STAG 2014 Report to Strategic Technical Advisory Group for Neglected Tropical Diseases

1. STAG 2014Report to Strategic Technical Advisory Group for Neglected Tropical Diseases Dr Lorenzo Savioli – Dr Dirk Engels Department of Control of Neglected Tropical Diseases

2. Report to STAG-NTD 2014 NTD highlights 2013-2014 Key achievements • Eradication • Elimination • Control Response to STAG 2013 recommendations Issues to be considered by STAG 2014

3. Comprehensive WHA Resolution on 17 NTDs After STAG 2013, World Health Assembly adopted WHA66.12 calling for: • country ownership of control programmes • expansion of interventions • advocacy for long-term financing of control activities and capacity strengthening • integration of control programmes into primary health-care services • universal access to interventions to achieve roadmap targets

4. Roadmap targets towards 2020 2 Eradication targets • 2015: Dracunculiasis • 2020: Yaws 4 Global elimination targets for 2020 • Blinding trachoma • Human African trypanosomiasis • Leprosy • Lymphatic filariasis 8Regional elimination targets 2015 • Onchocerciasis in Latin America • Human rabies transmitted by dogs in Latin America • Schistosomiasis in the EMR, Caribbean, Indonesia and Mekong River basin • Chagas disease through blood transfusion 2020 • Human rabies transmitted by dogs in SEAR and WPR • Schistosomiasis in AMR and WPR • Visceral leishmaniasis in the Indian subcontinent • Chagas disease intra-domiciliary transmission in AMR

5. Roadmap targets towards 2020 7 Control targets and milestones for 2015 and 2020 • Buruli ulcer • Cutaneous leishmaniasis • Dengue • Echinococcosis • Food-borne trematodiases • Soil-transmitted helminthiases • Taeniasis/cysticercosis

7. Universal health coverage for NTDs:population and health service coverage (2012) Share of population requiring PC … and not receiving PC Mostly middle-income countries The third NTD report will show investments required to achieve universal population and health service coverage for all PC and IDM NTDs

8. Universal health coverage for NTDs:financial protection *defined as >40% of annual household non-subsistence spending or >10% of household spending Catastrophic out-of-pocket spending* on case management • Visceral leishmaniasis • Eastern Sudan (2011): >75% of households experienced catastrophe despite free diagnosis and drugs • Nepal (2003/2010): 26%/51% of households experienced catastrophe • Buruliulcer • Central Cameroon: average spending of 25% of household earnings; 53% incurred debt • Dengue • Cambodia (2003/2006): 58%/67% of households incurred debt • Chagas disease, HAT, LF, leprosy, rabies, trachoma, yaws: no studies identified so far The third NTD report will show investments required by the public sector (or insurance schemes) to avoid catastrophic out-of-pocket spending by households affected by NTDs

9. Report to STAG-NTD 2014 NTD highlights 2013-2014 Key achievements • Eradication • Elimination • Control Response to STAG 2013 recommendations Issues to be considered by STAG 2014

10. Eradication

11. Dracunculiasis eradication • 148 cases during 2013, marking lowest number ever reported to WHO • Most endemic country, South Sudan reported zero cases for 4 consecutive months - November 2013 to February 2014 • 5 more countries certified in 2013 - Côte d’Ivoire, Nigeria, Niger, Somalia and South Africa – bringing the total to 197 countries, territories and areas (belonging to 185 WHO Member States) certified free from transmission • 9 Member States are still to be certified

12. Dracunculiasis eradication

13. Dracunculiasis eradicationRemaining challenges • Insecurity in Mali and South Sudan • Unusual disease epidemiology in canine population in Chad • Continued low-intensity transmission in Gambella region of Ethiopia • Unusual pattern of population movement due to security concerns - Mali, Niger and cattle camps in South Sudan • Complacency and weakening commitment due to low number of cases

14. Status as of April 2014 2013 2014 2015 2020 Yaws • 24–25 March 2014 consultation held to review ongoing pilot implementation of Morges strategy • Major challenge: secure free azithromycin for implementation • 4 countries reported positive results • All achieved >90% coverage • Rapid disappearance of lesions instilled confidence in the populations • Baseline azithromycin resistance surveys showed no evidence of resistance

15. Global Elimination

16. Status as of April 2014 2013 2014 2015 2020 Trachoma Blinding trachoma is now part of NTD Department and a medical officer has been appointed as focal point

17. Status as of April 2014 2013 2014 2015 2020 HAT • Trypanosoma bruceigambiense: found in 24 countries in west and central Africa, accounting for 98% of reported cases • Trypanosoma bruceirhodesiense: found in 13 countries in eastern and southern Africa, accounting for 2% of reported cases • In 2013: 6 314 cases (6 228 cases of gambiense and 86 cases of rhodesiense) • March 2014: Declaration for the elimination of gambiense human African trypanosomiasis; WHO HAT control programme moves to WHO HAT elimination programme; Commitment of endemic countries to go beyond 2020 target to interrupt transmission in 2030; WHO-network for HAT elimination established for gambiense HAT • End of 2104: establishment of the rhodesiense HAT component of the WHO network • New medicines and diagnostics available over next two years

18. Status as of April 2014 2013 2014 2015 2020 Leprosy • Leprosy elimination as a public health problem achieved and maintained in all but three countries in WPR • July 2013: SEAR Member States adopt Enhanced Global Strategy as part of Bangkok Declaration • 2012-2013: integration of leprosy programme into general health services improves case detection. More than 9 million school-children (5–14 years) treated for intestinal worms and screened for leprosy in 2013 in Brazil • Integration of leprosy in health programmes results in slight increase in new cases globally • 2012: 232 857 cases • 2011: 226 626 cases

19. Status as of April 2014 2013 2014 2015 2020 Lymphatic filariasis • Of 73 endemic countries: 59 completed mapping, 56 started MDA, 13 under post-MDA surveillance • 147.6M DEC tablets from Eisai donated to 13 countries • STAG Regional TAS training workshops completed in AFR, AMR, EMR, SEAR and WPR • STAG endorsed the latest provisional strategy to start interventions for LF in loiasis-endemic areas • Documents • Published - 10 TAS training modules (learners’ guide, facilitators’ guide) and TAS Eligibility and Reporting Form • Handbook of practical entomology for national elimination programmes • Provisional strategy for interrupting LF transmission in loiasis-endemic countries • Managing morbidity and preventing disability: an aide-mémoire for national programme managers • Toolkit for scaling up MMDP at the sub-national level in development

20. Regional Elimination

21. Status as of April 2014 2013 2014 2015 2020 Onchocerciasis • Onchocerciasis is now part of NTD Department and a medical officer has been appointed as focal point • Latin America: OEPA • April 2013 - Onchocerciasis elimination in Colombia verified • June 2014- Verification of interruption of transmission in Ecuador • Guatemala and Mexico post-treatment surveillance after MDA ongoing • Intensified MDA in cross-border transmission zone between Brazil and Venezuela ongoing • Yemen • Urgent need to launch elimination programme to meet 2020 elimination goal • Africa: APOC • 2014 APOC treatment targets: 120 million ONCH and increase LF treatment by 20% • 2016 Programme for the Elimination of Neglected Diseases in Africa (PENDA), replaces APOC • 2020 target: 12 out of 31 ONCH endemic countries targeted for elimination • Guidelines • September 2014: revised guidelines Verification of Elimination of Human Onchocerciasis – Criteria and Procedures completed

22. Status as of April 2014 2013 2014 2015 2020 Rabies • Proof of concept available for the control of rabies in dogs to eliminate human rabies: expansion to other countries beyond project sites • Currently elaborating the investment case • Initiating vaccine stockpiling/bank discussions with pharma and OIE for country programmes (criteria to be developed)

23. Status as of April 2014 2013 2014 2015 2020 Schistosomiasis • AFR progress status • 2012: 23 countries implemented treatment with 35.6M people treated (+ 60% as compared to 2011, but still only 14% of global coverage) • China/Africa/WHO collaboration on schistosomiasis control and elimination from Africa • Agreement on MOU between NHFPC-China, MOH Zanzibar and WHO on elimination of schistosomiasis in Zanzibar • WHO guidelines for efficacy testing of molluscicides for vector control are being updated • Assess interruption of transmission in Mauritius • EMR • assessment of interruption of transmission in Morocco and Iran following WHA 65.21 • 2014: supporting development of plan for elimination in Egypt • SEAR active follow-up of elimination in Indonesia • AMR • large scale chemotherapy initiated in Brazil; • situation assessment in Suriname and other Caribbean islands including St Lucia • WPR • implementation of 2012-2016 Regional Action Plan and Regional Committee Resolution; • elimination by 2016 in Cambodia and Lao PDR (Mekong River Basin) and China

24. Status as of April 2014 2013 2014 2015 2020 Chagas disease • Progress in achieving Roadmap targets: (i) interrupting transmission through blood in AMR by 2015 and (ii) interrupting vectorialintradomiciliary transmission in Latin America by 2020 • Methodology to verify interruption of transfusional transmission and organ transplantation updated based on global standardization of internal and external quality control of laboratories • Global estimates for Chagas disease updated and design of a computerized information and surveillance system completed • Increase in case detection and treatment at global level, after 2011-2012 shortage of benznidazole • Paediatric presentation of nifurtimox (30mg and 12.5mg tablets) and benznidazole (50 and 12.5mg) available

25. Status as of April 2014 2013 2014 2015 2020 Leishmaniasis • Visceral Leishmaniasis (VL) • Expanded implementation in Bangladesh of single dose AmBisome from 3 to 11 centres • Continued decline of VL incidence in all 3 endemic countries in SEAR • Significant achievement of kalaazar elimination in districts/sub-districts (>75%), < 1 case per ten thousand population in SEAR • VL case management, surveillance and outbreak detection capacity strengthening including health workers training and ensuring the cold chain logistics in east Africa; • Roll out of the AmBisome donation for severe VL cases in east Africa under way • Diagnosis and treatment guidelines updated in major VL endemic countries in east Africa, Bangladesh and AMR • Web-based regional leishmaniasis surveillance system established by AMR

26. Intensified control

27. Status as of April 2014 2013 2014 2015 2020 Buruli ulcer • Combined rifampicin/clarithromycin clinical trial in progress in Benin and Ghana • 2013 WHO/FIND meeting with experts to develop priorities for research into a rapid diagnostic test • WHO and Harvard University started evaluation of mycolactone detection method on human samples • Decline in number of cases in some countries requires investigation

28. Status as of April 2014 2013 2014 2015 2020 Leishmaniasis • Cutaneous leishmaniasis (CL) • Regional case management guidelines developed and made available to countries in EMR and AMR • Regional CL control: five strategic document endorsed by national programme managers finalized and available through WHO website • Medicines and training provided to Syrian Arab Republic and neighbouring countries (WHO/NTD & Emergency Department provided emergency medical supplies including provision of anti-leishmaniasis medicines to Syria and affected neighbouring countries) • Significant reduction of incident zoonotic CL cases in Morocco in the last 4 years (>90%) and anthroponotic CL cases in Afghanistan

29. Status as of April 2014 2013 2014 2015 2020 Echinococcosis • Develop early diagnostic and treatment SOPs for adaptation in local settings • Initiate capacity strengthening in peripheral health care centres for early detection and management of patients • Potential collaboration between China and Mongolia

30. Status as of April 2014 2013 2014 2015 2020 Foodborne trematodiases • Foodborne trematodiases • 608 285 people treated in 2012 • Fascioliasis • Progressive global expansion of fascioliasis treatment with focus on AMR • 470 000 tablets of triclabendazole donated through WHO for 2014 activities globally • Clonorchiasis, opisthorchiasis and paragonimiasis • Progressive expansion of treatment activities with focus on WPR • FBT challenges • Secure PZQ for large scale treatment, as no donation in place for clonorchiasis and opisthorchiasis • Occurrence of SAEs limiting treatment implementation in 2013. Lao PDR chose not to implement

31. Status as of April 2014 2013 2014 2015 2020 STH • 285 million children in need of treatment received anthelminthicsfor STH in 2012 corresponding to a global coverage of 32.6% • Medicine donation resulted an increased number of school children (5-14 years) treated - from 75 in 2011 to 132 million in 2012 • In contrast, coverage of pre-school (2-4 years) children continued to decline, after a peak of 37% in 2010 to 30% in 2011 and 25% in 2012 • Four publications prepared and being field-tested: (i) teachers' manual; (ii) mapping manual; (iii) model to predict prevalence changes during PC implementation; (iv) STH data collection during TAS • Involvement of BMGF in STH control (US$ 50M over 5 years) expected to leverage commitment/investment by other partners

32. Status as of April 2014 2013 2014 2015 2020 Neurocysticercosis (NCC) • Landscape analysis for diagnosis and case management for NCC and control options for Taeniasolium/NCC • July 2014: Informal consultation to initiate pilot programme strategy for control • Brazil and Madagascar, currently mapping Taeniasolium/NCC and exploring interest of other countries

33. Status as of April 2014 2013 2014 2015 2020 Dengue • Initiated estimates on burden of disease • Developed framework on monitoring and evaluation • Global Strategy adopted by more countries and regions and key activities identified • European RC resolution adopted on invasive species

34. Vector Ecology and Management Vector Control Advisory Group Meeting (joint with GMP) • Five new tools for vector control under review following first meeting • 2014 VCAG meeting: nine products assessed Integrated Vector Management • New project with Durham University in progress • Developed handbook on surveillance and control at points of entry Technical lead and communications surge capacity for World Health Day 2014

35. Vector Ecology and ManagementWHO Pesticide Evaluation Scheme (WHOPES) Support for vector control and pesticide management • Recommended five new pesticides for vector control; 13 products under evaluation; • Produced two guidelines and two training manuals • Completed WHO-Gates project on Pesticide risk reduction (2007– 2013) • Molluscicides • process initiated for the development of guidelines for efficacy testing of molluscicides under the WHOPES Scheme • use of mosquito larvicide risk assessment model to be extended for molluscicides • WHOPES will be able to accept new molluscicides for efficacy testing and development of specifications for quality control • In collaboration with FAO: • developed International Code of Conduct on Pesticide Management approved by EB134 • 12 pesticides under evaluation for setting quality standards • Collaborated with GMP to develop quality standards for long-lasting insecticidal nets

36. Scale-up PC projections to reach 2020 targets % Analysis includes current and projected % of people receiving PC for at least one disease (including LF, ONCH, SCH and STH) out of estimated number of people requiring PC WHO target of 75% coverage across diseases Target date for full PC scale-up Required trajectory Trajectory at the current rate of scale-up 2020 goals

37. Progress achieved 2012 • Challenges: • Consistent implementation of LF interventions • Extra resource mobilization • National/district capacity to implement *No improvement for LF in 2012, because of lesser coverage in India Myanmar and Mozambique did not implement MDA in 2012

38. CCB - Capacity strengthening Achievements: • Two meetings of the Working Group for Capacity Strengthening (WG-CS) • Finalized training modules for an International Training Course for national NTD programmemanagers; supported the implementation of NTD programme managers course in Nigeria • Started the establishment of a laboratory network for NTDs • Finalized NTD toolbox • Developed and field-tested awareness and education programmes for school-based platform NTD control programmes, such as illustrated comic booklets, etc. • Published new and improved edition of STH bench aids for laboratory technicians Current focus: • Strenghtening of national capacity to manage NTD programmes • Development of training materials and course for district-level managers • Ongoing development of an eLearning platformfor in-service training: targeting national/district PC programme managers; NTD M&E officers; NTD partners' technical officers; other health workers (in clinical and public health settings) • Strengthenlaboratorycapacity in support of NTD implementation

39. Report to STAG-NTD 2014 NTD highlights 2013-2014 Key achievements Response to STAG 2013 recommendations Main issues for this STAG

42. Report to STAG-NTD 2014 NTD highlights 2013-2014 Key achievements Response to STAG 2013 recommendations Main issues for STAG 2014

43. Issues to be considered by STAG 2014 • Principles and processes of verification, validation and certification • Positioning NTDs in the post-MDGs 2015 • Mobilizing resources for yaws eradication • Accelerating the work to control NZDs • Responding to dengue epidemic, notably in Africa

44. WHO NTD STAG meeting this week in Geneva recognized the great importance of the meeting in Paris (described above) and (urged the international community to consider…) is strongly recommending that elimination of NTDs be a proxy of alleviation of poverty. • STAG and WHO will work and build consensus on indicators to measure this commitment.