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1. Executive Summary

 Background: This was the first meeting which the GSA Implementation Working Group

organised in support of NTD/schistosomiasis programme managers from key schistosomiasis (SCH) endemic countries. Countries with the highest burden of SCH in Africa (Nigeria, DRC, Sudan, Ethiopia, Tanzania-Mainland, Mozambique) were invited to attend this first meeting, alongside representatives of mature SCH programmes in Uganda, Malawi and Tanzania-Zanzibar.

Together this group represents close to 70% of SCH in Africa. DRC and Sudan were not able to attend due to visa issues. The group will be expanded for future meetings.

 Purpose of Meeting: The purpose of this meeting was to assist country programme managers in the development and review of SCH-specific implementation plans and also to consider the availability of resources needed to deliver donated drugs. It also provided a platform to exchange experiences amongst countries including those that have implemented Preventive chemotherapy programmes (PC) for several years. In addition the meeting allowed country programme managers to specify their expectations of the GSA and what they want the GSA to do and focus on in the future to help them boost political and financial commitment to fight schistosomiasis and to scale up PC programme implementation.

 Elimination paradigm: Concerns were expressed by all participants on limited progress in what stands as the main PC disease in Africa regarding both disease burden and association with rural poverty. It also stand as a major impediment to agricultural and irrigation schemes development in sub-Saharan Africa. In spite of major successes in eliminating schistosomiasis in all continents and with both zoonotic and non-zoonotic species of schistosomes it still persist a mind-set, in spite of no evidence that this is true, that in Africa schistosomiasis cannot be eliminated. There was broad agreement about the need to change the collective mind-set of the SCH community from just ending the efforts at morbidity control instead of moving to the next stage of elimination following the 2012 WHO resolution WHA65.12. This was perceived as an important prerequisite to increase political commitment. The scale-up of treatment to national coverage is a necessary start and a very encouraging sign, but should be considered as a first step only towards elimination. The SCH community needs to gather lessons from the successful elimination programmes such as those in China, Morocco, and St. Lucia. The success of the ZEST Zanzibar elimination programme will be a crucial step to demonstrate that elimination can be achieved in Africa. Lesson learned in disease elimination in Africa will need to be monitored and documented.

 Country presentations: On the first day of the meeting countries provided updates about existing and planned SCH-specific in-country action/implementation plans. This included key challenges and priority activities as well as the plans to progress things further. The presentations by Ethiopia, Nigeria, Tanzania, and Mozambique were followed by Zanzibar, Malawi and Uganda which provided valuable insights in best practice approaches in their respective countries. Details of the presentations including subsequent questions and comments are reported and summarized in the annexes Page | 1  Output from Working Groups: On the second day of the meeting the group split into two smaller working groups in order to focus on the national scaling –up action plans and the specific needs of each of the targeted countries. Break-out group 1 consisted of Tanzania-mainland, Tanzania-Zanzibar and Ethiopia, with the addition of Malawi to provide their expertise on lessons learned. Break-out group 2 consisted of Nigeria, Mozambique, with the addition of Uganda who are further down the path from SCH control to elimination. The first group drafted and reviewed scaling up plans and discussed steps to review drafted plans for international and national support. The second group concentrated on developing a joint SWOT analysis using the input from the countries in their group. As well as looking at the weaknesses and challenges of the country programmes they also identified possible mitigation strategies. The detailed outputs from both groups can be found in annex x.

 The role of the GSA: at the beginning of the meeting the GSA clarified a number of issues

concerning its coordinating and enabling role:

 GSA activities to be directed by countries. The GSA is an open forum. Countries are strongly encouraged to pass on the invitation to other organisations to join.

 Working closely with the soil-transmitted helminth community. The GSA recognises that control of SCH and STH go hand in hand first of all to support together reaching the 2020 NTD road map target to at least 75% regular treatment with anthelminthics. The GSA will work closely with the STH community to achieve this joint target. The STH coalition was repeatedly called the twin brother of the GSA.

 Co-ordination with WHO. The GSA is intended to support the efforts of WHO in achieving two key WHA resolutions on elimination of schistosomiasis (WHA 65.21) and on NTDs (WHA 66.12). The progress made to date in SCH control, and its future progress is reliant on the very strong NTD teams at WHO headquarters, AFRO, and country offices and close coordination of activities with the schistosomiasis and STH focal points at WHO-NTD-HQ. The GSA will work in partnership with these teams.

 Areas of GSA activity: In the course of the meeting delegates identified a number of activity

areas where in their opinion the GSA should become more active:

 Praziquantel co-ordination. The GSA should work to bring praziquantel donating and procuring agencies together (Merck KGaA, WHO, SCI, RTI-ENVISION, World Vision).

Particular areas of focus would be: ensuring countries know exactly what drugs they will receive from which partner and when; how procurement of drugs for adults is handled alongside donations for children; and how to co-ordinate drugs from more than one source in a single country also to avoid duplication.

 Database and data management. The GSA should work to review the need and facilitate the development of a SCH specific database if identified as a priority. It can also work to review the processes that different countries use for data flow from the field back to the central level for reporting purposes.

 Advocacy and link to funders. The GSA is not a fundraising body. However, it should work to provide a link between country programmes and funders. Also, to help countries develop and strengthen their NTD plans and SCH / STH Action Plans, and grant proposals that are attractive to funders.

 Elimination Guidelines. The GSA should provide support to countries on the treatment approaches required to get to elimination (such as enhanced PC, WASH, health Page | 2 behaviour, snail control). It can also provide technical support on the mapping techniques required to identify transmission hotspots and the monitoring and evaluation approaches required to determine if the programme in on track to reach elimination.

Documenting progress in countries moving towards elimination will be important to shift the paradigm towards elimination. All of this information could be used to help develop or reviewing WHO PC guidelines.

 Follow-ups and next steps: Meeting participants pointed out several priority issues which should potentially be addressed and included in country-specific action plans. This included issues such as how to move from large-scale morbidity control to transmission control and elimination; how to progress from subnational to the national level; how to use lessons learned from small countries with impact on big countries; how to enable programmes to move at a faster speed towards elimination once the national level is reached. These priority issues will have to be developed further in countries and in the follow up meetings of the group to help country managers in improving their skills in the preparation and reviewing of country programmes in the framework of WHO resolution WHA65.21 on schistosomiasis elimination. This will be part of the plans for the follow-up meeting of the group to be held during the second half of 2016.

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2. Contents

1. Executive Summary

2. Contents

3. Attendees

4. Opening and welcome

4.1. Aims of this meeting

4.2. Transitioning to elimination

4.3. Collaboration with STH community

4.4. Lessons from China

5. Praziquantel co-ordination

5.1. Praziquantel co-ordination

5.2. Praziquantel for adults

6. Break-out sessions

6.1. Group 1 (Tanzania, Zanzibar, Ethiopia, Malawi)

6.2. Group 2 (Nigeria, Mozambique, Uganda)

7. Action points and Hot Topics

7.1. Hot Topics

8. Wrap-Up and Next Steps

8.1. Wrap Up

8.2. Next Steps

9. Annexes

9.1. Annex 1. Skeleton of Tanzania’s SCH / STH Executive Summary

9.2. Annex 2. SWOT analysis from Group 2

9.3. Annex 3. Presentations

9.3.1. Background to the GSA

1. The need for the GSA – SCH getting left behind

2. Current status of the GSA

3. Aims of the GSA

4. Questions and Comments from Introductory Session

9.3.2. Country Presentations

1. SCH and STH status in Ethiopia – Biruck Kebede

2. Nigeria - Ifeoma Anagbogu

3. Tanzania – Andreas Nshala

4. Mozambique – Olga Amiel

5. Zanzibar – Fatma Kabole

6. Malawi – Samuel Jemu

7. Uganda – Edridah Tukahebwa

10. Ethiopian experience – Mike French

–  –  –

Apologies were received from Alan Fenwick (SCI), Kate McCracken (Evidence Action), and the representatives from Sudan and the DRC, who were not able to attend.

4. Opening and welcome Johannes Waltz opened the meeting and invited the participants to introduce themselves. Achille Kabore was introduced as the co-chair of this Implementation Working Group of the GSA. Alan Fenwick is the other co-chair of the group, although unfortunately could not attend this meeting.

Lorenzo Savioli asked the group a question to kick off the meeting:

“Who here believes that schistosomiasis can be eliminated in Africa?” The hope is that we all go away from this meeting convinced that the answer to that question is yes.

Lorenzo stated that the GSA is grateful to colleagues in very strong WHO NTD team for all their help.

The GSA is working in partnership with WHO to reach the global targets set in the WHO NTD Road map and in the 2012 and 2013 WHO resolutions WHA 65.21 on elimination of schistosomiasis and WHA 66.12 on NTDs.

4.1. Aims of this meeting This is the first time ever that a group on schistosomiasis has met in this format. This is the first in a series of meetings in the coming years. For this meeting the GSA identified a small group of highpriority country for SCH control in SSA in collaboration with NTD/WHO Geneva. This group, alongside DRC and Sudan, constitute 70% of the SCH burden in Africa. This is a small group this time, but will expand for future meetings.

–  –  –

4.2. Transitioning to elimination The group discussed some of the necessary steps required for the SCH community to transition to an

elimination paradigm:

 Recognise that many countries have successfully achieved morbidity control, once this is achieved they continue for years PC campaigns without a shift in paradigm to transmission control and elimination.

 Develop plans of action which are different in their stated targets towards transmission control and elimination.

 Use the Merck donation of praziquantel (250m tablets in 2016) as effectively as possible in coordination with other praziquantel supplies.

 Think broader than just ‘standard’ praziquantel donation to include drug combinations, enhanced drug treatment, WASH, health education, and others in a comprehensive transmission control package.

 Change the mind-set of individuals and groups to think about elimination of transmission as soon as PC reduce morbidity  Have clear plans for identifying hot spots of infection – updated mapping approaches to set up ad hoc transmission control plans  Have clear plans for monitoring and evaluation for elimination  Have clear targets and milestones with intermediate and final deadlines.

4.3. Collaboration with STH community The importance of the GSA collaborating extensively with the STH community was highlighted. We are lucky to have Kim Koporc to represent the STH coalition at this meeting. The control of these diseases fit together very well. The STH control community is our twin brother. The other PC-NTDs are brothers and sisters as well, but we have a particularly close relationship with STH.

4.4. Lessons from China Lorenzo provided some lessons from SCH elimination in China. Schistosoma japonicum is a complex parasite, with many definitive hosts, and is therefore difficult to control. China has been very successful in controlling SCH. It is easy to dismiss disease control in China as being not replicable in other areas, but the main facto has been the ongoing political commitment from the government.

There has been a clear understanding from China of how SCH is linked with poverty and a lack of agricultural development. This lesson has not yet been learned in sub-Saharan Africa (SSA) and it is be a message that has to be spread.

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5. Praziquantel co-ordination

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