The Coalition for Operational Research on Neglected Tropical Diseases is pleased to announce the publication of transformational research, “Baseline Mapping of Neglected Tropical Diseases in Africa: The Accelerated WHO/AFRO Mapping Project,” published in The American Journal of Tropical Medicine and Hygiene. We caught up with Maria Rebollo, ESPEN team leader for the World Health Organization Africa and lead author, to learn more about the study and the results that were achieved.
Could you please briefly describe the AFRO Mapping Project?
It was a project designed to complete the endemicity map of NTDs in Africa. It covered 47 countries (the WHO AFRO region) and the five NTDs that have the highest burden in the region and affect the poorest people in the planet, These NTDs can be controlled and even eliminated by Preventive Chemotherapy.
Which NTDs can be controlled by preventive chemotherapy?
5 Neglected Tropical Diseases can be prevented or eliminated as a public health problem thanks to the generous donations of medicines that can be safely distributed to entire communities living in endemic areas: lymphatic filariasis (LF or elephantiasis), onchocerciasis (river blindness), schistosomiasis (SCH), soil transmitted helminthiasis (STH or intestinal worms), and trachoma.
How was mapping managed in Africa prior to this Mapping Project?
Before the accelerated WHO/AFRO NTD Mapping Project was initiated in 2014, mapping efforts in many countries were frequently carried out in an ad hoc and non-standardized fashion. This represented a number of challenges, including that often data reflected academic interests, rather than public health interests. They were often limited to geographies that were readily accessible from major cities, leaving more remote areas without any accurate data. In addition, mapping data was barely accessible even by the program owners at the Ministry of Health or MoH, difficult to compare across countries and of unreliable quality. In 2013 there were at least 2,200 different districts (of the 4,851 districts in WHO African region) that still required mapping, and in many of these districts more than one disease needed to be mapped.
Without a unified effort to map NTDs, what were the risks to NTD programs and people affected by NTDs?
Without a reliable source of mapping data for each country in Africa, decision-making was often based on expert opinion or outdated historical observations. Many countries in Africa had not started treatment, and those who had started had entire areas of under-treatment of needy populations. Conversely, treatment was being delivered in areas where it was no longer required, wasting donated medicines, time and precious resources.
Where were you mapping?
During its 3-year duration from January 2014 through the end of 2016, the Project carried out mapping surveys for one or more NTDs in at least 2,500 districts in 37 African countries, a really remarkable achievement that changed the program implementation landscape. Furthermore, it collected in one data base all historical information to complete the atlas of endemicity for all districts in the 47 countries in the region.
Who was involved?
WHO/AFRO mobilized NTD experts and public health workers from across the region and trained this group to support the effort on the ground.
For LF, SCH and STH, work was carried out by technical teams of national program workers guided by regional and international consultants, including members of WHO/AFRO’s NTD expert committee (the Regional Programme Review Group). Funding support came principally from the Bill & Melinda Gates Foundation (BMGF), national ministries of health, the international development agencies (United States Agency for International Development [USAID] and UK Department for International Development [then known as DfID, now part of the Foreign Commonwealth & Development Office]) and numerous non-governmental organizations (NGOs).
For onchocerciasis, since mapping had traditionally been the responsibility of the OCP (Onchocerciasis Control Programme, 1974-2002) and APOC (African Programme for Onchocerciasis Control, 1996 - 2015), WHO/AFRO allocated a specific portion of the mapping project funds to APOC to complete ‘standard’ onchocerciasis mapping where still necessary.
For trachoma, separate funds, principally from DfID and USAID, were used to create the Global Trachoma Mapping Project (GTMP) that took responsibility for trachoma mapping in Africa during the same period that the accelerated WHO/AFRO NTD Mapping Project was active. These two efforts resolved uncertainties about the geographic distribution of NTDs on an unprecedented scale.
What were the challenges of the mapping project?
In addition to the continental scope of the project, there were additional complexities, including: 1) the different numbers of different diseases needing to be mapped in different districts in different countries; to 2) many districts had remained unmapped largely because of their remoteness, lack of infrastructure, or the existence of civil conflict and insecurity; 3) the logistics requirement for diagnostics and supplies to be available in these remote settings.
How did the project unfold?
First, the need for mapping was defined by doing a careful review of all of the historical information available on NTD distribution and prevalence in the African Region. Next, standards and guidelines were established on how to establish accurate, updated datasets in each country. These rules helped determine how best to utilize the complex, but incomplete data to identify which areas needed no further mapping and which remained as ‘gaps’ that would require further attention. What followed these initial tasks was the progressive roll-out of a large-scale mobilization involving six principal mapping survey teams organized from the WHO/AFRO offices in Ouagadougou, Libreville, Harare and Brazzaville. These teams were responsible for planning, training, and oversight of the national teams across the [different countries.
After data collection, the AFRO team worked with countries to ensure that data were complete and accurate. All mapping data were housed and maintained in the database at WHO/AFRO Regional Office in Brazzaville. The mapping project catalyzed the development of an interactive online Portal with dashboards designed to provide data access to countries and stakeholders that included the mapping results, treatment activities and progress towards the control and elimination of the NTDs. This initial effort subsequently became the basis of the expanded ESPEN (Expanded Special Project for Elimination of Neglected Tropical Diseases) Portal, a truly important resource on high quality data for the region.
What do you think the mapping project achieved?
First, the project energized and empowered national NTD programs. Second, it provided African governments, all stakeholders and donors with greater clarity on where support was needed. These outcomes combined to create a massive scale up of delivery of drugs for NTDs. This is a huge success – and we are still seeing the benefits of that investment as the NTD programs continue to reduce the burden of NTDs. This project represented one of the best buys in public health, given the high value for money and return on investment, providing access to medicines to the most vulnerable, avoiding unnecessary wastage of medicines and contributing massively towards universal health coverage and our common goal of “leaving no one behind”.
What did you learn from the mapping project?
A lot! I learned how this region is ready to respond to a massive challenge. The human resources are here, including amazing scientist ready to be deployed in the field and governments that are keen to support programs that will benefit their people. Most National programs just need a little support (technical or financial) to get a high job done, and we were able to mobilize a strong partnership to provide that support. The African NTD programs are really an amazing success story. I never could have imagined that we would see such a vast number of people being treated for these diseases when I started this work and now we can achieve 100% geographical coverage thanks to a tremendous partnership that is making it happen. The AFRO mapping project was certainly a critical step on this success story.
You can read the full publication, "Baseline Mapping of Neglected Tropical Diseases in Africa: The Accelerated WHO/AFRO Mapping Project,” in The American Journal of Tropical Medicine and Hygiene here.