Tackling NTDs in Madagascar during the COVID-19 pandemic

Caroline Pensotti is a Programme Advisor who has been working at SCI Foundation since 2018.  She has visited Madagascar on many occasions and reflects on the importance of resuming treatment for neglected tropical diseases (NTDs) in the country, and the huge efforts made by the Government to deliver treatment during the pandemic.

Madagascar: an island where parasitic worms thrive

Madagascar is one of the largest islands in the world, and a low-income country. The island is endemic for eight Neglected Tropical Diseases (NTDs), namely Schistosomiasis (SCH), Soil Transmitted Helminths (STH), Lymphatic Filariasis (LF), dengue Fever, rabies, leprosy, tungiasis and shockingly, the plague.

These diseases cause a variety of symptoms in the early stages of infection for example, bloody urine, diarrhoea, malnutrition and anaemia. If left untreated, they can develop into chronic health problems such as growth stunting and reduced cognitive development in children.

Children suffering from ill-health miss out on essential education undermining the potential for future economic growth. Madagascar is a country of young people with almost half of the population (47%) under the age of 15. This is the age group most vulnerable to parasitic worm infections.

Poverty in Madagascar is complex and entrenched and rates are high throughout the country, particularly in rural areas. The country’s poor access to water, sanitation and hygiene (WASH) facilities is most inconsistent in these areas, where only 35 percent of the population has improved access to clean water, thus perpetuating the spread of NTDs.

Dealing with parasitic infections

SCIF follows the World Health Organization (WHO) recommendation to provide regular treatment for children in order to reduce morbidity and control the transmission of NTDs. We work closely with the Government of Madagascar to provide treatment for SCH and STH. We provide technical expertise to local partners in Madagascar, and use donated drugs through the WHO drug donation programme and give the Ministry of Health (MoH) and the Ministry of Education (MoE) logistical, technical and financial support needed to distribute the drugs effectively.

Treating all NTDs head on

This year, we were awarded a two year grant from the END Fund of over USD 2 million, which will allow us to support Madagascar in the delivery of over 4 million SCH/STH treatments to school aged children, through Mass Drug Administration (MDA). 

It is the first time the country has adopted an integrated approach to treatment, working with WHO, SCIF and the World Bank amongst other partners to treat children right across the country for several NTDs simultaneously.

The COVID-19 pandemic and NTDs

With the outbreak of the COVID-19 pandemic, WHO circulated new guidance to suspend all NTD mass treatment campaigns globally. The Madagascar MoH now faced a huge challenge – suspend treatment and risk a resurgence of these neglected diseases or continue as planned and risk the devastating effects of COVID-19.

In early June 2020, the MoH in conjunction with WHO, took the decision to carry out mass treatment in half of the targeted districts – those not affected by COVID-19.

Historically, the MDA is run as a school-based campaign in order to reach the highest number of children in the quickest time possible. This year, the MoH decided to conduct a door to door campaign rather than a school based one, using community drug distributors (CDDs) in order to reduce the risk of COVID-19 transmission.

This new approach posed several challenges –  increased cost, increased need for personnel on the ground, PPE provision (masks, hand sanitiser, medication receptacles), revised training programmes to include COVID-19 mitigation, heavy transportation regulations when moving between districts and the need for increased training for all personnel involved in the campaign.

 A huge undertaking

The majority of roads in Madagascar are unpaved, with many becoming impassable in the rainy season, and vast geographical areas to cover . The complexity of the task ahead was huge but the alternative – a rise in NTD prevalence – was simply not an option.

Within two weeks, all teams had made the arduous journey across the country to the 58 districts where treatment was to happen,  the much needed drugs had been delivered, CDD training was complete and village chiefs were mobilised to help out. The MDA was underway!

One word springs to mind when I think of the NTD program in Madagascar – dynamism. The challenges that the teams face year on year are enormous – outbreaks of the plague and measles, poor infrastructure, limited resources, inaccessible  “Red Zones” where armed bandits roam, and now COVID-19. But despite all of these obstacles, they remain undaunted and will do whatever it takes to get the job done, such is their dedication to win the battle against NTDs.