GLOBAL DISEASES:
Voices from the Vanguard
g
Bundling Grassroots Services
to Battle Neglected Diseases in
Africa
A Journey to Nigeria
Frank Richards Jr.,, MD
The Carter Center
March 18, 2008
“Four charismatic scientists invite you to
help defeat infectious diseases that thrive in
poverty and kill millions of people
worldwide.”
ld id ”
Another (the third)
‘charismatic scientist’
The “P’s”
•
•
•
•
•
•
•
•
•
P di t i
Pediatrics
Parasites
(The) Poor
Public Health
Programs
Pills (Tablets)
Public Private Partnership
Politics
President Carter
 Peace Prize
“…I was asked to discuss here in Oslo
the greatest challenge that the world
faces. Among all the possible choices,
I decided that the most serious and
universal problem is the growing
chasm between the richest and the
poorest people on earth….The
separation is increasing every
year….The results of this disparity
are the root causes of most of the
problems”
world’s unresolved p
President Jimmy Carter
2002 Nobel address
•‘Diseases of Poverty’
•‘Forgotten
‘F
tt Di
Diseases off Forgotten
F
tt People’
P
l ’
•‘Neglected Diseases of the Tropics’
An Integrated Community-based MDA Program in
Nigeria
Structure of my Talk
• Introduction
p
• Public Health Concepts
• Three neglected tropical diseases (RB, LF,
Schisto)
• Nigeria
g
• Future challenges
Structure of my Talk
• Introduction
• Concepts
 Control versus Elimination (Eradication)
Strategies
g
 Vertical versus Horizontal PH systems
• Three tropical diseases (RB, LF, Schisto)
• Nigeria
• Future challenges
Control versus Elimination
(Eradication) Strategy
Control
Elimination
li i i
TIME
Vertical versus Horizontal PH
systems
Focused
Controlled
Inputs
Outputs
Polyvalent
P
l l t
‘Basket’
Decentralized decisions
‘Sustainable’
Donors
Love It!
‘Integration of Programs means
Integration
g
of Problems’
Dr Hans Remme,
Dr.
Remme WHO/TDR
Structure of my Talk
•
•
Introduction
Concepts
 Control versus Elimination (Eradication) Strategy
 Vertical versus Horizontal PH systems
• Three tropical diseases
 Onchocerciasis River Blindness
 Lymphatic Filariasis (LF)
 Schistosomiasis
S
(‘S
(‘Schisto’)
)
•
•
Nigeria
Future challenges
g
Neglected Tropical Diseases
Preventive Chemotherapy
(Mass Drug Administration-MDA)
Pharmaceutical Drug Donation Programs
UGA’s Center for Tropical and
Emerging Global Diseases
(www.ctegd.uga.edu)
(
g
g
)
•
•
•
•
•
•
•
Leishmaniasis*
Chagas’ Disease*
African Trypanosomiasis*
S hi t
Schistosomiasis*
i i *
Cryptosporidiosis
Lymphatic Filariasis*
Malaria
*NTDs
DALY perspective ((millions))
•
•
•
•
•
•
TB
Malaria
Treatable NTDs
‘Treatable’
Diarrheal disease
HIV--AIDS
HIV
LRI
Hotez et al PLos Medicine 2006
34.7
46.5
56.6
62.0
84.5
84 5
91.3
Control versus Elimination
•
•
•
•
•
Onchocerciasis: Control
L
Lymphatic
h i Fil
Filariasis:
i i Eli
Elimination
i i
Schistosomiasis: Control
Trachoma: Elimination
Soil Transmitted Helminths: Control
‘N
‘Nearness
to rivers…
Can eat the eyes’
African Proverb
Geographic Distribution of Onchocerciasis
WHO 1999
Microfilaria
Intensity (‘load’) of Infection
Who suffers from ‘oncho?’
oncho?
•
•
•
•
•
A disease of rural poverty
90 million people at risk
34 million infected
37 countries
Some 800,000 people are either blind
or visually handicapped
• Rarely fatal
Clinical Manifestations
• Blindness
• Visual
Vi
l
Impairment
• Skin rashes
• Intense itching
g
WHO/TDR/Ward
MIcrofilaria
(‘MIcrofilaricide’)
MAcrofilaria
( MAcrofilaricide )
(‘MAcrofilaricide’)
Treatments approved and shipped by the MectizanR Donation
Program 1988
1988-2006
2006
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
70
60
50
40
30
20
10
0
Source: Annual Highlight
Mectizan Donation Program
www mectizan org
Treatments approved and shipped by the MectizanR Donation
Program 1988
1988-2006,
2006, with UTG
100
80
60
40
20
06
20
04
20
02
20
00
20
98
19
96
19
94
19
92
19
90
19
19
88
0
Source: Mectizan Donation Progra
www.mectizan.org
Carter CenterCenter-Assisted Mectizan Distribution
Mexico
Venezuela
Nigeria
G t
Guatemala
l
Ethiopia
Colombia
Ecuador
Sudan
Cameroon
Uganda
Brazil
Carter Center
Center--Assisted Areas
Carter CenterCenter-Assisted Programs:
Mectizan Treatments
1996 – 2007*
12,200,000
11,054,088
11,109,61110,798,434
12,000,000
9,694,415
8,964,429
10,000,000
8,000,000
6,882,422
8,019,378
7,229,829
6,209,580
6,000,000
5,090,511
3,828,180
4,000,000
2,000,000
0
1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007
*Provisional
November 2007
The Carter Center celebrates
Over
assisted
Ivermectin treatments in 11 Countries in
Africa and the Americas since 1996
Thank you to our partners!
Cost per Treatment in CarterCarter-assisted
African RB Programs Averages $0.50
$
(range $0.10$0.10-1.50)
Impact of Eight Years of Mass Ivermectin
Treatment in a Cohort of 411 persons in Imo
State, Nigeria
Nodule
Visual
Impairment
Papular
Dermatitis
1995
2002
Leopard Skin
0
Emukah, AJTMH 2004
20
40
60
Cohort Percent Positive
Who suffers from ‘LF?’
LF?
• A disease of rural and periurban
poverty
• Over
O
1 billion
billi people
l att risk
i k
• 120 million infected
• 80 countries
• Leading cause of disability
• Rarely fatal
Life Cycle of Lymphatic
Filariasis
56
www filariasis org
www.filariasis.org
Who suffers from ‘Schisto?’
Schisto?
• A disease of rural and periurban
poverty
• Over
O
650 million
illi people
l att risk
i k
• 200 million infected
• 76 countries
• Major and subtle morbidity
• Rarely fatal
Intestinal Schistosomiasis
Control versus Elimination
• Onchocerciasis: Control
• Lymphatic
L
h i Fil
Filariasis:
i i Eli
Elimination
i i
• Schistosomiasis: Control
Structure of my Talk
• Introduction
• Concepts
 Control versus Elimination (Eradication) Strategy
 Vertical versus Horizontal PH systems
• Three tropical diseases (RB, LF, Schisto)
• Nigeria
• Future challenges
Nigeria
Carter Nigeria
Center assisted
GRBP-Assisted
GRBP
Assisted
States
States
in Nigeria
SOKOTO
KATSINA
YOBE
JIGAWA
ZAMFARA
BORNO
KANO
KEBBI
BAUCHI
KADUNA
GOMBE
NIGER
ADAMAWA
PLATEAU
FCT
KWARA
NASSARAWA
OYO
TARABA
EKITI
KOGI
OSUN
BENUE
Nigeria Integrated Project
ONDO
OGUN
ENUGU
LAGOS
EDO
EBONYI
ANAMBRA
CROSS RIVER
DELTA
GRBP alone
Km
BAYELSA
0
50
IMO
GRBP & LCIF Sight
i h First
i
ABIA
100
RIVERS
AKWA IBOM
State Boundries
GLOBAL DISEASES:
Voices from the Vanguard
g
Bundling Grassroots Services
to Battle Neglected Diseases in
Africa
A Journey to Nigeria
Frank Richards Jr.,, MD
The Carter Center
March 18, 2008
Why
y ‘Bundling’
g (Integration,
(
g
,
Coimplementation) in Nigeria?
• Nigeria has the most River Blindness in the World (27
million in need of treatment) and the best Mectizan
treatment program in the World
• Most LF (22% of Nigerians infected). 3rd globally
(after
(
India/Indonesia))
• For Schisto, greatest praziquantel tablet requirement
of any country (60 million/yr)
• A lot
l t off other
th diseases
di
(T
(Trachoma,
h
IIntestinal
t ti l Worms,
W
Malaria)
Integrated Onchocerciasis, Lymphatic
Fil i i and
Filariasis
d Urinary
Ui
Schistosomiasis
S hi t
i i
Activities in Nigeria:
AC
Case St
Study
d
We integrated three MDA
programs at the LGA level by
• Building on the RB platform
• Mapping the distribution of LF and schisto
• Tailoring district level training and logistics based on
the results of mapping exercises
• Implementing community based annual health
education and mass treatment (with ivermectin,
albendazole and/or praziquantel) where appropriate,
per WHO guidelines
• Evaluating impact
Platform Programs and Integration Models
Plateau/Nasarawa ONCHO Program Map in 1998
Bassa
Jos North
Jos East
Jos South
B/Ladi
Riyom
Kanam
Kanke
Mangu
Pankshin
Bokkos
Wase
Karu
Keffi
Akwanga
Kokona
Mikang
Wamba
Nas/ Eggon
Quan Pan
Langtang South
Lafia
Obi
Nasarawa
Toto
Shendam
Awe
Doma
Keana
No ONCHO
ONCHO (12)
Impact on Onchocerciasisin Plateau and Nasarawa States of Nigeria
Onchocerciasis Nodule Prevalences in 23 Villages
Percent Nodule Prevalenc
ce
60%
51.2%
50%
40%
30%
20%
10%
2.9%
0%
1992
1999/2000
Distribution of Lymphatic Filariasis (LF) in Plateau / Nasarawa States
Results in Villages Sampled for LF Antigen Testing ( Numbers are % positive Antigenemia)
Binchi
22
"
Bakin Kgi
8
"Fursum
22
"Babale
22
"Laminga
4
"Ou
7
"Maijuju
21
"Chugw
15
Newo
"
"Hoss/Mkera 17
17
" Gura
"Gindiri
20
14
"Jing
30
"
Seri
62"Garam
56
Minzam Kadyis
y
"
38
57
Umaisha
4
Yerwa
12
"
Katakpa
26
"
Gwamlar
58
"
"
!
!
Chika/Kwatas Nlet
"Nl t
24
!
40
! Chip
"Gidan Mudu
35
"Daffo
Ang
Zaria
8
"
!! Gantang
27
0 !! Ag Habu "Mangar 9"Kakuruk/kurra
14
14
Garkawa
19
"
"Gbunchu
19 "Plapung
50
!! Gudi
"Mai Ganga
Kutu
"
28
44
54
32
"Gauta
"Yashi
"Kagbu
"Sabon Gida Galei
11 "Garaku
39
48
D k T
Tofa
f 10
"Doka
9
38
"Burum Burum
"Arikiya
"Bassa
11
Bong
"Magama
"
46
8
30
15
"Shmankar
"Gamakai
"Akunza Jarme
15 !! Gangum 90
22
27
"Apurugh
"Tunga
50
15
"Dudduguru
"Akwete
26
46
"
"
Dada
30
"
"Nasarawa
5
Dogon Kurmi
32
"
Idadu
36
"Kadarko
Keana 12
16
"
Azara
38
"
!!
Lamba
9
!!
Danyam
37
Takalara
17
"
Phases 2000 - 2003
2000 Phase 1 Oncho Endemic
"
LF Prevalence (Sample)
"
"
!
GLOBAL 2000 Villages: % ICT (2000)
WHO Villages: % ICT (2000)
LF Pilot Villages: % ELISA ( 1998)
2001 Phase 2 Oncho Endemic
2002 Phase 3 Non-Oncho endemic
2003 Phase 4 Non-Oncho endemic
Plateau/Nasarawa LF/ONCHO Programme Map
Bassa
Jos North
Jos East
Jos South
B/Ladi
Riyom
Kanam
Kanke
Mangu
Pankshin
Bokkos
Wase
Karu
Keffi
Akwanga
Kokona
Mikang
Wamba
Nas/ Eggon
Quan Pan
Langtang South
Lafia
Obi
Nasarawa
Toto
Shendam
Awe
Doma
Keana
LF ONLY (18)
ONCHO/LF (12)
Carter Center
Center--assisted Onchocerciasis and Lymphatic Filariasis Treatments,
Plateau & Nasarawa States, Nigeria
4,000,000
3,162,642
3,500,000
3,000,000
2,500,000
, ,
2,000,000
1,500,000
, ,
LF is now the ‘Platform Program’
1,000,000
500,000
,
0
1992
1993
1994
1995
1996
1997
LF & Oncho Endemic Area
1998
1999
2000
Oncho Txs
2001
2002
2003
2004
LF Endemic Areas
2005*
UTG
LF/Oncho Treatments in Plateau and Nasarawa States, Nigeria, by
Year
Y
4,000,000
3,500,000
3,000,000
2,500,000
2,000,000
1,500,000
1,000,000
500,000
0
1999 2000 2001 2002 2003 2004 2005 2006 2007
Integration of LF with RB was fast
and
d ‘easy’
‘
’
Top indicator of success for the
Nigeria LF Effort as a ‘Demonstration
Project’
We will attempt to show that annual treatment with
th ivermectin
the
i
ti andd albendazole
lb d l combination
bi ti can
demonstrate, on a large scale, the feasibility of
eliminating lymphatic filariasis from Africa.
Africa
Impact on Onchocerciasis, Schistosomiasis and Lymphatic Filariasis
in Plateau and Nasarawa States of Nigeria
Average Lymphatic Filariasis ICT Results in
Seven Sentinel Villages
50%
45.1%
40%
30%
20%
10.0%
10%
Average Lymphatic Filariasis Mosquito Infection
Rate (W. bancrofti) in 9 Sentinel Villages
0%
2000
10%
2004
Perrcent Mosquito IInfection
Percent ICT tes
sts positive
60%
9%
8%
7%
6%
5.2%
5%
4%
3%
2%
1 1%
1.1%
1%
0%
2000
2004
Onchocerciasis and Lymphatic Filariasis Treatments:*
Plateau and Nasarawa States; Past and Projected Future through 2014
Oncho
control
LF transmission interruption
3500000
3000000
2500000
2000000
1500000
1000000
500000
0
1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
LF & Oncho Txs
Oncho Txs
LF Alone
What happened to our platform??
Schistosomiasis
>1 million PZQ treatments
celebrated
l b t d in
i 2007
Integration of schisto with LF/RB
has been problematic and ‘slow’
Ui
Urinary
S
Schistosomiasis
hi t
i i
Photo credit Emily Staub
Hematuria
3+ 2+ 1+ Tr (-)
Urine Dipstick
Hopkins AJTMH 2002
Intestinal Schistosomiasis
April 2007: The first big donation
DG M Chan and Merck KGaA (E-Merck) Exec
Board member Elmar Schnee announce 200
million
o tab
tablet,
et, 10
0 yea
year PZQ
Q do
donation
at o ((20
0
million/year)
WHO Nigeria Pledge
• 1.5 million PZQ tablets/year for Carter Center
assisted programs in Nigeria
• Targeted for School aged children
• Tablets are now in Port of Lagos
Costt off PZQ
C
Costs of extra TX rounds
Cost of Mapping
Bull WHO Aug 2006
Na-Bangchang K, Kietinun S, Kumar Pawa K, Hanpitakpong W,
Na-Bangchang C and Lazdins J. Assessments of
Pharmacokinetic Drug Interactions and Tolerability
of Albendazole, Praziquantel and Ivermectin
C bi ti
Combination.
T
Trans
Royal
R l Soc
S Trop
T
Med
M d Hyg
H 2006
TRIPLE DRUG ADMINISTRATION (TDA)
Treating 3 diseases at once in Nigeria
Treating three diseases (Schisto, LF and river blindness) with PZQ, albendazole and
ivermectin administered at the same time. Eigege, Annals Trop Med Parasit 2008
Costt off PZQ
C
Costs of extra TX rounds
Cost of Mapping
Bull WHO Aug 2006
WHO PZQ
Q MDA Treatment
Guidelines (1993)
Prevalence*
Treat
-
Hyper
yp
>50%
Entire Population
p
Meso
20
20-- 49%
School aged children
Hypo
<20%
Infected children only
*Prevalence in sample of school aged children
NIGERIA CARTER CENTERCENTER-ASSISTED SCHISTO
VILLAGE PREVALENCE ASSESSMENT
800
747
700
600
48%
500
400
65%
35%
358
300
233
200
125
100
0
Assessed
N=22,402
Need PZQ
School Age
Mass Tx
Plateau/Nasarawa Programme Map
Bassa
Jos North
Jos East
Jos South
B/Ladi
Riyom
Kanam
*
Kanke
Mangu
Pankshin
Bokkos
*
Karu
Keffi
Akwanga
Kokona
Wase
Mikang
Wamba
Nas/ Eggon
Quan Pan
Shendam
Langtang South
Lafia
!
Obi
Nasarawa
Toto
Awe
Doma
Keana
LF ONLY (13)
LF/ONCHO (8)
LF/SCHISTO (5)
LF/ONCHO/SCHISTO (4)
Intestinal Schistosomiasis
Missed Treatment Opportunities for
Schistosomiasis mansoni in Plateau and
Nasarawa States
Julie R
R. Gutman1,Ayodele
Ayodele Fagbemi2,
Kal Alphonsus2, Abel Eigege2, Emmanuel S. Miri2, Frank O. Richards3
1Emory
University, Atlanta, GA, United States
2The Carter Center,
Center Jos,
Jos Nigeria
3The Carter Center, Atlanta, GA, United States
In press AJTMH (2008)
NIGERIA CARTER CENTERCENTER-ASSISTED URINARY SCHISTO
VILLAGE PREVALENCE ASSESSMENT
800
747
700
600
48%
500
400
65%
35%
358
300
233
200
125
100
0
Assessed
N=22,402
Need PZQ
School Age
Mass Tx
‘Mesoendemic’ ‘Hyperendemic’
Enrolled
Subjects
924 Children
25% have intestinal
Schisto
Missed opportunities
• Of the 50% of communities not needing
treatment for Urinary Schisto, over half need
treatment for Intestinal Schisto
• Overall, 80% of villages need treatment for
some form
f
off Schisto
S hi t (urinary
( i
and/or
d/ iintest)
t t)
Why then,
Why,
then are we mapping????
Costt off PZQ
C
Costs of extra TX rounds
Cost of Mapping
Bull WHO Aug 2006
New Ideas with New Resources
Simplify, Simplify, Simplify
Ralph Waldo Emerson
What should we do?
• Use donation to treat all the school aged population
((approximately
pp
y 1 million)) in two state area
• Use Triple Drug Administration (TDA)
• Get it done in a single round
• Less focus on mapping results
• Forgo community
community--wide PZQ treatment for now and
evaluate impact in higher prevalence areas
Community based treatment
SCHISTO TREATMENTS, 1999 – SEPTEMBER 2007 IN PLATEAU, NASARAWA AND DELTA
STATES
196,568
200,000
185,644
160,000
,
136,3
316
151,863
180,000
84,165
93,88 5
120 000
120,000
100,000
101 ,908
140,000
TRX
44,830
80 000
80,000
60,000
20,000
8,414
40,000
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
SCHISTO TREATMENTS, 1999 – SEPTEMBER 2007 IN PLATEAU, NASARAWA AND DELTA
STATES
1,000,000
900,000
800,000
700,000
600,000
500,000
400,000
300,000
200,000
,
100,000
0
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Conclusions
• Integrating LF and RB programs at
district level was easy
• LF took over from RB as the ‘platform
program’ due to size
• Control vs Elimination strategies.
Stopping LF MDA after 55-6 years
(
(2008)?
)? Do we loose our platform
f
program?
Conclusions
• Schistosomiasis integration was difficult,
not only because PZQ is not donated,
but:
 Slow and costly LGA level mapping and
village
illage stratification
 Delivery of praziquantel separately from
ivermectin and albendazole
• Going for 1,000,000 PZQ treatments in
2008
Structure of my Talk
•
•
Introduction
Concepts
 Control versus Elimination (Eradication) Strategy
 Vertical versus Horizontal PH systems
•
•
Three tropical diseases (RB, LF, Schisto)
Nigeria
• Future challenges
GLOBAL DISEASES:
Voices from the Vanguard
g
Bundling Grassroots Services
to Battle Neglected Diseases in
Africa
A Journey to Nigeria
Frank Richards Jr.,, MD
The Carter Center
March 18, 2008
Fostering Partnership
MOBILE DISTRIBUTION
COMMUNITY DIRECTED
TREATMENT (ComDT, CDTI)
Community-based
Communityvs.
vs
Facility--based
Facility
“That’s the difference between
government and individuals.
i i i
Governments don’t care, individuals
do.”
Mark Twain
Key Hypothesis of new BMGF
Grants on Integration
I
Integration
i off community
i b
based
d disease
di
control programs will increase effectiveness
and reduce cost
cost,, easing the strain on public
health systems in African countries.
Integration will therefore improve the health
off as many people
l as possible
ibl att a costt that
th t
can be sustained for as long as necessary.
A Nigerian woman and her baby show their insecticideinsecticide-treated bed
net.
GLOBAL DISEASES:
Voices from the Vanguard
g
Bundling Grassroots Services
to Battle Neglected Diseases in
Africa
A Journey to Nigeria
THANKS
G
Governments
t off Plateau/Nasarawa
Pl t /N
States
St t
Federal Government of Nigeria (FMOH)
University of Jos
CDC
Emory University
The Gates Foundation
Merck & Mectizan Donation Programme
GlaxoSmithKline (GSK)
Izumi Foundation
Lions International
APOC/WHO/World Bank
Reflections for Students
“Never Go Back the Way You Came”
From: A P
F
Profile
fil off D
Dr. B
Ben K
Kean,””
CUMC Alumni News, 1985
‘When
When a student asks me today about going into
tropical medicine, I tell him or her this: Decide
what field yyou want to ggo into;; master the
specialty; then, when you go into the tropics, you
can bring that special knowledge with you….
The basis for eventual success in tropical
medicine is temporary restraint of
enthusiasm...’
W. Foege: In Search of a National Agenda for
International Health Problems
AJTMH 1990; 42:293-97
Don’tt be afraid to be a ‘Globalist’
Don
Globalist
•Be
Be an Activist
•Be a Practical Scientist
Seek Simple Solutions
•Seek
•Be Confident
Be Focused
•Be
Thanks!