AFR/RC59/10 15 June 2009
REGIONAL COMMITTEE FOR AFRICA Fifty-ninth session Kigali, Republic of Rwanda, 31 August–4 September 2009 Provisional agenda item 8.8
ORIGINAL: ENGLISH
TACKLING NEGLECTED TROPICAL DISEASES IN THE AFRICAN REGION
CONTENTS Paragraphs BACKGROUND ............................................................................................................................... 1–6 ISSUES AND CHALLENGES ....................................................................................................... 7–15 ACTIONS PROPOSED................................................................................................................. 16–26
AFR/RC59/10 Page 1
BACKGROUND 1. Neglected Tropical Diseases (NTDs) are a group of infectious diseases that are endemic in a number of developing countries including countries in the African Region. They are usually associated with heat and humidity in tropical settings as well as poverty and illiteracy. NTDs affect, almost exclusively, poor and powerless people living in the rural parts of low-income countries, and are given little attention, hence the term “neglected”. Most of them are vector-borne, transmitted by mosquitoes, black flies, sand flies, tsetse flies and snails. A few are transmitted through contaminated waters and soils.1 2. NTDs can be bacterial or parasitic. In the African Region, NTDs most frequently found are Guinea worm disease (targeted for eradication), leprosy, lymphatic filariasis, onchocerciasis, human African trypanosomiasis (targeted for elimination), schistosomiasis, soil-transmitted helminthiasis, Buruli ulcer, yaws and other endemic treponematosis, leishmaniasis, and trachoma (targeted for control). 3. The neglected tropical diseases affect an estimated one billion people in the world. Up to 90% of the total disease burden is believed to occur in Africa.2 Some people are even affected by more than one NTD (Figure 1). The NTDs cause blindness, disfigurement and disability and account for an estimated 534 000 global deaths annually. They help perpetuate the cycle of poverty and cause stigma in communities. It is estimated that human African trypanosomiasis alone resulted in the loss of 1.54 million disability-adjusted life years (DALYs) across Africa in 2002.
1
2
http://www.who.int/neglected_diseases/WHO_HTD_2008.1_OK.pdf integrated control of the NTD, A neglected opportunity ripe for action, Geneva, World Health Organization, May 2008. Neglected Diseases: A human rights analysis, WHO, TDR/SDR/SEB/ST/07.2, 2007, Geneva; and The World Health Report 2003. Shaping the future. Geneva, World Health Organization, 2003.
AFR/RC59/10 Page 2
Figure 1: Co-endemicity of Lymphatic Filariasis, Onchocerciasis, Schistozomiasis, Soiltransmitted Helminthiasis and Trachoma in the African Region according to 2007 country reports
4. The World Health Assembly and the Regional Committee have passed resolutions3 calling for the global control of NTDs. In 2006, WHO and partners launched a strategy for preventive chemotherapy, focusing on coordinated use of medicines in programmes for the elimination of lymphatic filariasis and the control of onchocerciasis, schistosomiasis, and soil-transmitted helminthiasis. Member States are at various stages of implementing the strategy. 3
WHA39.21 Guinea worm disease eradication (1986); WHA.50.29 Elimination of Lymphatic filariasis as a public health problem (1997); Resolution AFR/RC57/R3, Onchocerciasis control in the WHO African Region: current situation and way forward. In: Fifty-seventh session of the WHO Regional Committee for Africa, Brazzaville, Republic of Congo, 27–31 August 2007, Final Report. Brazzaville, World Health Organization, Regional Office for Africa, 2007 (AFR/RC57/19), pp 11–12; WHA54.19 Schistosomiasis and soil-transmitted helminth infections (2001); WHA57.1 Surveillance and control of Mycobacterium ulcerans disease (Buruli ulcer) (2004); WHA60.13 Control of Leishmaniasis (2007); WHA44.9 Adoption of Multidrug Therapy for Elimination of Leprosy as a Public Health Problem (1991); AFR/RC55/R3 Control of Human African trypanosomiasis: A strategy for the African Region (2005).
AFR/RC59/10 Page 3
5. The prevalence of lymphatic filariasis has been reduced in some countries,4 thanks to regular provision of preventive chemotherapy for more than 53 million people through the communitydirected treatment strategy. In addition, other NTD programmes have achieved remarkable successes. The prevalence of Guinea worm disease decreased to only 3770 cases in 2007 compared to 3.5 million in 1985, leprosy has been eliminated at national level in all the 46 Member States as of 2007 and a 69% reduction in reported new cases of one form of human African trypanosomiasis, T.b. gambiense, has been achieved but only in a few of the 35 endemic countries,5,6 meaning that the reduction is limited to only a small proportion of the actual total population at risk. 6. Despite the progress made, effort must be intensified in order to attain the elimination and eradication of the targeted NTDs in the Region. This paper highlights key issues and challenges and proposes actions to be undertaken by Member States. ISSUES AND CHALLENGES 7. Health systems in most countries in the African Region do not facilitate adequate and equitable delivery of essential interventions to populations in greatest need. In remote areas where NTDs are prevalent, health workers are lacking and/or are not well trained, and field supervision visits are not frequent. Poverty levels in Member States, and stigmatization among marginalized groups make NTD control difficult. 8. Existing disease-specific control issues are hampering the integration and coordination of implementation of NTD interventions. Lack of integration of neglected tropical disease programmes into the health system is a major obstacle to sustainability. For example, diagnosis and treatment of sleeping sickness is not fully integrated into services provided at health centres in most countries. Furthermore, the absence of intercountry and cross-border collaboration makes it difficult to implement the various NTD interventions. 9. Although various NTD control strategies and approaches have been adopted by countries with resultant progress in the Region, many countries still bear a high burden of NTDs. The main reason is that the key activities to achieve the objectives of programmes are not being implemented effectively and efficiently in many countries. 10. Projections for the quantities of medicines needed to implement preventive chemotherapy strategies do not always match the actual reality on the ground, resulting in fewer orders for medicines. In addition, there is limited capacity of pharmaceutical companies to produce cheap generic medicines like diethylcarbamizine citrate (DEC) and mebendazole and, as a result, quantities donated by partners are inadequate. For other NTDs like trypanosomiasis and visceral leishmaniasis, lack of safe curative medicines and the high cost of existing ones contribute to ineffective control of these NTDs. 11. National medicines management systems are weak in many countries, resulting (in some cases) in shortages of essential medicines, expiry of medicines before their use and inefficient distribution. Furthermore, there is a huge gap between demand and supply of medicines for NTDs.
4
5 6
Burkina Faso, Ghana, Togo, Comoros, Tanzania including Zanzibar Island. The burden of human African trypanosomiasis. PLoS Neglected Tropical Diseases (2008), 2 (12). Weekly Epidemiological Record, 24 February 2006, 81st Year, No. 8, 2006, 81, 69–80http://www.who.int/wer.
AFR/RC59/10 Page 4
12. The overall regional goals and targets for most NTD programmes have not been achieved. For example, the resolution on lymphatic filariasis elimination was adopted in 1997, yet only 17% of the population at risk is being covered by mass drug administration (MDA) in the African Region as compared to the set minimum effective coverage target of 65%. In the case of schistosomiasis and soil-transmitted helminthiasis morbidity control, less than 10% of school-age children are receiving antihelminthics which is much below the expectation of 75% of school-age children in endemic areas. 13. While the delivery of a number of interventions in NTD programmes is community-based, the involvement of communities in control activities is suboptimal. Communities are not adequately empowered to fully participate in programme implementation. The information, communication and education aspects of neglected tropical disease programmes are not well developed. 14. A sustainable comprehensive package of interventions is needed in order to address aspects such as disease awareness, increasing coverage of curative/preventive chemotherapy, enhancing access to health services that can provide diagnostic facilities, carrying out surveillance, and controlling transmission to achieve good impact in control of other neglected diseases. There is need to ensure a wide coverage of underserved populations at risk of NTDs, such as those living in remote rural areas and urban slums, children not attending schools, and migrant labour. 15. A major challenge is how to develop an appropriate resource mobilization strategy and mobilize financial and other resources for controlling NTDs in the light of the current global financial problems. Despite the commitment demonstrated by Member States to control neglected tropical diseases, financial resources are much inadequate. ACTIONS PROPOSED 16. Strengthen health systems. Member States should strengthen their health systems to give more prominence to NTD interventions at community, subnational and national levels. This should include developing the required human resource capacity at all levels in order to deliver the required interventions, especially to those who need them the most. 17. Strengthen leadership and ownership. Member States should strengthen the leadership and ownership of NTD programmes. NTD diagnosis and treatment should be fully integrated at all levels of the health system. In addition, countries should facilitate the coordination of NTD partners in order to ensure the implementation of key NTD interventions in all countries. Furthermore, countries should work with the regional economic communities in strengthening NTD cross-border collaboration. 18. Streamline and strengthen national systems of management of medicines. Member States should streamline and strengthen national systems of management of medicines including their procurement, stock management, distribution and rational use at all levels. Countries should exploit the full potential of integrated preventive chemotherapy strategy with added opportunities for coimplementation of a number of NTD programmes based on evidence generated in the Region from the use of triple therapy (ivermectin, albendazole and praziquantel) to combat onchocerciasis, soiltransmitted helminthiasis and lymphatic filariasis.
AFR/RC59/10 Page 5
19. Reinforce supportive activities. Member States should reinforce national NTDs supportive activities for treatment, transmission control and community-based interventions including surveillance and supervision, monitoring at district level, and periodic evaluation at national level in order to reduce the burden of NTDs. 20. Intensify interventions for eradication of Guinea worm disease. Countries endemic for Guinea worm disease should intensify Guinea worm disease eradication interventions including surveillance in order to stop local transmission of the disease in the next two or three years. Eradicating Guinea worm disease in the African Region will contribute to achieving the Millennium Development Goal of sustainable poverty reduction. 21. Reorganize and strengthen surveillance, monitoring and evaluation. Member States should reorganize and strengthen all aspects of NTD surveillance, monitoring, and evaluation. The mapping of neglected tropical diseases should be effected in all countries within two years. NTD data collection and analysis should be fully integrated in the existing national health information systems. 22. Work with partners to scale up operational and clinical research. Member States should work with partners in scaling up operational and clinical research activities aimed at improving the effectiveness and efficiency of NTD case management. The development of new efficacious medicines for Buruli ulcer, human African trypanosomiasis and leishmaniasis should be a priority in this research agenda. 23. Organize joint advocacy visits to countries. Partners should organize joint advocacy visits to countries in order to support the prioritization of NTD interventions as well as the development of appropriate strategies to strengthen existing delivery systems, and the improvement of multi-disease approaches to NTDs control. 24. Develop effective strategies for advocacy. Member States should develop effective advocacy strategies to create awareness of NTDs and enhance efforts for local resource mobilization in order to ensure adequate availability of appropriate medicines. WHO should work with countries in developing regional networks and global alliances to combat NTDs. 25. Reduce poverty and stigma. Member States should continue implementing poverty reduction strategies as part of addressing NTD burden. Furthermore, countries should ensure that NTD-induced stigmatization of marginalized population is addressed through appropriate and effective communication strategies. 26. The Regional Committee is invited to examine and adopt the draft resolution attached along with the proposed actions for tackling NTDs in the African Region.