Tuberculosis has featured strongly in TropIKA.net in the last couple of weeks. This is appropriate as World TB Day (24th March) will soon be with us. There are many issues that must be urgently addressed if further progress is to be made in controlling this disease, which kills over one and a half million people every year. There are particular concerns over the growing numbers of cases of drug-resistant forms of TB and new understanding [1] of the mechanism of action of two drugs active against multiple-drug resistant TB may help inform the search for the new drugs that are so desperately needed.

A neglected area of TB research has been diagnosis. Sputum microscopy – sometimes referred to as the “gold standard” for diagnosing TB – is time consuming, can only be conducted in the lab and often gives incorrect results. A rapid test that can be used on the front line is required. News of new funding [2] provided by the Gates Foundation to a non-profit group that focuses on this issue is much to be welcomed. Interestingly, a manufacturer of breath tests for disease diagnostics says it has developed a simple test that can diagnose active pulmonary TB within minutes – see TropIKA.net News in brief [3].

The importance of partnership is always stressed in TB control efforts. Important partners in the delivery of care include the private health care sector and it is disappointing that in India [4] many private practitioners do not apparently provide the recommended TB treatment DOTS (directly-observed therapy short course.)

Good news

Several recent TropIKA.net articles report good news concerning other infectious diseases of poverty. For example, a trial in India [5] found that a single transfusion of the drug amphotericin B, for which patients stayed in hospital for just 24 hours, was as effective in the treatment of visceral leishmaniasis (VL) as a course of treatment requiring a one-month hospital stay. This finding could have major implications; it would be possible to significantly increase the number of VL patients who receive treatment.

When new drugs are introduced they are not always popular with patients and this is bound to affect their compliance with the treatments they are prescribed – something that is not always taken into consideration when implementing new programmes. Much depends on the switch to artemisinin-combination therapy (ACT) as the standard treatment for uncomplicated malaria and it is reassuring to learn [6] that the introduction of the ACT Coartem in Dar es Salaam, Tanzania has met with a positive reception from the local community, including mothers whose children have been treated for malaria.

A TropIKA “Research in brief” article [7] includes further welcome news: a new insecticide could be in prospect for mosquito control, research at the “basic” level could lead on to the development of treatments for cholera and for the kinetoplastid diseases, and a drug already in use in veterinary medicine could be developed as a new treatment for onchocerciasis.

Looking to the future, research into sleeping sickness (human African trypanosomiasis) will be boosted by new Gates funding, and the Australian government has made new grants to researchers working on malaria [8]. In both these cases the research will be based in institutions located in developed countries, but there is a pressing need for more research to be done in disease-endemic countries themselves and for it to be conducted by nationals of those countries. This was the theme of the African Expert Meeting on Pharmaceutical Innovation in Africa, held in Pretoria, South Africa [9], where a call was made for support to enable the development and production of medicines, “in Africa, by Africans”. The registration in African countries of new drugs shown to be effective against the infectious diseases of poverty was also discussed at this meeting [10]. Robust registration procedures are of course necessary but they must not lead to unnecessary delays in bringing the fruits of scientific research to those who most need them.

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

For many months there have been reports from Cambodia of cases of malaria showing resistance to what is now the mainstay of malaria treatment – artemisinin combination therapy (ACT) – see for example a Science paper featured on TropIKA.net last year. There was confirmation of this disturbing finding in a conference presentation in November (see TropIKA.net blog) and in a paper in the New England Journal of Medicine in December.

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