Turning the ambition of elimination into reality – new WHO guidelines for schistosomiasis

Today, the World Health Organization has released new guidelines on control and elimination of human schistosomiasis. The guidelines provide six evidence-based recommendations to endemic countries for their efforts in eliminating morbidity and interrupting transmission. There are several reasons why this document is important and moves us closer to elimination.

Sustaining and accelerating gains in schistosomiasis control

Due to concerted efforts over the past two decades, which were led by health ministries and supported by partners like SCI Foundation, the global burden of schistosomiasis has reduced by 60%. The new guidelines provide an opportunity to sustain and accelerate these gains by:

• moving beyond school-age children as the primary focus for preventive chemotherapy, to a more inclusive targeting of preschool-age children and adults within all communities
• simplifying the prevalence thresholds for decision-making and to support the efficient targeting of resources
• identifying and managing persistent ‘hot spots’ of transmission
• guiding the treatment and care of morbidity in health facilities
• emphasising the critical importance of an intersectoral approach for water, sanitation, environmental and behavioural interventions
• setting out a two-step diagnostic framework for the verification of interruption of transmission in humans, snails and, where appropriate, animals.

A more equitable approach

These changes are a response to growing evidence that any morbidity – ill health caused by schistosomiasis – including in areas of moderate and low prevalence, is important and needs to be prevented, in contrast to previous guidance that prioritised heavy infections in high prevalence areas. Additionally, there is increased evidence demonstrating the equity, feasibility, and cost-effectiveness of community-wide treatment for schistosomiasis. Historical efforts in interrupting transmission and more recent evidence from the Schistosomiasis Consortium for Operational Research and Evaluation (SCORE) have shown that preventive chemotherapy alone will not interrupt transmission.

As companion documents to the WHO’s Neglected Tropical Diseases (NTD) road map for 2021- 2030 and key components of SCI Foundation’s approach, both the global strategy on water, sanitation and hygiene (WASH) and NTDs and the One Health approach for action against NTDs outline to health ministries and implementing partners how these other essential components for schistosomiasis transmission interruption can be achieved in practice. These documents demonstrate a far more comprehensive and cross-cutting approach to schistosomiasis control and elimination than previously recommended.

What SCI Foundation is doing to support the implementation of the Guidelines

Our focus as an organisation is to ensure country ownership of health ministry disease control programmes and improving health equity through disease elimination. We can achieve this vision in support of the new guidelines by enabling knowledge exchanges, increasing coordination with other health sectors and providing technical support where needed to our partners. This could involve the development of surveys to support sub-district decision-making on interventions to reduce morbidity and transmission and increase efficiency in resource-use; multi-country meetings on preferred practices for community-wide treatment approaches; or support for collaboration between local WASH agencies and behaviour change groups.

Tackling the gaps

The changes in programming brought on by the new guidelines will need to ensure preventive chemotherapy delivery is of a high quality, and that it reaches all those who are at-risk equitably, including hard-to-reach populations. Monitoring this scale-up and initiating operational research where challenges arise is imperative.

A next step will be to develop a monitoring and evaluation framework for schistosomiasis, a pathway from control to interruption of transmission that defines which surveys and surveillance are needed with which diagnostics, where and when to determine impact, and how to detect hot spots, to support decision-making on optimal combinations of interventions.

Finally, the identification of the specific interventions in different schistosomiasis transmission contexts for increased access to safe water and sanitation services, for snail control, for One Health and for the treatment and care of morbidity, such as female genital schistosomiasis, is a significant area of research for our community to address and to build on these new guidelines and ensure countries can achieve the goals set out in the WHO NTD road map.

By Fiona Fleming, Director of Monitoring, Evaluation and Operational Research – SCI Foundation, and member of the Schistosomiasis Guidelines Development Group