Introduction
Schistosomiasis has the third highest global burden attributable to a neglected tropical disease (NTD) behind Soil Transmitted Helmintiasis (STH) infections and dengue.1 The main control strategy for the disease is chemoprophylactic treatment with praziquantel through mass drug administration (MDA) campaigns.2 As per all NTDs, accurate estimates on burden and MDA coverage are an issue3 even though the worldwide effort established through ESPEN in 20164 is trying to address this gap supporting better planning for control and elimination.
Madagascar has the fifth largest burden of schistosomiasis2 worldwide, with 106 out of 113 districts considered endemic for the disease.5 According to the 2015 estimates, in 40.7% of the districts (46/113) schistosomiasis prevalence is >50%, in 37.2% (42/113) between 10% and 50%, and less than 10% in 16.8% (19/113), while only 5.3% of them (6/113) are not endemic (figure 1). Schistosoma haematobium, responsible for urogenital schistosomiasis, is present in the western and northern regions of the island, while intestinal schistosomiasis due to S. mansoni is present in the eastern and southern parts so as in the central highlands of the country.6 Efforts have been made in the last years to control the disease, but programme coverage is jeopardised by limited financial resources required for the implementation and distribution, poor coordination of donors and local implementation challenges, with some districts in need for MDA still uncovered (figure 1).5.
Since 2001 World Health Resolution calling for widespread treatment for schistosomiasis and soil-transmitted diseases,7 schistosomiasis is receiving unprecedent attention from the global health community both in terms of research, guidelines and policies. The recently released WHO 2021–2030 road map for NTDs orients public health policies towards disease elimination as a public health problem (EPHP)3 by 2030.
In 2022, the WHO released additionally ad hoc guidelines for schistosomiasis with the purpose of boosting EPHP goal on the basis of six recommendations based on prevalence, target groups and type of interventions and ranked by strength and extent of scientific evidence8 (figure 2).
In 2021, over 58 million children have been treated globally, corresponding to 43% of the worldwide target.9 Praziquantel (PZQ), the drug of choice for treatment of schistosomiasis, is available as a donation through the WHO.3 To boost the achievement of the target, tailored strategies based both on local disease burden, territorial and infrastructural challenges are required.
In Madagascar, geographical, climatic and socioeconomic peculiarities represent a barrier for the achievement of the ambitious goal of EPHP by 2030. Moreover, political attention needs to be raised for a disease that affects more than half of the population.
The aim of this paper is to critically discuss the national factors to consider for the implementation of new guidelines for the elimination of schistosomiasis in the country, proposing a national implementation plan to align with the WHO roadmap. Additionally, we aim at rising attention of policy makers and local stakeholders for the achievement of EPHP.