudan, the newest country in the world after more than 20 years of conflict, is a land-locked country that borders Ethiopia to the east, Kenya to the south east, Uganda to the south, the Democratic Republic of the Congo to the south west, the Central African Republic to the west, and Sudan to the north. Although South Sudan is roughly the size of Texas and twice the size of the United Kingdom, it is one of the least densely populated countries in sub-Saharan Africa, with an average of only 13 people per square kilometer. Across this vast territory, public health programs and services struggle to reach rural communities that remain isolated due to a largely unpaved network of seasonally impassable roads.
Against this backdrop, it is all the more remarkable that the Ministry of Health of South Sudan appears to be on the verge of winning a public health battle against Guinea worm disease. Soon, it will join other countries that have been certified as Guinea worm-free. Once all the endemic countries have been declared free of this disease, it will become only the second human disease in history, after smallpox, to be eradicated. It will be the first parasitic disease to be eradicated and the first disease to be eradicated without the use of a vaccine or medicine.
A horrible, painful, disabling disease
Guinea worm disease, or dracunculiasis, is an incapacitating parasitic disease transmitted by water contaminated with water fleas that harbor Guinea worm larvae. It thrives in poor areas where there is little sanitation and people drink and bathe in stagnant water. These areas are typically extremely remote, with little infrastructure, low literacy and little education about disease and transmission.
When people swallow contaminated water, their stomach acids successfully digest the water flea but have no effect on the Guinea worm larvae, which find their way to the small intestine, where they penetrate the intestinal wall and pass into the body. During the next 10–14 months, the female worms grow to 60–100 cm in length and migrate to the site at which they finally emerge, usually the lower limbs. To emerge, the Guinea worm causes a lesion on the skin. The lesion begins with the formation of a blister, which causes a very painful burning sensation, and then ruptures within 24–72 hours. Once a worm has started to emerge, it must be carefully and completely removed over a period of weeks. Often, the wound develops a secondary infection, which increases the time an infected person needs to resume normal activities. Failure to properly remove the worm can result in additional bacterial infection, septicemia, and permanent disability.
There is no cure for, or vaccine against, Guinea worm disease. The only way to reduce the burden of the disease is to treat infected people and prevent its transmission to others.
Since 2006, South Sudan has been conducting a Guinea worm eradication program, which has had tremendous success. In 2006, 20,581 cases of the disease were reported in 35 endemic counties and districts, whereas in 2015 only five cases were reported in five villages in only four states. This achievement represents a cumulative decrease in the number of cases of 99.98%.
In 2015 only five cases were reported in five villages in only four states compared to 20,581 cases in 35 states at the start of the program in 2006
The strategy is centered on creating a community-based surveillance system to detect all Guinea worm cases in endemic and high-risk areas in South Sudan and establishing an effective intervention system to break the transmission cycle. This is no mean feat for a country double the size of the United Kingdom, with significantly less infrastructure. Many of the areas in which people suffer from Guinea worm disease are accessible only by foot.
How is the strategy feasible, and what exactly does ‘prevention‘ mean? The answers are beautifully simple and extremely cost-effective. This flagship demonstration of fighting NTDs has been described as “one of the best buys in public health”.
The core of the strategy consists of a community-based surveillance system; providing interventions via village volunteers nominated by their communities and taught to diagnose and report Guinea worm disease. This surveillance system creates a network of people who can monitor, treat, or refer infected people to case containment centers, designed by the program to treat the disease. A well-promoted cash reward, provided by The Carter Centre, the lead agency working with the Ministry of Health to break transmission of the disease and prepare the program for certification, provides an added incentive for local villagers to look out for symptoms of the disease, monitor areas where people are infected, and report any rumors to the program.
The success and capacity of the program would not have been possible without strong partnerships and collaboration. These partnerships help to provide training to village volunteers, to raise awareness about health-seeking behavior, and cash incentives via teachers, health workers, and the Red Cross in South Sudan.
The benefits of this approach are not only the huge success it has had in reducing Guinea worm disease in South Sudan but also strengthening of regional and local health systems. By mobilizing partners and investing in strengthening local capacity to diagnose, treat, and monitor diseases, projects such as this show that eliminating NTDs within our lifetime is possible.
By mobilizing partners and investing in strengthening local capacity to diagnose, treat, and monitor diseases, projects such as this show that eliminating NTDs within our lifetime is possible
About the scorecard
The Scorecard was created after the London Declaration on NTDs in January 2012, with indicators and milestones compiled from WHO and partners, in order to follow progress towards the WHO Roadmap goals.
Some new annual milestones had to be established by WHO or partners. Each year, the Stakeholders Working Group reviews progress toward multiple indicators on the basis of the most recent data and gives a score to indicate the degree of progress made towards achieving the WHO goal: green, on track; yellow, off track, but, with some catch up, should get back in line; and red, off track and will not achieve the goals without significant intervention. The colors do not represent a judgment of the program but rather a call to action, indicating where additional attention is required to reach the goals.
The colors do not represent a judgment of the program but rather a call to action, indicating where additional attention is required to reach the goals
In this fourth Scorecard, the Stakeholders Working Group, while acknowledging that good progress is being made and the trajectory is improving, noted that specific goals for several diseases had not been met. With 2020 fast approaching (only a short four years away), this Scorecard reflects the need for significant intervention: three diseases have moved from yellow to red; two diseases have moved from green to yellow; and five diseases have retained the same score. Significant additional resources will be required to ensure that scaling up continues.
We look forward to tackling the challenge, to working together on our ambitious journey toward the 2020 goals and to finding solutions to some of the implementation challenges faced by national programs.
- Achieved or minor delay; or 90–100 percent of requested treatments shipped
- Delayed but achievement anticipated; or 80–89 percent of requested treatments shipped
- Delayed, additional action required; or 0–79 percent of requested treatments shipped
- Global milestones in development
- Not applicable
Scorecard progress by disease
Lymphatic filariasis (LF) is a mosquito-transmitted disease caused by parasitic worms that damage the human lymph system. It can cause severe and sometimes very extensive swelling of the lower limbs (lymphedema), which can be accompanied by painful episodes of fever. People with lymphedema are prone to bacterial infections that can lead to a mobility-limiting condition where the skin thickens and hardens (elephantiasis). In men, LF can also result in swelling of the scrotum (hydrocele). LF afflicts the poorest communities, preventing affected individuals from living a productive working and social life, further trapping them in the cycle of poverty.
Treatment coverage for LF showed the greatest increase of all diseases treated by MDA in 2014 (40.7% to 50.2%) and reached the largest number of people globally. Some LF programs are scaling down as they achieve elimination targets. The global mapping project and use of a more sensitive and specific diagnostic tool have reduced the estimated number of individuals who require treatment. The results of research on the efficacy of triple drug therapy could shorten the treatment period for endemic communities. Even with strong program support, guidance from the Global Alliance for the Elimination of LF, and the LF non-governmental development organization group, program coverage and global resource parity have still not been achieved. Drug supply and research in this area are both showing progress; however, this area was scored yellow, as the scale up is not sufficient and the 2015 target of full geographic coverage will not be met. New indicators and milestones are anticipated that will better track progress, including scaling up and indicators for scaling down.
Onchocerciasis (or river blindness) is a disease caused by infection with a parasitic worm transmitted by blackflies, which breed in fast-flowing streams and rivers. Adult worms produce larvae (microfilariae) that migrate to the skin, eyes, and other organs, and can cause debilitating itching, disfiguring skin conditions, and visual loss (including irreversible blindness) over time. Onchocerciasis can therefore impact enormously on the lives of those infected, reducing their ability to work and learn.
The onchocerciasis program has had the highest coverage of all preventive chemotherapy diseases. In 2009, the global target for onchocerciasis moved from control to elimination, increasing the denominator for treatment and resulting in a slight decrease in coverage. Re-mapping according to new criteria may result in additional increases, which will reduce coverage further and increase the length of treatment required for elimination. The shift from control to elimination will also require revision of the global milestones and annual targets.
WHO has prepared guidelines for safely stopping MDA and verifying elimination, and these should be disseminated and implemented by countries. The Roadmap targets for 2015 were elimination in the Americas and Yemen, which were not met. Although there has been great progress in the Americas, access to the Yanomami people in Brazil and Venezuela remains a challenge. Security issues in Yemen have delayed progress towards elimination goals. The closure of the African Program for Onchocerciasis Control is a concern, as the Expanded Special Programme for Elimination of NTDs in Africa (ESPEN) is yet to be launched; this will help coordination of program activities for maintaining and scaling up in new areas in which treatment is required. The drug supply is fully meeting demand; however, countries should scale up more quickly to meet the elimination targets, and the research agenda should be realigned to the elimination target. Because of the missed targets in 2015 and the program transition in Africa, this area is scored red. It is anticipated that the new Expanded Special Program will help establish new milestones to track progress and ensure that the program is a success.
Schistosomiasis (snail fever or bilharzia) is an infectious tropical illness that people can develop when they come into contact with fresh water contaminated by certain snails carrying the disease-causing parasites, which penetrate the skin and migrate through the body. Infection primarily affects the urinary or intestinal system, causing chronic ill health and in some cases death. Poor hygiene and water-based activities (such as swimming and fishing) make school-age children the most vulnerable, with infection responsible for malnutrition, absenteeism, and impaired intellectual development. Children suffering from persistent and severe schistosomiasis infections are also likely to have chronic irreversible diseases later in life, such as scarring (fibrosis) of the liver, bladder cancer, or kidney failure.
There has been great progress in the past year in controlling schistosomiasis, with community organization, a commitment to creating new indicators, more countries implementing preventive chemotherapy, drug donations that have reached the 2015 target of 100 million tablets, and mapping almost completed. Overall, however, schistosomiasis has been scored red for several reasons. Although coverage and impact have increased in countries implementing preventive chemotherapy, coverage for schistosomiasis remains among the lowest globally for preventive chemotherapy diseases. The 2015 elimination goals were not met in any setting, and no guidelines are available to confirm whether elimination was achieved. While the scaling up of drug donations pledged by Merck is on track and reached the 2015 target of 100 million tablets, the requirement for drugs for achieving the NTD Roadmap targets exceeds the pledges. In order to achieve elimination goals, research should be conducted to determine how to stop MDA and to measure elimination. More support will be needed for implementation of schistosomiasis programs in new countries.
Soil Transmitted Helminths
Soil-transmitted helminthiasis (STH, or intestinal worms) is caused by a group of intestinal parasites that thrive in places where the soil is warm and humid, and sanitation is poor. The most common STH-causing parasites are roundworm, whipworm, and hookworm. People become infected after they come in contact with soil contaminated with the parasites’ eggs. STH reduces the body’s ability to absorb nutrients and vitamins, which exacerbates malnutrition, and leads to anemia, increased susceptibility to other infectious diseases, stunted growth, and impaired intellectual development. Symptoms of STH become more evident as the worm load in an infected person increases. STH is a poverty-related disease, linked to broader community development challenges, which severely limits the ability of those infected to live full and productive lives.
Coverage of communities endemic for soil-transmitted helminths is on track to achieve the 2020 goal of 75% coverage. All 10 countries identified by WHO as having a high burden of soil-transmitted helminths have started deworming programs, however not all currently cover school-aged children. The community has provided strong milestones and indicators to follow progress in countries. The drug donations continue to increase, and donors are prepared for further scaling up. Research is planned to find more ambitious goals for the impact of programs and to develop and monitor alternative treatment strategies if resistance is found. The soil-transmitted helminths program still relies heavily on LF programs to achieve its coverage. There is some concern that, with the success of the LF program in reaching elimination and scaling down treatment, coverage for soil-transmitted helminths will decrease. The stakeholders working group recommends that an indicator of the percentage of individuals who are treated for soil-transmitted helminths be measured as part of LF programs, and an indicator of the percentage of evaluation units, including soil-transmitted helminths, be included in transmission assessment surveys.
Trachoma is a disease caused by a contagious bacterial infection of the eye commonly spread through contact with contaminated hands or items such as clothing, and by flies coming into contact with a person’s eyes or nose. Trachoma often begins in early childhood, progressing over the years as episodes of reinfection cause inflammation and scarring of the inner eyelid. In some people, repeated infection damages the eyelids (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, a series 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 prevents individuals from being able to work or care for themselves or their families.
The GTMP ended in December 2015 in all accessible districts, and the new global estimate of the number of people requiring treatment is anticipated to be substantially lower than the number of confirmed and suspected cases in 2011. Knowledge of where the disease is will help to target treatment interventions and attract resources where support is urgently needed. While the number of treatments shipped has increased significantly in response to requests from endemic countries, drug supply scored yellow, as an isolated production issue delayed supply of Zithromax® to the field. Pfizer and trachoma partners worked together to revise and prioritize drug supply in 2015 to keep the global program on track while supply recovered, providing an impressive example of global collaboration. Global coverage was not affected but did not increase. There is concern that resources will not be found to cover the increased distribution needs for implementation of the ‘F’ (facial cleanliness) and ‘E’ (environmental improvement) elements of the strategy. This area scored yellow because of the low coverage, which is still lagging among preventive chemotherapy diseases. In spite of the strong trachoma partnership and collaboration and the newly available mapping data, elimination goals will not be achieved if additional financial resources are not mobilized to support scaling up of the SAFE strategy in areas that require public health interventions.
Chagas disease is a parasitic infection often caused by contact with the feces of infected blood-sucking insects (called “kissing bugs”) which infest people’s homes. It is also known for the illness to be passed on by eating food contaminated by the insects, through blood transfusions or organ transplants, or to children at birth. After an often mild acute phase of a few weeks, with non-specific symptoms such as fever, body aches, rash, diarrhea, and vomiting, most people will go for a long time without showing any signs of the disease, and in many instances will be unaware they have the illness. An estimated 30-40% of infected people will eventually develop serious complications, including heart disease and enlargement of the colon and/or esophagus, which can incapacitate and quite frequently result in death.
Drug supply requests are fulfilled, although it is unclear how much of the treatment requirement is met by the donation. Areas other than drug supply scored red because of insufficient indicators and data available to the stakeholders working group to assess progress; the timing of consolidation of the 2015 data did not coincide with the scoring meeting. In the absence of these data, it was not possible to determine whether progress had been made in meeting the inter-domiciliary 2020 goal or whether any of the endemic countries met the 2015 goal of stopping transfusional transmission of Chagas disease. Participation by Chagas community members is needed to ensure that appropriate targets for program support are agreed and that data are available to follow progress.
Guinea Worm Disease
Guinea worm disease (GWD, or dracunculiasis) is an incapacitating parasitic illness caught 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 grow to meter-long worms, which then begin to emerge from the skin through intensely painful blisters, usually on the legs or feet, accompanied by fever, nausea and vomiting. Once a worm 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 infected person to resume normal activities. Failure to remove the worm can result in additional bacterial infection, as well as infection of the whole body (septicemia) and permanent disability.
The global Guinea worm eradication program showed extraordinary progress in 2015. The number of human cases was reduced by 83% (22 vs 126 in 2014), and the number of villages reporting human cases dropped by 63% (20 vs 54). Of particular note is the progress in South Sudan. Ghana is the latest formerly endemic country to be certified Guinea worm-free. Despite evidence of progress, the global program appears to have missed its 2015 target of eliminating Guinea worm disease in Chad, Ethiopia and Mali, and certification for Kenya has been delayed. Endemic countries still struggle to achieve 100% containment of cases, and the number of Guinea worm infections in dogs continued to increase. Insecurity threatens the success of the program and the ability of countries to achieve certification. Although our knowledge about the dynamics of infection in Chad is increasing, the best interventions for decreasing transmission in humans are still not clear. Research should be strengthened to guide the program to the end game. As the 2015 goals have not been achieved, new program targets should be set to follow progress toward eradication. With only 22 cases remaining, it is time to rally for success.
Human African Trypanosomiasis
Human African trypanosomiasis (HAT, or sleeping sickness) is caused by infection with parasites transmitted to humans through the bites of infected tsetse flies. The disease manifests in two forms: chronic infection with Trypanosoma brucei gambiense (g-HAT) progressing over several years, and acute infection with Trypanosoma brucei rhodesiense (r-HAT) progressing over weeks or months. In the first stage the parasites multiply in the body causing fever, headaches, joint pain, and itching. In the second stage, the parasites invade the central nervous system and brain, leading to behavioral changes, confusion, poor coordination, and sensory as well as sleep disturbances (giving the name sleeping sickness). Without diagnosis and treatment, HAT is nearly universally fatal in humans.
The number of cases of human African trypanosomiasis continued to decrease, with fewer than 3000 reported in 2015, which indicates good progress. As noted last year, better indicators would help to chart progress. For example, inclusion of the ‘number of persons screened annually’, which is already collected by WHO, was not available at the time of scoring, nor was it included as an indicator on the Scorecard. If these data are included, they will help determine whether the decrease in the number of new cases is due to less disease or less screening. We are pleased to note the existence of a multi-stakeholder group for human African trypanosomiasis, which, we hope, will play a key role in defining program support milestones. Progress is being made in research, with new tools available and new treatments in late stages of development. Drug supply remains green with the close involvement of Sanofi and Bayer. Improved program targets and milestones will help in measuring progress and support a clearly defined plan for advocating new elimination targets.
Leprosy (or Hansen’s disease) is a chronic infectious disease caused by bacteria mainly spread through droplets from the nose and mouth of persons suffering from untreated leprosy (produced, for instance, when they sneeze or cough). The disease, which can have a long incubation period, causes disfiguring lesions on the skin and nerve damage. The first stage of leprosy leads to loss of sensation and muscle weakness in facial muscles, hands and feet (Grade 1 disability). If the disease is not detected and treated, it progresses to a second stage that causes observable and permanent impairments, such as loss and/or shortening of fingers or toes, and vision loss (Grade 2 disability). Leprosy is most common in areas of poverty, where overcrowding and poor nutrition make people more vulnerable to infection, and where it continues to be a major source of disability and social exclusion for persons affected and their families. The consequences of leprosy often persist beyond completion of treatment.
The leprosy community has defined a long list of indicators for following program progress and the uptake of new interventions. This is impressive work and a sign of the strong support of the non-governmental development organization community to leprosy programs and patients. A prioritized list of indicators for use at global level would be useful for following progress and identifying which indicators are critical for success. Reporting on progress in the 25 endemic countries improved over that of last year (20 vs 10 in 2014). All the reporting countries noted an increase in completed screening for disabilities. Program support is scored yellow, as country reporting remains incomplete and key targets have not been met, although progress is seen. More leadership from WHO would improve the global milestones and data.
Visceral leishmaniasis (VL, or kala-azar) caused by infection with leishmania parasites through bites of infected sandflies that breed in and around homes or farms. If VL progresses, it attacks the immune system and affects the bone marrow and internal organs (including enlargement and impaired function of the spleen and liver), as well as causing irregular bouts of fever, substantial weight loss, and anemia. Left untreated, VL can have a fatality rate as high as 100% within 2 years. The disease is linked to poverty and environmental changes.
In 2015, WHO reported a significant reduction in cases and case fatality, a trend that has been maintained since 2011. The revised monitoring indicators show that Nepal has already achieved the elimination target in all endemic districts and maintained it for the past three years, Bangladesh and India are on track to meet the 2020 elimination targets. The introduction of rapid diagnostic tests and subsequent scale up of diagnostic and treatment centres in all endemic areas in Asia have contributed to increasing the diagnosis and treatment coverage. Drug donations of AmBisome have been fully met for 2015, and this area remains green. The percentage of patients treated with AmBisome in Asia in 2015 increased to 84% – a significant leap from the 10% AmBisome treatment in 2010 and 28% in 2012. The duration of treatment has been reduced from 28 days to 1 day, resulting in significant economic gain to both patients and the health sector. Research is under way to fill gaps in knowledge about prevention in East Africa, treatment of concomitant HIV infection and visceral leishmaniasis, drug resistance and efficacy, and improved rapid diagnostic tests for the disease in East Africa and Latin America. Tools for large-scale implementation of vector control in Africa are lacking, and research for innovative tools and approaches is under way. The visceral leishmaniasis partners meet at least twice a year, and the Regional Technical Advisory Group meets once a year to provide the necessary guidance and technical support to programmes.
Coming up in 2016-2017
Women Deliver 4th Global Conference
16–19 May 2016, Copenhagen, Denmark
Launch of the Expanded Special Program for Elimination of Neglected Tropical Diseases in Africa (ESPEN)
23 May 2016, Palais de Nations, Geneva, Sixty-ninth World Health Assembly
42nd G7 Summit
26–27 May 2016, Ise-Shima, Japan
Royal Society for Tropical Medicine and Hygiene Biennial Meeting
12–15 September 2016, Corn Exchange, Cambridge, United Kingdom
NTD NGDO Network Annual Meeting
29 September – 2 October 2016, Washington DC, USA
USAID’s Celebration of the 10th Anniversary of the NTD program
30 September 2016, The Newseum, Washington DC, USA
World Health Summit
9–11 October 2016, Berlin, Germany
Global Alliance for the Elimination of LF and STH Coalition Meetings
19–20 October 2016, Brazil
Meeting of the Coalition for Operational Research on NTDs
10–11 November 2016, Atlanta, Georgia, USA
American Society for Tropical Medicine and Hygiene, 65th Meeting
13–17 November 2016, Atlanta, Georgia, USA
Launch of WHO’s fourth report on progress on Neglected Tropical Diseases
NTDs Summit: Uniting to Combat NTDs in Collaboration with WHO
Celebration of the fifth anniversary of the London Declaration and partners’ meeting, 2017 (date coming soon)
GSK/Marcus Perkins, Benoît Marquet/DNDi, Adriane Ohanesian/Sightsavers, L.Gubb/The Carter Centre, Kate Holt/Sightsavers, Dr Adrian Hopkins, MBE, WHO, The Fred Hollows Foundation/Antonio Fiorente, Programe Nacional de Chagas de Bolivia, DNDi/Simon Tshiamala, Netherlands Leprosy Relief and Bill & Melinda Gates Foundation/Prashant Panjiar.