Integration of female genital schistosomiasis into HIV/sexual and reproductive health and rights and neglected tropical diseases programmes and services: a scoping review.

Female genital schistosomiasis (FGS) affects approximately 56 million women and girls across sub-Saharan Africa and is associated with up to a threefold increased prevalence of HIV. Integrating FGS with HIV programmes as part of comprehensive sexual and reproductive health (SRH) services may be one of the most significant missed opportunities for preventing HIV incidence among girls and women. A search of studies published until October 2021 via Scopus and ProQuest was conducted using PRISMA guidelines to assess how FGS can be integrated into HIV/SRH and neglected tropical diseases (NTDs) programmes and services. Data extraction included studies that integrated interventions and described the opportunities and challenges. A total of 334 studies were identified, with 22 eligible for analysis and summarised conducting a descriptive numerical analysis and qualitative review. We adapted a framework for integrated implementation of FGS, HIV, and HPV/cervical cancer to thematically organise the results, classifying them into five themes: awareness and community engagement, diagnosis, treatment, burden assessment, and economic evaluation. Most activities pertained to awareness and community engagement (n = 9), diagnosis (n = 9) and were primarily connected to HIV/AIDS (n = 8) and school-based services and programming (n = 8). The studies mainly described the opportunities and challenges for integration, rather than presenting results from implemented integration interventions, highlighting an evidence gap on FGS integration into HIV/SRH and NTD programmes. Investments are needed to realise the potential of FGS integration to address the burden of this neglected disease and improve HIV and SRH outcomes for millions of women and girls at risk.

Profiling the knowledge of female medical/para-medical students, and expertise of health care professionals on female genital schistosomiasis in Anambra, South Eastern Nigeria.

BACKGROUND: Female genital schistosomiasis (FGS) is a largely neglected tropical disease (NTD), with little or no attention in the primary health care unit. Towards building momentum to address this challenge, we investigated the perception of medical and para-medical students about FGS, as well as the expertise of health care professionals in Anambra State, Nigeria. METHODOLOGY: We conducted a cross-sectional survey among 587 female medical and para-medical university students (MPMS), and 65 health care professionals (HCPs) saddled with the responsibility of delivering care for schistosomiasis-affected persons. Pretested questionnaires were administered to document the awareness and knowledge about the disease. In addition, the expertise of HCPs vis-à-vis suspicion of FGS and management of FGS patients during routine health care service were documented. Data were subjected to descriptive, chi-square tests and regression analysis in R software. RESULTS: Over half of the students recruited; 54.2% for schistosomiasis and 58.1% for FGS, were not aware of the disease. Knowledge about schistosomiasis was associated with student's year of study, with those in 2nd (OR: 1.66, 95% CI: 1.0, 2.7), 4th (OR: 1.97, 95% CI: 1.2, 3.2), and 6th (OR: 5.05, 95% CI: 1.2, 34.2) year having higher likelihoods of been more informed about schistosomiasis. For HCPs, we observed a contrastingly high knowledge about schistosomiasis (96.9%), but low knowledge about FGS (61.9%). Knowledge for both schistosomiasis and FGS was not associated with year of practice and expertise (95% OR included 1, p > 0.05). A considerable proportion (>40%) of the HCPs never suspected schistosomiasis during routine clinical diagnosis of patients who presented probable FGS symptoms (p < 0.05). Similarly, only 20% were certain about the use of praziquantel for treating FGS, and about 35% were uncertain of the eligibility criteria and dosage regimens. Commodities for managing FGS were also largely unavailable in about 39% of the health facilities where the HCPs operate. CONCLUSION: Awareness and knowledge about FGS among MPMS and HCPs were poor in Anambra, Nigeria. It is therefore important to invest in innovative methods of building capacity of MPMS and HCPs, with complementary provision of necessary diagnostics to perform colposcopy, as well as competence to diagnose pathognomonic lesions using diagnostic atlas or Artificial Intelligence (AI).

Improving the Response of Health Systems to Female Genital Schistosomiasis in Endemic Countries through a Gender-Sensitive Human Rights-Based Framework.

The right to health was enshrined in the constitution of the World Health Organization in 1946 and in the Universal Declaration of Human Rights in 1948, which also guaranteed women's fundamental freedoms and dignity. The Declaration of Human Rights was signed by almost every country in the world. Nonetheless, gender inequalities in health and health systems continue to persist, especially in lower and middle income countries that are disproportionately affected by a litany of neglected diseases. In this paper, we focus on one of the most neglected human rights, development, and reproductive health issues globally, female genital schistosomiasis (FGS), which imposes enormous unacknowledged suffering on an estimated 56 million women and girls in Sub-Saharan Africa. Despite increasing calls for attention to FGS, no country has fully incorporated it into its health system. An appropriate response will require a comprehensive approach, guided by human rights mandates and the redress of FGS-related gender inequalities. In this paper, we propose the application of existing human rights and its clients, women, and girls affected by FGS as rights holders. Within the different components or building blocks of the health system, we propose elements of an appropriate health system response using the four components identified within the FGS Accelerated Scale Together (FAST) Package-awareness raising, prevention of infection, training of health personnel, and diagnosis and treatment. The framework is aspirational, its recommended elements and actions are not exhaustive, and countries will need to adapt it to their own situations and resource availability. However, it can be a useful guide to help health systems define how to begin to incorporate FGS into their programming in a way that responds to their human rights obligations in a gender- and culturally sensitive manner.

Reflections on "Orchestrating for Impact": Harmonizing across Stakeholders to Accelerate Global Health Gains.

For developing countries and partners to accelerate the availability of new innovations to communities in need of intervention, it is necessary to find improved ways to work together that challenge today's status quo in global health. By adopting new approaches and accepting shared risk and reward, diverse partners can work together to accelerate progress toward a common global health goal. A symphony orchestra-with a conductor who recruits, arranges, harmonizes, and orchestrates diverse musicians to work together to create something not possible by individual musicians on their own-provides an apt metaphor for successful global health initiatives. In such settings, stakeholders must be engaged and harmonized, workplans composed, and partnerships conducted such that all stakeholder roles progress from workplans that are sequential and independent to those that are integrated and interactive. Reflecting on the successful global health partnerships discussed here and beyond, we use this orchestral metaphor to illustrate the elements needed to make partnerships increasingly successful.

Lessons Learned from the Japanese Encephalitis Vaccine Introduction in India That Supported the Introduction of Ivermectin-Diethylcarbamazine-Albendazole for Lymphatic Filariasis Elimination.

We used the introduction of the Japanese encephalitis (JE) vaccine in India as an example to understand more fully the process of introducing any new clinical product in India. We discuss the key decision-making points as well as the many activities involved in introducing a new clinical product in India's public health program. We write from our experience in supporting the government of India to introduce new products successfully-namely, vaccines-to India's health system. In India, the process begins with identifying the public health problem (e.g., an outbreak of JE), deciding to take action, prioritizing where action is needed, securing a supply and price of the intervention (the vaccine; in this case, the live, attenuated SA 14-14-2 vaccine), and determining how to ensure effective rollout of the intervention (the vaccination program). Reflecting on the experience of the JE vaccination program helped to inform the introduction of the triple-drug therapy of ivermectin, diethylcarbamazine, and albendazole in India as a new treatment protocol for lymphatic filariasis.

Accelerating the Uptake of WHO Recommendations for Mass Drug Administration Using Ivermectin, Diethylcarbamazine, and Albendazole.

Triple therapy with ivermectin, diethylcarbamazine, and albendazole (IDA) for the elimination of lymphatic filariasis (LF) represents a compelling example of accelerating the timeline from development to introduction and impact. Previous articles outlined how the clinical development process was able to compress timelines and provide the evidence needed for the WHO to issue guidelines on the use of IDA for mass drug administration for LF. We explored the drivers for the rapid and successful introduction of IDA in the early-adopter countries. Lessons from this experience highlight five key elements for moving from WHO recommendations to program uptake after the publication of the guideline: 1) early engagement with stakeholders to create partnerships to coordinate and plan for implementation; 2) recognition by countries and partners of the potential of IDA to improve efforts to eliminate LF; 3) high-level commitment and coordination at regional levels and, most importantly, at the country level; 4) understanding of the perspectives among people living in LF-endemic communities where mass drug administration is warranted; and 5) affirmation of the feasibility of IDA through sharing lessons learned.

Compressing the Timelines for Development and Delivery: Accelerating Access to Triple-Drug Therapy to Eliminate Lymphatic Filariasis.

The traditional timeline for a new innovation in public health to move from initial proof of concept to introduction into national programs is sequential and can take decades. Here, we discuss the development of a new drug therapy for lymphatic filariasis (LF) to help progress toward elimination as a public health problem and how this process was accelerated by a group of partners working together. This article documents the way that these partners worked together and made decisions that made it possible to accelerate the process of the development and introduction of the triple-drug therapy involving ivermectin, diethylcarbamazine, and albendazole (IDA). The partners were able to condense the development timeline from the first clinical efficacy data to delivery in a country program for the triple-drug therapy from a projected ∼28 years to less than 5 years while maintaining all of the safety standards. The approach required understanding stakeholders, their roles, need for data to inform decisions, and then looking at timelines focused on prioritizing activities that inform decision-making. This process relied on a close engagement of all stakeholders and good communication. Through this exercise, additional early data review points were added to study designs, studies were run in parallel not sequentially, and a plan put in place to engage all stakeholders necessary for adoption and uptake throughout the process, so they were prepared to make decisions as data became available. This process could provide some insights into how global health can work together in new ways to accelerate the availability of interventions and strategies to promote health and well-being.

Addressing a silent and neglected scourge in sexual and reproductive health in Sub-Saharan Africa by development of training competencies to improve prevention, diagnosis, and treatment of female genital schistosomiasis (FGS) for health workers.

BACKGROUND: Schistosomiasis is an acute and chronic disease caused by parasitic worms, that can take two main forms: intestinal or urogenital. If left untreated, the urogenital form can lead to female genital schistosomiasis (FGS) in women and girls; frequently resulting in severe reproductive health complications which are often misdiagnosed as sexually-transmitted infections (STIs) or can be confused with cervical cancer. Despite its impact on women's reproductive health, FGS is typically overlooked in medical training and remains poorly recognized with low awareness both in affected communities and in health professionals. FGS has been described as the one of the most neglected sexual and reproductive health issues in sub-Saharan Africa (Swai in BMC Infect Dis 6:134, 2006; Kukula in PLoS Negl Trop Dis 13:e0007207; Joint United Nations Programme on HIV/AIDS (UNAIDS) 2019). Increased knowledge and awareness of FGS is required to end this neglect, improve women's reproductive health, and decrease the burden of this preventable and treatable neglected tropical disease. METHODS: We conducted interactive virtual workshops, in collaboration with the World Health Organization (WHO), engaging 64 participants with medical and public health backgrounds from around the world to establish standardized skills (or competencies) for prevention, diagnosis, and treatment of FGS at all levels of the health system. The competencies were drafted in small groups, peer-reviewed, and finalized by participants. RESULTS: This participatory process led to identification of 27 skills needed for FGS prevention, diagnosis, and management for two categories of health workers; those working in a clinical setting, and those working in a community setting. Among them, ten relate to the diagnosis of FGS including three that involve a pelvic exam and seven that do not. Six constitute the appropriate behaviors required to treat FGS in a clinical setting. Eleven address the community setting, with six relating to the identification of women at risk and five relating to prevention. CONCLUSION: Defining the skills necessary for FGS management is a critical step to prepare for proper diagnosis and treatment of women and girls in sub-Saharan Africa by trained health professionals. The suggested competencies can now serve as the foundation to create educative tools and curricula to better train health care workers on the prevention, diagnosis, and management of FGS.

Compassionate Leadership: Essential for the Future of Tropical Medicine and Global Health.

Compassion-the awareness of suffering coupled with the desire to relieve that suffering-is an evolved human capacity that offers significant benefits for individuals and organizations. While the relief of suffering is central to tropical medicine and global health, compassion is more often assumed than explicit. Global health leaders participating in a compassionate leadership program recently reported that the most common personal barriers to compassionate leadership include inability to regulate workload, perfectionism, and lack of self-compassion; while the most common external challenges include excessive work-related demands, the legacy of colonialism, and the lack of knowledge on how to lead with compassion. These barriers can be surmounted. Within organizations, leaders are the primary shapers of compassionate cultures. Now is the time to bring our core compassionate values to bear in addressing the "unfinished business" of ensuring global health equity and deconstructing colonialist structures in global health and tropical medicine. Compassionate leadership offers us tools to complete this unfinished business.

A framework for scabies control.

Scabies is a neglected tropical disease (NTD) that causes a significant health burden, particularly in disadvantaged communities and where there is overcrowding. There is emerging evidence that ivermectin-based mass drug administration (MDA) can reduce the prevalence of scabies in some settings, but evidence remains limited, and there are no formal guidelines to inform control efforts. An informal World Health Organization (WHO) consultation was organized to find agreement on strategies for global control. The consultation resulted in a framework for scabies control and recommendations for mapping of disease burden, delivery of interventions, and establishing monitoring and evaluation. Key operational research priorities were identified. This framework will allow countries to set control targets for scabies as part of national NTD strategic plans and develop control strategies using MDA for high-prevalence regions and outbreak situations. As further evidence and experience are collected and strategies are refined over time, formal guidelines can be developed. The control of scabies and the reduction of the health burden of scabies and associated conditions will be vital to achieving the targets set in WHO Roadmap for NTDs for 2021 to 2030 and the Sustainable Development Goals.

Medicine donation programmes supporting the global drive to end the burden of neglected tropical diseases.

Neglected tropical diseases (NTDs) are targeted for global control or elimination. Recognising that the populations most in need of medicines to target NTDs are those least able to support and sustain them financially, the pharmaceutical industry created mechanisms for donating medicines and expertise to affected countries through partnerships with the WHO, development agencies, non-governmental organisations and philanthropic donors. In the last 30 y, companies have established programmes to donate 17 different medicines to overcome the burden of NTDs. Billions of tablets, capsules, intravenous and oral solutions have been donated, along with the manufacturing, supply chains and research necessary to support these efforts. Industry engagement has stimulated other donors to support NTDs with funds and oversight so that the 'heath benefit' return on investment in these programmes is truly a 'best value in public health'. Many current donations are 'open-ended', promising support as long as necessary to achieve defined health targets. Extraordinary global health advances have been made in filariasis, onchocerciasis, trachoma, trypanosomiasis, leishmaniasis, schistosomiasis, intestinal parasites and others; and these advances are taking place in the context of strengthening health systems and meeting the global development goals espoused by the WHO. The pharmaceutical manufacturers, already strong collaborators in initiating or supporting these disease-targeted programmes, have committed to continuing their partnership roles in striving to meet the targets of the WHO's new NTD roadmap to 2030.

A triple-drug treatment regimen to accelerate elimination of lymphatic filariasis: From conception to delivery.

The Global Programme to Eliminate Lymphatic Filariasis (LF) is using mass drug administration (MDA) of antifilarial medications to treat filarial infections, prevent disease and interrupt transmission. Almost 500 million people receive these medications each year. Clinical trials have recently shown that a single dose of a triple-drug combination comprised of ivermectin, diethylcarbamazine and albendazole (IDA) is dramatically superior to widely used two-drug combinations for clearing larval filarial parasites from the blood of infected persons. A large multicenter community study showed that IDA was well-tolerated when it was provided as MDA. IDA was rapidly advanced from clinical trial to policy and implementation; it has the potential to accelerate LF elimination in many endemic countries.

Schistosomiasis Consortium for Operational Research and Evaluation (SCORE): Its Foundations, Development, and Evolution.

The Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) was established in late 2008 to conduct operational research that would inform practices related to the control and elimination of schistosomiasis. This article traces SCORE's beginnings and underpinnings. These include an emphasis on openness and contributing to the development of a cohesive schistosomiasis control community, building linkages between researchers and national programs, and focusing on answering questions that will help Neglected Tropical Disease program managers to better control and eliminate schistosomiasis. It describes the development and implementation of SCORE's multiple projects. SCORE began by drawing on advice from a broad range of experts by holding wide-ranging meetings that informed the priorities and protocols for SCORE research. SCORE's major efforts included large, multicountry field studies comparing multiple strategies for mass drug administration with praziquantel, assessment of approaches to elimination, evaluation of a point-of-care assay for field mapping Schistosoma mansoni, and increasing the sensitivity of a laboratory-based diagnostic. SCORE also supported studies on morbidity due to schistosomiasis, quantification of vector snails and the detection of schistosome infections in snails, and changes in schistosome population genetics under praziquantel drug pressure. SCORE data and specimens are archived and will remain available for future research. Although much remains to be carried out, our hope is that through the already published articles and SCORE results described in this supplement, we will have provided a body of evidence to assist policy makers in the development of judicious guidelines for the control and elimination of schistosomiasis.

A Roadmap for the Development of Ivermectin as a Complementary Malaria Vector Control Tool.

In the context of stalling progress against malaria, resistance of mosquitoes to insecticides, and residual transmission, mass drug administration (MDA) of ivermectin, an endectocide used for neglected tropical diseases (NTDs), has emerged as a promising complementary vector control method. Ivermectin reduces the life span of Anopheles mosquitoes that feed on treated humans and/or livestock, potentially decreasing malaria parasite transmission when administered at the community level. Following the publication by WHO of the preferred product characteristics for endectocides as vector control tools, this roadmap provides a comprehensive view of processes needed to make ivermectin available as a vector control tool by 2024 with a completely novel mechanism of action. The roadmap covers various aspects, which include 1) the definition of optimal dosage/regimens for ivermectin MDA in both humans and livestock, 2) the risk of resistance to the drug and environmental impact, 3) ethical issues, 4) political and community engagement, 5) translation of evidence into policy, and 6) operational aspects of large-scale deployment of the drug, all in the context of a drug given as a prevention tool acting at the community level. The roadmap reflects the insights of a multidisciplinary group of global health experts who worked together to elucidate the path to inclusion of ivermectin in the toolbox against malaria, to address residual transmission, counteract insecticide resistance, and contribute to the end of this deadly disease.