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Opportunities and challenges for mass chemotherapy programs
against parasitic diseases in low-resource settings
Roger Prichard and Catherine Bourguinat
Institute of ParasitologyCentre for Host-Parasite Interactions
McGill UniversitySainte Anne-de-Bellevue Queacutebec
Focus of presentation Diseases caused by helminth parasites The burden of disease diseases of poverty Mass treatment programs New opportunities
Donations CDT Integration of programs
Challenges Compliance sustainability resources donor fatigue Treatment outcomes Drug resistance monitoring efficacy amp impact
The diseases
Lymphatic filariasis
Onchocerciasis
Soil transmitted helminths
Schistosomiasis
Burden of high prevalence NTDs (modified from Hotez et al Lancet 2009)
Disease DALYs(million)
Deaths yr Global prevalenc
e
Control
Lymphatic filariasis
58 500 120 m MDA (ABZ +DECIVM)
Hookworms
18-221 3000-65000
600 m MDA (ABZ)
Ascariasis 12-105 3000-60000
800 m MDA (ABZ)
Trichuriasis 16-64 3000-10000
600 m MDA (ABZ)
Onchocer-ciasis
15 500 37 m MDA (IVM)
Schistosom-iasis
17-47 15000-280000
200 m MDA (PZQ)
-12 billion people in 83 countries at risk-120 million people infected worldwide-India Indonesia Nigeria and Bangladesh (account for 70 of global lymphatic filariasis infections)-Estimates of annual economic loss in India due to lymphatic filariasis - US $1b -Lymphoedema hydrocele elephantiasis impaired motility social stigma
Lymphatic Filariasis
Soil-transmitted helminths The causal agent of soil-transmitted helminthiasis is any of the
following worms -Ascaris lumbricoides Impair childrenrsquos growth cognitive development physical
fitness -Trichuris trichiura Rectal prolapse impair childrenrsquos growth cognitive
development physical fitness - Hookworms (N americanus A duodenale) Anemia in children and pregnant
women impair childrenrsquos growth cognitive development physical fitnessSTHs affects more than 2000 million people worldwide
-Globally STHs cause 3 ndash 24 m DALYs per year -STH infections predominantly in sub-Saharan Africa the Americas east and south
Asia
-Onchocerciasis ndashblindness visual impairment severe skin pathology - greatly reduces income-generating capacity incurs significant health expenditures reduces life expectancy and exerts a very negative socioeconomic impact on the afflicted populations and land use
-Currently via APOCOEPA more than 40 million people receive regular ivermectin treatment through a community drug-distribution
Onchocerciasis- River Blindness
Distribution of OnchocerciasisCurrent Status of Global Onchocerciasis Control
APOCOEPA IVM distribution Former OCP now National IVM
distribution IVM + vector control Epidemiological surveys required
- 200 million people infected half in Africa (650 million people live in endemic areas)- 2nd most socioeconomically devastating parasitic disease after malaria- Anemia malnutrition impaired cognitive development damage to liver intestines lungs bladder (bladder cancer) hepatosplenomegaly- Found in 74 tropical countries -3 main species of Schistosome in humans ndash -The drug praziquantel costs 18 cents per dose- gt423 million tablets PZQ needed globallyyear to treat schistosomiasis
S mansoni S haematobium
S japonicum
Schistosomiasis
Lymphatic filariasis Treatment and control
MDA (national programs + Internat coord - GPELF) with ABZ + DEC or ABZ + IVM to reduce transmission amp arrest disease progression Drugs not curative Coupled with topical sanitation for secondary bacteria amp fungi ABZ donated by GSK (~180m dosesyr Σgt1 b doses donated) IVM (Mectizan) donated by Merck (gt450 m doses donated) DEC very inexpensive
Compliance amp ineligible people ABZ and IVM have collateral benefits of helping control STH Transmission by mosquitoes impregnated bed nets amp
insecticide spraying of houses for malaria control can reduce LF transmission
BMGF amp others supporting LF lsquoeliminationrsquo programs
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS
minus Treatment of STH infections through national LF programso gt170 m treatments for STH (ABZ) given to 56 million children by GPELF resulting in 1048707 Increased appetite weight gain and growth 1048707 Greater eye‐hand coordination learning ability and concentration 1048707 Better school attendance cognitition fitness scores amp spontaneous play activityo gt140 m treatments for STH (ABZ) given to 445 million women of childbearing age by GPELF improving nutritional status amp iron stores leading to 1048707 Increased infant birth‐weights by up to 50 grams 1048707 Decreased infant mortality by up to 40 amp decreased maternal mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of STH infections through national LF programs gt170 m treatments for STH (ABZ) given to 56 million
children by GPELF resulting in Increased appetite weight gain and growth Greater eye‐hand coordination learning ability and concentration Better school attendance cognitition fitness scores amp
spontaneous play activity gt140 m treatments for STH (ABZ) given to 445 million
women of childbearing age by GPELF improving nutritional status amp iron stores leading to Increased infant birth‐weights by up to 50 grams Decreased infant mortality by up to 40 amp decreased maternal
mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of onchocerciasis scabies and lice with IVM
through the GPELF in Africa gt149 million IVM treatments given by GPELF
coordination with APOC to gt45 million in African communities Millions of people living in onchocerciasis‐endemic areas not
previously treated received IVM through coordination between GPELF and APOC
IVMrsquos long‐lasting impact on scabies reduces community prevalence after 1 cycle and almost eliminates it after gt2 treatments Improved sleep patterns and overall well-being Protection from post‐streptococcal renal disease induced by
group B streptococcus skin infections that often complicate chronic scabies infection
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
Focus of presentation Diseases caused by helminth parasites The burden of disease diseases of poverty Mass treatment programs New opportunities
Donations CDT Integration of programs
Challenges Compliance sustainability resources donor fatigue Treatment outcomes Drug resistance monitoring efficacy amp impact
The diseases
Lymphatic filariasis
Onchocerciasis
Soil transmitted helminths
Schistosomiasis
Burden of high prevalence NTDs (modified from Hotez et al Lancet 2009)
Disease DALYs(million)
Deaths yr Global prevalenc
e
Control
Lymphatic filariasis
58 500 120 m MDA (ABZ +DECIVM)
Hookworms
18-221 3000-65000
600 m MDA (ABZ)
Ascariasis 12-105 3000-60000
800 m MDA (ABZ)
Trichuriasis 16-64 3000-10000
600 m MDA (ABZ)
Onchocer-ciasis
15 500 37 m MDA (IVM)
Schistosom-iasis
17-47 15000-280000
200 m MDA (PZQ)
-12 billion people in 83 countries at risk-120 million people infected worldwide-India Indonesia Nigeria and Bangladesh (account for 70 of global lymphatic filariasis infections)-Estimates of annual economic loss in India due to lymphatic filariasis - US $1b -Lymphoedema hydrocele elephantiasis impaired motility social stigma
Lymphatic Filariasis
Soil-transmitted helminths The causal agent of soil-transmitted helminthiasis is any of the
following worms -Ascaris lumbricoides Impair childrenrsquos growth cognitive development physical
fitness -Trichuris trichiura Rectal prolapse impair childrenrsquos growth cognitive
development physical fitness - Hookworms (N americanus A duodenale) Anemia in children and pregnant
women impair childrenrsquos growth cognitive development physical fitnessSTHs affects more than 2000 million people worldwide
-Globally STHs cause 3 ndash 24 m DALYs per year -STH infections predominantly in sub-Saharan Africa the Americas east and south
Asia
-Onchocerciasis ndashblindness visual impairment severe skin pathology - greatly reduces income-generating capacity incurs significant health expenditures reduces life expectancy and exerts a very negative socioeconomic impact on the afflicted populations and land use
-Currently via APOCOEPA more than 40 million people receive regular ivermectin treatment through a community drug-distribution
Onchocerciasis- River Blindness
Distribution of OnchocerciasisCurrent Status of Global Onchocerciasis Control
APOCOEPA IVM distribution Former OCP now National IVM
distribution IVM + vector control Epidemiological surveys required
- 200 million people infected half in Africa (650 million people live in endemic areas)- 2nd most socioeconomically devastating parasitic disease after malaria- Anemia malnutrition impaired cognitive development damage to liver intestines lungs bladder (bladder cancer) hepatosplenomegaly- Found in 74 tropical countries -3 main species of Schistosome in humans ndash -The drug praziquantel costs 18 cents per dose- gt423 million tablets PZQ needed globallyyear to treat schistosomiasis
S mansoni S haematobium
S japonicum
Schistosomiasis
Lymphatic filariasis Treatment and control
MDA (national programs + Internat coord - GPELF) with ABZ + DEC or ABZ + IVM to reduce transmission amp arrest disease progression Drugs not curative Coupled with topical sanitation for secondary bacteria amp fungi ABZ donated by GSK (~180m dosesyr Σgt1 b doses donated) IVM (Mectizan) donated by Merck (gt450 m doses donated) DEC very inexpensive
Compliance amp ineligible people ABZ and IVM have collateral benefits of helping control STH Transmission by mosquitoes impregnated bed nets amp
insecticide spraying of houses for malaria control can reduce LF transmission
BMGF amp others supporting LF lsquoeliminationrsquo programs
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS
minus Treatment of STH infections through national LF programso gt170 m treatments for STH (ABZ) given to 56 million children by GPELF resulting in 1048707 Increased appetite weight gain and growth 1048707 Greater eye‐hand coordination learning ability and concentration 1048707 Better school attendance cognitition fitness scores amp spontaneous play activityo gt140 m treatments for STH (ABZ) given to 445 million women of childbearing age by GPELF improving nutritional status amp iron stores leading to 1048707 Increased infant birth‐weights by up to 50 grams 1048707 Decreased infant mortality by up to 40 amp decreased maternal mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of STH infections through national LF programs gt170 m treatments for STH (ABZ) given to 56 million
children by GPELF resulting in Increased appetite weight gain and growth Greater eye‐hand coordination learning ability and concentration Better school attendance cognitition fitness scores amp
spontaneous play activity gt140 m treatments for STH (ABZ) given to 445 million
women of childbearing age by GPELF improving nutritional status amp iron stores leading to Increased infant birth‐weights by up to 50 grams Decreased infant mortality by up to 40 amp decreased maternal
mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of onchocerciasis scabies and lice with IVM
through the GPELF in Africa gt149 million IVM treatments given by GPELF
coordination with APOC to gt45 million in African communities Millions of people living in onchocerciasis‐endemic areas not
previously treated received IVM through coordination between GPELF and APOC
IVMrsquos long‐lasting impact on scabies reduces community prevalence after 1 cycle and almost eliminates it after gt2 treatments Improved sleep patterns and overall well-being Protection from post‐streptococcal renal disease induced by
group B streptococcus skin infections that often complicate chronic scabies infection
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
The diseases
Lymphatic filariasis
Onchocerciasis
Soil transmitted helminths
Schistosomiasis
Burden of high prevalence NTDs (modified from Hotez et al Lancet 2009)
Disease DALYs(million)
Deaths yr Global prevalenc
e
Control
Lymphatic filariasis
58 500 120 m MDA (ABZ +DECIVM)
Hookworms
18-221 3000-65000
600 m MDA (ABZ)
Ascariasis 12-105 3000-60000
800 m MDA (ABZ)
Trichuriasis 16-64 3000-10000
600 m MDA (ABZ)
Onchocer-ciasis
15 500 37 m MDA (IVM)
Schistosom-iasis
17-47 15000-280000
200 m MDA (PZQ)
-12 billion people in 83 countries at risk-120 million people infected worldwide-India Indonesia Nigeria and Bangladesh (account for 70 of global lymphatic filariasis infections)-Estimates of annual economic loss in India due to lymphatic filariasis - US $1b -Lymphoedema hydrocele elephantiasis impaired motility social stigma
Lymphatic Filariasis
Soil-transmitted helminths The causal agent of soil-transmitted helminthiasis is any of the
following worms -Ascaris lumbricoides Impair childrenrsquos growth cognitive development physical
fitness -Trichuris trichiura Rectal prolapse impair childrenrsquos growth cognitive
development physical fitness - Hookworms (N americanus A duodenale) Anemia in children and pregnant
women impair childrenrsquos growth cognitive development physical fitnessSTHs affects more than 2000 million people worldwide
-Globally STHs cause 3 ndash 24 m DALYs per year -STH infections predominantly in sub-Saharan Africa the Americas east and south
Asia
-Onchocerciasis ndashblindness visual impairment severe skin pathology - greatly reduces income-generating capacity incurs significant health expenditures reduces life expectancy and exerts a very negative socioeconomic impact on the afflicted populations and land use
-Currently via APOCOEPA more than 40 million people receive regular ivermectin treatment through a community drug-distribution
Onchocerciasis- River Blindness
Distribution of OnchocerciasisCurrent Status of Global Onchocerciasis Control
APOCOEPA IVM distribution Former OCP now National IVM
distribution IVM + vector control Epidemiological surveys required
- 200 million people infected half in Africa (650 million people live in endemic areas)- 2nd most socioeconomically devastating parasitic disease after malaria- Anemia malnutrition impaired cognitive development damage to liver intestines lungs bladder (bladder cancer) hepatosplenomegaly- Found in 74 tropical countries -3 main species of Schistosome in humans ndash -The drug praziquantel costs 18 cents per dose- gt423 million tablets PZQ needed globallyyear to treat schistosomiasis
S mansoni S haematobium
S japonicum
Schistosomiasis
Lymphatic filariasis Treatment and control
MDA (national programs + Internat coord - GPELF) with ABZ + DEC or ABZ + IVM to reduce transmission amp arrest disease progression Drugs not curative Coupled with topical sanitation for secondary bacteria amp fungi ABZ donated by GSK (~180m dosesyr Σgt1 b doses donated) IVM (Mectizan) donated by Merck (gt450 m doses donated) DEC very inexpensive
Compliance amp ineligible people ABZ and IVM have collateral benefits of helping control STH Transmission by mosquitoes impregnated bed nets amp
insecticide spraying of houses for malaria control can reduce LF transmission
BMGF amp others supporting LF lsquoeliminationrsquo programs
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS
minus Treatment of STH infections through national LF programso gt170 m treatments for STH (ABZ) given to 56 million children by GPELF resulting in 1048707 Increased appetite weight gain and growth 1048707 Greater eye‐hand coordination learning ability and concentration 1048707 Better school attendance cognitition fitness scores amp spontaneous play activityo gt140 m treatments for STH (ABZ) given to 445 million women of childbearing age by GPELF improving nutritional status amp iron stores leading to 1048707 Increased infant birth‐weights by up to 50 grams 1048707 Decreased infant mortality by up to 40 amp decreased maternal mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of STH infections through national LF programs gt170 m treatments for STH (ABZ) given to 56 million
children by GPELF resulting in Increased appetite weight gain and growth Greater eye‐hand coordination learning ability and concentration Better school attendance cognitition fitness scores amp
spontaneous play activity gt140 m treatments for STH (ABZ) given to 445 million
women of childbearing age by GPELF improving nutritional status amp iron stores leading to Increased infant birth‐weights by up to 50 grams Decreased infant mortality by up to 40 amp decreased maternal
mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of onchocerciasis scabies and lice with IVM
through the GPELF in Africa gt149 million IVM treatments given by GPELF
coordination with APOC to gt45 million in African communities Millions of people living in onchocerciasis‐endemic areas not
previously treated received IVM through coordination between GPELF and APOC
IVMrsquos long‐lasting impact on scabies reduces community prevalence after 1 cycle and almost eliminates it after gt2 treatments Improved sleep patterns and overall well-being Protection from post‐streptococcal renal disease induced by
group B streptococcus skin infections that often complicate chronic scabies infection
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
Burden of high prevalence NTDs (modified from Hotez et al Lancet 2009)
Disease DALYs(million)
Deaths yr Global prevalenc
e
Control
Lymphatic filariasis
58 500 120 m MDA (ABZ +DECIVM)
Hookworms
18-221 3000-65000
600 m MDA (ABZ)
Ascariasis 12-105 3000-60000
800 m MDA (ABZ)
Trichuriasis 16-64 3000-10000
600 m MDA (ABZ)
Onchocer-ciasis
15 500 37 m MDA (IVM)
Schistosom-iasis
17-47 15000-280000
200 m MDA (PZQ)
-12 billion people in 83 countries at risk-120 million people infected worldwide-India Indonesia Nigeria and Bangladesh (account for 70 of global lymphatic filariasis infections)-Estimates of annual economic loss in India due to lymphatic filariasis - US $1b -Lymphoedema hydrocele elephantiasis impaired motility social stigma
Lymphatic Filariasis
Soil-transmitted helminths The causal agent of soil-transmitted helminthiasis is any of the
following worms -Ascaris lumbricoides Impair childrenrsquos growth cognitive development physical
fitness -Trichuris trichiura Rectal prolapse impair childrenrsquos growth cognitive
development physical fitness - Hookworms (N americanus A duodenale) Anemia in children and pregnant
women impair childrenrsquos growth cognitive development physical fitnessSTHs affects more than 2000 million people worldwide
-Globally STHs cause 3 ndash 24 m DALYs per year -STH infections predominantly in sub-Saharan Africa the Americas east and south
Asia
-Onchocerciasis ndashblindness visual impairment severe skin pathology - greatly reduces income-generating capacity incurs significant health expenditures reduces life expectancy and exerts a very negative socioeconomic impact on the afflicted populations and land use
-Currently via APOCOEPA more than 40 million people receive regular ivermectin treatment through a community drug-distribution
Onchocerciasis- River Blindness
Distribution of OnchocerciasisCurrent Status of Global Onchocerciasis Control
APOCOEPA IVM distribution Former OCP now National IVM
distribution IVM + vector control Epidemiological surveys required
- 200 million people infected half in Africa (650 million people live in endemic areas)- 2nd most socioeconomically devastating parasitic disease after malaria- Anemia malnutrition impaired cognitive development damage to liver intestines lungs bladder (bladder cancer) hepatosplenomegaly- Found in 74 tropical countries -3 main species of Schistosome in humans ndash -The drug praziquantel costs 18 cents per dose- gt423 million tablets PZQ needed globallyyear to treat schistosomiasis
S mansoni S haematobium
S japonicum
Schistosomiasis
Lymphatic filariasis Treatment and control
MDA (national programs + Internat coord - GPELF) with ABZ + DEC or ABZ + IVM to reduce transmission amp arrest disease progression Drugs not curative Coupled with topical sanitation for secondary bacteria amp fungi ABZ donated by GSK (~180m dosesyr Σgt1 b doses donated) IVM (Mectizan) donated by Merck (gt450 m doses donated) DEC very inexpensive
Compliance amp ineligible people ABZ and IVM have collateral benefits of helping control STH Transmission by mosquitoes impregnated bed nets amp
insecticide spraying of houses for malaria control can reduce LF transmission
BMGF amp others supporting LF lsquoeliminationrsquo programs
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS
minus Treatment of STH infections through national LF programso gt170 m treatments for STH (ABZ) given to 56 million children by GPELF resulting in 1048707 Increased appetite weight gain and growth 1048707 Greater eye‐hand coordination learning ability and concentration 1048707 Better school attendance cognitition fitness scores amp spontaneous play activityo gt140 m treatments for STH (ABZ) given to 445 million women of childbearing age by GPELF improving nutritional status amp iron stores leading to 1048707 Increased infant birth‐weights by up to 50 grams 1048707 Decreased infant mortality by up to 40 amp decreased maternal mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of STH infections through national LF programs gt170 m treatments for STH (ABZ) given to 56 million
children by GPELF resulting in Increased appetite weight gain and growth Greater eye‐hand coordination learning ability and concentration Better school attendance cognitition fitness scores amp
spontaneous play activity gt140 m treatments for STH (ABZ) given to 445 million
women of childbearing age by GPELF improving nutritional status amp iron stores leading to Increased infant birth‐weights by up to 50 grams Decreased infant mortality by up to 40 amp decreased maternal
mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of onchocerciasis scabies and lice with IVM
through the GPELF in Africa gt149 million IVM treatments given by GPELF
coordination with APOC to gt45 million in African communities Millions of people living in onchocerciasis‐endemic areas not
previously treated received IVM through coordination between GPELF and APOC
IVMrsquos long‐lasting impact on scabies reduces community prevalence after 1 cycle and almost eliminates it after gt2 treatments Improved sleep patterns and overall well-being Protection from post‐streptococcal renal disease induced by
group B streptococcus skin infections that often complicate chronic scabies infection
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
-12 billion people in 83 countries at risk-120 million people infected worldwide-India Indonesia Nigeria and Bangladesh (account for 70 of global lymphatic filariasis infections)-Estimates of annual economic loss in India due to lymphatic filariasis - US $1b -Lymphoedema hydrocele elephantiasis impaired motility social stigma
Lymphatic Filariasis
Soil-transmitted helminths The causal agent of soil-transmitted helminthiasis is any of the
following worms -Ascaris lumbricoides Impair childrenrsquos growth cognitive development physical
fitness -Trichuris trichiura Rectal prolapse impair childrenrsquos growth cognitive
development physical fitness - Hookworms (N americanus A duodenale) Anemia in children and pregnant
women impair childrenrsquos growth cognitive development physical fitnessSTHs affects more than 2000 million people worldwide
-Globally STHs cause 3 ndash 24 m DALYs per year -STH infections predominantly in sub-Saharan Africa the Americas east and south
Asia
-Onchocerciasis ndashblindness visual impairment severe skin pathology - greatly reduces income-generating capacity incurs significant health expenditures reduces life expectancy and exerts a very negative socioeconomic impact on the afflicted populations and land use
-Currently via APOCOEPA more than 40 million people receive regular ivermectin treatment through a community drug-distribution
Onchocerciasis- River Blindness
Distribution of OnchocerciasisCurrent Status of Global Onchocerciasis Control
APOCOEPA IVM distribution Former OCP now National IVM
distribution IVM + vector control Epidemiological surveys required
- 200 million people infected half in Africa (650 million people live in endemic areas)- 2nd most socioeconomically devastating parasitic disease after malaria- Anemia malnutrition impaired cognitive development damage to liver intestines lungs bladder (bladder cancer) hepatosplenomegaly- Found in 74 tropical countries -3 main species of Schistosome in humans ndash -The drug praziquantel costs 18 cents per dose- gt423 million tablets PZQ needed globallyyear to treat schistosomiasis
S mansoni S haematobium
S japonicum
Schistosomiasis
Lymphatic filariasis Treatment and control
MDA (national programs + Internat coord - GPELF) with ABZ + DEC or ABZ + IVM to reduce transmission amp arrest disease progression Drugs not curative Coupled with topical sanitation for secondary bacteria amp fungi ABZ donated by GSK (~180m dosesyr Σgt1 b doses donated) IVM (Mectizan) donated by Merck (gt450 m doses donated) DEC very inexpensive
Compliance amp ineligible people ABZ and IVM have collateral benefits of helping control STH Transmission by mosquitoes impregnated bed nets amp
insecticide spraying of houses for malaria control can reduce LF transmission
BMGF amp others supporting LF lsquoeliminationrsquo programs
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS
minus Treatment of STH infections through national LF programso gt170 m treatments for STH (ABZ) given to 56 million children by GPELF resulting in 1048707 Increased appetite weight gain and growth 1048707 Greater eye‐hand coordination learning ability and concentration 1048707 Better school attendance cognitition fitness scores amp spontaneous play activityo gt140 m treatments for STH (ABZ) given to 445 million women of childbearing age by GPELF improving nutritional status amp iron stores leading to 1048707 Increased infant birth‐weights by up to 50 grams 1048707 Decreased infant mortality by up to 40 amp decreased maternal mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of STH infections through national LF programs gt170 m treatments for STH (ABZ) given to 56 million
children by GPELF resulting in Increased appetite weight gain and growth Greater eye‐hand coordination learning ability and concentration Better school attendance cognitition fitness scores amp
spontaneous play activity gt140 m treatments for STH (ABZ) given to 445 million
women of childbearing age by GPELF improving nutritional status amp iron stores leading to Increased infant birth‐weights by up to 50 grams Decreased infant mortality by up to 40 amp decreased maternal
mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of onchocerciasis scabies and lice with IVM
through the GPELF in Africa gt149 million IVM treatments given by GPELF
coordination with APOC to gt45 million in African communities Millions of people living in onchocerciasis‐endemic areas not
previously treated received IVM through coordination between GPELF and APOC
IVMrsquos long‐lasting impact on scabies reduces community prevalence after 1 cycle and almost eliminates it after gt2 treatments Improved sleep patterns and overall well-being Protection from post‐streptococcal renal disease induced by
group B streptococcus skin infections that often complicate chronic scabies infection
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
Soil-transmitted helminths The causal agent of soil-transmitted helminthiasis is any of the
following worms -Ascaris lumbricoides Impair childrenrsquos growth cognitive development physical
fitness -Trichuris trichiura Rectal prolapse impair childrenrsquos growth cognitive
development physical fitness - Hookworms (N americanus A duodenale) Anemia in children and pregnant
women impair childrenrsquos growth cognitive development physical fitnessSTHs affects more than 2000 million people worldwide
-Globally STHs cause 3 ndash 24 m DALYs per year -STH infections predominantly in sub-Saharan Africa the Americas east and south
Asia
-Onchocerciasis ndashblindness visual impairment severe skin pathology - greatly reduces income-generating capacity incurs significant health expenditures reduces life expectancy and exerts a very negative socioeconomic impact on the afflicted populations and land use
-Currently via APOCOEPA more than 40 million people receive regular ivermectin treatment through a community drug-distribution
Onchocerciasis- River Blindness
Distribution of OnchocerciasisCurrent Status of Global Onchocerciasis Control
APOCOEPA IVM distribution Former OCP now National IVM
distribution IVM + vector control Epidemiological surveys required
- 200 million people infected half in Africa (650 million people live in endemic areas)- 2nd most socioeconomically devastating parasitic disease after malaria- Anemia malnutrition impaired cognitive development damage to liver intestines lungs bladder (bladder cancer) hepatosplenomegaly- Found in 74 tropical countries -3 main species of Schistosome in humans ndash -The drug praziquantel costs 18 cents per dose- gt423 million tablets PZQ needed globallyyear to treat schistosomiasis
S mansoni S haematobium
S japonicum
Schistosomiasis
Lymphatic filariasis Treatment and control
MDA (national programs + Internat coord - GPELF) with ABZ + DEC or ABZ + IVM to reduce transmission amp arrest disease progression Drugs not curative Coupled with topical sanitation for secondary bacteria amp fungi ABZ donated by GSK (~180m dosesyr Σgt1 b doses donated) IVM (Mectizan) donated by Merck (gt450 m doses donated) DEC very inexpensive
Compliance amp ineligible people ABZ and IVM have collateral benefits of helping control STH Transmission by mosquitoes impregnated bed nets amp
insecticide spraying of houses for malaria control can reduce LF transmission
BMGF amp others supporting LF lsquoeliminationrsquo programs
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS
minus Treatment of STH infections through national LF programso gt170 m treatments for STH (ABZ) given to 56 million children by GPELF resulting in 1048707 Increased appetite weight gain and growth 1048707 Greater eye‐hand coordination learning ability and concentration 1048707 Better school attendance cognitition fitness scores amp spontaneous play activityo gt140 m treatments for STH (ABZ) given to 445 million women of childbearing age by GPELF improving nutritional status amp iron stores leading to 1048707 Increased infant birth‐weights by up to 50 grams 1048707 Decreased infant mortality by up to 40 amp decreased maternal mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of STH infections through national LF programs gt170 m treatments for STH (ABZ) given to 56 million
children by GPELF resulting in Increased appetite weight gain and growth Greater eye‐hand coordination learning ability and concentration Better school attendance cognitition fitness scores amp
spontaneous play activity gt140 m treatments for STH (ABZ) given to 445 million
women of childbearing age by GPELF improving nutritional status amp iron stores leading to Increased infant birth‐weights by up to 50 grams Decreased infant mortality by up to 40 amp decreased maternal
mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of onchocerciasis scabies and lice with IVM
through the GPELF in Africa gt149 million IVM treatments given by GPELF
coordination with APOC to gt45 million in African communities Millions of people living in onchocerciasis‐endemic areas not
previously treated received IVM through coordination between GPELF and APOC
IVMrsquos long‐lasting impact on scabies reduces community prevalence after 1 cycle and almost eliminates it after gt2 treatments Improved sleep patterns and overall well-being Protection from post‐streptococcal renal disease induced by
group B streptococcus skin infections that often complicate chronic scabies infection
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
-Onchocerciasis ndashblindness visual impairment severe skin pathology - greatly reduces income-generating capacity incurs significant health expenditures reduces life expectancy and exerts a very negative socioeconomic impact on the afflicted populations and land use
-Currently via APOCOEPA more than 40 million people receive regular ivermectin treatment through a community drug-distribution
Onchocerciasis- River Blindness
Distribution of OnchocerciasisCurrent Status of Global Onchocerciasis Control
APOCOEPA IVM distribution Former OCP now National IVM
distribution IVM + vector control Epidemiological surveys required
- 200 million people infected half in Africa (650 million people live in endemic areas)- 2nd most socioeconomically devastating parasitic disease after malaria- Anemia malnutrition impaired cognitive development damage to liver intestines lungs bladder (bladder cancer) hepatosplenomegaly- Found in 74 tropical countries -3 main species of Schistosome in humans ndash -The drug praziquantel costs 18 cents per dose- gt423 million tablets PZQ needed globallyyear to treat schistosomiasis
S mansoni S haematobium
S japonicum
Schistosomiasis
Lymphatic filariasis Treatment and control
MDA (national programs + Internat coord - GPELF) with ABZ + DEC or ABZ + IVM to reduce transmission amp arrest disease progression Drugs not curative Coupled with topical sanitation for secondary bacteria amp fungi ABZ donated by GSK (~180m dosesyr Σgt1 b doses donated) IVM (Mectizan) donated by Merck (gt450 m doses donated) DEC very inexpensive
Compliance amp ineligible people ABZ and IVM have collateral benefits of helping control STH Transmission by mosquitoes impregnated bed nets amp
insecticide spraying of houses for malaria control can reduce LF transmission
BMGF amp others supporting LF lsquoeliminationrsquo programs
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS
minus Treatment of STH infections through national LF programso gt170 m treatments for STH (ABZ) given to 56 million children by GPELF resulting in 1048707 Increased appetite weight gain and growth 1048707 Greater eye‐hand coordination learning ability and concentration 1048707 Better school attendance cognitition fitness scores amp spontaneous play activityo gt140 m treatments for STH (ABZ) given to 445 million women of childbearing age by GPELF improving nutritional status amp iron stores leading to 1048707 Increased infant birth‐weights by up to 50 grams 1048707 Decreased infant mortality by up to 40 amp decreased maternal mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of STH infections through national LF programs gt170 m treatments for STH (ABZ) given to 56 million
children by GPELF resulting in Increased appetite weight gain and growth Greater eye‐hand coordination learning ability and concentration Better school attendance cognitition fitness scores amp
spontaneous play activity gt140 m treatments for STH (ABZ) given to 445 million
women of childbearing age by GPELF improving nutritional status amp iron stores leading to Increased infant birth‐weights by up to 50 grams Decreased infant mortality by up to 40 amp decreased maternal
mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of onchocerciasis scabies and lice with IVM
through the GPELF in Africa gt149 million IVM treatments given by GPELF
coordination with APOC to gt45 million in African communities Millions of people living in onchocerciasis‐endemic areas not
previously treated received IVM through coordination between GPELF and APOC
IVMrsquos long‐lasting impact on scabies reduces community prevalence after 1 cycle and almost eliminates it after gt2 treatments Improved sleep patterns and overall well-being Protection from post‐streptococcal renal disease induced by
group B streptococcus skin infections that often complicate chronic scabies infection
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
- 200 million people infected half in Africa (650 million people live in endemic areas)- 2nd most socioeconomically devastating parasitic disease after malaria- Anemia malnutrition impaired cognitive development damage to liver intestines lungs bladder (bladder cancer) hepatosplenomegaly- Found in 74 tropical countries -3 main species of Schistosome in humans ndash -The drug praziquantel costs 18 cents per dose- gt423 million tablets PZQ needed globallyyear to treat schistosomiasis
S mansoni S haematobium
S japonicum
Schistosomiasis
Lymphatic filariasis Treatment and control
MDA (national programs + Internat coord - GPELF) with ABZ + DEC or ABZ + IVM to reduce transmission amp arrest disease progression Drugs not curative Coupled with topical sanitation for secondary bacteria amp fungi ABZ donated by GSK (~180m dosesyr Σgt1 b doses donated) IVM (Mectizan) donated by Merck (gt450 m doses donated) DEC very inexpensive
Compliance amp ineligible people ABZ and IVM have collateral benefits of helping control STH Transmission by mosquitoes impregnated bed nets amp
insecticide spraying of houses for malaria control can reduce LF transmission
BMGF amp others supporting LF lsquoeliminationrsquo programs
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS
minus Treatment of STH infections through national LF programso gt170 m treatments for STH (ABZ) given to 56 million children by GPELF resulting in 1048707 Increased appetite weight gain and growth 1048707 Greater eye‐hand coordination learning ability and concentration 1048707 Better school attendance cognitition fitness scores amp spontaneous play activityo gt140 m treatments for STH (ABZ) given to 445 million women of childbearing age by GPELF improving nutritional status amp iron stores leading to 1048707 Increased infant birth‐weights by up to 50 grams 1048707 Decreased infant mortality by up to 40 amp decreased maternal mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of STH infections through national LF programs gt170 m treatments for STH (ABZ) given to 56 million
children by GPELF resulting in Increased appetite weight gain and growth Greater eye‐hand coordination learning ability and concentration Better school attendance cognitition fitness scores amp
spontaneous play activity gt140 m treatments for STH (ABZ) given to 445 million
women of childbearing age by GPELF improving nutritional status amp iron stores leading to Increased infant birth‐weights by up to 50 grams Decreased infant mortality by up to 40 amp decreased maternal
mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of onchocerciasis scabies and lice with IVM
through the GPELF in Africa gt149 million IVM treatments given by GPELF
coordination with APOC to gt45 million in African communities Millions of people living in onchocerciasis‐endemic areas not
previously treated received IVM through coordination between GPELF and APOC
IVMrsquos long‐lasting impact on scabies reduces community prevalence after 1 cycle and almost eliminates it after gt2 treatments Improved sleep patterns and overall well-being Protection from post‐streptococcal renal disease induced by
group B streptococcus skin infections that often complicate chronic scabies infection
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
Lymphatic filariasis Treatment and control
MDA (national programs + Internat coord - GPELF) with ABZ + DEC or ABZ + IVM to reduce transmission amp arrest disease progression Drugs not curative Coupled with topical sanitation for secondary bacteria amp fungi ABZ donated by GSK (~180m dosesyr Σgt1 b doses donated) IVM (Mectizan) donated by Merck (gt450 m doses donated) DEC very inexpensive
Compliance amp ineligible people ABZ and IVM have collateral benefits of helping control STH Transmission by mosquitoes impregnated bed nets amp
insecticide spraying of houses for malaria control can reduce LF transmission
BMGF amp others supporting LF lsquoeliminationrsquo programs
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS
minus Treatment of STH infections through national LF programso gt170 m treatments for STH (ABZ) given to 56 million children by GPELF resulting in 1048707 Increased appetite weight gain and growth 1048707 Greater eye‐hand coordination learning ability and concentration 1048707 Better school attendance cognitition fitness scores amp spontaneous play activityo gt140 m treatments for STH (ABZ) given to 445 million women of childbearing age by GPELF improving nutritional status amp iron stores leading to 1048707 Increased infant birth‐weights by up to 50 grams 1048707 Decreased infant mortality by up to 40 amp decreased maternal mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of STH infections through national LF programs gt170 m treatments for STH (ABZ) given to 56 million
children by GPELF resulting in Increased appetite weight gain and growth Greater eye‐hand coordination learning ability and concentration Better school attendance cognitition fitness scores amp
spontaneous play activity gt140 m treatments for STH (ABZ) given to 445 million
women of childbearing age by GPELF improving nutritional status amp iron stores leading to Increased infant birth‐weights by up to 50 grams Decreased infant mortality by up to 40 amp decreased maternal
mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of onchocerciasis scabies and lice with IVM
through the GPELF in Africa gt149 million IVM treatments given by GPELF
coordination with APOC to gt45 million in African communities Millions of people living in onchocerciasis‐endemic areas not
previously treated received IVM through coordination between GPELF and APOC
IVMrsquos long‐lasting impact on scabies reduces community prevalence after 1 cycle and almost eliminates it after gt2 treatments Improved sleep patterns and overall well-being Protection from post‐streptococcal renal disease induced by
group B streptococcus skin infections that often complicate chronic scabies infection
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS
minus Treatment of STH infections through national LF programso gt170 m treatments for STH (ABZ) given to 56 million children by GPELF resulting in 1048707 Increased appetite weight gain and growth 1048707 Greater eye‐hand coordination learning ability and concentration 1048707 Better school attendance cognitition fitness scores amp spontaneous play activityo gt140 m treatments for STH (ABZ) given to 445 million women of childbearing age by GPELF improving nutritional status amp iron stores leading to 1048707 Increased infant birth‐weights by up to 50 grams 1048707 Decreased infant mortality by up to 40 amp decreased maternal mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of STH infections through national LF programs gt170 m treatments for STH (ABZ) given to 56 million
children by GPELF resulting in Increased appetite weight gain and growth Greater eye‐hand coordination learning ability and concentration Better school attendance cognitition fitness scores amp
spontaneous play activity gt140 m treatments for STH (ABZ) given to 445 million
women of childbearing age by GPELF improving nutritional status amp iron stores leading to Increased infant birth‐weights by up to 50 grams Decreased infant mortality by up to 40 amp decreased maternal
mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of onchocerciasis scabies and lice with IVM
through the GPELF in Africa gt149 million IVM treatments given by GPELF
coordination with APOC to gt45 million in African communities Millions of people living in onchocerciasis‐endemic areas not
previously treated received IVM through coordination between GPELF and APOC
IVMrsquos long‐lasting impact on scabies reduces community prevalence after 1 cycle and almost eliminates it after gt2 treatments Improved sleep patterns and overall well-being Protection from post‐streptococcal renal disease induced by
group B streptococcus skin infections that often complicate chronic scabies infection
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of STH infections through national LF programs gt170 m treatments for STH (ABZ) given to 56 million
children by GPELF resulting in Increased appetite weight gain and growth Greater eye‐hand coordination learning ability and concentration Better school attendance cognitition fitness scores amp
spontaneous play activity gt140 m treatments for STH (ABZ) given to 445 million
women of childbearing age by GPELF improving nutritional status amp iron stores leading to Increased infant birth‐weights by up to 50 grams Decreased infant mortality by up to 40 amp decreased maternal
mortality
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of onchocerciasis scabies and lice with IVM
through the GPELF in Africa gt149 million IVM treatments given by GPELF
coordination with APOC to gt45 million in African communities Millions of people living in onchocerciasis‐endemic areas not
previously treated received IVM through coordination between GPELF and APOC
IVMrsquos long‐lasting impact on scabies reduces community prevalence after 1 cycle and almost eliminates it after gt2 treatments Improved sleep patterns and overall well-being Protection from post‐streptococcal renal disease induced by
group B streptococcus skin infections that often complicate chronic scabies infection
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS Treatment of onchocerciasis scabies and lice with IVM
through the GPELF in Africa gt149 million IVM treatments given by GPELF
coordination with APOC to gt45 million in African communities Millions of people living in onchocerciasis‐endemic areas not
previously treated received IVM through coordination between GPELF and APOC
IVMrsquos long‐lasting impact on scabies reduces community prevalence after 1 cycle and almost eliminates it after gt2 treatments Improved sleep patterns and overall well-being Protection from post‐streptococcal renal disease induced by
group B streptococcus skin infections that often complicate chronic scabies infection
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
STH Treatment amp control MDA programs (Deworm the World ndash Clinton
Initiative FRESH ndash World Bank etc) Mainly BZ drugs ndash ABZ (best) or MBZ
ABZ being donated by GSK for LF control (not specifically for STH)
MBZ being donated by Johnson amp Johnson Efficacy ABZ (less for MBZ amp other anthelmintics)
~ 98 - Ascaris lumbricoides ~ 50 ndash 70 Hookworms ~ 30 ndash 50 Trichuris trichiura
Sometimes efficacy failure against hookworms amp Trichuris BZ resistance mutations recently found in N americanus amp T trichiura Need to monitor for drug resistance
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
Onchocerciasis Treatment amp control MDA by Community Directed Treatment (CDTI)
Compliance for CDTI variable Only IVM (Mectizan) available for MDA IVM donated by Merck (gt600 m doses donated so far)
IVM kills microfilaria (mf) and inhibits production of new mf by adult worms for 3-12 months
IVM reduces morbidity amp transmission (mf) Does not kill adult worms
Oncho as public health problem markedly reduced
20 years of IVM distribution in W Africa Transmission reduced but continues IVM resistance now seen in West Africa
Difficult to monitor efficacyresistance SAE occasionally with heavy Loa loa co-infection
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
Schistosomiasis Treatment amp control
National MDA particularly of school children Praziquantel must be purchased ~ US
$018dose Effectively no other drug now available PZQ effective against adult parasites not very
effective against juvenile stages Little immunity ndash reinfection Some PZQ resistance reports ndash not widespread Compliance amp lack of resources problems Snail vector control sometimes attempted
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
General opportunities for NTD Can use MDA including CDT Drugs donated or cheap to buy Donors willing to help MDA - major impact on morbidity Spectacular benefitcost ratios (World Bank calculated
intervention against NTD gave greatest returns on investments in development compared with all other investments)
Possible to integrate all of these MDA interventions with others for Trachoma malaria etc
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
Challenges Compliance amp ineligible populations (eg pregnant
women) Lack of resources (shadow of big 3 - HIVMalariaTB) ~ Drugs give ~ poor efficacy MDA not curative ndash how many years MDA - sustainability Donor fatigue (donors want quick amp easy fixes) SAE with IVM in heavy L loa infections Developing drug resistance in
O volvulus N americanus amp T trichiura Potentially in LF amp S mansoni
V few drugs no development pipeline Limited research funds amp trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
Conclusions Control of these helminthic NTD - huge returns on
investment in terms of human health and development reduced suffering amp social impacts
Huge numbers of people affected Current tools for control are inadequate Compliancesustainability problems Resistance developing to too few drugs Control of NTDs appeals to donors but Donor fatigue amp lack of realism Lack of resources in endemic countries Lack of research drug pipeline efficacy monitoring amp
trained personnel
