20–22 February 2018Nadi, Fiji

Meeting Report

PROGRAMME MANAGERS MEETING ON NEGLECTED TROPICAL DISEASES (NTD)

IN THE PACIFIC

WORLD HEALTH ORGANIZATION

REGIONAL OFFICE FOR THE WESTERN PACIFIC

English only

MEETING REPORT

PROGRAMME MANAGERS MEETING ON NEGLECTED TROPICAL DISEASES (NTD) IN THE PACIFIC

Convened by:

WORLD HEALTH ORGANIZATION REGIONAL OFFICE FOR THE WESTERN PACIFIC

Nadi, Fiji 20 - 22 February 2018

Not for sale

Printed and distributed by:

World Health Organization Regional Office for the Western Pacific

Manila, Philippines

May 2020

NOTE

The views expressed in this report are those of the participants of the Programme Managers Meeting on Neglected Tropical Diseases (NTDs) in the Pacific and do not necessarily reflect the policies of the conveners.

This report has been prepared by the World Health Organization Regional Office for the Western Pacific for Member States in the Region and for those who participated in the Programme Managers Meeting on Neglected Tropical Diseases (NTDs) in the Pacific in Nadi, Fiji from 20 to 22 February 2018.

CONTENTS

SUMMARY

1. INTRODUCTION ............................................................................................................................................. 1

1.1 Meeting organization ............................................................................................................................ 1 1.2 Meeting objectives ................................................................................................................................ 1

2. PROCEEDINGS ................................................................................................................................................ 1

2.1 Opening session .................................................................................................................................... 1 2.2 Global and regional updates and consultation on the draft Regional Framework for Elimination and Control of NTDs in the Western Pacific Region ............................................................................................. 2

2.2.1 Global progress, challenges and updates on elimination and control of NTDs ................................ 2 2.2.2 Priority for healthy islands in the Pacific .......................................................................................... 3 2.2.3 Regional progress, challenges and the draft Regional Framework for Control and Elimination of NTDs in the Western Pacific .......................................................................................................................... 3

2.3 Universal access to comprehensive NTD interventions ........................................................................ 6

2.3.1 Preventive chemotherapy (LF, trachoma, yaws, STH) ..................................................................... 6

2.4 Innovative and intensified disease management (LF, trachoma, yaws, leprosy, scabies) ................... 10

2.4.1 WHO guidance on integrated skin disease management ................................................................ 10 2.4.2 Regional situation analysis and updates on scabies ........................................................................ 10 2.4.3 Sharing experience on tackling scabies (French Polynesia) ........................................................... 11 2.4.4 Establishing and sustaining care for LF morbidity patients ............................................................ 12

2.5 Water, sanitation and hygiene (WASH) (trachoma, yaws, STH, scabies) .......................................... 15

2.5.1 Facial cleanliness and environmental improvement for trachoma elimination in the Pacific .............. 15 2.5.2 Identifying opportunities for WASH and NTD collaboration ............................................................. 16

2.6 Vector control (LF, dengue) ................................................................................................................ 17

2.6.1 Persistent transmission of LF and WHO guidance on vector control for elimination of LF........... 17 2.6.2 Global Vector Control Response Strategy 2017-2030 .................................................................... 18

2.7 Strengthening surveillance and response (all NTDs)............................................................................... 19

2.7.1 Strengthening NTDs surveillance by implementing an integrated platform for NTDs surveillance and control ........................................................................................................................................................... 19 2.7.2 Reorientation on NTD Diagnostics ................................................................................................. 21 2.7.3 Developing post-validation surveillance plans in the Pacific ......................................................... 22 2.7.4 Orientation on dossier for validation of elimination of LF as a public health problem .................. 23

2.8 Operational research opportunities on NTDs in the Pacific .................................................................... 24

3. CONCLUSIONS AND RECOMMENDATIONS .......................................................................................... 25

3.1 Conclusions ......................................................................................................................................... 25 3.2 Recommendations ............................................................................................................................... 26

3.2.1 Recommendations for Member States ............................................................................................ 26 3.2.2 Recommendations for WHO........................................................................................................... 27

ANNEXES

Annex 1 - List of participants Annex 2 - Meeting programme

ABBREVIATIONS

CL-SWASH community-led initiatives to eliminate Schistosomiasis by combining deworming

with WASH interventions

Ct Chlamydia trachomatous

DA DEC and albendazole

DEC diethylcarbamazine citrate

DHIS district health information system

FTS filarial test strip

GPELF Global Programme to Eliminate Lymphatic Filariasis

GVCR Global Vector Control Response Strategy

HIS health information system

IDA Ivermectin, DEC and albendazole

IDM intensive disease management

JAP joint application package

JRF joint reporting form

LF lymphatic filariasis

MDA mass drug administration

M&E monitoring and evaluation

MMDP morbidity management and disability prevention

NTD neglected tropical diseases

PacELF Pacific Program for Elimination of Lymphatic Filariasis

PC preventive chemotherapy

PVS post-validation surveillance

SAFE Surgery, Antibiotic treatment, Facial cleanliness and Environmental change

SCT supervisor's coverage tool

SDG sustainable development goal

STH soil-transmitted helminthiases

TAS transmission assessment survey

TCT total community treatment

TF Trachomatous inflammation – follicular

TTT total targeted treatment

VC vector control

WASH water, sanitation and hygiene

WHO World Health Organization

WPRO Western Pacific Regional Office

SUMMARY

The Programme Managers Meeting on Neglected Tropical Diseases (NTDs) in the Pacific was held in Nadi, Fiji from 20 to 22 February 2018. The meeting was attended by 27 participants from 17 countries in the Pacific, three temporary advisors, representatives from five partner agencies and eight World Health Organization (WHO) Secretariat members.

Significant progress has been made in the Pacific towards elimination of lymphatic filariasis as a public health problem through mass drug administration. Five countries in the Pacific – Cook Islands, Marshall Islands, Niue, Tonga and Vanuatu – were congratulated for their recent WHO validation of elimination of lymphatic filariasis as a public health problem. Encouraged by this success, there are ongoing efforts to accelerate elimination of trachoma and yaws in the Pacific through mass drug administration and strengthening other interventions.

With this, the NTD landscape in the Western Pacific Region is fast changing and new situations and opportunities are emerging. While preventive chemotherapy has been highly effective in reducing the prevalence and burden of some NTDs such as lymphatic filariasis and trachoma, the limitations of reliance on preventive chemotherapy alone to control and eliminate other NTDs are increasingly observed. Secondly, even though NTDs are less neglected as a result of intensive advocacy efforts at global level, NTDs beyond LF and trachoma often continue to be neglected particularly in affected communities. It is increasingly realized that community engagement is essential to enhance and sustain impacts of ongoing interventions. Thirdly, as more and more countries achieve elimination targets, there is an urgent need to establish and sustain post-elimination surveillance and provision of universal care for patients in post-elimination countries. Fourthly, with the success in elimination of LF and trachoma as the public health problem most prevalent throughout the Region, diversity in disease endemicity and progress across the Region is expanding, with more focus on zoonotic and foodborne diseases in the Asia sub-Region and skin-related NTDs in the Pacific. With this emerging situation, it has become difficult to develop a one-size-fits-all strategy for control and elimination of NTDs. NTDs are also now included in the Sustainable Development Goals. Universal health coverage will be key for NTD control and elimination, helping sustain gains by ensuring that needed health services reach all people, particularly marginalized and neglected populations. The SDGs present opportunities to accelerate progress on NTDs through whole-of-system multisectoral interventions, such as improvements in water and sanitation, food safety, environmental health and veterinary public health, in addition to health services. Acknowledging the changing NTD landscape and remaining challenges in the Pacific, the meeting agreed that the three strategic pillars of the draft Regional Framework for Control and Elimination of NTDs could be surveillance (including response), strengthening multi-sectoral cooperation and universal access to interventions, and community empowerment through effective risk communication.

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1. INTRODUCTION

1.1 Meeting organization

The Programme Managers Meeting on Neglected Tropical Diseases (NTDs) in the Pacific was held in Nadi, Fiji, on 20-22 February 2018. The meeting was attended by 27 participants from 17 countries in the Pacific, three temporary advisors, representatives from five partner agencies and eight World Health Organization (WHO) Secretariat members. The programme agenda is presented in Annex 1. The full list of participants is available in Annex 2. 1.2 Meeting objectives The objectives of the meeting were to:

1) share among countries the relevant progress, emerging challenges and lessons learnt since the 2016 NTD Programme Managers’ Meeting in accelerating elimination and sustaining control of NTDs in the Pacific;

2) update the programme managers on the latest WHO guidance, tools and strategies for elimination and control of NTDs; and

3) review and provide inputs to the draft Regional Framework for Elimination and Control of NTDs in the Western Pacific from the Pacific perspective.

2. PROCEEDINGS

2.1 Opening session

Dr Rabindra Abeyasinghe delivered the welcome address on behalf of Dr Shin Young-Soo, WHO Regional Director for the Western Pacific. The Regional Director applauded the Member States in their efforts to control and eliminate NTDs as a public health problem. He commended the five Member States which had been validated for having eliminated lymphatic filariasis (LF) as a public health problem and emphasized the ongoing efforts in various countries to eliminate other NTDs such as trachoma and yaws. He stressed the need to remain vigilant in the fight against NTDs with sustained surveillance even after elimination has been achieved in order to help prevent recrudescence of transmission. The efforts to ensure continued and sustainable universal access to care for all patients already affected by morbidity due to NTDs were also required within the general public health services. Scabies and other ectoparasitic infestations prevalent in the Pacific had also recently been added to the NTD portfolio. It was important to determine the true burden of such diseases within countries and prioritize actions to control them in the Pacific. Continued transmission of trachoma, yaws and soil-transmitted helminthiases (STH) in the Region was linked to poor sanitation and hygiene. Efforts to strengthen access to safe water and improved sanitation and hygiene, especially in affected communities, would not only help accelerate elimination and control of such diseases, but also significantly strengthen water, sanitation and hygiene (WASH) access and overall health in the communities.

The Sustainable Development Goals (SDGs) pledge was that no one would be left behind. In order to achieve elimination and control of all endemic NTDs effectively and sustainably, the country and regional focus needed to be strategically moved away from a disease-specific approach to an integrated, intervention-centred one, focused on multi-sectoral cooperation and universal access to comprehensive NTD interventions. Such an integrated approach would help address the challenge of those diseases of poverty and ensure that people affected by them would not be neglected and left behind in the future. It was through global collaboration that NTDs would become a disease of the

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past. Dr Shin thanked all participants for sharing their experiences and perspectives, and for their contribution to refining the proposed regional framework for the elimination and control of NTDs.

2.2 Global and regional updates and consultation on the draft Regional Framework for Elimination and Control of NTDs in the Western Pacific Region

2.2.1 Global progress, challenges and updates on elimination and control of NTDs

Dr J. King presented the overview of global updates on NTDs with a focus on the linkage of SDGs and the WHO General Programme of Work 2019-2023 to the work to control and eliminate NTDs. The General Programme of Work of WHO in 2019-2023 is structured around three interconnected strategic priorities to ensure healthy lives and well-being for all at all ages: achieving universal health coverage, addressing health emergencies and promoting healthier populations. NTD interventions are considered an integrated part of the universal health care (UHC) essential package of health services, as they focus on reaching the unreached and improving equity. Accelerating the elimination and eradication of high impact communicable diseases such as NTDs is a priority under the General Programme of Work of WHO in 2019-2023.

Globally, considerable progress has been made towards the elimination and control of NTDs. In 2016 alone, 1 497 billion preventive chemotherapy interventions were delivered to 1.031 billion individuals for at least one NTD. With the collaborative efforts of the private sector, pharmaceutical companies, and federal and local governments, several countries have made great headway in easing their country’s burden of NTDs. Pacific island countries have been exceptional pioneers and made extensive progress in eliminating NTDs.

The recommended treatment for yaws is a single dose of 30mg/kg of azithromycin whereas that for trachoma is a single dose of 20mg/kg of azithromycin. Studies have been conducted to compare the effectiveness of both dosages against yaws. While serological cure rates for patients administered 20mg/kg was lower, clinical cure rates for the treatment of the two dosages were found to be equivalent, justifying integrated mass drug administration (MDA) using a single 20mg/kg azithromycin dose for elimination of yaws and trachoma. Additionally, EMS S/A, a pharmaceutical company in Brazil, has announced a new donation programme through WHO of up to 153 million tablets of azithromycin for elimination of yaws over the coming five years, which presents an opportunity to accelerate yaws elimination in the Western Pacific Region.

Recently, five countries have been validated for having eliminated LF as a public health program. Of the 13 countries that have been validated to date, seven are within the Western Pacific Region. As of 2016, 74% of all implementation units within the Western Pacific Region have completed the Transmission Assessment Survey (TAS) for LF and met the criteria for MDA and moved into post-MDA surveillance.

Through the implementation of the Surgery, Antibiotic treatment, Facial cleanliness and Environmental change (SAFE) strategy, five countries have been validated for having eliminated trachoma as a public health problem as of 2017, two of which are in the Western Pacific Region. In the Pacific, Fiji, Kiribati, Papua New Guinea, Solomon Islands and Vanuatu are considered to be endemic for trachoma, but it is observed that while the active trachoma phenotype is common in the Pacific, other indicators such as the prevalence of ocular chlamydia trachomatous (Ct) infection and anti-CT antibodies are atypical and there is little trichiasis in Melanesia. Therefore, additional investigation on scarring is to be conducted in Melanesian countries to determine the next steps for elimination of trachoma as a public health problem.

STH is endemic among preschool children, school-aged children, and women of childbearing age. Currently, albendazole and mebendazole are donated only for school-aged children but WHO is in negotiation with pharma donors for the provision of donations for the other groups as well. Countries distributing albendazole or mebendazole for the control of STH or LF elimination for more than five years are encouraged to assess the prevalence of the disease and determine the next steps for accelerating STH control.

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2.2.2 Priority for healthy islands in the Pacific

Dr A. Merianos presented the priorities for healthy islands in the Pacific in relation to control and elimination of NTDs. The Healthy Islands Vision is a mission set forth by the Yanuca Island Declaration made at the first Pacific Health Ministers Meeting in 1995 for Pacific island countries and areas. The initiative emphasizes the need for preventative measures to protect the islands from climate change and natural disasters. Prioritizing environmental health and strengthening health emergency management capacities will also directly and indirectly contribute to control and eventual elimination of NTDs.

The Pacific island countries have seen challenges and accomplishments over the past years. Five Pacific island countries have been validated for having eliminated LF as a public health problem. 13 Pacific island countries have a national climate change and health adaptation plan in place. Overall, Pacific island countries have seen an increase in the proportion of individuals using safely managed drinking water followed by a decrease in the proportion of individuals practicing open defecation. Yet, there are still numerous outbreaks of diarrhoea, fever, typhoid and many more preventable diseases.

Efforts to combat poverty and improve environmental health, water and sanitation, along with NTD interventions are all closely linked and have improved greatly in the past years. However, climate change might jeopardize the immense progress made since any threat and outbreak of NTDs is considered a national health security risk. As a result, it is vital to address climate change and solidify the necessary infrastructure to protect the achievements in the event of an uncontrolled natural disaster. Such preparations require a coordinated system approach with community engagement and multisectoral partnerships.

2.2.3 Regional progress, challenges and the draft Regional Framework for Control and Elimination of NTDs in the Western Pacific

Dr A. Yajima presented the progress in the elimination and control of NTDs in the Western Pacific Region. There are 15 NTDs endemic in the Western Pacific Region, including scabies and snakebite envenoming that have been recently added to the portfolio. NTDs of particular importance in the Pacific are yaws, LF, trachoma, leprosy, STH, dengue fever and scabies. The previous NTD Regional Action Plan was in place from 2012 to 2016. During its time, the action plan reached some significant priority targets such as the control and elimination of LF, trachoma, and yaws in various Western Pacific Region countries.

Six countries (Cambodia, Cook Islands, Marshal Islands, Niue, Tonga and Vanuatu) out of 22 endemic countries have been validated for having eliminated LF in 2016-2017. Seven other countries have already stopped MDA and are undertaking post-MDA surveillance nationwide. The remaining nine countries are also progressing with MDA. In the Asia sub-Region, five remaining LF-endemic countries (Brunei Darussalam, Lao People's Democratic Republic, Malaysia and the Philippines) continue to be on track to stop MDA and move to post-MDA surveillance nationwide by the end of 2020. However, the progress of assessment and reporting of the morbidity burden associated with LF also needs to be accelerated. Countries achieving the elimination of LF as a public health problem also continue to be vigilant by establishing post-validation surveillance to help prevent recrudescence of transmission.

Two (Cambodia and Lao People's Democratic Republic) out of ten endemic countries have been validated for elimination of trachoma as a public health problem in 2017. In the Pacific other than in Kiribati, trichiasis and evidence of current ocular infection with Ct are rare despite signs of trachomatous inflammation – follicular (TF) being found in a moderately high proportion of children. In January 2018, the WHO Western Pacific Regional Office (WPRO) organized the Expert Consultation on the Elimination of Trachoma in the Pacific in Melbourne, Australia, to review the outcomes of the post-intervention impact surveys in Solomon Islands and Vanuatu and discuss the potential reasons for the observed association between TF and ocular Ct infection. The Consultation recommended implementation of an ancillary scarring survey in Melanesian countries to confirm the true burden of trachoma and determine the next steps and a population-based survey to establish baseline prevalence in countries where such data is lacking (Samoa, Nauru and Papua New Guinea).

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Yaws is endemic in three countries in the Pacific (Papua New Guinea, Solomon Islands and Vanuatu). In Solomon Islands, nationwide trachoma MDA using azithromycin was implemented in 2014, following which a significant reduction of yaws cases was observed in 6-month and 18-month post-MDA surveys. In Vanuatu, yaws MDA was conducted in the highest-burden province in 2013 followed by nationwide trachoma MDA in 2016. Since then, active surveillance and case investigation is ongoing. In Papua New Guinea, yaws MDA is planned in one of the districts in New Ireland Province in 2018.

Deworming against STH continued in Fiji, Kiribati and Vanuatu in 2016, and the data for 2017 is awaited. Pacific island countries face challenges with timely data collection and reporting from all islands due to limited national capacity and logistic challenges.

Overall, remarkable progress has been achieved in control and elimination of NTDs in the Western Pacific Region since the launch of the Regional Action Plan for Neglected Tropical Diseases in the

Western Pacific Region (2012-2016) in 2012. This includes significant overall reduction of NTD burdens resulting from full-scale preventive chemotherapy interventions for multiple NTDs, the increasing number of countries achieving elimination targets or on track to achieve elimination targets for LF and trachoma by 2020, and recent success in institutionalizing inter-sectoral collaboration for elimination of Asian schistosomiasis. With this, the NTD landscape in the Western Pacific Region is fast changing and new situations and opportunities are emerging. While preventive chemotherapy has been highly effective in reducing the prevalence and burden of some NTDs such as LF and trachoma, limitations to reliance on preventive chemotherapy alone to control and eliminate other NTDs, particularly schistosomiasis and other foodborne and zoonotic NTDs, are increasingly observed. Secondly, even though NTDs are less neglected as a result of intensive advocacy efforts at global level, NTDs beyond LF and trachoma often continue to be neglected particularly in affected communities. It is increasingly realized that community engagement is essential to enhance and sustain impacts of ongoing interventions. Thirdly as more and more countries achieve elimination targets, there is an urgent need to establish and sustain post-elimination surveillance and the provision of universal care for patients in post-elimination countries. Fourthly, with the success in the elimination of LF and trachoma as public health problems that have been most prevalent throughout the Region, diversity in disease endemicity and progress across the Region is expanding, with more focus on zoonotic and foodborne diseases in the Asia sub-Region and skin-related NTDs in the Pacific. With this emerging situation, it becomes difficult to develop a one-size-fits-all strategy for control and elimination of NTDs. Furthermore, in 2017, three disease conditions were added to the global NTD portfolio, namely scabies and other ectoparasitic infestations, snakebite envenoming, and chromoblastomycosis and other deep mycoses. As new disease conditions are added, actions must be taken to assess the most effective way to integrate them into the overall framework for control and elimination of NTDs. Finally, NTDs are now included in the SDGs. Universal health coverage will be key for NTD control and elimination, helping to sustain gains by ensuring that needed health services reach all people, particularly marginalized and neglected populations. SDGs present opportunities to accelerate progress on NTDs through whole-of-system multisectoral interventions, such as improvements in water and sanitation, food safety, environmental health and veterinary public health, in addition to health services.

Acknowledging progress and recognizing opportunities, it has been increasingly realized that a new regional vision for the control and elimination of NTDs in the Western Pacific is required. The new regional framework on NTDs will be different from the existing Regional Action Plan in the following aspects:

1) It will focus on an integrated and comprehensive approach across the Region to effectively address all NTDs:

- with a more sustainable approach for program managers (more efficient for island nations to cover more diseases at once)

- simultaneously build capacity of health systems and governments - progressing ahead of all other Regions, need a more regionally-specific plan if

success is to go beyond LF & trachoma

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2) It will accommodate a plan for new NTDs (scabies & snakebites), along with post-elimination surveillance & universal and sustained access to morbidity care

3) It will guide us on how to develop multi-sectoral programmes that also address disease-specific targets and individual interventions that were provided in the previous action plan.

The draft outlines and the key components of the proposed regional action framework were presented. The framework will reflect a vision of achieving a Western Pacific Region free from NTDs by building a robust health system capacity to detect, respond and manage NTDs and associated morbidity and disabilities so that quality of life of the affected people and communities is improved in the Western Pacific Region. The aim is to meet two goals: (i) to achieve and sustain the status of elimination of those NTDs targeted in resolutions of the World Health Assembly, and (ii) to achieve and sustain control of other NTDs and alleviate suffering due to NTD-associated morbidity and disabilities (Figure 1). In order to achieve these goals, three action pillars to focus strengthening of NTD programmatic components were proposed: (1) effective and sustained surveillance, (2) universal access to a comprehensive NTD intervention package, and (3) empowerment of affected people and communities.

M&E: monitoring and evaluation; PC: preventive chemotherapy; WASH: water, sanitation and hygiene

Figure 1. Schematic of a draft regional framework for control and elimination of NTDs

Proposed objectives, expected outcomes and priority actions under each pillar were presented and discussed. Emphasis was placed on the fact that many NTDs have various commonalities. Multiple NTDs frequently affect the same population in the same environment where poverty prevails, safe water supply and sanitation is lacking and disease vectors thrive. Interventions to achieve control and elimination of diseases and programmatic activities required to deliver such interventions overlap across multiple diseases, and this strength should be utilized to make further progress in strengthening NTD programme capabilities more effectively and efficiently. In countries or areas where multiple NTDs are co-endemic, integration and coordination of planning and implementation of intervention and associated activities across multiple diseases are expected to improve cost-effectiveness, logistic

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convenience, acceptability by affected populations, ancillary and synergic impacts of the intervention and political attention through increased visibility. The participants noted the proposed framework. Since the agenda of the meeting was designed to discuss each component of the draft framework in detail, the meeting participants agreed to provide comments and suggestions at each session and after the end of the meeting. All the suggestions and inputs from the session would be incorporated into the current draft framework and circulated to all Member States and partners for further consultation.

2.3 Universal access to comprehensive NTD interventions

2.3.1 Preventive chemotherapy (LF, trachoma, yaws, STH)

2.3.1.1 WHO guidance on triple drug therapy to eliminate lymphatic filariasis

The Global Programme to Eliminate Lymphatic Filariasis (GPELF) was launched in 2000 with the goal to stop transmission of LF by MDA and to reduce suffering and improve quality of life through morbidity management and disability prevention (MMDP). MDA medicines partially damage and reduce the reproductive capability of adult worms and also diminish the circulating microfilaria in the blood of an infected individual. The conventional WHO recommendation to reduce and interrupt transmission of LF is to conduct annual mass treatment of both infected and uninfected individuals in the entire endemic area with at least 65% treatment coverage of the total population for at least five rounds annually. However, the impact and required number of rounds of MDA depends on baseline LF prevalence, efficiency and abundance of vector mosquitoes, efficiency of medicines and consumption of medicines by the target population. As of February 2018, globally 11 countries have been validated for having eliminated LF as a public health problem and 9 others are under post-MDA surveillance nationwide. However, there are still 21 countries that have not started MDA, while an additional 18 countries are experiencing sub-optimal results in TAS globally. It is also often operationally difficult to sustain effective coverage of more than five rounds of MDA in endemic communities. This situation makes achievement of the global 2020 goal infeasible.

To this end, WHO, with support of various research partners, led operational research to identify more effective MDA regimens by comparing the triple therapy of ivermectin, diethylcarbamazine citrate (DEC) and albendazole (IDA) and the conventional two-drug regimen of DEC and albendazole (DA) or ivermectin and albendazole (IA), and also by comparing MDA twice a year versus once a year. Studies have shown a significantly greater reduction of microfilaria density in infected individuals by IDA compared to IDA at one-year and two-year post-treatment with only one round of treatment. There was no significant difference in microfilaria clearance between MDA once a year and twice a year. Additionally the number of reported adverse events in different categories and severe adverse events was found to be equivalent between IDA and DA. WHO accordingly issued a new guideline to recommend annual IDA for special populations and under specific circumstances; namely (a) for implementation units that have not started or have fewer than four effective rounds, (b) for implementation units that have not met epidemiological targets in sentinel and spot-check site surveys or in TAS despite meeting drug coverage targets, and (c) for communities where post-MDA or post-validation surveillance identified infection suggesting local transmission (Figure 2).

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Figure 2. WHO guidance on triple drug therapy to eliminate lymphatic filariasis in special

settings

However, it is important to note that IDA is not a replacement for poor programme delivery or poor community compliance. It is vital that the community works enhance their programme delivery and community compliance in order for the MDA to be effective. Furthermore, delivery methods must be enhanced to ensure directly observed treatment and effective coverage in each round of MDA. Lastly, it is necessary to improve and strengthen the capacity for reporting and management of adverse events and mitigating social implications of false information. In other words, pharmacovigilance must be integrated into the MDA. This might include bringing together programme managers and pharmacovigilance focal persons, including pharmacovigilance in guidelines, policies and strategic plans, along with providing pharmacovigilance training at all governmental levels. To be effective, a district investigational team should include designated pharmacovigilance mobile supervisors to cover the occurrence of an adverse event. To pre-empt public distrust, it is important that all programmes sensitize the public prior to the distribution of MDA about the importance of monitoring medicine safety and ensuring that there are available reporting mechanisms. For example, text messages may be used for a reporting and there can be a 24-hour toll-free reporting telephone line to pharmacovigilance focal points during the MDA.

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2.3.1.2 Preventive chemotherapy for trachoma, yaws and STH, and integration opportunities

The general programme steps for control and elimination of NTDs are as follows: mapping to determine the need for interventions, delivering preventive chemotherapy (PC) intervention complimented by other interventions, conducting post-intervention surveillance for validation or verification of elimination, and conducting post-elimination surveillance to be sustained after validation/verification.

For LF, MDA must be initiated after baseline data shows microfilaremia or antigenaemia prevalence above 1%. The original recommendation was to implement at least five rounds of MDA. However, it is now recommended that areas where MDA has not been initiated or which have fewer than four effective rounds of MDA should conduct two rounds of MDA with IDA. If the area fails pre-TAS or TAS, they must conduct two more rounds of MDA. TAS is implemented every two years for three rounds before validation of elimination as a public health problem.

For trachoma too, MDA is given to the entire population living in the endemic district/community. The number of required rounds of MDA is determined by the baseline TF prevalence. MDA is stopped if impact survey results show TF prevalence below 5%. Surveillance should be conducted once, two years after the impact survey shows TF prevalence below 5%. Trachoma MDA should be implemented in conjunction with activities that promote facial cleanliness and environmental improvement.

For yaws, total community treatment (TCT), which is equivalent to MDA, should be administered to the entire population aged over 6 months, living in a yaws-endemic community. The general recommendation is to deliver two to three rounds every six months. If greater than 90% coverage is achieved, the community should move to active post-TCT surveillance and total targeted treatment (TTT), where all new cases and individuals who are in close contact with the identified cases should be treated. Treatment should last until there are no more new infectious cases. Surveillance should be completed until yearly sero-surveys show that there are no sero-reactors found for three consecutive years.

For STH, deworming is recommended for school-aged children, preschool-aged children and women of child-bearing age. If the STH baseline prevalence is 20-50%, yearly deworming is recommended, whereas if baseline prevalence is ≥50%, semi-annual deworming is recommended. After five to six years of deworming with over 75% treatment coverage, implementation of a sentinel survey is recommended to assess the impacts of interventions and modify treatment strategy as needed.

When multiple NTDs are present, it is encouraged to compare interventions planned for each disease and identify opportunities for coordination or integration of similar activities targeting the same communities in order to maximize efficiency and medication adherence.

2.3.1.3 The Supervisor’s Coverage Tool: A rapid MDA assessment tool for programmes

Evaluation tools are necessary in order to assess the effectiveness of MDA; however, the coverage evaluation is often too expensive or complex and the evaluation results often come too late to be useful for the current MDA. In light of the need for a quick, simple and inexpensive tool for monitoring and supervising MDA, implemented by district supervisors, the Supervisor's Coverage Tool (SCT) was developed.

SCT consists of coverage evaluation, conducted thoroughly at the district level with statistically rigorous data compilation and periodical implementation. It includes coverage monitoring, which is simple, inexpensive, and rapid for routine use. SCT is implemented by district supervisors to classify coverage level, supervise sub-district planners and organizers, detect issues with compliance and drug distribution, and identify sub-districts that may need additional resources and/or services. SCT is to be conducted during the last week of MDA or up to two weeks following MDA. The evaluator will stratify the community and choose a specific number in the population to interview. In this case, the evaluator will interview 20 people from up to 20 different villages to assess coverage levels. Steps required to conduct SCT are:

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1. identify the survey population 2. identify the supervision area 3. determine how many individuals will be chosen from each village 4. select individuals using a village register or by numbering each household 5. interview the 20 selected individuals about MDA coverage 6. interpret the results 7. develop an action plan 8. implement the action plan

The supervision area is typically the smallest administrative unit for which a first-level supervisor is responsible (e.g. the catchment area of someone who supervises the community drug distributors). These are selected from areas where poor MDA coverage is suspected, recent migration or expansion makes denominator estimates uncertain, the work of the drug distributors or their direct supervisors needs supervising, or randomly. Within each supervision area, individuals are randomly selected using the village register, segmentation or a modified random walk approach to select households. Selected individuals are then interviewed using a questionnaire about consumption of the medicine. The results are then interpreted based on the number of people answering yes to the coverage question out of 20 people sampled. Countries implementing PC interventions are encouraged to adopt SCT.

2.3.1.4 Sharing success and challenges in achieving high PC coverage

The Cook Islands

The data on prevalence of LF and the number of lymphoedema cases in Cook Islands dates as far back as 1925. Despite having MDAs in all islands in the 1970-80s, LF continues to be a public health issue. In 1999, the Cook Islands launched a Program for the Elimination of LF aimed to achieve 80-100% geographic coverage with MDA by the year 2006 and to reduce the prevalence to below 1% by 2015 thus becoming LF-free.

The programme hosted several activities including: blood surveillance using the test and treat strategy, implementation of at least five rounds of MDA on all islands with the combination therapy of DEC and albendazole, followed by the verification process in 2015. During each round of drug distribution, every person’s weight was measured and the required dosage of drugs was given according to the weight. Some children aged 2-4 years had difficulties swallowing the drugs (DEC and albendazole) and were advised to chew albendazole tablets first as they are sweet. Parents were encouraged to help children consume the tablets. In 2016, WHO validated the Cook Islands for having eliminated LF as a public health problem. The programme did not stop operating after receiving verification in 2016. The team continue to screen immigrant workers arriving from endemic countries and manage vector control by holding biannual mass cleaning campaigns known as TUTAKA.T

The Cook Islands noted various strengths contributing to this success, such as the management team’s positive outlook and direction throughout the duration of the program; the dedication and commitment of the LF team; the continuous support by all sectors of the government and the support and technical advice from various international organizations. Solomon Islands

The Solomon Islands was found to have a high TF prevalence among the population of 1-9 years of age in the baseline survey. Based on this result, the Ministry of Health and Medical Services implemented nationwide MDA using azithromycin in 2013. This involved mobilization of resources from the donors, procurement and distribution of medicines, training of health workers on the proper distribution of azithromycin, and actual implementation of the campaign. Treatment coverage ranged from 58% to 109% by province. The cost breakdown of this MDA campaign showed that a majority of the expenses were attributed to transportation, followed by miscellaneous costs, allowances (for workers), accommodation, and community empowerment.

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Some notable achievements from this programme were the commitment of the Ministry of Health and Medical Services, the positive community response to receiving treatment, achievement of 100% geographical coverage, a high treatment coverage of the total population, and the overall reduction of yaws and chlamydia infection. Some notable challenges were less public awareness about the disease, the lack of transportation in most provinces, and the staff’s expectations.

After current analysis of the program, some recommendations were suggested to organize micro-planning at the provincial level to improve engagement of the provincial health department, and improve social mobilization by increasing resource allocation with cost-effective interventions in the community. It was realized that there needs to be a flexible and ample timeframe to conduct social mobilization.

2.4 Innovative and intensified disease management (LF, trachoma, yaws, leprosy, scabies)

2.4.1 WHO guidance on integrated skin disease management

Skin NTDs are often overlooked due to the stigma and lack of resources allocated to them. However, they remain as a great burden to individuals living with the conditions because the disease is visible and causes significant ostracism.

A patient’s skin is the first and most visible component of the body that any health-care worker encounters during the course of an examination. The skin is therefore an important point of departure for both diagnosis and management. Multiple skin NTDs are often co-endemic and have similar early manifestation signs. When an initiative combines several related skin NTDs, it is easier to manage and advocate for more human and financial resources. Since the disease is visible, it is easy to screen in communities and schools. Furthermore, certain skin diseases can be treated and thus motivate community members, policy-makers, and donors to support the cause and destigmatize skin NTDs. The consolidation of the diseases along with the integration of the local epidemiological affiliation will help strengthen the health system as there will be an aggregated system in place to monitor and treat the diseases.

A training guide was created for frontline health workers, who do not have specialist knowledge of skin diseases, to identify the signs and symptoms of skin NTDs from their visible characteristics. The guide also contains diagnostic information along with management and tips for wound care for the more common skin problems that health workers are often exposed to. The comprehensive training guide aims to educate local health workers to detect, manage, and treat these common conditions.

Notable challenges that this initiative has seen are the lack of political and donor support, reduced technical support and capacity building, and a lack of surveillance for skin diseases. Furthermore, there is a need for more mobile health services as many individuals living with a skin disease are often embarrassed or are unable to seek health care assistance due to the stigma of going out in public. Most funding sources are earmarked for specific diseases and associated programs for those diseases. As a result, the NTDs that are further neglected, such as skin NTDs, often do not receive abundant resources like the more “popular” NTD counterparts.

Some expected outcomes from this integrated skin NTD management approach are the improvement of early detection and treatment of specific skin NTDs; the documentation and sharing of best practices and outcomes in order to scale up the project; the framework for research to improve the control of skin NTDs; advocacy for greater attention to skin diseases; and most importantly the mobilization of resources to address skin NTDs.

2.4.2 Regional situation analysis and updates on scabies

Human scabies is a parasitic infestation caused by Sarcoptes scabiei var. hominis. The microscopic mite burrows into the skin and lays eggs, eventually triggering a host immune response that leads to intense itching and rash. Scabies infestation may be complicated by bacterial infection, leading to the development of skin sores that, in turn, may lead to the development of more serious consequences such as septicaemia, heart disease and chronic kidney disease. Scabies is not merely a nuisance but

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causes considerable morbidity and disability globally. Scabies was thus recently added to WHO’s list of NTDs in 2017.

Ensuring treatment compliance in topical treatment of scabies cases is challenging, especially when it is widespread in households or communities, and this explains why operational research to explore the potential of MDA using oral ivermectin for public health control of scabies is ongoing in several countries. Fiji conducted a trial to compare the impacts of standard care (administration of permethrin to affected persons and their contact), MDA with ivermectin and MDA with permethrin.1 The results after 12 months of treatment showed the highest reduction of prevalence in the group with MDA using ivermectin (94% reduction) compared to the group with MDA using permethrin (62% reduction) and the group with standard care (49% reduction). The 24-month post-treatment follow-up showed that the prevalence in the group with MDA using ivermectin remains the lowest (3.7% compared to 1.9% 12-months post treatment). There was another trial in Solomon Islands to compare efficacy and safety of combined MDA of azithromycin for yaws and ivermectin for scabies. At 12 months after MDA, an 89% reduction in scabies prevalence and a 75% reduction in impetigo prevalence were observed. No serious adverse events were reported.2 Currently a larger-scale trial to evaluate impacts of MDA for scabies and its serious bacterial complication in Fiji, and a trial to compare the efficacy of one versus two doses of ivermectin MDA on scabies in Solomon Islands, are ongoing.

A situation analysis of scabies in the Western Pacific Region was also conducted to further analyse the burden of disease that scabies induces. Although there was limited data, the Western Pacific Region is known to have the greatest burden of disease for scabies worldwide. Theoretically, everyone in the region is at risk; however, approximately 27 million individuals among 14 countries and areas are estimated to be at high risk of scabies.

There are no reliable data sources in the Pacific Island countries due to several factors that cause underestimation of the scabies burden. Overall, skin conditions are underreported by communities and are not represented in the health system because they are either normalized by communities or there is insufficient knowledge of the diagnostic criteria and consequent lack of treatment. In order to change this, the health system must be strengthened to capture the information.

Many high burden countries do not have a guideline in place for scabies. There are few standard treatment materials, yet there are no public health control measures and strategies that can help these countries. Only two countries, Fiji and Solomon Islands, were found to have guidelines on scabies in their NTD policy. Although scabies was mentioned in the Regional Action Plan for Neglected

Tropical Diseases in the Western Pacific Region (2012-2016), there were no specific actions listed.

Key recommendations to tackle the global burden of scabies were proposed as follows:

1) Developing an assessment tool and a standardized survey method integrated with other NTD surveys to estimate the overall burden,

2) Mapping the burden of scabies and other skin NTDs in the Western Pacific Region, 3) Creating an action plan for high burden areas and including scabies in the new Regional

Framework for Control and Elimination of NTDs, 4) Providing scabies treatment via intensive disease management (IDM) and/or MDA in public

health control of scabies, and 5) Continuing to conduct operational research to address remaining challenges to accelerate public

health control of scabies.

2.4.3 Sharing experience on tackling scabies (French Polynesia)

Scabies is highly prevalent in French Polynesia. Since 2012, the number of self-reported scabies cases began to rise, and in 2013, the network of health care providers was asked to formerly declare new cases of scabies through the health system. Since then, reports of syndromes and unusual pathology

1 Romani L et al. (2015) Mass Drug Administration for Scabies Control in a Population with Endemic Disease. N Engl J Med; 373:2305-2313. DOI: 10.1056/NEJMoa1500987 2 Romani L et al. (2019) Efficacy of mass drug administration with ivermectin for control of scabies and impetigo, with coadministration of azithromycin: a single-arm community intervention trial. Lancet Infectious Diseases, 19(5), 510-518.

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are collected on a weekly to bi-weekly basis by email or fax amongst a network of about 30 sentinel sites, from clinicians, the consultation registry and the main hospitals' database using ICD codes.

In 2013, the Bureau de veille sanitaire estimated 10 000 cases within a population of 268 000, which is equivalent to 3 731 cases per 100 000. From 2014 to 2017, there was a 400% increase in the number of cases declared to the Bureau de veille sanitaire, with 152 cases in 2014 and 808 cases in 2017. Scabies remains a significant burden because it is contagious and continues its exponential spread; it is difficult and expensive to treat; and it is reoccurring. Despite drug costs, ivermectin continues to be the leading drug treatment of choice for scabies in French Polynesia and its consumption in the country is increasing yearly, based on the data from the Social Insurance Fund.

Some of the challenges in addressing scabies are the lack of a standardized case definition and proper evaluation of the burden of scabies, impetigo and rheumatic heart disease, and a constant redefinition of treatment strategies. Traditional topical treatment is available in countries but it is difficult to ensure compliance. The modern treatment using ivermectin is expensive and not always available in countries. Patients are often hesitant about treatment owing to the cost and because scabies is commonly recurrent after individual case treatment. Consequently, healthcare providers often feel little motivation to treat their patients. One avenue to consider is more comprehensive control of the disease either through environmental treatment or excluding infected students from school.

Recommendations to manage outpatients and their families along with guidelines on the control of an outbreak in a school or hospital are currently available. However, there are no recommendations on public health control in an endemic situation which makes the current situation in French Polynesia difficult.

Moving forward, there needs to be a push to have systematic monitoring of the disease to evaluate the burden. Furthermore, updated and timely data about the disease transmission is essential for immediate treatment procedures. Lastly, a comprehensive environmental treatment and control strategy must be created with redefined goals for public health control of scabies.

The meeting participants emphasized the importance of utilizing potential opportunities for integrated control of multiple diseases using a single treatment, such as ivermectin for scabies, LF, head lice, and helminthiasis. Greater efficiency will be achieved if a scabies initiative coordinates with the efforts of other NTD control programmes.

2.4.4 Establishing and sustaining care for LF morbidity patients

2.4.4.1 WHO LF morbidity burden assessment and management tools

LF infection causes damage in the lymphatic vessels, which leads to accumulation of fluid in the tissues and can cause lymphoedema in men and women (legs, arms, breasts, genitals) and hydrocele in men (W. bancrofti areas only). The GPELF aims at 100% geographic coverage of services with a minimum package of care in all areas with known patients, which includes treating acute attacks, managing lymphoedema and hydrocele and providing anti-filarial medicines (MDA or individual treatment). Treatment of acute attacks includes antibiotic treatment and symptomatic management (analgesic, anti-inflammatory medication, antipyretics and supportive measures) and hygiene measures as tolerated. Management of lymphoedema includes hygiene, skin and wound care, exercise, elevation of legs and wearing suitable shoes. For management of hydrocele, hydrocelectomy has been identified as one of the 28 essential surgical procedures that need to be made available at first level hospitals worldwide. Surgical technique depends on hydrocele grade and local capacity, but proper, quality surgery can be curative.

MMDP for LF can be integrated with other chronic disease programmes that require long-term care such as noncommunicable diseases, leprosy, buruli ulcer, etc. It would be easier to integrate a MMDP into these established programmes, especially if there is already an existing community health worker network in place.

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GPELF recommends all endemic countries to (i) understand the burden of LF in the country, (ii) provide access to a basic package of care for all lymphoedema and hydrocele patients and (iii) ensure good quality of care is provided. As a first step, countries are encouraged to conduct situation analyses to understand the context for planning an MMDP program, such as potential partners, existing capacities, infrastructures and policies for planning for service provision and opportunities for integration such as primary health care/NCD programmes and other disease programmes such as those for leprosy, buruli ulcer, or diabetes..

Validation of elimination of LF as a public health problem requires estimation of patients in all areas that are endemic and in non-endemic areas that have been historically endemic (regardless of MDA implementation), generated down to the implementation unit level for both lymphoedema and hydrocele. It consists of the estimated or actual number of patients with lymphoedema and hydrocele per implementation unit. Patient estimation data can also be used for advocacy to raise funds for implementation of MMDP services, strengthen the health system to provide a basic package of care and include it as essential services under Universal Health Coverage, and determine where and at which scale MMDP services should be implemented (minimum at least 1 facility per IU with known cases). There is no standard survey methodology but various opportunities can serve to collect such information such as integration with MDA coverage survey, community-based TAS, or the key informative interview with community or health personnel. Health facility surveys using a questionnaire or door-to-door morbidity census may be alternative options. If estimates are collected by IU and are believed to remain representative of the current situation, historic patient estimates can also be used, but updating it might be considered for the emergence of new cases, internal migration, or the death of elderly patients. When conducting patient estimation, the following questions should be considered:

• Which strategies are available and feasible for quantifying patients? • How can MMDP activities be integrated into ongoing activities (e.g. MDA, household

surveys)? • How should your question be tailored to the survey type (group vs. individual question)? • What other programs provide opportunities for collaboration? • Does technology play a role in collecting these data?

Challenges to implement MMDP activities include an absence of one-size-fits-all solutions, a need for coordination beyond NTD programmes within clinical services, and typically limited funding. However, MMDP for LF have many opportunities for growth as the programme helps to ensure the legacy of NTD programmes through strengthening the health systems and assists countries in achieving LF elimination criteria.

2.4.4.2 Sharing country experiences

Tonga (burden assessment)

In preparation for validation of elimination of LF as a public health problem, the Kingdom of Tonga aimed to assess the current LF morbidity situation and evaluate the availability of MMDP services in 2017. The kingdom conducted a questionnaire-based survey of health facilities and face-to-face interviews with key focal persons in nearly all health facilities, targeting four hospitals, 13 health centres and six reproductive health clinics distributed throughout Tonga (Figure 3).

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Figure 3. Examples of questionnaires for patient estimation (above) and MMDP service

availability assessment used in Tonga

Overall, survey results found that the kingdom had very few cases of lymphoedema and one case of hydrocele post-surgery. Hydrocelectomy procedures were only available in two hospitals. Health facilities have adequate stocks of supplies to treat LF patients, and there was a referral system in place for health centres that do not provide LF services.

Analysis of the survey tool demonstrated that it was simple and easy to use. The questionnaires only needed minor adjustments and were able to capture the necessary information. The survey was resourceful because it required few staff and was cost-efficient compared to other types of surveillance systems. Although the survey was efficient, there were still challenges in the logistics and costs of administering the survey. For example, the surveyors travelled long distances to health facilities, there were many missing records and not all patients were known to particular health facilities.

In conclusion, health facility based surveys was found to be an adequate assessment tool to determine morbidity due to LF. In order to maintain elimination status, post-elimination surveillance measures must be continued. Furthermore, services must remain available to those who need them and health facility staff members must maintain the knowledge and skills to manage LF morbidities and disability prevention.

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Fiji (morbidity care and surgery)

From 2000 to 2001, a baseline survey of LF showed that Fiji had a 16.6% antigenaemia prevalence of the disease. Since then, MDAs have been conducted to reduce the burden of disease. To combat the morbidity of individuals living with the stigma of LF, Fiji, with support of French Embassy and WHO, initiated a hydrocelectomy project that provided individuals affected with hydrocele the necessary surgery. The four phase project lasted from 2009 to 2017, and consisted of 229 surgeries among one divisional hospital and four subdivisional hospitals. Outreach to determine eligible patients were conducted through subdivisional hospitals. The diagnosis and treatment was conducted by the hydrocelectomy/surgical team. To maintain updated data on individuals living with the disease, Fiji developed an LF Morbidity Database.

The programme faced several challenges that cannot be addressed through surgery alone. Individuals living with the disease are still highly discriminated against. Access to services becomes difficult since a majority of the nurses in the affected communities are females and since hydroceles affect males, they are often reluctant to seek services. There are often competing priorities among prospective patients, especially when they have to sacrifice family commitments as well as financially burdening their families. Furthermore, sociocultural beliefs and practices in some communities discourage surgical procedures and may spread rumours that affect the patients’ decision.

Despite these challenges, the programme had some celebrated accomplishments. For example, the patients regained their confidence and had the ability to return to their normal way of life and provide for their families. In the health sector, this programme provided a network connecting public health services with clinical services. Overall, the programme helped strengthen case reporting in health facilities and increased the capacity of trained health personnel.

In order to further strengthen the programme, the MMDP should be integrated for all NTDs and comprehensive training should be unified with other health services. To improve case management in health facilities, the cases must be diagnosed as early as possible, treatment to reduce infection and morbidities must be offered, and staff members must be equipped to manage complications. Social assistance programmes, implementing strategies to reduce stigma and elimination as well as provide welfare assistance to those living with the disease, are encouraged.

2.5 Water, sanitation and hygiene (WASH) (trachoma, yaws, STH, scabies)

2.5.1 Facial cleanliness and environmental improvement for trachoma elimination in the Pacific

Trachoma affects approximately 41 million individuals worldwide and another 200 million are at risk for exposure. WHO recommends the SAFE Strategy for trachoma elimination. Emphasizing facial cleanliness will help to reduce the risk of infection from the bacteria that cause trachoma, just as access to a sanitary environment with clean water and household latrines will help to reduce transmission, as flies use human faeces and unsanitary conditions to breed and transmit the bacteria.

WHO has several indicators to demonstrate improvement in the SAFE Strategy which includes 80% of children having clean faces, every community having access to one source of safe water and increased coverage and usage of latrines by 25% in 2020. Improvements towards the F & E component will require health promotion that influences behavioural change and strong working and sustainable partnerships.

There are various challenges that hinder the progress of these initiatives. Behavioural challenges such as the lack of knowledge about transmission routes and prevention methods puts individuals at a greater risk of contracting the disease. Furthermore, measuring the success of the F & E outcome is more difficult than anticipated as there are no agreed standard indicators.

Four of the current priorities to scale up F & E efforts are to collaborate with WASH and development agencies to establish and sustain water and sanitation services, coordinate planning and implementation with WASH partners for integrated programme delivery, incorporate hygiene messages into the school curricula and community-led initiatives, and promote behaviours that help interrupt trachoma transmission such as encouraging children to wash their faces whenever they are dirty.

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It is recommended that endemic countries create a sustainable and enabling environment to eliminate trachoma as a public health problem. Endemic countries should bring together key decision makers from health, education, WASH & finance ministries along with donors and implementing partners to better integrate elimination efforts.

For the public and private donors, it is recommended that they invest in and attract additional supporters for trachoma elimination. For NGOs and other implementing partners, it is recommended that they support endemic country governments by raising awareness of the available tools to support decision making, strengthening MDA planning for improved coverage, and coordinating the expansion by maximizing drug availability and involving WASH partners.

Other NTDs are using similar WASH interventions. In order to maximize efforts, trachoma eliminating initiatives should integrate their programmes with other NTDs. Integration activities can take the form of mapping surveys or research, or be conducted through MDAs.

In conclusion, there are great efforts being made towards the elimination of trachoma. However, trachoma initiatives are conducting similar activities to several co-endemic NTD elimination programmes in the area. In order to increase efficiency, collaborative efforts should be made in order to target a wider range of individuals and maximize resources.

2.5.2 Identifying opportunities for WASH and NTD collaboration

Provision of safe water, sanitation and hygiene is critical for the prevention and care of many NTDs. NTD programmes need to build friendship with WASH programmes because their technical support is essential for control and elimination of NTDs. WASH interventions in NTD-endemic communities not only demonstrate impacts on transmission of NTDs but also help sustain impacts of other interventions such as MDA, while having collateral impacts on many other waterborne diseases. One approach to marketing WASH programmes within NTD programmes is to emphasise the benefit of using NTDs as an indicator and opportunity to demonstrate the health impacts of WASH activities. A lack of safe water, sanitation and/or hygiene is a direct fundamental cause of many NTDs. Therefore, NTDs can be used as a tracer of equity in progress towards universal WASH in the SDGs. NTDs, particularly worms, are also easier to control and therefore easier to use to demonstrate the impacts of WASH interventions than many other waterborne diseases.

An example was presented of collaboration between WASH and NTD programmes to accelerate progress towards control and elimination of NTDs from Mekong countries. Schistosomiasis caused by Schistosoma mekongi is endemic in about 200 villages in one province of Lao People's Demographic Republic and 100 villages in two provinces of Cambodia along the Mekong River. In Lao People's Demographic Republic, the introduction of MDA saw a rapid decline in disease prevalence. However, when the MDA stopped, the prevalence grew exponentially. The fluctuating prevalence demonstrates the need to initiate a more sustainable programme that targets the root cause of the disease, which is poor sanitation.

A multisectoral stakeholders meeting in Lao People's Demographic Republic was held to discuss the best WASH-NTDs community-based approach to enhance community participation in 2016. The suggested initiative had three goals: to focus on strengthening “health literacy” at the community level, to institutionalize multisectoral cooperation, and to facilitate replication of activity in all endemic communities using the existing programme called Water Safety Plans. Water Safety Planning is an approach promoted through the partnership of WHO and Australia’s Department of Foreign Affairs and Trade since 2005 to help communities build a capacity to assess their WASH situation and develop a plan of action to improve it on their own. At the meeting participants agreed to establish an initiative called the community-led WASH-NTD initiative for the elimination of schistosomiasis by integrating health education on the prevention and control of schistosomiasis in the WSP approach. They also decided to establish the National CL-SWASH Task Force which has representatives from governmental authorities responsible for NTDs, WASH, animal health, education and nutrition.

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The initiative consisted of a two-phase training session. The first session was to train provincial and district health and WASH officers to become programme facilitators. The training consisted of lectures to understand the linkage between WASH and NTDs and teach villagers to assess risks and make a plan. The second involved the provincial and district leaders leading the dialogue among endemic villages to promote a change.

With guidance from health leaders, the village would construct an implementation plan to combat NTDs using WASH improvement measures. The community-based programme empowers the villagers to be able to recognize and make a change in their health behaviours. However, the programme does come with some challenges such as its sustainability and level of importance and interest to other stakeholders. Since different ministries are responsible for NTD and WASH, it is essential that the interministerial collaboration is institutionalized in order to sustain the programme’s progress and interest and ensure a balance of responsibilities/leaderships between two ministries. NTDs can serve as a tracer of equity in progress towards universal WASH in SDG. Because different institutions prioritize WASH target areas with different criteria such as the local economic status, accessibility, convenience, politics, and distance from the nearby rivers, it is also important to attract WASH teams to the idea of using NTDs as an indicator and opportunity to demonstrate tangible health impacts of their WASH activities and convince them that they represent an investment for sustained and multiple impacts in community health.

2.6 Vector control (LF, dengue)

2.6.1 Persistent transmission of LF and WHO guidance on vector control for elimination of LF

In the GPELF Strategic Framework, MDA is recommended as a primary strategy for interruption of transmission of LF for the following reasons:

Biological factors

• Parasite does not multiply in vector

– One infected mosquito has the potential to infect only one person (in a 4-day period)

• Parasite multiplies in humans

– One microfilareamic person has the potential to infect multiple mosquitos (for as long as 4-6 years)

• Multiple species of mosquito so no single vector control measure

Operational factors

• Effective and safe medicines to kill microfilaria and reduce fecundity of adult worms

• Many examples showing that the single strategy of MDA is effective and feasible

• Simple rapid diagnostic tests for monitoring impact in people are available

However, vector control is also recommended in certain settings as visualized in Figure 4.

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LF: lymphatic filariasis; MDA: mass drug administration; VC: vector control

Figure 4. Algorithm to determine the needs of vector control intervention in LF elimination

programme

In the Pacific, LF has a complex epidemiology as there are various behavioural variations among the different vectors. The type of vector control implemented depends on the species and local ecology of the vector. Measures to target the adult mosquito include the prevention of biting and killing of adult mosquitos. The elimination of larvae requires environmental modification or management as well as the use of a larvicide. The primary choice is closely tied to the available resources.

Figure 5. Characteristics of LF mosquitoe vectors in the Pacific

Several vectors are responsible for multiple diseases, and some interventions are effective against several vectors. Therefore, in order to be most cost effective, a joint vector management programme should be implemented. An example would be a vector control programme for Aedes mosquitoes for control of dengue and LF. Such collaboration will help to maximize the cost and resources.

2.6.2 Global Vector Control Response Strategy 2017-2030

Today, approximately 80% of the world’s population is at risk from at least one vector-borne disease. Although significant progress has been made against malaria through vector control, the current activities are insufficient to eliminate the disease. There needs to be a push towards additional tools along with better implementation strategies to eliminate the disease.

During the 140th session of the WHO Executive Board, a draft resolution was prepared for the Global Vector Control Response Strategy (GVCR). The resolution was adopted without amendments by the Assembly. The GVCR is accessible in 6 different languages, providing a comprehensive framework for the access and feasibility of VC.

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One reoccurring recommendation for vector control programmes is to incorporate the local context disease profile into a community-specific programme. This will assist in a more customized and efficient method to manage the disease that will accommodate to the needs and resources of a community. Furthermore, vector control has helped with the reduction of malaria, onchocerciasis and Chagas disease, but has not been used to its full potential to target other diseases.

The overall mission of the GVCR is to reduce the burden and threat of vector-borne diseases through effective locally adapted and sustainable vector control. The GVCR recommended nine priority activities for 2017-2022, that can be referred to in WHO’s Global Vector Control Response 2017-

2030 booklet in order to determine a programme’s progress.

In conclusion, to make the greatest effect in vector control, it is crucial for country leadership to prioritize vector-borne disease prevention and control efforts. All recommended policies and activities should be evidence-based and expanded beyond the health sector where applicable. To strengthen efforts, actions within countries and between countries should be harmonized and strengthened. It is recommended that all efforts are integrated, community-based approaches that involve the municipalities and local governments. Community vector control activities are encouraged to adopt approved WHO tools to assist with their initiative. The encompassing goal is to ensure that all countries achieve success in their vector control project regardless of their current disease burden, capacities and resources.

2.7 Strengthening surveillance and response (all NTDs)

2.7.1 Strengthening NTDs surveillance by implementing an integrated platform for NTDs surveillance and control

WHO Joint Application Package

The Joint Application Package (JAP) is a tool designed to facilitate integrated planning, implementation, M&E and reporting of preventive chemotherapy interventions. It includes the “Joint Request for Selected Preventive Chemotherapy Medicines”, the “Joint Reporting Form (JRF)” for PC, and the PC “Epidemiological Data Reporting Form”. Currently albendazole for LF and STH, mebendazole for STH and DEC for LF are available for donation through WHO. Ivermectin for LF and onchocerciasis is available as well for donation, but the application is forwarded to the Mectizan Donation Programme using the same Joint Application Package

The process of requesting preventive chemotherapy medicines requires several steps and can take 6-8 months from the first submission of the Joint Application Package until shipment of the medicines to a recipient country. Countries are therefore encouraged to place their order request and all supplemental documents as soon as they can in order to receive their medicines in a timely manner.

Some related recommendations from the NTD Strategic and Technical Advisory Group meeting, conducted in May 2015, suggest countries establish an internal data submission deadline to improve the timeliness and completeness of the Joint Application Package. Villages should also immediately submit their MDA data within a week of completion. Districts should submit their MDA completion data to the national level within a month of the programme completion. These recommended standards will help countries gather the most up-to-date and highest quality data possible.

Furthermore, countries should also monitor their drug usage and inventory at the national and sub-national levels. Drugs that remain in stock or en route to a location should also be reported in the JAP. Countries should report all medicines regardless of the supplier, to ensure that there is improved coordination among all other donors and partners.

When requesting medicines, countries should use the Joint Request for Selected Preventive Chemotherapy Medicines, which will auto-estimate the number of tablets required in each district and within the country. The Joint Request for Selected Preventive Chemotherapy Medicines will also help monitor the dispersal of medications to ensure there is no overlap in medication distribution between LF and STH programmes. This is especially important for areas where both diseases are endemic.

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The JRF should be used to report any PC intervention implemented, regardless of the source of the medicines, and by sub-national/district level for the entire country. The JRF will auto-calculate the number of people treated and the geographical/programme/national coverage for each specific disease. This will help to visualize districts endemic with multiple diseases, and can help to identify areas that conducted unnecessary and replicated treatment. The reported data will be uploaded to the WHO PCT Databank and Global Health Observatory to be shared with partners. Lastly, the Epidemiological Data Reporting Form is used to report new mapping data of completed surveys, survey results, results of LF TAS, and morbidity-related data. The data will be used to monitor progress of the national programs by WHO, and to re-estimate the population requiring PC. Further clarification for the usage of the Joint Application Package can be found on WHO’s main webpage under the NTD’s “Planning, requesting medicines and reporting” page.

DHIS2-based NTD module

In order to increase coordination and quality of data for a community’s disease profile, an integrated and standardized surveillance mechanism should be implemented and utilized by all levels of care and governance.

The District Health Information System (DHIS2) is the recommended data collection platform for integration for various diseases. This web-based, open-source information system enables data collection, visualization, and sharing, and is already used by various countries as part of their national health information system. The system can offer several data collection forms such as individual patient files, patient registers, active case search registers, total community treatment registers, and monthly reporting forms. Depending on the health facility and community’s capacity and resources, the data can be highly specific or very broad. The system can be designed to collect specific patients’ health profiles from the start of their symptoms and diagnosis, all the way through to their treatment plans. Health facilities and communities may also report monthly aggregated data, which can still be greatly beneficial in terms of collecting time and special profiles for certain diseases. The use of a single platform and reporting channel will enhance data collection, analysis, interpretation, and dissemination. Additionally, it will help to improve data quality and data use, as well as build a common understanding and language towards the disease reporting. With an established system in place, the data can be easily shared and accessed for both internal and external usage. The shared system will help to reduce duplication of efforts and better allocation of resources towards more effective implementation projects.

WHO began development of the DHIS2-based skin NTD module and data platform in 2016 and is currently testing it in a few African countries. In the Western Pacific Region too, development of the DHIS2-based PC NTD module is underway and should be available for interested countries in 2019. During the discussion, a few participating countries expressed their interest to receive technical support for introduction of a DHIS2-based NTD information system.

Experience of Vanuatu on integrated NTD Surveillance

Vanuatu shared an example of integrated reporting of multiple NTDs through the health information system. Vanuatu currently has two platforms to collect NTD data in place, which are the national health information system (HIS), and the NTD package reporting system. The HIS collects data on clinical diagnosis of yaws, scabies, leprosy and lymphatic filariasis and worm treatment on a monthly basis through the health system, achieving approximately 90% reporting coverage, but the data does not come in a timely manner and takes, on average, more than 2 months. The HIS currently uses the DHIS2 system and reports are submitted online from the provincial to the national level. The NTD package reporting is a monthly collection of an elimination disease integrated report for malaria and NTDs from health facilities throughout the country. The report includes the data on suspected and confirmed cases of yaws and scabies and the number of children who were given worm treatment. When a positive report is found, the provincial focal point is instantly notified to initiate a case investigation and a focal treatment. Feedback on the reported data is provided to the provincial team, health facilities and aid post staffs regularly through meetings, community talks, health education activities and radio programmes. After some feedback from the programme was received, Vanuatu

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created several initiatives to be addressed in 2018. These initiatives included creation of an NTD newsletter, integration of NTD data reporting into the new DHIS2-based health information system under development and organization of regular supervisory visits to health facilities.

2.7.2 Reorientation on NTD Diagnostics

Filariasis Test Strip (FTS)

There are four potential detection targets to measure transmission of LF, namely microfilariae, filarial antigen and anti-filarial antibody circulating in the blood of an infected individual, and DNA of a filarial worm in mosquitoes.

Currently, GPELF recommends the use of FTS to detect filarial antigen in monitoring and evaluation of MDA and TAS. FTS donation can be requested from WHO, six months prior to the planned surveys. The FTS procedure requires a finger stick blood collection of 75 microliters of blood per test. The results are available in 10 minutes and there is a downloadable video that provides step-by-step instructions on how to use the FTS. The results are readily available; however, as the test kit approaches its expiration date, it becomes less effective.

The FTS does experience operational challenges. Sometimes it takes more than five minutes for blood to start flowing or there may be no blood flow at all. This makes it difficult to standardize reading time; it is recommended to start the reading time when the sample reaches the reading window and not add any liquid such as water or saline to accelerate sample migration. It is advisable to repeat the test in such a situation if possible. When a high blood volume is applied to the sample pad, blood spillage might occur. It is thus recommended to add the sample drop by drop for absorption in the sample pad. The accompanying micropipette might show slow capillary action or clot formation; training in the use of the micropipette is therefore recommended. Minor irregularities of the kits are often observed, such as duplicate desiccant but no strips, or duplicate strips without desiccant. To report such irregularities, there is a feedback form on the diagnostic test quality to be found in the WHO Publication Responding to failed transmission assessment surveys: Report of an ad hoc meeting under Annex 4. WHO requested meeting participants reporting such issues using the above template to fully record any irregularities and operational challenges and communicate with the manufacturer.

Coordination of LF transmission assessment survey and STH survey

Globally, 1.5 billion people are infected with STH, and 870 million children are at risk of infection. Since MDA for LF using albendazole has an impact on STH, it is important also to assess the overall impacts of a series of LF MDA on the STH burden. It is also imperative to keep in mind that if TAS results lead to the cessation of MDA for LF, there will be negative implications for STH control. Integrating soil-transmitted helminthiases evaluation with TAS provides a timely opportunity to determine continued MDA needs for STH control. Furthermore, this can help to determine a new baseline for monitoring the impact of school-based MDA on STH infection.

In 2015, WHO published a manual: Assessing the epidemiology of STH during a TAS in the global

programme to eliminate LF. The characteristics of a TAS and STH-coordinated survey will be very similar to a standalone TAS. Both surveys will target the same geographical area, during the same time period, and the primary sampling and target sample size will be the same. The difference comes in the target population. The target population is among 8-10 year-olds for school-based surveys and 6-7-year-olds for household surveys. Furthermore, the diagnostic material specific for STH is stool, and the tools used are either the Kato-Katz or the Mini-FLOTAC. The Kato-Katz requires samples to be processed and read within 4-6 hours of collection, whereas the Mini-FLOTAC provides more flexibility and can be preserved, processed, and read within 2 weeks of collection (Figure 6). The introduction and collaboration of STH surveys with current TAS surveys will help with the progress to control STH.

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Figure 6. Guidance on use of mini-FLOTAC as an option for diagnosis of soil-transmitted

helminths

2.7.3 Developing post-validation surveillance plans in the Pacific

Several WPR countries have made significant strides towards the elimination of NTDs. As these countries approach elimination, they must conduct surveillance activities to ensure that any re-emergent or introduced cases are detected early to prevent the re-establishment of transmission. In June 2017, WHO-WPRO organized an Informal Consultation on Post-elimination Surveillance of Neglected Tropical Diseases to discuss the scope and framework of post-elimination surveillance of NTDs. The meeting agreed that the primary objectives of post-validation surveillance (PVS) are to ensure recrudescence does not occur, confirm interruption of transmission, and detect and manage clinical cases. PVS should be prioritized in areas with potential risks of resurgence or introduction of transmission, for example migrant populations and positive clusters identified in TAS 2 and 3. Countries should select an appropriate platform(s) for surveillance, diagnostic tools, and thresholds for action and response, based on each country’s capacity to manage each component. Also, instead of creating a standalone PVS activity, countries are encouraged to identify existing platforms to integrate PVS. General agreement is that representative, population-based platforms are preferred. These might include malaria surveys, nutrition surveys or an integrated disease surveillance system. Facility-based collection of blood samples from adult in- and out-patients might also be another option, but geographical representativeness of the samples should be considered.

Migrant workers from LF-endemic countries (Palau)

Historical records of activities on LF in Palau date back to 1953 when microfilaria prevalence data ranging from 0 to 37.3% was found in villages of Palau. MDA using DEC once every other month was carried out between 1970 and 1972, which reduced the microfilaria prevalence to 0.3% in 1972. No further action was taken until Palau joined the Pacific Program for Elimination of Lymphatic Filariasis (PacELF) in 1999. During assessments carried out with PacELF support in 2001, overall antigen prevalence was 0.44% and all positive cases were found in one state (Ngardmau). All positive individuals were provided with annual treatment by public health nurses. A national survey was conducted in 2012 with sampling across all communities. The total number of persons tested was 1963 and of these, only 2 persons in Ngardmau were antigen-positive, who were treated annually for five years.

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Palau submitted a dossier to WHO in 2013 for validation of elimination of LF as a public health problem. However, Palau has a relatively large population of immigrants from the Philippines and Bangladesh (approximately 20% of the total population) and the LF infection rate in this population was unknown and the risk of reintroduction of LF by migrant workers was not assessed. On the advice of the RPRG, cross-sectional serosurvey was conducted in Palau from April to June 2017 to determine the prevalence of LF among migrant workers from the Philippines and Bangladesh. As a result, out of 893 migrant workers tested, a total of 52 FTS-positive migrant workers were identified, equivalent to an overall antigenaemia prevalence of 5.8%. Antigenaemia prevalence was higher in workers from Bangladesh (8.5%) compared to those from the Philippines (4.6%). All those tested positive were referred to a local Communicable Diseases Unit where they were provided with more information about their condition, along with medications, and were asked to maintain annual follow-up for 5 years.

Migrant workers from both Philippines and Bangladesh were found to originate from multiple regions across their home countries and be highly mobile, living in many countries across the world over the past 10 years but mostly in countries that are not endemic for LF. Those found to be FTS-positive lived in multiple places in their home countries.

Given the high risk of re-introduction and resurgence of LF in Palau due to migrant workers, an ongoing screening and treatment programme for migrant workers was recommended, rather than a single mass screening and treatment programme, due to the continuous influx of the migrant worker population. It is common to see a clustering of cases at the household level. Therefore, household members of LF FTS-positive individuals should also be tested. With this plan included in the dossier, Palau was validated by WHO for having eliminated LF as a public health problem in 2018.

Cross- and in-country population movement (Samoa)

Samoa has a long history of efforts to eliminate LF. Since joining the PacELF in 1999, annual rounds of MDA were implemented until 2004, when MDA efforts began to dwindle to one every two to three years instead of every year. In 2013, one evaluation unit failed TAS 1, then in 2017, the entire nation failed TAS 1 or 2. In 2018, American Samoa also failed TAS 3.

In order to revitalize efforts, Samoa will implement nationwide MDA with triple drug therapy in 2018 and 2019. There are various factors to the continuous transmission of LF such as poor MDA coverage, underdosing of medications, repeatedly unreachable cohorts of individuals, a change in vectors, and changing environmental conditions. To address these discrepancies, the new MDA efforts aim to better coordinate MDAs and increase coverage areas, take into consideration height and weight measurements to ensure sufficient dosing, and use the triple drug therapy instead of conventional two drug regimen. Taking account of a significant movement of people within country and between Samoa and American Samoa every day, MDA campaigns will be synchronized with those in American Samoa as a joint effort.

In conclusion, to increase MDA efforts and eliminate transmission of LF in Samoa, the country must strategize well, coordinate MDAs using directly observed treatment with American Samoa, consider a dosing schedule, and consider the use of Coverage Supervisor’s Tools to ensure achievement of effective coverage throughout the country.

2.7.4 Orientation on dossier for validation of elimination of LF as a public health problem

GPELF was launched in 2000 with the goal to stop transmission by MDA and to reduce suffering and improve quality of life through MMDP). There is an official process that each Member State must go through to be validated as having eliminated LF as a public health problem. The process includes the preparation and submission of a dossier to WHO Representative by the Member State’s Ministry of Health. The regional office will then deliberate the dossier and question the results if necessary. If the recommendation is validated, the Member State must begin implementing post-validation activities which include surveillance and morbidity management to ensure that achievements are sustained. However, if the validation is not approved, countries must begin the process over again.

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To be validated for having eliminated LF as a public health problem, and as regards the first goal to stop transmission by MDA, a country is considered to have met the validation criteria if 100% of endemic areas pass a final TAS* conducted no sooner than 4 years after MDA stops. For the second goal to reduce suffering and improve quality of life through MMDP, a country needs to provide evidence to indicate that the recommended minimum package of care is available in all areas of known patients (100% geographical coverage). For example, all health facilities must be able to provide a minimum package of care in every district with known LF patients. The package must include treatment of acute attacks, management of lymphoedema, surgery for hydrocele, and/or treatment of infected patients. The MMDP indicators required for dossier is (i) the disease burden, which entails estimates of the number of lymphoedema and hydrocele patients per implementation unit, (ii) availability of MMDP services, which is the number of facilities providing services for implementation units with known patients, and (iii) readiness and quality of MMDP through assessment of at least 10% of designated facilities.

The dossier should be submitted when all evaluation units have passed TAS3 during post-MDA surveillance, and all MMDP indicators are documented. Countries are encouraged to start data collection and archiving early in order to ensure timeliness of the dossier submission.

2.8 Operational research opportunities on NTDs in the Pacific

Operational research opportunities and NTD programmes are often seen as two different fields, but when working in conjunction with one another, there is a greater capacity to make an impact. For example, further supplemental research can be conducted based on an NTD programme’s records, research can be a supplemental component to an NTD programme, or research can be done alongside an NTD programme.

For example, when research is conducted based on a programme’s records, questions of coverage levels, MDA rounds, and clinical services can be answered. However, issues in data consistency, quality, and accessibility may arise. Furthermore, some expert analysis skills are required to interpret the results.

When research is an added component to an NTD programme, it helps to ensure a strong linkage to the results. This element can help answer questions in regards to community understanding and acceptability, as well as alternative service models within guidelines. Conversely, some issues that may arise include the burdening and complication of the service delivery and implementation, as well as the lack of expertise in technical areas.

When research is conducted in parallel to a programme, there are opportunities for innovative questions. Research can help to explore new diagnostic strategies for surveys as well as assess the safety and efficacy of new drugs/combinations. Unfortunately, this will impact the programme staff and programme delivery as people will have to do twice the amount of work.

Some future considerations and opportunities for the conjunction of the public health programmes and operation research include data standardization, storage and analysis, incorporating expertise on the social research in the programme, and incorporating a research agenda into new NTD plans and initiatives both at national and regional level.

2.9 Summary of priorities, support needed and the way forward in the Pacific

The meeting participants discussed the priorities and support needs to accelerate control and elimination of NTDs in the Pacific.

For lymphatic filariasis, countries’ priorities include accelerating elimination efforts with the use of IDA where warranted, ensuring the compliance of MDA using the directly observed treatment strategy and supervisor’s coverage tool, assessing the morbidity burden and access to care with the most feasible measurement tool, and exploring potential platforms to establish post-validation surveillance in post-elimination countries. Selected countries requested support for building national capacity on hydrocele surgery at national or regional level.

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For trachoma/yaws, countries’ priorities include the implementation of the recommended survey and MDA, employment of social mobilization to improve compliance to MDA, ensuring compliance to MDA by using the directly observed treatment strategy and supervisor’s coverage tool, monitoring impacts of trachoma MDA on yaws prevalence, and ensuring the implementation of F&E action plan by involving WASH programme and partners.

For STHs, countries’ priorities include collaboration with partners and assessment of current burdens whenever opportunities exist to integrate STH assessment. Additionally, relevant countries should continue to scale up and improve coverage of deworming among school-aged and preschool children. Support and technical guidance from WHO, experts and partners on diagnosis of STH in the field setting with limited HR/logistic capability in remote islands was requested by a number of countries.

For scabies, countries’ priorities include collaboration with partners to assess the true national burden, and collaboration with partners on research for public health interventions and diagnosis.

Other cross-cutting country priorities include:

1) exploring the possibility to pilot the DHIS2 NTD module for interested countries 2) ensuring the submission of the Joint Application Package to WHO regional offices as

soon as possible 3) initiating internal discussion to establish post-validation surveillance in post-validation

and pre-validation countries, and 4) sharing inputs/view/suggestions to the draft Regional Framework for Elimination and

Control of NTDs.

Support was requested from WHO and partners for the facilitation of cross-sectorial collaboration on WASH and vector control interventions.

3. CONCLUSIONS AND RECOMMENDATIONS

3.1 Conclusions

1) Significant progress has been made in the Pacific towards elimination of lymphatic filariasis as a public health problem through mass drug administration. Five countries in the Pacific – Cook Islands, Marshall Islands, Niue, Tonga and Vanuatu – were congratulated for their recent WHO validation of elimination of lymphatic filariasis as a public health problem.

2) Ongoing efforts to accelerate elimination of trachoma and yaws in the Pacific through mass drug administration and strengthening other interventions were also acknowledged.

3) There is concern about possible re-introduction and re-establishment of transmission of NTDs in post-validation countries due to significant population movement and migration of people from other endemic countries and areas. The programme managers agreed on the urgent need of establishing post-validation surveillance.

4) The meeting recognized a considerable discrepancy between the reported number of scabies cases within the health system and the prevalence of the disease assessed through population-based surveys in some Pacific island countries and emphasized the need to assess the true burden of the disease in all countries.

5) Limitations in human resources and technical capacity were recognized as contributing to a general lack of recent data on the burden of soil-transmitted helminthiases and impacts of interventions.

6) Acknowledging the changing NTD landscape and remaining challenges in the Pacific, the programme managers agreed that the three strategic pillars of the draft Regional Framework for Control and Elimination of NTDs could be: surveillance (including response), strengthening multisectoral cooperation and universal access to interventions, and community empowerment through effective risk communication.

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3.2 Recommendations

3.2.1 Recommendations for Member States

Member States agreed on the following as priorities:

Lymphatic filariasis

(1) Adopt the WHO-recommended triple drug therapy using a combination of ivermectin, diethylcarbamazine citrate and albendazole to accelerate elimination of lymphatic filariasis as a public health problem where warranted.

(2) Maximize compliance with mass drug administration by ensuring use of the directly observed treatment strategy and the supervisor’s coverage tool.

(3) Assess the true burden of morbidity due to lymphatic filariasis and access to a minimum package of care for every person with associated chronic manifestations of lymphatic filariasis.

(4) Initiate in-country discussions to explore potential platforms and to establish post-validation surveillance, particularly in countries that have achieved or are nearing validation of elimination of lymphatic filariasis as a public health problem.

Trachoma and yaws

(5) Implement the surveys and mass drug administration as recommended by the Expert Consultation on Elimination of Trachoma in the Pacific held on 17–19 January 2018 in Melbourne, Australia.

(6) Ensure implementation of careful micro-planning and well designed social mobilization to enhance compliance with mass drug administration.

(7) Maximize compliance with mass drug administration by ensuring use of the directly observed treatment strategy and the supervisor’s coverage tool.

(8) Ensure that impacts on transmission of yaws are assessed whenever mass drug administration for elimination of trachoma is implemented in co-endemic areas.

(9) Ensure implementation of the national facial cleanliness and environmental improvement (F&E) action plans prioritizing trachoma-endemic areas in countries by involving programmes and partners working on water, sanitation and hygiene (WASH).

Soil-transmitted helminthiases

(10) Assess the current prevalence of soil-transmitted helminthiases whenever opportunities arise to integrate such assessment with other surveys and activities.

(11) Identify opportunities and platforms to integrate and scale up deworming for school-aged children and preschool children.

Scabies

(12) Collaborate with partners and assess the true burden of scabies in countries.

(13) Collaborate with partners to progress operational research to establish public health interventions and standard diagnosis.

Cross-cutting

(14) Ensure annual submission of treatment data, epidemiological data and drug applications to WHO in a timely manner using the WHO Joint Application Package.

(15) Share views, inputs and suggestions with WHO on the next version of the draft Regional Framework for Control and Elimination of NTDs.

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3.2.2 Recommendations for WHO

WHO was requested to do the following:

(1) Support capacity-building for hydrocele surgery in relevant countries.

(2) Provide technical support and guidance to scale up diagnosis of soil-transmitted helminthiases in field settings with limited human resource and logistic capability.

(3) Pilot an NTD module that is being developed based on the District Health Information Software (DHIS) 2 in selected countries, finalize the module and disseminate to interested countries.

(4) Facilitate cross-sectoral collaboration on WASH and vector control interventions at national and regional levels where needed by identifying and engaging relevant partners.

ANNEX 1

PARTICIPANTS

Dr Faraitoafa Utu, Deputy Director, Department of Health, Tutuila, American Samoa, Tel.No.: +684 733 4764, Fax: +684 633 7868, Email: farautu@doh.as Mr Charlie Ave, Acting Manager, Health Protection, Ministry of Health, Avarua, Rarotonga, Cook Islands, Tel.No.: +682 29110, Fax: +682 29110, Email: charlie.ave@cookislands.gov.ck Mr Valentino Wichman, Acting Director, Community Health Services, Ministry of Health, Avarua, Rarotonga, Cook Islands, Tel.No.: +682 52733, Fax: +682 23109 Email: valentino.wichman@cookislands.gov.ck Dr Aalisha Sahukhan, Acting National Advisor, Centre for Communicable Disease Control Tamavua Hospital Complex, Princes Rd. Suva, Fiji, Tel.No.: +679 3320066 Email: aalisha.sahukhan@health.gov.fj Dr Daniel Faktaufon, Medical Officer, Fiji Center for Control of Communicable Disease Tamavua Hospital Complex, Princes Rd. Suva, Fiji, Tel.No.: +679 3320066 Email: dbfaktaufon@gmail.com Dr Jean Marc Ségalin, Médecin responsible du Bureau des, Programmes de Pathologies Infectieuses Direction de la Santé, Papeete, French Polynesia, Tel.No.: +00 689488215, Fax: +00 689488224 Email: jean-marc.segalin@sante.gov.pf / jmsegalin@yahoo.fr Ms Evelyne Le Calvez, Infirmiére référente du programme de, Lute contre la filarioses lymphatique Bureau des Programmes de Pathologies, Infectieuses, Direction de la Santé, Papeete, French Polynesia, Tel.No.: +00 689488261, Fax: +00 689488224, Email: evelyne.lecalvez@sante.gov.pf / evelau12000@yahoo.fr Ms Marou Tikataake, General Medical Officer, Ministry of Health and Medical Services Bikenibeu, Tarawa, Kiribati, Tel.No.: +730 69657, Email: m6tikataake@gmail.com Ms Eretii Timeon, Director of Public Health Services, Ministry of Health and Medical Services Naverevere, Tarawa, Kiribati, Tel.No.: +686 28100, Fax: +686 28152, Email: eretii1979@gmail.com Ms Earlynta Chutaro, Environmental Health Manager, Ministry of Health and Human Services Majuro, Marshall Islands, Tel.No.: +692 6253355, Email: ysilluk96@gmail.com Dr Mayleen Jack Ekiek, National Medical Director, Communicable Diseases, Department of Health and Social Affairs, Palikir, Pohnpei, Federated State of Micronesia, Tel.No.: +691 3202619, Fax: +691 3205263, Email: mekiek@fsmhealth.fm Dr Moses Pretrick, National Environmental Health Coordinator, Department of Health and Social Affairs, Palikir, Pohnpei, Federated State of Micronesia, Tel.No.: +691 3208300, Fax: +691 3208460, Email: mpretrick@fsmhealth.fm Dr Grace Eobob, Junior Medical Officer, Republic of Nauru Hospital, Benig District, Buada, Nauru Tel.No.: +674 5581982, Email: g.debao@gmail.com

Ms Violaine Baron, Infirmiére de prévention et, des programmes de santé publique, Direction des Affaires Sanitaires, et Sociales, Nouméa Cedex, New Caledonia, Tel.No.: +687 721855 Email: violaine.baron@gouv.nc Dr Anne Pfannstiel, Médecin de programmes de sante publique., Direction des Affaires Sanitaires et Sociales, Nouméa-Cedex, New Caledonia, Tel.No.: +687 243785, Fax: +687 243714 Email: anne.pfannstiel@gouv.nc Ms Andy Manu, Environmental Health Officer, Niue Foou Hospital, Box 33, Kaimiti, Alofi, Niue Tel.No.: +00 6834100, Email: andy.manu@mail.gov.nu Ms Cheryl-Ann Ruth Udui, Epidemiologist, Bureau of Public Health, Ministry of Health P.O. Box 6027 Koror, Palau, Tel.No.: +680 4884773, Fax: +680 4884701 Email: tmong.udui@palauhealth.org Ms Wendy Houinei, Technical Officer, Neglected Tropical Diseases, Department of Health 807 Waigani, Papua New Guinea, Tel.No.: +675 3013732, Email: whouinei7@gmail.com Ms Mary Yohogu, Technical Officer, Lymphatic Filariasis, National Department of Health 807 Waigani, Papua New Guinea, Tel.No.: +675 3013819, Email: myohogu51@gmail.com Dr Tile Ann Lui, Primary Health Care Manager, National Health Services, Motootua, Apia, Samoa Tel.No.: +685 7627790, Email: TileAL@nhs.gov.ws Ms Rosalei Maureen Tenari, Senior Surveillance Officer, Ministry of Health, Motootua, Apia, Samoa, Tel.No.: +685 68100, Email: RosaleiT@health.gov.ws Ms Georgina Tonghasa Kilua, Coordinator, National Neglected Tropical Diseases, Ministry of Health and Medical Services, P.O. Box 349, Honiara, Solomon Islands, Tel.No.: +677 20610 Email: ginakoelau@gmail.com Mr Oliver Zimuku Sokana, Coordinator, National Public Health Eye Care, Ministry of Health and Medical Services, P.O. Box 349, Honiara, Solomon Islands, Tel.No.: +677 20610 Email: osokana@moh.gov.sb Dr Louise Simone Fonua, Senior Medical Officer, Communicable Diseases, Ministry of Health P.O. Box 59, Nuku'alofa, Tonga, Tel.No.: +676 23200, Fax: +676 24 291, Email: lsfonua@gmail.com Dr Suria Elisala Puafolau, Medical Officer, Princess Margaret Hospital, Funafuti, Tuvalu Tel.No.: +688 7006111, Email: surieli16@gmail.com Ms Macklyne Garae, Neglected Tropical Diseases Officer, Public Health Directorate, Health Department, Ministry of Health, Iatika Complex, PMB 9009, Port Vila, Vanuatu Tel.No.: +678 22512 ext 2104, Email: gmackline@vanuatu.gov.au Mr Len Tarivonda, Director of Public Health, Department of Public Health, Ministry of Health Iatika Complex, PMB 9009, Port Vila, Vanuatu, Tel.No.: +678 22512, Email: ltarivonda@vanuatu.gov.au TEMPORARY ADVISERS

Dr Anasaini Tinairatuki Cama, Regional Coordinator, Fred Hollows Foundation, Brown Street, Suva, Fiji, Tel.No.: +64 2102413563, Email: anaseini2001@yahoo.com

Dr Kimberly Won, Health Specialist, Division of Parasitic Diseases and Malaria, Centers of Disease Control and Prevention, Decatur, Georgia, United State of America, Tel.No.: +1 404 718 4137 Fax: +1 404 718 4193, Email: kfw@cdc.gov Ms Caitlin Margaret Worrell, Epidemiologist, Center for Disease Control and Prevention Atlanta, Georgia 30030, United States of America. Tel.No.: +716 3920098 Email: CWorrell@cdc.gov OBSERVERS

Dr Mark Bradley, Director, Neglected Tropical Diseases, Middlesex TW8 GS, London, United Kingdom, Tel.No.: +44 2080475521, Email: mark.h.bradley@gsk.com Dr Birgit Bolton, Senior Programme Associate, Decatur, Georgia, United States of America Email: bbolton@taskforce.org Mr Shin Suto, Assistant Resident Representative, Level 8, BSP Suva Central Building Corner of Pratt Street and Renwick Road, Suva, Fiji, Tel.No.: +679 330 2522, Fax: +679 330 2452 Email: Suto.Shin@jica.go.jp Professor John Kaldor, Professor and Program Head, Level 6, Wallace Wurth Building High Street Kensington NSW 2052, Australia, Tel.No.: +61 0 2 9385 0900, Fax: +61 0 414 295 546 Email: jkaldor@kirby.unsw.edu.au Dr Daniel Engelman, Consultant Pediatrician, Department of General Medicine, The Royal Children's Hospital Melbourne, Melbourne, Australia, Email: Daniel.Engelman@rch.org.au SECRETARIAT Dr Jonathan King, Scientist, Lymphatic Filariasis Elimination, Preventive Chemotheraphy and Transmission Control, Department of Control and Neglected Tropical Diseases, Avenue Appia 20 1211 Geneva 27, Switzerland, Tel.No.: +41 22 791 1423, Email: kingj@who.int Dr Rabindra Abeyasinghe, Coordinator, Malaria, Other Vectorborne and Parasitic Diseases Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines Tel.No.: +632 5289725, Email: abeyasingher@who.int Dr Aya Yajima, Technical Officer, Neglected Tropical Diseases, Malaria, Other Vectorborne and Parasitic Diseases, Regional Office for the Western Pacific, P.O. Box 2932, 1000 Manila, Philippines Tel.No.: +632 5289754, Email: yajimaa@who.int Dr Angela Merianos, Team Coordinator, Pacific Health Security, Communicable Disease and Climate Change, Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva, Fiji Tel.No.: +41 22 791 9784, Email: merianosa@who.int Dr Mohd Nasir Hassan, Sanitary Engineer, Health and Environment, Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva, Fiji, Tel.No.: +63 2 5289886, Email: hassanm@who.int Ms Merelesita Rainima-Qaniuci, Consultant, Division of Pacific Technical Support, Level 4 Provident Plaza One, Downtown Boulevard, 33 Ellery Street, Suva, Fiji, Tel.No.: +679 332 3346Ms Lepantai Blanche Hansell, National Programme Officer, Communicable Diseases

77 Apia, Samoa, Tel.No.: +685 30087, Email: hanselll@who.intMs Fasihah Taleo, National Programme Officer, Communicable Diseases, Iatika Complex, Port Vila Vanuatu, Tel.No.: +685 83205, Email: taleof@who.int

ANNEX 2

AGENDA

Day 1: Tuesday, 20 February 2018

08:30 – 09:00 Registration

Opening Session

09:00 – 09:30 Welcome address Dr Aalisha Sahukhan, Acting National Advisor, MOHMS, Fiji

Dr Corinne Capuano, WHO Representative to the South Pacific, WHO/Fiji

Meeting objectives and the proceedings Dr Rabindra Abeyasinghe, Coordinator, WHO/WPRO

Self-introduction of participants and observers

Administrative announcements Ms Andrea Mathias, WHO/Fiji

09:30 – 10:00 Group photograph followed by coffee/tea break

Session 1: Global and regional updates and consultation on the draft Regional Framework for Elimination and

Control of NTDs in the Western Pacific Region

10:00 – 10:30 Global progress, challenges and updates on elimination and control of NTDs

Dr Jonathan King, LF focal point, WHO/HQ

10:30 – 10:45 Priority for healthy islands in the Pacific Dr Angela Merianos, Team leader, WHO/DPS

10:45 – 11:15 Regional progress, challenges and the draft Regional Framework for Elimination and Control of NTDs

Dr Aya Yajima, NTD focal point, WHO/WPRO

11:15 – 12:00 Review and discussion o Chapter 1: Background – Regional progress,

challenges and priorities All

12:00 – 13:00 Lunch break

13:00 – 14:00 o Chapter 2: Regional framework for elimination and control of NTDs All

14:00 – 15:00 o Chapter 3: Supporting elements All

15:00 – 15:30 Coffee/tea break

Session 2: Universal access to comprehensive NTD interventions

Session 2.1: Preventive chemotherapy (LF, trachoma, yaws, STH)

15:30 – 16:30 WHO guidance on preventive chemotherapy (PC) to accelerate elimination and control of NTDs

o Triple drug therapy for elimination of LF o PC for trachoma, yaws and STH and integration

opportunities o Lessons learnt on WHO coverage evaluation tools to

ensure high coverage

- Dr Jonathan King - Dr Aya Yajima

- Dr Aya Yajima

Discussion All

16:30 – 17:00 Sharing success and challenges in achieving high PC coverage

o Cook Islands (LF) o Vanuatu (LF)

o Solomon Islands (Trachoma)

- Mr Charlie Ave, MOH, Cook Islands - Ms Macklyne Gare, MOH, Vanuatu

and Ms Fasihah Taleo, NTD focal point, WHO/Vanuatu

- Mr Oliver Sokana, MHMS, Solomon Islands

Discussion on key success factors, challenges and support need for successful PC/MDA

All

18:00 – 20:00 Welcome reception

Day 2: Wednesday, 21 February 2018

Session 2.2: Innovative and intensified disease management (LF, trachoma, yaws, leprosy, scabies)

08:30 – 09:30 WHO guidance on integrated skin disease management Dr Asiedu Kingsley, Yaws focal point, WHO HQ (Skype)

09:30 – 09:45 Regional situation analysis and updates on scabies Dr Daniel Engelman, Secretary, International Alliance for the Control of Scabies

09:45 – 10:30 Sharing experience on tackling scabies – burden, current practices and challenges

o French Polynesia

o Fiji

- Dr Jean Marc Segalin, DS, French Polynesia

- Dr Aalisha Sahukhan, MOHMS, Fiji

Discussion on the way forward All

10:30 – 11:00 Coffee/tea break

11:00 – 12:30 Establishing and sustaining care for LF morbidity patients o WHO LF morbidity burden assessment and

management tools o Sharing country experience

- Tonga (burden assessment) - Fiji (morbidity care and surgery)

- Ms Caitlin Worrell, Epidemiologist,

US CDC

- Dr Louise Simone Fonua, MOH, Tonga

- Dr Daniel Faktaufon, MOHMS, Fiji Discussion on the way forward All

12:30 – 13:30 Lunch break

Session 2.3: Water, sanitation and hygiene (WASH) (trachoma, yaws, STH, scabies)

13:30 – 14:00 Facial cleanliness and environmental improvement (F&E) for elimination of trachoma in the Pacific

Dr Ana Cama, Regional coordinator, Fred Hollows Foundation

14:00 – 15:00

Identifying opportunities for WASH and NTD collaboration

o WHO health and environment programme

o Mekong countries (CL-SWASH) o Vanuatu (PHAST)

- Dr Nasir Hassan, Health and Environment focal point, WHO/Fiji

- Dr Aya Yajima - Ms Fasihah Taleo

Discussion on the way forward All

15:00 – 15:30 Coffee /tea break

Session 2.4: Vector control (LF, dengue)

15:30 – 16:30 Persistent transmission of LF and WHO guidance on vector control for elimination of LF

Dr Jonathan King

Global Vector Control Response Strategy 2017-2030 Dr Rabi Abeyasinghe

Discussion All

16:30 – 17:00 Operational research opportunities on NTDs in the Pacific Dr John Kaldor, Professor, the Kirby Institute, Australia

Discussion

Day 3: Thursday, 22 February 2018

Session 3: Strengthening surveillance and response (all NTDs)

08:30 – 10:00 Improving NTD data reporting and management o DHIS2-based NTD module

o WHO Joint Application Package o Sharing experience on NTD surveillance

- Vanuatu

- Dr Lise Grout, Epidemiologist,

WHO/HQ (Skype) and Dr Aya Yajima

- Dr Aya Yajima

- Ms Fasihah Taleo Discussion All

10:00 – 10:30 Coffee/tea break

10:30 – 11:30 Re-orientation on NTD diagnostics o FTS and STH

- Ms Kim Won, Health scientist, US

CDC and Ms Mereleshita Rainima-Qaniuci, NTD focal point, WHO/Fiji

Discussion on challenges, priorities and support need All

11:30 – 12:30 Developing post-validation surveillance plan (PVS) in the Pacific

Ms Kim Won and Dr Aya Yajima

(i) Identifying potential risks o Migrant workers from other endemic countries

(Palau) o Cross- and in-country population movement (Samoa)

- Ms Cheryl-Ann Ruth Udui, MOH,

Palau - Dr Tile Ann Lui, NHS, Samoa

Discussion All

12:30 – 13:30 Lunch break

13:30 – 15:00 (ii) Identifying platforms and tools for PVS (iii) Identifying pilot opportunities of PVS options

Ms Kim Won and Dr Aya Yajima

Discussion All

15:00 – 15:30 Challenges with LF dossier development o Orientation on LF validation dossier Dr Jonathan King

15:30 – 16:00 Coffee /tea break

16:00 – 16:40 o Sharing country experience of LF dossier development

− Marshall Islands

- Ms Earlynta Chutaro, MOHHS, Marshall Islands

Discussion on challenges and support need All

Session 4: Closing session

16:40 – 17:00 Summary of priorities, support need and the way forward in the Pacific

Dr Aya Yajima

Discussion

17:00 – 17:20 Conclusions and recommendations Dr Rabindra Abeyasinghe

17:20 – 17:30 Closing Dr Rabindra Abeyasinghe