This presentation was given by Prof Russell Stothard to the Department of Biosciences at Cardiff University on Thursday, 18th Januray 2018.

1. COUNTDOWN on WHO 2020 Targets:
A focus on African schistosomiasis
Russell Stothard
Department of Parasitology
E-mail: russell.stothard@lstmed.ac.uk
Twitter: @StothardRuss & @countdownonntds

3. Background
Background on NTD control landscape
- from 2002 onwards to 2020 & 2030 perspectives
Focus on African schistosomiasis
- issues about surveillance, scale-up & control targets
Introducing COUNTDOWN implementation research
- why are multi-disciplinary approaches needed?

4. NTDs are strongly
associated with
poverty-stricken regions
within LMIC.
Broadly grouped into:
PC e.g. helminths
IDM e.g. protozoans
Control is largely by
partnerships typically
inspired by the London
Declaration in 2012.
WHO approved
strategies.

5. Several NTDs are amenable to preventive chemotherapy
• Preventive chemotherapy (PC) is a rapid
impact ‘health’ package (i.e. tool ready)
• Donated medicines, promoted access, often
with integrated drug administration(s)
• PC typically a ‘vertical-programme’ although
may use ‘horizontal-platforms’ at periphery
2020 challenges – scale-up, performance, impact, demand & sustainability

6. Community
Global
Regional
National
District
Actual treatment coverage (year on year)
homogeneous or heterogeneous respondents?
an important indicator but only a proxy of impact
Preventive chemotherapy becomes the front-line tool

7. 694M
705M
711M
729M
700M
0
10
20
30
40
50
60
70
80
90
100
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020
Target date for full PC scale-up
2020goals
WHO target of 75% coverage across diseases
%
Projected % of people receiving PC for at least one disease
(including LF, ONCH, SCH and STH) out of the total number that require PC
WHO’s scale-up of future PC to reach 2020 targets
Urgent need to
address bottlenecks in
scale-up of PC
and
to accelerate towards
WHO 2020 targets
The development of the NTD scorecard

8. 4th NTD scorecard shows un-even progress across diseases
?

9. 4th NTD scorecard shows un-even progress across diseases
Three reasons why schistosomiasis is placed in the RED?
First
PC is not a complete solution
Second
PC stretches health system performance

10. 4th NTD scorecard shows un-even progress across diseases
Three reasons why schistosomiasis is placed in the RED?
Third
Policies & practices are lagging behind technology, especially at micro-spatial
Infectious Diseases of Poverty

11. 4th NTD scorecard shows un-even progress across diseases
and more widely
the NTD implementation landscape is becoming more
dynamic (parasite/human/vector)
complex (mixed targets)
fragmented (communications)
and
fatigued (donors)

12. Reducing poverty in SSA with implementation science for NTD control
Programme of implementation research to inform the effective and sustainable scaling-
up of integrated Neglected Tropical Disease (NTD) control initiatives
OJEU: 2013/S 181-312697
Open tender: one final application for £8M in the Nov. 2014 - Oct. 2019 period
In 2008, DfID committed £50M for to support control of NTDs
Implementation portfolio including:
Sightsavers (Trachoma)
Schistosomiasis Control Initiative (ICOSA)
Centre for NTDs (LSTM)
UNITED (Nigeria)
….with The Research and Evidence Division supporting

13. COUNTDOWN
• Working in Liberia, Ghana, Nigeria & Cameroon
• Active research uptake/communications & 5 main research themes

14. Background
Background on NTD control landscape
- from 2002 onwards to 2030 perspectives
Focus on schistosomiasis & soil-transmitted helminthiasis
- issues about scale-up and accelerating towards targets
Introducing COUNTDOWN implementation research
- why are multi-disciplinary approaches needed?

15. 2030 Ensure healthy lives & promote well-being for all at all ages
How do NTDs fit in across this agenda?
both pro and con aspects

16. Mass Scale-up Theme 1:
Evidence Synthesis
Mass Scale-up Theme 2:
Applied Social Science
Mass Scale-up Theme 3:
Health Economics
Integrated Complementary Strategy Theme 1:
Macrofilaricides & Vector Control
Integrated Complementary Strategy 2:
Schistosomiasis/STH & Diagnostics
COUNTDOWN activities set across five major themes

17. Theobald (2017) et al.
• NTD interventions need better gender programming, reporting & analysis
But there are several current gaps
in gender & age-related equity
(maternal & child health - SCH)

18. • R F Burton FRGS
(1821-1890)
first cultural anthropologist
& cartographer of Africa
very likely had schistosomiasis
but still had a very colourful life
Multidisciplinary examples

19. Breaking across boundaries
is not easy and requires
• at individual-level
patience & respect
• at group-level
effective communications
but
• is very rewarding
holistic ‘team’ insight
• has broader appeal
pragmatic outcomes

20. Preventive chemotherapy needs intensification
How can NTD treatments
be scaled-up to meet the
demand?
What bottlenecks need to
be opened?

21. www.countdownonntds.wordpress.com
www.countdownonntds.org
@NTDCOUNTDOWN
At the very least you need a solid e-footprint to be visible

22. COUNTDOWN is a multi-country research consortium
COUNTDOWN
…generates research evidence to respond to
priority information needs of NTD policy makers
and program managers
…supports incorporation of evidence to
improve policies and operational plans and
practices for scale-up of NTD control
…strengthens capacity for evidence-based
decision making and planning through learning
by doing amongst its staff, associated partners
and country based research communities
reporting logframe of
impact, outcomes, outputs
meshed within a
theory of change
model and indicators

23. Mass Scale-up Theme 1:
Evidence Synthesis
Mass Scale-up Theme 2:
Applied Social Science
Mass Scale-up Theme 3:
Health Economics
Integrated Complementary Strategy Theme 1:
Macrofilaricides & Vector Control
Integrated Complementary Strategy 2:
Schistosomiasis/STH & Diagnostics
COUNTDOWN activities set across five major themes
‘ access / equity ’ of interventions
(better surveillance systems)

24. Background
Background on NTD control landscape
- from 2002 onwards to 2030 perspectives
Focus on schistosomiasis & soil-transmitted helminthiasis
- issues about scale-up and accelerating towards targets
Introducing COUNTDOWN implementation research
- why are multi-disciplinary approaches needed?

25. Peripatetic nature of tropical medicine studies
Parasitology
PZQ
Peri-urban areas of Ghana
Crater Lakes of Cameroon
exposure contamination
Mapping in Namibia

26. • Background
• Logistics
• Phase I & II
• Distribution
• Outlook
Mapping in Namibia – prior to COUNTDOWN
• Background

27. Background I
• Spatial distribution of schistosomiasis is focal
‘over-dispersion’ of prevalence (variance >> mean)
what ‘mapping data’ are needed for treatment decisions
‘under’ treatment

28. Background II
• What spatial resolution is needed to define the pattern?
sampling by: ecozone, administrative unit or sample ratio
granularity versus resolution
Unclear … clear … perfect?clear enough…
classic parasitology 1 : 20
with RDTs 1 : 4
(NOTE: towards exhaustive sampling)

29. Background II
• What spatial resolution is needed to define the pattern?
sampling by: ecozone, administrative unit or sample ratio
stability versus popularity ?
Unclear … clear … perfect?clear enough…
But political priorities change & so does
B&MGF and USAID priorities

30. Background III
• What spatial resolution is needed to define the pattern?
higher spatial resolution means more: time, money & samples

31. Logistics
• Namibia is in need of a background map for control
Stool & urine microscopy 1 : 20 (SCH & STH
urine RDTs & stool FOB
Phase I & II
Sample frame:
N=17 896 children from 299 schools
at each school 30 5-6 yo & 30 12-15 yo
Urine RDTs 1 : 4 (SCH – CCA & hemastix)
Questionnaire
History treatment
WASH
Symptomology

32. Logistics
• Pre-school children can be infected with schistosomiasis
- can they be monitored within school-based surveys too?
Ansong et al. (2011)
%ageprevalence
Typical age-prevalence relationship
Age and gender
5-6 yo 12-14 yo
%ageprevalence
Map distribution & flag a problem
10%+
Note: sample size per school doubles
this has both pro- and con- implications

33. Phase I & II • Mean SCH prevalence 9.0%
Phase I
Younger Older p-value
S. h. 7.1% 8.0% 0.19
S. m. 10.3% 11.9% 0.05*
Phase II
Younger Older
S. h. 3.4% 4.0% 0.09
S. m. 1.1% 0.9% 0.32
• Unusual age-prevalence
seasonal flooding (snails)

34. Distribution I
• SCH increased towards the East
Aggregating into treatments
WHO prevalence thresholds
0.0%
0.1-10.0%
10.1-50.0%
>50.0%

35. Distribution II
• Better estimate of PZQ needs through time
Aggregating into treatments
WHO prevalence thresholds
0.0%
0.1-10.0%
10.1-50.0%
>50.0%

36. • How much did this cost?
In total $126, 282 USD, roughly $7.06 per child
Outlook I
About 49% of costs were staff time (per diem)
For 1 : 4 resolution with RDTs
$3.59 USD per child
For 1 : 20 with microscopy
$9.55 USD
• Not forgetting the good GPS basemap of schools
• Could be cheaper without 5-6yo sampling?

37. Peripatetic nature of tropical medicine studies
Parasitology
PZQ
Peri-urban areas of Ghana
Crater Lakes of Cameroon
exposure contamination

38. How we should be thinking of WASH and indicators

39. 1) Precision mapping to
better tailor treatment
2) Mapping snail
distribution for control
3) Pinpointing key
water contact sites
Intensification of multisector actions for better impact

40. Research uptake:
targeted activities playing into policy action…
• Indicators of environmental transmission
- WASH factors, e-DNA tracers of NTDs
- PZQ MDA + biannual / expanded access
• Drivers of national policy change
- advocate for increased PZQ supplies
- accelerate towards public health goals
- widen health system engagement (NB academia)

41. Summary from TES meeting

42. 42
Urogenital disease
S. haematobium
MGS/FGS
• Cervical inflammation

43. Connecting HIV/HPV/sub-fertility
(www.fgsworkshop.org)
(FGS)
COUNTDOWN implementation research

44. Systematic review: FGS widespread but under-reported
COUNTDOWN implementation research
Also MGS in Malawi

45. 1. Gendered experiences of living in affected communities have often been
ignored in policies and interventions for schistosomiasis
2. Health workers lacked the capacity to effectively diagnosis and treat
female genital schistosomiasis (lack of awareness)
3. Qualitative studies have given voice to women and explored their broader
environment to assess ways to reduce transmission (revealed stigma)
4. New strategies and interventions are needed that reflect women and girls
lived experiences with this disease (encourage cross-sector dialogue)
5. Key intervention areas include:
bespoke training and educational interventions
gender sensitive WASH interventions
integration into gynaecological screening (HPV/cancers)
COUNTDOWN implementation research
In Ghana

46. COUNTDOWN implementation research

47. Mass Scale-up Theme 1:
Evidence Synthesis
Mass Scale-up Theme 2:
Applied Social Science
Mass Scale-up Theme 3:
Health Economics
Integrated Complementary Strategy Theme 1:
Macrofilaricides & Vector Control
Integrated Complementary Strategy 2:
Schistosomiasis/STH & Diagnostics
COUNTDOWN activities set across five major themes

48. Conclusions (in three Cs)
Communicate (whatever language)
Cross-talk (break down silos)
Collaborate (teams reach targets)

49. Thank you Prof J. Cable & univ. of Cardiff
Key COUNTDOWN ICST-2 UK staff
Suzanne Campbell (LSTM)
Lucas Cunningham
Faye O’Halloran
Deborah Sankey
Tim Durant
Grace Macklin
Lisa O’Halloran
Zikmund Bartoníček
James LaCourse
Martyn Stewart
Emily Adams
Supporting the
COUNTDOWN
consortium
NHM David Rollinson Bonnie Webster
Tilburg Hospital Jaco Verweij
Lieden University Medical Centre Lisette van Leishout, Govert van Dam
Acknowledgements