0. The case of Schistosomiasis and NCD‘s
UNESCO-MARS
Session: Identifying the scientific research priorities for evolving health needs: the case of infectious diseases and women health
Addis Ababa, Nov. 28th
Jutta Reinhard-Rupp
Head of Global Health R&D, Merck

1. Setting the Scene 1 Schistosomiasis in Women
Female Genital Schistosomiasis 2
NCDs impacted by Schistosomiasis
Fertility
Cancer 3
Research Needs
Merck Global Health

2. Schistosomiasis – some Key Facts
258 Mio.
People in need of treatment worldwide
20, ,000 deaths annually
One of the
Most prevalent parasitic diseases in Africa
Most important in terms of public health burden & economic impact
Theodor M. Bilharz
(S. haematobium)
1851, Cairo
Chronic disease caused by a parasitic worm (S. mansoni, S. haematobium, S. japonicum)
Risk
of infection due to exposure to infected water (children, women, fishermen)
Effects
anemia, stunted growth, impaired learning ability & chronic inflammation of the organs
Preventive Chemotherapy (PCT) with praziquantel
To prevent from developing severe late-stage disease (>100 Mio people treated since 2007)

3. Female Genital Schistosomiasis (FGS)
“A case of bilharzia of the vagina” was published in the Lancet in 1899 by F.C. Madden

4. Female Genital Schistosomiasis (FGS)
A call for action against a neglected gynaecological disease (IJP; 2016 V. Christinet et al.)
highly prevalent disease manifestation (> Mio girls & women infected)
one of the most common gynecological conditions in sub-Saharan Africa
FGS results in :
Adnexal masses
Uterine body associated pathology
Vulvo-vaginal pathology
Cervical alterations
Ectopic pregnancies
Cervical schistosomiasis and HIV
Cervical schistosomiasis, HPV and cervical carcinoma
Subfertility & Infertility (Sub-Saharan Subfertility belt)
Mental harm & Stigmatization
Ref.: WHO – FGS Pocket Atlas -

5. Setting the Scene 1 Schistosomiasis in Women
Female Genital Schistosomiasis 2
NCDs impacted by Schistosomiasis
Fertility
Cancer 3
Research Needs
Merck Global Health

6. Infertility and Sub-Fertility
World-wide infertility prevalence: 8-12%
Sub-Saharan Africa “Infertility Belt”: 30% +
Case-control studies have shown a significant association between S. haematobium and infertility (Zimbabwe, Malawi)
Tubal schistosomiasis was found in 40% of cases with primary & secondary infertility (Zanzibar)
Urinary schistosomiasis was found in 38.5% of cases with infertility (Niger)
What would we find out with more awareness, better training and diagnosis?

7. HPV and Cervical Cancer …. and Cervical Schistosomiasis (FGS)
Plausible link between FGS and HPV infection & Cervical Cancer
Chronic disease which can be acquired during childhood, damages the cervical epithelium
Local immune environment becomes favorable for viral infections
FGS characterized by sandy patches, erosion, mucosal bleeding, abnormal blood vessels
HPV vaccination and effective health interventions (Broutet et al., 2013)
=> 14 health-related interventions that are affordable:
screening (for schistosomiasis and defects in vision)
health education (on mosquito-borne diseases, the benefits of exercise, accessing health care, and sexual and reproductive health)
skills building (improving condom usage)
delivery of commodities (anthelminthic drugs), vitamin A supplements, soap and/or bed nets
Cervical Cancer – Cervical Schistosomiasis
Risk of misdiagnosis due to cervical schistosomiasis

8. Setting the Scene 1 Schistosomiasis in Women
Female Genital Schistosomiasis 2
NCDs impacted by Schistosomiasis
Fertility
Cancer 3
Research Needs
Merck Global Health

9. Research needs– FGS should NOT remain the forgotten gynaecological disease
NEED FOR ...
Awareness & Advocacy
Directors of Health Services, incl. Public Health and Family Health
Institutional Care divisions
Health staff (clinicians, public health officers, obstetricians, gynaecology consultants, nurses, CHWs)
Training
Inclusion of FGS in training sessions at all levels; FGS pocket atlas
Research
Disease Research (epidemiology, diagnosis, treatment of younger children)
Social Science Research (how women understand FGS symptoms, who they consult, community messaging, engagement strategies, traditional health networks)
Collaboration
Intensify multi-sectoral collaboration with Ministries of Health/ Water/ Works/ Housing/ Education

10. Global Health R&D at Merck Our Vision
“No more children without a health solution”
Mission:
Synergizing Merck business competencies to deliver sustainability and impact in health solutions addressing major Global Health challenges in most vulnerable populations
One Merck for Children
Healthcare
Life Science
Focus on children
Performance
Materials
Integrated Merck
Diagnostic Devices
Medical Devices
Digital Services
Drugs

11. Global Health R&D at Merck Our Objectives
Integrated health solutions addressing major Global Health challenges
Deliver comprehensive Health Solutions
Focus on Malaria and Schistosomiasis
Concentrate on Children & Women Health
Foster strong external partnerships

12. Synergies within Merck delivering unique benefits to patients
Global Health R&D at Merck
“One Merck for Schisto” : Integrated approach to tackle one of the most neglected tropical diseases
Treatment
Transmission
Synergies within Merck
delivering unique benefits to patients
Detection
Control Program
Merck Healthcare
Pediatric PZQ Consortium
Drug discovery
Disease Management (FGS)
Co-infections
Merck Life Science
& Healthcare
Diagnostics, e.g. Muse Schisto Kit
Merck
PZQ Donation Program
Anti-counterfeiting e.g. The GPHF-Minilab™
eHealth & Education
Merck Innovation Cup
Vector control

14. Lessons learned from literature review
Target organs for FGS
All female genital organs can be involved: the vulva, the vagina, the cervix, the uterus, the Fallopian tubes and ovaries.
From post-mortem studies it appears that the most frequently affected female reproductive organs are the cervix and the uterus body, then followed by the adnexa and the vulvo-vagina.
The clinical presentation of FGS is nonspecific, therefore, diagnosis requires histopathological visualization of the eggs in the lesions.
The lesions are the result of a granulamatous reaction to live or dead eggs.
S. haematobium eggs can be found in the lesions while they can be absent in the urine (by current detection methods).