Complex emergencies and the control and elimination of neglected tropical diseases in Africa: developing a practical approach for implementing safe and effective mapping and intervention strategies

Abstract

Background: Complex emergencies resulting from conflict and political instability are a major challenge for national neglected tropical diseases (NTDs) control and elimination programmes, especially in sub-Saharan Africa. Currently, there are no formal guidelines for national programmes to use and plan activities in these humanitarian situations, therefore the aim of this study was to develop a new methodological approach for making decisions about the implementation of safe and effective mapping and mass drug administration (MDA) intervention strategies.

Methods: The study focussed on the 47 World Health Organization's African Region (AFR) countries. NTD data were based on five diseases controlled by preventive chemotherapy (PC; i.e. lymphatic filariasis, onchocerciasis, schistosomiasis, soil transmitted helminths, trachoma), obtained from the WHO data portals and The Global Trachoma Atlas for 2018. Data on complex emergencies were obtained from the Armed Conflict Location and Event Data Project for 2018-2019. NTD and conflict data were summarised and mapped. A decision tree was developed using NTD mapping, endemicity, MDA and implementing partners data, together with conflict status information at district level. South Sudan was used as a case study, given its current nexus of high NTD prevalence, incidences of conflict, and the presence of a national NTD programme and supporting partners.

Results: For the five NTDs, between 26 and 41 countries required PC, 69.2-212.7 million people were treated with coverage between 54.8-71.4%. In total 15,273 conflict events were reported including high rates of violence against civilians (29.4%), protests (28.8%), and battles (18.1%). The decision tree process included four main steps including i) information gathering ii) determine a disease mapping strategy iii) determine an MDA implementation strategy and iv) create a disease and conflict database. Based on these steps, risk maps were created. The South Sudan case study on onchocerciasis found the majority of the districts requiring mapping or MDA had a conflict event, and required specialised methods adapted to context and risk, with support from implementation partners in selected areas.

Conclusions: The paper presents a new methodological approach for implementing safe and effective mapping and intervention strategies in NTD endemic countries with ongoing complex emergencies, which will help to address challenges and make progress toward the NTD Roadmap targets of 2030.

Keywords: Complex emergencies; Conflict; Crisis; Lymphatic filariasis; MDA; Mapping; Mass drug administration; NTDs; Neglected tropical diseases; Onchocerciasis; SDGs; Schistosomiasis; Soil transmitted helminths; South Sudan; Sub-Saharan Africa; Sustainable development goals; Trachoma.

Fig. 1

Maps of the WHO African Region disease elimination status for selected NTD in 2017. Map source: ESPEN [23]

Fig. 2

Location of reported conflict event types on the WHO African region, September 2018 – August 2019. Data source: ACLED [24]. Note: Maps include continental Africa; however, analysis focused on the AFR region which does not include North Africa

Fig. 3

Disease and conflict data for mapping and/or implementation decision tree development

Fig. 4

Location of recorded conflict events and districts affected in South Sudan September 2018 to August 2019. Data sources: ACLED [24] and Administrative boundary source: Humanitarian Data Exchange [30]. Note: State abbreviations include WBG-Western Bahrel Ghazal; NBG- Northern Bahrel Ghazal; W- Warrup; U – Unity; UN- Upper Nile; J-Jonglei; EE- Eastern Equatoria; CA – Central Equatoria; Western Equatoria

Fig. 5

Onchocerciasis endemicity, conflict, implementing partners stratified to inform mapping and MDA implementation strategies in South Sudan. Data sources: ESPEN [23], ACLED [24] and Administrative boundary source: HDX [30]