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

As we report [1], the health authorities in Zanzibar, where there have been substantial reductions in malaria in recent years, have been asked to decide whether there is sufficient political will to tackle the financial and operational challenges that would have to be overcome to achieve elimination there. Zanzibar is much better placed to realize such a goal than most parts of mainland Africa but it would, nevertheless, be a bold move to make elimination the official policy. If Zanzibar takes this step, could it inspire similar policy switches elsewhere? (Meanwhile, although less is usually heard from South America’s national malaria programmes, the TropIKA.net blog reports that in both Brazil [2] and Venezuela [3] rises in case numbers have been noted, and have been associated with increased exploitation of the rain forest.)

Elimination of the disfiguring and disabling disease lymphatic filariasis (LF) has been set as a worldwide goal for 2020. A meeting [4] of the Global Alliance to Eliminate Lymphatic Filariasis concluded that efforts to meet this deadline are on track. Recent successes in the Philippines [5] provide an example of the progress that has been made. However, researchers in Tanzania [6] found that encouraging reductions in LF, following the launch of a mass drug administration programme, soon levelled off. The study demonstrates that it is essential to monitor elimination programmes to determine how they are performing in specific locations.

But elimination will always need more than a technical fix. As Bill Gates recently noted, there is a “human piece” in global health. Following his intervention as a major donor, the Global Polio Eradication Initiative will introduce new elements into its strategic plan. These include: training for health care workers on hygiene and sanitation; interventions aimed at increasing access to clean water and zinc supplementation; and the sensitization of communities to the importance of personal hygiene, routine immunization and breastfeeding. Gates has been noted for his focus on the use of technology in disease control. As we discuss in a TropIKA.net Editorial [7], his new enthusiasm for the human piece could have far-reaching implications.

Tuberculosis is sadly an example of a disease where there are no prospects for elimination in the foreseeable future, but a recent conference on TB vaccine research did hear that potential new tools against the disease are in the pipeline [http://www.tropika.net/svc/news/20100607/Chinnock-20100607-News-TBVI#page-comments]. A protein that protects against TB has also been [9] identified. Less encouraging news is the finding that, in African countries that have expanded their mining industries, the whole population (not just the miners themselves) faces a higher risk of TB [10]. Also of concern is that, despite the growing rates of multidrug-resistant TB in South Africa, nurses there seem to have very little knowledge of the condition [11].

The remit of TropIKA.net extends beyond the more widely known infectious disease of poverty, such as malaria, TB and polio. We recently highlighted a review [12] that argues for more action against neurocysticercosis – a consequence of tapeworm infection – which is responsible for many cases of epilepsy. A conference [13] on this much neglected condition will take place in Uganda in July.

The TropIKA.net blog continues to publish many items of interest. We report for example [14] that three research institutions in Kenya have combined their expertise to develop a scientific model that can predict surges in malaria. They claim to be able to achieve accuracy levels of 80–100%. Such achievements demonstrate what African scientists can achieve – in Africa – if given sufficient opportunities to do so. It is welcome news therefore [15] that the new $38 million Human Heredity and Health in Africa Project (H3 Africa) will employ African scientists in the search for new insights into genes, environment and health among African populations.

Paul Chinnock
Editor, TropIKA.net

Peter Hotez also explains the justification for the Global Network’s current focus on just seven neglected infections: three soil-transmitted helminths (ascariasis, trichuriasis and hookworm), lymphatic filariasis, onchocerciasis, schistosomiasis and trachoma. All of these diseases could already be brought under control, if sufficient support were to be provided for mass drug administration programmes. Different strategies, Hotez says, will be needed to address other diseases of poverty. The Global Network will broaden its focus later.

TropIKA.net already takes a wider view in our coverage of the infectious diseases of poverty. Our content also features new developments in such areas as malaria, tuberculosis, dengue and the kinetoplastid diseases (Chagas disease, leishmaniasis and human African trypanosomiasis [sleeping sickness]). Recent developments we have lately highlighted include research that, according to some interpretations, suggests that vivax malaria may be getting more common in Africa.

We have also examined some of the new advances being made in leishmaniasis research. It is not often that molecular targets are identified for potential new treatments against the infectious diseases of poverty, so it is gratifying to be able to report that such a target has been found by researchers seeking new drugs for sleeping sickness.

Other significant advances recently announced include genomic research on Mycobacterium tuberculosis, the organism that causes TB. The M. tb genome was first sequenced in 1998 but less than 40% of its genes had been “annotated”, meaning that their functions and pathways had yet to be understood and described. Important new insights have now been gained through the work of scientists at the Open Source Drug Discovery (OSDD) initiative in India. (A TropIKA.net article published in March provides more information about OSDD and the concept of open-source drug discovery.)

Another area where progress is being made is in the search for vaccines to prevent dengue. We take a look at some of the initiatives that are now under way.

Scientific advances such as these give us cause for hope, but there is also a need for political commitment from governments in disease-endemic countries and the global community as a whole. It has therefore been disappointing to read the findings of new research that suggests many African governments have reduced the proportion of their budgets that they are devoting to health.

Finally, don’t forget to visit the TropIKA.net blog where there have been some interesting postings by guest bloggers from Farmabrasilis and the Asia Pacific Malaria Elimination Network.

Paul Chinnock
Editor, TropIKA.net

We simply don’t know how many projects are in operation; it is quite possible that we only get to hear of those that are considered to be successful. And how is success defined? If a TB programme distributes phones, so that patients can be reminded to take their treatments, then success could be considered to have been achieved once the phones have been distributed to those who need them, or on the basis of whether health workers and patients are enjoying using them. What we need is hard evidence that more patients are indeed completing their full course of treatment and that cure rates have been improved.

TropIKA.net has published a review article [1] on the current progress in mHealth that describes some exciting examples of what is being done, but also looks at efforts being made by researchers to assess what these programmes are actually achieving.

Innovation in drug development has been the theme of some of our other recent articles. Efforts are under way to improve the efficiency and cut the cost of producing the drug praziquantel, used in the treatment of schistosomiasis. This project involves the use of an innovative approach to research – “open-source science” [2].

Another drug, flubendazole is widely used to treat worm infestations in animals but delivered disappointing results when used in humans against the filarial worms responsible for elephantiasis (lymphatic filariasis) and river blindness (onchocerciasis). A project [3] is investigating whether a reformulation of the drug can make it viable as an effective treatment for people with these conditions.

But even when effective drugs are available, getting them through to all those who need them remains a considerable barrier. One reason for this is the number of fake and substandard products on the market – see, for example a new report on substandard antimalarials [4]. A meeting in West Africa heard of the need to develop innovative techniques to stop the flow of these drugs [5].

Elsewhere on TropIKA.net we have reported some good news. The finding that Buruli ulcer, if diagnosed at an early stage, can be successfully treated with antibiotics without resorting to surgery [6] is one such development. This appalling condition is becoming more common and surgery has been recommended for all cases, despite the fact that it is often hard to access in the areas where the disease is most common and that patients do not like it. Now the challenge is to see that they are diagnosed in good time.

And President Obama has, in his budget placed before Congress, proposed significant increases in what would be spent on the infectious diseases of poverty [7]. The overall budget for global health would rise by a useful amount but the re-prioritization of particular diseases and issues is perhaps of greater interest.

Infectious diseases claim the lives of millions, both in peace time and in war. A study published in the Lancet [8] found that, for some 80% of the 300,000 people who died as a consequence of the war in Sudan’s Dafur region, the cause of death was not violent injury but infectious conditions, most notably pneumonia and diarrhoea.

Sadly, those who seek innovative ways to deliver health care most endeavour to develop mechanisms that will also prove effective in conflict situations.

Paul Chinnock
Editor, TropIKA.net

It is therefore encouraging to learn that the Inter-American Development Bank and the Global Network for Neglected Tropical Diseases intend to mobilize $30 million from the public and private sectors to raise awareness and funding for the control and elimination of neglected tropical diseases (NTDs) in the region – see TropIKA.net Blog. We also report in TropIKA.net News of new efforts to eliminate malaria and filariasis from the Americas.

Meanwhile, the Drugs for Neglected Diseases initiative has announced that it has established a cooperative agreement with a pharmaceutical company for the clinical development of a drug that has been shown in lab tests to have activity against Trypanosma cruzi, the pathogen responsible for Chagas disease. This disease is confined to the Americans and kills at least 200,000 people every year. There is no vaccine and no specific treatment. Control of the disease vectors (triatomine bugs) remains the main focus of efforts to fight the disease and findings reported in a new research article will help guide control programmes in deciding when it is best to spray insecticide.

Oceania is another part of the world where infectious diseases remain an important cause of ill-health but receive little attention from the international media. Nevertheless, efforts are being pursued to control or eliminate these conditions and it is heartening to read a recent report of major successes achieved against malaria in Vanuatu and Solomon Islands.

TropIKA.net continues to highlight and comment upon new research findings, wherever the studies have been conducted. Our recent selections have included an important step forward in understanding how the parasite responsible for leishmaniasis establishes itself in its human host, a prevalence study that confirms the return of yaws to the Democratic Republic of Congo, and a study from China which examines the factors explaining why so many tuberculosis patients fail to complete their course of treatment. An Ethiopian study provides an illustration of the poor performance that is often seen in TB programmes, thus demonstrating the importance of monitoring and evaluation.

The TropIKA.net team cannot, of course, identify all the new reports of research into the infectious disease of poverty that are of particular significance. We need the help of our readers. If a new paper strikes you as being of exceptional importance, let us know about it.

One piece of good news is that an increasing amount of research is being conducted in developing countries. There has been an encouraging rise in the number of researchers in these countries, which doubled in a five-year period according to a report from the UNESCO Institute for Statistics. There is still of course a long way to go for the South to catch up. One initiative that should further speed up progress is the African Network for Drugs and Diagnostics Innovation (ANDI). The network aims to increase new health products developed in Africa by Africans. The ANDI 2009 meeting, which took place in South Africa this month, received in-depth coverage on TropIKA.net.

But sometimes the problem is not a lack of basic research. We highlight an opinion article which argues that the lack of progress against schistosomiasis in Africa represents one of this decade’s greatest failures. Cheap and effective treatments already exist for this disease, the second most common parasitic condition after malaria, but only 5% of Africans who need treatment actually receive it. Progress against the infectious diseases of poverty requires that the needs of neglected people should be met, in whichever part of the world they may live.

Paul Chinnock
Editor, TropIKA.net

China itself has a malaria problem in parts of the country, although it is not on the scale faced by Africa. The Chinese government has announced that, using more conventional methods, it expects to be able to eliminate malaria as a public health problem by 2015.

New ideas on cholera are badly needed, given the current African epidemic (see our report on the situation in Mozambique) and the high case numbers still found in many parts of Asia. No one believes that the global threat of cholera can be resolved solely through the development and deployment of an effective vaccine; this is truly a disease of poverty and it will be with us as long as millions of people are denied the right to safe water and sanitation. Nevertheless, an effective vaccine would make a major contribution and the low effectiveness of cholera vaccines in the field has always been disappointing. A possible explanation comes from a study in Bangladesh which indicates that people infected with intestinal worms have a reduced response to V. cholerae. Deworming programmes, important in their own right, could become an important part of cholera prevention efforts. The study has been published at a time when a new cholera vaccine is about to be brought into use in India. This vaccine was found to be 70% effective in an Indian trial and its performance within a public health programme will be followed with great interest.

New threats require policy makers to act swiftly and appropriately. Health systems have so far responded too slowly to the worsening problem of drug-resistant forms of tuberculosis. It is thought that fewer than 5% of cases are detected and fewer than 3% are treated according to WHO standards. In Beijing a meeting of representatives of 27 countries facing a high burden of drug-resistant TB heard the current situation described as “potentially explosive”.

New information on Buruli ulcer is sadly in short supply. There is considerable public alarm in many countries regarding this dreadful condition but at a conference in Cotonou it emerged that there is still no clear understanding as to how it spreads or even how commonly it occurs.

Regular readers of my Editor’s choice blog will know that I like to conclude by highlighting a new success in disease control. The encouraging progress made against onchocerciasis in Guatemala is a suitable way for me to sign off, but the last word must belong to the readers TropIKA.net. We are an interactive platform so please use the ‘Leave a Reply’ function below in order to share your views on some of these new developments.

Paul Chinnock
Editor-in-Chief, TropIKA.net

Now, in TropIKA.net News, we publish details of the launch of a programme seeking to contain the spread of artemisinin resistance. It must be hoped that these efforts will achieve some success. The loss of this drug would be calamitous for malaria control globally.

Since it was first established that artemisinin offered an effective replacement for the older malaria treatments to which the malaria parasite had become resistant, massive investments have been made with the aim of making ACT drugs accessible to those who need them. While these efforts still face many challenges, some resulting from insufficient supplies of artemisinin, there has been encouraging progress. Steps towards the production of a synthetic version of artemisinin (see TropIKA.net blog) have added to the sense of optimism as to what can be achieved. However, should artemisinin resistance now spread rapidly from Southeast Asia to Africa and other malaria-endemic areas, then these investments may turn out to have been wasted.

The sale of substandard ACTs containing inadequate levels of the active drug and the use of artemisinin as a monotherapy both promote the development of resistance. It is essential that these practices should be halted.

And the good news

Not all of the new developments featured on TropIKA.net recently have been so bleak. Two new moves are likely to boost research into the infectious diseases of poverty. See:
- African initiative launched to strengthen health research
- India plans to boost investment in research for drugs for the infectious diseases of poverty.

Some national programmes aiming to eliminate infectious diseases of poverty are achieving success:
- Lymphatic filariasis eliminated from province in the Philippines

Elsewhere existing control efforts are being reinvigorated:
- Kenya plans to eliminate trachoma
- Nigeria tries again on polio

And, somewhat belatedly, the Australian government is getting to grips with a major cause of blindness in its indigenous people:
- Trachoma: Australia’s government at last promises to take action

Paul Chinnock
Editor-in-Chief, TropIKA.net

In our look at recent research articles on lymphatic filariasis, one paper we featured was a qualitative study on the impact of social stigma on women with this disease in two countries, the Dominican Republic and Ghana. My thoughts keep returning to the comment, recorded by the researchers, of a woman in Ghana:

“If it had not been for my nasty leg, I could have gone to school and been a teacher. I would have been someone, not just the woman with the leg.”

The tragedy of a person whom society defines by the parasitic condition from which she suffers and the waste of her capabilities clearly sets out, in just two sentences, why such diseases can no longer be neglected.

It also demonstrates one of the advantages of qualitative data – a single human story is often more moving, more memorable, and more effective as an advocacy tool than any qualitative statistic.

The considerable impact of stigma revealed in this study adds to the case for more social research on the infectious diseases of poverty. A recent review article considers the current status of such research.

Elsewhere on TropIKA.net there have been a number of good news stories lately:
• a small study has examined a new way of addressing the life-threatening complication of hypoglycaemia in children with malaria
• a reduction in trachoma case numbers has been reported from Nepal
• a new initiative will facilitate the conduct of high-quality clinical trials in Africa.

And there have been curious stories too:
• the introduction of a new malaria drug is seen as a threat to local industry

TropIKA.net is of course an interactive knowledge platform. Please use our Comment function or the blog to give your own views on any of these developments.

Paul Chinnock
Editor-in-Chief, TropIKA.net

Malaria has been much in the news during the last couple of weeks. We have seen a three-billion dollar boost to funding for the global battle against the disease and the launch of Global Malaria Action Plan (GMAP). A five-year plan has also been announced by the Medicines for Malaria Venture. The journal Nature has expressed concerns that basic research is not receiving enough attention but, as we note, basic research is only one of many issues that must be addressed. A report from Médecins Sans Frontières sounds a salutary note; improved control programmes often fail to reach the very poorest people, unless diagnosis and treatment are free.

While more funding is still needed, the attention malaria is now receiving does makes it quite clear that it can no longer be described as a neglected tropical disease (NTD). While the NTDs receive grossly inadequate attention from the international community, their profile also may be starting to rise. A series of excellent films from the BBC is focusing on these diseases and will surely raise awareness. NTDs have even emerged as an issue in the debates between the two US presidential candidates. One neglected disease in Africa, guinea worm disease, is to receive new funding and it is claimed that it could be eradicated within five years.

It is too easy to think of NTDs as confined to Africa and Asia but they are important causes of sickness and death elsewhere. A recent article has highlighted the disease burden due to NTDs in Latin America and the Caribbean. An encouraging development has been the announcement of plans by the Carter Center, Haiti and the Dominican Republic to eliminate lymphatic filariaisis and malaria from the island of Hispaniola, their last reservoir in the Caribbean.

There have been other developments which have caught my eye in the last few days. Diarrhoeal disease is still one of the biggest infectious killers of poor children; rotavirus is often the disease agent responsible. Many countries are considering whether they can afford to introduce rotavirus vaccine to their national programmes. A study from Mexico, which found that such a move would be cost-effective, is of great interest. The use of ivermectin in the control of onchocerciasis is now well established but a study in Ecuador has shown there can be beneficial side effects; the drug is also active against some soil-transmitted helminths.

Paul Chinnock
Editor-in-Chief, TropIKA.net