Public-private partnerships in neglected tropical disease control: the role of nongovernmental organisations.

Successful public-private partnerships for health control have usually included nongovernmental development organisations (NGDOs), and these have long been in the forefront of pinpointing particular social and health issues. The immensely successful control and elimination programmes for onchocerciasis are a case in point. NGDOs were the driving force in early advocacy for onchocerciasis control in West Africa, leading eventually to the remarkably effective and long lasting partnership of the Onchocerciasis Control Programme (OCP). With the donation of Mectizan(®), NGDOs were the driving force in developing onchocerciasis control in non-OCP countries, especially programmes for community based action. These were, further modified by the African Programme for Onchocerciasis Control (APOC) to become the successful Community Directed Interventions. NGDOs came together to coordinate activities in partnership with the World Health Organisation (WHO). Innovations by NGDOs led to integration of mass drug administration for Vitamin A deficiency and then for other parasitic diseases, leading to the current trend of preventive chemotherapy. The success of the NGDO Group for Onchocerciasis Control has led to the creation of similar groups for trachoma control and lymphatic filariasis elimination. These groups have now come together to form an NGDO Network for Neglected Tropical Disease control.

Challenges for the integration of mass drug administrations against multiple 'neglected tropical diseases'.

Simple and safe medications for some of the common, but often neglected, diseases that afflict the poor are not only available but are often donated. Other medications indicated for neglected diseases are extremely cheap and cost-effective. These drugs can be administered together and combined, when feasible, into rapid-intervention packages based on mass drug administrations. It is therefore logical to integrate mass drug administrations when possible. Integration is, however, not always as simple as it seems, and 'integration' means different things to different people. Drugs are needed at different frequencies for different lengths of time, sometimes for the whole population, sometimes only for children. Care has to be taken that parallel systems are not created that bypass primary healthcare. Much can be achieved, however, by sensible integration, whether it be in the mapping of diseases or the setting up of treatment platforms that tackle several diseases at once. As governments and international organizations seek to create policies for integration that include not only mass drug administration but also morbidity control, and as various partnerships develop for implementation, there is the possibility to scale up health interventions, which will have a very positive impact on the poorest communities globally. Nevertheless, integration should not be forced for the sake of policy. Where things fit well they should be developed, where not, coordination within the primary-healthcare system can produce an equally long-lasting impact.

Health care at the end of the road: opportunities from 20 years of partnership in onchocerciasis control.

The unprecedented decision of Merck & Co., Inc., to donate ivermectin through the Mectizan(R) Donation Program, has catalysed an exemplary partnership, to distribute the drug to the communities at risk of onchocerciasis, and empower them to take charge of the drug distribution themselves. Integration with other activities has always been part of the plan, but has been accelerated in recent years because of the need to strengthen primary health care, and to meet the challenges of integrating the rapid impact of Neglected Tropical Disease programmes. Activities that have been integrated include provision of vitamin A capsules, elimination of lymphatic filariasis, the distribution of insecticide-treated nets, and comprehensive eye health. Although these integrated activities show promising results for all programmes involved, challenges still remain. The risk of overburdening communities with multiple activities, and the problem of remuneration at the community level, are the major concerns, as is the need for effective coordination. The expanded onchocerciasis control partnership is a model of translating the eighth Millennium Development Goal (MDG), namely 'develop a global partnership for development', into action and also addresses other key MDGs. In 2006, the partnership provided more than 62 million treatments for onchocerciasis control, and offers a firm foundation from which to deliver other needed health interventions while safeguarding the achievements of onchocerciasis control thus far.

Ivermectin and onchocerciasis: is it all solved?

The donation of ivermectin by Merck and Co. Inc. has led to one of the most effective private-public partnerships controlling a disease of major public health importance particularly in Africa. The up scaling of ivermectin distribution during the last 15 years has been remarkable with almost 40 million people treated in 2003, many already on their regular annual dose. The tools that have been developed particularly by the APOC programme have been instrumental in this increase. However, ivermectin is a microfilaricide and does not kill the adult worms. Distribution will be needed for at least 25 years and latest estimates indicate that 90 million people need annual treatment if onchocerciasis is to be eliminated as a public health problem. In spite of this incredible progress it is difficult to see how the programme will be sustained, especially after the closure of APOC in 2010. A macrofilaricide destroying adult worms and safe for mass distribution would solve the problem of onchocerciasis.

The effect of 5 years of annual treatment with ivermectin (Mectizan) on the prevalence and morbidity of onchocerciasis in the village of Gami in the Central African Republic.

To assess the impact of 5 years of annual community treatment with ivermectin (Mectizan) on the prevalence of onchocerciasis and onchocerciasis-associated morbidity, data collected, before and after such treatment, in the village of Gami, in a hyper-endemic area of the Central African Republic, were analysed. Skin snips from all the villagers treated in 1990 and/or 1995 were used to assess the prevalence and intensity of infection with Onchocerca volvulus. Ocular and dermatological morbidity was assessed by ophthalmological and clinical examinations of the same subjects. Following the five annual treatments, there was a reduction in the prevalence of infection and a dramatic decrease in the microfilarial load of the community. The prevalences of pruritus, onchocercal nodules and impaired vision were all significantly reduced. The results emphasise the long-term benefits of the mass-treatment programmes, particularly for children aged <10 years.

Mectizan delivery systems and cost recovery in the Central African Republic.

The Central African Republic (CAR) has a serious onchocerciasis problem. The disease is endemic in three quarters of the country and there is considerable onchocercal blindness in the north-west. The low population density and extreme poverty (the CAR being one of the 20 poorest countries in the world) combine to make mass treatment with Mectizan (ivermectin, MSD) a challenge. Although planned, primary health care (PHC) is not widely developed in the country. Mectizan distribution was carried out in 1993-1994 by mobile teams in order to address the most urgent need, particularly in the north-west. Since then, the strategy has been one of community involvement, using village health workers, chosen by their own communities, to do the treatment. The system has been a stimulus to the development of PHC in some areas, as the co-ordinators of the Mectizan programme are often the only health personnel to visit every village. The long distances between health centres, with a mean of 45 km, are likely to be an obstacle to the population collecting their own Mectizan, within the self-treatment system otherwise in place. Operational research is planned to examine ways in which the population can contribute to cost recovery without there being a reduction in treatment coverage.

A method to determine the coverage of ivermectin distribution in onchocerciasis-control programmes.

Onchocerciasis is a human filarial infection responsible for an estimated 750,000 blind and severely visually disabled people. In some African countries, this disease represents the main cause of blindness, with considerable socio-economic impact on the affected communities. Since the introduction of ivermectin as a microfilaricidal agent, there is hope that visual loss from onchocerciasis can be eliminated through community-based ivermectin-distribution programmes. The African Programme for Onchocerciasis Control (APOC) has now been initiated, by the World Health Organization and World Bank, to distribute ivermectin in 19 African countries where onchocerciasis is endemic. Estimates of ivermectin coverage in distribution programmes for onchocerciasis control have so far been based on the number of treatments given, in any one year, to a target population. There is a need for a standardized method to evaluate, measure and monitor coverage over time. In April 1996, a cluster random-sampling method was used to calculate coverage with ivermectin in an urban population of 30,000 people in the Central African Republic. The method was adapted from that used to determine coverage by the WHO Expanded Programme on Immunization. It proved to be inexpensive and easy to perform, requiring only local equipment and personnel. The method used and results obtained in Bossangoa and the potential use of the technique in other distribution programmes are discussed.

Therapeutic trial of four amoebicide regimes in rural Zaire.

A prospective comparative trial of four amoebicide regimes was carried out with protozoological control using 300 patients presenting with symptomatic intestinal amoebiasis at a tropical rural hospital during a five month period. 195 (76.2%) of 256 treated supplied three follow-up stools. Of those treated with Metronidazole and Oxytetracycline 10.9 per cent continued to excrete Entamoeba histolytica while with Di-iodohydroxyquinoline and Oxytetracycline the figure was 25.5 per cent falling to 20.0 per cent when Dehydroemetine was added and with Clioquinol and Oxytetracycline 27.5 per cent continued to excrete Entamoeba histolytica. These figures with the absolute numbers of patients involved do not show any one of the regimes used to be significantly more effective than the others in unclassified symptomatic intestinal amoebiasis. We conclude therefore that in the rural situation the cheapest regime should be preferred as the standard one, namely Clioquinol and Oxytetracycline. However, in view of the reported serious side-effects of Clioquinol, Di-iodomydroxyquinoline and Oxytetracycline could be considered as the second cheapest and with slightly better results.