Such research, at the “basic” level, is essential if new tools active against malaria are to be developed, but putting effective interventions into practice is not easy. Research is also therefore needed at the implementation stage. A study in Tanzania [4] found that only a minority of women receiving bednets in a distribution programme were actually sleeping under them; studies like this one help to identify the points at which such programmes can fail.

The implementation of another new antimalarial tool – the rapid diagnostic test (RDT) – also continues to be the subject of research. A Nigerian study [5] asked people whether, if they were ill, they would pay to be tested with an RDT. The majority said they would do so and, on average, the amount they were prepared to pay was greater than the current cost of an RDT in Nigeria (about $1.25). Nevertheless, the study’s findings indicate that many people would not be willing (or could not afford) to be tested. It is therefore important that testing should be available free of charge. Further research in Tanzania [6] suggests that the introduction of RDTs could cut health care costs; malaria is considerably over-diagnosed and many antimalarials are given to patients who do not need them. (Tanzania is, by the way, one country where anti-malaria programmes are being significantly stepped up [7]).

But programmes to treat and control malaria must be integrated with those for other infectious diseases. It is good to hear of new funding that will enable the Malaria Consortium [8] to demonstrate how government-led integrated community case management programmes (iCCM) can be scaled up, so that more children with malaria, pneumonia and diarrhoeal diseases receive appropriate treatment.

A worrying story relating to the epidemiology of malaria has also been in the news during the last few days. It has become commonplace in the debate on climate change - which is likely to increase cases of many infectious diseases - to cite the rise of malaria in the East Africa highlands in order to demonstrate that global warming has already had such an impact. But where is the evidence that malaria has become more common in this part of Africa? When the UK government’s Department for International Development (DFID) issued a statement referring to the increase, an environmental campaigner asked to see the research on which the claim was based [9]. What he was sent was certainly not convincing. The need for reliable evidence on the prevalence of malaria has thus, once more, been underlined.

Also in TropIKA.net
News on other infectious diseases of poverty also appearing on TropIKA.net within the last few days has included an analysis of the funding provided for tuberculosis research worldwide [10] – it is growing but is still nowhere near the level that is required. It has also been demonstrated in a new study [11] that individuals with a low birth weight are particularly susceptible to TB.

Recent months have seen major outbreaks of cholera across Africa for reasons that are by no means clear. A new surveillance programme [12] is therefore a welcome development.

Leptospirosis is an important zoonosis (a disease of animals that can spread to people) in many countries but rarely receives attention from researchers. A study in India [13] suggests that the disease in people is spreading northwards.

And a TropIKA.net opinion article [14] looks at WHO’s response to the appearance of H1N1 (“swine”) flu. This infection seemed likely to pose greater dangers for people living in the world’s poorest countries. Did WHO exaggerate the threat or was it correct to err on the side of caution?

Paul Chinnock
Editor, TropIKA.net

WHO also adopted an upbeat tone in its recently published World Malaria Report 2009. However, detailed inspection of the report reveals that, while there has been encouraging progress in prevention programmes (particularly as regards the distribution of insecticide-treated bednets), diagnosis and treatment are lagging behind. To quote from the report: “…in 18 high-burden WHO African Region countries for which data were available, 22% of the reported suspected malaria cases were confirmed with a parasite-based test … countries received only about 50% of the ACTs [artemisinin-combination therapies] needed to treat malaria cases at health facilities in the public sector … less than 15% of children under 5 years of age received an ACT when they had fever in 11 of 13 African countries for which survey data were available”.

There is indeed cause for optimism following some of the recent achievements against malaria but there is still much to be done before the goal of eliminating the disease can be reached. It is encouraging therefore to learn of new Gates Foundation funding to support the development of one potential vaccine. The US government has also announced the award of a grant to support further research that it is hoped will facilitate the development of vaccines against malaria, and also against dengue and tuberculosis.

It is very much to be hoped that such support will continue but, as we have reported on TropIKA.net, many experts believe that donor contributions have now peaked and that further increases may not be seen until the world recovers from the continuing economic crisis.

Malaria is also the focus of our latest TropIKA.net Profile interview, in which Dr Laurence Slutsker, chief of the malaria branch at the Centers for Disease Control, USA speaks about CDC’s major contributions to malaria research and describes the organization’s current work in evaluating potential new tools to fight the disease.

Our role on TropIKA.net is to facilitate debate, not just on malaria research, but on efforts to combat all the infectious diseases of poverty. Other recent items on the knowledge platform have concerned tuberculosis, leishmaniasis, rotavirus, dengue and zoonoses.

Paul Chinnock
Editor, TropIKA.net

On the credit side, the Accord makes provision for additional funds to be made available to assist developing countries in adapting to climate change. New funding will begin from next year and, by 2020, $100 billion will be available for this purpose annually. It is by no means clear what this money will be spent on, or to what extent adaptation efforts will address health issues generally and infectious diseases specifically. As we reported in TropIKA.net News, adaptation efforts so far have generally ignored health. But to some extent this is understandable; we do not yet know enough about the impact that climate change will have on infectious diseases and on the most effective ways of mitigating this impact. There is a desperate need for more research, and powerful advocacy efforts will be required to ensure that some of the adaptation funding is devoted to this purpose.

During the conference, TropIKA.net has interviewed a number of medical researchers with particular interests in this area. In our most recent interview, epidemiologist Jonathan Cox says that it is important that climate effects are put in the wider context of other potentially important drivers. Our “Copenhagen Blog” has also identified a number of recent climate change developments. These include the publication of an article that identifies climate factor as a factor in the growing number of cases of zoonoses, and a call for the development of R&D capacity in the South. And there is news of new US government grants made available for research intended to improve understanding of the ecological mechanisms that govern relationships between human-induced environmental changes and the emergence and transmission of infectious diseases.

Elsewhere on TropIKA.net…

There has always been uncertainty as to how much money is going into research into the infectious diseases of poverty, not to mention where this funding comes from and the extent to which research on specific infections is supported. The G-FINDER project was launched to provide information on such questions and this project’s latest report is now featured on TropIKA.net. The G-FINDER team concludes that, since the beginning of the global economic crisis, new financing has “ground to a standstill” and AIDS continues to receive a disproportionately large share of the total funding available. But perhaps the most interesting conclusion of the report is that India and Brazil are emerging as key players, particularly for the more neglected diseases. Also recently featured in TropIKA.net Reports section are A new “blueprint” for TB diagnostics and Dengue: guidelines for diagnosis, treatment, prevention and control.

The number of distinguished researchers who have been interviewed by the TropIKA.net team has increased lately. We spoke with Dr Stephen Hoffman founder and CEO of Sanaria, a biotechnology company dedicated to the production of a sporozoic pre-erythrocytic-stage vaccine for P. falciparum malaria. And Dr Christine Moe told TropIKA.net that sanitation remains a neglected area, adding that, “I do get concerned about money and resources and effort going into vaccine development for diseases that I think would be better reduced by water and sanitation”.

Finally, there is always something going on in the TropIKA.net Blog. Amongst other developments we have recently reported here are the welcome news of increased US funding for research into neglected tropical diseases, a continuation of the debate as to whether it is helpful to talk in terms of eliminating malaria, and a remarkable story from Senegal – No bednet? Pay a fine!

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