United we fight Neglect

If this blog series has at all achieved it purpose, it should be blatantly obvious by now that NTDs are no small matter. More needs to be done to eradicate and at least move towards creating a better quality of life for those affected.

The World Health Organisation (WHO, 2010) has taken steps to create change by publishing its five strategies for helping control and eliminate NTDs:

1.) Use preventative therapy

2.) Increase disease management

3.) Control vectors and responsibly manage environments

4.) Look into connecting the veterinary public health to human health more effectively

5.) Provide safe water, sanitation and hygiene and create better sustainability

Luckily, as wonderful as these ongoing strategies are, other organisations are running in conjunction to help  fight NTDs.

Children without Worms

This organisation is focused on eradicating intestinal worms in those aged under 18, by partnering with local communities to provide basic sanitation, increase agriculture efficacy,  in addition to providing education and treatment. This advocacy and project work is important, and the organisation works as a charity in partnership with many sectors, as they understand that eradication comes down to a combined team effort ( Children without Worms, 2017)

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A widely successful and effective campaign has been lead by the END7 project, which works as a branch of Sabin Vaccine Institute. The user friendly media, celebrity endorsements and site accessibility have attracted people to learning more about NTDs and offering financial and advocacy support. The campaign has focused on making the complete eradication of elephantiasis, river blindness, snail fever, trachoma, roundworm, whipworm and hookworm a goal by 2020. The money goes to research, and the provision of cheap treatments to endemic regions. The campaign has been monumental in reaching the general public and has gained lots of support ( END7, 2016).


Centre for Disease Control

Lastly an important player in creating global shifts in the elimination and control of NTDs, is the CDC. The CDC plays a huge role in developing global policy, conducting research, evaluating and monitoring the progression of NTDs and providing technical support to ongoing projects. The CDC is important in terms of being the governing arm of NTD research and also in policy making. The CDC also works extensively to provide safe and effective mass drug distribution of NTD medications currently available (CDC, 2011)

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Call to arms

As tempting as it is to think that there is nothing left for us to do or contribute, the truth is that NTDs are still such a huge global issue and it is imperative that we take an interest in creating better healthcare standards for the poorest and most disadvantaged in our world. We can get so caught up in our own lives and issues that we can fail to see how much we have to offer in terms of time, advocacy, financial aid and innovative thinking.

Yet moreover we need to not understate the importance of those individuals living with NTDs who have been ostracised, have resulting emotional trauma and the impact this has on the surrounding community. Recognition of the struggles of people suffering under the rule of NTDs allows us to be grateful for the medical care provided to us, and allows us to realise we have a duty to pass it on. So go on, don’t just let others do it, go out and find ways to promote and create real lasting impacts on NTD sufferers.

By: Roberta Dumbrava

The killer kissing bugs and Chagas Disease.

Think back to the last time you were bitten by a mosquito. Did the bite itch? If so, did you scratch it? The body’s instinctive reaction to an itch is to scratch, so it’s highly likely you did give in to the temptation. In the case of our humble mosquito bite, scratching may exasperate and prolong the irritation or even lead to secondary infection. If you think these are serious complications of a little relief via scratching, perhaps we should compare it to the potential consequences of scratching a triatomine bug bite.


The triatomine bug (Source: CDC)

Triatomine bugs- also known as “kissing bugs” or “assassin bugs”- are large bloodsucking insects that occur mainly in Latin America and Southern USA (WHO, 2017). They can be found in low socioeconomic domestic environments in areas such as under porches, in poorly constructed walls or roofs, between rocky structures, under cement, or in chicken coops, and are all potential vectors of the Chagas Disease parasite- Trypanosoma cruzi. The kissing bugs hide during the day and become active at night when they feed on human blood, typically taking advantage of an exposed area of skin such as the face. The parasite is then deposited when the bugs defecate near the bite. Instinctive scratching or rubbing can smear bug faeces or urine into the bite, eyes, mouth, nose, or any other break in skin, permitting T. cruzi to access the bloodstream unbeknownst to the host. Other modes of transmission account for just 20% of transmissions (Aiga, 2012) and include consumption of food contaminated with T. cruzi, blood transfusion or organ transplantation from infected donors, and passage from an infected mother to her newborn.


Shortly after inoculation, a high number of parasites circulate in the blood stream, with the acute phase commencing. Symptoms are present in less than 50% of cases (WHO, 2017) and may include:

  • Fever
  • Fatigue
  • Body aches
  • Diarrhea
  • Nausea
  • Vomiting
  • Hepatosplenomegaly
  • Swelling at the site of inoculation (notably the eye which is known as Romaña’s sign)


Romaña’s sign (Source: CDC)

These are most severe in individuals with a compromised immune system (CDC, 2010). Although these symptoms often resolve spontaneously, even with treatment, the disease will progress to the chronic phase. Most patients will be unaware of their infection during this phase, however 30-40% of cases will develop complications, the most frequent and severe (being potentially fatal) of which is chronic cardiomyopathy (RAGCP, 2014). Other patients suffer from digestive complications (typically enlargement of the oesophagus or colon), neurological, or mixed alterations.


Global estimates for the number of people infected with T. cruzi range from 8 million to 12 million, whereas the estimates for the number of annual deaths attributable to Chagas Diseases are less variable ranging from 10, 600 to 12, 500(Stanaway, 2015). As a low-mortality high-morbidity disease, much like many of the other NTDs, the majority of the global health burden stems from the health care requirements, non-fatal health loss and chronic disability. Chagas is estimated to be responsible for 550, 000 disability adjusted life years (DALYs), precipitating an economic burden of USD $7.19 billion per year. This places the economic burden of Chagas well in excess of other prominent diseases in all socio-economic populations such as rotavirus ($2.0 billion), cervical cancer ($4.7 billion) and Lyme disease ($2.5 billion) (Stanaway, 2015).


With no vaccination available for Chagas Disease, vector control is currently the most effective method of prevention. Bearing this in mind, it is surprising that we don’t invest more in this intervention. In Colombia alone, the economic burden of medical care for Chagas Disease (not factoring in loss of productivity) was estimated to be USD $267 million in 2008. Only USD $5 million was allocated to vector control via insecticides (WHO, 2017). This amounts to less than 2% of the funds allocated to medical care, despite triatomine bugs accounting for 80% of all transmissions of T. cruzi. We must advocate the cost effective nature of vector control prevention and make better use of the resources we have. From both a humanitarian and economical perspective, prevention is superior to treatment. This becomes even more evident when we consider the current treatments for Chagas are unsatisfactory. The drugs of choice Benznidazole and Nifurtimox are not cost effective and produce an elaborate concoction of side effects. Additionally, they are of no use in patients who have already developed heart damage (Ross, 2017).


An example of the impoverished environment triatomine bugs thrive in (Source: Stanford University)

The elimination of Chagas Disease is fundamental in breaking poverty cycles. The kissing bugs invade dilapidated, poorly constructed houses and their impoverished inhabitants. Subsequent poor access to health and decreased productivity entrap these people in the poverty cycle and it continues to gain momentum. There is an urgent need for more research and development. A greater emphasis must be put on vector control and developing a vaccination. More effort must be dedicated to screening and etiological treatment. If a humanitarian perspective isn’t enough to motivate many of us to act, as it seems has been the case with many Neglected Tropical Diseases for numerous years, perhaps the fact that some scientists have predicted that Chagas may become more common in developed areas, as we increase infrastructure in areas where triatomine bugs are found, or that they could spread North to the USA with climate change would hit a bit closer to home and force us to act (Ross, 2017). Either way, we must kill the killer kissing bugs.


Hook-worm, Line and Sinker…

Hookworm together with whip-worm and roundworm, accounts for a disease burden of 576-740 million worldwide.

While it may be tempting to think that problems such as  hookworm and roundworm are problems for just the developed world. We’ve been fed this hook, line and sinker. It is worth noting that hookworm was actually a huge problem in the Southeastern region of the US for many years (CDC, 2013). Just because hookworm doesn’t affect us doesn’t mean it isn’t our concern. Yet how can we replicate the success of eradicating and reducing helminth infections in the third world as we did in the US?


The typical appearance of hookworm under microscopy ( Source: CDC)

The Facts first

Hookworm is a soil transmitted helminth with the species Necator americanus and Ancylostoma duodenale is the most common cause of roundworm in humans. As with most NTDs, these nematode parasites are found geographically in moist, warm climates where human waste is used to fertilise soil, or where poor waste management systems are in place (CDC, 2010).

Typically the eggs of the worms are found in human stool and hatch in 1 to 2 days where they can then enter the host via a wound, orally, trans-mammary or trans-pulmonary to infect the blood vessels and alveoli tissue where they eventually attach to the small intestinal wall to cause severe blood loss. These worms typically can be eliminated in one to two years but typically can remain attached for several years following infection (CDC, 2010).

Common signs and symptoms may include:

-Protein deficiency
-Blood loss
-Retard growth
-Mental impediment

Once again as with many diseases, those at higher risk of serious disease complications are pregnant women, children and individuals with compromised immune function (CDC, 2010). However with lower intensity hookworm infections it is also likely that adults in particular will display no signs or symptoms of hosting the worms in their GIT. (WHO, 2011).

The costs of hookworm

While anaemia and protein deficiency may sound like mild side effects of unfortunately acquiring hookworm, global estimates place anaemia as the leading cause of years lived with a disability among under 18 year olds, as it affects approximately 619 million children (The Global Burden of Disease Pediatrics Collaboration, 2015). In addition to this alarming statistic, protein energy- malnutrition contributes to 225 906 deaths per year and is particularly prevalent in poorer communities which lack this base sanitation, adequate food supply and lack of medical care.

Since hookworm has low morbidity and a high disability rate, it can often be over-looked as a serious, urgent area of medical research much like many of the other NTDs. However it is this lack of sanitation and lack of food supply, which creates a cycle of poverty and disease. Hookworm is estimated to be responsible for 4,087,803 disability adjusted life years (DALYs), which adds up to a very expensive bill exceeding other highly researched diseases with its costs ranging from $7.5 to $138.9 billion depending on the GNI capital (Bartsch. et al., 2016). In terms of global productivity lost, it is estimated to be $11.1 billion annually lost, which is greater than many other diseases.


Luckily there is medication available for hookworm treatment known as “Anthelminthic medications” called albendazole and mebendazole, which are used for infections over the course of 1-3 days. These drugs are known to be extremely effective and carry very few side effects. In addition to these drugs iron supplements may also be prescribed if the infected person has anaemia (CDC, 2010).

Yet as wonderful as treatment options are, distribution, access and funding are hard in many communities and from both a humanitarian and economical perspective, prevention is superior to treatment. By creating greater sewage disposal, educating people on basic sanitation and wearing shoes (or providing footwear) in these areas, the spread could be reduced significantly.


An example of the common packaging for worm treatment ( Source: CDC)

Why the facts matter

The elimination of hookworm is crucial in breaking poverty cycles. Inadequate access to health, poor sanitation and decreased productivity  create an ongoing cycle. There is an urgent need for more education and innovative development to help stop the spread of hookworms and to additionally give equal opportunity to those stuck in a cycle of poverty and disease. Remembering to “love thy neighbor as thyself” may be the only way to come away from our own lavish and selfish perspective to truly empathise and create meaningful change. If this philanthropic approach doesn’t entice you, maybe we need to consider how interconnected our world is becoming, and how we too may become affected. Its certainly cause to pause when we start imaging the impact on ourselves.


Going viral to end the neglect: A step in the right direction, but where to next?

Neglected (adj) /nɪˈɡlɛktɪd/: suffering a lack of proper care; not receiving proper attention; disregarded.

So, how is it a group of 17 disabling, communicable diseases that are endemic amongst those living in poverty constitute this category of neglected tropical diseases (NTDs)? How did they fall into this hole of neglect? And, more importantly, how can we dig them out?

In the year 2000, following the Millennium Summit of the United Nations, the Millennium Declaration and its 8 Millennium Development Goals (MDGs) were developed with the ultimate objective to address and eradicate poverty in its many facets by 2015. They provided a platform for large-scale donor support and had a prominent influence on Global Health policy over the next decade (Hotez, 2011). The goal directly relating to NTDs was MDG 6: To combat AIDS, malaria, and other diseases, however, NTDs fell under the umbrella term “other diseases”, denying them the attention they deserved and needed. Awareness and subsequent progress was made in the spheres of HIV/AIDS and malaria with the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and the U.S. President’s Malaria Initiative, in addition to novel research and advocacy programs (Hotez, 2011). However the “other diseases” remained nameless and were largely left out of the spotlight and excitement, and thus left behind.


(Source: The United Nations)

The idea of NTDs falling under this umbrella term “other diseases” is now obsolete. The first global effort to combat NTDs as an integrated framework was made in 2006 with the launch of The Global Network for Neglected Tropical Diseases at the Clinton Global Initiative Annual Meeting (Smith, 2013). The World Health Organisation (WHO) also played a crucial role in this progression, issuing their first report on NTDs in 2010- Working to Overcome the Global Impact of Neglected Tropical Diseases. The report recognised the role NTDs play in the weakening of impoverished populations, the perpetuation of cycles of poverty, and the impediment of achieving other MDGs due to synergies between goals. These are just examples of monumental events that have been instrumental in positioning NTDs in both the political and the public eye. Other campaigns such as END7 have effectively utilised forums, such as social media, to appeal to an even broader audience. Their video How to Shock a Celebrity has received over 300 000 views.


(Source: END7 Campaign via Stirling Media)

The increased advocacy and awareness of NTDs is the first step in a multifaceted and intertwining network of developments that are absolutely necessary to treat and eradicate these diseases. More effort and more action are still desperately required in the areas of financial resources, distribution of resources, diagnostics and treatment. If we consider that NTDs affect almost 20% of the entire population and almost 50% of the impoverished population, yet receive only 0.6% of the Official Development Assistance for Health (Smith, 2013), we can certainly see where this “neglected” tag stems from. This becomes even more significant, and quite frankly astounding, when we acknowledge that 42.1% of the same budget is dedicated to HIV/AIDs, malaria and tuberculosis (Rafati, 2015) even though estimates for the number of Disability Adjusted Life Years (DALYs) attributed to NTDs place them at best on par with those attributed to tuberculosis, and at worst in excess of those attributed to HIV/AIDs (WHO, 2004). We must appeal to the business sector and ensure that the bleak effect of NTDs on productivity and profit are well understood. A similar strategy was implemented in South Africa regarding HIV/AIDs. The economic argument for HIV treatment was well received with companies sponsoring anti-retroviral treatment programs for their employees (Lee, 2013).

There is currently an estimated USD $220 million global annual funding gap for treating NTDs (Zwane, 2015). Funding provides the vessel for evolution in research and development (R&D); without sufficient amounts we can’t make the essential voyage to new territory in terms of diagnostics, which present a significant challenge in themselves due to a lack of efficacy in remote areas, invasiveness and inaccessibility (Kessel, 2014). Promoting the economic benefit of accurate diagnoses and treatment must become a priority in an effort to educate existing major donors and attract new donors. There is no proper health intervention without accurate diagnosis. There is no accurate diagnosis and subsequent treatment without sufficient resources.

There is no denying that the process of increasing funding allocated to the prevention, diagnosis, and treatment of NTDs is not one that will happen overnight. So in the meantime, we must make better use of the resources we do already have, in particular the drugs used for treatment. The NTD drug supply chains currently face significant challenges and will continue to face these challenges if we don’t take action. These including a lack of understanding of NTD supply needs amongst both central and district staff; ad hoc supply chain solutions; duplicative supply chains; and incomplete data (John Snow Inc, 2015). Such challenges precipitate stock outs, disrupted supply chains, increases in cost, ineffective planning, supply imbalances, and ultimately wastage with the return of unused drugs (John Snow Inc, 2015). If we were to provide easier access to supply chain expertise via Regional Technical Access Centres we could improve human capacity at the community level. If we were to implement standard operating procedures, we could strengthen planning, management and budgeting for NTD mass drug administration. Finally, if we maintained a greater focus on strengthening the logistics management system and introduced performance based incentives, we could see the effective, high-performing drug supply chains we need. There will be no control and elimination of NTDs without a full supply of NTD drugs and the capacity to distribute them. Let’s implement these strategies and achieve our short term and long term NTD goals for the sake of those with no voice.


Out of Sight, but not out of miND…

Why is it that diseases with an incidence of more than 1 million* in our world population are so prevalent? What contributes to such a high disease burden and mortality rate?
The table below gives a basic overview of four broad determinants of NTD prevalence:


1.) Poverty

It is no coincidence that more than 70% of territories affected by NTDs are classified as either low-income or lower-middle income countries ( WHO, 2017 ). In addition to this, 100% of these low socioeconomic countries are affected by at least five NTDs (WHO, 2017 ). For example, in Brazil, low-income is a direct predictor of dengue fever, while in Africa poverty is the major “potentiator of leishmaniasis morbidity and mortality” (WHO, 2017 ). Why is this?

From a community viewpoint, lack of economic growth and development leaves room for poor sanitation, malnutrition and limited access to education. To top this off, generally these regions are underdeveloped and isolated so there is poor access to healthcare (Ghose, 2014). This clearly affects individuals within these communities who lack access to safe environments, placing them at higher risk to be infected by parasites causing NTDs.

NTDs also act in perpetuating the cycle of poverty by disabling workers and draining families of money following costly treatments. NTDs can also magnify the physical effects of malnutrition as many intestinal worms cause the loss of iron and vitamin A which affects growth and have detrimental effects in pregnancy ( Sabin, 2014).

2.) Social Inequalities

Ethnicity and gender plays a huge part in access and stigmatization of NTDs within local communities. According to WHO females often find it harder to access treatment due to their perception in many communities as being inferior. Also on this note, different African tribal groups are often shunned and isolated from accessing clinics or certain territories due to stigma.

Lastly, the tribal traditions of many groups, particularly their religious views play a huge role in how they view the medication profession, with sickness often seen as a bad “omen” and a punishment. It is social factors such as these which can make educating communities extremely hard.

3.) Lack of Funding

The reason many people in the first world have never heard of diseases such as trachoma and African trypanosomiasis is due in part to the lack of research and funding put into NTDs ( WHO, 2017). Since first world countries suffer from cancer and diabetes, public funding is focused on these diseases, which diverts research away from NTDs. This decreases awareness of for NTDs and poses a serious ethical concern in regards to how we can morally choose which diseases deserve more or less funding. This leads to less choices for drugs on the market which  can treat NTDs!


Chart showing the allocation of funding and people affected by four diseases (Source: Thomson Reuters Web of Knowledge, 2011 )


Pie chart showing the number of drugs on the market (Source: CDC)

4.) Political

As wonderful as it is to want to isolate NTDs as its own issue, the lines blur quite quickly when we start considering treatment, risk factors and causes of NTDs. The challenge in population growth and the refugee risis pose a serious threat in spreading NTDs. These diseases occur and spread when family groups live in close proximity, and with political crises forcing people to leave and find safety, these condition are often over-crowded.

There is also the environmental issue of climate change which bears with it the issues of severe drought and famine which governments need to create policies for and deal with appropriately. In times of crisis such as natural disasters this can be particularly challenging due to the unequal distribution of resources can become a huge issue, with limited access to clean water, sanitation and infrastructure destruction causing problems (CDC, 2010). These issues in poorer nations are hard to deal with, particularly when oppressive dictatorships, limited funds and civil unrest can contribute to poor policy making, placing healthcare on the back-burner.


Picture typical of close-knit communities in Africa ( Source: CDC)

Wouldn’t it be wonderful if issues weren’t this complex? Unfortunately it a a cruel fact that life, and especially health isn’t as black and white as we would hope.



Ignorance isN’T(D) bliss.

For those of us fortunate enough to be living in the developed world, the tropics and subtropics may be envisaged as regions of vast expanses of lush, green rainforests, or islands surrounded by crystal clear oceans and overwater bungalows. However, what many of us fail to realise is that a group of 17 bacterial, parasitic protozoal, and viral infections (Bhutta, 2014) thrive in these environments. Specifically, these are:

  • Buruli ulcer
  • Chagas disease
  • Dengue and Chikungunya
  • Dracunculiasis (guinea-worm disease)
  • Echinococcosis
  • Foodborne trematodiases
  • Human African trypanosomiasis (sleeping sickness)
  • Leishmaniasis
  • Leprosy (Hansen’s disease)
  • Lymphatic filariasis (elephantiasis)
  • Onchocerciasis (river blindness)
  • Rabies
  • Schistosomiasis (snail fever)
  • Soil-transmitted helminthiasis
  • Taeniasis/Cysticercosis
  • Trachoma
  • Yaws (Endemic treponematoses)


Global distribution of NTDs (Source: CDC, 2011)

The symptoms of each disease may be vastly different to the next (ranging from massive skin ulceration to seizures to irreversible blindness), but in unison, they comprise Neglected Tropical Diseases (NTDs) and affect ~1 in 6 people across the globe. This means that over 1 billion people living in poverty suffer from at least one NTD (WHO, 2017). To put that into perspective, it translates to approximately the total number of people who are active on Facebook each day. Imagine if all of these people were affected by NTDs, would they still be “neglected”?


Source: (FNDR, 2014)

NTD’s are the most common diseases of the world’s poorest populations, and cause not only debilitating consequences for the suffering individuals but contribute to social stigma, perpetuate cycles of poverty and give rise to a massive global health burden. The estimated number of deaths attributed to NTDs is up to 534 000 every year (Olatunwa, 2014). However, as a group of low-mortality, high-morbidity diseases, the majority of the adverse global health impact is associated with the chronic, disabling features of NTDs. In order to gain an appreciation of this impact, we must consider it in terms of disability-adjusted life years (DALYs), to account for the number of healthy life-years lost due to premature death or disability (Hotez, 2011). The number of DALYs attributed to NTDs has been estimated to lie between 20 million, which would place them amongst the top 20 leading causes of disease burden, and 57 million (Hotez, 2011) which would place them amongst the top 3 leading causes of disease burden in low-income countries (WHO, 2004). This translates to decreased productivity, and thus extreme economic burdens. For example, Leishmaniasis results in approximately USD $1.3 billion per year lost in productivity, and the loss in productivity attributed to trachoma alone is estimated at USD $2.9 billion per year (Bhutta, 2014).

The development of “rapid impact packages” has enabled just $0.50 USD to treat and protect a person (Hotez, 2011) against seven of the most common NTDs for up to one year. More information on how we can be involved can be found via the END7 campaign. If we- the daily Facebook users- all contributed in this simple, cost effective way, would they still be “neglected”? Or perhaps eradicated?

By Jemma Saxton