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Editor’s choice

From the range of articles recently featured on TropIKA.net, Editor Paul Chinnock offers a personal selection of items of particular importance.

Archive for the ‘Americas’ Category

Nov 30 2009

Reporting the debate – Testing the tests

Posted by: Paul Chinnock - Editorial Team

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Once again, the TropIKA.net team has been out and about. We have provided in-depth coverage of Forum 2009, the latest conference of the Global Forum for Health Research (GFHR) held in Cuba. Highlights from our in-depth reports include interviews with Anthony Mbewu, President of the Medical Research Council, South Africa and next Executive Director of GFHR. He described his plans for moving the global health research agenda forward and also the steps now being taken to establish a biotechnology platform in South Africa.

Also interviewed was Carlos Morel, Director of the Center for Technological Development in Health at Fiocruz, Brazil. He discussed the difficulties in transferring innovations in health technology developed in one part of the South to other countries, where circumstances may be very different.

Forum 2009 made it possible for delegates to exchange their sometimes very different views on innovative approaches to health. For example a session on digital health care in rural India led to some lively exchanges.

Testing the tests

Rapid diagnostic tests (RDTs) will, it is hoped, play a major part in advancing efforts towards the elimination of malaria. The successful management of other infectious diseases of poverty would also benefit from the development of simple, affordable tests that can be used on the front line of care. However, such tests must themselves be tested for their accuracy and, when tests are tested, rigour is required both in the conduct of the work involved and in its reporting. It is therefore disturbing to read the findings of a review evaluating the quality and reporting of diagnostic accuracy studies in TB, HIV and malaria. It would appear that the required rigour has been lacking in much of the testing so far conducted. This does of course raise again the question of how much we can depend on the RDTs themselves.

The dependability of the drug supply has for many years been a topic of great concern – a large proportion of the drugs available in developing countries are faked or substandard. It is good news that efforts to control counterfeiting are to receive a boost with new support from USAID.

For some neglected infections, the drugs that are really needed do not yet exist. This is particularly the case for the three kinetoplastid diseases: Chagas disease, human African trypanosomiasis and leishmaniasis. The Drugs for Neglected Diseases initiative (DNDi) continues its remarkable work in the search for new treatments and a few days ago announced a collaboration with drug giant Pfizer, which will allow screening of its library of compounds to identify any that may have potential for use against these three diseases.

Other new developments also featured on TropIKA.net include Brazilian research demonstrating that the movement of people may be more important than previously thought in the transmission of dengue fever; the findings suggest that the disease is often transmitted outside the home, for example at school or in public spaces. And from Nigeria there is worrying news that the savannah-dwelling blackflies that transmit blinding onchocerciasis are becoming more common in the southwest of the country. Meanwhile, from southeast Asia comes the unwelcome, though predictable, news that resistance to the key antimalarial artemisinin has now spread from the Cambodia–Thailand border to China, Myanmar and Vietnam.

Facilitating communication between professionals seeking to address the infectious diseases of poverty is at the centre of our efforts on TropIKA.net and we are well aware of the dominance of English as the medium in which most communication on global health takes place. We welcome the news that the Portuguese-speaking health community will benefit from a newly launched email forum.

Paul Chinnock
Editor, TropIKA.net

Nov 17 2009

Virtual participation

Posted by: Paul Chinnock - Editorial Team

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A major component of the TropIKA.net project is the “knowledge hub”, where we feature international meetings of major importance to efforts to combat the infectious diseases of poverty. A TropIKA.net team attends each meeting and – on a specially created section of the TropIKA.net website – the team posts summaries of individual sessions and overviews of each day’s proceedings. Interviews with delegates, news stories and commentaries are also provided. Not only does this service enhance the experience of those who attend the meeting, but it also allows people who are not present to become “virtual participants”. Three meetings have been featured this year, two of them within the last two weeks! Our coverage of the 5th MIM Pan-African Malaria Conference in Nairobi is our most ambitious so far, featuring interviews, news and commentaries, as well as summaries of individual sessions and day-by-day overviews. We are now in the process of covering the 13th Annual Meeting of the Global Forum for Health Research in Havana. Keep up to date with what is happening at this event by visiting the hub for this meeting.

The expert deliberations in Nairobi are of course not all that is going on. TropIKA.net has reported in the last few days on epidemics of leishmaniasis in southern Sudan and dengue fever in Cape Verde. The latter is the biggest ever dengue outbreak ever recorded in West Africa.

Many diseases afflict the world’s poorest people continuously and not just in the form of major epidemics. Pneumonia is both the world’s biggest infectious killer and the most common cause of death in children under five in developing countries. It can only be hoped that a new pneumonia action plan devised by the World Health Organization may be a signal this most neglected of diseases is at last winning recognition as a global health priority. Another WHO report featured on TropIKA.net has highlighted the unequal position of women in health care.

As well as reports, we also continue to highlight articles published in the journals – see our Research, Reviews and Editorial opinion sections. It is always an invidious task to suggest which of the recent articles in the literature are the most significant but I should like to recommend two. A review article on the global burden of blindness due to trachoma is important in its own right – at least 1.3 million people are living with blindness as a result of this infection. However, in their discussion of the assumptions that must be made in calculating disease burden, the authors demonstrate how hard it is to reach firm conclusions for any infectious disease of poverty. In contrast, there is good evidence that prevention and treatment strategies for trachoma are highly cost effective. Whether we know precisely how many DALYs or dollars are lost, the human cost of this readily preventable disease is clearly on such a scale that every effort should be made to step up action against it.

I was also impressed by the insights emerging from a systematic review of qualitative data on the barriers to effective treatment and prevention of malaria in Africa. Qualitative studies often provide such insights, and what is most striking here is the finding that only a minority of people in Africa are aware that malaria is transmitted by mosquito bites. If people do not understand how an infection is spread (or indeed that is an infection) then this will clearly have in impact on their participation in control efforts and treatment seeking behaviour.

Finally, a magazine article that I can particularly recommend was referred to in our TropIKA.net blog; it deals with the encouraging growth of public-private partnerships (PPPs) in the development of new technologies to address the infectious diseases of poverty. Let us know if you spot something in the media that is worth highlighting on the blog.

Paul Chinnock
Editor, TropIKA.net

Oct 19 2009

Neglected diseases in neglected regions

Posted by: Paul Chinnock - Editorial Team

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The infectious diseases of poverty exact a massive burden on the populations of Asia and Africa, but their impact in the Americas is often forgotten. (The extent of this neglect was made clear in a research article published a year ago in PLoS Neglected Tropical Diseases).

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

Jul 31 2009

Overcoming neglect: profiling the people

Posted by: Paul Chinnock - Editorial Team

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An important part of TropIKA.net is our Profiles section in which Tatum Anderson interviews key figures working against the infectious diseases of poverty. We are delighted that our latest interviewee is Dr Awa-Marie Coll-Seck executive director of the Rollback Malaria Partnership (RBM). She plays a crucial role in coordinating the activities of the myriad of organizations now involved in international efforts to improve malaria control. One of the many new malaria initiatives is the Affordable Medicines Facility for malaria (AMFm). There is currently much debate, for example in a recent PLoS Medicine article, as to the merits of this scheme and how it might best be implemented.

Another recent Profile interviewee, Brian Greenwood, is probably best known for his work against malaria but in his long career in tropical medicine he has also focused on other diseases, among them is meningitis. We report on the launch of the African Meningococcal Carriage Consortium (MenAfriCar), to be headed by Professor Greenwood, which will make a concerted effort to understand the spread of meningococcal meningitis in Africa.

We also report good news on another disease that is predominantly an African problem – onchocerciasis (river blindness). Mass administration of the drug ivermectin kills the larvae of the parasite responsible but not the adult; repeat treatments (once or twice a year) are therefore given. It has been widely believed that communities living in areas endemic for the disease would need to be given these treatments indefinitely. However, a study in Mali and Senegal found that, after 15-17 years of mass drug administration with ivermectin, only a few people were still infected and treatment could safely be stopped. Ivermectin is not, however, an ideal drug. Many patients find it extremely unpleasant to take and parasite resistance to the drug has been reported. Research to find new ways to control river blindness that do not depend on ivermectin therefore remains important – see TropIKA.net news story on the latest meeting of the SCOOTT Consortium (Sustainable Control of Onchocerciasis today and Tomorrow).

Amongst the other good news has been the announcement by the International Trachoma Initiative that three more countries (Ghana, Mexico and Saudi Arabia) have now met the criteria for elimination of trachoma as a public health problem. It is unusual to see a low-, a medium- and a high-income country mentioned together for the same achievement! Tropical diseases can indeed afflict both rich and poor but it those who live in poverty who are the most vulnerable.

Many of the countries where dengue fever is a problem are emerging economies in Latin America and Southeast Asia. The economic impact of the disease is therefore considerable. Probably the most comprehensive study to date seeking to quantify this impact has just been published. Infectious diseases that affect poor people are by and large neglected, but with increasing wealth in dengue-afflicted nations, perhaps the economic imperative will lead to an expansion of efforts to develop a vaccine and a treatment for this increasingly common disease.

The diagnosis of the infectious diseases of poverty is itself a neglected issue. When advances are made in the treatment of a disease, rapid and reliable diagnosis becomes even more important, as was discussed in the case of malaria in a recent BMJ article.

Two initiatives to address the neglect of diagnosis have made an appearance in TropIKA.net during the last few days. The African Network for Drugs and Diagnostics Innovation (ANDi) has announced that it will present its strategy and business plan in October, and the TropIKA.net blog links to an interview with Joseph Ndung’u of the Foundation for Innovative New Diagnostics (FIND) about the search for a new diagnostic test for trypanosomiasis (sleeping sickness).

- For more on new developments in diagnosis, see also a recent article in TDR News.

Paul Chinnock
Editor-in-Chief, TropIKA.net

Jun 30 2009

Too many organizations, too much talk

Posted by: Paul Chinnock - Editorial Team

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Every few days there seems to be an announcement of the launch of a new programme or a new organization that seeks to address in some way the infectious diseases of poverty. When one considers the previous neglect of the disease burden in the world’s poorest countries, new initiatives are to be welcomed. One result, however, is that the so-called “institutional landscape” of global health is growing ever more complicated.

A study in the Lancet, highlighted on TropIKA.net analysed the flow of funding for global health programmes and one of its findings was that the role of the UN system has been diluted in recent years, since the launch of new programmes and agencies. An accompanying editorial asked, “Who runs global health?” The same study confirmed the dominance of HIV/AIDS, malaria and tuberculosis in the funding provided for global health, and another Lancet study bears out the view that big programmes focusing on these diseases can harm the ability of health systems to provide comprehensive health care. There is cause for concern that the proliferation of agencies and programmes, each with their own agenda, may have harms as well as benefits. Are there now too many institutions in the landscape?

Could there also be too many conferences? There are numerous TB conferences and when the annual Pacific Health Summit also chose to focus this year on drug-resistant TB one delegate told the meeting that she was tired of attending expensive gatherings hearing the same people say the same things – see TropIKA.net News. The organizers of this event did have a specific aim in mind – to get industry more involved in efforts to beat drug resistance and – while phrases like “stakeholder engagement” seem to many of us to be the worst sort of jargon – the activity they describe is important and international meetings are a part of the process. That said, many will have sympathy with the view that the global health conference circuit is getting out of hand.

Does it all lead to advances in research, and to progress in the control and treatment of diseases on the front line of health care? There has certainly been no shortage of progress for us to report on TropIKA.net in recent days. There has been media interest in the continuing phase 3 trials of the most advanced vaccine under development for malaria, RTS,S. The development of further malaria vaccines may be assisted by the resources for immunologists made available by the US National Institute of Allergy and Infectious Diseases on the new website of its malaria research programme. Meanwhile, a dengue candidate vaccine is soon to enter a phase 1 trial. The TB Alliance will provide support for the further development of a promising new TB drug.

Vaccination against pneumococcal disease in developing countries has come a step closer with the announcement of a $1.5 billion “Advance Market Commitment” [8].

Reports from Ethiopia describe the successful integration of trachoma and malaria control campaigns. Community level action has been shown in a study to be effective in controlling the mosquito vector of dengue fever in Cuba, and from India there are encouraging reports of community level projects for TB. All this is a long way from complex institutional landscapes and expensive conferences. However, if constant new initiatives and meetings at a global level really are essential to progress on the front line, then we shall have to learn to live with them.

Paul Chinnock
Editor-in-Chief, TropIKA.net

Apr 17 2009

New ideas, new threats, new success

Posted by: Paul Chinnock - Editorial Team

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A Chinese medical team expects to be able to announce soon that it has eliminated malaria from Mohéli, an island in the Indian Ocean. The team says its methods – mandatory mass drug administration using artemisinin combination therapy – would also be successful if used across Africa and globally, but the approach is not favoured by Western scientists. Will it lead to artemisinin resistance? Is it unethical? Is it only feasible in a small-island setting? It would be a pity if the experience gained in Mohéli were to be rejected entirely out of hand, and sadder still if a great divide were to open up in malaria elimination, between those who favour the currently accepted strategy and those opting for the new ideas put into practice by this Chinese team.

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

Mar 02 2009

The woman with the leg

Posted by: Paul Chinnock - Editorial Team

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Sometimes one can read a great number of research articles on infectious diseases and come away with just a single case uppermost in one’s in mind.

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

Oct 28 2008

Conferences, reports and vaccines

Posted by: Paul Chinnock - Editorial Team

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The 39th Union World Conference on Lung Health has been held at a time when there are many exciting developments to report on tuberculosis but the need for increased funding for research is nevertheless apparent.

Another important event within the last couple of weeks has been the publication of the annual World Health Report. It appears almost exactly 30 years after the historic Alma Ata conference which led to an emphasis on primary health care (PHC). The World Health Organization says that, to address persisting health inequalities, a return to the spirit of Alma Ata is required.

China has undergone many changes in recent years. The impact of these changes has been discussed in a series of articles in the Lancet. There is no doubt at all that China has much to contribute towards the global battle against the infectious disease of poverty. TropIKA.net has recently highlighted a number of studies on infectious diseases conducted within China from which there are lessons for other nations. For example, a trial has been reported which examined the safety and efficacy of combined praziquantel and artemether treatment for schistosomiasis. Another Chinese trial has shown the drug tribendimidine to be effective against hookworm, roundworm, whipworm, tapeworm and threadworm.

Research that will lead to the development of new vaccines is often reported on TropIKA.net but the development of an efficacious vaccine should never be regarded as the final goal. There are many diseases which can be prevented by vaccines already available, but strategies must still be found to deliver those vaccines to those who need them. Pneumococcal disease is one of the biggest infectious killers of poor people, particularly children. There is now a vaccine and it is coming into use in richer nations. A UK parliamentary group is campaigning for the vaccine to be introduced in developing countries, and also for other action to be taken against this infection.

And of course even effective vaccines can be improved. Encouraging news comes from Nigeria where a polio vaccine that only requires one dose, instead of three, has been shown to be effective.

Amongst the recent research that has been the subject of commentaries on TropIKA.net, have been two important genomic studies on malaria. The completion of the P. vivax genome provides the scientific community with a valuable resource that can be used to advance investigation into this relatively neglected species. The genome of the simian and human malaria parasite P. knowlesi has also been published. Both studies were published by Nature which is not of course an open-access journal. However, Nature has taken the decision to make these two articles freely available.

Other important studies on which we have commented include a systematic review which looked at hookworm-related anaemia during pregnancy. Based on their findings, the reviewers call for improved deworming programmes for pregnant women. And there is good news from Peru, where a study found that extensively drug-resistant tuberculosis could be successfully managed in out-patients. (The patients in the study were not HIV infected.)

Paul Chinnock
Editor-in-Chief, TropIKA.net

Oct 16 2008

Malaria and more

Posted by: Paul Chinnock - Editorial Team

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TropIKA.net continues to provide in-depth coverage of key meetings relating to the infectious diseases of poverty. The latest such meeting is the First Meeting of the African Network for Drugs and Diagnostics Innovation(ANDI).

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