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Southern Sudan has been ravaged by decades of conflict and is thought to have one of the highest burdens of neglected tropical diseases (NTDs) in the world. Health care delivery, including efforts to control or eliminate NTDs, is severely hampered by a lack of infrastructure and health systems. However, the post-conflict environment and Southern Sudan's emerging health sector provide the unprecedented opportunity to build new, innovative programmes targeting NTDs. This article describes the current status of NTDs and their control in Southern Sudan and outlines the opportunities for the development of evidence-based, innovative implementation of NTD control.
Neglected tropical diseases (NTDs) are a range of diseases that occur in conditions of poverty and frequently overlap in endemic countries [http://www.who.int/neglected_diseases/en]. Funding for their control and elimination has recently seen a dramatic expansion, with an emphasis on co-administration of preventive chemotherapy (PCT) . However, operational experience in delivering PCT packages has, to date, been from countries with relatively well-established health systems [e.g. 2-5]. Little is known about implementation in post-emergency settings, where delivery structures are less developed or absent. One such setting is Southern Sudan which, until recently, was plagued by a series of conflicts since independence in 1956 . The cessation of conflict coupled with the commitment of the Ministry of Health (MoH) of the Government of Southern Sudan (GoSS) has yielded new opportunities and funding for NTD control, notably support from the US Agency for International Development to develop an integrated NTD control programme. There exists therefore a unique opportunity to develop an integrated programme from scratch, and to generate crucial evidence on cost and cost-effectiveness in the process.
Southern Sudan and the Khartoum Government signed on 9 January 2005 the Comprehensive Peace Agreement, ending decades of civil war. Health systems are now being rebuilt, providing opportunities and funding to integrate the control of multiple NTDs. However, the country's recent history, as well as its sheer size, also pose several challenges . Southern Sudan covers an area of 231,177 square miles (Figure 1) but has an estimated population of 11 million at the most, which equates to 47 people per square mile. Migrant populations and the return of refugees and internally displaced persons result in constantly fluctuating population figures. In 2004, 98% of the population lived in rural areas [Facts about South Sudan (http://www.codecan.org/media/PLS-%20Facts%20about%20South%20Sudan%202008.pdf)]. Physical, health and education infrastructure is largely absent and many areas are only accessible by plane, boat, four-wheel drive, or foot, especially during the rainy season. The proportion of the population with access to a health facility has been estimated below 25% [7,8], while in 2002 just over 20% of school-age children were enrolled in schools [Towards a baseline: Best estimates of social indicators for Southern Sudan (http://www.unicef.org/media/media_21825.html)].
Notwithstanding such challenges, the ongoing transition towards development and its associated lack of entrenched government structures and processes provide great opportunities to improve public health, including NTD control. For such improvements to take place, it is essential to build up a credible evidence-base to understand the epidemiology of infection and disease, and develop, as well as appropriately implement, intervention strategies.
Twelve NTDs are endemic to Southern Sudan (Table 1) [Neglected Tropical Disease in Southern Sudan (http://www.malariaconsortium.org/data/files/pages/ntds_southern_sudan.pdf)]. However, as in all post-conflict settings, reliable disease surveillance data are sparse. Estimates of incidence or prevalence are based either on passive case-detection [9,10] or localized surveys undertaken in areas where specific NTDs are known or suspected to occur [11-14]. Although comprehensive empirical data are few, those that do exist indicate that lymphatic filariasis (LF), schistosomiasis, soil-transmitted helminth (STH) and trachoma are endemic over large areas, whereas visceral leishmaniasis (VL), human African trypanosomiasis (HAT), Buruli ulcer and leprosy occur more focally. To date, comprehensive epidemiological mapping has been undertaken for only onchocerciasis, loiasis and Guinea worm. Determining the prevalence and distribution of the other NTDs remains an important operational necessity, because NTD transmission is heterogeneous and scarce resources for control need to be geographically targeted .
Despite decades of civil unrest, progress has been made with the control of some NTDs (Table 2). These efforts can be broadly categorised as: (i) large-scale programmes targeting at least 10% of the population (onchocerciasis and Guinea worm; see Figure 1); (ii) smaller, ad-hoc public health campaigns (STH and trachoma); and (iii) treatment provided, to varying degrees, by health facilities on an in-patient basis (VL, HAT) and through outreach (Buruli ulcer, leprosy). Since the populations at risk are not precisely known, it is generally not possible to reliably estimate coverage rates or their change over recent years.
Implementation of both onchocerciasis and Guinea worm control is through community-based structures, utilizing volunteers for community-directed treatment with ivermectin (CDTI) and for distribution of water filters and surveillance, respectively. Trachoma control is currently integrated with the Guinea worm eradication program in Eastern Equatoria and Jonglei States, and consists of the SAFE strategy with its four components of eyelid surgery (S), antibiotics to treat the community pool of infection (A), facial cleanliness (F), and environmental changes (E). To date, deworming against STH has been carried out during national immunization days and schistosomiasis treatment is being provided by some health facilities.
Treatments for VL, HAT, leprosy and Buruli ulcer are considered too toxic, lengthy or difficult to be delivered through community-based mechanisms, and are only available at health facilities or through outreach, if at all. Historically, treatment services for VL and HAT were provided by non-governmental organizations during epidemics (see, for example, Ref ), allowing temporary expansion of service coverage [17,18]. Activities were scaled-back shortly after the disease was considered to be under control, leaving opportunity for disease resurgence [19-21]. Current access to and quality of treatment to VL and HAT, as well as leprosy and Buruli ulcer, remains inadequate .
Ongoing post-conflict reconstruction provides a number of key opportunities to improve on current NTD control, which are outlined below and in Box 1. An immediate opportunity for expanding NTD control is through integration of PCT delivery into the CDTI onchocerciasis network. Delivery of albendazole can readily be added to annual ivermectin distribution in areas where onchocerciasis and LF are co-endemic, with the collateral benefit of controlling STH, scabies and lice . Southern Sudan will start co-administration of ivermectin and albendazole through CDTI structures in 2009.
In some Guinea worm endemic areas, health education and distribution of antibiotics for trachoma control have been integrated into the community-based Guinea worm activities. Anecdotal reports suggest that this has been popular with the communities. Once the transmission of Guinea worm has been interrupted and the network needs to be maintained for surveillance, Southern Sudan will have the opportunity to expand the existing integration, both geographically and in scope.
Together the CDTI and Guinea worm network provide about 80% geographic coverage (Figure 1). This means that other mechanisms are required to deliver PCT to parts of the country where neither onchocerciasis nor Guinea worm are endemic, as well as within administrative units where distribution of these two diseases is focal and where the existing networks do not reach all individuals eligible for other treatments. This is particularly relevant for elimination of LF, a disease that tends to be endemic over large areas . Co-administration through the expanded programme on immunization provides one alternative delivery structure, as it was successfully used in 2006 and 2007 for mass de-worming with albendazole. Another option may be de-worming for schistosomiasis and STH through schools; an approach that is already well established elsewhere in the region [24-26]. However, distribution through schools, as well as modification of the curriculum to improve knowledge, attitudes and practices related to NTD control, will only become viable once rebuilding of infrastructure has progressed and school attendance has substantially increased. Meanwhile, ongoing campaigns for distribution of long-lasting insecticidal nets (LLINs) present an interim opportunity for PCT distribution until LLIN coverage has been scaled-up .
In the medium-term, Southern Sudan will have the opportunity to develop an innovative platform for community directed delivery of PCT and other interventions (e.g. LLINs and vitamin A supplementation). Building on a recent TDR study [Community Directed Interventions for major health problems in Africa (http://www.who.int/tdr/svc/publications/tdr-research-publications/community-directed-interventions-health-problems)], a standardized delivery platform could be developed. A common set of interventions could be identified that address Southern Sudan's needs and are suitable for integration, and donors would then be asked to invest into the platform, instead of supporting specific diseases. The delivery platform could be part of a health facility – community linkage, and pre-service training of the country's new nurses and doctors could emphasize supervision and management of the platform as a central part of their job. To inform the development of such platform, more in-country experience with integration will be needed.
For VL, HAT, leprosy and Buruli ulcer, where confirmative diagnosis is required before infected individuals receive treatment [27-30], the existence of community-based MDA structures cannot be harnessed to provide mass treatment, but presents an opportunity to improve treatment outcomes and to reduce transmission through prevention. CDDs can be trained to provide health education, case identification, early referral and community follow-up.
For those NTDs not suitable for MDA, both diagnosis and treatment are only available at a few facilities, often many hours if not days away from endemic communities. As a result, infected individuals generally present late or not at all, resulting in high morbidity and mortality [e.g. 31]. With Southern Sudan having the highest caseload of VL in Africa  and being among the top three endemic countries for HAT  there is an obvious and urgent need for improvement. As mentioned above, such improvement should involve the affected communities where feasible, but also requires better and more accessible case-management. Ongoing upgrading of facility-based health care undertaken by the MoH-GoSS and partners provides an important opportunity to ensure that the skills and supplies to provide routine NTD diagnosis and treatment are put in place, and that a link between the facilities and the communities is being established. Initial steps to do so have been taken by the MoH-GoSS with considerable support from WHO and other agencies. The required drugs and other supplies have been included in the essential drug kit list and training of national staff, including those operating at the periphery, on diagnostic and treatment procedures is ongoing.
Until 2005, communicable diseases in Southern Sudan were either managed using strategies developed by the Khartoum Government or according to the protocols of individual aid agencies. Since then, the MoH-GoSS has put in place a number of new or revised strategies with the aims of: i) standardizing diagnosis, treatment and prevention among implementing partners operating in the South, and ii) providing a framework for the MoH-GoSS and other development partners to allocate funding. The most recently addition specifically addresses integrated NTD control [Integrated Control of Neglected Tropical Diseases (http://www.malariaconsortium.org/data/files/ntd_ss_strategic_plan_june_2008_final.doc).
Revision or development of new strategies continues to provide opportunities to include new evidence and to identify specific areas requiring further in-country research (see below). Due to the absence of large government bureaucracies such strategic planning processes can be undertaken relatively quickly and with extensive consultation. This dynamic environment also allows for specific implementation needs, such as a strong government commitment to community-based delivery, to be readily incorporated into emerging health policies.
More generally, improvements in environmental hygiene are the ultimate answer to the control and elimination of many NTDs, but for Southern Sudan as for many low-income countries these are expensive and represent long-term objectives. Multiple agencies are working with the GoSS to strengthen water, hygiene and sanitation infrastructure, and efforts should be made to ensure integration between NTD control and government departments coordinating the provision of water and sanitation. Here there is opportunity for cross-sectoral collaboration and influencing strategies and policies, for example to formulate standardised, rather than disease-specific, education on water and sanitation and to target the construction of new boreholes and latrines to areas with high population densities and a high risk of specific NTDs.
Integrated NTD control has now been initiated in at least ten African countries, although to date, there are few empirical data on the health benefits and cost savings of an integrated approach over and above single-disease control programmes [4,33,34]. There thus remains an urgent need to strengthen the evidence-base for integrated control. Southern Sudan provides particular opportunities to do so, because all of the targeted NTDs are endemic and most of them have not been mapped. This means that extensive epidemiological surveys are needed. With the aim of saving time and money, the feasibility of an integrated survey tool covering a range of NTDs is being investigated. Integrated surveys will need to overcome a number of important difference in epidemiologies and survey methodologies of NTDs [15,35], and thus generate useful information to guide similar undertakings elsewhere.
It is also apparent that the commonly quoted annual MDA cost of US$ 0.4 – 0.5 per person [36,37] are not applicable in Southern Sudan. Actual cost data is thus being collected and will be used to generate evidence on cost and cost-effectiveness of this approach. The methodology and costing templates used will be available for similar data collection elsewhere, providing an opportunity to generate figures that can be readily compared between countries.
Lastly, the planned expansion of co-administration of PCT through community-based structures and campaigns will require exploration of new and innovative delivery approaches, to ensure that full coverage (both geographically and of the eligible population) is achieved and can be retained. Amongst others, this will provide opportunities to contribute to the evidence-base on recruitment, training, supervision and retention of community drug distributors (CDDs), and on factors associated with coverage. At present, the Southern Sudan Onchocerciasis Task Force already faces the challenge that about 30% of CDDs discontinue their involvement in CDTI every year, resulting in considerable costs for recruitment and training of new volunteers. Useful insight on improving CDD retention has been gained from other countries with well-established onchocerciasis control programmes [e.g. 42], as has been on factors associated with coverage [e.g. 43]. However, there is as yet limited evidence on how best to address these issues once a package of drugs or other interventions is delivered through community-based mechanisms, though TDR and others have recently started to fill this knowledge gap [44, Community Directed Interventions for major health problems in Africa (http://www.who.int/tdr/svc/publications/tdr-research-publications/community-directed-interventions-health-problems)].
Information on the distribution and burden of NTDs in Southern Sudan is limited, but existing data consistently indicate that this is a country with a high burden and great need. In itself, this is not unlike many other developing countries. What sets Southern Sudan apart is that most NTDs are endemic, that most of them have benefited from little control and that infrastructure and systems are practically absent. Though this presents great challenges, it also offers great potential to increase treatment coverage for co-endemic NTDs, integrate more complex case-management into facility-based health care delivery and strengthen the link between communities and health facilities. This unprecedented opportunity to build evidence-based systems for NTD control or elimination needs to be maximised now while rebuilding of the health sector is ongoing.
We wish to thank all the individuals and organizations that have contributed to the control of NTDs in Southern Sudan over the last decades. Without their dedication, many lives would have been lost and many people would not have been cured from disabilities.
The information presented in this publication was collated for a comprehensive situation analysis on NTDs recently published by the Ministry of Health, Government of Southern Sudan (http://www.malariaconsortium.org/data/files/pages/ntds_southern_sudan.pdf). Major contributions to the analysis were made by Jose Ruiz, Michaleen Richer, Samson Baba, Lasu Hickson, Karinya Lewis, Steven Becknell and Samuel Makoy. Development of the situation analysis was led by Malaria Consortium [http://www.malariaconsortium.org] and funded by COMDIS, a Research Programme Consortium coordinated by the Nuffield Centre for International Health and Development, University of Leeds, with funds from the Department for International Development, UK. COMDIS also funded Malaria Consortium to lead writing of this publication. Simon Brooker is supported by a Wellcome Trust Career Development Fellowship (081673). Current scale-up of integrated NTD control in Southern Sudan is funded by the US Agency for International Development, through RTI International.