Buruli Ulcer HIGHLY PRELIMINARY · 06/06/2019 · Buruli Ulcer Overview Buruli ulcer is caused by Mycobacterium ulcerans, a bacteria belonging to the family which causes tuberculosis

Buruli UlcerOverview

▪ Buruli ulcer is caused by Mycobacterium ulcerans, a bacteria belonging to the family which causes tuberculosis and leprosy

▪ The disease causes ulcers (mostly on limbs) which affect the skin and sometimes bone, and can lead to permanent disfigurement and long-term disability.

▪ The mode of transmission is not known and there is no prevention against the disease. BCG vaccination appears to provide limited protection.

▪ The bacteria produces a unique toxin – mycolactone – which causes tissue damage and inhibits the local immune response suppressing pain

Disease and epidemiology

Buruli ulcer is endemic in 33 countries in Africa, Latin America and Western Pacific

Strategic interventions

Vector control N/A

Preventive chemotherapy N/A

Veterinary public health N/A

Other Early diagnosis is essential Morbidity management includes surgery, wound and lymphoedema management,

physiotherapy, and long-term rehabilitation

Case management Combination of antibiotics including rifampicin + clarithromycin and rifampicin +

moxifloxacin used in Australia

WASH N/A

Buruli ulcer cases reported to WHO, by region, 2008-2018 Number of reported cases

5,000

0

2,000

1,000

3,000

4,000

6,000

20

08

20

09

20

14

20

10

20

11

20

12

20

18

20

13

20

15

20

16

20

17

Burden of disease

Progress against WHO 2020 targets

Completed clinical trial and incorporated results into control and treatment

% of cases detected and cured at an early stage (category I and II)

Impact indicator 2012

Not started

75%

2020 target

Completed

70%

Current status

Completed

66%

Western Pacific

African

For more details, please visit: https://www.who.int/buruli/en/

28%Disability at diagnosis, 2018

HIGHLY PRELIMINARY

SOURCE: All data sourced from WHO unless otherwise indicated

1 G-Finder report 2018

~2,700New cases in 2018

New BU cases reported

<10 cases

50-100

100-500

500 cases and over

Endemic – No data

No case reported

10-50

Previously reportedcases

Not applicable

No data

Selected efforts to overcome NTD

▪ Total of USD ~3 million in global funding is dedicated to R&D for fighting Buruli ulcer: ~1.3m basic research, ~1.2m drugs, ~0.3m diagnostics1

▪ Contribution of many different organizations and countries is essential for the fight against Buruli ulcer. Some of the organizations and institutions are members of the overarching Global Buruli ulcer initiative

Target: disease control

Buruli Ulcer

Impact indicator 20252020 (Baseline) 2023 2030

Proportion of cases reporting with disability upon diagnosis1 <20%25% <22% <15%

Proportion of cases in Category III (late stage) at presentation <23%30% <26% <18%

HIGHLY PRELIMINARY

WHO 2030 target

Category Current status Actions requiredCurrent Assessment

Additional risks that require mitigation

Technical progress

No bottleneck towards target Critical action required to reach target

Assessment of actions required to meet 2030 targets

1 Defined as a presence of joint limitation

Scientific understanding

▪ Mode of transmission is unknown ▪ Improve understanding of the epidemiology - modes of transmission and its drivers

▪ Understand environmental reservoirs to allow for designing preventive public health interventions

▪ Relate environmental studies to human disease distribution by studying whole genome sequences of M. ulcerans

Collaboration and multisectoral action

▪ Collaboration with other skin-NTDs to reach populations affected by these diseases

▪ Collaboration with education and social sectors for case detection and awareness

▪ Continue roll-out of integrated approach across skin-NTDs to increase coverage of case detection and treatment, and improve monitoring and reporting

▪ Collaboration with tuberculosis and leprosy programmes in supply chain, treatment, follow up, and laboratories

▪ Collaborate with academic and healthcare institutions in endemic countries on developing knowledge for skin-NTDs

Capacity building ▪ Integration of training across skin-NTDs is in progress▪ Ongoing trainings for laboratory diagnosis, skin-grafting, and

woundcare▪ Essential community education for reducing stigma is currently not

sufficient

▪ Capacity development of health workers at the community, health center and district levels for integrated skin-NTD detection, treatment, and surgery

▪ Develop online training packages which can be easily adapted by countries

Planning and governance

▪ WHO Technical Advisory Group on Buruli ulcer exists▪ National Buruli ulcer Control Programmes are in place▪ National NTD coordination bodies exist but are weak (in some

countries only on paper or coordinating PC only)

▪ Strengthen national NTD coordination bodies to effectively carry out their remits across full range of NTDs

▪ Consistently include Buruli ulcer in NTD package

Supply and logistics ▪ WHO procures Buruli ulcer medicines and provides them to countries at no cost

▪ Governments and partners provide dressings and other supplies

▪ Secure donation of medicines▪ Ensure adequate supplies of dressings

Healthcare infrastructure and workforce

▪ Decentralization of care within the PHC to move care closer to the patient in progress

▪ Sufficient national laboratory capacities to confirm cases

▪ Strengthen health care system at all levels through capacity development to increase access to early detection care, and surgery, to ensure access to oral treatment at sub-district level, and to enable management of other chronic skin conditions

Strategy and service delivery

Operational and normative guidance

▪ Buruli ulcer global strategy and national plans are in place▪ WHO Diagnosis and treatment guidelines exist

▪ Update treatment guidelines based on results of clinical trial assessing oral treatment course

Effective intervention ▪ There is currently no prevention against the disease▪ Combination of rifampicin and clarithromycin is recommended for 8

weeks; in Australia, combination rifampicin and moxifloxacin is used ▪ Surgery particularly skin grafting is used to speed up healing in

extensive lesions.▪ Effectiveness of vector control and protective wear is currently being

assessed in Australia

▪ Evaluate new promising drugs to provide new treatment options including reduction in duration of treatment

▪ Evaluate new wound-care approaches (e.g. new dressings that can be changed less frequently)

▪ Develop innovative strategies to improve adherence (e.g. community health workers check-ups, SMS reminders)

Diagnostics ▪ Diagnosis done clinically or using laboratory techniques (direct microscopy, histopathology, culture, PCR, f-TLC)

▪ Early detection is essential in reducing severe disease▪ RDT LAMP test and RPA test are currently being piloted in selected

countries

▪ Develop rapid diagnostic tools for use at the public health centre and community levels to enable early diagnosis, reduce morbidity and confirm cases

▪ Improve detection of viable M. ulcerans in wound samples to distinguish between treatment failure and paradoxical reaction through methods such as mycolactone detection and 16S rRNA

Monitoring & Evaluation

▪ 14 out of 33 known endemic countries report data in 2018 ▪ Mandate reporting of Buruli ulcer and start reporting data in all endemic countries

▪ Enhance surveillance in countries that are not reporting cases through integrated skin-NTD reporting system

▪ Initiate micro-mapping of Buruli to identify overlaps with other NTDs▪ Monitor resistance to antibiotics phenotypically and through genetic

markers

Enablers

Advocacy and funding ▪ Political commitment through Yamoussoukro Declaration (1998) and Cotonou declaration (2009)

▪ Donors and partners supporting implementation at country level▪ Research community provides visibility and advocacy through

mobilizing research resources

▪ Enhance political commitment among endemic countries and partners to mobilize funds and manpower

▪ Community engagement and mobilization to support programme implementation

▪ Engage research community for knowledge generation and advocacy to mobilize resources for research

Summary of key actions to achieve targets

For effective morbidity control, it is essential to discover the disease early and to be able to treat it effectively. For this reason, the following three areas are critical to reach the targets: Build capacity of health workers to clinically diagnose and treat the disease and community health workers to detect and refer cases for treatment, furthering integration across skin NTDs Develop rapid diagnostic test for use at levels of the healthcare system closer to the patient Create comprehensive surveillance systems in all endemic countries including micro-mapping

Chikungunya



WASH Reduce the number of natural and artificial water-filled container habitats supporting breeding of mosquitoes through insecticides

Vector control Environmental management and modificationInsecticides useRestricting mosquitoes access to water and homes through use of lids, wire mesh or other covers

Veterinary public health

Case management Relieving symptoms, particularly joint pain

Other N/A

1 WHO PAHO Fact Sheet on Chikungunya 2 Chikungunya Virus Net – Epidemiology

~2 millioninfections from chikungunya since 20041

Countries with reported non-imported cases (2015)2


Burden of disease


Impact indicator 2012 2020 target Current status

N/A N/A N/A N/A


▪ A viral disease caused by an alphavirus of family Togaviridae▪ Causes sudden onset of fewer and joint pain, muscle pain, headache, rash and leukopenia; joint pain can may persist

for months or years▪ Transmitted to people through bites of female mosquitoes of species Aedes aegypti and Aedes albopictus▪ The disease comes in strong outbreaks causing up to 68% attack rate which may put sudden and heavy burden on

health services▪ Spread of Chikungunya has drastically increased since 2005; currently 60+ countries in all continents are affected

HIGHLY PRELIMINARY

▪ Total of USD [~XX million] in global funding is dedicated to fighting chikungunya▪ Contribution of many different organizations and countries is essential for the fight against chikungunya. Some of these organizations

include: The Global Dengue & Aedes-Transmitted Diseases Consortium (GDAC), Partnership for Dengue Control (PDC)

Overview

Countries with reported cases

Countries with no reported cases

For more details, please visit: https://www.who.int/news-room/fact-sheets/detail/chikungunya


Dengue and Chikungunya


Identify and map high burden countries for CHK 100%TBC 50% TBC

Develop strategies and guidance for management of chronic joint pains and further deterioration

TBCTBC TBC TBC

Initiated efficacy trials for one or more vaccine candidates and completed preliminary assessments of the potential public health benefits of a range of integrated strategies, by 2025

TBCTBC Mapping vaccine pipeline

TBC




Category

Technical progress

Current Assessment Current status Actions required

▪ Rising resistance to insecticides among vectors

▪ Climate sensitive diseases closely linked to urbanization


Diagnostics ▪ Clinical challenge in differentiating chikungunya from

dengue ▪ Serological tests, including ELISA can confirm

presence of antibodies▪ RT-PCR methods are available to determine virus in

blood but vary in sensitivity

▪ Need more sensitive, specific and accurate diagnostic tests


▪ Outbreaks have been reported in 60+ countries ▪ Linked to erratic water supply and water storing

practices ▪ Understand mutation of virus and its association with

vectors

▪ Identify high burden countries and develop surveillance systems to map burden

▪ Streamline referral systems in country ▪ Establish regional network of medical staff for case management

and chronic pains

Enablers


▪ Global Dengue and Aedes transmitted Diseases Consortium (GDAC) coordinates collaboration

▪ Academic institutions and biotech companies jointly researching chikungunya vaccines2

▪ Incentivize multisectoral collaboration for surveillance, prevention, treatment

Advocacy and funding

▪ Lack of data behind economic costs of infection results in under-recognition of disease impact2

▪ Develop and share resources among all stakeholders.

▪ Increase the commitment of resources from international donors, countries, and NGOs

Capacity building ▪ Currently integrated with dengue training ▪ Healthcare professionals to be trained on differentiating

chikungunya from dengue



▪ Currently piggy-backing off of dengue planning efforts due to similarities in disease profile

▪ Concrete vector surveillance, management and control programmes/strategies to identify indicators related to disease incidence in addition to indicators on impact on vector populations.

Supply and logistics ▪ Regional stockpiles of spray equipment and

insecticides in WPRO▪ Develop regional stockpiles in other endemic regions


▪ Outbreaks have been reported in PAHO region previously free of Chikungunya

▪ Monitor resistance of vectors against insecticides▪ Monitor presence & activity of mosquitos in areas of potential risk


▪ PAHO/WHO and US CDC published preparedness and response for Chikungunya in the Americas

▪ Define compliance of private health care provider as per national protocol


▪ Healthcare workforce instructed to treat suspected chikungunya cases as dengue until dengue ruled out1

▪ Chikungunya to be recognized as an endemic disease and programmatic approach needed

Effective intervention

▪ No specific antiviral drug or commercial vaccines available, but some vaccines in testing

▪ Sustained vector control includes measures targeting the eggs, larval and adult stages

▪ Community based source reduction measures and contact training approach with IRS of residences and place of work/schools have good evidence for control of the disease

▪ Window screening and larval control evidence base is moderately strong

▪ Implement and integrate new vector control tools with ongoing vector control (e.g. control of larvae and removal of breeding sites)

▪ Assess current usage of insecticides and ensure they are not used indiscriminately to avoid environmental contamination and development of insecticide resistance

▪ Implement community based container management and insect growth regulator (IGR) in non drinking water containers

▪ Incentivize public-private partnerships to accelerate vaccine R&D▪ Ensure blockage of households with infected individuals through the

use of insecticide treated nets or windows and door screening▪ Further develop evidence base on effectiveness of window screens

and larval control

HIGHLY PRELIMINARY

WHO 2030 target

ChikungunyaDengue and Chikungunya

1 CDC Chikungunya Information for Healthcare Providers 2. PLOS NTD Journal, “Chikungunya as a paradigm for emerging viral diseases,” Jan 2019

Mycetoma, Chromoblastomycosis & other deep mycoses

Overview

▪ A chronic fungal infection of the skin and subcutaneous tissue caused by a group of fungi; the three most common species are Fonsecaea pedrosoi, Cladophialophora carrionii and Phialophora verrucosa

▪ Causes lesions which are clinically polymorphic, the most frequent are nodular, verrucous and tumoral▪ Transmitted through traumatic inoculation through the skin▪ Deep mycoses also include different widely distributed fungal infections such as sporotrichiosis,

paracoccidiodomycosis and others


The highest prevalence of the disease is in tropical and subtropical regions, mostly in the Amazon region of Brazil, the northern part of the Bolivarian republic of Venezuela, and in Madagascar


Vector control N/A



Other Wearing protective cloths, gloves & shoes

Case management No “gold standard” treatment for chromoblastomycosis exists; treatment options

include antifungals, physical therapies and immune adjuvants When the initial lesions are detected early, surgical resections can be applied Management of other deep mycoses depends on the specific disease and causative

organisms; antifungals are mainstay of treatment for most

WASH Personal hygiene

Number of reported cases of Chromoblastomycosis from surveys1

Burden of disease


N/A


N/A

2020 target

N/A

Current status

N/A

For more details, please visit: https://www.who.int/neglected_diseases/diseases/mycetoma-chromoblastomycosis-deep-mycoses/en/index1.html

HIGHLY PRELIMINARY

SOURCE: All data sourced from WHO unless otherwise indicated1 Gaffi fact sheet; http://www.gaffi.org/wp-content/uploads/chromobastomycosis-briefing-document-Nov-2014.pdf

Exact burden of the disease unknown


▪ Various international organization and professional societies including GAFFI, international league of dermatological society, International Society of Dermatology and others are making significant efforts in advocacy, capacity building and policy and strategic push for skin diseases control

Chromoblastomycosis & other deep mycoses

Reported no. ofcases

10-49

100-499

Unknown

Not applicable

No data

1-9

50-99

≥500

HIGHLY PRELIMINARY


Number of countries where chromoblastomycosis & priority deep mycoses included in national control programs and surveillance system

TBC TBC TBC TBC

WHO 2030 target


Mycetoma, Chromoblastomycosis & other deep mycosesChromoblastomycosis & other deep mycoses



▪ Diagnosis based on clinical manifestation, epidemiological link and demonstration of etiologic agents from skin scrapings or biopsies

▪ No rapid diagnostic test or any serologic test▪ Early detection improves outcomes

▪ Develop rapid diagnostic or serological tests to improve early detection at primary health care level

Diagnostics

▪ Transmission pathways of the disease are well understood ▪ Determine the exact magnitude, trend and distribution of the disease and associated causative species


▪ Collaboration with various professional societies, NGOs, research and academic institutes initiated

▪ Initiate collaboration with various research institutes, drugs and diagnostics developers, manufacturers and donors


▪ Most health workers in endemic areas may not be able to recognize most of the deep mycoses at early stage

▪ In many endemic countries the majority of health workers lack the required knowledge and skills to manage cases

▪ No standard & structured training programs for health professionals

▪ Train health professionals and community health workers across priority skin NTDs to improve early detection based on local epidemiological contexts

▪ Improve the diagnostic and managing capacities of health care system in the endemic regions of the countries

Capacity building

▪ There is no information on any country having a national control plan

▪ Include chromoblastomycosis and other deep mycoses in control programmes against NTDs or communicable diseases in endemic countries


▪ No donation of medicines▪ Countries procure and manage their supply system

▪ Secure donations of medicines or significantly reduced pricesSupply and logistics

▪ No surveillance protocol or system, no standard indicators▪ No M&E system

▪ Develop a surveillance guide with standard indicators▪ Establish M&E system or integrate with national health

information system


Technical progress

▪ No global guidance on case management, surveillance, prevention and control

▪ Develop global guidance on case management, surveillance, prevention and control needs.



▪ Some organization and groups such as GAFFI, ISHAM etc. are making advocacy, awareness raising and capacity building efforts.

▪ Ensure political commitment from endemic countries and partners to mobilize funds and human resources

▪ Engage community and mobilize support for programme implementation


Enablers

▪ Health systems are not prepared to provide control services or run control programmes


▪ To be confirmed

▪ Improve therapeutic regimens (shorter duration and increased efficacy to reduce refractoriness to treatment)

▪ Develop innovative preventive tools based on local understanding of the transmission


▪ Case management with antifungals and local treatment has low cure rate and require several months of treatment

▪ Protective shoes, gloves or garments help prevention▪ Improved nutrition and hygiene



Overview

Current status Impact indicator 2012 Target

By 2015, sustainable dengue vector control interventions established in endemic priority countries3

2 10 10




WASH Safe storage of water (e.g. regular access, safe disposal of household water)

Vector control Environmental management and modification Use of insecticides and indoor fogging Restricting mosquitoes access to water and homes through use of lids, wire mesh and other covers


Case management Medical care by physicians and nurses for severe dengue (prevention of plasma leaks and organ failure) Maintenance of patient’s body fluid volume and platelet count Anti-pyretics and optimal analgesics to relieve body pain and fever

Other Existing vaccine for people who have previously had dengue infection as confirmed by lab testing


▪ Total of USD ~81 million in global funding is dedicated to R&D for fighting dengue in 2018: ~38m general research, ~22m drugs, ~7m diagnostics, 9m vector control, ~5m unspecified2. This represented year on year decline of approximately 30%

▪ Contribution of many different countries, organizations and institutions is essential for the fight against dengue. Some of these organizations collaborate through The Global Dengue & Aedes-Transmitted Diseases Consortium (GDAC) and The International Society for Neglected Tropical Diseases


▪ A viral disease caused by four distinct serotypes of Flaviviridae family▪ Causes fewer, muscle and joint pain, severe headache, pain behind the eyes, nausea, rash, and vomiting; severe dengue causes severe

abdominal pain, persistent vomiting, bleeding gums, fatigue and restlessness and can lead to death▪ Transmitted to people through bites of female mosquitoes of species Aedes aegypti and Aedes albopictus▪ Spread of dengue has been drastically increasing over the recent years; currently 3.9 billion people are estimated to be at risk of infection

in 128 countries; over 100 countries are endemic for dengue

DALYs in 2016, ‘000

Majority of people affected in approximately. 90 endemic countries and in need of case management lives in Africa, Asia and Latin America

1 IHME Global Burden of Disease 2 G-finder report 2018 3 Bangladesh, Brazil, India, Malaysia, Mexico, Pakistan, Sri Lanka, Singapore, Thailand, Vietnam4 Limited decrease in other regions

~104 millionEstimated infections from dengue in 20171

~3 millionEstimated DALYs, 2016

Burden of disease

~40,000Reported deaths in 2016

6 5

DALYs per region, ‘000

HIGHLY PRELIMINARY

For more details, please visit www.who.int/denguecontrol/en/

12%

2%

4%

82%

2000

74%

5%1%7%

3%

2016

1,142

3,095

Reduction in number of cases and case fatality rate (2020; 2009–2010 as base line)

Not applicable 25%/50% 50%/20% reduction in American region following Zika epidemic (2016)4

AMRO

WPRO

EMRO

SEARO

AFRO

Dengue control and surveillance systems established in all regions (2020)

DALYsThousands

<0.2

0.2-1.2

1.2-4.6

≥4.6

Officially no casesreportedNot applicable

No data

DengueDengue and Chikungunya

3



▪ Ensure that dengue programs in countries are established and develop programmatic approach

▪ Develop concrete vector surveillance management and control programmes/strategies and identify indicators related to disease incidence

▪ Streamline country referral systems

▪ The strength and organization of dengue programs varies by country

Supply and logistics ▪ Ensure availability of quality assured RDTs▪ Regional stockpiles of spray equipment's, RDTs (not quality assured) and insecticides in WPRO


▪ Regularly monitor the presence and activity of the mosquitos at sentinel sites using traps

▪ Ensure monitoring and reporting systems are established in all African endemic countries

▪ Monitor insecticide resistance

▪ Current M&E system is weak resulting in common underreporting▪ Insecticide resistance is emerging


▪ Establish regional network of medical staff for case management▪ Dengue is treated at all levels of health system▪ Severe dengue is managed in hospitals


▪ Establish Intersectoral Task Force for coordinating resources at national level and co-implementation

▪ GDAC – Global Dengue and Aedes transmitted Diseases Consortium coordinates collaboration

▪ Successful cross border, cross state and district level exchange of information

Capacity building ▪ Target communities with tailored educational messages for various groups (e.g. schools, women’s groups, religious leaders)

▪ Two WHO supported international courses on dengue are organized (one per year) in Cuba and Singapore.

▪ Support provided to countries for local trainings


▪ Estimate burden of dengue in countries▪ 80% of the cases are asymptomatic▪ Secondary infections can be severe▪ Dengue virus is maintained in a sylvatic, enzootic cycle of transmission

between canopy-dwelling non-human primates and Aedes mosquitoes in Borneo, Africa etc.

▪ Linked to erratic water supply and water storing practices

Diagnostics ▪ Develop PCR test for confirmation of diagnosis▪ Dengue diagnostics now included in Essential Diagnostic List (EDL) of WHO

▪ Unassured quality RDTs exist for point of care diagnosis

▪ Case management has improved leading to decline of CFR in all regions▪ Sustained vector control includes measures targeting the eggs, larval

and adult stages▪ Community based source reduction measures and contact tracing

approach with IRS of residences and place of work/schools have good evidence for control of the disease

▪ Window screening and larval control evidence base is moderately strong.

▪ Implement and integrate new vector control tools with ongoing vector control (e.g. control of larvae and removal of breeding sites)

▪ Assess current usage of insecticides and ensure they are not used indiscriminately to avoid environmental contamination and development of insecticide cross resistance

▪ Implement community based container management and insect growth regulator (IGR) in non drinking water containers

▪ Develop new preventive vaccines for all at risk populations▪ Ensure blockage of households with infected individuals through the use of

insecticide treated nets or windows and door screening▪ Further develop evidence base on effectiveness of window screens and larval

control


HIGHLY PRELIMINARYDengueDengue and Chikungunya

Case fatality rate due to dengue 0.5%TBC 0.5% 0%

% dengue outbreaks prevented TBCTBC TBC 75%

Technical progress

No bottleneck towards target Critical action required to reach targetCurrent AssessmentCategory Current status Actions required


WHO 2030 target


Summary of critical actions to achieve targets

Key actions:▪ To be confirmed▪ To be confirmed▪ To be confirmed

# countries no longer at risk of dengue epidemics 64/128 (50%)TBC 26/128 (20%) 128/128 (100%)


▪ Rising resistance to insecticides among vectors▪ The incidence of the disease may increase with changing climate and continued urbanization


▪ Define compliance of private health care provider as per national protocol▪ Develop global operational guidance for managing dengue outbreaks to be

used at a country level▪ Recognize dengue as an endemic disease

▪ Guidelines for diagnosis, treatment, prevention and control (2009) are currently being updated and a new edition expected in 2020.



▪ Increase the commitment of resources from international donors, countries, and NGOs

▪ Current levels of R&D funding have decreased

Enablers

Dracunculiasis (Guinea Worm)Overview

▪ Parasitic disease caused by the Guinea worm (Dracunculus medinensis)▪ Causes people to be non-functional for weeks when the adult female worm(s) emerge(s) from the body

through a painful burning blister; the worm develops in the body for about a year▪ Usually transmitted to people from drinking stagnant water with parasite-infected water fleas; patients

often immerse the limb in water to relieve burning when the worm is emerging; in the water, the worm releases larvae, completing the cycle

▪ Infection also occurs in animals, particularly in dogs (currently in Angola, Chad, Ethiopia, and Mali)




Cases reported worldwideCases reported, 2018

Burden of disease


# of countries certified as free of GW transmission


180

2020 target

189

Current status

187

For more details, please visit: www.who.int/dracunculiasis/en/

HIGHLY PRELIMINARY



Contribution of many different countries, organizations and institutions is essential for the fight against dracunculiasis. WHO facilitates cooperation within the ecosystem

542

148 126

22 25 30 28

20182012 2013 2014 20172015 2016

The disease is in 5 countries across Africa

28Cases reported, 2018

Not applicable

10 in South Sudan

1 in Angola

17 in Chad

No reported cases

WASH ▪ Ensuring access to safe drinking water sources▪ Filtering water from open water bodies before drinking▪ Preventing contamination of drinking-water by advising patients to avoid wading into

water

Vector control ▪ Temephos to control cyclops, the intermediate host (also called water fleas)

Veterinary public health ▪ Proactive tethering of dogs (including infected dogs) to prevent contamination of the environment and management of infection.

Case management ▪ Containment of human cases

Other ▪ Surveillance to ensure early detection and containment of transmission ▪ Increasing awareness of cash reward scheme for voluntary reporting and promoting

behavioral change

▪ Dracunculiasis is on the verge of eradication with only 28 human cases reported in 2018 and 7 countries remaining to be certified as free of the disease: Angola, Chad, Ethiopia, Mali, South Sudan (indigenous transmission occurs), Sudan (precertification stage), and Democratic Republic of Congo (no history of dracunculiasis since 1980 but need for assessment)

Target: Eradication

Dracunculiasis (Guinea Worm)

# member states certified free of transmission 191189 194

Technical progress

Diagnostics ▪ Develop serological diagnostic test▪ Develop a pond-side test

▪ Field test to detect of prepatent Guinea worm infection in humans, dogs and other animals

▪ Field pond-side test for detecting D. medinensis DNA in copepods


▪ Undertake operational research to better understand transmission dynamics and pathways in animals, particularly in dogs

▪ Develop understanding of copepod biology▪ Understand the Guinea worm transmission in Angola

▪ Good understanding of transmission pathways to humans


▪ MoH to take the lead to get guinea worm eradication activities integrated with other programmes & sectors (e.g. polio, integrated surveillance, veterinary services, other NTDs)

▪ Integration of guinea worm eradication activities with other programmes and sectors such as WASH and education is not formalized in all countries

Enablers


▪ Ensure and sustain commitment for adequate funding from donors till eradication

▪ Eliminate delays in releasing funding at all levels

▪ Insufficient funds for programme requirements▪ Delays in releasing funding at all levels

Capacity building ▪ Train health staff, ensure availability of SOPs, include GW surveillance and response in the curriculum for health workers in affected countries

▪ Increase awareness of GW prevention, cash reward scheme for voluntary reporting and promote behavioral change

▪ Suboptimal capacity of health staff in non-endemic areas to respond to any GW emergence should it occur


▪ Higher level advocacy in affected countries to sustain momentum and commitment at national level to the goals of eradication

▪ Initiate certification process in Sudan, Central African Republic, and Democratic Republic of Congo to avoid missing targets due to process challenges

▪ 7 WHA resolutions supporting the eradication▪ Annual ministerial meeting of GW affected countries on the

margin of the WHA

Supply and logistics ▪ Ensure minimum stock of temephos in countries bordering endemic areas that can be used immediately should GW detected

▪ Sufficient supply of temephos in endemic areas shall be sustained

▪ Sufficient supply of GW ID cards (photos) and cash reward material shall be maintained.


▪ Ensure that monitoring systems are functional in non-endemic and previously endemic areas which have not reported any cases for long time

▪ Revise norms for vector control in collaboration with key partners▪ Improve the way of measuring effectiveness of vector control

intervention▪ Improve indicators for monitoring temephos application

▪ Improve programme coverage in not known endemic but at risk areas

▪ Better way of measuring effectiveness of vector control intervention

▪ Improved indicators for monitoring temephos application


▪ Governments to strengthen the overall health systems in the context of Universal Health Coverage

▪ Integrate training on GW in the curricula of health staff▪ Train and equip sufficient number of vector control teams

▪ High turn-over of trained staff▪ Low coverage of health facilities▪ Insufficient number of trained persons for vector control


▪ Finalize the review of the criteria for certificationOperational and normative guidance

▪ The criteria for certification are currently being updated by a group convened by the ICDE and supported by WHO in order to develop a protocol to certify remaining countries in context of GW infection in animals (dogs)


▪ Intensify and scale up the scope and quality of the interventions in the remaining few foci including improved transmission containment and effective use of temephos in endemic localities.

▪ Explore the use of new technologies such as drones for identification and treatment of hidden water sources in endemic localities.

▪ Research alternative products to control copepods▪ Ensure access to safe water sources for affected and at risk

communities

▪ There is currently no medicine to treat or vaccine to prevent guinea worm▪ Current strategies are effective and include:

– Detection of all worms emerging from hosts (human and animals) to contain transmission

– Treating all eligible stagnant surface water bodies in all affected communities with Temephos (Abate)

– Providing safe drinking water sources to affected communities– Providing health education to increase awareness in affected

communities

▪ Animal infections with GW▪ Population displacement, political instability

HIGHLY PRELIMINARY

WHO 2030 target

Impact indicator 20252020 (provisional estimate) 2023 2030



Category

Current Assessment Actions requiredCurrent status



To achieve eradication, the challenges surrounding animal reservoirs have to be tackled and necessary processes put into motion. The actions required include: Develop a scientific and operational protocol for elimination in animals Initiate certification process in Sudan, Central African Republic, and Democratic Republic of Congo to avoid missing targets due to process challenges Investigate why Guinea Worm infection surfaced in Angola to better understand the current challenges

Food-borne trematodiases


Preventive chemotherapy MDA of anthelminthic medicines (praziquantel, triclabendazole) in endemic areas

WASH Sanitation and fecal waste processing

Vector control N/A


Case management Anthelminthic medicines (praziquantel, triclabendazole)

Other Safe food preparation and storage

Accurate data on incidence and prevalence are not available

939,426 920,517

93,942

14,806 16,971

20162010

44,273 50,256

1,101,586 1,083,682

101,250EURO

AFRO

EMRO

AMRO

SEARO

WPRO

Endemicity of trematodiases globally DALYs per region1 in 2010, 2016

200,000People infected annually

~2mDALYs, 2016

~7,000Annual deaths

For more details, please visit: https://www.who.int/foodborne_trematode_infections/en/

▪ Caused by trematode worms (“flukes”) - Clonorchis sinensis, Opisthorchis viverrini, Opisthorchis felineus, Fasciola hepatica, Fasciola gigantica, Paragonimus spp.

▪ Causes severe pain in abdominal region, general malaise, inflammation and fibrosis of the liver (clonorchiasis and opisthorchiasis, fascioliasis), fatal bile duct cancer (clonorchiasis and opisthorchiasis), blockage, colic pain and jaundice (fascioliasis), chronic cough with blood, chest pain, dyspnea, and fever (paragonimiasis).

▪ Transmitted through raw or undercooked food (fish, aquatic vegetables, crabs and crayfish) infected with larvae


Burden of disease


▪ Limited to no funding for fighting food-borne trematodiases ▪ Triclabendazol donation by Novartis secured until 2022 (600,000 tablets/year)▪ Contribution of many different organizations and countries is essential for the fight against food-borne trematodiases. Some of these

organizations include: [TBD]


Trematode infections included in mainstream preventive chemotherapy strategy N/A N/A N/A


Population at risk reached by preventive chemotherapy N/A 75% N/A

Morbidity due to foodborne trematode infections controlled in all endemic countries N/A 100% N/A

Overview

HIGHLY PRELIMINARY

Clonorchiasis1

Opisthorchiasis2

Fascioliasis3

Paragonimiasis4

3 + 4

2 + 3

1 + 3 + 4

2 + 3 + 4

+ + +1 2 3 4

Not applicable

No data


1 Data in AFRO unavailable. Other regions are likely underestimated due to lack of reliable data.


Food-borne trematodiases

# countries with intensified control in hyperendemic areas 5NA 2 10




CategoryCurrent Assessment Current status Actions required


▪ Evaluation of the number of individuals at risk in each endemic country is not available

▪ Estimate the number of individuals at risk by country


▪ Difficult to reach remote and marginalised communities▪ Donations of triclabendazole are in place but only in 1

country

▪ Secure donations of praziquantel (number of tablets in need for FBT control should be estimated) Supply and logistics

▪ Disease burden not well understood ▪ Accurate surveillance and mapping is urgent – particularly layered with information on the environmental factors involved in infection

▪ Produce reports on coverage of individuals at risk

▪ Report future reduction in liver cancers associated with control of these diseases


▪ No manuals on public health approach to FBT control ▪ Develop guidance to FBT controlOperational and normative guidance

▪ Poor knowledge of the disease among health staff ▪ Develop manual for public health intervention in high risk areas Healthcare infrastructure and workforce

Technical progress

▪ Clinical diagnosis or parasitological techniques (e.g. detection of eggs in stool) are usually used

▪ More sensitive serological techniques and molecular techniques (PCR) are at experimental stage

▪ Increase access to imaging diagnostics, which can be used in resource limited settings

▪ Evaluate and implement diagnostics developed in recent years in endemic regions

▪ Associate FBT with Tuberculosis programme in Paragonimiasis high-endemic areas for case detection

Diagnostics

▪ Good understanding of the parasites lifecycle ▪ Conduct eco-epidemiology studies including use of new technologies for field studies (drone mapping, environmental DNA, etc.) as tools for providing local information for education based practices

▪ Understand the mode of transmission and the process/pathway involved in the cause of disease


▪ Preventive effective measures (PC + education+ sanitation) are known but rarely applied

▪ Develop detailed map of FBT distribution, promote the application of effective measures, evaluate the impact and disseminate the results


▪ No comments thus far


Enablers

▪ WHO promotes the inclusion of flukes among the targets of preventive chemotherapy interventions

▪ Focus on effort to rally action / mobilise across FBTs

▪ Excellent examples of multi-sectoral control of O. virerrini in Thailand can be used to prompt other countries to develop their own actions


▪ No strong advocacy group able to voice a global vision on these diseases

▪ Limited to no funding for FBT

▪ Create and sustain advocacy group for FBT

▪ Secure funding to tackle critical actions required to reach 2030 targets


▪ To be completed ▪ Training for health staff on FBT diagnosis and treatment Capacity building

WHO 2030 target

HIGHLY PRELIMINARY

Human African trypanosomiasis (HAT)Overview

▪ Caused by Trypanosoma brucei gambiense (gHAT; 98% of HAT cases) and rhodesiense (rHAT; 2% of HAT cases)

▪ gHAT causes chronic infection in two stages: in haemo-lymphatic stage, it causes bouts of fever, headaches, joint pains and itching; in neurological stage when the parasite crossed the blood-brain barrier, disturbance of sleep cycle, changes of behavior, confusion, sensory and motor disturbances take place

▪ rHAT causes an acute infection with similar symptoms which rapidly develops and invades the central nervous system

▪ Transmitted primarily by the bite from tsetse fly previously infected; other ways of transmission include mother-to-child.




Number of HAT cases 2006-2016Number of HAT cases in 2017 (T. b. gambiense)

For more details, please visit: www.who.int/trypanosomiasis_african/en/

HIGHLY PRELIMINARY


1 Franco, J. R. et al. (2018). Monitoring the elimination of human African trypanosomiasis: Update to 2016. PLoS neglected tropical diseases, 12(12), e0006890 2 G-Finder report 2018


Number of HAT cases declared (Global elimination of HAT as a public health problem)


7,211

2020 target

< 2,000

Current status

<1,000


Total of USD ~38 million in global funding is dedicated to R&D for fighting HAT: ~20.5m general research, ~16m drugs, ~1m preventive vaccines, ~1.2m diagnostics, ~0.3m unspecified2

Contribution of many different countries, organizations and institutions is essential for the fight against HAT.

HAT is endemic in sub-Saharan Africa,

57,000,000People at risk1

<1,000People reported suffering in 2018

36Endemic countries

WASH N/A

Vector control Reduction of tsetse flies by insecticide spraying, sterile insects release, baits and traps including impregnated screens

Veterinary public health Treatment of animals (cattle, pigs), restricted application of insecticides

Case management Control of disease is based on case detection and treatmentDiagnosis includes screening with serological tests (in gHAT), parasite confirmation (in blood, lymph nodes or cerebrospinal fluid) and determining stage of progression by examining cerebrospinal fluid from lumbar puncture Medicines used for rHAT: suramin (haemo-lymphatic stage) and melarsoprol (neurological stage) Medicines used for gHAT: pentamidine (haemo-lymphatic stage) eflornithine and nifurtimox (neurological stage), fexinidazole (haemo-lymphatic and not severe neurological stage)

Other Detection of cases is done by active (mobile units visiting villages in endemic areas and screening the whole population) or passive screening (clinical suspects attending to health facilities)

Burden of disease

T.b.gambiense

>1,000

100-1,000

<100

0 cases reported

≥10

<10

0 cases reported

T.b.rhodesiense

Endemic countries(no data available)

Non endemic countries

Not applicable

0 T.b.gambiense &≥10 T.b.rhodesiense cases

10.771

08 112006

9.870

07 1309 1210 14 152016

11.825 10.639

7.1296.747

7.2026.317

3.797 2.8012.164

Rhodesiense

Gambiense

Target: Elimination of transmission

Human African trypanosomiasis (Gambiense; gHAT) HIGHLY PRELIMINARY

Number of gHAT cases declared TBC<1000 TBC 0 (100%)

WHO 2030 target


Category


Technical progress

▪ Inability to screen and treat due to conflict and political instability in the most affected country

▪ Lack of integration of activities into a weak health system

▪ Asymptomatic infections and animal reservoirs as elimination is approached could lead to resurgence

▪ Reduction in surveillance once zero cases are reported locally, or cessation of activities in low prevalence settings

▪ Screening tools available but imperfect. Current confirmation tools are cumbersome

▪ Lack of tools to assess absence of the disease

▪ Different initiatives (DiTECT, FIND, IRD, ITM…) are developing and evaluating new tools and protocols for screening and diagnosis

▪ Case-finding (active and passive) is the main activity for control and surveillance.

▪ Develop field-adapted diagnostic/detection tools (e.g. a simplified diagnostic that does not require confirmatory testing by microscopy)

▪ Ensure independent, multicenter evaluation of new tools

Diagnostics

▪ There are key gaps in the knowledge about transmission of the disease (e.g. latent infections in humans, role of animal reservoirs)

▪ Epidemiological situation is not well known in some geographical areas.

▪ Evaluate role of epidemiological elements (e.g. latent infections in humans, assessment of the role of the skin as a reservoir, understanding the role of animal reservoirs)

▪ Understand prevalence of infection in regions with low or limited surveillance


▪ HAT control and surveillance is led by National Sleeping Sickness Control Programs with the support of WHO network for HAT elimination which coordinates stakeholders on HAT control and surveillance

▪ The ownership of the elimination process and targets by endemic countries is weak

▪ Reinforce ownership of the elimination process and targets by endemic countries through advocation to health authorities and heads of states (e.g. PATTEC) in a context of dropping cases

▪ Participate in efforts advocating for UHC. Efforts from countries are needed to integrate control and surveillance into strengthened national health systems


▪ Access to treatment is 100% ensured by donation of manufacturers and distribution is ensured by WHO.

▪ Access to screening and diagnosis is not ensured and distribution of diagnostic tools is not systematic

Supply and logistics ▪ Ensure availability and access of HAT diagnostic tools through involvement

of manufacturers and securing donations

▪ HAT Atlas is a helpful tool for planning and monitoring control and elimination activities

▪ Global indicators and methods for validation of HAT elimination as PHP are available

▪ The verification of HAT elimination is not developed and tools are limited

▪ Use data distribution and case mapping tools to improve targeting of case-finding activities

▪ Better understand the coverage of the population screened to help focus on the population at risk (e.g. develop assessment methodology, transfer the process to country surveillance programmes)

▪ Secure financial and technical support for validation and verification

▪ Develop high-throughput test to assess elimination and post-elimination surveillance on samples in a reference laboratory


▪ Decrease of HAT-skilled staff and decrease in prevalence makes it difficult to gain experience

▪ Challenging integration of control and surveillance activities in a weak health system

▪ Develop national plans for staff training, awareness and motivation within the national health systems

▪ Integrate HAT control and surveillance activities into health systems where health systems are strengthened (including peripheral)


▪ There is a global strategy defined to achieve elimination

▪ Operational guidelines are defined for different settings

▪ Develop and adopt guidance for assessing elimination as interruption of transmission (how to measure HAT as truly eliminated.)

▪ Create guidance for targeting vector control activities



▪ The WHO network for HAT elimination provides a framework in which activities conducted by its members are coordinated, facilitating HAT control and surveillance

▪ Interface with animal trypanosomiasis (One Health approach trough the PAAT initiative.

▪ Collaboration with some other NTD programmes (e.g. leprosy, guinea worm for case finding)

▪ Enhance cross-border collaboration for elimination of transboundary foci

▪ WHO coordination of countries and other stakeholders must be ensured to maximize synergies.

▪ Establish collaboration with malaria programme on diagnosis


▪ International Course on African Trypanosomiasis (ICAT) covers key aspects to underpin the capacity of the programmes.

▪ Efforts of multiple partners (IRD, ITM, FIND, DNDI, MakUniv,...) in coordination with SSNCP

▪ Capacity-building e.g. cascade training/retraining for treatment services

▪ Develop training to transition HAT expertise from specialized HAT programs into national health systems.

Capacity building

▪ Important funding (Belgian Government, Sanofi, Bayer and BMGF) is guaranteed for next 2-5 years but extension for long term support is required

▪ Maintain current support to ensure the sustainability of the current gains (e.g. lobbying to avoid donor fatigue)

▪ Develop a long term funding plan, including a campaign to mobilize resources to meet needs


Enablers

▪ Current intervention are effective but need to be adapted to new epidemiological situations

▪ Tools for vector control have demonstrated utility in reducing disease transmission when strategically deployed and coordinated with medical intervention.

▪ Trials for new simpler medicines (e.g. acoziborole) are ongoing.

▪ Adapt interventions to a new epidemiological scenario of low and very low prevalence and integration in health system to ensure sustainability

▪ Develop safe and efficient single oral dose for both stages (e.g. acoziborole) to help integration of treatment into primary health system. Diagnostic algorithms with a lower specificity could be considered if safer treatments become available





Target: Elimination as a public health problem

Human African trypanosomiasis (Rhodesiense; rHAT) HIGHLY PRELIMINARY

WHO 2030 target

Areas with > 1 HAT case per 10 000 people per year (average of 5 years) TBC10 000 sq km TBC 0 (100%)


▪ Challenged with integration of activities in a weak health system

▪ Cessation of activities in low prevalence settings

▪ International Course on African Trypanosomiasis (ICAT) covers key aspects to underpin the capacity of the programs.

▪ Efforts to maintain diagnostic and treatment capacities supported by WHO and SSNCP, (and DNDi in Malawi and Uganda),

▪ Reinforce capacity-building including training to transition HAT expertise from specialized HAT programs into national health systems.

▪ Develop guide materials and manuals for improvement of patient management in endemic areas

Capacity building

Technical progress

▪ HAT control and surveillance is led by National Sleeping Sickness Control Programs; the WHO network for HAT elimination coordinates stakeholders on HAT control and surveillance

▪ The ownership of the elimination as PHP process by endemic countries is weak

▪ Reinforce ownership of the elimination process and targets by endemic countries

▪ Contribute to efforts advocating for UHC, strengthening peripheral health systems (leadership from countries is needed)

▪ Integrate control and surveillance into national health systems


▪ Access to treatment is 100% ensured by donation of manufacturers and distribution by WHOSupply and logistics

▪ No bottleneck towards the target

▪ HAT Atlas is a helpful tool for planning and monitoring control and elimination activities.

▪ Global indicators and methods for validation of rHAT elimination as PHP are available.

▪ Under-detection remains a concern

▪ Use data distribution and case mapping tools to improve targeting of case finding activities

▪ Secure financial and technical support for validation process

▪ Reinforce surveillance through setting up sentinel surveillance sites with trained staff and equipment


▪ Decrease of HAT-skilled staff and prevalence makes it difficult to gain experience

▪ Challenging integration of control and surveillance activities in a weak health system

▪ Widespread use of malaria RDTs reduces possibilities of microscopy for rHAT

▪ Develop national plans for staff training, awareness and motivation within the national health systems

▪ Integrate HAT control and surveillance activities into health systems where health systems are strengthened (including peripheral)


▪ There is a control global strategy in place ▪ Develop guidelines to ensure good use of vector control tools tailored to different environments as needed

▪ A multi-sector approach should be developed



▪ The WHO network for HAT elimination provides a framework in which activities conducted by its members are coordinated, facilitating rHAT control and surveillance

▪ Build an inter-sector body to address trypanosomiasis

▪ Enhance cross-border collaboration for elimination of transboundary foci

▪ Coordinate vector control and animal trypanosomiasis management across countries, stakeholders and other sectors (e.g. tourism, wildlife) through multisectoral national bodies to maximize synergies

▪ Coordinate with malaria program to use microscopy in some cases


▪ Considering low prevalence, there is a significant funding gap for control and research activities.

▪ Develop a long term funding plan, including a campaign to mobilize resources to meet needs.

▪ Advocate for external donors and national appropriation


Enablers

▪ No serological tests available and no research going on

▪ The spread of use of RDT for malaria has decreased the use of blood smear diagnostic technique required for rHAT

▪ Develop a new field-adapted tools to detect rHAT (e.g. RDT) to use in primary healthcare facilities (screening or diagnostic)

▪ Include blood microscopy into clinical and laboratory algorithms

Diagnostics

▪ A zoonotic disease in which wildlife and domestic animals are the main reservoirs and play a central role in transmission to humans.

▪ There are grey geographical areas were the epidemiological situation is not well known.

▪ No serological screening tools, and highly toxic medicines available. A clinical trial for fexinidazole is ongoing

▪ Understand prevalence of infection in regions with low or limited surveillance.


▪ The main interventions are vector and animal reservoirs control (e.g. treatment of animals, insecticide application in cattle)

▪ Early case detection and treatment reduces the impact of the disease in humans

▪ Available treatment is toxic. Trials for new simpler medicines (e.g. fexinidazole) are ongoing.

▪ Reinforce human case detection activities

▪ Integrate treatment into health system to ensure sustainability

▪ Develop safe and efficient treatments (e.g. fexinidazole, acoziborole) replacing arsenic based treatments (melarsoprol)

▪ Develop strategies on One health approach to reduce trans-mission from animals (livestock and wild animals) to humans




Category



Leishmaniasis – visceral (VL)Overview

▪ Caused by protozoan Leishmania parasite which is transmitted by the bite of female phlebotomine sandflies; only 10-25%, of those infected by the Leishmania parasite will develop the disease

▪ Causes irregular bouts of fever, weight loss, enlargement of the spleen and liver, and anaemia; if left untreated, VL is fatal in over 95% of cases

▪ Post-kala-azar dermal leishmaniasis (PKDL) is a sequel of VL where 5–10% of patients develop a rash up to 2-3 years after VL was treated; people with PKDL are considered a potential source of VL infection

▪ Associated with malnutrition, population displacement, poor housing, a weak immune system and lack of financial resources


75 countries are endemic for VL (2016)

In 2017, more than 95% of new reported cases occurred in 10 countries: Bangladesh, Brazil, China, Ethiopia, India, Kenya, Nepal, Somalia, South Sudan, and Sudan


Case fatality rate, percentNumber of new VL cases reported in 2017Burden of disease

Number of countries validated as having eliminated VL (as a PHP) 0 Bangladesh, India and Nepal

Further validation action required


Percentage of districts/sub-districts on Indian subcontinent (Nepal, Bangladesh and India) reported as having reached the elimination as PHP threshold (<1 case/10,000 pop)


Bangladesh 88%, India 54%,

Nepal 100%

2020 target

100%

Current status

Bangladesh 100%, India 92%,

Nepal 100%

For more details, please visit: www.who.int/leishmaniasis/visceral_leishmaniasis/en/

HIGHLY PRELIMINARY


1 Bangladesh, Brazil, Ethiopia, Nepal, Somalia, South Sudan and Sudan 2 IHME Global Burden of Disease 3 Also referred to as non-endemic country 4 G-Finder report 2018 5 Assessment of endemicity in some districts in Nepal and sub-districts in Bangladesh has to be carried out; relapses and HIV-VL patients are not regularly included in the denominator in India which deflates the prevalence in India compared to other countries


▪ ~USD 44 million in global funding is dedicated to R&D for eliminating all types of leishmaniasis: ~USD 17m for general research, ~USD 14 million for drug development, ~USD 13 million for other areas (e.g. development of preventive vaccines and diagnostics)4

▪ The contribution of many different organizations and countries is essential for the fight against leishmaniasis. Organizations active in fighting VL at the global level include MSF, DNDi ,FIND, Gilead Sciences, Sanofi, and the Probitas Foundation

~510,000deaths reported among VL patients

in seven countries1 in 2017

~570DALYs, 20172

~22,270New VL cases reported in 2017

100-499

≥1000

No Autochthonouscases reported3

Not applicable

No data

0

<100

500-999

Ban

glad

esh

1,0

7,0

Som

alia

Bra

zil

1,1

Eth

iop

ia

Sud

an

Sou

th S

ud

an

Nep

al

7,7

0,5

3,02,4

3,0 2,82,0 2,1 2,2

0,3

4,6

2014 2017

Insecticide spraying, insecticide-treated nets, and environmental management Vector control

N/APreventive chemotherapy

N/AWASH

N/AVeterinary public health

The treatment of leishmaniasis depends on several factors including type of disease, concomitant pathologies, parasite species and geographic location. Medicines include pentavalent antimonials, amphotericin B, paromomycin, among others

Case management

Early diagnosis (rapid diagnostic tests combined with clinical signs) and prompt treatmentOther


Leishmaniasis – visceral (VL)

▪ Outbreaks may overwhelm the capacity of existing health infrastructure/workforce ▪ Single manufacturers of medicines which are difficult to produce at the required quantity and quality▪ Limited availability of treatments for concomitant diseases (e.g. anemia, malnutrition, co-infections) may increase case fatality rate


▪ A second line serological test (DAT) available in case rapid tests show a negative result in a VL suspected patient

▪ Time between onset of symptoms and treatment is too long -in most cases up to 3-6 months

▪ Sensitivity of diagnostic rapid tests differs in different areas

▪ Develop more sensitive rapid diagnostic tests for VL in East Africa

▪ Reduce time elapsed between onset of symptoms and treatment by ensuring prompt diagnosis and early treatment (e.g. through conducting active case finding - fever camps)

Diagnostics

▪ Factors linked to a fatal prognosis have been described in some settings

▪ Improve understanding of parasitic and patient factors linked to a fatal prognosis

▪ Deepen understanding of the vector lifecycle for more effective vector control


▪ Regular coordination meetings in-country and regionally occur although there is need for better dissemination of the minutes of those meetings to all stakeholders

▪ Cross-border meetings are not held

▪ Establish regular coordination mechanism in-country, regional and cross-border with dissemination of minutes to all stakeholders


▪ Although capacity building is done regularly, high turnover of staff causes gaps in training and some personnel is assigned to tasks without specific training

▪ Train community health workers and national health personnel for timely and adequate diagnosis and treatment

▪ Train newly deployed health personnel upon arrival to an endemic area on diagnosis and treatment of VL

Capacity building

▪ Key interventions such as provision of medical supplies or M&E are fully dependent on external donors in several countries

▪ Increase domestic funding to procure quality-assured medical supplies for diagnosis and treatment


Enablers

1 Defined as an immunocompetent patient with no other concomitant condition which is not the result of VL (e.g. transplantation, HIV, cancer, immunosuppressive medicines, diabetes, renal failure, etc.)


The most devastating consequence of visceral leishmaniasis is death. There are currently patients dying who could be saved if early diagnosis and prompt treatment would be implemented. VL is a complex disease which manifests differently in various geographies and thus the response may need to be adapted to local context. Nevertheless, there are three key areas to be addressed: Early detection is essential in order to ensure prompt treatment, through, for example, active case detection Endemic areas have to remain well-supplied due to the epidemic nature of VL More user friendly treatment is needed, especially for East Africa

▪ National guidelines for VL control are in place ▪ Fully implement diagnostic and treatment algorithms in the field level


▪ Some countries do not report regularly and on time on medical supplies consumption which causes stocks out sometimes

▪ Some countries do not use WHO quality-assured medicines

Supply and logistics ▪ Develop reporting system on monthly basis for stocks at health

facility level to anticipate and avoid stocks out▪ Ensure WHO quality-assured medical supplies closely accessible to

population at risk and patients

▪ Some countries do not have a single national electronic patient-based database to allow effective M&E

▪ Insecticide Residual Spraying (IRS) activities are not conducted according to international quality standards in many instances

▪ Establish an electronic national databases with patient-based data for analysis

▪ Implement independent M&E of IRS to ensure quality and measure impact


▪ There is shortage of properly trained health personnel in several high endemic areas.

▪ Maintain awareness within health systems and community to ensure detection and treatment of cases


HIGHLY PRELIMINARY

▪ Effective treatment is available but costly, access is challenging and requires specific skills to be administered

▪ In addition to the antileishmanial medicines, some patients require blood transfusion, antibiotics and/or therapy against severe malnutrition

▪ Complex treatment for immunosuppressed patients (e.g. HIV, cancer, elderly)

▪ Rising resistance in South-East Asia (only one drug effec-tive as 1st line treatment; 2 drugs not effective anymore)

▪ Develop a preventive vaccine

▪ Develop new, cheaper oral drugs, not requiring cold chain

▪ Assess shorter regimen for first line treatment in East Africa

▪ Pursue further research on combination therapies to increase the number of treatment options



▪ Guidelines for case management are in place▪ Guidelines for disease surveillance and vector control are

planned to be published in 2019


▪ No bottleneck towards target

WHO 2030 target

# of endemic countries achieving target case fatality rate (3% for New World, 0% for Old World) due to primary VL1

56/75 (75%)0/75 (0%) 38/75 (50%) 75/75 (100%)




Technical progress

Category


1 New World regions include Americas. Old World regions include Europe, Western Pacific, Eastern Mediterranean, Africa, South-East Asia

Leishmaniasis – cutaneous (CL)Overview

▪ Caused by the protozoan Leishmania parasite which is transmitted by the bite of female phlebotomine sandflies; only 10-25% of those infected by the Leishmania parasite will develop the disease

▪ Causes skin lesions (mostly ulcers), leaving life-long scars and serious disability and stigma▪ Associated with malnutrition, population displacement, poor housing, a weak immune system and lack of

financial resources


87 countries are endemic for CL (2016)

In 2017 over 95% of new reported CL cases occurred in six countries: Afghanistan, Algeria, Brazil, Colombia, Iran (Islamic Republic of), Iraq and the Syrian Arab Republic


Vector control Insecticide spraying, insecticide-treated nets, and environmental management



Other Early diagnosis and prompt treatment are important

Case management The treatment of leishmaniasis depends on several factors including type of disease, concomitant pathologies, parasite species and geographic location. Medicines include pentavalent antimonials, amphotericin B, and others

WASH N/A

Number of new CL cases reported by WHO region in 2017Number of new CL cases reported in 2017

Burden of disease


Percentage of cases detected in the Eastern Mediterranean Region

Proportion of all detected cases treated/managed according to guidelines


Unknown

20%

2020 target

70%

≥ 90%

Current status

Estimated ~20%

Unknown

For more details, please visit: www.who.int/leishmaniasis/cutaneous_leishmaniasis/en/

HIGHLY PRELIMINARY


1 IHME Global Burden of Disease 2 Also referred to as non-endemic country 3 G-Finder report 2018

~260,000DALYs, 20171

~143,000New CL cases reported in 2017


▪ ~USD 44 million in global funding is dedicated to R&D for eliminating all types of leishmaniasis: ~USD17m for general research, ~USD 14 million for drug development, ~USD 13 million for other areas (e.g. development of preventive vaccines and diagnostics)3

▪ The contribution of many different organizations and countries is essential for the fight against leishmaniasis. Organizations active in fighting VL at the global level include MSF, DNDi, FIND, Gilead Sciences, Sanofi, and the Probitas Foundation

26%

68%

192,597

2015

4%

2013

4%21%

73%

55%

35%

10%

2017

216,134

142,635

WPRO

SEARO

EMRO

EURO

AMRO

AFRO

100-999

≥5000

No Autochthonouscases reported2

Not applicable

No data

0

<100

1000-4999

Target: Disease control

Leishmaniasis – cutaneous (CL)


▪ In the absence of a topical, not painful treatment it is very challenging to get patients with minor lesions willing to get diagnosed/treated▪ Getting medical supplies/devices to treat some 150,000 new cases per year will cost some USD 7-8 million. Until now domestic funding or external donors have not committed that level of financial support


▪ Current diagnosis based on parasitological tests and/or clinical features lacks adequate sensitivity in several endemic areas and laboratory diagnosis is not always available

▪ Develop affordable and more sensitive rapid diagnostic tests at species level which can be used at the health centre and community level (especially important in foci where several Leishmania species co-exist)

Diagnostics

▪ Incomplete understanding of barriers and factors linked to low diagnosis, treatment and reporting rates

▪ Identify challenges to improving diagnosis, treatment and/or reporting rates through research

▪ Improve understanding of the vector lifecycle for more effective vector control


▪ CL is mainly treated with pentavalent antimonials, difficult to obtain and to administer, including painful injections for patients.

▪ Better therapies, such as cryotherapy or thermotherapy are rarely implemented in highly endemic areas due to high price

▪ Develop oral/topical treatment that can be used at the health centre and community level is needed

▪ Include care for all skin NTDs in an integrated approach regardless of the specific causative agent

▪ Develop a preventive vaccine


unknown 66/87 (75%)44/87 (50%)# of CL endemic countries having reached 85% of all cases detected1 are reported and 95% of reported cases were treated

87/87 (100)

▪ Although capacity building is done regularly, the high turn over causes some gaps and some personnel is assigned to tasks without being specifically trained for

▪ Train community health workers and national health personnel for timely and adequate diagnosis and treatmentCapacity building

▪ Key interventions such as provision of medical supplies or M&E are fully dependent on external donors in several countries

▪ Increase domestic funding to procure quality-assured medicinesAdvocacy and funding

Enablers

▪ Regular coordination meetings in-country and regional occur although there is need to better dissemination the minutes of those meetings with all stakeholders

▪ Cross-border meetings not held


▪ Develop regular coordination mechanism in-country, regional and cross-border with dissemination of minutes to all stakeholders

▪ National guidelines for case management of CL are in place ▪ Distribute national guidelines at the local level to ensure implementation

▪ Reduce time elapsed between onset of symptoms and treatment by implementing activities aimed at early diagnosis and prompt treatment


▪ Several high burden countries lack the necessary medicines or physical treatment options for case managementSupply and logistics

▪ Ensure availability of medicines and/or physical treatment for case management (procured or donated) in all countries

▪ Improve access to diagnosis and treatment for rural populations

▪ Most countries use aggregate data which does not allow for in-depth analysis or struggle to accurately report

▪ Most countries lack comprehensive databases including disease and vector surveillance and control interventions data

▪ Establish electronic national databases with patient-based data for analysis, including vector surveillance and control interventions data

▪ Ensure cutaneous leishmaniasis is made notifiable and decouple roles dedicated to managing cases and reporting


▪ There is shortage of properly trained health personnel in several high endemic areas.

▪ High turn over of health personnel poses a challenge to consistently have trained personnel

▪ Maintain awareness within health systems and community to ensure detection and treatment of cases



▪ Guidelines for case management are in place▪ Guidelines for disease surveillance and vector control are planned to

be published in 2019



HIGHLY PRELIMINARY



The precise burden of CL remains to be calculated. The treatment is complex. The key actions towards controlling the disease include: Develop and scale up easy-to-administer oral/topical treatment which could be used at a health centre level Improve the affordability and sensitivity of rapid diagnostic test for easy detection of cases Understand the burden of the disease through improving surveillance and establishing a patient database to ensure effective monitoring of the impact of the control interventions

WHO 2030 target


Technical progress


1: Detected through active case search and/or strengthened passive surveillance

LeprosyOverview

Current status (2017) Impact indicator 2012 2020 target

Reduction of grade 2 disabilities in newly detected cases 2.19/million Below 1/million 1.7/million

Reduce new grade 2 disabilities in new child cases No data Zero 2392



Vector control N/A

Preventive chemotherapy Single dose rifampicin administered to all contacts of detected cases

WASH


Case management Multi-drug therapy lasting 6-12 months combines dapsone, rifampicin, and clofazimine Treatment of immunological lepra reactions (type 1 and 3) and nerve damage Disability management and rehabilitation Management of adverse drug reactions

Other Early detection of cases is important to contain spread of infection and prevent disabilities Behavioural change interventions to reduce stigma against leprosy Interventions to mitigate the impact of disabilities and stigma on mental wellbeing and social

participation


▪ Total of USD 11million in funding dedicated to R&D for leprosy of which is dedicated: ~7m general research, ~4m other1

▪ Contribution of many different countries, organizations and insitutions is essential for the fight against leprosy.


▪ Communicable disease caused by bacillus Mycobacterium leprae with average incubation period of 5 years

▪ The disease affects the skin, peripheral nerves, mucosa of the upper respiratory tract and the eyes and can cause permanent damage to the skin, nerves, limbs and eyes

▪ Likely transmitted by droplets from the nose and mouth during frequent contact with untreated patients

▪ Discrimination and stigma play major role in leprosy and overcoming them is essential to improve case finding

Burden of disease

Number of new leprosy cases, 2017

Leprosy is endemic in 122 countries globally with highest burden in South East Asia, Africa and South America

New leprosy patients with visible deformities, 2017

~200,000New leprosy patients diagnosed globally,

2017

~14,000

1 G=Finder report 20182 Figure based on incomplete data . Estimate including all countries is 400-500 cases

HIGHLY PRELIMINARY

For more details, please visit: https://www.who.int/lep/en/

Zero countries with discriminatory laws

25 discriminatory laws in 11 countries

No standardized data available

2%

AFRO

12.268

WPRO

SEARO 53%

24%AMRO

18%EMRO 3%

New leprosy patients with deformities by region, 2017

New child cases diagnosed with leprosy, 2017

~12,300

Reduction of stigma against the persons affected by leprosy

No. of Cases

101-1,000

1-10

Not reported

Not applicable

1,001-10,000

11-100

0

>10,000

Provision of clean water for wound care and routine self care including daily soaking of hands and feet to prevent secondary disabilities

Target: elimination of transmission

LeprosyWHO 2030 target

Impact indicator 203020252020 (provisional estimate) 2023


No bottleneck towards target Critical action required to reach targetCategory


Technical progress


▪ Mainly clinical diagnosis▪ Slit-skin smear examination and histopathology available for some

cases▪ PCR exists for referral facilities

▪ Develop point of care test to diagnose leprosy ▪ Create field-friendly diagnostic test for subclinical cases of infectionDiagnostics

▪ Limited understanding of host and agent factors ▪ Improve understanding of transmission of M. leprae▪ Develop understanding of potential transmission from armadillos to

humans


▪ Ongoing efforts to reduce of discrimination against persons affected by leprosy


▪ Drug donation for MDT from Novartis in place is expected to be renewed after 2020

▪ Limited availability of 2nd line drugs and drugs to mitigate reactions▪ Assisted devices to improve quality of life of persons affected by

disabilities due to leprosy are mostly available but often with poor access

Supply and logistics ▪ Bring drug supply chain systems in line with annual leprosy data▪ Identify drug donation programme for Single Dose Rifampicin ▪ Ensure availability of 2nd line drugs and drugs to treat leprosy

reactions▪ Ensure access to assistive devices including tailor-made footward

▪ Development of digitalized case based data management system is ongoing

▪ Integrated programme review – focus on reviewing progress in reaching the leprosy programme targets

▪ Mapping of all endemic areas under way

▪ Develop strong surveillance system (including mapping) to ensure detection of sporadic and hidden cases

▪ Routinely and periodically identify contacts for a better implementation of post-exposure prophylaxis strategies

▪ Develop monitoring of adverse events due to multidrug therapy and PC


▪ Guidelines for the Diagnosis, Treatment and Prevention of Leprosy published;

▪ Guide for Surveillance of Anti-Microbial Resistance in Leprosy published;▪ Global Leprosy Strategy, Operational Manual, Monitoring and Evaluation

Guide published

▪ Create surveillance strategy for low endemic settings▪ Develop validation/verification guidelines


▪ Limited capacity of laboratories for diagnostic services ▪ Limited corrective surgery, wound care and disability care for persons

with disabilities due to leprosy

▪ Mapping tool to plan, monitor and document reduction of disease burden

▪ Ensure access to corrective surgery for improving appearance and function



▪ Collaboration with ministries of social justice and empowerment and other departments to ensure reach of services is ongoing in some countries

▪ Collaboration with donors and partners in implementing programme▪ Collaboration with communities especially to address stigma and

discrimination▪ Integration of leprosy programme with other health programmes is

ongoing in specific countries (e.g. yaws, other case-management NTDs, tuberculosis, disability care)

▪ Closely coordinate with the UHC/PHC efforts▪ Ensure collaboration with ministries of social justice and

empowerment and other departments to increase reach of services▪ Strengthen coordination with other skin diseases and use common

indicators▪ Engage with private sector (especially dermatologists) as well as

traditional healers▪ Engage with communities and affected persons to combat stigma and

discrimination▪ Integrate with other relevant programmes for case detection, patient

and programme management and surveillance


▪ Many national leprosy programmes depend on external funding▪ High level monitoring to sustain interest in elimination of leprosy▪ Promotion of interest and investment in research ongoing – clinical,

basic and operational research

▪ Advocate with governments to sustain and increase domestic funding▪ Carry out mid-term evaluation of high level monitoring to inform

ministries on progress and gaps and to increase engagement▪ Inform policy based on evidence from research


▪ Clinical expertise among frontline health workers is often not sufficient▪ Promotion of counselling services in health facilities providing leprosy

services is ongoing

▪ Ensure capacity of frontlline as well as referral-level health staff▪ Develop and disseminate e-learning modules▪ Develop and disseminate counselling procedures

Capacity building

Enablers

▪ Single dose rifampicin to all contacts of new patients▪ Limited information on anti-microbial resistance in leprosy; resistance

of first-line drugs appears low

▪ Swiftly adopt new post-exposure chemo-prophylaxis (rifampicin)▪ Identify and screen population at risk for treatment, e.g., contacts▪ Develop preventive vaccine


HIGHLY PRELIMINARY

# of countries with zero new indigenous leprosy cases 9550 75 120

% children diagnosed with leprosy <3%8% <5% 0

▪ Reduce stigma to encourage new cases to reveal themselves▪ Enhance coverage of medical and social rehabilitation

Lymphatic filariasis (elephantiasis)Overview

Current status Impact indicator 2012 2020 target

Global elimination as a public health problem (% endemic countries) 3% 100% 23%



Preventive chemotherapy

WASH

Vector control

Veterinary public health ▪ Efforts to prevent transmission of Brugia malayi among animals and humans

Case management Surgery cures hydrocele Skin care, exercises and elevation prevent severity and progression of lymphedema Treating acute attacks Doses of albendazole with diethylcarbamazine and/or ivermectin to treat infected persons


▪ WHO launched the Global Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000 which represents the aggregate effort of allindividual stakeholders towards LF elimination. Advocacy and fundraising is supported by The Global Alliance to Eliminate Lymphatic Filariasis (a public-private partnership of over 150 partners committed to supporting GPELF).

▪ Currently, USD ~15 million in funding is dedicated to R&D for fighting LF: ~5m general research, ~6m drugs, ~4m unspecified


▪ Caused by infection with the filarial parasites Wuchereria bancrofti, Brugia malayi, Brugia timori▪ Transmitted by mosquito species from genera Aedes, Anopheles, Culex, Mansonia▪ Causes morbidity due to damage by adult parasite nests in the lymphatic vessels and microfilaria released in the blood▪ Impaired lymphatic function leads to chronic, overt manifestations of lymphedema and hydrocele as well as acute

episodes of adenolymphangitis▪ Persons with physical impairment due to LF live with physical disability and are often socially excluded

1 IWER 9344HME Global Burden of Disease2 WHO Global Health Estimates

Burden of disease

Progress in scaling down Population requiring MDA in 2017

HIGHLY PRELIMINARY

For more details, please visit: www.who.int/lymphatic_filariasis/disease/en/

0% 20% 40% 60% 80% 100%

Western Pacific

South-East Asia

Eastern Mediterranean

Americas

African

Proportion of known endemic implementation units (IUs) that have completed transmission assessment surveys (TAS) and

no longer require MDA

Prior to 2016 2016 2017 2018

Current status

~1.2 million~890 millionPeople living in endemic areas requiring

mass drug administration 20172 DALYs, 20163

~50 million People infected with LF 20171

▪ Lymphatic filariasis is endemic in 72 countries across Africa, the Americas, Eastern Mediterranean, South-East Asia and the Western Pacific region

▪ Mass drug administration to stop the spread of infection using recommended regimens of ivermectin, diethylcarbamazine, and albendazole (in different combinations depending on co-endemicity with loiasis and onchocerciasis)

▪ Hygiene of affected limbs is essential for LF morbidity management▪ Sanitation improvements can reduce vector breeding habitats

▪ Vector control to supplement MDA depends on parasite-vector species and local ecology, e.g. the use of insecticide-treated nets in areas where Anopheles is the primary vector for filariasis

Target: elimination as a public health problem

Lymphatic filariasis (elephantiasis)WHO 2030 target



Category

Technical progress

▪ Risk of countries shutting down their programs when validated by WHO and potential for resurgence of the disease without robust post-validation activities in place

▪ Systematic non-adherence could impact effective coverage and MDA programme success



Enablers


▪ Countries to develop or update national NTD strategic plan including potential changes with alternative MDA strategies and focus on UHC

▪ Ensure robust post-validation activities to avoid risk of countries closing programmes after validation by WHO


▪ Improve planning, request sufficient medicines and diagnostic tests well in advance of programme activities

▪ Make contingency plans for failed impact assessments or emergencies

Supply and logistics

▪ Map areas with uncertain occurrence of the disease to determine need for MDA▪ Identify epidemiological settings where current thresholds for stop MDA surveys

may not be sufficient, define new thresholds and develop survey methodology▪ Determine the combination of indicators to best evaluate impact of IDA▪ Develop clearer guidance on the standard of surveillance and interventions that

need to be sustained post-MDA ▪ Establish integrated surveillance platforms▪ Develop alternative M&E strategy for new MDA regimens


▪ Include LF morbidity management modules in health workforce training curriculums

▪ Include LF interventions in essential UHC packages


▪ Integrate vector management and surveillance (where feasible) through the Global Vector Control Response to supplement MDA

▪ Strengthen integrated management of skin NTDs▪ Create link with Global Surgery Initiatives to ensure availability of surgery in IUs

with known hydrocele burden, and with Social services, rehabilitation and mental health to build capacity for assessment and referral for psychosocial support

▪ Coordinate with STH and onchocerciasis programmes for evidence based planning when IUs implement TAS and stop MDA

▪ Expand local partnerships to sustain morbidity management and surveillance post-validation


▪ Advocate the success and cost effectiveness of LF interventions to facilitate government support and mobilize resources


▪ Build capacity for quality pre-TAS and TAS implementation▪ Increase awareness and reduce stigma associated with LF in the community▪ Disseminate existing morbidity management and disability prevention toolkit

tools (situation analysis, patient estimation methods, DIP, MMDP modules)▪ Build capacity in social mobilization, microplanning, and supervision

Capacity building

▪ Continued research around correlation of biological markers of infection and exposure with transmission interruption


▪ Update Aide Memoire with new targets, indicators and link to UHC▪ Specify the minimum standards for post-validation surveillance and how to set up

and maintain activities▪ Define criteria to achieve verification of interruption of LF transmission▪ Develop policies and strategies for treatment specific to urban settings


▪ Develop diagnostic test which is not cross-reactive with L. loa▪ Improve reliability of the Alere Filariasis Test Strip (FTS) and the Brugia Rapid

point-of-care cassette test (BRT)▪ Ensure reporting of issues with diagnostic tests for quality monitoring

Diagnostics

▪ Lack of prioritization

▪ Remote, rural areas and islands are difficult to reach▪ Inconsistent delivery of MDA and impact surveys in some

countries

▪ Lack of resources for M&E implementation▪ Identification of focal, residual infection can be challenging▪ Limited areas where endemicity was not determined when

programmes started▪ Health workers and/or programme managers at different

levels may be incentivized to report inflated coverage figures

▪ Limited capacity within Primary Health Care to deliver the minimum package of care for morbidity management

▪ Limited collaboration and coordination with:– Environmental sector and vector control– Primary Health Care system– Deworming and onchocerciasis elimination

programmes

▪ Limited prioritisation and resourcing for LF MDA in some countries

▪ Lack of technical and operational capacity in some countries

▪ Good understanding of transmission and parasite lifecycle▪ Uncertainty of the impact of zoonotic B. malayi on efforts to

interrupt transmission

▪ Guidelines are available for MDA, M&E, and morbidity management

▪ Specific guidance for post-validation surveillance is needed▪ Criteria for elimination of transmission are not defined

▪ Diagnostic tests are available for recommended M&E▪ Loa loa infection can create a false positive result of the

recommended LF antigen test.

▪ Multiple rounds of annual MDA are effective at reducing infection prevalence below target thresholds with high coverage

▪ The new, triple-therapy regimen of ivermectin, DEC and albendazole is more effective at clearing mf for longer periods of time than two-drug regimens

▪ Surgery cures hydrocele▪ Management of lymphedema reduces acute attacks

▪ Start MDA in all endemic districts and sustain high coverage▪ Implement IDA and other alternative MDA regimens where warranted▪ Ensure accessible and inclusive care for lymphademia as part of the package

(setting a target for effective "affected people" platform/ IU and stigma/mental wellbeing) to ensure more holistic NTD programming and better health outcomes



# countries implementing post-MDA or post-validation surveillance 4026 37 72 (100%)

# countries that meet WHO criteria for validation of elimination as a public health problem 3419 23 58 (81%)

HIGHLY PRELIMINARY

Population requiring MDA 180mnTBC 330mn 0

MycetomaOverview

▪ Caused by several microorganisms of bacterial or fungal origin, and based on its causative agent is classified as actinomycetoma (bacterial mycetoma) or eumycetoma (fungal mycetoma).

▪ Causes chronic infection of skin and subcutaneous tissues characterized by large deformities, disabilities, and is associated with severe morbidity and increased mortality. It affects the skin, connective tissue, muscle and bone

▪ The mode of transmission is currently not well understood


The causative organisms are distributed worldwide but are endemic in tropical and subtropical areas in the ‘Mycetoma belt’ which includes the Bolivarian Republic of Venezuela, Chad, Ethiopia, India, Mauritania, Mexico, Senegal, Somalia, Sudan and Yemen.

Number of reported Mycetoma cases by the systematic review 2013 and WHO Survey 2014 – 2016

Burden of disease

N/A N/A N/A



N/A

For more details, please visit: https://www.who.int/buruli/mycetoma/en/

HIGHLY PRELIMINARY



▪ The WHO has supported efforts through burden assessment, organization of consultative meetings to identify priority areas, and through support of international trainings to build national capacities in selected countries

▪ The Mycetoma Research Center in Khartoum (a WHO collaborating center) is a lead on the research and control efforts against mycetoma. Other organization and partners are also involved mainly in research

▪ An informal global working group on mycetoma coordinated by CDC Atlanta is facilitating a forum to address various aspects of the disease.

840 casesReported in a WHO survey in 2016. This most

likely underestimates the actual burden


Vector control N/A


Other Protective clothes and shoes

Case management Treatment depends on the causative organisms: bacterial - long term antibiotics combination fungal - combined antifungals (mainly itraconazole) and surgery

Wound care

WASH Personal hygiene

Veterinary public health Keeping domestic animals far from human dwellings has been shown to reduce risk of mycetoma

Mycetoma cases everreported or published

<_______________>

<_______________>

Mycetoma, Chromoblastomycosis & other deep mycoses

HIGHLY PRELIMINARY


Number of countries where mycetoma is included in national control programs and surveillance system

81 4 15

WHO 2030 target


MycetomaMycetoma, Chromoblastomycosis & other deep mycoses


• The diagnosis is largely based on clinical presentation• Causative organisms are identified through direct examination,

microscopy or culture of the grains, or through PCR of biopsies.

• Develop diagnostic test (preferably point-of-care)Diagnostics

• Health promotion to increase use of protective clothes and wearing of shoes is ongoing

• Separation of animals from human dwellings decreases incidence• Current treatment is either antibiotics, antifungals or a

combination delivered for several months.

• Improve dwellings and living conditions• Develop better treatment (shorter duration and high efficacy)


• The mechanism of transmission of mycetoma to be fully understood which limits the development of a sound preventive strategy.

• Understand transmission pathwaysScientific understanding

• Collaboration with various research institutes, drugs and diagnostics developers initiated

• Establish collaboration with various research institutions, drugs and diagnostics developers, manufacturers and donors required


• Continuing integration across skin NTDs• Peripheral health workers in many areas may not be able to

recognize mycetoma early• In many endemic countries the majority of health workers lack

the required knowledge and skill to manage cases

• Train health workers and community health workers across skin NTDs to improve early detection

• Improve the diagnostic and managing capacities of health care system in the endemic regions of the countries

Capacity building

• Only Sudan has a national control plan • Include mycetoma in their strategic plans against NTDs or develop specific plans in endemic countries


• No donation of medicines• Countries procure and manage their supply system

• Secure donations of medicines or significantly reduced pricesSupply and logistics

• No surveillance protocol or system, no standard indicators• No M&E system

• Develop guidance on surveillance with standard indicators• Establish M&E system or integrate data collection with national

health information system


Technical progress

• No global guidance on case management, surveillance, prevention and control

• Develop global and national guidance on case management, surveillance, prevention and control



• Partners and various mycetoma research institutions are exerting maximum efforts to bring attention to mycetoma

• Some partner and government engagement, however, increase is needed

• Ensure and sustain political commitment from endemic countries and partners to mobilize funds and human resources

• Increase commitment for drug donation or reduced price• Engage and mobilize community to support programme

implementation


Enablers

• Health systems are not prepared to provide control services or run control programmes


• To be confirmed



Category Assessment Current status Actions required

Onchocerciasis (river blindness)Overview

▪ River blindness is caused by the parasitic worm Onchocerca volvulus ▪ Causes severe itching, disfiguring skin conditions and visual impairment, including permanent blindness▪ Transmitted to humans through repeated bites of infective Simulium blackflies which breed mostly along

fast-flowing water▪ By 2017, 1.8 million people no longer required treatment (post-treatment surveillance completed) and 4

countries have been verified by WHO as having eliminated transmission


Population at risk worldwide in millionsPopulation at risk in 2017

Burden of disease



# of countries eliminating transmission – Americas 0 6 (2022) 4

eliminating transmission in Yemen 0 1 (2015) 0

~1.3 millionPopulation at risk in 2017

For more details, please visit: https://www.who.int/onchocerciasis/en/

205 millionDALYs lost, 20172

HIGHLY PRELIMINARY


1 IHME, global burden of disease2 GBD 2017 Lancet 2018; 392: 1859-9223 In 2013, South Sudan with 5.7m cases was transferred from EMRO to AFRO4 G-finder report 2018

~21 millionExisting cases estimated in 20171


▪ Total of USD 12 million in global funding dedicated to R&D for eliminating Onchocerciasis: ~1m general research, ~9m new drugs, ~1m preventive vaccines, ~1m diagnostics4

▪ Contribution of many different countries, organizations and institutions is essential for the fight against onchocerciasis. Some of these organizations include: Onchocerciasis Control Programme (closed), African Programme for Onchocerciasis Control (closed), Expanded Special Project for the Elimination of NTDs (Africa), and Onchocerciasis Elimination Program for the Americas, NGDO Coordination Group and Bilateral Donors

PopulationThousands

<100

1,000-2,999

3,000-9,999

≥10,000

No PC required

No data

Not applicable100-999

Non-endemic

Elimination verified

0,4%

99,6%

2060,5%

4,7%

2012

186

0,1%

95,2%

2016

99,5%

2017

1313

WPRO

AMRO

AFRO

EMRO

EURO

SEARO



Other Where Loa coexists, systems to manage severe adverse events have to be in place

WASH N/A

Preventive chemotherapy Once to twice yearly community-based mass drug administration of ivermectin with adequate coverage for 10 or more years

Vector control Environmentally safe insecticide spraying of blackflies

Case management Ivermectin treatment

eliminating transmission in Africa where possible 0 Undefined 0

HIGHLY PRELIMINARYOnchocerciasis (river blindness)

# countries verified for achieving elimination of transmission 64 4 10

# countries which stopped MDA for ≥ 1 focus 219 20 34

# countries which stopped MDA for ≥ 50% of population 136 8 >14

# countries which stopped MDA for 100% of population 94 4 > 10

WHO 2030 target


Target: Elimination of transmission

▪ Goal may not be feasible with current tools in hyper- and holoendemic areas

▪ Cost of mapping and Loa loa strategies

▪ Resurgence if MDA is stopped prematurely


Technical progress

Assessment of actions required to meet 2030 targets No bottleneck towards target Critical action required to reach target

Category Assessment

Diagnostics ▪ Continue to evaluate performance of diagnostics

▪ Develop target product profiles for new diagnostics designed for the needs of the programs

▪ Develop a confirmatory diagnostic for use in low-prevalence settings and for stopping MDA decision

▪ Relate prevalence with serology to vector transmission indices

▪ Serological test available, but suboptimal


▪ Develop a macrofilaricide to accelerate interruption of transmission.

▪ Develop macrofilaricide that could be used in Loa loa co-endemic areas

▪ Demonstrate effectiveness and safety of use of moxidectin in children (moxidectin would theoretically replace the need for 2x per year ivermectin)

▪ Once-to-twice-yearly ivermectin MDA is effective at breaking transmission but takes 10-15 years or more

▪ Ivermectin cannot be used safely in MDA settings in Loa loa/hypoendemic onchocerciasis co-endemic areas


▪ Develop understanding of transmission and transmission thresholds in hypo-endemic areas to inform guidelines

▪ Good understanding of the transmission and parasite life-cycle


▪ Strengthen integrated management of skin NTDs and use common indicators

▪ Increase collaboration with vector management

▪ To be confirmed

Enablers


▪ Develop advocacy plan

▪ Continue to ensure donor support

▪ Seek cost-effective interventions

▪ Develop a partner forum

▪ Most programmes dependent on external donor support

Capacity building ▪ Continue efforts to develop entomological and laboratory capacity▪ Many countries with limited capacity to perform needed laboratory-based tests

▪ Shortage of entomological capacity


▪ Include Onchocerciasis in country UHC packages

▪ Scale up national onchocerciasis committees in countries where these are currently not present and support their functioning

▪ Develop an onchocerciasis partner forum

▪ Good coordination among stakeholders (through NTD NGO network, ESPEN and OEPA)

▪ National onchocerciasis elimination committees and national laboratories are needed to provide guidance to programs on onchocerciasis response

▪ Country ownership of and investment in their programmes is variable

Supply and logistics ▪ Develop a plan to decrease the logistical burden of obtaining needed diagnostics

▪ Develop a plan to facilitate the addition of new medications to the supply chain as they become available

▪ Strong supply chain for medications donated by Merck

▪ Ensuring supply of diagnostics in-country is challenging


▪ Design operationally feasible elimination mapping

▪ Develop and disseminate protocols for standardization of mapping to ensure consistency of data

▪ Improve mapping and sampling in Loa-loa co-endemic areas to allow for granular treatment approaches

▪ Close data gaps in hypoendemic areas through development of more easy-to-use tools

▪ Mapping of hypoendemic areas in Africa is incomplete

▪ M&E strategies are being updated for current tools

▪ Strategy for post-elimination surveillance needs to be developed



▪ Provide clear guidance on strategies in areas that are hypo-endemic for onchocerciasis and co-endemic for Loa loa

▪ Update entomological guidance

▪ Update manuals for programme managers with strategy for elimination and elimination verification process

▪ Guidelines for stopping MDA and post-treatment surveillance are available

▪ Better guidance for steps required to achieve interruption of transmission is needed

▪ Continue effort to ensure in-country capacity for the performance of quality assured diagnostics


▪ Not all countries have in-country capacity to perform laboratory testing in quality assure manner

Current status Actions required

RabiesOverview


Vector control N/A

Preventive vaccines are recommended for people at high risk of exposure to rabies e.g. laboratory staff working with the rabies virus, veterinarians, animal handlers


Mass vaccination of dogs (vaccinating 70% of dog populations in high-risk areas) is a cost-effective measure to break the rabies transmission cycle

Veterinary public health

Timely diagnosis and accurate risk assessment of wound and bite circumstances are important (rapid diagnostic tests combined with clinical signs)

Education, especially for children, on how to avoid being bitten and what to do in the event of a bite is crucial to prevent deaths from rabies

Other

Post-exposure prophylaxis (with the rabies vaccine as well as immunoglobulin for severe category 3 exposures) is needed immediately after exposure to a rabid animal

Thorough wound washing

Case management

Access to water for wound washing (e.g. with soap and water) post-exposure can significantly decrease the viral load in the wound

WASH

DALYs by region (‘000)Endemicity of dog-transmitted human rabies, 2016

Burden of disease


Regional Elimination


TBC

2020 target

Elimination in:▪ Latin America (2015)▪ South-East Asia (2020)▪ Western Pacific (2020)

Current status

▪ Postponed ▪ Timeline under revision▪ Timeline under revision

For more details, please visit: https://www.who.int/rabies/en/

HIGHLY PRELIMINARY

SOURCE: All data sourced from WHO (e.g. Global Health Estimates) unless otherwise indicated

Dog-transmitted human rabies is present or suspected in 89 countries, mostly in Africa and Asia

~59,000Deaths, 2015

~1.6 millionDALYs, 2016

~851,000 People receiving post-exposure

prophylaxis, 2017


▪ Organizations and institutions involved in the fight against rabies include the Global Alliance for Rabies Control (GARC), FAO, OIE, WHO (Rabies Consultative Group), Partners for Rabies Prevention

16%1%

~3,1501% 7%

1%38%

2016

37%

1%

2000

8%18%26%

47%

~1,600

-4% p.a.

EURO

AMRO

WPRO

EMRO

SEARO

AFRO


▪ Caused by the rabies virus (RABV) and other lyssaviruses▪ Causes progressive and fatal inflammation of the brain and spinal cord; there are two types of rabies:

– Furious rabies (80% of cases) - people exhibit hyperactivity and excitable behavior with death occurring within few days

– Paralytic rabies (20% of cases, often misdiagnosed) - muscles gradually become paralyzed, leading to eventual coma and death

▪ Transmitted to humans mainly through the bites and scratches of dogs (up to 99%), though rabies can also be transmitted by various other mammals

▪ ~40% of rabies victims are children under 15 years of age

Present

Suspected

Absent


Rabies



Category

Technical progress

▪ TBC



Enablers

▪ Support countries in developing multi-sectoral plans for rabies through collaboration between United against Rabies and partners

▪ Understand potential for cost-effectiveness in combining rabies interventions with other diseases (e.g. leishmaniasis, echinococcosis)


▪ One Health approach (WHO, OIE, FAO)

▪ UAR collaboration established

▪ OIE Rabies Vaccine Bank supports the implementation of dog vaccination campaigns

▪ TBCAdvocacy and funding

▪ UAR donor landscaping ongoing▪ Potential investment of Gavi in rabies vaccines▪ World Rabies Day helps raise awareness

▪ Train health workers on rabies exposure assessment, intra-dermal administration of PEP (more cost effective than intramuscular)

▪ Enhance information, education and communication (IEC) among non-health organizations

Capacity building ▪ TBC

▪ Model with a ratio of the number of persons bitten/number of doses of vaccine administered and calculation of loss between first and last dose

▪ Improve understanding of vaccination safety


▪ Good understanding of disease pathology▪ Gavi learning agenda available to drive research

progress


▪ Strengthen rabies control framework by the WHO resolution taking into account the One Health approach

▪ Improve country-level coordination of relevant activities, including who pays


▪ Global Strategic Plan ‘Zero by 30’ with operational plan how to achieve zero deaths by 2030

▪ Strengthen anti-rabies services with the EPI vaccines (same cold chain, stock management)

▪ Improve monitoring of vaccine/RIG use and forecasting of demand▪ License monoclonal antibody products as an alternative to RIG▪ Ensure availability of quality-assured human and animal PEP vaccines▪ Develop innovative technologies to improve access to treatment e.g.

drone delivery of post-exposure prophylaxis

Supply and logistics ▪ Country studies on logistics of PEP completed▪ OIE dog vaccine bank operational▪ Weak vaccine demand forecasting results in stock-

out issues

▪ Improve country compliance with reporting and data availability

▪ Introduce surveillance indicator of suspicious death after bite - would be investigated in the same mode as the PFA


▪ DHIS2 module on rabies has been finalised

▪ Ensure health facility equipment for wound washing and vaccine storage

▪ Enhance lab capacity▪ Develop anti-rabies services with trained staff for the intradermal

vaccine administration route and wound infiltration with RIG▪ Maintain the workforce for diagnosticians


▪ TBC

▪ Continue dissemination of guidance to accelerate country uptakeOperational and normative guidance

▪ Guidelines in place include:

– WHO guidance on rabies prevention, vaccines, laboratory diagnostics and case management in humans and animals available (TRS No 1012)

– OIE standards on prevention/control, stray dog population control, diagnostic methods, international movement of dogs and cats originating from rabies infected countries

▪ Global strategic plan for rabies “Zero by 30” (by WHO, OIE, FAO, GARC)

▪ Develop field-deployable ante-mortem diagnostic test for use in primary healthcare facilities

▪ Simplify postmortem diagnosis of rabies in animals (e.g. non-invasive sample collection combined with RDT) to improve post-bite treatment

Diagnostics ▪ Comparative assessments of various diagnostics

ongoing

▪ Effective preventive and post-exposure vaccines ▪ Adapt mass dog vaccination methods to the settingEffective intervention


# endemic countries having reached 70% vaccination coverage of dogs in high risk areas TBCTBC TBC TBC

# endemic countries having reduced mortality due to dog transmitted rabies by 50% 47TBC 13 TBC

# endemic countries having eliminated canine rabies as a public health problem – defined as having achieved zero deaths from rabies

TBC89 (2015) TBC TBC

WHO 2030 target

HIGHLY PRELIMINARY


Monitoring & Evaluation: TBC Supply & Logistics: TBC Capacity building: TBC

ScabiesOverview

▪ Caused by a microscopic mite Sarcoptes scabiei var hominis that is transmitted person-to-person through close skin contact

▪ The female mite burrows in the skin and lays eggs, triggering an immune response that causes intense itching and rash.

▪ Bacterial infections can complicate the disease leading to serious consequences such as severe soft tissue infections, septicaemia, kidney disease and rheumatic fever.


Accurate data on incidence and prevalence are not available


Vector control N/A

Preventive chemotherapy MDA is effective using oral ivermectin and topical scabicides


Other N/A

Topical scabicides such as permethrin, benzyl benzoate, malathion, & Sulphur ointmentOral ivermectinImportance to treat all household contactsSpecialist case management of crusted scabies cases.

Case management

WASH N/A

Cases per region in 2016Age-standardised disability-adjusted life-years per 100 000 people1

Burden of disease


N/A


N/A

2020 target

N/A

Current status

N/A

For more details, please visit: www.who.int/neglected_diseases/diseases/scabies/en/

HIGHLY PRELIMINARY


1 https://www.sciencedirect.com/science/article/pii/S1473309917304838#fig3

~5.6mDALYs, 20161

455 millionPeople affected by scabies at any time


▪ Contribution of many different countries, organizations and institutions is essential for the fight against scabies. Some of these organizations include: International Alliance for the Control of Scabies and the International League of Dermatological Societies

▪ Mass drug administration with ivermectin for lymphatic filariasis or onchocerciasis has had some impact on transmission, though these strategies miss some children at risk for infection

10-20

30-40

0-10

20-30

50-60

70-80

40-50

60-70

90-100

110-120

80-90

100-110

130-140

150-160

120-130

140-150

Not applicableNo data

0%

2016

2%

1,186

56%

WPRO

SEARO

EMRO

AMRO

EURO

AFRO


Scabies

# of countries incorporated scabies management in the UHC package of care TBC0 TBC TBC

HIGHLY PRELIMINARY

# of countries using MDA intervention nationwide 60 3 TBC

WHO 2030 target


Technical progress

Category



Diagnostics ▪ Good methods for individual diagnosis▪ New international consensus criteria 2019 will facilitate

programmatic screening

▪ Validate clinical diagnostic algorithms for programmatic use▪ Develop population level diagnostics to facilitate integration with other

NTD programme activities


▪ Understand the life cycle and impact of treatments on individuals

▪ Significant research has been performed to define the impact of mass drug administration strategies on the transmission of scabies

▪ Evaluate epidemiological burden globally▪ Improve understanding of rebound of transmission in settings where MDA

with ivermectin for other NTDs has stopped


▪ To be confirmed ▪ Strengthen integration of management of skin NTDs. Use indicators common to other (co-endemic) skin NTDs.

Enablers

Advocacy and funding ▪ Currently minimal donor support ▪ Develop a global advocacy plan and partner forum▪ Aim to secure low-cost or donated access to both oral ivermectin and

topical scabicidals

Capacity building ▪ Needs have not been assessed ▪ To be confirmed


▪ Informal bodies exist to support coordination ▪ Include scabies and impetigo in national UHC and IMCI guidelines▪ Incorporate scabies into national NTD programme planning documents in

known highly endemic countries

Supply and logistics ▪ Work in progress towards adding ivermectin to Model List of

Essential Medicines▪ Identify potential generic manufacturers of ivermectin that might be able

to obtain WHO pre-qualification▪ Ensure good quality prescribing practices in skin neglected tropical

diseases


▪ Burden of the disease and its prevalence are poorly understood

▪ Design operationally feasible mapping▪ Develop and disseminate protocols for standardization of mapping to

ensure consistency of data▪ Develop system for tracking scabies outbreaks


▪ Provisional framework in development ▪ Develop guidance for mapping endemic countries▪ Develop guidance for programmatic implementation of MDA


▪ WHO skin NTDs manual provides some guidance on diagnosis and management in the primary healthcare setting

▪ Develop national plans for staff training in diagnosis and management of scabies

▪ Strong evidence for effectiveness for ivermectin MDA in combination with topicals for those who cannot take ivermectin

▪ Determine if ivermectin-based single-dose MDA rather than 2 doses 7 days apart, is effective for programmatic use

▪ Identify alternative strategies that require only a single dose or application in MDA






SchistosomiasisOverview


Majority of people requiring treatment live in Africa

Number of DALYs per region in 2016Number of DALYs in 2016, thousands

Burden of disease

HIGHLY PRELIMINARY


1 IHME Global Burden of Disease 2 Eastern Mediterranean Region, Caribbean, Indonesia and the Mekong River basin 3 Americas, Western Pacific Region, Selected African countries

~24,000Deaths in 2016


~143 millionPeople suffering from Schistosomiasis in 20171


▪ Total of USD ~18 million in global funding (2018) is dedicated to R&D for fighting schistosomiasis: ~9m general research, ~5.5m drugs, ~5.5m preventive vaccines, ~1m diagnostics, ~2.5m unspecified1

▪ Contribution of many different countries, organizations and institutions is essential for the fight against schistosomiasis. Some of these organizations and institutions include: Global schistosomiasis Alliance and its members, NGOs organized in the NNN, Merck, and donors

▪ Parasitic disease caused by the schistosoma trematode worms▪ There are two main types of the disease:

– Intestinal schistosomiasis results in abdominal pain, diarrhoea, blood in the stool; in advanced stages also enlargement of liver and spleen, fibrosis, portal hypertension, and accumulation of fluid in the peritoneal cavity.

– Urogenital schistosomiasis results in blood in urine; in advanced stages also fibrosis of bladder and ureter, and kidney damage. Genital forms could manifest in pain of the testicle and blood in the sperm in men, abdominal and pelvic pain in women, pain during intercourse, ectopic pregnancies, and infertility; association with HIV transmission has been demonstrated in co-endemic areas.

▪ Transmitted to humans through contact with infested water (e.g. swimming, washing clothes, fishing); Inadequate hygiene increases risk of transmission

▪ The disease affects poor rural communities but has been spreading to urban areas and to tourists visiting endemic areas

6%

2016

4%

89%

~2.5m

AFRO

EMRO

AMRO<1.3

1.3-9.0

9.0-33.6

≥33.6

Officially no casesreported

No data

Not applicable


Vector control Snail control

Veterinary public health Treatment of animals, keeping animals out of transmission sites

Other Behavioral change and environmental management interventions

Case management One dose treatment with praziquantel

WASH Access to safe water Improved sanitation

Preventive chemotherapy Regular treatment with praziquantel of at-risk groups (school-aged children, pre-school aged children, adults, communities in highly endemic areas, people in occupations involving contact with infested water)


Regional Elimination

Percentage of school-aged children covered with PC


TBC

TBC

2020 target

2015 – multiple regions2

75%

Current status

TBC

71%

2020 – multiple regions3

TBC

For more details, please visit: www.who.int/schistosomiasis/en/


SchistosomiasisWHO 2030 target



Category

Technical progress

▪ Potential decline in the role of big pharma due to clear desire to transition to national financing which may become a threat to MDA if national financing fails

▪ Zoonotic reservoirs could continue transmission

▪ Reintroduction of disease by migration

▪ Bounce-back of the disease if MDA is stopped without sustainability interventions in place (e.g. WASH)



Enablers


▪ New guideline includes treatment of all at risk groups

▪ Process for verification of the transmission of schistosomiasis developed

▪ Snail control plans developed by many countries

▪ No bottlenecks towards the targetPlanning and governance

▪ New guideline include treatment of all at risk groups

▪ Lack of PZQ for adults is a barrier to achieving interruption of transmission

▪ Ensure there is enough praziquantel to treat all in need and that it is available for access ▪ Advocate for donated pediatric formulation of PZQ when available for the PC in PSAC


▪ Working group established to provide new guidance for M&E and micromapping and impact assessment

▪ Collect M&E data from per-SAC, SAC and adults to inform optimal treatment strategy▪ Implement strategies/precision mapping to support targeted MDA at lower administrative/ community

levels▪ Utilize environmental mapping through eco-epidemiology studies using new technologies (drone

mapping, environmental DNA, etc.)▪ Actively monitor MDA impact for potential strategy adjustment


▪ Manuals on WASH and NTD published▪ Advocacy document on schistosomiasis

and HIV published

▪ Coordinate interventions with ministries and WASH organizations in ensuring access to clean water and behavioural change interventions to prevent bounce-back

▪ Coordinate MDA activities with other NTDs for efficiencies▪ Include effective and accessible/inclusive referral systems to specialized disease management capacity


▪ Need of country financial contribution to the programme

▪ Mobilize extra resources for progress towards the ultimate goal of elimination of transmission which would allow for stopping MDA

▪ Donate molluscicides and PZQ


▪ Manual on use of molluscicide published

▪ FGS atlas published to help in diagnostic

▪ Manual on morbidity management under development

▪ Manual on malacology and web training platform and app under development

▪ Support training of health staff in lab diagnostic, clinical management of cases and FGS, malacology, and snail controlCapacity building

▪ Research ongoing regarding indicators of morbidity

▪ Understand of zoonotic transmission ▪ Better understand the implications of egg-negative but worm positive SCH for transmission▪ Develop strategies to maintain EPHP once achieved and prevent bounce back▪ Develop vaccination to prevent re-infection


▪ Process for verification of elimination of transmission developed

▪ WHO Manual on indicators of morbidity published

▪ Create guidance on how to sustain the depression of the disease to avoid bounce-back (e.g. WASH interventions in place before MDA is stopped)

▪ Develop methodological guidance for reaching target: diagnostic to be used and sampling strategy▪ Update the criteria for elimination as a public health problem if diagnostic is changed (the level of

infection is heavily reliant on the diagnostic used)


▪ Kato-Katz and urine filtration employed for measuring prevalence and intensity

▪ Intensity results vary greatly base on diagnostic used

▪ More sensitive and specific RDT under development by FIND

▪ Develop field-deployable diagnostic to evaluate pre and post-intervention prevalence for areas with low infections

▪ Create biorepository of SCH samples for assay development, validation and comparison between diagnostic tests

▪ Develop test for PZQ resistance▪ Develop molecular test for xenomonitoring▪ Validate and standardize diagnostic techniques for S. japonicum and S. mekongi

Diagnostics

▪ 250m tablets of PZQ available for MDA in SAC

▪ Research on improved formulation of praziquantel

▪ Some children may not receive MDA as they do not attend school; girls may be kept out of school for social or religious reasons

▪ Snail control implemented in some countries, however, environmental concerns exist

▪ Develop new safer molecules to complement PZQ in case of resistance▪ Effectively implement WASH strategies in communities, schools and health facilities in all endemic

areas▪ Expand treatment to include adults according to the guidelines▪ Implement MDA in community in order to reach other age groups and SAC not attending school. ▪ Overcome environmental challenges for snail control through specific guidelines on appropriate

strategies in different settings minimizing environmental impact▪ Implement test & treat strategies in countries striving for elimination of transmission



# countries which have eliminated SCH as a public health problem1 385 18 52

# countries where interruption of transmission has been verified 192 10 25

HIGHLY PRELIMINARY

1 Defined as: proportion of heavy intensity schistosomiasis infections <1%

▪ Build capacity building in malacology and snail control▪ Build lab capacity in surveillance ▪ Integrate activities in the Health system


▪ Weak lab capacity ▪ Low availability of skills in malacology

and snail control ▪ Low level of integration

Snakebite Envenoming

Overview

Global/regional incidence and prevalence incomplete; country level data is of variable quality/completeness

14459

500

5

1,600

Cases

2,263

Latin America & Caribbean

Oceania

Africa & Middle East

North America

Europe Asia

Prevalence of snakebite Cases and deaths per region, ‘000s, 2016

~2.7 millionPeople are bitten by snakes with

envenoming annually

~6-8 millionDALYs, 20151

~80,00 – 140,000Annual deaths


▪ Caused by the injection of a mixture of different toxins (“venom”) following the bite of a venomous snake or having the venom sprayed into the eyes by certain species of snakes

▪ The toxins can cause paralysis that may prevent breathing, cause bleeding disorders that can lead to a fatal hemorrhage, or cause other effects such as irreversible kidney failure and tissue damage that can lead to permanent disability, limb amputation and other sequelae.

▪ Risk factors include walking barefoot at any time, sleeping on the ground without a tucked-in mosquito net, and walking outside at night without a light

Burden of disease

For more details, please visit: www.who.int/health-topics/snakebite#tab=overview

HIGHLY PRELIMINARY


▪ USD 100 million in funding is dedicated to fighting snakebite by Wellcome Trust, USD3.8 million by Hamish Ogston Foundation, USD11.3 million by DFiD and USD4.0 million by the Lillian Lincoln Foundation

▪ The expected cost between 2021-2030 to achieve the 2030 goals is ~USD137M, including: ~USD27M for empowering communities, ~USD50M for treatments, ~USD37M for strengthening health systems, and ~USD23M for increasing coordination and resources

▪ Organizations involved in the fight against snakebite include: Global Snakebite Initiative (GSI), Médecins Sans Frontières (MSF), Health Action International (HAI), International Society of Toxinology (IST), African Society of Venimology (ASV) and Wellcome Trust. Additional comprehensive stakeholder mapping is needed

▪ Improving the safety, effectiveness and quality of existing antivenoms and ensuring affordable access by all who need then can lead to achievement of key target of 50% reduction in deaths and disabilities by 2030.



WASH ▪ Improved sanitation and access to drinking water helps eliminate risky behaviours

Vector control N/A

Veterinary public health ▪ Education of local communities to prevent snakebite envenoming of livestock and companion animals

Case management High quality snake antivenoms Ancillary treatments such as mechanical ventilation, wound care, infection control and surgery

Other▪ Housing improvements including beds with bed nets to prevent sleeping on the floor, improved

sealing of gaps in walls, roofs and around doors▪ Behavioural changes e.g. use of footwear, use of lights outdoors from dusk to dawn ▪ Community education to reduce risk and to seek health care


N/A – snakebite envenoming was only categorised as a WHO neglected tropical disease in 2017

1 Habib et al. (2015), Wellcome Trust

26

004

0

Deaths

111

80

USA & Canada:

3800-6500 (7-15)

Europe: 8000-9900 (30-128)

Asia: 1.2-2.0 Million (57000-100000)

Africa & Middle East 435000-

580000 (20000-32000)

Latin America & Caribbean:

137000-150000

(3400-5000)

Oceania: 3000-5900 (200-

520)


Snakebite Envenoming

# endemic countries achieving reduction of mortality and morbidity by 50% 13239 61N/A

HIGHLY PRELIMINARY

WHO 2030 target



No bottleneck towards target Significant effort required to reach target

Category

Technical progress



Enablers

▪ Species-specific immunodiagnosis not essential for effective treatment but valuable for disease ecology

▪ Introduces additional costs to patients without funds

▪ Yes/No diagnostic to confirm envenoming would reduce delays in administration of antivenom

▪ Standardization and validation of current clinically relevant bedside diagnostic tests that confirm specific clinical syndromes (e.g.: 20WBCT for coagulopathy) in specific populations

▪ Immunoassay, AI-based or PCR-based identification of biting species for disease ecology; simple low-cost “Yes/No” diagnostics

Diagnostics

▪ Substantial knowledge of disease pathology caused by various species but improvement needed

▪ Epidemiology, ecology and disease burden requires greater resolution globally, regionally and nationally

▪ Clinical evidence for safety and effectiveness of specific antivenoms is lacking; hampered by cost, logistics and lack of available expertise in countries

▪ Other scientific gaps exist and require prioritization

▪ Encourage investment in broad range of SBE research questions related to WHO strategy needs

▪ Blind spots include sociocultural, toxinological, clinical, economic, ecological and epidemiological research areas

▪ Balance demand for stronger clinical evidence against high costs and other barriers; need for rapid & pragmatic approach (a) is it safe? (b) is it effective? (c) is it cost-effective?

▪ Encourage investment in broad range of SBE research questions


▪ Stakeholder map and network development required

▪ WHO strategy calls for action in 10-12 African/Asian countries in 2019-20

▪ Establish a stakeholder database to build a collaboration network

▪ Multi-stakeholder engagement meetings in Africa and Asia to initiate implementation of projects in pilot phase countries


▪ Advocacy and fund-raising limited by need to identify and map donors and their interests

▪ WHO funding limited ($500K LLF, $100K Germany)

▪ Country funding needs stimulation

▪ Donor mapping and engagement strategy + business case needed

▪ Increase resource mobilization to WHO; need to overcome donor reluctant to support HR and administrative costs

▪ Mobilise domestic financing at country level for projects


▪ Countries need increased regulatory, MoH, health work force and antivenom producer capacity building

▪ Community partners need capacity building

▪ Need for monitoring and evaluation

▪ Develop and deploy capacity building training packages, resources and implementation guidance across all sectors in need

▪ Develop and implement M&E framework to measure outcomes and outputs

Capacity building

▪ Work plan with measureable outcomes required

▪ Need for coordination of implementation efforts

▪ Donors request business/investment case from WHO

▪ Develop detailed workplan and business case

▪ Establish coordination framework and implement

▪ Set up small technical working group of experts to support WHO


▪ Vicious cycle of weak confidence driving demand and supply down, raising prices and reducing availability

▪ Weak regulatory environments facilitate spread of ineffective products and counterfeits

▪ Poor procurement, supply and distribution policies and practices and need for education and training

▪ Create a virtuous cycle: requires quality-assured products, market stimulus, monitoring and surveillance

▪ Ensure effective national/regional regulation to stop spread of ineffective, inferior or fake products

▪ Establish a revolving stockpile of effective antivenoms

▪ Complete global risk-benefit assessment: need WHO QA products


▪ Baseline epidemiological and Burden of Disease (BoD) data is deficient, fragmented or incomplete

▪ Lack of socioeconomic data

▪ Need for clear common definitions of parameters

▪ Implement mandatory reporting to improve disease burden data

▪ Improve quality and extent of epidemiological surveillance for accurate BoD measurement and resource planning

▪ Integrated solutions to facilitate NTD data collection and reporting


▪ A global strategy for prevention and control of snakebite envenoming has been launched by WHO

▪ WHO antivenom assessment results being released

▪ Need for additional regulatory guidance & controls

▪ Integrate effective prevention, treatment and snakebite envenoming management into national health systems through uptake of strategy by countries

▪ Undertake additional regional assessments; strengthen N&S


▪ Poor training of health workers in both basic clinical and SBE specific clinical skills

▪ Lack of basic medical equipment, consumables and other essential medicines

▪ Substandard infrastructure, amenities and services

▪ Develop core training materials for deployment; update guidance

▪ Develop resources to support HSS activities such as equipment, drug and consumables lists for various levels of health facility, treatment flowcharts, antivenom selection charts

▪ Identify, and activate resources and implementation partners


▪ Availability of substandard antivenoms = loss of confidence among users = reduced demand = declining production = higher cost (Vicious Cycle)

▪ Need for R&D and technology modernization to sustain and expand current antivenom production

▪ Poor quality venoms and poor quality hyperimmune plasma are major barriers to high quality, efficacious antivenoms especially in Africa and Asia

▪ Invest in the modernization of current production capacity and incorporation of new technology, collaboration with academia and support for increased GMP compliance

▪ Increase current production and stimulate investment in new manufacturing capacity and development of new products

▪ Improve production of venoms and hyperimmune plasma

▪ Rational preclinical and clinical testing pathways with accelerated market deployment that includes post-marketing surveillance




% new antivenom producers joining market by 2030 25%5% 15%N/A# effective treatments for snakebite envenoming available worldwide 3 million300,000 500,00050,000# WHO-recommended polyspecific antivenom products in each region 62 3N/A

Slide 35

A3 To be color coded based on the curruent status (Expert opinion)Author, 6/6/2019


Snakebite Envenoming HIGHLY PRELIMINARY


No bottleneck towards target Significant effort required to reach target

Category

Technical progress



Enablers

▪ Species-specific immunodiagnosis not essential for effective treatment but valuable for disease ecology

▪ Introduces additional costs to patients without funds

▪ Yes/No diagnostic to confirm envenoming would reduce delays in administration of antivenom

▪ Standardization and validation of current clinically relevant bedside diagnostic tests that confirm specific clinical syndromes (e.g.: 20WBCT for coagulopathy) in specific populations

▪ Immunoassay, AI-based or PCR-based identification of biting species for disease ecology; simple low-cost “Yes/No” diagnostics

Diagnostics

▪ Substantial knowledge of disease pathology caused by various species but improvement needed

▪ Epidemiology, ecology and disease burden requires greater resolution globally, regionally and nationally

▪ Clinical evidence for safety and effectiveness of specific antivenoms is lacking; hampered by cost, logistics and lack of available expertise in countries

▪ Other scientific gaps exist and require prioritization

▪ Encourage investment in broad range of SBE research questions related to WHO strategy needs

▪ Blind spots include sociocultural, toxinological, clinical, economic, ecological and epidemiological research areas

▪ Balance demand for stronger clinical evidence against high costs and other barriers; need for rapid & pragmatic approach (a) is it safe? (b) is it effective? (c) is it cost-effective?

▪ Encourage investment in broad range of SBE research questions


▪ Stakeholder map and network development required

▪ WHO strategy calls for action in 10-12 African/Asian countries in 2019-20

▪ Establish a stakeholder database to build a collaboration network

▪ Multi-stakeholder engagement meetings in Africa and Asia to initiate implementation of projects in pilot phase countries


▪ Advocacy and fund-raising limited by need to identify and map donors and their interests

▪ WHO funding limited ($500K LLF, $100K Germany)

▪ Country funding needs stimulation

▪ Donor mapping and engagement strategy + business case needed

▪ Increase resource mobilization to WHO; need to overcome donor reluctant to support HR and administrative costs

▪ Mobilise domestic financing at country level for projects


▪ Countries need increased regulatory, MoH, health work force and antivenom producer capacity building

▪ Community partners need capacity building

▪ Need for monitoring and evaluation

▪ Develop and deploy capacity building training packages, resources and implementation guidance across all sectors in need

▪ Develop and implement M&E framework to measure outcomes and outputs

Capacity building

▪ Work plan with measureable outcomes required

▪ Need for coordination of implementation efforts

▪ Donors request business/investment case from WHO

▪ Develop detailed workplan and business case

▪ Establish coordination framework and implement

▪ Set up small technical working group of experts to support WHO


▪ Vicious cycle of weak confidence driving demand and supply down, raising prices and reducing availability

▪ Weak regulatory environments facilitate spread of ineffective products and counterfeits

▪ Poor procurement, supply and distribution policies and practices and need for education and training

▪ Create a virtuous cycle: requires quality-assured products, market stimulus, monitoring and surveillance

▪ Ensure effective national/regional regulation to stop spread of ineffective, inferior or fake products

▪ Establish a revolving stockpile of effective antivenoms

▪ Complete global risk-benefit assessment: need WHO QA products


▪ Baseline epidemiological and Burden of Disease (BoD) data is deficient, fragmented or incomplete

▪ Lack of socioeconomic data

▪ Need for clear common definitions of parameters

▪ Implement mandatory reporting to improve disease burden data

▪ Improve quality and extent of epidemiological surveillance for accurate BoD measurement and resource planning

▪ Integrated solutions to facilitate NTD data collection and reporting


▪ A global strategy for prevention and control of snakebite envenoming has been launched by WHO

▪ WHO antivenom assessment results being released

▪ Need for additional regulatory guidance & controls

▪ Integrate effective prevention, treatment and snakebite envenoming management into national health systems through uptake of strategy by countries

▪ Undertake additional regional assessments; strengthen N&S


▪ Poor training of health workers in both basic clinical and SBE specific clinical skills

▪ Lack of basic medical equipment, consumables and other essential medicines

▪ Substandard infrastructure, amenities and services

▪ Develop core training materials for deployment; update guidance

▪ Develop resources to support HSS activities such as equipment, drug and consumables lists for various levels of health facility, treatment flowcharts, antivenom selection charts

▪ Identify, and activate resources and implementation partners


▪ Availability of substandard antivenoms = loss of confidence among users = reduced demand = declining production = higher cost (Vicious Cycle)

▪ Need for R&D and technology modernization to sustain and expand current antivenom production

▪ Poor quality venoms and poor quality hyperimmune plasma are major barriers to high quality, efficacious antivenoms especially in Africa and Asia

▪ Invest in the modernization of current production capacity and incorporation of new technology, collaboration with academia and support for increased GMP compliance

▪ Increase current production and stimulate investment in new manufacturing capacity and development of new products

▪ Improve production of venoms and hyperimmune plasma

▪ Rational preclinical and clinical testing pathways with accelerated market deployment that includes post-marketing surveillance




Slide 36

A3 To be color coded based on the curruent status (Expert opinion)Author, 6/6/2019

Soil-transmitted helminthiases (STHs)Overview

▪ Caused by intestinal parasites: Ascaris lumbricoides, Strongyloides stercoralis, Trichuris trichiura, and hookworms Necator americanus and Ancylostoma duodenale

▪ Cause anemia, malnutrition, impaired growth and cognitive development1, delayed development, abdominal pain, diarrhea and hyperinfection syndrome which can lead to death

▪ Transmitted by eggs and larvae (S. stercoralis, A. lumbricoides) present in human faeces which contaminate areas with poor sanitation


Widely distributed in tropical and subtropical areas; greatest in sub-Saharan Africa, the Americas, China and South East Asia

Number of casesDALYs due to STHs, 20162

Burden of disease

For more details, please visit: www.who.int/intestinal_worms/disease/en/

HIGHLY PRELIMINARY

SOURCE: All data sourced from WHO unless otherwise indicated1 Pabalan et al., (2018) Soil-transmitted helminth infection, loss of education and cognitive impairment in school-aged children: A systematic review and meta-analysis. PLoS Negl Trop Dis 12(1): e0005523.2 There are large regional differences in STH burden within countries

~6,300Deaths in 2016


~1.5 billionPeople infected with STH, 2003


▪ The main priorities for STH R&D for in recent years have been: improved diagnostics, new combinations of existing drugs and new drugs

▪ Contribution of many different countries, organizations & institutions is essential for the fight against STH.

~1.5 billion3%

10%

13%

20%

53%

DALYsThousands

<0.001

0.001-0.51

0.51-9.58

≥9.58


Not applicable

No data

EMRO

EURO

WPRO

SEARO

AMRO

AFRO


Vector control N/A


Case management N/A

WASH

▪ Prevention of open defecation▪ Adequate sanitation facilities ▪ Faeces management and improved hygiene practices at the household level and

beyond (e.g. in schools)


▪ WHO recommends deworming with albendazole, mebendazole for A. lumbricoides, T. trichiura and hookworms and ivermectin for S. stercoralis in all at-risk people in endemic areas

▪ PC 1x/year where STH prevalence is >20%; 2x/year where prevalence is >50%


2012 2020 targetImpact indicator Current status

32% 75%Percent of preschool and school-aged children in need of treatment are regularly treated

~70%

10 75Number of endemic countries in which 75% coverage achieved in preschool and school-aged children

68

Soil-transmitted helminthiases (STHs) HIGHLY PRELIMINARY



# endemic countries with proportion of STH infections of moderate and heavy intensity <2%

7 (2017)


▪ Current Kato-Katz diagnostic method uses samples of stool for examination under microscope

▪ The method has relatively low sensitivity

▪ Develop biomarkers with high specificity for a highly sensitive, field-deployable test

▪ Develop field-applicable tests for resistance▪ Develop field-deployable molecular platforms (multiplex) to

detect multiple NTDs (e.g. LF, SCH) to allow for cross-cutting use▪ Standardize diagnostic procedure and develop guidance to limit

variation in prevalence

Diagnostics

▪ Good understanding of epidemiology▪ Good understanding of pathology

▪ No bottleneck towards target Scientific understanding

▪ Collaboration with Ministry of Education for school-based programme

▪ Sustainability of STH control programmes is not ensured due to potential funding challenges

▪ Integrate MDA with other programs (e.g. nutrition, WASH) to increase cost effectiveness and coverage

▪ Integrate surveillance and mapping across diseases (e.g. lymphatic filariasis, schistosomiasis, onchocerciasis, polio)

▪ Ensure effective WASH strategies to prevent resurgence


▪ Teachers and community health workers are trained▪ Lab technicians are trained on diagnostics▪ Training manuals available

▪ Integrate training in the routine activities of health facilitiesCapacity building

▪ STH control is currently integrated into child health days (with vitamin A and vaccination) for preSAC and into school health programme for SAC

▪ Utilize new technologies (drone mapping, environmental DNA, etc.) to decrease cost of surveillance and mapping

▪ Adopt policies for effective quality control of diagnostics and drugs by countries based on WHO global guidance including control procedures


▪ Albendazole and mebendazole for school-aged children are donated and distributed through WHO

▪ Effective school-based programmes ensuring access for SAC

▪ Improve access to drugs for women of reproductive age and pre-school childrenSupply and logistics

▪ Limited funding dedicated to monitoring of STH and consequently limited scope of activities

▪ Develop a surveillance guide with standard indicators▪ Establish M&E system or integrate with national health

information system▪ Monitor efficacy of drugs and resistance


Technical progress

▪ Guidelines on preventive chemotherapy to control STH in at–risk population group are in place

▪ Manual on indicators and procedures to measure the reduction of morbidity due to STH exists

▪ Initial estimation of the need of ivermectin, prequalification of a generic ivermectin and pilot interventions are underway for control of strongyloidiasis

▪ Include strongyloidiasis in the group and develop guidelines for the disease

▪ Prioritize control efforts against strongyloidiasis▪ Develop practical guidelines for interventions for women of

reproductive age (WRA)



▪ Many countries depend on drug donations and external funding for the programme implementation

▪ Number of donated tablets needed is expected to substantially decrease as large countries become self-sufficient and as PC frequency decreases after successful intervention; number of individuals in need of treatment is expected to remain similar

▪ Increase domestic financing to ensure sustainability▪ Secure drug donations for women of reproductive age and pre-

school aged children


Enablers

▪ PC is implemented through schools and community using teachers and community health workers as drug distributors


▪ Integrate with others health programmes (e.g. use of facilities, health workforce distributing drugs for women of reproductive age) to ensure sustainability

▪ Increase number of testing facilities for routine lab testing of STH

60 70 96 (out of 101)

▪ Add ivermectin to PC programmes to enhance efficacy of treatment for T. trichiura and S. stercoralis

▪ Develop more effective treatments and drug combinations


▪ Antihelmintics are effective but number of available drugs is limited

▪ New medicines and novel combinations of existing drugs are needed in case of rise of resistance

▪ WASH strategies are essential for sustainable improvement of situation

WHO 2030 target




▪ No additional risks identified so far

Taeniasis by T. solium/cysticercosis

▪ Caused by the tapeworm Taenia solium▪ Taeniasis is usually asymptomatic (however, may cause abdominal pain, nausea, diarrhea or constipation);

neurocysticercosis (NCC) can cause chronic headaches, epilepsy, intracranial hypertension and other neurologic symptoms

▪ The tapeworm is acquired by the ingestion of contaminated undercooked pork; NCC is developed after the ingestion of the parasite eggs by the fecal-oral route, hand contamination, or through contaminated food or water

▪ Parasite eggs can survive up to 10 years in the environment


Burden of disease

Cysticercosis - DALYs in thousands in 2016, ‘000

~5.5 million

people are infected worldwide1

~28,000

annual deaths, 2010

~2.8 million

DALYs, 2010

1 IHME Global burden of disease 2 2018 G-Finder Report

For more details, please visit https://www.who.int/taeniasis/en/


▪ In 2017, total of USD ~5.4 million in global funding dedicated to R&D for fighting taeniasis/cysticercosis: ~3.6m general research, ~1.7m drugs, ~0.1m diagnostics2

▪ Contribution of many different organizations and countries is essential for the fight against taeniasis/cysticercosis.


Vector control N/A

Preventive chemotherapy MDA with ciclosamide or prasiquantel at single dose, or albendazole for 3 days. PZQ and ALB have the potential to trigger adverse reactions in patients with NCC

Veterinary public health Improved pig husbandry (e.g. prevent access of pigs to human faeces) Vaccination of pigs Anthelminhtic treatment of pigs with oxfendazole

Other Community health education on WASH

Case management

Taeniasis: single administration of praziquantel or niclosamide, or 3 day albendazol Neurocysticercosis: high doses and long courses of praziquantel and/or albendazole and supporting

therapy with corticosteroids and/or anti-epileptic drugs; possible surgery

WASH Basic sanitation Hygiene and food safety (e,g, preparation of food in hygienic environment to avoid hand-to-food

contamination)

Impact indicator 2012 Target Current status

Validated strategy for control and elimination of T. solium taeniasis/cysticercosis available

TBC Target for 2015 TBC


TBC TBCInterventions scaled up in selected countries for T. solium taeniasis/cysticercosis control and elimination

TBC

Overview

HIGHLY PRELIMINARY

DALYsThousands

<0.01

0.01-0.16

0.16-5.25

≥5.25


Not applicable

No data


Taeniasis is endemic in over 75 countries with heaviest burden in Africa, Latin America and Asia


Taeniasis by T. solium/cysticercosis

▪ Interventions may not be sustained in long-term due to lack of financing, political will and interventions being considered cumbersome


Category

Technical progress


Enablers

▪ Develop coordination with schistosomiasis program, soil transmitted helminths, and epilepsy program (e.g. community awareness programmes, delivery, and surveillance)

▪ Coordinate with animal programmes (e.g. Utilize cold-chain for rabies; vaccinate for taeniasis at the same time as for classic swine flu)


▪ Currently limited collaborations

▪ Increase advocacy from WHO/FAO/OIE for control activities

▪ Increase funding and support for animal health through evidence collection and dissemination of economic losses

▪ Increase commitment of governments to prioritize control of taeniasis/cysticercosis through evidence collection and dissemination of economic losses

Advocacy and funding ▪ Lack of advocacy to encourage governments and philanthropic agencies to invest in control

▪ Lack of commitment by governments to invest in control

▪ Provide education based on the local values to improve effectiveness (local people, local language/culture, local health)

▪ Educate health staff on new NCC guidance

▪ Build capacity for disease triaging at secondary level

▪ Build surveillance capacity

Capacity building ▪ Lack of capacity in NCC diagnosis and management

▪ Understand adult tapeworm lifespan

▪ Study processes regulating parasite acquisition in humans and pigs including frequency of eggs expulsion

▪ Estimate health & economic burden (currently likely underestimated), and age distribution of patients


▪ Parasite cycle well understood▪ Lack of knowledge on the frequency of eggs expulsion▪ Lack of understanding of transmission

▪ Provide access to imaging for neurocysticercosis diagnosis (CT, …)

▪ Establish neurocysticercosis diagnosis and case management in high endemic settings


▪ To be completed


▪ Make the disease notifiable in endemic countries

▪ Set up targeted programmes in high endemicity setting adapted to local conditions

▪ Collect baseline data

▪ Combine community wide MDA with one health interventions


▪ Currently, very limited planning and governance in all endemic countries

▪ Register Cysvax® pig vaccine in more endemic countries▪ Register oxfendazole for treatment of porcine cysticercosis in endemic countries

and ensure its availability▪ Develop supply chain in endemic countries

Supply and logistics ▪ Recent commitment of drug donations from Bayer for all patients above age of 5; contractual agreement being finalized

▪ As drugs donations only recently secured, existing supply chain very limited

▪ Develop comprehensive screening programmes to fully understand the scope of the challenge

▪ Develop a high-throughput test for evaluation of control programmes in resource limited settings and map endemic areas


▪ Minimum list of indicators defined

▪ Create standardized definition of control (WHO/expert group)Operational and normative guidance

▪ Guidance on detection, and management prevention and control will be available by 2020

▪ Develop and validate specific and sensitive diagnostic tools for porcine cysticercosis

▪ Develop diagnostic tools for surveillance of taeniasis and asymptomatic neurocysticercosis

▪ Develop diagnostics for neurocysticercosis in epileptic patients in resource limited settings, ideally point-of-care

Diagnostics ▪ Most tools for taeniasis not sensitive enough; sensitive tools

too expensive

▪ Tools for porcine cysticercosis not specific enough

▪ Integrated approaches between addressing the disease in animals and humans are essential

▪ MDA alone is ineffective

▪ Demonstrated successful interventions so far are expensive and not easily replicable

▪ Pig vaccine (Cysvax®) and medication can stop transmission to pigs

▪ Develop simple and effective validated disease control model

▪ Roll-out vaccination and treatment of pigs

▪ Ensure availability of latrines and reduction of open defecation through cross-sector capacity building and community engagement

▪ Test long-term intervention approaches (e.g. minimum maintenance interventions in pigs) to asses long-term epidemiological impact


Impact indicator 203020252020 (provisional estimate) 2023

# of endemic countries with intensified control in hyperendemic areas1 9TBC 4 17

WHO 2030 target

HIGHLY PRELIMINARY




In order to achieve the set target, three critical actions are necessary:

▪ Develop a high-throughput test for evaluation of control programmes in resource limited settings and map endemic areas▪ Set up targeted programmes in high endemicity setting, to reduce the disease burden and better understand the transmission of T. solium.▪ Increase advocacy from WHO/FAO/OIE to increase priority of controlling the disease

1 Area with prevalence of >10% in school-aged children as indicated by positive test for IgG antibodies to T. solium

YawsOverview

▪ A childhood chronic disease caused by spiral bacteria Treponema pallidum subspecies pertenue▪ Affects skin, bones and cartilage and causes disfigurement and debilitation▪ Transmitted from human to human by skin to skin contact through scrapes or cuts▪ One of the first diseases targeted for eradication in 1950s; renewed eradication efforts started in 2012


Endemic mainly in Africa, Americas, South-East Asia and Western Pacific regions


Vector control N/A

Preventive chemotherapy Oral azithromycin used for Total Community Treatment (TCT)


Other N/A

Case management Azithromycin used as 1st line treatment Patients should be examined after 4 weeks – in over 95% cases, complete healing will take place Intramuscular benzathine penicillin for 2nd line treatment and for those with proven resistance to azithromycin

WASH Personal hygiene and wound care are important

Number of Countries by Endemicity Status as of 2018 Number of reported suspected cases, 2018

Burden of disease


Global eradication


0 certified countries

2020 target

194 countries

Current status

1 certified; 106 non-endemic

For more details, please visit: https://www.who.int/yaws/en/

HIGHLY PRELIMINARY


1 G-Finder report 2018


▪ Contribution of many different organizations, institutions and countries are essential for the fight against yaws. There is currently no global umbrella initiative for fight against yaws

9 2

53

1

27

2414 20

11

8

5

9

AMRO SEAROAFRO

3 3

111

4

WPRO EURO EMRO

47

35

2721

Endemic

Certified

Non-endemic

Unknown

countries certified free of yaws, 2018

0~80,000 Suspected yaws cases

reported, 2018

Annual number of suspectedyaws cases

1-10

101-1,000

0 case reported

11-100

Not applicable

No data

>10,000

1,001-10,000

Currently endemic

Previously endemic(status unknown)

Yaws Endemicity

Target: Eradication

Yaws


# Member States certified free of Yaws transmission 136 (70%)1 97 (50%) 194 (100%)

HIGHLY PRELIMINARY

WHO 2030 target



Technical progress



▪ Thorough understanding of epidemiology ▪ No prominent negative effects of treatment known other

than potential onset of drug resistance



▪ MDA TCT presents challenges in terms of costs and coverage▪ Relatively effective integration with school health

programmes exists in case detection

▪ Integrate with other programmes to increase surveillance (immunization, nutrition, MCH, skin NTDs)

▪ Collaborate with ministry of education school health programmes on case finding, screening and treatment

▪ Strengthen integrated management of skin NTDs and integrate TCT with other PC NTDs where applicable

▪ Strengthen collaboration with WASH providers and local government

Capacity building ▪ Health workers and community health workers in rural areas trained to recognize and report yaws

▪ Some integration across skin NTDs▪ Health workers trained to use RDTs/DPP and to collect

samples for PCR

▪ Develop capacity of health workers and community health workers for integrated skin-NTD detection and treatment, and reporting


▪ Ad-hoc global advisory Group can be convened▪ NTD programmes and master plans exists in some countries▪ National Yaws Eradication Programmes

▪ Establish national technical committees or include yaws within existing National NTD Technical Committees

▪ Expand the membership of guinea worm global certification commission to include yaws eradication

Supply and logistics ▪ Availability of azithromycin for TCT is assured▪ In remote areas, access to medicines and RDTs may be

lacking▪ Availability of antibiotics within primary health care facilities

to treat cases and contacts (TTT) in between TCT

▪ Improve access to RDTs and medication in endemic locations including isolated pockets (as part of UHC)

▪ Ensure that drugs for MDA are of assured quality


▪ Yaws is currently treated through verticalized mass drug administration programme

▪ TTT carried out through primary healthcare system

▪ Identify and strengthen lab infrastructure for yaws surveillance (using PCR}

▪ Consider integration of yaws TCT with other PC diseases



▪ The Morges strategy outlines way towards eradication of yaws by 2030

▪ Programme managers guide, AFRO integrated guidelines, and verification and certification documents are available

▪ Technical guidance from WHO on monitoring and evaluation is underway and will be finished by 2020

▪ Provide technical guidance on establishing country committees on yaws (and other NTDs)


▪ TCT treatment is aiming for at least 90% coverage of endemic areas

▪ Total targeted treatment (TTT) is used for immediate treatment if cases are discovered in-between scheduled TCT rounds

▪ Develop new antibiotics as a back up option in case antimicrobial resistance develops against azithromycin

Diagnostics ▪ Disease is diagnosed using rapid PoC tests and serological laboratory-based tests

▪ The diagnosis is confirmed from swabs using PCR in labs

▪ Develop sensitive point of care molecular test (e.g. PCR) to distinguish yaws from other skin ulcers (e.g. Haemophilus ducreyi)


▪ PCR can be used for assessment of antimicrobial resistance▪ Surveillance systems are working well in some endemic

countries

▪ Establish active integrated surveillance and response in all endemic and previously endemic countries (status unknown) and upgrade frequency of reporting

▪ Assess 76 previously endemic countries to confirm the current status of the disease

▪ Monitor drug resistance

Enablers


▪ Limited political and donor/partner support▪ Good community engagement▪ Good support from research community

▪ Increase commitment among endemic countries, donors, and partners to mobilize funds and manpower

▪ Sustain community engagement to support programme implementation

▪ Sustain research community engagement for knowledge generation and advocacy to mobilize resources for research


To eradicate yaws, the key question to resolve is assessment of the current prevalence of the disease and to ensure access to diagnostics and medication. The following actions are key to achieve this:▪ Strengthen active surveillance system integrated across NTDs▪ Ensure effective and efficient integration and/or co-implementation with other programs and sectors▪ Ensure uninterrupted availability to quality assured oral treatment at sub-district level


▪ Total targeted treatment (TTT) may not be effective as latent and active infections are often in different households▪ The eradication goal demands enormous resources which may be difficult to sustain

43

Dimensions for assessment – disease-specific

Technical progress

Enablers


Dimensions

Alignment and coordination of efforts among relevant stakeholders towards overall goals and milestones Appropriate country-level governance for programme management and effective delivery Clarity of stakeholder responsibilities and effective, coordinated working processes

Effective supply chain that ensures timely access to and availability of quality-assured medicines, products and pharmaceutical supplies at all levels and avoiding e.g. stockout, wastage, loss of tablets

Collaboration between stakeholders across levels and sectors with a clear accountability framework to enable an effective, synergetic approach to delivering interventions

Capacity building to enable high-performing programmes, e.g. pre-deployment and in-service training

Effective policy dialogue and advocacy to mobilise support for required interventions included in the national and district health care delivery plans Domestic and international funding deployed with adequate lead time and consistency

▪ Existence of effective diagnostic tools to enable timely detection, assessment of endpoints, surveillance

▪ Availability of point-of-care diagnostic usable at community level and in low-resource settings

▪ Thorough understanding of disease epidemiology and pathology▪ No “blind spots” in research that would hinder progress toward achieving targets▪ Understanding of unintended consequences of intervention (e.g. ancillary benefits,

environmental effects etc.)

▪ Existence of interventions for prevention, treatment, case management & rehabilitation▪ Continued innovation and adaptation of interventions to new developments &

opportunities.

Clear understanding of end points and operational approach to achieve and sustain these Availability of technical guidelines e.g. validation or verification guidelines



Collaboration & multisectoral action

Capacity building


Framework and mechanisms to monitor and report progress against stated goals Mapping and impact assessments to show granular view of disease epidemiology &

progression. Continuous, systematic and institutionalized collection, analysis and interpretation of

disaggregated health data (by age, gender, location), supported by strong data management systems and tools to assist in data interpretation Strengthened and institutionalized surveillance for the disease, including post-

validation/elimination surveillance


Diagnostics

Scientific understand-ing




Robust health systems/primary health care infrastructure delivering NTD interventions in integrated patient care models Existence of laboratory capacity/network to support NTD programme needs & monitor drug

efficacy Availability of aptly skilled healthcare workers to address clinical and community-based

needs related to the disease

Trachoma

Current status Impact indicator 2012 2020 target

Proportion of endemic or unknown status countries achieving elimination as a public health problem

1/64 (2%) 100% 8/64 (13%)



Preventive chemotherapy Mass drug administration of azithromycin to reduce the reservoir of ocular C. trachomatis infection (the “A” of the WHO-recommended SAFE strategy2)

WASHFacial cleanliness and environmental improvement (the “F” and “E” of the SAFE strategy)Includes access to water & improved sanitation

Vector control Improved access to and use of sanitation removes human faeces from the environment, reducing breeding sites for muscid flies, which are vectors of ocular C. trachomatis


Case management Surgery to treat trachomatous trichiasis (the “S” of the SAFE strategy)

Other N/A


▪ Total of USD ~2 million in global funding is dedicated to R&D for fighting trachoma: ~1.5m preventive vaccines, ~1m unspecified2

▪ Implementation of the SAFE Strategy3 is driven by the WHO Alliance for the Global Elimination of Trachoma by 2020 (GET2020) comprising trachoma-endemic member states, NGOs, academic institutions, donors and other interested parties.

▪ The International Coalition for Trachoma Control is a membership group of non-governmental, donor, private sector and academic organizations working together to support the WHO Alliance for GET2020.

▪ The International Trachoma Initiative stewards Pfizer’s donation of Zithromax, develops and strengthens partnerships for disease elimination, and provides access to data and knowledge about trachoma.


▪ An eye disease caused by the bacterium Chlamydia trachomatis ▪ Causes eyelashes to be drawn in so that they rub the surface of the eye (trichiasis). This causes pain and may permanently

damage the cornea, resulting in irreversible visual impairment or blindness ▪ Spreads through personal contact (e.g. hands, clothes, bedding) or by flies which were in contact with eye or nose discharge of

infected individuals; risk factors for transmission include inadequate hygiene, crowded households, inadequate access to water, and lack of sanitation

▪ Causes a considerable economic burden for individuals and communities in terms of lost productivity (ca. USD 2.9–8 billion)

Trachomatous trichiasis backlogs by countryPeople requiring surgery, March 2019

The number of people at risk of trachoma has fallen from 1.5 billion in 2002 to just over 142 million in 2019, a reduction of 91%4

The number of people requiring surgery for trachomatous trichiasis has dropped from 7.6 million in 2002 to 2.5 million in 2019, a reduction of 68%4

1 IHME Global Burden of Disease 2 G-Finder report 20183 Surgery for individuals with trichiasis, MDA with Antibiotics (azithromycin) to reduce the reservoir of ocular chlamydial infection, and Facial cleanliness and Environmental improvement 4 June 2019 WHO news release

142 Millionpeople at risk of trachoma, 2019

Burden of disease

<1,000

1,000-10,000

10,000-50,000

≥50,000

No cases reported

Cases

Status uncertain

2.5 Millionpeople requiring surgery, 2019

For more details, please visit: www.who.int/trachoma/en/

0%2%5% 24%

68%

2016

2.5 M Europe

South-East Asia

Western Pacific

Eastern Mediterranean

Africa

Americas

Overview

HIGHLY PRELIMINARY


0annual deaths, 2016

Trachomatous trichiasis backlogs by regionPeople requiring surgery, March 2019


Trachoma

▪ Possibility of recrudescence of infection in populations considered to have eliminated trachoma as a public health problem, due to in-migration


▪ Implementation of the SAFE Strategy is driven by the WHO Alliance for GET2020 with support from multiple stakeholders

▪ Reduce backlog of individuals requiring surgery▪ Reduce the number of districts yet to start interventions▪ Coordinate F and E interventions with relevant stakeholders▪ Increase availability of accessible and inclusive care (e.g.

stigma, mental wellbeing, rehabilitation)

Planning, governance, & programmeimplementation

▪ Pfizer has donated more than 860 million doses of antibiotic Zithromax® since 19992; pledged through 2025

▪ ITI provides extensive support for Zithromax supply chain, including managing data and tracking drug shipments

Supply and logistics ▪ Continue to maintain, review and improve systems as

needed

▪ The Global Trachoma Mapping Project successfully completed with limited areas remaining unmapped by 2016

▪ GET2020 database provides a global data repository and Tropical Data supports countries to generate prevalence data

▪ Develop systems to track surgeries and outcomes▪ Develop methods for improved surveillance for

recrudescence of infection and disease


▪ Operational guidelines are clearly defined in SAFE strategy▪ Coherent country-level templates are in place

▪ Test decision algorithms for discontinuing antibiotic MDA▪ Assess whether adjustments to guidelines are needed for

high-transmission settings


▪ A Network of WHO Collaborating Centres for Trachoma has been initiated

▪ Ethiopia launched an initiative to clear the surgical backlog

▪ Optimize methods for detecting trichiasis cases and reduce backlog of individuals requiring surgery

▪ Develop a system to follow-up individuals who have received trichiasis surgery and track outcomes

▪ Deploy trained surgeons most effectively



▪ The GET2020 Alliance has proven to be a dynamic forum for information exchange; stakeholder responsibilities are clearly defined

▪ Determine post-2020 plan▪ Coordinate WASH activities with relevant stakeholders and

coordinate post-elimination surveillance with other programmes


▪ Trachoma has been described as a “best buy” and major donors include USAID, DFID, The Queen Elizabeth Diamond Jubilee Trust, The END Fund and others

▪ Countries also critically provide domestic funding

▪ Mobilize an estimated $750M to support scaling up of the SAFE strategy ($200-300 pledge of $1B; 2017 estimate)


▪ Technical skills for diagnosis and trichiasis surgery exist, however there are limitations in some countries

▪ The mannequin-based trichiasis surgery training system “HEAD START” helps in training TT surgeons

▪ Continue to build capacity in diagnosis and trichiasis surgery, emphasizing quality and consistency Capacity building

Enablers


Technical progress

▪ Undertaken based on examination by trained graders ▪ Conduct research to understand whether tests for current or previous ocular C. trachomatis infection would help programmes determine need for interventions or monitor populations after interventions are discontinued

Diagnostics

▪ Insufficient understanding of transmission pathways, vectors, and infection reservoirs

▪ Particular gaps in understanding of differences in transmission in high-transmission settings relative to other settings

▪ Conduct scientific and operational research in high-transmission settings and understand which populations require A, F and E

▪ Improve understanding the importance of coverage of A, F and E to achieving and sustaining elimination


▪ The SAFE (Surgery for individuals with trichiasis, Antibiotic MDA to clear ocular C. trachomatis infection, and Facial cleanliness and Environmental improvement to reduce transmission) strategy is effective. The evidence for the F and E interventions is weak

▪ Conduct research to determine how best to manage post-operative trachomatous trichiasis

▪ Conduct research to identify critical F and E interventions for reducing C. trachomatis transmission


1 Defined as XXX 2 As of July 2019


Number of people requiring A, F and E of SAFE for trachoma elimination purposes

2025

TBC

2020 (provisional estimate)

TBC

2023

TBC TBC

# countries validated as having achieved elimination1 43TBC – 8+ 28 64

WHO 2030 target




▪ Develop systems that improve access to surgery, tracking of outcomes, and management of post-surgery trachomatous trichiasis; Immediately address backlogs▪ Build knowledge through research and expand partnerships to enhance efforts around F and E components of SAFE▪ Develop an efficient and cost-effective way to detect recrudescence of infection without relying on clinical signs ▪ Accelerate operational research to understand why progress in high-transmission settings has been weaker and whether a different strategy may be needed in these settings▪ Identify additional funding sources and coordinate efforts with other NTDs

HIGHLY PRELIMINARY

Number of people requiring management of trachomatous trichiasis; S of SAFE TBCTBC TBC TBC

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