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Eliminating Neglect and Neglected Tropical Diseases

PLOS NTDs Editor-in-Chief, Peter Hotez, highlights progress in the elimination of neglected tropical diseases through mass drug administration and other measures.

This month, a landmark paper was published in PLOS Neglected Tropical Diseases.  A group of scientists and public health experts from the ministry of health of Togo and Togo’s Université de Lomé, together with Norway’s Health & Development International and the Georgia-based Mectizan Donation Program, Rollins School of Public Health at Emory University, and the United States Centers for Disease Control and Prevention (CDC), reported that Togo will soon become the first sub-Saharan African country to eliminate lymphatic filariasis [1]. Their approach to elimination relied on mass drug administration (MDA) with ivermectin and albendazole donated by Merck & Co. and GlaxoSmithKline, respectively, together with programs of morbidity management – lymphedema management and hydrocele surgeries – and monitoring and evaluation [1].

The importance of the paper stems from the fact that it provides further proof of principle that sub-Saharan African nations are building on their previous successes in elimination or eradication of selected neglected tropical diseases (NTDs) including dracunculiasis (guinea worm) in most of the region, onchocerciasis (river blindness) in two countries, and human African trypanosomiasis (sleeping sickness) in more than a dozen countries. In addition, the article highlighted the roles of morbidity management alongside MDA and essential financial support for the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) [1].

I previously reviewed the success stories achieved to date for eliminating 11 of the high prevalence NTDs using MDA and other measures [2], which can now be updated to include information from the World Health Organization’s (WHO’s) 2020 Roadmap on NTDs included in the Second WHO Report on NTDs [3], together with new information on eliminating onchocerciasis in Guatemala and southern Mexico [4] and trachoma elimination [5]. The six diseases listed in Table 1 are those specifically targeted for elimination in 2012 by a London Declaration on NTDs in collaboration with a consortium of donors and industrial partners [6].

Table 1. Progress in Elimination for Diseases Targeted by the London Declaration on NTDs (Modified from Hotez P 2011 [2])
Table 1. Progress in Elimination for Diseases Targeted by the London Declaration on NTDs
Modified from: Hotez P. 2011. Enlarging the “audacious goal”: elimination of the world’s high prevalence neglected tropical diseases. Vaccine 29S: D104-D110
In 2011 I recommended efforts to eliminate the high prevalence NTDs globally by expanding MDA efforts for seven of these conditions, as well as multi-drug therapy for leprosy, while simultaneously investing funds to research and development (R&D) to improve the available diagnostic tests and in some cases discover, develop, and deliver new drugs and vaccines [2].  In the same year together with colleagues from the Global Network for NTDs and the Earth Institute at Columbia University we called for an expansion of the mandate of GFATM and the US President’s Emergency Plan for AIDS Relief (PEPFAR) to include NTDs [7].

The London Declaration on NTDs that followed in 2012 articulated a framework for control and elimination targets for the NTDs. In order to continue reaching elimination targets for the high prevalence NTDs such as the one reported this month in PLOS Neglected Tropical Diseases I believe that three important stars will need to align:

1.    The governments of the US and United Kingdom through their overseas development agencies, USAID and DFID, respectively, have been absolutely wonderful in supporting and leading MDA efforts, including “rapid impact” packages of drugs for integrated NTD control [8].  However, we need other governments to step-up and provide support.  In a new paper in Foreign Policy I reported that two-thirds or more of many of the high prevalence NTDs actually occur in the group of 20 (G20) nations especially the BRICS countries and Indonesia, but even wealthy countries such as the United States and Australia have intense pockets of poverty and NTDs [9].  The emerging economies must become more proactive in supporting MDA globally.  In the meantime a private END (Ending Neglected Diseases) Fund continues to provide key gap funding, especially for Africa [10].

2.    The Togo study highlighted the importance of GFATM funding in making LF elimination possible.  We need both GFATM and PEPFAR to prioritize NTDs as an essential component of their activities and to address people living with HIV/AIDS who are co-infected with parasites [11].  Female genital schistosomiasis – possibly the most common gynecological condition on the African continent – and one with well-established links to HIV/AIDS [12] – continues to be largely ignored.

3.    We will need an expansion of public support for R&D on new drugs, diagnostics, and vaccines.  We still continue to rely mostly on support from the Governments of the US (mostly from the National Institutes of Health) and UK, and also the Bill & Melinda Gates Foundation.  This year in collaboration with the Institute of Medicine a group of us provided a discussion paper that points to the importance of securing support from the other G20 countries, many of which (as pointed out earlier) are themselves beset by NTDs [13].   The new Office of Global Health Diplomacy in the Department of State could have an important role in exerting diplomatic pressure on these countries [13].

Finally we will continue to require a strong and empowered WHO together with its regional offices to help in the coordination of these important activities. We will also need to maintain a strong program of independent advocacy, which will work with the G20 countries and continue to heighten awareness on the NTDs as the most common infections of humankind. I am very excited about the results coming out of Togo, which give me cause for great optimism and hope!

Literature Cited

  1. Sodahlon YK, Dorkenoo AM, Morgah K, Nabillou K, Agbo K, Miller R, Datagni M, Seim A, Mathieu E. 2013. A success story: Togo is moving toward becoming the first sub-Saharan African nation to eliminate lymphatic filariasis through mass drug administration and countrywide morbidity alleviation.  PLOS Negl Trop Dis  7: e2080, accessed April 20, 2013
  2. Hotez P. 2011. Enlarging the “audacious goal”: elimination of the world’s high prevalence neglected tropical diseases.  Vaccine  29S: D104-D110
  3. World Health Organization. 2012.  Sustaining the drive to overcome the global impact of neglected tropical diseases: Second WHO report on neglected tropical diseases, accessed April 20, 2013
  4. No authors listed. 2012. Progress towards eliminating onchocerciasis in the WHO region of the Americas in 2011: interruption of transmission in Guatemala and Mexico.  Wkly Epidemiol Rec  87: 309-14, accessed April 20, 2013
  5. No authors listed. 2012. Global WHO Alliance for the elimination of blinding trachoma by 20120.  Wkly Epidemiol Rec  27: 161-8, accessed April 20, 2013.
  6., accessed April 20, 2013
  7. Hotez PJ, Mistry N, Rubinstein J, Sachs JD. 2011. Integrating neglected tropical diseases into AIDS, tuberculosis, and malaria control.  N Engl J Med  364: 2086-9
  8. Molyneux DH, Hotez PJ, Fenwick A. 2005. “Rapid-impact interventions”: how a policy of integrated control for Africa’s neglected tropical diseases could benefit the poor. PLOS Med  2: e336
  9. Hotez P. 2013. The Disease next door. Foreign Policy March 25, 2013, accessed April 20, 2013
  10., accessed April 21, 2013
  11. Hotez PJ, Molyneux DH, Fenwick A, Ottesen E, Ehrlich Sachs S, Sachs JD.  2006. Incorporating a rapid-impact package for neglected tropical diseases with programs for HIV/AIDS, tuberculosis, and malaria. PLOS Med  3: e102.
  12. Hotez PJ, Fenwick A, Kjetland EF. 2009. Africa’s 32 cents solution for HIV/AIDS.  PLOS Negl Trop Dis  3: e430
  13. Hotez P, Cohen R, Mimura C, Yamada T, Hoffman SL. 2013. Strengthening Mechanisms to Prioritize, Coordinate, Finance, and Execute R&D to Meet Health Needs in Developing Countries.  Institute of Medicine Discussion Paper, January 15, 2013, accessed April 20, 2013
  1. Thank you Professor Hotez – your continued advocacy for the NTDs is brilliant and stimulating, and look at the progress in the last 10 years since we all pulled together. SCI, Imperial College has just assisted delivery of the 100 millionth praziquantel treatment in 16 countries (and many more against STH) improving the quality of life for so many children in Africa. We could not do it without so many contributions, the advocacy , WHO, the World Bank, the funding from USAID ad DFID, the donated treatments from big pharma, and the country buy-in. Keep those advocacy pieces coming please Alan

  2. I agree with Peter Hotez that the PLoS NTD article on the prospects for eliminating lymphatic filariasis (LF) in Togo is a significant piece of work, especially as we approach the endgame phase for LF elimination globally. The success story for Togo gives hope to many other African countries where the same mosquito acts as the carrier for both the LF and malaria parasites. Efforts to eradicate malaria in Togo in the 1960s, through indoor residual spraying with DDT, resulted in the interruption of LF transmission in some areas. It is therefore not surprising that only 7 of the 35 health districts were found to be endemic during the initial mapping. The link between malaria control and LF elimination needs to be emphasised more. The added value of this synergy may have contributed to the successful application to the Global Fund to flight AIDs, Tuberculosis and Malaria (GFATM) to support LF elimination activities in Togo. There is growing evidence that many countries scaling up efforts to control malaria with anti-mosquito tools, including long lasting insecticidal nets (LLIN) are impacting LF transmission. With very effective MDA programmes, Anopheles-transmitted LF can be easily eliminated. The Liverpool School Centre for Neglected Tropical Diseases since it was established in 2000 has provided support, for MDA implementation to interrupt LF transmission, to more than 20 countries globally, undertaken operational research to understand vector-parasite relationships in different epidemiological settings.

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