Togo becomes first country to eliminate four neglected tropical diseases

With the help of town criers, community health workers, and data, Togo has become the first country to eliminate four neglected tropical diseases (NTDs) – Guinea worm in 2011, lymphatic filariasis in 2017, sleeping sickness in 2020, and trachoma in 2022.

Togo joins 11 other countries that have eliminated more than one NTD and is a symbol of the remarkable progress being made against these diseases despite the COVID-19 pandemic.

A new WHO report quoted Dr. Ibrahima Socé Fall, the Director of the WHO’s Department of Control of Neglected Tropical Diseases, on the progress: “Although disruptions caused by COVID-19 were severe, countries continued to attain targets. In 2021, the number of people requiring NTD interventions decreased by some 80 million people.”

NTDs include 20 bacterial, parasitic, and viral diseases, which can cause blindness or other disabilities, incapacitate individuals, and trap families and entire communities in poor health and poverty. The diseases plague large swaths of the globe. About 40% of the 1.7 billion people affected by NTDs live in Africa. Currently, an estimated 888 million people globally are receiving treatment for at least one NTD.

Togo achieved its success through a four-pronged effort focused on mass drug administration by community health workers (CHWs) in villages; building awareness about NTDs and treatment through village criers, tribal chiefs, and religious leaders; training front-line health workers to screen for, treat, and collect data on NTDs; and ensuring a robust supply chain to equip CHWs with diagnostic tools and treatments.

Leveraging CHWs proved critical. Togo, a country of nearly 8 million people, has only about 400 physicians. To deliver basic healthcare in rural areas unserved by physicians, the government and its partners built a robust network of 13,000 CHWs, with every village of at least 400 inhabitants having its own dedicated health worker.

“Togo has a policy of community-based interventions that optimizes the work of community health workers through the integration of the fight against disease at the community level,” said Frederic Gmakouba, a manager in Togo’s Ministry of Health. He added that the same community health workers who diagnose and manage malaria also diagnose and treat pneumonia, diarrhea, NTDs, and provide Vitamin A supplementation and chemoprophylaxis during malaria season.

“This integration makes it possible to optimize treatment to eligible targets and avoids multiple contacts with the same person eligible for several treatments. Integrating the fight against NTDs optimizes results and allows efficiency in the allocation of resources,” Gmakouba said.

CHWs have had a leading role in addressing each of the four NTDs for years.

For example, for more than two decades, Togo's community health workers have identified and managed cases of Guinea worm. In 1997, the country also began providing affected communities with ivermectin for lymphatic filariasis, also known as elephantiasis. By 2000, CHWs were distributing the drug across eight districts, ensuring that everyone at risk received preventative treatment for a decade. And to support screening at scale for trachoma, the government trained CHWs to identify suspected cases while they were already conducting door-to-door mass drug administration activities for onchocerciasis, schistosomiasis, and soil-transmitted helminthiases. Suspected trachoma cases were referred to specially trained ophthalmic nurses and, if confirmed, scheduled for surgical correction.

“In the beginning, CHWs were kept motivated by the community itself contributing either financially or providing gifts of food to the CHWs,” said Dr. Piham Gnossike, the National NTD Coordinator for the Togo Ministry of Health, Public Hygiene and Universal Access to Care. Later, as the program matured and the responsibilities of CHWs expanded, “the government came to support this motivation which is paid annually.”

CHWs, who work in pairs during mass treatment activities, are trained annually in advance of the activities, and at the conclusion of each door-to-door campaign they gather at their local health center to submit data on their activities.

Government health leaders help ensure the annual door-to-door mass drug administration activities are successful by holding a press conference each year on the eve of mass treatment activities to explain the need and purpose of the activities to the public. Likewise, health facility managers meet with village chiefs and community leaders before the launch of annual treatment activities.

“The chiefs are therefore strongly involved in all mass activities that take place in the community,” said Dr. Gnossike. “The town criers who circulate in the neighborhoods to inform the population of the various activities that take place are under the responsibility of the village chief. CHWs in their community also participate in this social mobilization under the authority of the village chief. We have a budget line financed by the partners which is designed to ensure social mobilization at all levels. This organization makes it possible to have the support of village chiefs and the adhesion of communities for mass treatment.”

The country had previously suffered from high levels of the NTDs, explained Dr. Gnossike. A 1991 guinea worm survey had identified 5,000 cases across 24 of the country’s 40 districts. A 1998 mapping of lymphatic filariasis found 1.3 million people at risk in seven districts. The country’s campaign against human African trypanosomiasis dates from the colonial era, with records from 1940 showing 1,938 cases. Trachoma rates were as high as 12% in the country’s northern districts in 2009, the first baseline mapping exercise.

CHWs continue to work against NTDs today, monitoring for any recurrence.

Last year, world leaders met in Kigali and committed to eradicating NTDs by 2030. Since 2012, 47 countries have eliminated at least one NTD. In 2022 alone, eight countries eliminated a NTD – the Democratic Republic of Congo, Equatorial Guinea, Malawi, Rwanda, Saudi Arabia, Togo, Uganda and Vanuatu according to a new World Health Organization report. Currently, the world is close to eradicating Guinea Worm.

Togo provides health leaders with one more reason for optimism. “Togo's elimination of four NTDs in less than two decades is proof to countries that the NTD elimination and eradication targets in the WHO 2030 Agenda are achievable,” said the Secretary General of Togo’s Ministry of Health, Dr. Marin Kokou Wotobe. “The political commitment of the state and …ownership of the fight against these NTDs by actors at all levels of the health pyramid, including community health workers, makes it possible to achieve the necessary coverage to achieve success.”