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 fitness

STHs 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 programs

o 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 activity

o 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

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 fitness

STHs 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 programs

o 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 activity

o 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

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 fitness

STHs 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 programs

o 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 activity

o 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

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 fitness

STHs 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 programs

o 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 activity

o 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

-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 fitness

STHs 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 programs

o 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 activity

o 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

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 fitness

STHs 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 programs

o 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 activity

o 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

-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 programs

o 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 activity

o 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

- 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 programs

o 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 activity

o 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

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 programs

o 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 activity

o 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

HEALTH IMPACT lsquoBEYOND LFrsquo BENEFITS

minus Treatment of STH infections through national LF programs

o 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 activity

o 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

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

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

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

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

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

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

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

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