Integrated Control of Neglected Tropical Diseases, Southern Sudan
Situation:
After almost 50 years of conflict, allowing hardly any disease control, Southern Sudan is thought to be among the countries with the highest burden of neglected tropical diseases (NTDs) in the world. Twelve NTDs are endemic:
• Onchocerciasis (river blindness)
• Schistosomiasis (bilharzia)
• Soil-transmitted helminths (common intestinal worms)
• Lymphatic filariasis (elephantiasis)
• Loiasis (eye worm)
• Trachoma
• Dracunculiasis (Guinea worm)
• Visceral leishmaniasis (kala-azar)
• Human African trypanosomiasis (sleeping sickness)
• Buruli ulcer
• Leprosy
• A condition known as ‘nodding disease’
Only onchocerciasis and dracunculiasis have benefited from large-scale control while some of the other NTDs, such as kala-azar and sleeping sickness have received intermittent attention in response to epidemics. With the signing of the Comprehensive Peace Agreement in January 2005, the return of relative stability now provides unprecedented opportunities to initiate or expand programs for NTD control or elimination.
Response:
In recognition of the high burden caused by NTDs, the Ministry of Health (MoH) of the Government of Southern Sudan (GoSS) has included NTD control or elimination among its health sector priorities and has committed itself to the integrated control of NTDs using preventive chemotherapy (PCT), as recommended by the World Health Organization (WHO 2006). This approach targets schistosomiasis (Schistosoma haematobium and S. mansoni), soil-transmitted helminths (hookworm, Ascaris lumbricoides and Trichuris trichiura), lymphatic filariasis, trachoma and onchocerciasis through community-based or campaign mass drug administration (MDA).
Funding to conduct a comprehensive situation analysis on NTDs was awarded to Malaria Consortium by the Department for International Development, U.K. in 2007. All key stakeholders (Ministry of Health, World Health Organization, The Carter Center, CBM) closely collaborated on this work, which provided baseline information for formulation of a proposal to RTI International. As a result, funding from the US Agency for International Development to assist the MoH-GoSS in establishing a national programme for MDA of PCT was awarded to Malaria Consortium through RTI International in early 2008. In April 2008, a National Integrated NTD Control Programme Technical Committee was formed in Juba, which leads the implementation of co-administration of PCT. A national stakeholder meeting on 8 May 2008 identified the following steps as essential to establish and roll-out the national program:
1. Mapping of the NTDs to be targeted in geographical areas where there is no or insufficient data
2. Starting-up co-implementation of PCT in two target states with an existing drug distribution network and/or existing data on NTD prevalence
3. Expanding the number of drugs distributed through existing structures
4. Expanding mapping, followed by co-implementation of PCT distribution, to other states, building on lessons learned in the initial target areas
Initially, co-implementation of MDA will be carried out through the structures for community-directed treatment with ivermectin (CDTI) established by the onchocerciasis control programme. Ivermectin is distributed through CDTI structures once a year. Addition of albendazole to the ivermectin distribution will allow for ready expansion of the existing onchocerciasis control program to one that also deals with the elimination of LF (treated with ivermectin + albendazole) and control of soil-transmitted helminthiasis (treated with albendazole). Praziquantel for control of schistosomiasis can be safely added to this combination in areas where several rounds of ivermectin treatment have been implemented. Azithromycin treatment for trachoma will need to distributed at a different time, to avoid the potential risk of adverse events.
Southern Sudan’s NTD control programme will initially target two states, Western Equatoria and Northern Bahr el Ghazal. From June 2008 onwards, rapid NTD mapping will be conducted to establish which of the target NTDs exceed the threshold for intervention in which areas. Subsequently, the first round of MDA co-administration will be carried out between September 2008 and March 2009. Expansion of mapping and MDA to additional states is scheduled for 2009. The ultimate goal of the programme is to develop a comprehensive national map of the geographical distributions of those NTDs that are controlled through MDA, and to use this map to target the required PCT and complementary interventions to all at-risk populations.
Trachoma mapping ongoing in Southern Sudan, in preparation for mass drug administration during 2009
Points to note:
• Southern Sudan’s NTD control programme is a partnership between the MoH-GoSS, UN agencies, NGOs and health sector donors. The establishment of the programme, including rapid mapping and PCT intervention in some target states, is supported through a USAID/RTI grant. However, additional resources are required to provide complementary interventions, such as morbidity control and health promotion, and to expand the programme to all endemic areas, as well as to sustain it once the RTI/USAID funds have come to an end.
• Diseases that are not suitable for control through PCT, as for example kala-azar or sleeping sickness, are not targeted by this programme and generally receive no sustained financial support. They must be addressed as a component of multi-functional health care delivery, which is currently undergoing reconstruction. To support integration of these NTDs into routine service delivery, sustained funding is urgently needed.
Publications:
Photos: Hugh Sturrock