The World Health Organization (WHO) advocates an integrated approach to control neglected tropical diseases of the skin (the so?called skin NTDs1) and enhance early detection, timely treatment, morbidity management and disability prevention.
Skin NTDs prevail in settings characterized by fragile health systems and can lead to psychosocial problems, stigmatization, exclusion and distress.
The WHO webinar on 21 October on tackling skin NTDs to reach the 2030 road map targets addressed this long-neglected aspect of NTDs, with unanimous calls for decisive action.
Panel one: Addressing gaps
Roderick Hay, Advisor, International Foundation for Dermatology, UK said that almost 1 billion people have skin conditions caused mainly by six or seven common skin diseases. Skin NTDs present visible skin alterations, and because many of them occur in the same settings and have similar manifestations, joint approaches and resources can be used to detect and resolve the problems they create. Integration also benefits the partners that support work to control and prevent these diseases.
Giorgio Cometto, Unit head, WHO Department of Human Resources for Health, noted the role and importance of community health workers in delivering primary health care interventions, as demonstrated in campaigns against HIV/AIDS and tuberculosis. He referred to a study that assessed the role of health workers in enhancing community care and supporting many interventions against NTDs.
Victoria Williams, Assistant Professor, University of Pennsylvania, USA explained how technology can be used to detect and diagnose skin NTDs at an early stage. Today, education in visual health can be delivered through various devices including smart phones that can be used online and offline even in rural settings. She also mentioned use of the WHO application on skin NTDs and of artificial intelligence as clinical support tools and the potential of tele-dermatology.
Pauline Kleinitz, Technical Advisor, WHO Disability and Rehabilitation unit, commented on WHO’s plan to develop a disability strategy that would include skin NTDs to promote equality in access to health services. She emphasized the importance of rehabilitation, care and case management in primary and secondary health levels, particularly for NTDs that result in chronic health conditions.
Panel two: role of partnership and research
Claire Fuller, Chair, International Foundation for Dermatology, UK recalled that the new road map puts people at the centre of health delivery through inclusive, cross-cutting, integrated interventions. She said that inclusion is critical to tackling skin NTDs through dermatological care and acknowledged the support of a relatively new organization, GLODERM, in helping to advance NTD dermatology.
Isra Cruz, Head, National School of Public Health, Instituto de Salud Carlos III, Spain spoke of integrated approaches and the need for appropriate tools to diagnose diseases, particularly skin NTDs, and the creation of WHO’s Diagnostics Technical Advisory Group, which has a dedicated sub-group working on skin NTDs. He referred to innovative ways to tackle many skin NTDs, including yaws and Buruli ulcer, and of public–private partnerships to develop tools for diseases such as mycetoma.
Christian Johnson, Medical Advisor, Raoul Follereau Foundation, France said that integrating programmes represents a unique opportunity to reinforce and improve the efficiency of current interventions. Country ownership of programmes can generate investment in training and capacity strengthening – factors that have the potential to boost the morale of the health workers.
Sahar Bakhiet, Head, Research Unit, Mycetoma Research Centre, Khartoum, Sudan explained how a holistic approach has enabled the Centre to diversify its operations, bringing services closer to people in villages who are affected by mycetoma and enabling early case detection and access to timely treatment in many cases. She also spoke of software training for various categories of health workers, which has facilitated exchange of precious data.
Chandrakant Revankar, Public Health Consultant, USA described a WHO strategic framework document he is developing to help guide work on integrated control of skin NTDs and the immense response to an initial survey (more than 250 respondents from 58 countries have contributed ideas). Integration is already happening in many countries, but more work may need to be done in areas such as social mobilization and tackling of stigmatization.
Panel three: integrate to maximize country level impact
Yves Barogui, Chief Medical Officer, Buruli Ulcer Treatment Centre, Benin explained that interventions against skin NTDs including Buruli ulcer, leprosy, cutaneous leishmaniasis, lymphatic filariasis and yaws have been implemented in Benin and Côte d’Ivoire since 2015. Integration has resulted in the examination of more than 16 000 people. One out of every 10 cases showed manifestation from an NTD, whereas most dermal cases examined were not NTDs. Among the commonest skin NTD manifestations were scabies, followed by Buruli ulcer and leprosy. He also highlighted challenges of implementing an integrated approach to skin NTDs.
Julian Trujillo, Coordinator, Ministry of Health and Social Protection, Colombia spoke of control activities in Colombia, the problems faced in other countries and the challenges and gaps in overcoming them, including access to remote communities that mostly suffer from NTDs. He also referred to challenges posed by scarce resources, lack of capacity and deficiency of tools and diagnostics.
Mourad Mokni, Head, Dermatology Department, La Rabta Hospital, Tunisia reported that a survey in WHO’s Eastern Mediterranean Region that included eight skin NTDs clearly showed cutaneous leishmaniasis with the highest burden. Other skin diseases that are prevalent in the region include fungal diseases and scabies. The survey also revealed that the challenges facing integration of skin NTDs are weak surveillance, cost of medicine and stigmatization associated with NTDs.
Prima Yosephine, National Programme Manager for Leprosy and Yaws, Ministry of Health, Indonesia described the challenges that Indonesia faces in dealing with NTDs. Recently, leprosy and yaws elimination activities have been integrated to include active case-finding and school case-screening. She also referred to ongoing collaboration between various ministries and directorates of health services in tackling skin and other NTDs.
Aya Yajima, Technical Officer, WHO Regional Office for the Western Pacific, described how Vanuatu’s success against NTDs has resulted in elimination “fatigue” in populations subjected to large-scale treatment programmes. Indonesia is now integrating screening of NTDs with noncommunicable diseases. Although this innovative approach has been welcomed by the population, it has meant re-training staff and producing additional materials. Overall, however, it stands as a model intervention.
Oriol Mitja, Associate Professor, Hospital German Trias I Pujol, Barcelona, Spain spoke of the importance of integration in the delivery of interventions, which can also be very cost–effective and timely. He spoke of his experience in dealing with multiple diseases in Papua New Guinea and the important role of village health workers. He lauded the efforts of many of those present at the webinar, which have led to integrated approaches to skin NTDs since 2017. Although it started slowly, he noted that some countries are adopting the approach and are allocating resources to tackle these skin NTDs.
Mwelecele Ntuli Malecela, Director, WHO Department of Control of Neglected Tropical Diseases, emphasized the importance of holistic, integrated approaches in tackling the physical, mental suffering and distress caused by skin NTDs and of integration in almost all its aspects including diagnostics, technology and capacity strengthening. She spoke of the importance also of working with sectors beyond health such as water, sanitation and hygiene and education. Most important of all is country ownership. She said skin NTDs are now an integral part of the new road map and that the shifts envisaged therein speak of everyone’s collaboration – from the ground level to national programmes.
1The skin NTDs include Buruli ulcer, cutaneous leishmaniasis, post-kala-azar dermal leishmaniasis, leprosy, lymphatic filariasis (lymphoedema and hydrocele), mycetoma, onchocerciasis, scabies, yaws and fungal diseases.