SOCIOECONOMIC BURDEN OF ENDEMIC DISEASES IN AFRICA WITH

SOCIOECONOMIC BURDEN OF ENDEMIC DISEASES IN AFRICA WITH

SOCIOECONOMIC BURDEN OF ENDEMIC DISEASES IN AFRICA WITH EMPHYSIS ON MALARIA Professor Mustafa Idris Elbashir MD, PhD Faculty of Medicine University of Khartoum, Sudan [email protected] [email protected] ED and socioeconomic burden Good health is important for building

vibrant and productive communities, stronger economies, safer nations, and better world. Endemic tropical diseases are the highest contributors to the socioeconomic burden of disease in Africa. indicators for the huge socioeconomic burden of ED in

Africa Years of life lost from premature death, and years of life lived in less than full health High mother, infant, and child mortality

Decreased life expectancy ED are maltreated in Africa Many Africans seek care from several health care providers: Substandard public hospitals run under prevailing weak public healthcare systems Low level treatment providers such as barefaced medicine dealers, wandering drug sellers, and traditional medicine dealers These dealers diagnose and treat

endemic diseases ED are maltreated in Africa People in need of health care might wander between unauthorized practitioners without getting cure for their illnesses for long time. The preference of healthcare provider is usually determined by affordability, nearness to homes, striking unsubstantiated propaganda and advocacy for sold drugs, and the prompt

attention and attitudes of service providers Major EDs in Africa The big three endemic diseases in Africa are malaria, tuberculosis TB, and

HIV/AIDS They have serious direct costs in terms of treatment, treatment seeking, absenteeism from work and school, and funeral expenses in the event of death which is a very common consequence. Morbidity and mortality from these three diseases have a major socioeconomic impact on individuals, communities and nations Major EDs in Africa Endemic diseases in Africa also include a group of diseases called, collectively,

neglected tropical diseases (NTDs). The concept of NTDs emerged recently and has been recognized as a valid way to categorize diseases that affect the poorest individuals NTDs can be transmitted by viruses, bacteria or parasites. NTDs They include multi-cellular helminths that are visible to the naked eye or microscopic single-celled protozoa.

There are many NTDs, but we concentrate on the 18 that have been given priority by WHO. Many otherscholera Ebola..hemorrhagic fevers Existing efforts to combat ED Interventions exist to prevent and control ED with very gratifying results

in some African countries. However, the coverage still remains low in the face of many challenges including; shortage of finance, antimicrobial resistance, political instability, poor health facilities and medical records. The presentation scope Brief account on the socioeconomic

burden of the NTDS, HIV/AIDS, TB and malaria in Africa. Highlight the collective progress made in the fight against these endemic diseases through partnerships and the existing challenges to be faced. Role for FIMA and Turkish

foundations I propose the scale up of NGOs role, including the Federation of Islamic Medical Associations (FIMA) and Turkish government and Foundations, in building capacity of local communities in Africa, to empower community-based delivery of medical and health services, and probably the establishment of centers of excellence for basic and applied research on endemic diseases in Africa..

Partnership with other stakeholders This is to be delivered in close collaboration with official bodies involved in health service provision, and with other stakeholders already exerting appreciable efforts to control or eradicate endemic diseases in Africa such as Carter Center

Socioeconomic burden of (NTDs) Socioeconomic burden of (NTDs) They are defined as a group of infections strongly associated with poverty in tropical and subtropical environments and they are diverse in biological and transmission characteristics.

They spread in 149 countries, affecting more than one billion people, costing developing economies billions of dollars every year. Socioeconomic burden of (NTDs) NTDs blind, mutilate, disfigure and debilitate hundreds of millions of

people in the poorest parts of the world, mainly in Africa. They are now almost restricted to tropical and sub-tropical regions with unsafe water, inadequate hygiene and sanitation, and poor housing conditions. Socioeconomic burden of (NTDs)

More than 70% of countries and territories that report the presence of NTDs are low or lower-middle income economies with limited access to health services. There is great need in the fight against NTDs in these countries for health education, affordable products in the areas of diagnostics, effective drugs,

and insecticides Socioeconomic burden of (NTDs) Challenges such as insecurity and weak health systems continue to prevail in many of these poor countries, inhibiting progress in scaling up control or eradication measures

The following is brief summary of the socioeconomic burden of each of the 18 NTDs selected by WHO. 1-Dengue Dengue is a systemic viral infection transmitted between humans by Aedes mosquitoes It has been estimated that there are 390 million dengue infections per year and up to 100m infections are estimated to manifest annually in more

than 100 endemic countries. No specific treatment or licensed vaccine for dengue It causes flu-like symptoms, joint pains and rashes and is potentially fatal for some patients Vector control programs have failed to contain the disease and worst of all, no specific treatment is available at the moment, and no licensed effective vaccines yet.

WHO target: Reduce cases by more than 25% and deaths by 50% by 2020 public health.. 2-Rabies Dog-mediated rabies is a cause for more

than 95 per cent of human deaths from the disease The virus is transmitted in the saliva of rabid animals and generally enters the body via a wound or bite. There are two forms: furious and paralytic. Furious is the most common form in humans. It causes hyperactivity, hydrophobia, aerophobia, and death by cardio-respiratory arrest within days. Rabies: fearful killer Paralytic rabies causes a slow

progression from paralysis to coma to death. Rabies is one of the most feared human diseases, estimated to cause some 55,000 deaths each year, 95 per cent of them among children from rural poor people in Asia and Africa Rabies: lingering global burden

The global burden estimates for rabies 931,600 disability-adjusted life years (DALYs) One DALY (disability-adjusted life year) can be thought of as one lost year of healthy life. Despite the availability of effective vaccines and messaging tools, rabies will not be sustainably controlled in the near future

3-Yaws Yaws is an infectious, debilitating and disfiguring disease of poverty that mainly affects children in rural communities in tropical areas.

It is caused by the spirochete bacteria Treponema pallidum Yaws: bone destruction Yaws is usually contracted in childhood (75% of cases occur before age 15) and infectious lesions are infrequent after the age of 30

It is characterized by highly contagious primary and secondary cutaneous lesions and non-contagious tertiary destructive lesions of the bones Yaws: disfigurement and disability Painful and itching lesions commonly appear on the upper and lower limbs, fingers, toes, soles of the feet, face, genital areas, and buttocks The tertiary stage is characterized by destruction of tissue, bone, and

cartilage resulting in disfigurement and disability WHO target: Eradication of yaws by 2020 4- Buruli Ulcer Buruli ulcer is the third most common mycobacterial infection worldwide and it is related to the ones that cause leprosy and tuberculosis.

It is endemic in tropical, subtropical, and temperate climates and has been identified in at least 33 countries in Africa. Buruli ulcer: unsightly ulcer The infection starts as a small nodule that later ulcerates, giving rise to an

unsightly ulcer with undermining edges and a cotton wool-like appearance, and thickening and darkening of the skin surrounding the lesion Buruli ulcer: debilitating skin disease Mycobacterium ulcerans produces a toxin, mycolactone, which destroys tissue resulting in large ulcers causing debilitating skin disease with ugly morbidity, often requiring

reconstructive surgery. WHO target: 70% cases cured with antibiotics in all endemic countries by 2020. 5-Trachoma: blindness leader Chlamydia trachomatis, an obligate intraocular bacteria causing trachoma It was the leading cause of blindness in the last century worldwide Trachoma infection afflicts

predominantly young children. The sub-Saharan Africa region currently bears the largest burden Trachoma: from number one to number four blinder In 1990, the WHO reported that 146 million individuals across the globe had active trachoma, 10 millions were in need of surgery, and 8 millions were

blind due to trachoma. In 2002, ~3.6% of the total visual impairment was due to trachoma, and it was the fourth major cause of blindness globally. Trachoma: thanks to Carter Center

The Carter Center's Trachoma Control Program was established in 1998. As a global leader in the fight against trachoma, the Center and partners implemented the World Health Organization endorsed Surgery, Antibiotics, Facial cleanliness, and Environmental (SAFE) strategy for trachoma control

Trachoma can be eliminated In 2015, seven countries, three of them are Africans (China, Gambia, Ghana, the Islamic Republic of Iran, Morocco, Myanmar, and Oman) had submitted reports to WHO of achieving 100% elimination goals of trachoma In Ethiopia, repeated mass antibiotic distributions dramatically reduced infection after 3 to 4 years of treatment

6-leprosy more than 200000 cases annually Mycobacterium leprae, was the first bacterium to be identified as causing disease in humans. Leprosy is a disease that mainly affects the skin, nerves, upper respiratory tract

and eyes. Currently, worldwide, more than 200,000new cases of leprosy are detected annually,many in India, Brazil, Indonesia and sub-Saharan Africa. Progress in leprosy control Earlier World Health Assembly set a goal for elimination of leprosy as a

public health problem, defined as a prevalence of less than 1 per 10,000, by the year 2000. More recently, the WHO has formulated new targets for leprosy reduction of grade-2 disabilities in newly detected cases to below 1 per million population at global level by 2020 7- Taeniasis and cysticercosis These are caused by an infection with T. solium or T. saginata, and Swine are the intermediate hosts of T. solium ,

whereas cattle are the intermediate hosts for T. saginata. Taeniasis, and cysticercosis have been ranked as the most important foodborne parasitic diseases of humans in terms of public health, socioeconomic, and trade impact. Taeniasis and cysticercosis

They are transmitted by eating raw or insufficiently cooked pork or beef containing infective larvae. It was estimated that approximately 300,000 individuals were infected with T. solium cysticercosis globally, resulting in over 28,000 deaths in 2010. Between 2.5 and 5 millions people are estimated to harbor adult tapeworms of T. solium

Taeniasis and cysticercosis In humans, the symptoms of taeniasis are subtle and mild and include abdominal distension, abdominal pain, digestive disorders and anal pruritis but humans can also develop cysticercosis from the tapeworm larvae in multiple tissues and organs, which can be fatal Taeniasis and cysticercosis

In neurocysticercosis (NCC) the symptoms and signs include headaches, blindness, convulsions or epileptic seizures, paralysis, dementia. Muscular or cardiac lesions may also be present or even death. WHO target: Scaled-up interventions in selected countries for control and elimination by 2020. 8- Dracunculiasis (Guinea worm disease)

Dracunculiasis, known as guinea-worm disease, is a crippling disease caused by the parasite Dracunculus medinensis. It is long threadlike worm which grows up to a meter in length It is transmitted exclusively when people drink water that has been contaminated with parasite-infected water fleas. Dracunculiasis (Guinea worm disease) transmission

The female Guinea worm migrates through the body under the skin, causing severe pain, and eventually emerges from the body (usually from the feet), causing an ulcer, fever, nausea and vomiting. Larvae are released into the water and begin the cycle of infection all over again through water fleas Dracunculiasis (Guinea worm disease) was heavy burden in Africa

Guinea worm disease was devastating used to incapacitate people for extended periods of time, making them unable to care for themselves, work, grow food for their families, or attend school. In 1986, the disease afflicted an estimated 3.5 million people a year in 21 countries in Africa and Asia Dracunculiasis (Guinea worm disease) and Carter Center

There is no known curative medicine or vaccine to prevent Guinea worm disease When Ernesto Ruiz-Tiben, the head of Carter Center against guinea worm, began his work to eradicate guinea worm disease more than 30 years ago, he felt it was going to be like dragging a dead elephant through a swamp by its tail. Dracunculiasis (Guinea worm

disease) Eradication Guinea worm disease is set to become the second human disease in history, after smallpox, to be eradicated. It will be soon the first parasitic disease to be eradicated, and the first disease to be eradicated without the use of a vaccine or medicine .public health measures Thanks to the Carter centerstory of success

Extensive collaborative efforts to eradicate Guinea worm disease Through his non-governmental organization, former US President Jimmy Carter championed the cause to eradicate guinea worm disease with corporates and heads of states. He kept up pressure and accountability by visiting affected countries, even brokering a ceasefire in Sudan in the 1990s to allow health workers access to those at risk in South Sudan.

Simple measures with high impact The Center with ministries of health almost stopped the spread of Guinea worm disease by providing health education and helping to maintain political will, in addition to larvicides, water filters and dogged determination.

Carter program helped cut incidence of the disease in 2016 to just 25 cases reported in only four countries South Sudan, Mali, Chad, and Ethiopia Community-based interventions As stated earlier the incidence of the disease was estimated to be 3.5 million in 1986. The success has been achieved through community-based interventions; education and change of behavior:

Teaching people to filter all drinking water and preventing transmission by keeping anyone with an emerging worm from entering water sources. 9- Soil-transmitted helminthiases (STH) transmission

STH are caused by intestinal worms including roundworm, whipworm and hookworm They are among the most common infections worldwide and tend to affect the most deprived communities. They are transmitted by eggs present in human feces, which in turn contaminate the soil in areas where sanitation is poor and sewage is left untreated STH burden

Infected children are physically, nutritionally and cognitively impaired. It is estimated that 576-740 million individuals are infected with hookworms worldwide. Of the infected individuals, about 80 million are severely affected.

WHO policy for control of STH The major hookworm infections are due Necator americanus which is found in the Americas, sub-Saharan Africa, and Asia and Ancylostoma duodenale which is found in more scattered focal environments, namely Europe and the Mediterranean The WHO policy for control of the STH largely centers on two groups, preschool aged children (pre-SAC), and schoolaged children (SAC).

WHO policy for control of STH WHO aims to scale up mass drug administration (MDA) for STH, so that by 2020, 75 % of the pre-SAC and SAC in need will be treated regularly. In 2013, global coverage of those in need was 39 % for SAC and 49 % for pre-SAC. WHO policy for control of STH

In 2015, STH moved from yellow to green in the progress score card chart (recently developed by Uniting to Combat NTDs), in part due to better coordination between UNICEF and WHO which has led to an improvement in reporting of coverage for pre-SAC 10- Foodborne trematodiases Foodborne trematodiases are a group of infections caused by trematode

worms (known as flatworms or flukes). People become infected by eating raw or poorly cooked fish, crustaceans and vegetables that harbor the minute larvae of the parasites. Foodborne trematodiases burden Recent estimates indicate that at least 56 million people suffer from one or more foodborne trematode infections

(clonorchiasis, opisthorchiasis, fascioliasis, paragonimiasis and others). Cases of trematodiases have been reported from more than 70 countries worldwide. Foodborne trematodiases burden Tropical fasciolosis caused by Fasciola gigantica infection is one of the major diseases infecting ruminants in the

tropical regions of Asia and Africa. It causes a significant economic loss in livestock industry in developing and underdeveloped countries for more than 3.2 billion US dollars per annum. Foodborne trematodiases control The WHO has been aiming to control morbidity due to foodborne

trematodiases by the inclusion of these infections in the mainstream preventive chemotherapy strategy with the necessary veterinary publichealth support. FT- WHO target By 2020: 75% of the at-risk population will have been reached by preventive chemotherapy

Morbidity associated with foodborne trematode infections will be under control in 100% of the endemic countries 11- Lymphatic filariasis Lymphatic filariasis (LF) commonly known as elephantiasis, is a mosquitotransmitted parasitic disease caused by infection with Wuchereria bancrofti, Brugia malayi, or B. timori, in tropical and subtropical regions People of all ages can be infected and

symptoms of an infection in childhood can appear much later in life. Lymphatic filariasis The worms live in, and cause blockage of, the lymphatic system that normally returns fluids in our extremities to the circulatory system.

This blockage results in fluid collection in the tissues (most commonly the legs and genitalia), severe swellings, and periodic fevers from bacterial infections of the collected fluids. Lymphatic filariasis A long-standing infection with lymphatic filariasis results in an irreversible condition called

elephantiasis, in which there is a marked enlargement and hardening of the limbs so that they resemble those of an elephant, and patients suffer from persistent recurring fevers Lymphatic filariasis burden Approximately 120 million people are infected by lymphatic filariasis, and 1.1 billion are at risk of infection. In endemic communities as many as 10 percent of women and men can be affected with swollen limbs, and 50

percent of men can suffer from the mutilating disease of their genitals Elephantiasis Lymphatic filariasis burden These physical disfigurations result in

social stigma with significant social and economic consequences for patients, families, and communities Global strategy for elimination of LF The global LF elimination strategy includes stopping the spread of infection through annual Mass Drug Administration( MDA) of albendazole together with either ivermectin or

diethylcarbamazine (DEC) to eligible individuals in affected areas for 4-6 years, and alleviation of suffering through morbidity management and disability prevention (MMDP). Good progress in control of LF MDA has been implemented in 63 of the 73 endemic countries. 556 million people in 39 countries were treated during 2015, the cumulative total of treatments since 2000 now exceeds 6.2 billion

Thank to the Carter centerMerck,. GlaxoSmithKline.. very gratifying results.. Eliminated in some non African countries Nigeria good progress?? 12- Onchocerciasis Human onchocerciasis or river blindness is caused by the filarial nematode Onchocerca volvulus and transmitted by the tiny black flies that live by fast-flowing water from person

to person Once inside the body, the larvae of the worms migrate to the skin, eyes and other organs, where they grow into adult worms that can live in the body for up to 15 years Onchocerciasis Onchocerciasis burden The disease causes skin lesions, severe itching and visual impairment,

including permanent blindness, reduces an individual's ability to work and learn, and can shorten life expectancy by up to 15 years. More than 99 per cent of infected people live in 31 countries in subSaharan Africa Onchocerciasis strategy for elimination It is earmarked for elimination by the

WHO as articulated by the 2012 Roadmap and the London Declaration on Neglected Tropical Diseases The principal strategy to achieve elimination is mass drug administration (MDA) with ivermectin ..Prof Mamoun..Carter center. Onchocerciasis progress towards elimination

Good progress towards elimination has also been made in Africa which bears 99% of the onchocerciasis burden, with notable successes in regions of Mali, Senegal, Nigeria, Sudan and eastern Uganda Onchocerciasis good progress towards elimination The Carter Center and its partners have successfully broken river

blindness transmission in Uganda and Sudan by providing twice per year Mectizan treatments Eliminated from Colombia (2013), Ecuador (2014), Mexico (2015), and Guatemala (2016). Onchocerciasis 13-Schistosomiasis urogenital or intestinal

Schistosomiasis or bilharzia is a waterborne parasitic infection. There are two major types of schistosomiasis disease manifestations: urogenital schistosomiasis (most prevalent in Africa) caused by Schistosoma haematobium, and intestinal schistosomiasis, caused by, depending on the tropical region of the world, either S. intercalatum, S. mansoni, S. japonicum, S. guineensis or S. mekongi

Schistosomiasis transmission People are infected during routine agricultural, domestic, occupational and recreational activities which expose them to infested water. It is caught through fresh water that contains the larvae of worms. The parasite can live for years in the veins near the bladder or intestines, laying eggs that pass out of the body in urine or feces and reinfect water sources..

Schistosomiasis transmission Snails are infected when fresh water is contaminated by eggs excreted in human urine or feces. Infected snails release larvae that infect humans when they expose their skin to water contaminated by the snails Schistosomiasis burden

It results in a debilitating chronic disease with extensive morbidity and organ pathology. It is endemic in 76 countries worldwide, with about 207 million people infected of which 123 million are children.

The majority (88%) of the people infected with schistosomiasis live on the African continent Schistosomiasis burden Schistosomiasis is implicated in several clinical conditions including bladder cancer leading to death, liver periportal fibrosis, cirrhosis,

hydronephrosis, reproductive complications, and human immunodeficiency virus (HIV) transmission and fast progression to acquired immune deficiency syndrome (AIDS) in adults Schistosomiasis burden It is the most deadly of the neglected tropical diseases and it is the second most common parasitic disease, after malaria. In terms of socioeconomic and public

health impact, schistosomiasis is second only to malaria as the most devastating parasitic disease in tropical countries Schistosomiasis control Nigeria is the most endemic country for schistosomiasis, with approximately 20 million people, mostly children, needing treatment.

For schistosomiasis, main control strategy is preventive chemotherapy (prazequantel) in which several countries in Africa have now embarked.. Bilharzia 14- Echinococcosis zoonotic disease

Human echinococcosis is a zoonotic disease caused by tapeworms of the genus Echinococcus. It occurs in 4 forms: cystic echinococcosis, also known as hydatid disease or hydatidosis, caused by infection with Echinococcus granulosus

Alveolar echinococcosis, caused by infection with E. multilocularis; polycystic echinococcosis, caused by infection with E. vogeli; and unicystic echinococcosis, caused by infection with E. oligarthrus. Echinococcosis: two major forms The two most important forms of medical and public health relevance in humans, are cystic echinococcosis (CE) and alveolar echinococcosis (AE)

The disease has the highest incidence in countries where sheep are raised with the help of dogs Echinococcosis burden In endemic regions, human incidence for HD can reach >50/100,000 person per year, and prevalence levels as high as 5%10% may occur in parts of East Africa, Central Asia China, Argentina,

and Peru Both cystic echinococcosis and alveolar echinococcosis represent a substantial disease burden. Echinococcosis burden More than 1 million people are affected with echinococcosis at any one time. Echinococcosis is often expensive and

complicated to treat, and may require extensive surgery and/or prolonged drug therapy. Many of the patients will be experiencing severe clinical syndromes which are life-threatening if left untreated. Echinococcosis burden Even with treatment, people often face reduced quality of life. The most common hydatid cyst sites in

humans are the hepatic, 60%70% of cases, followed by lung and brain In livestock, the prevalence of cystic echinococcosis found in slaughterhouses in hyperendemic areas of South America varies from 20%95% of slaughtered animals Echinococcosis burden The 2015 WHO Foodborne Disease Burden Epidemiology Reference Group (FERG) estimated echinococcosis to be

the cause of 19300 deaths and around 871 000 disability-adjusted life years (DALYs) globally, each year. Annual costs associated with cystic echinococcosis are estimated to be US$ 3 billion for treating cases and losses to the livestock industry. 15-Chagas disease epidemiology It is also known as American trypanosomiasis, and it is potentially

life-threatening illness. The etiologic agent that causes Chagas disease is the protozoan parasite Trypanosoma cruzi (T. cruzi). The parasite is transmitted by popularly known as the kissing bug Chagas disease: clinical In humans, Chagas disease manifests in acute and chronic phases.

The acute phase has mild symptoms that may last for approximately two months. In the chronic phase, the majority of cases are of the asymptomatic indeterminate form, which may last a lifetime

Chagas disease: pathology The parasite can move to the muscles of the heart or bowels, where it can cause severe damage to organs The most important health consequence of Chagas disease is cardiomyopathy, which over a lifetime occurs in 20 to 40%

of infected persons with an incidence of 1.85% persons per year. Estimates of mortality attributable to Chagas disease vary considerably (between 0.2% and 19.2% annually) Chagas disease burden Estimates of the number of infected individuals in the world have decreased from approximately 20 million in 1981, to 7-8 million in 2014. The majority of infected individuals live in 21 countries of Central and South

America. The disease has spread to other continents over the past century as global population movements have increased. 16- Leishmaniasis Leishmaniasis is a parasitic disease caused by intracellular protozoan parasite, Leishmania and transmitted by the bite of a certain female sandflies of Phlebotomus and

Lutzomyia species. Leishmaniasis is classified as cutaneous (CL), visceral (VL), and mucocutaneous (MCL) by clinical manifestations and it is among the worlds six major tropical diseases. Leishmaniasis burden

It ranks third in disease burden in disability-adjusted life years (DALY) caused by neglected tropical diseases, and is the second most frequent cause of parasite-related deaths after malaria. It is endemic in 98 countries and causes significant morbidity and mortality mainly Eastern Africa which is the second-highest-burdened region, after the Indian subcontinent. Leishmaniasis burden Overall, annual prevalence is 12 million

and the population at risk is approximately 350 million. The global burden of visceral leishmaniasis (VL) alone is estimated at 0.2 to 0.4 million cases, resulting in 50,000 deaths every year, if left untreated, the fatality rate of VL is as high as 100%; in some areas. Leishmaniasis: control progress Combined WHOs Roadmap and the London declaration have accelerated

interventions since 2012 with significant levels of progress. There was 82% reduction in reported cases of visceral leishmaniasis (VL) in Bangladesh, India and Nepal. WHO target is the elimination of the visceral form on the Indian subcontinent, not Africa, by 2020 Leishmaniasis

17- Sleeping sickness Known as human African trypanosomiasis, (HAT) It is transmitted by the bite of the Glossina, commonly known as the tsetse fly. Trypanosomes cause a variety of diseases in man and domestic animals in

Africa, Latin America and Asia. Trypanosoma brucei gambiense and T. b. rhodesiense cause human African trypanosomiasis Sleeping sickness burden Infected people typically suffer fevers, headaches and joint pains followed by confusion, poor co-ordination, numbness and trouble sleeping.

70 million population are at risk of getting HAT Trypanosomiasis Sleeping sickness control progress Significant progress after HAT has been included in the WHO NTD

roadmap (2012) as one of the diseases targeted for elimination as a public health problem by 2020. This progress has been demonstrated by 89% drop in new HAT cases between 2000 and 2015. 18- Mycetoma

It can be caused by bacteria actinomycetoma, or fungi eumycetoma, and typically affects poor communities in many tropical and subtropical regions. It is an infection of subcutaneous tissues resulting in mass and sinus formation and a discharge that contains grains. The lesion is usually on the foot but all parts of the body can be affected.

Mycetoma Mycetoma burden Despite its distressing deformities, disability, high morbidly, and negative socioeconomic impacts on patients, communities, and health authorities it enjoys meagre national and international

attention and recognition A major problem in mycetoma is that most of the patients are of poor socioeconomic and health education status and hence the late presentation, poor treatment compliance and high follow-up dropout rates. Mycetoma burden It is still challenging and hard to treat patients with mycetoma; in particular eumycetoma. The current treatment is still not optimal and disappointing.

To cure, this disease both extensive and destructive surgery and prolonged antifungals treatment are necessary. The progress in control or elimination of NTDs Global partners for control of NTDs The WHO has been the major actor and

coordinator of efforts to fight against NTDs. It succeeded to bring many global stakeholders together in one forum. The first global partners meeting on NTDs was held in 2007, and adopted the theme, Collaborate. Accelerate.

Eliminate. Global partners for control of NTDs Following the meeting a variety of local and international stakeholders have worked alongside ministries of health in endemic countries to deliver qualityassured medicines, and provide people with care and long-term management. Roadmap and London

declaration 2012 In 2012 and inspired by the declared WHO NTDs Roadmap, partners signed the London Declaration on Neglected Tropical Diseases through which they pledged to support WHO in the control and elimination of 10 neglected tropical diseases by 2020. Global partners meeting 2017

The most recent Global Partners Meeting on NTDs was held in Geneva, 19 April 2017. WHO presented the fourth report which showed remarkable achievements in the fight against NTDs. Representatives of Member States, donor agencies, foundations, the private sector, academia and various stakeholders attended the meeting. Progress in one decade 20072017

The fourth report reflected the achievements of the past decade, and declared to sustain support towards the 2020 WHO Roadmap targets. Partners were called to facilitate availability of resources needed beyond 2020 Among the achievements of the past decade an estimated 1 billion people received treatment in 2015 alone. Dr Margaret Chan-EX WHO

director WHO has observed record-breaking progress towards bringing ancient scourges like sleeping sickness and elephantiasis to their knees, said WHO EX-Director-General, Dr Margaret Chan. Over the past 10 years, millions of people have been rescued from disability and poverty Thanks to one of the most effective global partnerships in modern public health.

WHO report (2017) In a recently published WHO report (2017), Integrating neglected tropical diseases in global health and development, it has been clearly demonstrated how strong political support, generous donations of medicines, and improvements in living conditions have led to sustained expansion of disease control programs

in countries where these diseases are most prevalent. Achievements in figures One billion people were treated for at least one neglected tropical disease in 2015 alone.

one billion people in 88 countries have benefited from preventive chemotherapy in 2014. Five hundred and fifty six million people received preventive treatment for lymphatic filariasis (elephantiasis) and more than 114 million people received treatment for onchocerciasis (river blindness); 62% of those requiring it. Achievements in figures Only 25 human cases of Guinea-worm disease were reported in 2016, putting

eradication within reach. Cases of human African trypanosomiasis (sleeping sickness) have been reduced from 37000 new cases in 1999 to well under 3000 cases in 2015. Achievements in figures Trachoma, the worlds leading infectious cause of blindness has been eliminated as a public health problem in Mexico, Morocco, and Oman.

More than 185 000 trachoma patients had surgery for trichiasis worldwide More than 56 million people received antibiotics in 2015 alone Achievements in figures Concerning visceral leishmaniasis in 2015, the target for elimination was achieved in 82% of sub-districts in

India, in 97% of sub-districts in Bangladesh, and in 100% of districts in Nepal. Only 12 reported human deaths were attributable to rabies in the WHO Region of the Americas in 2015, bringing the region close to its target of eliminating rabies in humans by 2015. Important new recommendation 2017

The partners meeting 2017 also stressed the importance of integrating NTDs in the Global Health and Development (GHD), and to be part of the Universal Health Coverage (UHC) policy which has been recommended in the 58th World Health Assembly resolution in 2005. Universal Health Coverage(UHC)

UHC means all people receiving the health services they need, including health initiatives designed to promote better health (such as antitobacco policies), prevent illness (such as vaccinations), and to provide treatment, rehabilitation, and palliative care (such as end-of-life care) of sufficient quality to be effective while at the same time ensuring that the use of these services does not expose the user to financial hardship.

Universal Health Coverage(UHC) In 2013, the World Health Assembly approved Resolution WHA 66.12, which defined strategies for NTDs with clear targets and milestones for 17 NTDs, and endorsed the WHO NTDs-Roadmap goals linking NTDs to (UHC). Thus, countries were encouraged to plan for stepping-up implementation of the UHC which entails integration of NTDs into regular health services with improved quality.

Five strategies for addressing NTDs Thus, in this setting NTDs are to be addressed through five strategies: preventive chemotherapy, intensified disease management, vector control, veterinary public health measures for zoonotic neglected diseases, and through improved water and sanitation.

Effective partnership in the fight against NTDs In the fight against NTDs emphasis is placed on building partnerships for change among international agencies, governments, nongovernmental organizations, corporations, national ministries of health, and most of all, with people at the grass roots. People at the grass root level are helped to acquire the tools, knowledge, and resources they need to transform their

own lives Thanks to those and others The WHO Carter Center Health Programs Drug companies such as Merck Bill & Melinda Gates Foundation . The Carter Center

Since 1986, The Carter Center has led the international campaign to eradicate Guinea worm disease, working closely with ministries of health and local communities, the U.S. Centers for Disease Control and Prevention, the WHO, UNICEF, and many others. The Carter Center

Inspired by the successful eradication of smallpox in 1977, the International Task Force for Disease Eradication (ITFED) has been formed at The Carter Center in 1988 to evaluate disease control and prevention and to see the potential for eradicating other infectious diseases. The Carter Center

Thus, in addition to sponsoring and hosting the ITFDE meetings, Carter Center health programs address two of the diseases currently identified by the ITFDE for eradication, dracunculiasis and lymphatic filariasis, and three diseases identified for elimination or better control, onchocerciasis,, trachoma, and schistosomiasis. The center uses health education and simple, low-cost methods The Carter Center

Scientists and notable international health organizations serving on the task force have identified additional diseases that potentially could be eradicated, thereby dramatically and permanently improving the quality of life for many millions of the world's poorest people. These diseases include poliomyelitis, mumps, rubella, measles, and yaws The socioeconomic burden

of three big endemic diseases in Africa HIV/AIDS, TB and malaria HIV/AIDS burden HIV infection represents a global health concern. It has an extremely uneven

geographical distribution, with SubSaharan Africa bearing more than twothirds of the global burden. HIV/AIDS is by far the leading cause of premature mortality in sub-Saharan Africa and the fourth-biggest killer worldwide HIV/AIDS burden In sub- Saharan Africa, HIV prevalence among adults had reached around 7.4%, rising to over 20% in some

settings At the end of 2004, an estimated 39 million people globally were living with HIV, and there were 3.1 million AIDS deaths, including 510,000 children HIV/AIDS burden In 2011, 34 million people were living with HIV globally, 3.3 million were children under 15 years and 16.7

million were women In 2015, the UNAIDS Program estimated that 36.7 million people were living with HIV globally, and 1.1 million people died in the same year from AIDS resulting from HIV infection.39.34.37..ART HIV/AIDS: progress in control

Progress has been made on some fronts. Provision of millions of people living with HIV in LMICs with antiretroviral treatment (ART) June 2016 around 18.2 million, or 49%

of people living with HIV (PLHIV), were taking ART HIV/AIDS: progress in control The United Nations Program on HIV/AIDS (UNAIDS) World AIDS Day Report 2012, reported a 50% reduction in HIV incidence in 25 LMICs between 2001 and 2011 In Sub- Saharan Africa, the number of

newly infected children declined by 24% between 2009 and 2011 new strategy.. New strategy for AIDS control The importance of accelerating access to diagnosis, treatment, and viral suppression as significant elements in ending the epidemic has prompted the UNAIDS in 2014 to release the HIV 9090-90 target. The 90-90-90 target states that by

2020, 90% of individuals living with HIV will know their HIV status, 90% of people with diagnosed HIV infection will receive antiretroviral treatment (ART), and 90% of those taking ART will be virally suppressed. The 90-90-90 target Data has been obtained from 82 countries between 2010 - 2016, representing 33.8 million (92%) of the 2015 global estimate of PLHIV.

Of the 82 countries, only Sweden has achieved the 90-90-90 target. Data on PLHIV diagnosed were available for 51 of 82 countries, data for those on ART indicator for 80 of 82 countries, and data for viral suppression for 53 of 82 countries. The 90-90-90 target in Africa Care continua with viral suppression estimates were available in the public

domain from only nine countries in sub-Saharan Africa (Kenya, Malawi, Mauritius, Namibia, Rwanda, South Africa, Swaziland, Uganda, and Zimbabwe), representing only 35% of the 2015 HIV burden. More effective initiatives are needed for Sub Saharan Africa . Socioeconomic burden of tuberculosis (TB) in Africa Tuberculosis is the second greatest

killer worldwide due to a single infectious agent after HIV/AIDS. It kills nearly 1.7 million people annually, most of them in their prime productive years. Over 95% of TB deaths occur in LMICs with the highest burden in Africa and Asia. TB burden in Africa

Africa has 24% of the worlds TB cases, and the highest rates of cases and deaths per capita. The emergence of drug resistant strains, the spread of HIV/AIDS, enhanced susceptibility to tuberculosis, as well as the growing number of refugees and displaced peoples

Deadly combination: TB and HIV/AID Although the MDG target to halt and reverse the TB epidemic by 2015 is already achieved, the disease burden remains enormous with resurgence in many areas due to HIV/AIDS. An estimated 13% of the TB cases in

2011 were co-infected with HIV and 430,000 deaths were among the HIVpositive population MDR and XDR burden The burden of multidrug-resistant (MDR) and extensively drug-resistant (XDR) tuberculosis has evolved in several tuberculosis-endemic countries. Approximately 20% of tuberculosis

isolates globally are estimated to be resistant to at least one major drug (first-line or group A or B second-line), with approximately 10% resistant to isoniazid. MDR and XDR burden WHO has defined multidrug-resistant (MDR) tuberculosis as resistance to at least isoniazid and rifampicin, when first-line therapy is unlikely to cure the

disease and a switch to a second-line drug regimen is recommended. XDR TB is defined as drug-incurable or totally drug-resistant tuberculosis. The socioeconomic burden of Malaria in Africa Malaria continues to have a severe

socioeconomic impact in Sub Saharan Africa and a major impediment to health, where it frequently takes its greatest toll on very young children and pregnant women. A child dies every minute from malaria in Africa where it is estimated that 9 out of 10 malaria deaths occur. 20% of all child death in

Africa The consensus view of recent studies and reviews is that malaria causes at least 20% of all deaths in children under- 5 years of age in Africa Malaria can also be spread to the fetus during pregnancy as well as before and/or during childbirth resulting the so called congenital malaria which can cause infant death and low birth weight.

How does it kill children First, an overwhelming acute infection, which frequently presents as seizures or coma (cerebral malaria), Second, repeated malaria infections contribute to the development of severe anaemia, which substantially increases the risk of death. Third, low birth weight, frequently the consequence of malaria infection in pregnant women, is the major risk factor for death in the first month of life.

How does it kill children Repeated malaria infections make young children more susceptible to other common childhood illnesses, such as diarrhoea and respiratory infections, and thus contribute indirectly to mortality Perpetuate poverty and ignorance

It is one of the causes of household poverty because it results in absenteeism from the daily activities of productive living and income generation Malaria also continues to prevent many school children from attending school due to illness, diminishing their capacity to realize their full potential. Children who survive malaria may suffer long-term consequences of the infection.

uncontainable burden in Africa Demographic and health surveys (DHS) indicate that less than 40% of malaria morbidity and mortality is seen in formal health facilities in Sub-saharan Africa. In 2013, there were 528 000 deaths from malaria and about 78% of these were children under 5 years of age. In 2015, 88% of global cases and 90% of global deaths were still in the Africa

uncontainable burden in Africa In all malaria-endemic countries in Africa, 2540% of all outpatient clinic visits had been for malaria. In these same countries, between 20% and 50% of all hospital admissions are a consequence of malaria

Factors accounting for the continued burden factors accounting for the continued malaria burden in Africa, include: Climate changes, poverty, weak health and public infrastructures, emerging drug and insecticide resistance, massive population and demographic shifts, and high costs of containment and therapy.

Recent progress in control However, due to concerted and highly scaled efforts in the fight against malaria between 2000 and 2015, the number of malaria cases declined by 42% while the malaria death rate declined by 66% in the Africa. Despite these successes made by new

effective measures the malaria burden is still startling New effective measures The reduction of malaria burden is due to: Improved availability and use of insecticide-treated nets (ITNs), Diagnosis-based treatment with artemisinin-based combination therapy (ACT), Engagement of communities in malaria control, Strengthening capacity in vector

control Insecticide-treated nets (INTs) Insecticide-treated nets (INTs) are highly effective in reducing malaria mortality in young children. They are low- cost and highly effective way of reducing the incidence of malaria in people who sleep under them, and they have been conclusively shown in a series of trials to

substantially reduce child mortality in malaria-endemic areas of Africa Insecticide-treated nets (INTs) Almost all malaria-endemic African countries now have active programs under way to encourage ITN use, and most of these countries support a variety of different mechanisms to increase net coverage. ITNs and the insecticide to treat them

can now be purchased in small shops and markets and even on street corners in many endemic African countries. Insecticide-treated nets (INTs) Major efforts are now being made in several African countries to provide subsidized ITNs to the most vulnerable

groups, young children and pregnant women. New technological developments promise nets that will retain insecticidal activity for many years, and novel ways of encouraging regular net treatment with insecticide should make it possible to increase the proportion of nets that are effectively treated long-lasting insecticidal nets (LLINs) WHO prompted industry to develop longlasting insecticidal nets (LLINs), readyto-use, factory-pretreated nets that require no further treatment during their

expected lifespan of 45 years. LLIN is already commercially available and the current price is around US$ 5 per net, The Roll Back Malaria (RBM) partnership is facilitating technology transfer and stimulating local production of LLINs in Africa Antimalarial drug resistance Antimalarial drug resistance has

become one of the greatest challenges in malaria treatment. Since the 1980s, parasite resistance to chloroquine, the cheapest and most widely available antimalarial drug, has emerged as a major challenge since it has lost its clinical effectiveness in most parts of Africa. Antimalarial drug resistance Unfortunately, resistance to the most

common replacement drug, sulfadoxinepyrimethamine, has also emerged, especially in Eastern and Southern Africa WHO recommends artemisinin-based combination therapy (ACT), which is highly efficacious and promises to delay emergence of resistance.??. Home-based management of fever (HBMF)

Home-based management of fever (HBMF) is a promising strategy for improving the coverage of prompt effective treatment Recent studies indicate that home treatment, supported by public information and pre- packaging (as an aid, to ensure that patients take the full treatment course at the right time), can help to reduce malaria mortality in

children. Many publications Mass drug administration (MDA) One of the adopted approaches is mass drug administration (MDA) which involves the time-limited distribution of drugs to a target population, irrespective of infection status.

It has been used only sporadically against malaria in most settings, and cluster-randomized trials Mass drug administration (MDA) In September, 2015, WHOs Malaria Policy Advisory Committee recommended for the first time the use of MDA in specific circumstances: When transmission is close to being interrupted, vector control, effective surveillance, and access to case

management are at high coverage, and importation of infection is minimal Mass drug administration (MDA) It can also be applied in areas which are under threat of multidrug resistance, or for malaria epidemics or during complex emergencies. Malaria vaccines

During the last thirty years scientists have been working hard to get long lasting vaccines for malaria without any real success so far. Recently, a partially protective vaccine candidate, RTS,S, has been in trials Phase IIb trial in Mozambique found that the vaccine offered partial protection for young children, cutting their risk of severe malaria by 58%..... Malaria burden during

pregnancy P. falciparum infection during pregnancy is estimated to cause an estimated 75 000 to 200 000 infant deaths each year. Despite the toll that malaria exacts on pregnant women and their infants, this was, until recently, a relatively neglected problem, with less than 5% of pregnant women having access to effective interventions in Africa.

Malaria burden during pregnancy For many years WHO recommended that pregnant women in malaria endemic areas should receive an initial antimalarial treatment dose on their first contact with antenatal services, followed by weekly chemoprophylaxis Malaria burden during

pregnancy In 2000, the WHO Expert Committee on Malaria recommended that intermittent preventive treatment (IPT) with an effective, preferably onedose, antimalarial drug, should be made available as a routine part of antenatal care to women in their first and second pregnancies in highly endemic areas. Intermittent preventive

treatment (IPT) This strategy provides at least two treatment doses of an effective antimalarial at routine antenatal clinics to all pregnant women living in areas at risk of endemic falciparum malaria At present, sulfadoxinepyrimethamine (SP), given at a therapeutic dose, is the single- dose antimalarial with the best

overall effectiveness for prevention of malaria in pregnancy in areas with high transmission, and low resistance to SP. intermittent preventive treatment (IPT) Studies in Kenya and Malawi have shown that IPT with at least two treatment doses of SP is highly effective in reducing the proportion of women with anaemia and placental

malaria infection at delivery. High cost management Government annual spending on all health care is low in most African countries, typically less than US$ 15 per person. The costs of malaria control are high:

artemisinin-based combination drugs to treat resistant malaria are likely to cost US$ 13 per treatment, and ITNs cost around US$ 5. Most of the costs of preventing and treating malaria in Africa today are in fact borne by people themselves which may contribute to poverty Control versus eradication

During the 1950s and 1960s, the malaria eradication campaign successfully eliminated the disease in countries with temperate climates and in some countries where malaria transmission was low or moderate The emergence of drug and insecticide resistance, coupled with concerns about the feasibility and sustainability of tackling malaria in areas with weak infrastructure and high transmission, brought an end to the eradication era.control

Malaria control In the last three decades the international community began to appreciate that the malaria burden was unacceptably high and worsening, particularly in Africa, and that real reductions in malaria mortality and morbidity were possible with existing but under used tools and strategies.

Malaria control alliances Many stakeholders have already been involved in malaria control. Formal partnerships have been created and a statement of intent issued, indicating what will be achieved, and how. Resources have been mobilized from partners and systems are set up to monitor achievements in rolling back malaria.

Partnership on malaria control In 1992, malaria control was reestablished as a global health priority by a Conference of Ministers of Health held in Amsterdam Between1991-1998 malaria control expertise and capacity were expanded and strengthened, particularly in Africa, especially through the project for Accelerated Implementation of Malaria Control

The Multilateral Initiative on Malaria, WHO/TDR The Multilateral Initiative on Malaria formed by WHO/TDR in 1997 . In1998 the Roll Back Malaria (RBM) Partnership was launched and consensus on the core technical strategies for tacking malaria established In 2000 the United Nations declared 20012010 the Decade to Roll Back Malaria in developing countries, particularly in Africa

Roll Back Malaria The goal of Roll Back Malaria has been to halve the burden of malaria by 2010. Targets for specific intervention strategies were established at the Abuja Malaria Summit, April 2000, attended by heads of states in a historic meeting, Heads of states expressed their personal commitments to tackling

malaria and to establish targets for implementing the technical strategies Roll Back Malaria Roll Back Malaria has been supporting efforts to improve the early recognition of, and effective and timely response to, malaria epidemics

Indoor residual spraying which plays an important role in malaria vector control, especially in the control of epidemics. Roll Back Malaria Malaria early warning systems have been established in Southern Africa to improve outbreak detection and response and are being developed in other epidemic-prone parts of Africa. Prompt access to effective treatment,

Insecticide-treated nets (ITNs), Prevention and control of malaria in pregnant women, Malaria epidemic and emergency response Abuja Summit commitment The African heads of states participating in the Abuja Summit agreed that by the year 2005 at least 60% of those suffering from malaria

should have prompt access to and be able to use correct, affordable, and appropriate treatment within 24 hours of the onset of symptoms RBM targets 2000-2015 Back Malaria (RBM) targets to achieve a 75% reduction in malaria cases by 2015, as compared to those in 2000. Fifteen epidemic-prone countries have developed a preparedness plan of action. Very good progress was made through

RBM simple strategies in most malaria endemic countries New targets.2017 onwards. The new targets of RBM Partners (2017) The new targets of RBM Partners declared shall be to work together to support achievement of the following goals by 2020: Malaria mortality rates and incidence is reduced by at least 40% compared

with 2015. Malaria does not re-emerge in countries that were malaria-free in 2015. The new targets of RBM Partners (2017) Malaria is eliminated in a further 10 countries in 2020 compared to 2015

By 2030 malaria incidence and mortality rates are reduced globally by at least 90% compared with 2015 levels The new targets of RBM Partners (2017) In 2030 elimination of malaria from at least 35 countries in which malaria was

transmitted in 2015, Prevent re-establishment of malaria in all countries that are malaria free The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) was

established 2001 It is a major new source of grant funding for tackling malaria in Africa The endemic countries have been awarded a total of US$ 256 million for an initial two years to scale up malaria control activities. Malinda and Gate foundation. Challenges in fight against EDs

1- WHO estimates that 2.4 billion people still lack basic sanitation facilities such as toilets and latrines, while more than 660 million continue to drink water from unimproved sources, such as surface water. 2-The lack of robust, sustained international and domestic financing

Challenges in fight against EDs 3- Inadequate performance of health systems in most of affected African countries. 4- Many of the people who harbor infections remain asymptomatic or undiagnosed and act as potential reservoirs.

5- In some parts of Africa, vector-control tools cannot effectively protect against a disease given the diversity of vectors and the differences in their behaviors Challenges in fight against EDs 6- The emergence of resistance to medicines and insecticides is major concern. New combinations of drugs

and innovative, faster-acting medicines with fewer side-effects are needed. The lack of financial incentives for pharmaceutical companies has tended to discourage research and development in the area of endemic diseases in poor countries.. Challenges in fight against EDs 7- Lack of capacity to implement

effective surveillance and monitoring compromises getting reliable data which is needed to expose coverage inequities, and to make sure whether people receive the services they need, and also takes into account the quality of services provided, and the ultimate impact on health. Challenges in fight against EDs

8- Disruptive armed conflicts in many African countries 9- Barriers to accessing needed health services that range from poverty to stigmatization. 10- Once you move towards elimination, communities forget the burden of the contained disease. We have to remind the community to remain alert and

report cases to make sure that the diseases could not come back. Challenges in fight against EDs 11- Eliminating transmission of NTDs and ensuring that the delivery of health services meets the needs of those still living with NTD-related disease. 12- Lack of a strong political voice. People affected by endemic diseases in Africa are generally overlooked

Challenges in fight against EDs 13- How to overcome endemic zoonotic diseases through strategies of veterinary public health activities and the One Health approach which recognizes that the health of people is connected to the health of animals and the environment.

Role of NGOs and Turkish Government NGOs including the Federation of Islamic Medical Associations (FIMA) and Turkish Foundations can have influential role in building capacity of local communities in Africa to fight endemic diseases.

They can be involved in programs to empower community-based delivery of medical and health services Role of NGOs and Turkish Government This is to be achieved in close collaboration with official bodies involved in health service provision, and with other stakeholders already

exerting appreciable efforts to control or eradicate endemic diseases in Africa Centers of excellence for research and training in Africa The Turkish government can help in establishing centers of excellence for research and training on endemic diseases control in several African countries. These centers can carry epidemiological studies on prevalence, vulnerability and spread of endemic

diseases in Africa using modern technological tools. Centers of excellence for research and training in Africa Such studies can give solid data on the magnitude and perception of the burden of the endemic diseases in Africa. The centers can help in the design and availability of effective and

practical interventions to combat endemic disease Centers of excellence for research and training in Africa Such interventions could include research on vaccines or other primary preventive measures, curative treatments with new effective drugs, or new means of eliminating vectors. Ideally, interventions should be effective, safe, inexpensive, longlasting, and easily deployed.

Carter Center and others Carter center has demonstrated feasibility of elimination of endemic diseases by mobilizing efforts of many stakeholders. Also the generous funding by The Bill & Melinda Gates Foundation has made real appreciable difference in the fight against endemic diseases in Africa.

KAMRI, AMRI, Nogouchi institute. FIMA and Turkish Government Many Islamic countries are active in relief operations to disasters in poor countries... It is better to prevent disasters before they occur and prevail. Thus, I call upon relatively wealthy Islamic countries such Turkey to make a move in collaboration with FIMA and

others to establish centers of excellence in Africa bearing in mind the majority of the affected people in Africa are Muslims. Thank you for listening

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