Focus on Disability: Community care cuts NTD burden

River blindness
Copyright: Dieter Telemans/Panos

Speed read

  • NTDs infect 1.4 billion and cause dire disabilities
  • Providing drugs and education directly within communities is effective
  • Such initiatives should be rolled out in all endemic nations

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Last month, the cross-sector coalition Uniting to Combat NTDs launched its third progress report on the 2012 London declaration on neglected tropical diseases (NTDs) — a landmark agreement in which government agencies, global health organisations and donors pledged to control or eliminate ten NTDs by 2020. [1]

The report follows the establishment in April of an as-yet unnamed WHO entity to guide the acceleration of NTD elimination across Africa by 2020. [2] This new body would do well to draw on lessons from similar organisations and the report’s findings, especially given the huge disability burden NTDs cause. In particular, it should heed one of the report’s most pressing findings: that a shortfall in funding on the ‘last mile’ — getting drugs into communities — may thwart global efforts.

NTDs are a diverse group of diseases that affect more than 1.4 billion people globally, with a disproportionately high burden in Sub-Saharan Africa and South-East Asia. If untreated, they can cause dire disabilities. Of the seven most prevalent NTDs, three can cause malnutrition and stunting in children (ascariasis, bilharzia and trichuriasis), one causes debilitating and stigmatising limb swelling (elephantiasis) and two cause vision loss and permanent blindness (river blindness and trachoma).

Treatment for most of these diseases is relatively simple, often involving giving drugs to entire populations — or ‘mass drug administration’ (MDA) — to treat or protect against disease for as little as 40 US cents per person. [3] Indeed, the report highlights enormous achievements in managing and eliminating the most widespread NTDs so far. For example, disability related to elephantiasis has seen a 59 per cent drop globally since 2000, and several Latin American countries have eliminated river blindness entirely. If progress is sustained and the coalition’s goals are met, 600 million disability-adjusted life years (years of healthy life lost to disability) will be averted in endemic countries between 2011 and 2030. [3]

But the report also stresses that progress is threatened by a continued funding shortfall for programmes aimed at reaching all vulnerable communities. Drugs might get to a country, but then aren’t properly distributed to ensure they reach all those who need them. To do this well — and to do it sustainably — will require a type of intervention that has been proven to accelerate treatment uptake: community-based interventions (CBIs).

These involve health workers or local people going out and delivering treatment within a community itself, rather than putting the onus on infected people to travel to a health facility. This in itself ramps up treatment uptake.

But there is another element that makes this system even more effective than simply dishing out drugs, and helps cut the risk of reinfection: the focus on community education and behaviour change programmes at the point that treatments are distributed.

Research shows that community interventions can be far more effective at boosting treatment than facility-based care or drug administration without these extra elements. For example, a recent systematic review of CBIs for the prevention and control of non-worm related NTDs reported that the prevalence of trachoma fell by over three-quarters when drug treatment was combined with community education on hygiene. [4]

But CBI is also much more costly than facility-based programmes or mass drug administration alone. It requires more staff and staff time than simply handing out a drug in a health centre or at someone’s front door. And it calls upon extensive community participation to build knowledge and appropriate attitudes around NTDs and the disabilities they cause. As a result, such programmes are significantly underfunded, with dire consequences for NTD control goals.

Given evidence of their benefits, donors and health agencies could do far more to develop comprehensive CBI in all endemic countries, bridging the “last mile” in a sustainable way. And the new WHO organisation for Africa should take note.
Islay Mactaggart is a research fellow in disability and global health at the International Centre for Evidence in Disability, part of the London School of Hygiene & Tropical Medicine, United Kingdom. Before joining the centre in 2011, she worked for various disability and development organisations in Africa, Asia, the Caribbean and the Middle East. She can be contacted on [email protected] and is on Twitter @IslayMactaggart 



[1] London declaration on neglected tropical diseases (Uniting to Combat Neglected Tropical Diseases, January 2012)
[2] Country leadership and collaboration on neglected tropical diseases (Uniting to Combat Neglected Tropical Diseases, 25 June 2015)
[3] Nick Feasey and others Neglected tropical diseases (British Medical Bulletin, 10 December 2009)
[4] Jai K. Das and others Community based interventions for the prevention and control of Non-Helmintic NTD (Infectious Diseases of Poverty, 31 July 2014)