Mathematical tools to inform sustainable interventions against schistosomiasis in Uganda

Lead Research Organisation: University of Surrey
Department Name: Veterinary Medicine & Science

Abstract

Schistosomiasis is a neglected parasitic disease, second only to malaria in its socio-economic and public-health importance. It is estimated that 240 million people are infected worldwide, most of which belong to the poorest populations in many sub-Saharan African countries. Individuals with this disease, the majority children, acquire the infection when they contact infected fresh water through behaviours such as fishing and bathing, and transmit the disease in areas with inadequate sanitation. There is a drug available to treat cases, and the World Health Organization recommends mass treatment of school-age children or whole communities, depending on the disease burden. However, the drug does not prevent reinfection, which occurs rapidly.

Combining the drug treatment campaigns with improving sanitation infrastructure could hold the key to finally controlling and eventually eliminating this disease in these populations. The question then becomes what is the best intervention, or combination of interventions, that will most rapidly and efficiently reduce disease burden. To tackle this, we propose to develop a mathematical approach, that integrates the biological infection process (i.e. modelling transmission of infections) with individual behaviour and preference for the different interventions (i.e. using a process of modelling interaction between humans called game theory). Combining these two we can find the most suitable combination of interventions that would be successful in the community and decrease disease. We can then explore the costs associated with the combination of interventions, to leverage the most popular and effective, with the most affordable. Another important aspect is evaluating the interventions, once they are implemented, to measure progress. We need to add the use of different diagnostics to our model, as they might provide different information depending on the setting.

The combination of all of this work will then enable us to write recommendations for a field trial to test a control program, with an efficient and popular campaign, which we can effectively monitor. The project is highly multidisciplinary and will bring together expertise from mathematics and biology, as well as, statistics, epidemiology and health economics. We will build the models based on our previous work and additional published materials in the literature, using social and economic data locally collected with our partners in Uganda. The project outcomes, specific to local populations in Uganda, could then be expanded to other countries by engaging with other communities and key stakeholders.

Planned Impact

There are a number of beneficiaries to this project and impact will be maximised through many channels:

Staff working on the project:
Project staff will have the opportunity to develop a range of scientific skills, such as data analysis, mathematical modelling and health economics. In addition, staff will also gain experience in project management, team leading, writing research publications and presenting research to both academics and the general public. There will be opportunities in the project to travel to Uganda and participate in important meetings with key stakeholders, which will enhance the visibility of the project. The project will also impact other academics working in related fields (see academic beneficiaries).

Government bodies and policy makers:
There are three main areas of impact which are of interest to government bodies: disease control, sustainability, and water and sanitation development. The project outcomes will be shared with relevant government bodies and key stakeholders in the countries of interest, and will include time-frames for expected control and elimination as a public health problem. One particular area of interest is reducing dependence on drugs to limit development of resistance as well as preventing or reducing reinfection, and therefore our integrative approach with WASH infrastructure development and associated behaviour change will directly address these concerns.

Ugandan stakeholders and researchers:
One focus of the project is to make the research approachable and applicable in the real world to benefit these rural less developed communities. There will be various meetings along the project's duration to discuss concerns with our partners in Uganda. Resources have also been allocated to organise a meeting at the end of the project with local stakeholders in Uganda to present the project outcomes and maximise the impact of the interventions, as well as a training workshop in health economics, strengthening capacity in Uganda's academic researchers.

Endemic communities:
The work leading up to this project have worked closely with endemic communities with the key focus being on what they want and are willing to either work or pay for. Whilst this project itself will not collect data from endemic communities, the findings will be directly relevant to them as well as needing to be discussed with them. Mini workshops with Acting for Health will be run in the communities after the Stakeholder meeting to gain an understanding of their views of potential interventions as well as to disseminate the findings of the models.

Additional time and funding has been allocated to public engagement and outreach activities (see Pathways to Impact). This includes, but is not limited to, sessions with undergraduate students, outreach activities with the general public and interaction with non-scientific media. This will increase awareness on the problem of schistosomiasis, and Neglected Tropical Diseases in general, and how integrative approaches can provide additional insights for designing control interventions and monitoring.

Publications

10 25 50
 
Description Collaboration with BDI (Oxford University) 
Organisation University of Oxford
Department Big Data Institute
Country United Kingdom 
Sector Academic/University 
PI Contribution Our groups have been collaborating on the development of an individual-based mathematical model for Schistosomiasis. We are working on some extensions to the base model, as well as collating data for model fitting to our setting in Uganda. Our two groups have been collaborating for many years on other diseases, but the collaboration on Schistosomiasis is more recent and was initiated thanks to this project.
Collaborator Contribution The group at Oxford has developed an individual-based mathematical model of Schistosomiasis, which we are adapting for our needs in this project.
Impact Manuscripts are still in preparation.
Start Year 2020
 
Description MRC Uganda Virus Research Institute 
Organisation Medical Research Council (MRC)
Department Medical Research Council (MRC), MRC/UVRI Unit, Uganda
Country Uganda 
Sector Academic/University 
PI Contribution MRC/UVRI are co-investigators on my MRC GCRF FA. We provide guidance and research support from all Glasgow PI and Co-Is.I have paid for my flight from other grants and combined visits to the MRC with ongoing work funded elsewhere. We provide capacity strengthening to two RAs employed by the grant at MRC/UVRI
Collaborator Contribution The main contributions are scientific, and are extensive, with social science knowledge, trainging and experience. The co-I from MRC/UVRI provides guidance and support free of charge. Vehicles are made available to us and we only pay a per diem for the driver.
Impact This is very much a multi disciplinary collaboration, combining social sciences, with my ongoing epidemiology, population genetics and diagnostics work.
Start Year 2017
 
Description Vector Control Division, Ministry of Health, Uganda 
Organisation Ministry of Health, Uganda
Country Uganda 
Sector Public 
PI Contribution During this MRC project: Co-investigators on my MRC GCRF FA.We work closely with VCD, MoH training technicians in economics discrete choice experiments (DCE) and working with them in the field to perform the DCE surveys.
Collaborator Contribution During this MRC project: The training took place in VCD buildings, and was co-organised by VCD technicians, taking up their time.
Impact Multi disciplinary: National and international policy, field epidemiology, parasitology, malacology, anthroplogy, economics, engineering - sanitation solutions.
 
Description Stakeholder meetings in communities, district and at the national and via zoom the international level. 
Form Of Engagement Activity Participation in an activity, workshop or similar
Part Of Official Scheme? No
Geographic Reach International
Primary Audience Study participants or study members
Results and Impact Stakeholder meetings in communities, district and at the national level in person, and via zoom at an international level. These ran through the whole of February and March 2021 and were led by Moses Arinaitwe from the Vector Control Division, Ministry of Health, and Sande Silvester from the Uganda Virus Research Institute. These stakeholder meetings were redesigned due to Covid, with extensive in put from Dr Lamberton, Dr Pickering and Lazaaro Mujumbusi from the MRC project and assisted by Dr Alonso and Dr Janouskova from the EPSRC project. Extensive (one per day) interactive workshops with fisherfolk, students, women, opinion leaders were held in each of the three study communities. groups of 8-12 people per workshop.

In summary, at the start of February 2021, Moses and Sande mobilised each community. They then spent 6 days in total in each community, holding one workshop a day with different groups ( fisherfolk, School-aged children, women, opinion leaders and then a fifth day of a combined group) with 8-12 people. These workshops started with a short presentation of the MRC background, introducing schisto, the life cycle, and also the aims and methods of the study and the WP1 results. followed by an interactive workshop on the participants views on interventions for reducing risk to self (RTS) and risk to others (RTO), with a list of the interventions that the WP2 worked on. As a group they ordered these by what they think are the most popular/might be the best to put in place. This order was photographed and compared to our findings from the discrete choice experiment from WP2. After discussion of these, the top two RTS and RTO were chosen for further discussion with open ended questions such as:
1. How could these be put in place?
2. Who do you think should pay for these?
3. Who do you think should be responsible for maintaining these?
4. How much do you think you would pay for each of these in money/month or time/week
5. If time, what kind of work would you be interested/ happy to do for this? For putting in, or maintaining.
6. What type of work would you not do?

Then for each of these 4 interventions (2 RTS 2 RTO) they discussed facilitators and barriers in turn, in a conversational, workshop manner. Each person was asked in order around the room to suggest a barrier, until the group ran out of suggestions. These were then photographed. and then reordered by group consensus and photographed again. they then discussed facilitators for that intervention before moving on to the next intervention.
After the meeting all attendees were asked in private what % of people they thought would take up each intervention and how much did they think it would cost to put these into place. These individual level data will help inform the priors for the models being run in the EPSRC.

At the end of the five intense workshops, Sande and Moses gave a larger feedback session to a group of no more than 200 people (Covid-19 limits) with a more detailed presentation on a projector. This included more details on methods, numbers etc. and the full results of the WP1 and WP2, with plenty of time for questions.

The exact same format of hte workshops were held with the district and national stakeholders to assess difference between the hierarchies and to provide full feedback of the project to all. The national meetings included zooms and finally a full international meeting will be held at the end of March.

Sande and Moses reported excellent levels of involvement and a strong desire for change. qualitative and quantitative analysis is ongoing of impact, with decisions on what to model in the EPSRC project and applications for intervention trials being strongly influenced by these workshop sessions.
Year(s) Of Engagement Activity 2021