Impact case study database

Our studies identified improved and cost-effective solutions to prevent and treat CM in low resource settings. The inclusion into WHO guidelines between 2013 and 2018 led to widespread adoption of these new approaches in most countries when practicable. This benefitted both individuals living with HIV and at risk of the opportunistic infection CM, and resource-poor healthcare systems, particularly in Africa, by improving outcomes and reducing the costs associated with CM treatment.

Influence upon treatment guidelines and clinical practice.

The Vietnam trial demonstrating clear benefit from combination therapy with amphotericin and flucytosine in terms of survival rates, and showing that both drugs could be safely administered in settings where therapeutic drug monitoring is not available, informed policy and clinical practice in many countries (including Germany, USA, Australia and Indonesia) and has underpinned WHO recommendations for combination therapy since 2013 [1,2].

Although most countries in Africa typically follow WHO guidance, this new treatment regime was not widely adopted in this continent due to resource constraints. The ACTA trial evaluated practical comparatively low-cost interventions for Africa including a new, shorter treatment regime which proved to be highly cost effective. It led to an immediate change in WHO guidelines, published simultaneously alongside the paper in 2018 recommending this regimen as the gold standard for CM management [2]. The advice to change to the ACTA regimens was graded as “strong recommendation, moderate-certainty evidence”. The dexamethasone study demonstrating that use of corticosteroids was harmful in HIV-related CM was also cited as high-quality evidence against the use of dexamethasone in the 2018 WHO guidelines [2] and immediately influenced clinical practice in many countries, being adopted into US IDSA guidelines in the same year for example. The findings of all these trials are included in the on-line decision-making resource ‘UpToDate’ used by 1,900,000 doctors worldwide [3].

The WHO had been recommending CrAg screening and it changed its guidelines to “strong recommendation” following the REMSTART trial [4]. However, uptake of this recommendation has been very limited outside of South Africa (which has a well-funded health system), because the REMSTART package was a complex intervention involving both patient empowerment and CrAg screening and needed substantial infrastructure and resources to scale-up. The TRIP study adapted the REMSTART package and demonstrated that a) it can be scaled up in a low-resource setting and b) that in a real-life setting, the death rate is as low as observed under trial conditions in the REMSTART trial. Tanzania, with one of the weakest infrastructures for their HIV programmes, has used the evidence generated to scale up screening for CrAg in over 200 health facilities so far (over 1,000,000 people with HIV-infection in the country) and by the end of 2021 coverage is expected to cover the entire country.

The CRYPTO-PRO trial demonstrated the value of fluconazole prophylaxis in certain populations and was one of only two studies contributing to “high quality evidence” for recommendations in the 2017 WHO advanced HIV guidelines [4] and 2018 WHO Cryptococcal guidelines [2] recommending that fluconazole prophylaxis should be used in patients with advanced HIV that could not immediately access antiretroviral therapy.

Implementation of revised guidelines for CM treatment and diagnosis.

As a result of the ACTA trial findings and WHO recommendations that followed, in January 2019 UNITAID announced USD20,000,000 funding to support 7 African countries to scale the WHO recommendation on advanced HIV disease (which REMSTART and TRIP had informed) and scale up management of CM (which ACTA had informed) [5]. The African countries targeted by UNITAID were Tanzania, Nigeria, South Africa, Botswana, Malawi, Lesotho, and Uganda and they have used the funds to support training of health care staff and acquire commodities including CrAg tests and treatments (flucytosine and amphotericin). The US Centers for Disease Control has also invested in supporting governments to scale up CrAg screening in these countries and approximately 21 other countries in Africa, who are at varying levels of scale-up. On the basis of our research, it is evident that this rapid adoption of improved screening and treatment strategies has been key to saving tens of thousands of lives in the continent with the highest burden of CM.

Increased availability of treatment

Prior to the ACTA trial, flucytosine was not registered in Africa and no generic formulation existed. The results from this trial incentivised the pharmaceutical industry to manufacture flucytosine and the WHO approved the first generic version of this drug, manufactured by Mylan, in 2018 [6]. Other pharmaceutical companies started working on generic flucytosine in 2019 including Lupin Pharmaceuticals (India), Strides Pharma (India), Macleods Pharmaceuticals (India). This will ensure, for the first time, that CM management will become widely available in many more centres. In those centres unable to provide the gold standard of i.v. amphotericin and flucytosine, an effective oral combination regimen of fluconazole and flucytosine can be used (this is far superior than using fluconazole alone, as was common practice prior to the ACTA trial).

The beneficiaries of two decades of research at LSTM on the biology and behaviour of malaria mosquitoes include: (1) bednet manufacturers, who have translated our research into new ‘resistance-breaking’ nets that now make up a significant share of total net sales; (2) communities in malaria-endemic regions of Africa, who are now at reduced risk of malaria; (3) global policy makers and implementers, who have a strengthened evidence base on which to select malaria-prevention tools; and (4) national malaria control programmes, who have an improved toolset to mitigate against insecticide resistance.

Impact on bednet manufacturers, agrochemical companies and the communities their products protect

LSTM’s research into the mechanisms of insecticide resistance has directly led to the development of new ITNs. Our evidence that blocking P450-based metabolism with the synergist piperonyl butoxide (PBO) can restore pyrethroid efficacy in malaria mosquitoes led to manufacturers developing a new class of nets that contain pyrethroids plus PBO, with the aim of maintaining ITN efficacy even in the face of pyrethroid resistance. Four manufacturers (Vestergaard (Switzerland), Sumitomo Chemical Co., Ltd (Japan), AKA Polymers (India) and Moon Netting (Pakistan)) now produce PBO-pyrethroid nets. These have all been pre-qualified by WHO (a necessary step before most major donors will procure a new type of net). Over 43,000,000 PBO-pyrethroid nets were distributed in Africa in 2020, protecting over 95,000,000 people. Since 2020, 27 of the 40 African national ITN distribution programmes included PBO-pyrethroid nets, with PBO-nets constituting 21% of the market share of nets delivered to Africa for malaria prevention in 2020 [1].

The discovery that malaria vector mosquitoes preferentially contact the top of a net when seeking a bloodmeal led one major net manufacturer (Vestergaard) to incorporate PBO only into the roof panel in their market leading PermaNet 3.0 ®. Since 2017, LSTM have been working with Vestergaard to develop novel bednet prototypes exploiting this aspect of mosquito behaviour. Limiting insecticides to small external net barriers improves the net’s performance, while using less insecticide thereby reducing manufacturers costs, and limiting the risk of adverse effects caused by insecticide exposure [2, 3].

Our clinical trial of the pyriproxyfen-pyrethroid net, Olyset Duo®, demonstrated the potential of insect sterilizing agents to reduce malaria transmission when combined with pyrethroid insecticides in bednets. Although Olyset Duo® is not currently being deployed, the positive results of our trial of ITNs with this mode of action led to a very similar competitor product (Royal Guard, DCT USA that was listed by WHO in 2019) being deployed in Mozambique and Nigeria since 2020 (1,000,000 nets distributed in 2020) [1, 4].

Hemingway established the Innovative Vector Control Consortium (IVCC) in 2005 at LSTM. IVCC is the leading global agency for the development of new insecticides and vector control tools. The consortium has re-formulated two classes of agricultural insecticide that have been in use for indoor residual spraying, a very effective alternative to ITNs for malaria control, since 2014. Rotation of these chemistries has enabled the implementation of resistance management strategies, and these new formulations have been deployed in indoor residual spraying in 30 malaria endemic countries, averting over 4,800,000 malaria cases between 2016 and 2019 [5]. In addition, the work of the Liverpool Insect Testing Establishment (LITE), plus the suite of tools developed by LSTM including the P450 in vitro screen and transgenic mosquito lines, has streamlined the insecticide development pathway, terminating investment in chemistries exhibiting potential resistance liabilities and accelerating the most promising candidates. For example, the multi-national agrochemical company Syngenta (Switzerland) used the LSTM testing pipeline as a critical differentiator to drive candidate selection and investment decisions [6].

Impact on global policy makers, implementation agencies and national malaria programmes

LSTM led the evaluation of PBO-pyrethroid classes of nets pre and post deployment. Our meta analyses of the performance of PBO-pyrethroid versus standard ITNs on mosquito populations, which Ranson presented at Evidence Review Groups on PBO-pyrethroid nets at WHO in 2015 and 2017, led to policy recommendations on use of this net class (WHO 2015, 2017) [7]. We conducted one of only two clinical trials that have demonstrated significant improved public health benefit of PBO-pyrethroid nets in reducing malaria transmission compared to standard ITNs; the scale of this trial was unprecedented and enabled 10,700,000 Ugandans to benefit from the increased protection afforded by this new net class (reduction of 27% in malaria prevalence) whilst the evaluation was ongoing [8].

LSTM vector biologists play a key role in advising WHO. Donnelly was the lead entomologist on the WHO study on the impact of insecticide resistance on malaria control (between 2012 and 2016) which helped raise the profile of the public health threat posed by pyrethroid resistance. We have been members of the WHO Vector Control Advisory Group (VCAG) since its inception in 2014 (Hemingway, Ranson) advising WHO on trial designs, and evaluating results from trials prior to policy recommendations. Wondji is a member of the WHO pre-qualification team of independent assessors who review data packages submitted by ITN manufacturers to determine whether these meet accepted WHO standards [9]

LSTM has made a major contribution to the development of WHO guidelines on resistance monitoring and management, both from the outputs of our research which has informed best practice, and via our participation in WHO committees. For example, Ranson and Donnelly contributed to the 2016 WHO guidelines on insecticide resistance monitoring and Coleman, Hemingway and Ranson were major contributors to the 2012 WHO Global Report on Insecticide Resistance Management in malaria vectors [10]. Via long-term partnerships with African Ministries of Health, we have greatly strengthened capacity in resistance monitoring and supported the interpretation of national data to inform the sub national deployment of different insecticide-based strategies (e.g. Zambia and Equatorial Guinea Insecticide Resistance Management Plans and policy briefs for Malawi [11]).

Positioning snakebite as a priority neglected tropical disease

LSTM has been central to the international effort to increase awareness of the substantial disease burden posed by snakebite that culminated in the WHO recommendation that snakebite be listed as a priority neglected tropical disease. We organised highly influential international meetings that raised the global profile of snakebite, including the Wellcome-funded ‘ Mechanisms to reverse the public health neglect of snakebite victims’ 2015 meeting chaired by Harrison [1], and the 2016 Kofi Annan Foundation meeting, also organized and chaired by Harrison, in which Mr Kofi Annan declared snakebite as “ the biggest public health crisis you’ve never heard of ” [2]. In 2018, Casewell co-organised the Dutch Government funded “ Snakebite: from science to society” international meeting that brought over 300 individuals (scientists, clinicians, pharmaceutical companies, public health practitioners, charities, policy makers, governments and funders) together to discuss solutions for tropical snakebite [3]. These meetings were instrumental in effecting change in international health policy. Initiatives resulting from this series of meetings include, WHO’s 2018 listing of snakebite as a priority NTD (see below), the 2019 WHO strategy to halve snakebite mortality and morbidity by 2030 co-authored by Harrison and Lalloo [4] and Wellcome’s 2019 investment of GBP80,000,000 in snakebite research.

The 2017 WHO recommendation that snakebite be listed as a priority neglected tropical disease. was ratified by the World Health Assembly in 2018 [4] and has galvanised action from several governments. For example, the Kenya Ministry of Health NTD department has established a Snakebite Task Force, which includes a LSTM-research collaborator (Dr George Omondi) in its membership, and written national guidelines [5], that LSTM and its Kenya partners are delivering to hospitals and communities across Kenya. While awaiting full impact assessments, we have already observed increased hospital admission of snakebite victims (Kitui County) and demand for antivenom from Ministries of Health (Kitui & Baringo Counties).

LSTM has led many other advocacy activities that have improved global recognition of the public health burden posed by snakebite including advising and participating in numerous documentaries with a global reach between 2013 and 2019 for the BBC, BBC World, Discovery Channel, China Global Television Network, Natural History Museum and Royal Society for Tropical Medicine and Hygiene [6]. In particular, Harrison had extensive input into the development of a documentary with the Lillian Lincoln Foundation entitled “ Minutes to Die” [6] which highlighted the plights of victims and the scientists seeking to redress the issue.

In 2018, LSTM was a main partner with the Royal Society of Tropical Medicine & Hygiene in the development of the inaugural International Snakebite Awareness Day. This initiative included participation from the Wellcome Trust, the Global Snakebite Initiative, Medecins Sans Frontiers, the Kofi Annan Foundation and Health Action International. Casewell and Harrison filmed a short documentary film on snakebite and contributed to the recording of BBC World visual and audio documentaries on snakebite in Kenya, both of which were used in the inaugural event in London [6]. Casewell’s co-written opinion piece for the general public on the BBC News website in 2019 “Why are so many people still dying from snake bites?” [6] has been viewed over 500,000 times.

Improving snakebite therapies

The EchiTAb Study Group activities resulted in the development of two new, efficacious, safe and cost-effective antivenoms that received National Marketing Authorisations from the Nigerian National Agency for Food and Drug Administration and Control (NAFDAC), in 2005 [7]. A two year evaluation on the impact of the introduction of these antivenoms into Nigeria, conducted between 2009 and 2010, found snakebite mortality decreased from 35-45% in the absence of antivenom to 1.52% after the venom was introduced [8]. In addition, the dose of antivenom required with the new therapeutics was decreased from 6 vials to between 1 and 3 vials, compared with previous products [8], thereby also resulting in a decrease of at least 50% to the cost of treatment to impoverished victims and the health system. Our in-country partners indicate that these pre-REF 2021 efficacy, cost-effectiveness and mortality-reduction figures have remained constant thereafter and the EchiTAb antivenoms remain the standard of care in Nigeria and other countries (see below).

Our findings that adrenaline prophylaxis can reduce severe reactions to antivenom led to the routine recommendation of adrenaline prophylaxis in WHO guidelines in 2016 [9]; adrenaline is included as a strong recommendation in almost all national snakebite guidelines. The routine use of adrenaline prophylaxis has been reported to be associated with reduced mortality from snakebite; some clinicians avoided antivenom use because of their fear of reactions and being able to prevent or manage reactions using adrenaline increased the use of life-saving antivenom [10].

Enabling access to antivenom

As a result of our advocacy on the need for quality assurance processes, WHO have established an ‘antivenom prequalification’ process, by which independent risk benefit analyses following robust laboratory assessment of available antivenoms are performed to ensure the quality of snakebite therapeutics for Africa [11]. The EchiTAb Study Group-developed antivenom EchiTAbG, manufactured by MicroPharm Limited, was the first product to receive WHO-approval via this process in 2019.

The EchiTAb Study Group project also resulted in commercial and reputational benefits to the antivenom manufacturers. Thus, the SME, MicroPharm Limited (UK) benefitted from (i) 5 years investment in their production of EchiTAbG, (ii) ownership of a brand that is now the standard snakebite treatment throughout Nigeria and neighbouring countries, and (iii) an Africa-antivenom production reputation that resulted in its selection to sustain the production/delivery of FavAfrique from Sanofi (2019/20). Similarly, based upon the success of its antivenom (EchiTAb-Plus) in Nigeria, the Costa Rican antivenom manufacturer, Instituto Clodomiro Picado (ICP), is now distributing EchiTAb-Plus to many other countries, including Burkina Faso, Mali, Ghana, Central African Republic and irregularly to other West African countries. While no formal epidemiological studies have quantified the impact this antivenom has had in these countries, the similar pattern of snake envenoming and well documented challenges with poor quality or non-availability of antivenom make it highly likely that there has been a decrease in mortality of at least 33%, as observed in north-east Nigeria [8]. The EchiTAb Study Group project has since become recognised as a model for north-south and south-south collaboration for delivery of significantly improved snakebite therapies to tropical countries in greatest need [12]. Indeed, using the ‘EchiTAb’ model, ICP has established similar new partnerships in Sri Lanka (~2014-2018) and Papua New Guinea (~2012-2016) to deliver new life-saving antivenom products to market in these resource-poor, high snakebite burden, areas [12].

Prof ter Kuile and Dr Hill applied a systematic approach to ensure the translation of research into policy by working with WHO to convene four consecutive Evidence Review Group meetings on malaria in pregnancy (between 2012 and 2017), which reviewed results from research led by LSTM and other partners and made recommendations both to WHO’s Malaria Policy Advisory Committee (MPAC) [1] and regulators (see below). Dissemination and technical support activities targeting policymakers and practitioners were undertaken to support policy uptake in endemic countries, improving pregnancy outcomes of millions of women in malaria-endemic countries.

Update to drug labels of ACTs for treatment of malaria in pregnancy

The safety studies in 1^st trimester pregnancy described above resulted in label changes by the United States Food and Drug Administration (FDA, August 2019), the Coordination Group for Mutual Recognition and Decentralised Procedures at the European Medicines Agency (September 2020), and the WHO pre-qualification team (March 2018) for the use of the ACT artemisinin-lumefantrine in pregnancy [2-4]. The label change requested by the FDA was to lift the restriction on the use of Coartem® in pregnancy, including in the 1^st trimester, based on the results of the 2017 meta-analysis. These label changes affect the use of these drugs in pregnancy by clinical practitioners and enable national malaria programmes to improve the quality of case management in the 1^st trimester by shifting to the more effective 3-day ACT regimens from the current 7-day quinine regimen, which is poorly tolerated and badly adhered to, leading to adverse pregnancy outcomes.

The results were also reviewed by WHO’s MPAC in 2015 (6) which recommended a change from quinine to artemisinin combination therapies (ACTs) as a first-line therapeutic option for uncomplicated malaria in the 1^st trimester, which was subsequently endorsed by WHO’s Technical Expert Group on Malaria Chemotherapy in December 2017 [1]. As a result of the label changes by the Stringent Regulatory Authorities (SRAs), WHO is proceeding and has requested our group to update the meta-analysis with any new data in preparation for the development of an update to the WHO treatment guidelines in 2021. Independent of WHO, Indonesia was the first country (September 2019) to change its national policy for treatment of malaria in 1^st trimester to the ACT, dihydroartemisinin-piperaquine [7], which was already the first line therapy for treatment in all population groups, including in the 2^nd and 3^rd trimester.

WHO’s updated policy on prevention of malaria in pregnancy in sub-Saharan Africa

IPTp with SP: Increasing resistance to SP in parts of Africa led malaria-endemic countries to place pressure on WHO to provide further guidance on whether to continue using IPTp with SP. The LSTM-led studies on the continued effectiveness of IPTp-SP on reducing low birth weight, even in areas with relatively high SP resistance (likely due to the non-malarial effects of SP), led WHO in September 2013 to recommend continued implementation of IPTp-SP in all endemic areas until alternative drugs become available [5].

IPTp with DP: Our research showing the efficacy of dihydroartemisinin-piperaquine, for use in areas with very high SP resistance, and related studies of its acceptability and feasibility presented to WHO’s MPAC in 2015 [6], led WHO to recommend further studies with IPTp-DP to provide definitive evidence for consideration of IPTp-DP for policy in 2021 [8].

Implementation of revised guidelines on prevention of malaria in pregnancy in Africa

Results from our key meta-analysis comparing 3-or-more doses vs the standard 2-dose regimen of IPTp with SP led WHO to revise its guidelines in 2012, and updated in 2014, from 2 doses to monthly doses of SP [9]. The IMPPACT project (between 2016 and 2019), led by Hill, supported the uptake of evidence from the MiP Consortium in African country-level policies and guidelines. In collaboration with the Roll Back Malaria (RBM) Partnership, and the West Africa Health Organisation (WAHO), the MiP Consortium results were disseminated to 21 African countries [10a]. The WAHO meeting in 2017 involving National Malaria Control Programme Managers, M&E Officers, and Reproductive Health Managers from the 15 Economic Community of West African States (ECOWAS) member States, WHO, UNICEF, RBM, research organisations and the private sector, took place in the context of the preparation of country Global Fund applications between 2018 and 2020 [10b]. Countries reached a regional consensus on the implementation of malaria control activities, including the monthly IPTp-SP policy, articulated in the ECOWAS Regional Strategic Plan for Malaria Control and Elimination. WHO’s 2019 World Malaria Report reported that the updated policy had been adopted in 36 endemic countries in Africa [11]. As a result, annually, 32,000,000 pregnancies in Africa continue to benefit from this life-saving strategy for pregnant women annually.

National prevention policy uptake in Asia-Pacific

Results from the prevention trial with dihydroartemisinin-piperaquine (DP) and nested acceptability, feasibility and cost effectiveness studies in Indonesia were discussed with more than 110 ministries of health representatives from 18 countries in the Asia/Pacific region at a dissemination meeting in collaboration with WHO-WPRO and WHO-SEARO regional offices in 2017 [10c]. In 2019, as a direct result of these studies, the Indonesian Ministry of Health requested support from Hill and ter Kuile to evaluate the pilot implementation of IPTp-DP in Papua-Indonesia, and an LSTM-led study funded by the Medical Research Council (MRC) is ongoing.

Tiny Targets protected approximately 1,800,000 people in the 5 countries where 89.6% (34653 of the total 38668 cases) of all g-HAT cases were reported in the last decade (between 2010 and 2019) [1]. Evidence of the impact of Tiny Targets on g-HAT across a range of epidemiological settings led to tsetse control being included in national and global strategies to eliminate g-HAT as a public health problem.

Impact on populations at risk of g-HAT

Following successful trials conducted between 2011 and 2013 (reference 3 & 4 in Section 3), use of Tiny Targets was scaled up in in Uganda and Guinea to cover all g-HAT foci by 2020. Tiny Targets were also adopted by national HAT control programmes in Chad (2014), DRC (2015) and Côte d’Ivoire (2016). The largest deployment was in DRC where the Tryp-Elim programme, funded by the Bill & Melinda Gates Foundation (BMGF) supported the annual deployment of 43,000 Tiny Targets and by 2019 approximately 300,000 people across 5,300km² were protected from g-HAT. A second BMGF-funded programme (“Trypa-NO!”) has supported the scale-up of Tiny Targets in additional countries and, since 2017, a total of approximately 1,500,000 people have been protected in Guinea (1,900km², 200,000 people protected), Chad (960km², 80,000 people), Uganda (3,900km², 1,139,000 people) and Ivory Coast (250km², 170,000 people) [2].

The scale-up of Tiny Targets has had a dramatic impact on disease incidence. In addition to our own data from Chad (reference 4 in Section 2), others have shown that targets reduced the annual incidence of g-HAT in the Boffa focus in Guinea by over 90% (14/1279=1.09% without vector control vs 2/2777=0.07% with vector control) [3]. Continued deployment of Tiny Targets in the Mandoul and Maro foci of Chad has contributed to a decrease from 95 (2014) to 16 (2019) in the total number of cases reported nationally. The development of a tsetse control method that is affordable and practicable for local communities (Tiny Targets can be distributed using bikes and dugout canoes rather than lorries) has strengthened the resilience of control programmes. In Guinea, the Ebola crisis interrupted programmes to screen-and-treat populations for g-HAT and in the Boffa focus, prevalence of g-HAT increased in areas where Tiny Targets were absent but remained low in areas where the local community deployed Tiny Targets [3]. Similarly, deployment of Tiny Targets continued in all countries during the Covid-19 pandemic.

Impact on national g-HAT strategies

Economic [4] and epidemiological models [5] indicated that the addition of tsetse control using Tiny Targets to the standard screen-and-treat strategies accelerates progress towards the WHO elimination goals. For instance, analyses of progress towards elimination goals in DRC suggested that 37 of 43 Health Zones in DRC health zones will require vector control to meet the 2030 elimination goal [5]. Since starting with a pilot project in 2015, deploying Tiny Targets in Yasa Bonga Health Zone, which demonstrated >85% reduction in tsetse numbers [6], activities have now expanded to six further Health Zones (Masi Manimba, Kikongo, Bandundu, Kwamouth, Bulungu and Bolobo) as part of the national strategy to meet the 2030 elimination goal. Theoretical and empirical evidence of the impact of Tiny Targets led the national programmes of Chad (PNLTHA), Cote d’Ivoire (IPR), DRC (PNLTHA), Guinea (PNLTHA) and Uganda (COCTU) to adopt Tiny Targets as part of their national strategies to control g-HAT. Consequently, use of Tiny Targets has increased from 10,000 deployed in 2013 to 100,000 deployed annually in 2020. Over the same period, the aggregate area over which Tiny Targets were deployed increased from approximately 750km² to 13,000km² to protect approximately 1,800,000 people. Recognising its philanthropic and ethical responsibilities, Vestergaard, the manufacturer of Tiny Targets, announced that they will donate all Tiny Targets free from 2020 onwards [7].

Global policy

Our empirical and theoretical evidence combined with outreach and engagement activities with normative bodies led to a 2014 WHO recommendation that tsetse control should be an integral part of the global programme to eliminate g-HAT [8]. Policy makers were engaged through regular visits by LSTM researchers to the headquarters of WHO (Geneva), African Union (Addis Ababa) and national ministries of health, as well as presentations at international meetings organised by WHO [7], the AU’s Pan-African Tsetse and Trypanosomiasis Eradication Campaign (PATTEC) and International Scientific Council for Trypanosomiasis Research and Control (ISCTRC), meetings with the leaders of national programmes [9] and engagement with print and broadcast media [10].

the inclusion of vector control tools has ensured that the WHO’s program to eliminate g-HAT as a public health problem by 2020 is on track with, for example, the specific goal of less than 2,000 new cases reported annually being achieved from 2017 (1,409 cases) onwards (2018, 953 cases; 2019, 864 cases). These low numbers contrast with the decade between 2005 and 2014, prior to the inclusion of vector control, when the number of new cases reported globally ranged between 3,679 (2014) and 15,624 (2005) annually [1].