We have also over the last few weeks reported on a number of new initiatives. These include the wonderfully named “This Wormy World” – an open-access information resource on the distribution of soil-transmitted helminths and schistosomiasis [2]. Also launched is a new organization that seeks to accelerate the development of new pharmaceutical products for the diseases of the developing world – formerly part of the George Institute and known for its influential G-FINDER survey, Policy Cures [3] has progressed to become an independent entity.

The UK Department for International Development (DFID) has long been a major player in malaria research and control programmes. It now intends to develop a new “malaria business plan” [4] and has begun a public consultation as part of this process.

In the USA, the announcement of the start of a dengue vaccine trial [5] comes at the same time as news of plans to start trials with a vaccine for leprosy [6]. Vaccines, drugs and other new tools are of course much needed, but so often things go wrong when it comes to delivering them to where they are most required. Praziquantel is a cheap and effective treatment for schistosomiasis, but less than 10% of school-aged children at risk are reached by disease control programmes [7].

But disease control programmes can be made to work. The global eradication of dracunculiasis (guinea worm) is drawing closer with further progress reported from West Africa [8]. Only in the southern Sudan is the relative lack of progress a cause for concern.

Research

TropIKA.net continues to highlight new research findings that are of particular interest. Recent examples include epidemiological research that has made possible the completion of a global map showing populations at risk of vivax malaria [9], molecular biological findings that bring new understanding of the metabolism of the malaria parasite [10], and studies in Australia that suggest that wild mammals may play a part in the transmission of Buruli ulcer [11].

But such research often seems a long way from the delivery of effective care. How interventions are brought to the individuals who need them also requires study. Much neglected, for example, is the role played by the retail outlets (often unlicensed) through which the majority of Africans obtain their medicines. A new systematic review [12] finds that little study has been made of efforts to improve the service such shops can offer. Nevertheless, there is some encouraging evidence that training programmes do help.

A 1000-word, plain-language summary [1] of the review is published on the main TropIKA.net website, from where there is a link to the full 7000-word document with figures and annexes.

Over the next few days, a further four review summaries (with links to the full reports) will also be published on TropIKA.net:

Insecticide resistance in dengue vectors
Treating patients with visceral leishmaniasis in the Indian subcontinent: the evidence from clinical trials
What is the best way to distribute insecticide-treated nets to help prevent malaria?
Do the poor benefit from infectious disease programmes?

New tools

A theme of much of the other new content on TropIKA.net has been new tools for use in IDP control. With an increasing level of research on IDPs now taking place, there has been a welcome rise in the development of such tools. For example, we note the discovery of a diagnostic test able to identify Chagas disease in asymptomatic patients – see the TropIKA.net blog [2]. But how effective are the new tools and how well are they received by those who use them in the field?

We highlight a new Cochrane review [3] that was able to find insufficient evidence to quantify the benefits of indoor residual spraying (IRS) of insecticide, regarded as an component of malaria control programmes. We also feature a study from Ghana [4] in which health workers were asked about their experience using the new rapid diagnostic tests from malaria.

Despite the growth in IDP research, the number of new tools that have reached approval stage is not as high as perhaps would be expected. According to a new study [5], only 26 new drugs and vaccines for “neglected diseases” reached the approval stage in the first ten years of this century. (Eleven were for malaria and ten for HIV/AIDS. One new drug and two vaccines were for diarrhoeal diseases, one vaccine was developed against bacterial meningitis, and one new drug was approved for leishmaniasis.)

But the task of developing new tools often seems to be less formidable than bringing them to the front line of disease control, so that they benefit the communities and individuals at risk of IDPs. One programme that aims to do this is the sometimes controversial Affordable Medicines Facility-malaria (AMFm). The programme has now ‘gone live’ – see our interview [6] with AMFm’s Director Dr Olusoji Adeyi. Madagascar [7] is the first country to benefit.

Also on TropIKA.net

Our popular Profile series normally profiles key individuals involved in the war against the IDPs but the latest in the series focuses on an organization – the Public Health Foundation of India [8], which aims to boost the country’s number of trained public health staff.

And also of particular interest are the following articles and blogs:

Schistosomiasis: new findings [9]
Chikungunya: a timely update on a worrying infection [10]
New study will help develop dengue vaccines that do not increase the risk of severe disease [11]
Zambian scientists to study human resources for health [12].

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

There are of course many ways in which climate change threatens human health, including injury from extreme climatic events such as flooding, and food shortages caused by droughts. Many infectious diseases are also likely to become more widespread. Poor communities face the greatest threats and are least well placed to respond. Health inequalities are in consequence likely to widen.

The 15th UN Climate Change Conference (COP15) is now under way in Copenhagen, 7-18th December. So far, since the conference began, very little time appears to have been devoted to the infectious diseases of poverty, although some delegates have made reference to their concerns regarding the likely increase in certain infections including malaria, dengue, pneumonia and diarrhoeal disease.

The health community itself has come late to the climate change debate, seemingly content until now to leave it to climatologists and politicians but, in the run-up to the conference, the Lancet has performed a considerable service in highlighting the health dimension in a series of articles that deserves detailed scrutiny.

In the first week of COP15, other medical journals are also publishing editorials on the subject but, thus far, we have not seen the publication of new data timed to coincide with the beginning of the conference. Data, however, are needed to inform the debate and to determine the action that the world must now take to address climate change.

There is indeed so much that we do not yet know. As Tony McMichael of Australia’s National Centre for Epidemiology & Population Health points out in a TropIKA.net interview, how people will respond to climate change is more difficult to predict than climate change itself. Professor McMichael’s view is that far the biggest infectious disease risk from climate change is diarrhoeal disease. Others, however, have been more inclined to highlight the threats posed by vector-borne diseases particularly malaria, dengue and Chikungunya.

These are not the only diseases that could become more common in a warmer world. Schistosomiasis seems to be expanding its range in many countries. In a TropIKA.net interview Dr Justin Remais of Emory University, USA discusses his use of a mathematical model to quantify environmental impacts on transmission intensity.

But will there, for example, be any effect on tuberculosis as a result of climate change? We don’t know. We should not jump to too many conclusions or try to blame everything on climate change. It has been commonplace, for example, to blame the serious outbreaks of dengue now occurring in many countries on global warming, but this ignores the role of increasing urbanisation and the growth of populations in poor urban environments where vector control activities are inadequate.

We need to be better informed and research will be crucial in determining the effectiveness of efforts to adapt to a changing climate. As Andrew Githeko points out in a guest blog on TropIKA.net, the organisms responsible for the transmission of infectious disease have demonstrated their ability to adapt. We must now do the same.

See the TropIKA.net Copenhagen blog for other climate change developments that relate to the infectious diseases of poverty.

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

A new Wellcome Trust initiative will boost research capacity in Africa, a gene map has been constructed for the parasite that causes schistosomiasis, opening up new avenues for research, and a potential new rabies vaccine has given promising results in mice. A trial has begun of a new drug for river blindness, and a trial of an improved treatment for sleeping sickness has been completed with encouraging results.

Meanwhile the US government has made it clear that, following the broadening of its policies on global health, it will provide new support for the control of neglected tropical diseases (NTDs). Unfortunately, only seven infections from the long list of NTDs have been targeted by the US at this stage. (Leishmaniasis, Chagas disease and dengue fever are examples of the NTDs not yet included.) Nevertheless, this is still an exciting initiative and other countries in the North might now be expected to follow the US lead.

These examples of positive developments contrast with the news from Kenya that over 70% of malaria patients there are given the wrong malaria treatment; they receive older ineffective antimalarials and not artemisinin combination therapy (ACT), the internationally recommended treatment. This finding (from the 2007 Kenya Malaria Indicator Survey, the full report of which is not yet freely available) supports observations in many African countries that ACTs are only getting through to a minority of those who need them.

Coincidentally, within the same month that the Kenyan report was published, the 250 millionth dose of the most widely available ACT, Coartem, was delivered. (TropIKA.net marked the event with an interview with the head of marketing and access for the malaria initiative at Coartem’s manufacturer, Novartis.) Progress is therefore being made but there is a long way to go.

An example of what a malaria control programme can achieve comes from a study conducted in the tiny island of Bioko, Equatorial Guinea where, within four years of the introduction of a multi-intervention strategy, prevalence in children dropped from 42% to 18% and all-cause child mortality fell by two-thirds. Such research demonstrates what is possible, but the challenge remains of bringing the potential benefits of research evidence to entire populations in disease-endemic countries.

“Evidence into policy” is the first part of this challenge. A recent article in Lancet Infectious Diseases noted that, while national guidelines in most Africa countries now list ACTs as the recommended first-line treatment for malaria, the majority of these guidelines have not changed as regards second-line treatment, for which they still recommend oral quinine monotherapy. This is despite the fact that the World Health Organization has stated that ACTs should also be the mainstay of second-line treatment.

But “policy into practice” is the next part of the challenge. In the case of ACTs, practitioners cannot give them to patients, as either first- or second-line treatment, if the drugs are not actually available. I am reminded of the British civil servant who said, after a new directive from his political masters, “If the policy is that pigs will fly, whose fault is it when they don’t?” (Sometimes those who write policy documents and guidelines need to distinguish between aspirational and operational targets.)

Two other research articles highlighted on TropIKA.net have implications for policy making in child health. A systematic review concludes that WHO is wrong in its recommendation that iron supplements should not be given to children under two years, if they live in malarious regions. In contrast, a South African study provides evidence to support the WHO position that children known to be HIV-infected shown not be given BCG, even in countries where the risk of TB infection is high. The interpretation of the evidence in such studies is, however, always likely to be controversial. Putting evidence into policy and policy into practice both present formidable obstacles.

Paul Chinnock
Editor-in-Chief, TropIKA.net

The Gates Foundation gives particular emphasis to finding new technological solutions – inevitable perhaps as Bill Gates made his money through technology. (We can only speculate what his approach to global health would have been had he become wealthy as a result of a career in the media, finance, energy or some other sector.) However, critics are asking whether the Foundation’s technological emphasis detracts attention from the social determinants of health, and from efforts to improve the delivery of existing interventions of proven effectiveness. Critics have also commented on the Foundation’s tendency to prioritise support for a small number of diseases; in particular there is a poor correlation between Foundation funding and the childhood disease burden. The Foundation not only provides a significant proportion of global health funding but also plays a part in setting priorities more widely. Perhaps the most important criticism is that it provides no information as to the processes it uses in deciding upon those priorities.

Priority setting has also created controversy elsewhere. A renewed appeal has been made, in another article in the Lancet, for the control of “neglected tropical diseases” (NTDs) to receive more funding. The authors particularly emphasise seven of the long list of NTDs that they consider to be both the most widespread and the most amenable to control. The seven include schistosomiasis; new research on the prevalence of this condition in Mali demonstrates that if successful programmes are not sustained then progress can easily be reversed.

Meanwhile, others make the point that diarrhoeal diseases are amongst the very biggest killers of poor children but have lost the position they once held on the priority list. Can we now say that they should therefore be added to the “neglected” category? A new report marks the start of attempts to restart international action against these diseases. We also carry news of a project which may lead to new treatments for diarrhoea but see, however, the cautionary note sounded in a TropIKA.net blog .

The last few days, have seen the emergence or re-emergence of other controversies. The use of DDT as part of malaria control efforts – see our news story – is an issue where passions have often run high. Also in the news and also likely to be controversial is the decision of an Indian company to continue the development of a new malaria drug, despite the fact that the Medicines for Malaria Venture with which it was in partnership decided to withdraw its collaboration following disappointing trial results.

And in America, details are awaited of what support the Obama administration [9] will give to global health. Announcements made from the White House have led some critics to accuse Obama of failing to deliver on his pre-election promises on, most notably, AIDS. However, the President has said that his new approach will be ‘comprehensive’. Whatever he decides will be controversial but it may be that previously neglected areas will receive more attention and that his priority setting will be more in line with the disease burden.

Perhaps then it is good that the infectious diseases of poverty have lately become the subject of so much controversy. It is an indication that the issue is now receiving attention at senior levels and that efforts are being made to identify the best ways forward. Controversy, however, should not be allowed to drag on for too long. Words must give way to action.

Paul Chinnock
Editor-in-Chief, TropIKA.net

Another bank, the World Bank, has just published a frank and transparent evaluation of the effectiveness of the health programmes within its ‘portfolio of investments’. Nearly half of the Bank’s health support is for action against infectious diseases. However, almost 90% of the infectious disease programmes it supports are focused on just one disease – HIV/AIDS. Critics have said that this disproportionate emphasis has distorted health priorities in countries receiving Bank assistance. Also of great concern is the fact only a minority of Bank HIV/AIDS programmes (29%) have performed satisfactorily. In contrast most (89%) of the programmes devoted to other infections are regarded as being satisfactory.

There must surely be two conclusions here. Firstly, better ways must be found of addressing HIV/AIDS. (No one would argue that the Bank or the international community at large should give up on this disease.) But secondly, since the evaluation has established that action against other infections (such as schistosomiasis, leprosy, malaria and TB) offers good value for money, investment in such programmes should be increased …if only on economic grounds.

Also recently featured in the TropIKA.net Reports section is a document from UNICEF: Malaria & Children: Progress in Intervention Coverage. Although UNICEF believes that “We are, for the first time in history, poised to make malaria a rare cause of death and disability” many outstanding challenges are noted in this report. Progress in getting effective antimalarial treatment to all who need it has been slow and the number of pregnant women who sleep under insecticide-treated nets is still much too low. The latter point has been underlined by recent news from Liberia.

As well as highlighting important news and reports published elsewhere, TropIKA.net continues to publish original content. Our recent extended interview with Michael Gottlieb, head of the Grand Challenges project at the Foundation for the US National Institutes of Health is of particular interest, as it comes at a time when the entire Grand Challenges in Global Health project – a research funding initiative that is worth almost half a billion dollars – is at a crossroads.

Paul Chinnock
Editor-in-Chief, TropIKA.net

It is heartening to learn that new initiatives continue to be launched to provide funding both for research and for control efforts. However, it is clear that much more financial support is still needed. A US consumer group has reported on government expenditure on neglected infections and says it is not enough. Also in the US, the Institute of Medicine has called upon the incoming President to make health a pillar of foreign policy and to double US funding for global health initiatives within the next four years.

Of the diseases which we feature on TropIKA.net, malaria and tuberculosis attract the most funding and in consequence there is always more for us to report regarding new research findings. However, recent weeks have seen the publication of a number of studies on schistosomiasis. One that we have featured concerns the role of hygienic bathing in the transmission of the disease. (Do visit our Research Articles section to see the other studies that we have recently highlighted.)

We also report that schistosomiasis control in China will benefit from the use of satellite technology and that new funding from the Gates Foundation will be used for operational research on the control of the disease.

The development of effective new interventions against the infectious diseases of poverty is only part of the process. Their effective delivery is also crucial. This is well illustrated by vaccination programmes. Many programmes are still failing to reach targets and a worrying study published in the Lancet now suggests that some programmes over-report their success rates. As we go forward into the New Year it is important to maintain a positive position on what it being achieved but also that we should be realistic; our efforts should be informed by accurate data and not by over-estimates.

Paul Chinnock
Editor-in-Chief, TropIKA.net