Feb 1, 2008: There are over a dozen diseases, prevalent mainly in tropical areas of the planet, inhabited by people living in abject poverty. These diseases together affect one-sixth or over one billion people, crippling their lives and keeping them away from meaningful economic activities and also burden the world’s health care systems. After nearly five years of extensive debate among health experts, governments of almost all the countries, various United Nations organizations, top pharma companies and civil society groups, The World Health Organization (WHO), based in Geneva, Switzerland, has launched an ambitious global plan to combat these neglected diseases. BioSpectrum presents the highlights of the plan, abstracted from the Executive Summary of 50-page document unveiled recently. Excerpts

Communicablediseases represent one of the greatest potential barriers to achievement of the global health agenda because they collectively account for 20 percent of mortality in all age groups (33 percent in the least developed countries) and 50 percent of child mortality. Without a significant reduction in the burden of communicable disease, the achievement of other health-related goals as well as those in education, gender equality, poverty reduction and economic growth will be jeopardized. Reducing the burden of communicable diseases is therefore key to achieving the Millennium Development Goals.

Neglected tropical diseases (NTDs) and zoonoses are a devastating obstacle to human settlement and socioeconomic development of already impoverished communities. A growing body of evidence demonstrates that control of these diseases can contribute directly to achievement of several Millennium Development Goals. Interventions against NTDs and zoonoses have already benefited millions of people, protecting them from physical pain, disability and poverty.

Over the past decades, the WHO, together with its partners, has formulated an innovative strategy to ensure cost-effective, ethical and sustainable control towards elimination or eradication of several NTDs. The strategy encompasses the following components:

• A multi-pronged approach;
• Focus on populations and interventions rather than specific diseases;
• Use of a quasi-immunization model for preventive chemotherapy;
• Introduction of innovative tools for disease control;
• A multi-disease, intersectoral and interprogrammatic approach.

The “tool-ready” category of diseases is the one for which powerful and inexpensive control tools are currently available and for which well-developed implementation strategies are immediately feasible. Large-scale use of safe and single-dose medicines (preventive chemotherapy) makes their control, prevention and possible elimination more feasible than
ever before.

The major tasks for control of the tool-ready diseases are to expand coverage of packaged preventive chemotherapy interventions in order to access hard-to reach populations at risk with innovative delivery systems and to continue regular treatment.

Current control strategies for the “tool-deficient” diseases rely on costly and difficult-to-manage tools. For most of those diseases, early detection and treatment are vital to avoid irreversible disability or death. There is urgent need to develop simple, safe and cost-effective tools and to make them accessible. Such innovative tools will drastically alter the existing control strategies.

The opportunities presented by an intersectoral and interprogrammatic approach and its successful use in many settings show that such a synergistic approach improves cost-effectiveness and ensures that all necessary treatments are simultaneously delivered to neglected populations who nearly always suffer from several overlapping diseases linked to poverty.

The Global Plan aims to translate this strategy into reality. The Global Plan has been formulated according to the following key principles: 1) The right to health 2) Existing health systems as a setting for interventions 3) A coordinated response by the health system 4) Integration and equity 5) Intensified control of diseases alongside pro-poor policies.

Challenges

The major challenges for controlling NTDs and zoonoses are:
1) Procurement and supply of anthelminthic medicines 2)  Quantification of the burden of NTDs among neglected populations 3) Provision of treatment and other interventions free of charge to communities in need 4) Asystem for delivery of medicines to cover the entire at-risk population 5) Delivery of multi-intervention packages 6) Urgent development of diagnostic tools, medicines and pesticides 7) Production of more effective medicines and insecticides 8) Promotion of integrated vector management 9) Advocating an intersectoral, interprogrammatic approach to control of NTDs 10) Early protection of children and 11) Post-implementation surveillance and monitoring.

Goal and targets, 2008–2015
The goal of the Global Plan is to prevent, control, eliminate or eradicate NTDs. The targets for the plan period 2008– 2015 are:

• To eliminate or eradicate those diseases targeted in resolutions of the WHO Assembly and regional committees.
• To reduce significantly the burden of other tool-ready diseases through current interventions.
• To ensure that interventions using novel approaches are available, promoted and accessible for tool-deficient diseases.

Strategic areas for action
The Global Plan has nine strategic areas, each of which proposes a series of actions to meet specific targets during 2008–2015. The strategic areas are:

1) Assessment of the burden of NTDs and zoonoses 2) Integrated approach and multi-intervention packages for disease control 3) Strengthening health care systems and capacity building 4) Evidence for advocacy 5) Ensuring free and timely access to high-quality medicines and diagnostic and preventive tools 6) Access to innovation  7) Strengthening integrated vector management and capacity building 8) Partnerships and resource mobilization 9) Promoting an intersectoral, inter-programmatic approach to NTD control.

‘Let us push these tropical diseases back’

Excerpts from the WHO chief’s address to the WHO Global Partners Meeting on Neglected Diseases in April 2007 where the 2008-2015 Plan was finalized

In just the past decade, health has achieved unprecedented prominence as a key driver of socioeconomic development. This prominence is formally expressed in the Millennium Development Goals, which recognize the two-way link between health and poverty, and give health development a central role to play. The neglected tropical diseases express this link between health and development in an explicit, almost visual way—a way that is more compelling than statistics alone.

Conditions of poverty perpetuate these diseases, while the health impact of these diseases perpetuates poverty. This strong association with poverty is readily apparent from just a few examples. Some forms of African sleeping sickness and leishmaniasis are 100 percent fatal if not detected and treated in time. All of the other diseases debilitate, blind or maim, permanently curtailing human potential and impairing economic growth.

This is not difficult to understand. People whose limbs are deformed, and people who have been blinded by disease will not contribute fully to society and economies. The drain on productivity is enormous. More than one billion people are affected. These people are a double burden for society. They cannot work to full capacity, and they require chronic care. The costs of care can bankrupt households. Stigma and social isolation, especially for women, compound the misery and further embed people in poverty.

These diseases are also a burden for health systems. For many other infectious diseases, management is an intermittent emergency. The patient either survives or dies. This is not the case for these diseases, where the misery is prolonged. Patients whose internal organs have been permanently damaged by parasites are a burden on hospitals. For some severe consequences of Chagas disease, the only truly effective treatment is a heart transplant. Surgical treatment of advanced Buruli ulcer requires weeks—if not months—of hospital care. The burden of these diseases on a population can increase dramatically when an epidemic-prone disease of poverty, like cholera, causes explosive outbreaks.

First, a major step was to view these diseases as a group. This makes practical sense in operational and strategic terms. Strongly associated with poverty, these diseases frequently overlap geographically, with as many as six major diseases present in large parts of the world. Although medically very diverse, all of these diseases thrive under conditions of poverty and filth. They tend to cluster together in places where housing is substandard, drinking water is unsafe, sanitation is poor, and access to healthcare is limited or non-existent, and insect vectors are constant household and agricultural companions.

When these diseases are viewed together, we gain critical mass. We get a better grip on the scale of the economic and social as well as the health burdens. Arguments for giving these diseases higher priority become more powerful, more persuasive. As yet another advantage, grouping these diseases together creates opportunities for the sharing of innovative solutions, especially as most control programs face similar operational constraints.

For example, the dose pole was pioneered by the onchocerciasis control program as a way to determine drug dosage, by height, for ivermectin. This innovation is now being used for schistosomiasis control, where praziquantel is administered in remote settings by non-specialized staff.

As a group, these diseases can participate in a shared momentum, where success for one disease spills over to benefit others. The eradication of guinea worm disease is now in sight despite the absence of a vaccine or curative drugs.

Two broad groups of disease were defined at a meeting in Berlin in 2005. The first includes diseases having rapid-impact interventions: drugs so safe and so powerful, they can be administered to all at-risk populations. The emphasis here is on morbidity control, reducing the pool of human infection, and thus reducing levels of transmission.

The second group includes more challenging diseases—the diseases that cannot be treated under a tree. For diseases like African sleeping sickness, leishmaniasis, Chagas disease, and Buruli ulcer, the focus is on better case detection and clinical management. Dramatic steps forward must await the development of better diagnostics and drugs. These must be affordable and suitable for use under field conditions.

The next step came in 2006, when WHO and multiple partners launched an integrated strategy for preventive chemotherapy for four of the highest-burden tropical diseases: lymphatic filariasis, onchocerciasis, schistosomiasis, and soil-transmitted helminthiasis. Blinding trachoma may also benefit from this approach.

Research has also demonstrated a surprising number of ancillary benefits of preventive chemotherapy: improved micronutrient uptake and nutritional status, better cognitive performance, and improved childhood growth. Moreover, mass campaigns have completely eliminated some dreaded parasitic skin diseases. This unexpected benefit has increased public perceptions that these drugs are beneficial. It has also made populations receptive to subsequent campaigns.

This meeting is a turning point in the long and notorious history of some of humanity’s oldest diseases. Historically, these diseases—so strongly tied to poverty—have gradually vanished from large parts of the world as incomes increased and standards of living and hygiene improved.

Today, we no longer have to wait for these diseases to gradually disappear. We no longer have to wait for gradual improvements in housing, water supply, sanitation, and other basic infrastructures to take place. We can act right now to deliberately push these diseases back. This is why this moment in history is different. 

Populations left behind by socioeconomic progress are in dire need of safe water and adequate sanitation, better access to health services, more opportunities for education, and improved nutrition.

However, they also need to be freed from the burden of disabling and debilitating infectious diseases. For the first time, we have a head-start on these ancient companions of poverty. For the first time, more than one billion people left behind by socioeconomic progress have a chance to catch up. I believe this is our shared ambition.