One Health approach making inroads against neglected disease in Madagascar
A pig butcher in Madagascar sought medical attention after suffering symptoms that included three months of recurring headaches. Dr. Andry Fanomezana Rabesisoa, from the regional referral hospital in Antsirabe, explained that an investigation reached a diagnosis of cysticercosis.
The patient was admitted to hospital and received the WHO-recommended course of treatment for this neglected tropical disease that can have a devastating impact on people’s lives and livelihoods. Apart from the loss of income during his hospital stay, the butcher spent the equivalent of about CAD150 for a CT scan and other tests. The cost of a CT scan alone is 450,000 Malagasy ariary (CAD98), which is unaffordable for most of the country’s inhabitants.
Cysticercosis is caused by a tapeworm transmitted from infected pigs. In humans, infections reaching the brain lead to a neurological condition called neurocysticercosis, which is considered the most common parasitic infection of the central nervous system and is a major cause of epilepsy. In Madagascar, previous efforts to control this preventable disease focused only on mass drug administrations, targeting everyone in endemic regions. However, the disease has not been entirely controlled, as infected pigs continue to have cysts in their meat, exposing people to infections.
IDRC-funded research promotes integrated effort
Treatment of neurocysticercosis is complicated. It includes the use of steroids, antiseizure drugs and, in some cases, anthelmintics, which are antiparasitic drugs that expel parasitic worms from the body. Surgery may also be recommended.
The incidence of cases can be greatly reduced or even eliminated from Madagascar and other endemic countries by a One Health approach that includes a combination of vaccination and treatment of both livestock and humans to break the cycle of transmission between people and pigs.
One Health is an integrated, unifying approach that aims to sustainably balance and optimize the health of people, animals and ecosystems. As much as this concept is widely accepted as the best strategy for addressing global health challenges, it is not yet significantly operationalized. This is in spite of well-intentioned One Health policies in many countries. IDRC-supported research carried out as part of the Livestock Vaccine Innovation Fund (LVIF) is demonstrating the operationalization of the One Health approach and how, as in this particular project, it can be used to reduce the incidence of neurocysticercosis, which results in an estimated 28,000 deaths a year and affects around 50 million people worldwide.
The LVIF project, led by Madagascar’s National Center for Applied Research in Rural Development (FOFIFA) and the University of Melbourne in Australia, has facilitated the treatment and vaccination of more than 90,000 pigs across Madagascar's Betafo and Mandoto districts. Pigs are treated to eliminate any cysts in the muscles, and vaccinated to prevent future infections. An effective pig vaccine called Cysvax® is being used in the research initiative. At the same time, about 120,000 people have been treated with an antiparasitic drug over the past two years, using praziquantel or the alternative niclosamide.
This pioneering cysticercosis control model follows a practical One Health collaboration among FOFIFA, the University of Melbourne, WHO and the ministries of health and livestock of Madagascar. It is the world’s largest One Health cysticercosis control effort so far. Lessons from this project are already influencing WHO protocols for conducting mass drug administrations, such as through the use of the alternative antiparasitic drug niclosamide, to reduce adverse effects for infected people who are not eligible for praziquantel. The project is also featured as a case study in an open access WHO One Health course on neglected tropical diseases.
Involvement of traditional leaders helps raise awareness
Betafo hospital in Madagascar’s Vakinankaratra region has provided a laboratory for the research effort. Hospital personnel, district-level public health officers and animal health counterparts all work together in a coordinated way to ensure sensitization campaigns, treatments, vaccinations and testing of both pigs and humans are done in a synchronised manner.
Dr. Claudia Ravonirina, district veterinary officer for Antsirabe, said that the project had, “Demonstrated the importance of involving the focutan [chiefs of Fokontany, the lowest administrative regional unit in Madagascar] and traditional leaders in sensitization of the population concerning porcine cysticercosis.” She added that several challenges had been overcome thanks to these awareness-raising efforts.
The project’s multisectoral collaboration has in many ways demonstrated that the One Health concept can be effectively operationalized when adequate resources are available and when program objectives and partners’ roles are clear. Coordination among partners and the proper timing of project activities have been key to efforts aimed at breaking the disease’s cycle of transmission.
LVIF is a joint initiative supported by Global Affairs Canada, the Bill & Melinda Gates Foundation and IDRC that works through partnerships to develop vaccines that are affordable, available and acceptable to livestock smallholders and to facilitate their use at scale. LVIF targets livestock diseases that have the most impact on both women and men livestock smallholders in sub-Saharan Africa, South Asia and Southeast Asia.
Contributors: Victor Mbao, senior program specialist, IDRC; and Evelyn Baraké, program officer, IDRC