Knowledge Brief Health, Nutrition and Population Global Practice NTDS AND DEWORMING AFRICA INITIATIVE (DAI): MADAGASCAR Fernando Lavadenz, Linda Schultz, Opope Oyaka Tshivuila Matala, Nashira Calvo, and Jumana Qamruddin February 2018 KEY MESSAGES: • Madagascar’s multi-sectoral efforts have helped to reduce the burden of Neglected Tropical Diseases (NTD), which has declined from 5,975 disability adjusted life years (DALYs) per 100,000 people in 1990 to 2,423 in 2016. • The World Bank (WB) has financed more than US$4 million towards NTD control activities in the country since 2013 through the IDA financed PAUSENS project, (P131945). The WHO provided technical support. Both, the WB and the WHO are the primary development partners engaged in NTD control and elimination efforts in Madagascar. • In 2016, all preschool-age children (100 percent coverage), and nearly nine out of 10 school-age children at-risk of infection with soil transmitted helminths (STH) (87 percent coverage) were dewormed. However, an estimated 29 million people still require preventive chemotherapy (PC) for at least one neglected tropical disease (NTD). • The annual loss in economic productivity attributed to NTDs in Madagascar is estimated at US$29 million, which is equivalent to 0.29 percent of its annual GDP. • Schistosomiasis, lymphatic filariasis and STH, together represent 65 percent of total NCDs in the country. These diseases can be controlled by mass drug administration (MDA) with an annual investment of US$7 million. Country Context productivity. This brief provides an overview of the burden of Population (2016) 24.24MM NTDs in Madagascar, and opportunities to integrate prevention and control activities in active World Bank projects. Annual GDP per capita (2016) 420 USD Five diseases, namely Lymphatic Filariasis, Onchocerciasis, HDI Madagascar (2015) 0.512 Schistosomiasis, Soil transmitted Helminths, and trachoma account for almost all the burden of NTDs (90 percent) in the HDI Africa 0.523 country. These can be prevented, controlled, and where possible, eliminated with preventive chemotherapy (PC) Neglected Tropical Diseases are a group of 18 parasitic, viral through MDA. and bacterial infections1 that are endemic to 47 countries in Africa. These diseases, negatively impact the world’s poorest MDA, a safe and effective treatment against NTDs, has been and most vulnerable. The diseases can cause disabilities that delivered in more than 7 billion treatments to people in need may in turn have a detrimental impact on a country’s economic globally2. In 2012, the London Declaration on NTDs reaffirmed 1 NTDs include Buruli ulcer, Chagas disease, dengue and chikungunya, dracunculiasis (guinea- (STH; collectively comprised of hookworm, roundworm, and whipworm), snakebite worm), echinococcosis, foodborne trematodiases, human African trypanosomiasis (sleeping envenoming, taeniasis/cysticercosis, trachoma, and yaws. 2 sickness), leishmaniasis, leprosy (Hansen’s disease), lymphatic filariasis (LF ; elephantiasis), Fitzpatrick, et al. 2016. Benchmarking the cost per person of mass treatment for selected mycetoma, chromoblastomycosis and other deep mycoses, onchocerciasis (river blindness), neglected tropical diseases: an approach based on literature review and meta-regression rabies, scabies and other ectoparasites, schistosomiasis (bilharzia), soil-transmitted helminths with web-based software application. PLOS NTDs. https://doi.org/10.1371/journal.pntd.0005037 Page 1 HNPGP Knowledge Brief • the global commitment of governments, development partners Madagascar, with an estimated prevalence rate of 31 percent. and the private sector to lift over one billion people from the Additionally, more than 5 million Malagasy people are heavy burden that NTDs place on their lives. Thirteen estimated to be infected, with a further 7 million at risk for the pharmaceutical companies committed to donating medicines disease, making schistosomiasis a public health concern in free of charge for 10 of the most prevalent NTDs through the country. 2020, including the five amenable to MDA. Their commitment has led to a massive increase in the delivery of treatment to Figure 2: Burden of NTDs in DALYs for Madagascar against those affected. Regional Averages, 1990-2015 (DALYs per 100,000) 11,855 11,644 11,291 10,209 Deworming is a public health and education intervention that 14,000 12,000 DALYs per 100.000 7,524 targets schistosomiasis and STH. Periodic deworming for 6,095 10,000 5,975 5,569 5,183 5,075 schistosomiasis and STH among children with heavy 8,000 3,402 2,423 infections can lead to gains in weight and height, reduction in 6,000 4,000 school absenteeism, improved cognition, and improved future 2,000 earnings. Furthermore, deworming significantly reduces the - worm burden in pregnant women. 1990 1995 2000 2005 2010 2015 Africa Madagascar The World Bank has taken a strategic approach to control schistosomiasis and STH through deworming activities during Schistosomiasis accounts for 328 DALYs per 100,000, and the IDA 18 period (FY18-20), with the aim to achieve the WHO represents 0.72 percent of the total burden of disease in target of 75 percent coverage among at-risk school-age Madagascar (Figure 3). children (SAC) (5 to 14 years old) by 2020. Figure 3: Principal NTDs in Madagascar and Africa 2015 BURDEN OF NTDs IN MADAGASCAR (DALYs per 100,000 Madagascar’s NTD burden has seen a significant decline Madagascar from 5,975 in 1990 to 2,423 DALYs per 100,000 people in 2015 (Figure 2). Schistosomiasis 328.2 Other neglected tropical diseases 240.3 Lymphatic filariasis 197.5 Figure 1: Population requiring PC in Madagascar in 2016 Soil-Transmitted Helminths (STH) 113.4 Rabies 50.3 (WHO) Cysticercosis 36.9 Cystic echinococcosis 3.3 Dengue 2.9 Leprosy 2.8 Leishmaniasis 0.3 Soil-Transmitted Helminths - 50.0 100.0 150.0 200.0 250.0 300.0 350.0 2,775,565 (STH) DALYs per 100.000 Lymphatic filariasis 18,863,123 Africa Schistosomiasis 162 Intestinal nematode infections 108 Onchocerciasis 98 Schistosomiasis 7,803,826 Lymphatic filariasis 68 Rabies 38 Yellow fever 35 Leishmaniasis 20 0 10000000 20000000 Cysticercosis 16 African trypanosomiasis 13 In spite of this, in 2016, more than 29 million people required Dengue 9 - 50 100 150 200 PC for 1 or more NTDs in Madagascar (Figure 1). LF, schistosomiasis3, and STH collectively represent 65.5 percent of the NTD burden in Madagascar. ECONOMIC COSTS OF NTDs IN MADAGASCAR The lost economic productivity due to NTDs in Madagascar is Schistosomiasis is the most common NTD in Madagascar estimated at US$29 million per annum4, which is equivalent to (Figure 3). Schistosomiasis affects 95 out of 111 districts of 3 4 Two forms of schistosomiasis are endemic to Madagascar. The first, intestinal schistosomiasis The human capital approach was used to calculate the annual economic cost of NTDs. This (S. mansoni), is endemic in the southern and eastern parts of the country. The second form, entails equating the present value of a human life to the discounted market value of the output urinary schistosomiasis (S. haematobium), is endemic in the northern and western regions of the produced by an individual over an expected lifetime as a proxy for future productivity. This value country. Page 2 HNPGP Knowledge Brief • 0.29 percent of its annual GDP. Schistosomiasis and STH, 2016, only 21.7 percent of the 3,5 million SAC at risk for both of which can be controlled by MDA, collectively represent schistosomiasis and 44.0 percent of the 18,8 million adults at an annual economic cost of US$7 million. The treatment of risk for LF received treatment. It is important to sustain and schistosomiasis and STH in Madagascar would significantly build upon the gains achieved to reduce the infections, reduce the annual loss of productivity and increase GDP prevalence and intensity of these diseases. incrementally by 0.07 percent each year. MDA is a cost- Figure 5: Estimated Cost to Scale Delivery of Anti-Helminth effective solution for treating PC-NTDs, with an estimated Drugs to Young Children and Pregnant Women, 2016 – 2020 delivery cost per person per year of US$0.10 to US$0.50 1.10 1.2 1.04 1.07 (WHO 2015). 0.99 1.01 US$ Constant 2015 (million) 1.0 We estimated the gap in treatment coverage for three 0.8 populations: young children (12-23 months), school-age 0.6 children (5-14 years) and pregnant women. The coverage gap 0.4 is the difference between the WHO target or reaching 75 0.16 0.17 0.17 0.18 0.18 0.2 percent of the at-risk population and the national coverage for STH treatment. In Madagascar, there are approximately 1.56 0.0 2016 2017 2018 2019 2020 million young children and 0.35 million pregnant women who are not receiving treatment. Projected Gap Cost YC Projected Gap Cost PW The estimated cost of delivery to meet the current treatment Figure 6: Evolution and Coverage of Deworming in target is US$ 0.99 million for young children and US$ 0.16 Madagascar and Infection with Schistosomiasis, STH and million for pregnant women per year, totaling US$ 1.1 million LF 1990-2015 for one year. The treatment coverage for SAC exceeds the 800 150 WHO target (87.2 percent), indicating that there is no coverage gap for this population (Figure 4). 600 Figure 4: Estimated Cost to Meet the Current Gap in Drug DALYs per 100.000 100 Delivery to Young Children, School-Age Children, and Coverga rate Pregnant Women in Madagascar, 2016 400 1.5 US$ Constant 2015 50 0.99 200 1.0 (million) 0.5 0 0 0.16 1990 1995 2000 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 - 0.0 Soil-Transmitted Helminths (STH) Schistosomiasis Cost Gap YC Cost Gap SAC. Cost Gap PW. Schistosomiasis coverage STH coverage The Government uses several service delivery platforms to The cost of scaling up drug delivery to this same population deliver NTD medicines to at-risk populations, including (i) from 2017 to 2020 is estimated to be US$ 4.2 million for young children and US$ 1.5 million for pregnant women. This cost independent NTD campaigns and (ii) Maternal and Child estimate includes the delivery of anti-helminth drugs for 6.7 Health Weeks (MCHWs). million young people and 0.55 million pregnant women during Independent NTD Campaigns: MDA campaigns include this period to deworm 75 percent of these populations at-risk. community-based distribution of drugs to all populations at- GOVERNMENT LED INITIATIVES TO CONTROL AND risk for PC-NTDs, as well as school-based deworming. ERADICATION OF NTDs Community-Based Distribution: Community-based agents The Government of Madagascar has significantly reduced the provide MDA to populations at-risk for lymphatic filariasis, burden of schistosomiasis and STH since 2012 (Figure 4). schistosomiasis, STH, and trachoma. However, a substantial proportion of the population remains School-Based Deworming: In Madagascar, the Ministry of without access to treatment for schistosomiasis and LF. In Public Health (MOH), the National Nutrition Office (NNO), and is multiplied by the number of DALYs4 caused by the disease and discounted by the annual productivity loss for each NTD (Lenk 2016). Page 3 HNPGP Knowledge Brief • the Ministry of Education (MOE) collaborate to deliver tablet (400mg) to preschool-age children and one tablet of deworming treatment to SAC through schools. The MOH mebendazole (500mg) to SAC. The project strengthened the organizes the school-based deworming and transfers drugs Government’s capacities for implementing the NTD Plan from its warehouse to regional level school authorities, who 2012-2016, particularly through MDA (community-based, then distribute the medicines to schools. The MOH also trains door-to-door, and school-based delivery) in 24 districts of five teachers to deliver deworming medicines. The MOE ensures of the poorest regions in the South of Madagascar. The project regional administrators and directors are prepared to oversee was financed by an IDA loan of US$ 4 million for NTD-related the campaign and raises awareness at the community level activities, and was further supported by drug donations from around when deworming days are scheduled. Teachers deliver deworming tablets to children in schools under the pharmaceutical industry, distributed by the WHO. supervision by primary health care providers. The NNO Analytical work: In preparation for the first phase of the prepares and distributes light snacks to children before US$200 million Improving Nutrition Outcomes using the deworming drugs are distributed. Multiphase Approach project in Madagascar, the World Bank, Maternal and Child Health Weeks: MCHWs provide with financing from the Bill and Melinda Gates Foundation, immunization, vitamin A, as well as deworming for young conducted a detailed analysis of NTD and deworming children (12-23 months), preschool-age children (24-59 activities in Madagascar, and reviewed the effectiveness and months), and women of reproductive age. feasibility of current and novel treatment modalities. Key bottle-necks in Madagascar’s NTD program include (i) insufficient financing of existing programs (e.g. MCHWs), and PARTNERS ON THE GROUND (ii) low quality or absent census data to identify at-risk Currently, the World Bank is the only financial partner populations. A lack of complete or updated census data on engaged in NTD control and elimination efforts in SAC negatively impacts the organization and logistics of Madagascar. The World Food Program is independently school-based deworming activities. supporting deworming activities as part of its school feeding activities in select southern districts, and urban areas in WBG COUNTRY LEVEL PROJECTS TO DELIVER NTD Antananarivo, Tamatave, and Tulear. The WHO provides AND DEWORMING TREATMENT technical support. The World Bank has supported a range of NTD control activities in Madagascar since 2013, with a total investment of References De Neve J-W et al. 2018. Health, wealth, and education gains of investing in USD 6 million for NTD-related activities. neglected tropical disease control in Madagascar: an extended cost-effectiveness analysis. Forthcoming. Projects: Approved Project: The Government will begin Institute for Health Metrics and Evaluation (IHME). 2016. GBD Compare Data Visualization. Seattle, WA: IHME, University of Washington. Available from implementation of the IDA financed Improving Nutrition http://vizhub.healthdata.org/gbd-compare. (Accessed September 2017). Outcomes using the Multiphase Programmatic Approach International Monetary Fund. 2003. Poverty Reduction Strategy Paper. Accessed: Program (P160848) in 2018. The project will finance a https://www.imf.org/en/Publications/CR/Issues/2016/12/30/Madagascar-Poverty- Reduction-Strategy-Paper-16936. package of NTD interventions to be delivered at the Lenk EJ, Redekop WK, Luyendijk M, Rijnsburger AJ, Severens JL. 2016. community level in areas that are endemic for at least one of Productivity Loss Related to Neglected Tropical Diseases Eligible for Preventive Chemotherapy: A Systematic Literature Review. PLoS Negl Trop Dis 10(2): the five PC-NTDs. The project has budgeted US$3 million for e0004397. MDA through community based drug distribution and provides WHO. 2015. Investing to overcome the global impact of neglected tropical diseases [Internet]. [cited 19 Jun 2015]. Available: financing (US$450,000 total, for five years) to fully fund the http://www.who.int/neglected_diseases/9789241564861/en/ Government’s leprosy elimination action plan. A school-level WHO PCT Databank. 2016. PCT Databank: A Tool for Planning, Implementation NTD package will be financed under the new IDA/GPE Basic and Monitoring of Integrated Preventive Chemotherapy for Control of Neglected Tropical Diseases (NTD). Education Support Project (P160442). WHO. 2017. Crossing the Billion. Preventive chemotherapy for neglected tropical diseases: Lymphatic filariasis, onchocerciasis, schistosomiasis, soil-transmitted Closed Project: The WB supported deworming activities in helminthiasis’s and trachoma. Geneva: World Health Organization. Available: http://www.who.int/neglected_diseases/resources/9789240696471/en/ the country through the Emergency Support to Critical The Health, Nutrition and Population Knowledge Briefs of the World Bank are a quick reference on the essentials of specific HNP-related topics summarizing new findings and information. These may highlight an issue and key interventions proven to be effective in improving health, or information on this topic, go to: www.worldbank.org/health. WHO. 2017. Neglected tropical diseases. [cited 28 September 2017]. Available: Education, Health and Nutrition Services Project (P131945) http://www.who.int/neglected_diseases/diseases/en/ WHO. 2017. Preventive chemotherapy to Control Soil-transmitted Helminth Three rounds of MDA were implemented from 2013 to 2015, infections in At-risk population groups [cited 28 September 2017]. Available: http://www.who.int/nutrition/publications/guidelines/deworming/en/ through a multisector approach between the MOH, MOE, and the NNO. The MDA campaigns distributed one albendazole Page 4