Highlights
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Scoping review included 480 articles, 6 cochrane reviews, and 134 technical reports.
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There are significant gaps in published scientific articles by disease and country.
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Ten countries did not have published national multi-year strategic plans for NTDs.
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There is a need to standardize NTD programs and activities across the region.
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Mobile, displaced, hard-to-reach, disabled, vulnerable populations require attention.
Keywords: Neglected tropical diseases, Control, Elimination, Eradication, African region, Scoping review
Abstract
Objectives
NTDs historically receive less attention than other diseases in the same regions. Recent gap analyses revealed notable shortcomings despite NTD elimination progress. This systematic scoping review was conducted to understand NTD control, elimination, and eradication efforts in the WHO African region over the last 30 years.
Methods
Peer-reviewed publications from PubMed, Web of Science, and Cochrane databases related to NTD control, elimination, and eradication in the WHO African Region from 1990 to 2022 were reviewed. Included articles were categorized based on NTD; study location, type, and period; and topic areas. Technical and guidance documents from WHO, UN, partner, and academic/research institutions were reviewed. Country-specific multi-year NTD master plans were documented.
Results
Four hundred eighty peer-reviewed articles, six Cochrane reviews, and 134 technical reports were included. MDA and non-interventional/survey-related studies were common topics. Lymphatic filariasis, trachoma, schistosomiasis, and onchocerciasis were the most frequently studied NTDs. Tanzania, Ethiopia, and Nigeria were the most represented countries; multi-country studies were limited.
Conclusion
The review highlights progress made in NTD control, elimination, and eradication efforts in the WHO African Region and can inform national/regional strategies. Disease and geographical disparities were evident, warranting focus and research in certain countries. A standardized approach to NTD control programs is needed for sustained progress.
Funding
There was no funding source for this study.
Introduction
Neglected tropical diseases (NTDs) represent a group of diseases and conditions occurring most commonly in settings of extreme poverty [1,2]. These chronic, disabling, and sometimes disfiguring diseases historically receive less attention compared to other diseases occurring in the same regions [3]. The World Health Organization (WHO) African region bears the greatest burden of NTDs, accounting for 40% of global cases as of 2022, excluding chagas disease [4], and with the most countries experiencing a high NTD burden per million inhabitants [5].
Efforts to combat NTDs focus on internationally established control, elimination, and eradication targets [6,7]. Key definitions include:
Control: Reduction of disease incidence, prevalence, morbidity and/or mortality to a locally acceptable level as a result of deliberate efforts; continued interventions are required to maintain the reduction; may or may not be related to global targets set by WHO [7].
Elimination (interruption of transmission): Reduction to zero incidence of infection caused by a specific pathogen in a defined geographical area, with minimal risk of reintroduction, as a result of deliberate efforts; continued action to prevent re-establishment of transmission may be required; documentation of elimination of transmission is called verification [7].
Elimination as a public health problem: A term related to both infection and disease, defined by achievement of measurable targets set by WHO in relation to a specific disease; when reached, continued action is required to maintain the targets and/or to advance interruption of transmission; documentation of elimination as a public health problem is called validation [7].
Eradication: Permanent reduction to zero of worldwide incidence of infection caused by a specific pathogen, as a result of deliberate efforts, with no risk of reintroduction; documentation of eradication is termed certification [7].
Ten NTDs are targeted for either elimination or eradication: (1) schistosomiasis and soil-transmitted helminths (STHs), (2) onchocerciasis, (3) lymphatic filariasis (LF), (4) trachoma, (5) yaws, (6) guinea worm, (7) human African trypanosomiasis (HAT) for Trypanosoma brucei gambiense, (8) visceral leishmaniasis, (9) leprosy, and (10) chagas disease [6,7]. Of note, not all targets include the WHO African region [7].
Over the last decade, progress has been made in reducing the burden of NTDs in the WHO African region [8]. Nineteen countries successfully eliminated at least one NTD, with Togo notably eliminating four: Guinea worm, LF, HAT (gambiense), and trachoma [8]. Despite these achievements, gap analyses conduced in 2019 identified moderate to severe gaps across technical (e.g., scientific understanding, effective interventions), strategy and service delivery (e.g., operational and normative guidance, monitoring and evaluation, health care infrastructure and workforce) and enabling (e.g., advocacy and funding, capacity and awareness building) factors [9].
The Millennium Development Goals (MDGs), established in 2000, included combating HIV/AIDS, malaria, and other diseases as the 6th goal [10]. NTDs fell under the “other diseases” domain, highlighting the lack of specific focus [11]. The Sustainable Development Goals (SDGs) succeeded the MDGS in 2015 [12] focusing on impact indicators, with an SDG #3 (good health and wellbeing) sub-indicator focusing exclusively on the number of people requiring interventions against NTDs (Target 3.3: “By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases and combat hepatitis, water-borne diseases and other communicable diseases” and the reported number of people requiring interventions against NTDs indicator) [13]. The SDGs promote a multisectoral response [12] aligning with integrated approaches leveraged against NTDs in recent years [10,14]. Addressing NTDs has implications beyond health, impacting poverty reduction (SDG1), hunger (SDG2), education (SDG4), economic growth (SDG6), urban sustainability (SDG11), climate change resilience (SDG13) [14]. Further still, NTD mass drug administration (MDA) campaigns exemplify effective global partnerships (SDG17) [14].
Even with continued population growth, the global percentage of people requiring NTD interventions in the WHO African region decreased from 40% in 2022 [4] to 35.3% as of January 2023 [8], despite interruptions in NTD services caused by the COVID-19 pandemic in 2020 and 2021 [2]. Continued investments [15] and new partnerships [16] drive NTD control, elimination, and eradication efforts across the region. In 2020, the World Health Assembly endorsed "Ending the neglect to attain the Sustainable Development Goals: a road map for neglected tropical diseases 2021−2030," building on past successes and lessons learned [17]. The accompanying sustainability framework [17], released in 2021, provides a systematic method for identifying and harnessing synergies within NTD programs, throughout health systems, and across sectors to achieve targets for NTD control, elimination, and eradication.
Though a relatively newer approach to evidence synthesis, scoping reviews instead of systematic reviews are useful when the purpose of the review is to identify knowledge gaps, scope a body of literature, clarify concepts, or to investigate research conduct [18]. More specifically, scoping reviews can help identify types of available evidence in a given field or on a given topic and can be useful in identifying and analyzing knowledge gaps [18]. This systematic scoping review of published literature was conducted to highlight NTD control, elimination, and eradication efforts in the WHO African region over the last 30 years (January 1990-December 2022) and aims to inform regional strategies and further NTD control, elimination, and eradication initiatives in the WHO African Region.
Methods
This systematic scoping review investigated control, elimination, and eradication efforts for NTDs in the 47 Member States of WHO African region. This review was conducted by a team of three researchers in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidance and the PRISMA-ScR extension. The International Register of Systematic Reviews (PROSPERO) does not accept scoping review protocols; therefore, this review was not registered.
Search strategy and selection criteria for peer-reviewed literature
A comprehensive search strategy was developed for PubMed, Cochrane, and Web of Science databases. The search terms included (1) scientific and common names of targeted NTDs, (2) the 47 WHO African region member states, and (3) keywords related to control, elimination, and eradication. The complete search strategies for each database are provided in the supplementary materials (Table S1), along with the PRISMA-ScR checklist (S2). Disease conditions rather than pathogen names were used to target articles focusing on disease control, elimination, and eradication efforts among human populations. The intentionally broad search strategy did not restrict for specific intervention types. Searches were conducted on December 3, 2022, and February 27, 2023, with a custom date restriction from January 1, 1990 to December 31, 2022. Results were exported to Microsoft Excel and deduplicated based on title, year, and DOI.
Two reviewers conducted title and abstract screening with discordant outcomes resolved by a third reviewer. The inclusion criteria for title and abstract screening required the study setting to include a WHO African region member state and focus on an NTD of interest. Abstracts meeting these criteria underwent full-text review by two reviewers, with discordant outcomes resolved by a third reviewer. Exclusion criteria during full-text review included: (1) not focused on locations in the WHO African region, (2) not focused on an NTD of interest, (3) not focused on elimination, eradiation, or control efforts (e.g., commentaries or letters to editors, highly theoretical papers, etc.), or (4) articles focused on modeling or laboratory studies without field validation or application.
Search strategy and selection criteria for technical and guidance documents
A comprehensive search of relevant sites was conducted to identify technical and guidance documents and included websites and repositories of main NTD actors in the WHO African region: (1) the WHO Regional Office for Africa (WHO AFRO) publications [19], (2) WHO AFRO's Expanded Special Project for Elimination of Neglected Tropical Diseases (ESPEN) [20], (3) Uniting to Combat NTDs [21], (4) humanitarian response organizations (e.g., United Nations High Commission for Refugees [UNHCR] [22], the International Organization for Migration [IOM] [23], and the Inter-Agency Standing Committee [IASC] [24]), (5) Africa Centers for Disease Control and Prevention (Africa CDC) [25], and (6) Nigeria Centre for Disease Control (Nigeria CDC) [26]. The availability of country-specific multi-year NTD master plans [27] was also documented.
Data analysis
Included articles were reviewed for NTD of interest; study location, type, time period, focus (e.g., MDA, health education intervention, etc.); and topic areas (e.g., post-intervention prevalence, risk factors for NTD, social/cultural opinions of intervention, knowledge, attitude, and practice [KAP]) based on study objectives and methodology. Information collected during full-text review included (1) cost analysis, (2) disease prevalence and risk factors, (3) health education or behavior, (4) intervention-based (case management- or treatment-based interventions; environmental modification or vector control; mass drug administration [MDA]; surgery, antibiotics, facial cleanliness, and environmental improvements [SAFE]; and water, sanitation and hygiene [WASH]), (5) laboratory and diagnostics, (6) modeling, (7) program evaluation, (8) surveillance, and (9) vaccination (human and animal) thematic areas. Studies focused on topics beyond the pre-determined thematic areas were classified as “other.” Program evaluations or program reviews articles were analyzed separately. Frequencies were reported for measures of interest. Data management and analyses were conducted in Microsoft Excel and STATA (version 15).
Results
A total of 1268 peer-reviewed articles were identified through searches conducted in PubMed (n = 759), Web of Science (n = 884), and Cochrane (n = 8). A total of 772 unique full-text articles from PubMed and Web of Science were reviewed; 176 (22.8%) were excluded while 116 (15.0%) were technical reports or program evaluations as shown in Figure 1. Four hundred eighty (62.2%) articles were included. The identification, screening, and inclusion process is outlined in the PRISMA diagram (Figure 1). The supplementary materials contain the summary of full-text articles reviewed and categorized by disease type (S3), the full list of included articles (S4), author affiliations and author institutions for all included articles (S5), author affiliations and institutions by country (S6), and the funding entities reported in the included articles (S7).
Figure 1.
PRISMA diagram. *Cochrane studies were screened and reviewed separately (see Table S4 in the supplementary materials).
With the exception of snake bite envenoming, chromoblastomycosis, and deep mycoses, all remaining NTDs were represented among included articles. The majority (n = 430) reported on one NTD, with the highest number of articles on LF 18.1% (n = 78), trachoma 18.1% (n = 78), schistosomiasis 17.9% (n = 77) and onchocerciasis 16.0% (n = 69). A total of 10.4% (n = 50) investigated two or more NTDs, often reporting on schistosomiasis and STHs (n = 16). Chikungunya (n = 2), echinococcosis, loiasis, and scabies (n = 1 each) were least represented. None exclusively focused on dengue.
Among the 480 included articles, 105 were from interventional studies; of these, 41 (39.0%) from non-randomized intervention/control trials, 21 (20%) from community randomized trials, and 20 (19%) form randomized control trials. The interventional studies focused on multiple NTDs, most commonly schistosomiasis (22.0%), trachoma (18.1%), HAT (12.4%), LF (12.4%), and onchocerciasis (7.6%). There were no interventional studies specifically addressing chikungunya, echinococcosis, or leishmaniasis. Tanzania (19.0%), Ethiopia (11.4%) and Nigeria (9.5%) were common study locations.
Most of the articles (n = 427) focused within a single country (Figure 2, Table 1). However, 9.4% (n = 45) included two or more countries within and outside of the WHO African region: 34 focused on locations within the WHO African region only and 11 included countries outside the region. Five articles (1.0%) had a global focus, and the study setting was unclear for three (0.6%). Tanzania (16.2%), Ethiopia (10.1%), and Nigeria (9.6%) were the most frequent study locations of articles focusing on a single country (n = 427). Of the 69 articles with study locations in Tanzania, 58 specifically examined mainland Tanzania, while 11 focused on Zanzibar. Seven countries had only one article, while 12 countries were not represented in any of the included articles (Figure 2).
Figure 2.
Count of included articles by location (country).
Table 1.
Number of included articles by NTD and study setting.
| Location | Buruli ulcer | Neglected Tropical Disease |
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|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Chikungunya | Echinococcosis | Guinea worm | Human African Trypanosomiasis | Leishmaniasis | Leprosy | Loiasis | Lymphatic filariasis | Multiple NTDs | Onchocerciasis | Rabies | Scabies | Schistosomiasis | Soil-transmitted helminths | Trachoma | Yaws | Total | ||
| Angola | – | – | – | – | – | – | – | – | – | 1 | – | – | – | – | – | – | – | 1 |
| Benin | – | – | – | – | – | – | – | – | 1 | – | – | – | – | 1 | 1 | – | – | 3 |
| Burkina Faso | – | – | – | – | 3 | – | 1 | – | – | – | 3 | – | – | 1 | – | 1 | – | 9 |
| Burundi | – | – | – | – | – | – | – | – | – | – | – | – | – | 1 | – | 1 | – | 2 |
| Cameroon | 1 | – | – | – | 1 | – | 1 | 1 | 2 | 2 | 22 | – | – | – | 1 | – | – | 31 |
| Chad | – | – | – | 12 | 1 | – | – | – | – | – | – | 0 | – | – | – | 1 | – | 14 |
| Cote d'Ivoire | 1 | – | – | – | 2 | – | – | – | 1 | 1 | 1 | – | – | 4 | – | – | – | 10 |
| Democratic Republic of Congo | – | – | – | – | 8 | – | – | – | – | 1 | 2 | – | – | – | – | – | – | 11 |
| Equatorial Guinea | – | – | – | – | – | – | – | – | – | – | 3 | – | – | – | – | – | – | 3 |
| Ethiopia | – | – | – | 1 | 1 | 1 | 1 | – | 2 | – | 4 | 2 | 1 | 2 | 1 | 27 | – | 43 |
| Gabon | – | – | – | – | – | – | – | – | – | – | 2 | – | – | – | – | – | – | 2 |
| Gambia | – | – | – | – | – | – | – | – | 1 | 2 | – | – | – | – | – | 3 | – | 6 |
| Ghana | 2 | – | – | 1 | 1 | – | – | – | 13 | 2 | 4 | – | – | 2 | 1 | 3 | 3 | 32 |
| Guinea | – | – | – | – | 2 | – | – | – | – | – | – | – | – | – | – | 1 | – | 3 |
| Kenya | – | – | – | – | – | 1 | – | – | 11 | 4 | – | 3 | – | 14 | 7 | – | – | 40 |
| Lesotho | – | – | – | – | – | – | – | – | – | – | – | 1 | – | – | – | – | – | 1 |
| Liberia | – | – | – | – | – | – | – | – | – | 1 | – | – | – | – | – | – | – | 1 |
| Madagascar | – | – | – | – | – | – | – | – | – | – | – | – | – | 1 | – | – | – | 1 |
| Malawi | – | – | – | – | – | – | – | – | 1 | – | – | – | – | 1 | – | 1 | – | 3 |
| Mali | – | – | – | – | – | – | – | – | 6 | 1 | 1 | 2 | – | 2 | – | 3 | – | 15 |
| Mozambique | – | – | – | – | – | – | 1 | – | 1 | – | – | 1 | – | 1 | 1 | – | – | 5 |
| Namibia | – | – | – | – | – | – | – | – | – | – | – | 1 | – | – | – | – | – | 1 |
| Niger | – | – | – | – | – | – | – | – | – | – | – | – | – | – | – | 2 | – | 2 |
| Nigeria | – | – | – | 4 | 1 | – | 1 | – | 10 | 4 | 3 | 4 | – | 3 | 3 | 8 | – | 41 |
| Rwanda | – | – | – | – | – | – | – | – | – | – | – | – | – | 2 | – | – | – | 2 |
| São Tomé e Príncipe | – | – | – | – | – | – | – | – | – | 1 | – | – | – | – | – | – | – | 1 |
| Senegal | – | 1 | – | – | – | – | – | – | – | 1 | 1 | – | – | 4 | – | – | – | 7 |
| Sierra Leone | – | – | – | – | – | – | – | – | 4 | 3 | 1 | – | – | 1 | 1 | – | – | 10 |
| South Africa | – | – | – | – | – | – | – | – | – | 2 | – | 3 | – | – | – | – | – | 5 |
| South Sudan | – | – | – | 1 | 1 | – | – | – | – | 1 | 1 | – | – | – | – | 2 | – | 6 |
| Sudana | – | – | 1 | – | – | – | – | – | – | – | – | – | – | – | – | – | – | 1 |
| Togo | – | – | – | – | – | – | – | – | 3 | 3 | – | – | – | – | – | – | – | 6 |
| Uganda | – | – | – | – | 5 | – | 1 | – | 1 | 4 | 10 | 2 | – | 3 | – | 1 | – | 27 |
| Tanzania | – | – | – | – | – | – | – | – | 16 | 5 | 1 | 4 | – | 22 | 3 | 18 | – | 69 |
| Zambia | – | – | – | – | 1 | – | – | – | – | – | – | 2 | – | 2 | – | 1 | – | 6 |
| Zimbabwe | – | – | – | – | 1 | – | – | – | – | – | – | 1 | – | 4 | 1 | – | – | 7 |
Studies occurring before separation of Sudan and South Sudan were included.
Table 1 presents the distribution of articles focusing on each NTD by country. The highest proportion of articles focusing on guinea worm originated from study locations in Chad (57.1%, n = 12) and Nigeria (19.0%, n = 4). Regarding HAT, 25% (n = 8) of the articles originated from study locations in the Democratic Republic of Congo, and 15.6% (n = 5) in Uganda. The two articles focusing on leishmaniasis were from studies conducted in Ethiopia and Kenya. Most articles focusing on LF were from studies conducted in Tanzania (20.5%; n = 16), Ghana (16.7%; n = 13), Kenya (14.1%; n = 11) and Nigeria (12.8%; n = 10). For onchocerciasis, most articles were from studies conducted in Cameroon (31.9%; n = 22) and Uganda (14.5%; n = 10). Of note, 10.1% (n = 7) of the onchocerciasis articles focused on multiple countries. Among the articles focusing on schistosomiasis, 28.6% (n = 22) were from studies conducted in Tanzania, with 11 each conducted in mainland Tanzania and Zanzibar. An additional 18.2% (n = 14) of articles focusing on schistosomiasis were based on studies conducted in Kenya, while at least one article focusing on schistosomiasis control and elimination originated from studies in 19 countries.
The categories of thematic areas related to the control, elimination, or eradication of NTDs are shown in Table 2. MDA was the most common thematic area; the impact or effectiveness of MDA for the control and elimination of NTDs investigated in 159 articles, of which most focused on LF (28.9%), onchocerciasis (20.1%), trachoma (17.0%) and schistosomiasis (13.8%). The non-intervention/survey category (n = 99) was the second-most common thematic area; common sub-categories included risk factors associated with NTDs and/or NTD control, elimination and/or eradication (n = 16; 16.2%), KAP/perspectives studies (n = 12, 12.1%) and pre-intervention and baseline prevalence of the disease(s) (n = 12, 12.1%). Additionally, eight (8.1%) focused on testing or creating disease surveillance systems. Trachoma (26.3%), rabies (12.1%) and guinea worm (11.1%) were most represented in this category. Among articles classified as “other” (n = 76), 24 (31.6%) focused on diagnostics for NTDs, four (5.3%) on genetic testing, mutations, or resistance, and three each (3.9%) on cost-analysis and NTD morbidity-related outcomes. The remaining articles examined the roles of community workers in NTD control, elimination, and eradication; effectiveness of NTD interventions; and program planning and decision making, amongst others. Schistosomiasis (19.7%) and onchocerciasis (17.1%) were the most represented NTDs in this category.
Table 2.
Thematic area of included articles by NTD and country.
| Thematic area |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| Case-management for treatment-based interventions | Health behavioral/environmental (e.g., WASH/SAFE) | Health knowledge/education (e.g., campaign, intervention) | MDA | Multiple Focus | Non-intervention/Survey | Other | Statistical/GIS-modeling | Vaccination Campaign | Vector or environmental modification (non-human) | |
| By NTD of interest | ||||||||||
| Buruli ulcer | – | – | – | – | 1 | 2 | 1 | – | – | – |
| Chikungunya | – | – | – | – | – | 1 | 1 | – | – | – |
| Echinococcosis | – | – | – | – | – | 1 | – | – | – | – |
| Guinea worm | 2 | – | – | – | 1 | 11 | 3 | 2 | – | 2 |
| Human African Trypanosomiasis | 3 | – | 1 | – | 2 | 8 | 5 | 2 | – | 11 |
| Leishmaniasis | – | – | – | – | – | 2 | – | 1 | – | – |
| Leprosy | 4 | – | – | – | – | 1 | 2 | – | – | – |
| Loiasis | 1 | – | – | – | – | – | – | – | – | – |
| Lymphatic Filariasis | 2 | – | – | 46 | 7 | 4 | 7 | 6 | – | 6 |
| Multiple NTDs | – | – | 2 | 22 | 3 | 10 | 12 | 1 | – | – |
| Onchocerciasis | 1 | – | – | 32 | 5 | 6 | 13 | 5 | – | 7 |
| Rabies | – | – | 1 | – | 1 | 12 | 3 | – | 13 | – |
| Scabies | – | – | – | 1 | – | – | – | – | – | – |
| Schistosomiasis | 2 | 2 | 7 | 22 | 10 | 8 | 15 | 9 | – | 2 |
| Soil transmitted helminths | – | – | – | 8 | 1 | 7 | 4 | – | – | 1 |
| Trachoma | 4 | 5 | 2 | 27 | 4 | 26 | 7 | 1 | – | 2 |
| Yaws | 1 | – | – | 1 | – | – | 3 | – | – | – |
| Total | 20 | 7 | 13 | 159 | 35 | 99 | 76 | 27 | 13 | 31 |
| Abbreviations: DRC, Democratic Republic of the Congo; MDA, Mass Drug Administration; M&E, Monitoring and Evaluation; SAFE, Surgery, Antibiotics, Facial hygiene, and Environmental change; WASH, Water, Sanitation, Hygiene and Education. | ||||||||||
| By country | ||||||||||
| Angola | – | – | – | – | – | – | 1 | – | – | – |
| Benin | – | – | – | 1 | – | 2 | – | – | – | – |
| Burkina Faso | 1 | – | – | 2 | – | 2 | 2 | – | – | 2 |
| Burundi | – | – | – | – | – | 1 | 1 | – | – | – |
| Cameroon | 2 | – | – | 18 | 1 | 2 | 4 | 3 | – | 1 |
| Chad | – | – | – | – | 1 | 9 | 2 | 1 | – | 1 |
| Cote d'Ivoire | – | – | 1 | 3 | 1 | 1 | 3 | 1 | – | – |
| DRC | 2 | – | – | 2 | – | 3 | 2 | – | – | 2 |
| Equatorial Guinea | – | – | – | 1 | – | 2 | – | – | – | – |
| Eritrea | ||||||||||
| Ethiopia | 1 | 3 | 2 | 17 | 5 | 9 | 1 | 2 | 1 | 2 |
| Gabon | – | – | – | 1 | – | – | – | 1 | – | – |
| Gambia | 1 | – | – | 2 | – | 2 | – | – | – | 1 |
| Ghana | 2 | – | 1 | 13 | 2 | 2 | 8 | 2 | – | 2 |
| Guinea | 1 | – | – | – | – | 1 | – | – | – | 1 |
| Kenya | – | 1 | 1 | 14 | 4 | 9 | 7 | 2 | 1 | 1 |
| Lesotho | – | – | – | – | – | 1 | – | – | – | – |
| Liberia | – | – | – | 1 | – | – | – | – | – | – |
| Madagascar | – | – | – | – | – | – | – | 1 | – | – |
| Malawi | – | – | – | 1 | – | – | – | 2 | – | – |
| Mali | 1 | – | 1 | 8 | 1 | 2 | – | – | 2 | – |
| Mozambique | 1 | – | 1 | – | – | 1 | – | – | – | 2 |
| Namibia | – | – | – | – | – | – | – | – | 1 | – |
| Niger | – | – | – | 1 | – | – | 1 | – | – | – |
| Nigeria | 3 | – | 1 | 11 | 3 | 14 | 4 | 2 | 1 | 2 |
| Rwanda | – | – | – | 1 | – | – | – | 1 | – | – |
| São Tomé e Príncipe | – | – | – | 1 | – | – | – | – | – | – |
| Senegal | – | – | – | 3 | – | 2 | 2 | – | – | – |
| Sierra Leone | – | – | – | 7 | – | 3 | – | – | – | – |
| South Africa | – | – | – | – | – | 3 | – | – | 2 | – |
| South Sudan | – | – | 1 | 1 | – | 2 | – | 1 | – | 1 |
| Sudana | – | – | – | – | – | 1 | – | – | – | – |
| Togo | – | – | – | 4 | 1 | 1 | – | – | – | – |
| Uganda | – | – | – | 10 | 3 | 5 | 3 | 1 | – | 5 |
| Tanzania | 3 | 2 | 3 | 29 | 11 | 10 | 6 | 2 | – | 3 |
| Zambia | – | – | – | – | – | 1 | 3 | – | 2 | – |
| Zimbabwe | – | – | 1 | 2 | – | 1 | 2 | – | – | 1 |
Though Sudan is not a member state of the WHO African region, studies occurring in Sudan before South Sudan gained independence were included in this review.
Thirty-one articles investigated the effectiveness or impact of environmental modification or vector control interventions, most of which focused on HAT (35.5%), onchocerciasis (22.6%), and LF (19.4%). Twenty-seven presented results from modeling studies that used primary/secondary data to develop/validate a model pertaining to NTD control, elimination and/or eradication, including expected timelines to reach different targets and how the combination of multiple interventions could contribute to accelerated achievement. Twenty articles focused on NTD case management and treatment. The least-represented thematic areas were health knowledge or education interventions (n = 13), vaccination campaigns (n = 13), and health behavior interventions (n = 7).
The Cochrane database search yielded eight results. Three reviews focused on trachoma, two on LF, and one each on ascariasis (STH), diarrhea and STHs, and dental caries (provided in the supplementary materials, Table S8). The review on dental caries was excluded during the title and abstract screening phase and the review on diarrhea and STHs was excluded during full-text review, as the articles included from countries in the WHO African region focused on general diarrheal and child growth outcomes rather than STH control, elimination, or eradication, or any outcomes specific to STHs.
Overall, the six included reviews focused on health education/behavior (hygiene promotion/behavior) (n = 4), case management or treatment-based interventions (n = 3), WASH, (n = 3) and MDA (n = 2). Across these six reviews, 48 articles included data from countries in the WHO African region, where three countries represented most study settings (Tanzania [n = 14], Ethiopia [n = 9], and Kenya [n = 7]). Of these 48 relevant articles, 13 (27.1%) were captured in this review, and all 13 were included following full-text review. Most of these articles focused on MDA for LF. The articles not captured in this review focused on clinical efficacy of treatment regimens or drug combinations (Table S8).
Regarding guidance documents, 37 of the 47 countries in the WHO African region published at least one multi-year strategic plan for NTDs with the recommended four components: situational analysis, strategic agenda, operational framework, and budgeting for impact (Table 3). Notably, only five countries (Ethiopia, Rwanda, South Africa, Tanzania, and Zambia) had master plans still current. The multi-year master plans of Congo and Equatorial Guinea expired in 2022 while 26 other countries had plans that expired in 2020.
Table 3.
Availability of multi-year NTD strategic plan by country.
| Country | Availability of multi-year NTD strategic plan (Year) | Part 1: NTD situational analysis | Part 2: Strategic Agenda – Purpose and Goals | Part 3: Implementing the strategy: NTD Operational Framework | Part 4: Budgeting for Impact: Estimates and Justifications |
|---|---|---|---|---|---|
| Algeria | No | – | – | – | – |
| Angola | Yes (2017-2021) | √ | √ | √ | √ |
| Benin | Yes (2016-2020) | √ | √ | √ | √ |
| Botswana | Yes (2015-2020) | √ | √ | √ | √ |
| Burkina Faso | Yes (2016-2020) | √ | √ | √ | √ |
| Burundi | Yes (2016-2020) | √ | √ | √ | √ |
| Cabo Verde | No | – | – | – | – |
| Cameroon | No | – | – | – | – |
| Central African Republic | No | – | – | – | – |
| Chad | Yes (2016-2020) | √ | √ | √ | √ |
| Comoros | Yes (2016-2020) | √ | √ | √ | √ |
| Congo | Yes (2018-2022) | √ | √ | √ | √ |
| Cote d'Ivoire | Yes (2016-2020) | √ | √ | √ | ? |
| Democratic Republic of Congo | Yes (2016-2020) | √ | √ | √ | ? |
| Equatorial Guinea | Yes (2018-2022) | √ | √ | √ | X |
| Eritrea | Yes (2015-2020) | √ | √ | √ | X |
| Eswatini | Yes (2015-2020) | √ | X | X | X |
| Ethiopia | Yes (2021-2025) | √ | √ | √ | √ |
| Gabon | Yes (2013-2016) | √ | √ | √ | √ |
| Gambia | Yes (2015-2020) | √ | √ | √ | √ |
| Ghana | Yes (2016-2020) | √ | √ | √ | √ |
| Guinea | Yes (2017-2020) | √ | √ | √ | √ |
| Guinea-Bissau | Yes (2014-2020) | √ | √ | √ | √ |
| Kenya | Yes (2016-2020) | √ | √ | √ | √ |
| Lesotho | No | – | – | – | – |
| Liberia | Yes (2016-2020) | √ | √ | √ | √ |
| Madagascar | Yes (2016-2020) | √ | √ | √ | √ |
| Malawi | Yes (2015-2020) (2022–2026)a | √ | √ | √ | √ |
| Mali | Yes (2017-2021) | √ | √ | √ | √ |
| Mauritania | No | – | – | – | – |
| Mauritius | No | – | – | – | – |
| Mozambique | No | – | – | – | – |
| Namibia | Yes (2015-2020) | √ | √ | √ | X |
| Niger | Yes (2016-2020) | √ | √ | √ | √ |
| Nigeria | Yes (2015-2020) | √ | √ | √ | √ |
| Rwanda | Yes (2019-2024) | √ | √ | √ | √ |
| São Tomé e Príncipe | Yes (2016-2020) | √ | √ | √ | X |
| Senegal | Yes (2016-2020) | √ | √ | √ | √ |
| Seychelles | Yes (2015-2020) | √ | √ | √ | √ |
| Sierra Leone | Yes (2016-2020) | √ | √ | √ | √ |
| South Africa | Yes (2019-2025) | √ | √ | √ | √ |
| South Sudan | Yes (2016-2020) | √ | √ | √ | √ |
| Togo | Yes (2016-2020) | √ | √ | √ | √ |
| Uganda | No | – | – | – | – |
| United Republic of Tanzania | Yes (2021-2026) | √ | √ | √ | √ |
| Zambia | Yes (2019-2023) | √ | √ | √ | √ |
| Zimbabwe | No | – | – | _– | – |
Master plan under development.
√ = part is presented in the official multi-year NTD master plan; X = part is not presented in the official multi-year NTD master plan; _ official multi-year NTD master plan not available; ? = status unknown.
Additionally, 44 technical reports were reviewed in this scoping review: 28 from the U.S. Centers for Disease Control and Prevention (CDC), 10 from WHO ESPEN, five from Uniting to Combat NTDs, and one from WHO. Of note, the CDC repository was not searched directly, as the sources targeted for this review were focused on entities located in the WHO African region and organizations focused on NTDs; however, the 28 CDC technical reports (27 on Guinea worm yearly progress updates and one on LF elimination progress in Togo) were captured in the peer-reviewed literature search strategy and were considered technical reports during full text review. Five of the 10 ESPEN reports and all five Uniting to Combat NTDs reports were annual updates on the London declaration on Neglected Tropical Diseases [28]. Two were meeting reports of the NTD National Programme & Data Managers from the WHO African Region. The last three reports included the utilization of data to aid in the control, elimination, or eradication of NTDs, NTD elimination factsheet, and ESPEN's role in health systems strengthening.
Further, articles from the PubMed and Web of Science results presenting review or evaluation of NTD programs, activities, or outcomes were classified as program evaluations and analyzed separately (n = 116). Guinea worm (n = 35), onchocerciasis (n = 18), and LF (n = 16) were the most common NTDs, and the African region (>1 unspecified country, n = 30), Ghana (n = 15), and Nigeria (n = 9) where the most common locations. NTDs least-represented in the program evaluation literature included STHs (n = 4), leprosy (n = 3), and Buruli ulcer and yaws (n = 1 for both).
Discussion
This scoping review summarizes 30 years of NTD control, elimination, and eradication efforts throughout the WHO African region. There were notable differences in the total number of published scientific articles available depending on disease and country. There were no included scientific publications on NTD control, elimination, or eradication conducted in 12 African countries. However, in 2021, ESPEN reported one or more endemic NTDs and at least one preventive chemotherapy required in all but two of these countries (Mauritius and Seychelles) [29]. While inherent differences exist in national policies, program funding, and human resource capacity within each country, studies for assessing true disease burden in these locations are needed; due to lack of generalizability and different disease dynamics across locations, these kinds of localized analyses are essential.
Additionally, the included articles were not evenly distributed across the region (Table 2). Over half of included articles were conducted in Tanzania (16.2%), Ethiopia (10.1%), Nigeria (9.6%), Kenya (9.4%), Ghana (7.5%), Cameroon (7.3%) and Uganda (6.3%); all of which have documented high NTD burden and require preventive chemotherapy (PC) for 4-5 NTDs [29]. Conversely, only one article was included in six countries, yet South Sudan required PC for five NTDs, Angola required PC for four, Madagascar and São Tomé e Príncipe each required PC for three, and Lesotho required PC for one NTD [29]. To address this discrepancy, it is imperative to investigate existing gaps and bolster local research capacity and funding.
Disparities in the diseases of focus were also identified. Trachoma (16.3%), LF (16.3%), schistosomiasis (16.0%), and onchocerciasis (14.4%) were the NTDs most represented in this review. This was further reflected in thematic areas of the included articles, as most focused on MDA, routinely implemented for control and elimination of these NTDs [30,31]. While these NTDs represent much of the disease burden [9], it remains essential to bolster research on others that remain public health problems [29] and further develop integrated, multi-NTD strategies for control, elimination, and/or eradication.
Regarding national planning for NTD control, elimination, and eradication, ten countries in the WHO African region did not have published multi-year strategic plans; nine of these countries still require PC for at least one NTD [29]. Only Mauritius does not currently require PC for any NTDs. National efforts for NTD prevention, control, elimination, or eradication should be coordinated through multi-year master plans for effective planning, implementation, and accountability of NTD programs in the WHO African region. These master plans should outline specific, measurable, achievable, relevant, and time-bound specific actions; monitoring strategies; and the financial provisions for planned activities [32]. Development, updates to, and revisions of such master plans require conducting a situational analysis for NTDs in the country and identifying appropriate and tailored actions. This is a crucial step towards coordinating and harmonizing the prevention, control, elimination, or eradication of NTDs at the national level.
This scoping review presents a high-level summary of data extracted from articles on the control, elimination, or eradication of NTDs in the WHO African region from 1990 to 2022. While providing an overview of study characteristics offered contextual information, the aim of this scoping review was to provide a broad overview of the literature. Detailed examination of study designs, specific results, and quality of the studies was not conducted. Additionally, while the reviewers and co-authors came to consensus on the thematic areas to include in the full-text review based on relevance to the literature, additional thematic areas of interest could have been explored. Further, while reviews, commentaries, and opinion pieces can offer additional perspectives on successes, challenges, and recommended priorities of NTD control, elimination, and eradication efforts, such articles were not included in this review. Moreover, reviewers assessed the presence or absence of country-level multi-year NTD strategic plans without evaluating the content or quality of information contained within. Lastly, interventions addressing the mental health impacts resulting from the stigma, discrimination, and social exclusion associated with NTD infections were not included in this review, however this is an important element to consider as these elements can impact the uptake and effectiveness of NTD treatments [33].
Additional important context in which to situate the findings of this review is the exclusion of Sudan, the third largest country by landmass and 9th largest by population on the African continent [34]. While South Sudan was included in this review as a member state of the WHO African region, Sudan remains a member state of the Eastern Mediterranean region [35] and was therefore excluded. Nine NTDs remain recognized public health problems in the country: leishmaniasis, schistosomiasis, lymphatic filariasis, onchocerciasis, trachoma, guinea worm, mycetoma, soil transmitted helminths, and leprosy, with large populations living in rural areas often infected by one or more NTD [36]. It is important to acknowledge that NTD transmission in Sudan has direct implications for the NTD transmission in neighboring countries, five of which are within the WHO African region (Eritrea, Ethiopia, South Sudan, Central African Republic, and Chad), especially given ongoing crisis, decimation of the health system, and resulting mass displacement internally and to surrounding countries [37].
Large strides have been made towards the control, elimination, and eradication of NTDs across the WHO African region since the announcement of the MDGs. Togo and Malawi successfully eliminated lymphatic filariasis as a public health problem in 2017 and 2020, respectively [38]. Human African trypanosomiasis (T. b. gambiense) has been eliminated as a public health problem in seven countries as of 2023, with five more eligible for validation [39]. Seven countries have eliminated trachoma as a public health problem [40]. Additionally, reported Buruli ulcer cases decreased by 71% between 2010 and 2021 [39]. Burkina Faso has eliminated urogenital schistosomiasis as a public health problem in 8 out of its 13 regions [41], though challenges such as inadequate or lack of surveillance and monitoring—of schistosomiasis and other NTDs—persist throughout the region.
As progress continues towards the SDGs, ongoing global factors must be accounted for. Conflict, as demonstrated in Sudan, remains a persistent challenge in effective NTD control, elimination, and eradication initiatives though the disruption of program activities, weakening of the health system, and resulting population displacement [42,43]. Additionally, climate change is associated with the spatiotemporal variation in exposure and transmission of each species of infection—in both microbe and vector—among the NTDs [44]. While the definitive trajectory of climate change remains unknown, it is prudent to anticipate changes to global patterns of NTD transmission, both in the near- and long-term, though the magnitude of these changes may only be revealed over time [44,45]. The environmental and societal impacts of climate change are also expected to fuel conflict [46], which further disrupts disease control efforts.
This review provides a high-level overview of the state of literature since 1990; however, it is important to investigate and discuss implementation of NTD control programs in the region, as there is a need to standardize the diagnostic tools, MDA campaigns, and monitoring and evaluation activities for NTD programs. Such standardization will allow for improved comparisons of NTD elimination, eradication, and control efforts both within and between countries. An integrated approach—rather than disease-specific—can maximize the impact of available resources. More attention is needed on NTD elimination, eradication, and control efforts among mobile or displaced populations and in areas that are hard to reach, either due to remoteness or security concerns, as these subpopulations may be a source of re-emergence or recrudescence as countries move to interrupt transmission. The importance of operational research must be addressed, too. The production of publications depend on the institution or country commitment to NTD programs, national leadership, human capacity, financial resources, strength of partnerships, and involvement of academic institutions. Supporting operational research as part of national and institutional NTD programs can further support the production of publications originating within the WHO African region, which can document successes, challenges, and continued progress. Lastly, the establishment of academic partnerships or regional centers of excellence could further these efforts. These findings can contribute to regional strategy and position to further NTD control, elimination, and eradication initiatives by addressing the identified gaps, facilitating discussions with donors to focus on the identified needs (both disease- and location-specific), and contributing to the scientific evidence base generated within the African continent.
Ethical approval statement
This scoping review did not require ethical approval. The results of the scoping review consisted of peer-reviewed publications and publicly available technical documents.
Funding
There was no funding source for this study.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Author contributions
BF, BI, and CMW conceptualized this scoping review. CMW and BF conceptualized the approach. AC and CMW developed the search strategies and literature tables for data extraction. AB, AC, and CMW conducted the title and abstract screening, full-text reviews, and data analysis. AB, AC, and CMW wrote the first drafts of this manuscript. AB, AC, AK, BF, BI, CMW, DA, and EJ participated in the editing and revision process.
Footnotes
Further information on the studies the authors referenced can be found in the Supplementary Material.
Supplementary material associated with this article can be found, in the online version, at doi:10.1016/j.ijid.2024.01.010.
Appendix. Supplementary materials
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