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Bringing Attention to Neglected Tropical Diseases: the Inter-American Development Bank, the Pan American Health Organization, and partner agencies in Latin America and the Caribbean are joining forces to control and eliminate these forgotten diseases throughout the region.

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Neglected tropical diseases (NTDs) are a group of fourteen parasitic and bacterial infections that thrive wherever there is poverty, poor sanitation, unsafe water, and malnutrition. These diseases are termed "neglected" because the international community has only recently taken into full account the suffering and chronic disability they inflict on over a billion of the world's poorest people. Throughout Latin America and the Caribbean, the devastating consequences of these diseases are felt by more than 200 million people.

According to the World Health Organization, water-related diseases are the leading cause of death in the world, taking the lives of 6,000 people a day. They are responsible for 80 percent of all sickness in the world. Several NTDs are directly related to the availability of safe and clean water. Housing conditions are also associated with NTDs. Replacing dirt floors of dwellings with cement ones can improve the health of young children significantly.

Soil-transmitted helminthiases (STH), or intestinal worm infections, are some of the most common diseases in the region. They are treatable but they currently pose an immeasurable threat to the health of children throughout the region. Based on recent estimates by the Pan American Health Organization (PAHO), 94 percent of pre-school age and school-age children in the Americas are at risk--12,088,816 and 29,927,933 respectively. Intestinal worm infections in children cause malnutrition, limit mental and physical development, and are associated with up to a 43 percent reduction in future wage-earning capacity. Infected children have more difficulty concentrating in school and that leads to poor performance and decreased attendance. In many marginalized communities chronic infection and reinfection, often with multiple NTDs, has become the norm. If people do not have access to annual de-worming medication and if the socio-economic determinants of the transmission of the disease are not addressed (e.g. inadequate or lack of access to basic sanitation and inadequate hygiene practices), infections could lead to the loss of billions of dollars in future wage earnings, all but ensuring that those at risk of infection remain trapped in a cycle of poverty and disease.

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The health and livelihoods of some communities in the region are also threatened by four other common NTDs: trachoma, schistosomiasis, lymphatic filariasis, and onchocerciasis.

Trachoma, the second most endemic NTD, poses a threat to nearly 50 million people who live in high-risk areas of Mexico, Brazil, Guatemala, and Colombia. Transmitted by flies and by subsequent direct or indirect contact with an infected person, this blinding condition requires a focus on hand washing, hygiene, and improved sanitation.

Schistosomiasis threatens the lives of around 25 million people who live primarily in the coastal areas of Brazil. The most frequent mode of transmission is contact with water that contains snails infected with Schistosoma larvae. The disease results in progressive enlargement of the liver and spleen, intestinal damage, and hypertension of the abdominal blood vessels.

Lymphatic filariasis (LF), an incredibly debilitating disease transmitted by mosquito bites, can lead to lymphedema, or swelling of limbs or genitals. The chronic conditions caused by LF are often the source of increased stigma and marginalization. Roughly nine million people are at risk of infection, and the vast majority of them live in Haiti.

Through the Onchocerciasis Elimination Program for the Americas--a coordinated effort between public, private, and government agencies--the fight to eliminate onchocerciasis has seen great successes, leading to significant reductions in numerous endemic communities.

Controlling, preventing, and eventually eliminating some of these diseases in the Americas so that they no longer represent a public health problem is a high priority. Several highly cost-effective and proven interventions have been developed to treat NTDs. One such method is known as a "rapid impact package," a combination of four drugs that effectively treat the seven most common NTDs. With increasing political will among governments and rising interest from regional, private, and international donors, the region is poised to end the suffering and disability caused by NTDs.

In order to successfully control and potentially eliminate NTDs, efforts must be made in geographical areas where these diseases are endemic. Interventions in these areas need to be sustained over several years to ensure that enough rounds of treatment are delivered for the eventual elimination of these diseases. Along with effective treatment plans, complementary activities like hygiene training must be implemented in order to keep individuals from being re-infected.

In order to ensure maximum coverage and sustainability, the most effective treatment programs are being coordinated through country governments in collaboration with partners. These partnerships prioritize projects that focus on poor, marginalized, and under-served populations; integrate with other health programs or existing distribution channels; educate about disease elimination; encourage government commitment and collaboration between actors and stakeholders; and create opportunity for sustainable, long-term health.

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In 2009, the Global Network for Neglected Tropical Diseases--an initiative of the Sabin Vaccine Institute, the Inter-American Development Bank (IDB), and the Pan American Health Organization (PAHO), with support from the Bill & Melinda Gates Foundation and other partners---came together to establish a regional initiative for the prevention, control, and elimination of neglected tropical diseases.

In December 2008, a forum with the region's governments, partners, and stakeholders was held at PAHO headquarters to discuss the establishment of this innovative partnership mechanism that would seek to pool public and private resources and support cost-effective NTD prevention, control, and elimination efforts. The IDB is in the process of setting up a LAC (Latin America and the Caribbean) NTD Fund to pool such resources.

In October 2009, PAHO's Directing Council approved a resolution that expressed the political commitment of the region's governments to eliminate, or at least reduce, neglected and other infectious diseases to levels that are no longer considered public health problems by the year 2015.

Leveraging the financial facilities, regional experiences, and replicability potential of the IDB, the technical expertise of PAHO, and the advocacy and fundraising resources of the Global Network, the LAC NTD Initiative has established a regional agenda to address the treatment gap for those afflicted by NTDs, such as indigenous groups, rural communities, the elderly, and women and children.

To date, NTD control projects in the Latin America and the Caribbean region are highly localized and fragmented. There has been some success in both national and regional efforts to control NTDs in the region, including progress towards the elimination of LF and onchocerciasis.

* Brazil has reduced LF transmission from eleven known foci to one to two small areas.

* Haiti and the Dominican Republic are receiving Mass Drug Administration (MDA) for LF transmission.

* Onchocerciasis-endemic countries have met their treatment goals.

* Prevalence of trachoma and leprosy are declining and there is optimism that both could be eliminated within a decade.

Many challenges remain, however. Efforts to eliminate schistosomiasis in the Caribbean and to stop the transmission of LF, onchocerciasis, and trachoma need to be supported and improved. Initiatives to control Chagas disease and intestinal worm infections must be strengthened.

The LAC NTD Initiative seeks to leverage the IDB's investments in water and sanitation and other multi-sector programs including education, nutrition, health, housing improvements, and environmental changes as part of an effort to promote integrated approaches to NTD control.

One of the strongest opportunities for integration lies in the combination of water and sanitation projects. Many NTDs are water related, either because water is a direct transmission vehicle or because the absence of good water sources contributes to poor hygiene. Combining increased access to treatment with efforts to change hand-washing behavior, improve latrines, and provide drinkable water can be more effective at controlling and eliminating NTDs than treatment campaigns alone. Research indicates that such integrated programs can reduce the prevalence of water-related NTDs by more than 25 percent.

Over the last year, the LAC NTD Initiative has worked to develop eight projects in five different countries (Brazil, Guyana, Haiti, Mexico, and Guatemala).

Chiapas, Mexico. One of the first demonstration projects of this regional initiative began in February 2011. The IDB, Global Network/Sabin, the Government of Chiapas, and PAHO began working with the government's efforts to eliminate and control diseases like trachoma--the second leading cause of blindness in the world--and soil-transmitted helminthiasis, leishmaniasis, Chagas, onchocerciasis, and rabies. This integrated approach is being implemented, in coordination with the FEMSA Foundation, by installing water-treatment plants in endemic districts that will benefit from Mass Drug Administration (MDA) and an extensive hygiene campaign. Additional support for this program is being provided by PAHO and the International Trachoma Initiative. Communities in the state of Chiapas will also benefit from a national rural water and sanitation program approved by the IDB in 2011. The districts were chosen based on the prevalence of intestinal worm infections and trachoma. An estimated 132,223 people in 113 locations throughout five municipalities of the state will benefit from these integrated and coordinated intervention efforts.

Port-au-Prince, Haiti. In 2009, the IDB began including de-worming and lymphatic filariasis treatment as part of its water and sanitation projects to improve water supplies and make families healthier. The aftermath of the earthquake in Haiti was aggravated by terrible sanitary conditions, an absence of clean drinking water, and an increased risk to the population of Port-au-Prince. In this context, it became even more urgent to combat NTDs. NTD treatments have also been integrated into rural and semi-rural water and sanitation programs.

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DINEPA, the water authority in Haiti, is using part of a $15 million grant from the IDB to improve the municipal water system and extend the coverage of water services in Port-auPrince. In addition to IDB resources, contributions from PepsiCo Foundation and the University of Notre Dame are being used to treat the city's population for intestinal parasites, renovate toilets in schools, and teach appropriate hygiene to children, teachers, and health workers. This effort is helping to strengthen the capacity of health and water authorities to collaborate with each other.

The LAC NTD Initiative is also developing projects in Recife, Brazil, Guatemala, and Guyana. The Recife project will contribute to produce evidences for future implementation and scale up of the innovative model of NTDs prevention and treatment. The model aims at reducing the burden of NTDs on a community-oriented approach, bringing together school and family-based models. In Guatemala, efforts to control intestinal worms, trachoma, leishmaniasis, and Chagas and to eliminate onchocerciasis are combining MDA treatments with improvements in access to clean water, sanitation, and housing. In Guyana, lymphatic filariasis and intestinal worms are proving amenable to control with a combination of MDA techniques and improvements in water and sanitation conditions.

The IDB supports the creation of public-private partnerships that address key development challenges which cannot successfully be achieved through traditional vertical interventions. These partnerships require innovative and integrated responses from multiple sectors and stakeholders. In response to NTDs that affect 200 million of the poorest in the region, the IDB is creating a financial mechanism that builds on the advocacy and technical strengths of its partners to reach those impacted by these diseases. By addressing the determinants of health through effective partnerships between the public and private sectors, this initiative is developing innovative projects that integrate health and water interventions in the hope that more organizations will join in the effort to control and eradicate NTDs in the region.

THE BURDEN OF NTDs

Latin America and the Caribbean's Most Common NTDs

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Soil-Transmitted Helminths (intestinal worms)

At least 44 MILLION pre-school age and school-age children at risk. Intestinal worms include ascariasis, hookworm, and trichuriasis, and transmission is closely associated with a lack of access to clean water and sanitation.

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Schistosomiasis (snail fever)

Approximately 1.8 MILLION infected, 25 MILLION at risk. Schistosomiasis infection occurs in freshwater reservoirs when the fluke penetrates the skin and enters the bloodstream. Globally, 280,000 people die from schistosomiasis each year, making it the most deadly of the NTDs.

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Trachoma (blinding trachoma)

Approximately 1.1 MILLION infected, 50 MILLION at risk. The world's leading cause of preventable blindness is a bacterial infection spread through flies and poor hygiene.

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Lymphatic Filariasis (elephantiasis)

Approximately 720,000 infected, 11 MILLION at risk. Infection is caused by a mosquito-borne parasitic worm that damages the lymphatic system, causing gross disfiguration and incapacitation.

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Onchocerciasis (river blindness)

While much progress has been made toward eliminating river blindness in the Americas, an estimated 500,000 people are still at risk. Infection is caused by a parasitic worm transmitted by bites from black flies.

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American Trypanosomiasis (Chagas disease)

Approximately 8-9 MILLION infected. Infection is transmitted primarily by an insect, the "kissing bug," g, found in poorly constructed houses, but also through blood transfusions and contaminated food.

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Leishmaniasis (kala-azar)

Approximately 909,000 infected. Infection is transmitted through the bite of a sand fly and leads to skin sores, fever, anemia, and liver and spleen damage.

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Dengue (breakbone fever)

Approximately 59,000 clinical cases. Equally prevalent in urban and rural areas, infection is transmitted by mosquitos that feed during the day. Dengue produces painful fevers and other symptoms.

This article was made possible in part by collaboration with the Inter-American Development Bank (IDB). The IDB would like to acknowledge the Global Network for Neglected Tropical Diseases/Sabin Vaccine Institute and the Pan American Health Organization for their contributions to this project.

Text and photographs by the Inter-American Development Bank
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Title Annotation:Development in the Americas Series
Publication:Americas (English Edition)
Geographic Code:30SOU
Date:May 1, 2011
Words:2439
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