Developments reported on TropIKA.net within the last few days have challenged some common assumptions made about the infectious diseases of poverty…

most of the really poor people in the world live in Africa; most fevers in Africa are caused by malaria; persistent brain damage is an inevitable consequence of cerebral malaria; we know (roughly) the prevalence of TB in countries like South Africa; childhood TB is not a priority area; pneumonia and diarrhoea are not neglected diseases; and innovations in medical research always happen in the North, not in disease-endemic countries themselves…

Whether these recent developments represent good news or bad, they call into question the ordering of many of the current priorities for research, policy and public health practice.

Researchers at Oxford University have applied a new “multidimensional poverty index”, to conclude that there are more poor people in eight of India’s states than in the 26 countries of sub-Saharan Africa combined [1]. Not everyone will agree with this analysis, but the infectious disease burden of India’s poor surely deserves to be accorded a higher priority.

It has for some years been believed that an African child with fever is most likely to have malaria. As confirmatory diagnostic tests are usually unavailable on the frontline of care, the practice of “presumptive” diagnosis and treatment is therefore recommended. However, a mathematical modelling study [2] has concluded that most fevers are not malaria. In some parts of Africa, 80% of children attending public clinics with fever are probably suffering from some other infection. The findings provide strong support for the new rapid diagnostic tests to be made available at all health facilities in Africa.

One of the most serious consequences of malaria is the lasting cognitive damage suffered by children who develop cerebral malaria. A very “early” study [3] with laboratory mice suggests that adding antioxidants to standard malaria treatment may help prevent this. (By coincidence, this research has been published within a few days of an analysis [4] appearing to show that a high prevalence of parasitic infections holds back rises in the average IQ in disease-endemic countries.)

A post-mortem study [5] in a South African hospital produced findings that are truly shocking; half of the young adults who died in this hospital were culture-positive for TB and one case in six involved a drug-resistant strain of M. tuberculosis. The country is known to have a high prevalence of tuberculosis and of drug resistance but the situation may be worse than previously believed.

TB programmes usually focus on adults. However, in a recent article [6] Indian and Indonesian specialists argue convincingly that this has led to a neglect of paediatric TB. Once again the priority list has been challenged.

The establishment of the Millennium Development Goals has had a major influence on policies and priorities. The latest annual report [7] on progress made towards the MDGs makes interesting reading; there have been both encouraging achievements and some disappointments. However, the report is unequivocal on one matter: “The need to refocus attention on pneumonia and diarrhoea – two of the three leading killers of children – is urgent”. Acute respiratory infections and diarrhoeal disease were at one time high on the priority list and it is unclear why they have steadily slid downwards. Now is the time to reverse that trend.

The latest of our popular ‘Profiles’ series of articles on TropIKA.net [8] highlights the achievements of BIOTEC, a research centre created by the Thai government to generate biotechnology innovations. The innovatory research programme conducted at BIOTEC, which has included the development of a new malaria drug that will soon be entering clinical trials, challenges the notion that, while innovations may be evaluated in the South, the original breakthroughs will always take place in the better-resourced research environments of the North.

Also on TropIKA.net…

Other examples of progress towards new treatments have been reported on TropIKA.net lately. Merck & Co is investigating the potential use of one its existing drugs as a treatment for Chagas disease [9] and an agreement [10] between two non-profit groups will see potential new TB drugs tested also for their possible use against neglected conditions including Chagas, African trypanosomiasis and leishmaniasis.

There has been good news on lymphatic filariasis (LF). It has been calculated that, in its first eight years, the Global Programme to Eliminate Lymphatic Filariasis has brought benefits worth $21.8 billion to individuals, and savings of $2.2 billion to the health systems of endemic countries [11]. Many national LF efforts have experienced difficulties, including the reluctance of many people at risk of infection to comply with mass drug administration programmes. A study from India [12] has shown that community education can improve compliance rates, particularly if this education includes advice on self-care of afflicted limbs for those already suffering from the distressing symptoms of this condition. The study has neatly illustrated the importance of considering not only long-term public health considerations but also the needs of individuals.

Paul Chinnock
Editor, TropIKA.net