TropIKA Blog Portal

Mapping the burden of neglected diseases

This week sees the launch of a Global Atlas of Helminth Infection, detailed in this paper in PLoS Neglected Tropical Diseases, on which the journal’s Editor-in-Chief Peter Hotez is a co-author (http://dx.plos.org/10.1371/journal.pntd.0000779). The atlas is important for several reasons. Mapping the burden of disease is a critical first step to control and elimination. Without knowing how many are affected, and where the disease hotspots are located, health experts trying to tackle these diseases are largely aiming in the dark. For many years, this is what researchers fighting neglected diseases have had to do. National reporting on the burden of diseases such as African sleeping sickness or lymphatic filiariasis has been patchy at best, largely because of weak surveillance systems or problems with diagnosis. While there have been large-scale mapping efforts for schistosomiasis and onchocerciasis, the information they contain is now fairly outdated. The atlas will exploit new methods of data-capture, in which data is sent as soon as it has been collected to a central database via laptops or other mobile technologies. GIS (geographical information systems) frameworks allow this disease data to be meshed with environmental data on climate variability and weather patterns, which are key in the transmission of infectious neglected diseases. The ease with which data can now be captured and organised on a macro level has been at the heart of other mapping efforts such as new global maps for malaria (see Q&A with Simon Hay on mapping malaria, http://www.tropika.net/svc/specials/mim2009/profiles/Q_A_Hay). These maps have offered malaria researchers an opportunity to better target their efforts. The world is finally seeing substantial political will to fight neglected diseases. The Obama administration, for example, is expected to release US$100 million a year to fight these diseases under its new Global Health Initiative. The atlas for helminth infection is a start - neglected disease researchers must now pool their efforts to create more atlases of neglected diseases.

US health institute funds ten global malaria research centres

The US National Institute of Allergy and Infectious Diseases (NIAID) will be providing $14 million as first-year funding to ten new research centres, in order to support their work on malaria. The awards, renewable for six years, are intended to establish international centres of excellence for malaria research in regions where malaria is endemic, including parts of Africa, Asia, the Pacific islands and Latin America. Further details here.

Mouse study finds clindamycin-plus-azithromycin protects against malaria

Kenyan and German scientists have shown, in laboratory mice, that a combination of two cheap and readily available antibiotics (clindamycin and azithromycin) gives protection against malaria. They believe that it may be possible to use the combination as a preventive treatment in endemic communities, given periodically during peak transmission seasons. More details may be found in a Voice of America article.

A call for improved coordination between HIV and TB programmes

One reason for the rise in tuberculosis cases seen in some parts of the world is the high prevalence of HIV in those countries. HIV-infected people are particularly vulnerable to infection with TB, making it the most common cause of death in HIV/AIDS patients. There is still, however, a tendency to run HIV and TB control programmes as separate, 'vertical' activities. Many calls have been made for improved coordination. Citizen News reports a persuasive and detailed account of the benefits of coordination (and how it should be done in practice) made by Professor Anthony Harries, Senior Adviser to International Union Against Tuberculosis and Lung Disease, speaking at the pre-conference session of the XVIII International AIDS Conference (IAC) in Vienna, Austria. Professor Harries describes three aspects of coordination: for people living with HIV, for people with TB, establishing mechanisms for collaboration between TB and HIV programmes. [Also on Citizen News, a brief article makes the case for the use of isoniazid preventive therapy (IPT) to prevent latent TB developing into the active form of the disease.]

NTD news from Colombia

Nora Cardona-Castro of the Instituto Colombiano de Medicina Tropical - Universidad CES has written to us about the work of the Institute.

The Colombian Institute of Tropical Medicine "Antonio Roldan Betancourt" ICMT-CES is a center of excellence in research, nonprofit, described by COLCIENCIAS full exaltation granted by that organization: Group A1 "Institution of Excellence in research." It was founded in 1989 as a Joint Participation Corporation for purposes of public and social interest. Currently the Institute has an operating headquarters in the CES University facilities in the town of Sabaneta and another office located in Apartado - Antioquia. The ICMT is managed by the University of Medellín CES, an institution renowned for the quality of its academic programs and unconditional support to the development of research and science, as well as the provision of services, consulting and advisory services in the Colombian health sector and Latin America. ICMT-CES Mission Working continuously for the development of science, through research and academic training of health professionals, with the aim to contribute actively in improving the health of the citizens. Our Institute has international recognition, thanks to the work associated with other research institutions and the many publications of scientific contribution. ICMT-CES focuses its research activities in all areas of Tropical Medicine, based on epidemiology and immunology of infectious diseases, supported by the most advanced techniques of molecular biology for diagnosis. They stand out for their development research in progress: leishmaniasis, Chagas disease, intestinal parasites, salmonellosis, leprosy, tuberculosis, malaria, cysticercosis, dengue, leptospirosis, diagnostic methods, medical entomology and brucellosis.

Journal examines "global health crisis"

The the summer 2010 issue of World Policy Journal is devoted to what it describes as "the global health crisis". Articles focus on topics including tuberculosis, sanitation, influenza and counterfeit drugs. Well worth a look. Articles are freely accessible online at: http://www.mitpressjournals.org/toc/wopj/current.

Global Network appoints new managing director

Dr Neeraj Mistry has been appointed Managing Director of the Global Network for Neglected Tropical Diseases. A public health physician, Dr Mistry was a founding member and former vice president of the Global Business Coalition on HIV/AIDS, Tuberculosis and Malaria (GBC), and brings extensive experience in global health policy and programming. The Global Network, a major programme of the Sabin Vaccine Institute, is an advocacy and resource mobilization initiative dedicated to eliminating the most common disabling, disfiguring and deadly neglected tropical diseases. Further details of Dr Mistry's appointment are available in a press release.

Uptake of new and emerging health technologies: a questionnaire

TropIKA.net reader Aashee Aziz writes...

I am currently a student on the Master in Public Health programme at the University of Birmingham, United Kingdom. For my MPH dissertation, I am distributing a questionnaire about health technologies in developing countries. The questionnaire looks at the managed uptake of new and emerging health technologies in developing countries and the implementation of an Early Awareness and Alert System (EAAS) and Health Technology Assessment (HTA). It will be distributed to anyone who could offer insight in this issue such as providers of health care, commissioners of health care, researchers and policy makers in developing countries.

Aashee is looking for people who would like to contribute to this exercise by completing the questionnaire. He can be contacted on: siamesetabby@hotmail.com

Duke Global Health Institute to conduct implementation research for malaria control

The Duke Global Health Institute, USA, has received a $2.2-million, 4-year grant from the National Institutes of Health (NIH) to support research by a Duke University-led team to promote sustainable strategies to curb the spread of malaria and protect human and environmental health in endemic areas. According to principal investigator Randall A. Kramer, professor of environmental economics at Duke's Nicholas School of the Environment at the DGHI, the team will conduct experiments in 24 villages in the Mvomero district of Tanzania to assess the effectiveness of different intervention strategies individually and in combination. Using the findings from these studies, the Duke team will refine a new tool used to improve the effectiveness and safety of malaria control strategies in different settings worldwide. Designed by Duke researchers in 2007, the Malaria Decision Analysis Support Tool (MDAST) was developed to address the controversial re-introduction of DDT in several East African countries by assessing the economic, environmental and human health risks with alternative strategies for managing malaria (1). In the Tanzania studies, villages will be randomly assigned to receive one of four disease-control strategies: no intervention; treatment with mosquito-larvicides; rapid diagnostic testing for malaria by health workers; or both larviciding and rapid diagnostic testing. "The central objective is to improve malaria control through an implementation science approach that integrates health delivery and decision support modelling to promote joint optimization of vector control and disease management strategies," says Kramer. Marie Lynn Miranda, associate professor of environmental sciences and policy and director of the Children's Environmental Health initiative at the Nicholas School, is Kramer's co-principal investigator on the new grant. Their team includes collaborators from Duke University, the University of Pretoria in South Africa, and the National Institute for Medical Research in Tanzania. References 1. Beerbohm, E. A pilot expert elicitation to assess the risks of malaria vector control strategies in East Africa. Unpublished.

Rethinking priorities

Developments reported on TropIKA.net within the last few days have challenged some common assumptions made about the infectious diseases of poverty…

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.

TB vaccine candidates still in development

The Aeras Global TB Vaccine Foundation plays a key role in research and development efforts to produce a new tuberculosis vaccine. Peg Willingham, the Foundation's Senior Director, External Affairs, gives a brief update of the progress made in an interview with Citizen News Service. She says that there are six candidate vaccines in the Aeras research pipeline. One is an improved version of the long-established BCG vaccine; the others would be potential boosters for BCG (or the improved BCG). Willingham says that, in total, there are nine TB vaccines at different stages of development around the world. However, she estimates that it will be 2020 before there is one that is ready for use.

Children with TB deserve more attention

Fewer children than adults have tuberculosis and children are not usually infectious. As a result, paediatric TB is usually not high on the priority list for control programmes. Nevertheless, 20-50% of children who live in households where an adult has active TB, become infected and their power to resist TB infection is poor, as the immune system is less developed in the first few years of life. Children with other infections and with malnutrition are particularly at risk. An article from the Citizen News service, quotes experts in Indonesia and India who want to see more attention paid to paediatric TB, which often goes undiagnosed (due to technical issues as well as a lack of resources). They say that more information is needed as to how common the condition is in both HIV-infected and HIV-uninfected children. Greater efforts are needed to bring TB treatment to the children who need it.

GM mosquito is 'malaria-proof'

The control of malaria through the release of genetically modified (GM) mosquitoes is receiving increasing from researchers. US scientists report that they have created a mosquito that is 'malaria-proof'. Release of these insects, and the displacement of normal mosquitoes, could be used to block the transmission of malaria. The researchers introduced a gene that affected the insect's gut in such a way that the malaria parasite could not develop there. They reduced the number of infected mosquitoes by 60–99%. They report their work, in which they used the mosquito Anopheles stephensi, in PLoS Pathogens [1]. The study is discussed in BBC News, where researcher Professor Michael Riehle of the University of Arizona explains that, while the ultimate goal is to introduce malaria-resistant mosquitoes into the environment: "Before we do this, we have to somehow give the mosquitoes a competitive advantage over the disease-carrying insects". The introduction of the gene into the main mosquito species responsible for malaria transmission (such as Anopheles gambiae) will also be necessary. There is therefore some way to go before GM mosquitoes are used in control programmes. Nevertheless, it is currently an exciting area of research. Reference 1. Corby-Harris V, Drexler A, Watkins de Jong L, Antonova Y, Pakpour N, et al. (2010) Activation of Akt Signaling Reduces the Prevalence and Intensity of Malaria Parasite Infection and Lifespan in Anopheles stephensi Mosquitoes. PLoS Pathog 6(7). Accessible online: http://www.plospathogens.org/article/info%3Adoi%2F10.1371%2Fjournal.ppat.1001003.

The poor: where are they?

It is the world's poorest people who face the biggest infectious disease burden and who should, therefore, attract most attention in disease control efforts. But who are the world's poorest people and where do they live? The focus is generally upon Africa. For example, in the best-selling book The Bottom Billion, it was argued that the countries in which the poorest one billion people live are almost all in Africa. New research suggests, however, that a large proportion of the world's ultra-poor are in India. The Guardian (UK) reports that specialists at Oxford University have devised a new "multidimensional poverty index", according to which there are more poor people in eight of India's states than in the 26 countries of sub-Saharan Africa combined. The index uses 10 major variables including education, nutrition and sanitation. According to the index, more than 410 million people live in poverty in the eight Indian states, and the intensity of the poverty is equal or worse than what is found in Africa. For example, the Democratic Republic of the Congo (population 62 million) is perhaps the poorest nation in Africa, but India's vast central Indian Madhya Pradesh state (70 million) has a near-identical level of poverty. Many laudable efforts have been made in recent years to address poverty and disease in Africa. India's poor, in comparison, have been neglected. This is all the more tragic, given the impressive growth of India's national economy. From the research perspective, India's needs must help shape the agenda. Vivax malaria, dengue, visceral leishmaniasis and leprosy are amongst the infections which threaten the poor in many parts of India.

Nigerian herbal medicines and malaria

The prospects of finding an effective treatment for malaria amongst the many herbal preparations used by traditional healers have been discussed in an article in Nigerian Tribune. The article focuses on research at the University of Ibadan, first announced three years ago, in which 164 plants were found to be used by healers in malaria treatment in Nigeria's Middle Belt alone. Twelve of these were particularly commonly used, and one of them, Enatia chlorantha, was studied further by the researchers. They found it to be active against malaria in mice, but mice that received it regularly died. Determining an appropriate dose rate would therefore be essential before human trials could be conducted. As healers in other parts of Africa use a different range of herbal preparations for malaria, there certainly remains much work to be done to screen all these preparations both for effectiveness and for safety.

International onchocerciasis meeting held in Ghana

A group of experts on river blindness (onchocerciasis) has conducted an independent evaluation of the African Programme for Onchocerciasis Control (APOC) during a meeting held in Ghana. WebGhana interviewed some of those taking part. Dr Sam Adjei, Chief Executive Officer of Ghana's Centre for Health and Social Services, said there was a need to integrate onchocerciasis control with the control of other infections, such as schistosomiasis, elephantiasis and Buruli ulcer. Fragmented health systems should be strengthened to ensure comprehensive and integrated care. APOC's Director, Uche Amazigo, said it was important to empower communities through education. This would require time, and she urged health providers and developmental NGOs and donors to exercise patience with the process. Deputy Minister of Health, Mr Rojo Mettle-Nunoo, told the meeting that there was a need for innovative public education on the causes and treatment of onchocerciasis. This was necessary because of the re-emergence of the disease in some communities in Ghana. The meeting included field trips to onchocerciasis-endemic villages in Ghana's Eastern Region.

Climate change and malaria

A helpful discussion on how climate change might impact on the prevalence of malaria has been published in the US online newspaper The Faster Times. Written by a scientist - Anome Akpogheneta PhD, whose own doctoral research focused upon malaria immuno-epidemiology - the article makes it clear that there are different views as to whether global warming will have a significant impact on the number of malaria cases. Different modelling studies have produced conflicting results. Dr Akpogheneta quotes Professor Steve Lindsay of the London School of Hygiene & Tropical Medicine who says that while models can help provide a "broad brush understanding" they should not be taken too seriously. Professor Paul Reiter at the Institut Pasteur has also said that many models "sidestep factors that are key to the transmission and epidemiology of the disease: the ecology and behaviour of both humans and vectors, and the immunity of the human population". The author concludes that, "Over-emphasis on global warming in relation to malaria misses the mark on the immediate need to address persistent socio-economic and political factors which drive malaria transmission". It is unusual to see such balanced and well-informed discussion in the "popular" media. More scientists should write like this.

Modelling infectious disease

In recent years, the techniques of mathematical modelling have been increasingly applied to the infectious diseases of poverty. Calculations are made to produce estimates of how far and how fast epidemics are likely to spread, and the likely impact of control measures. Despite the growth in infectious disease modelling – and despite controversies over the reliability of the technique and sometimes conflicting calculations by different modellers – there have been few standard resources available to those who want to learn more about this rising discipline. An introductory textbook, Infectious Disease Modelling, aims to fill the gap. Written by Emilia Vynnycky and Richard White of the London School of Hygiene & Tropical Medicine it is aimed at epidemiologists, public health researchers, policy makers, veterinary scientists, medical statisticians, health economists, infectious disease researchers, and applied mathematicians. More details are available on: http://anintroductiontoinfectiousdiseasemodelling.com

TB treatment is granted orphan drug status

Rifapentin, already a key drug in the standard WHO recommended treatment for tuberculosis, has been made an "orphan drug" by the European Medicines Agency (EMA), part of the European Commission. The decision was made because manufacturer Sanofi-aventis wishes to develop a new a rifapentine-based combination regimen, which EMA considers may benefit TB patients with non-resistant forms of the disease. It could shorten their treatment time, which would reduce the poor levels of compliance that are a barrier to effective TB control. The orphan drug designation will assist in the development of the proposed new regimen. It confers several benefits, including protocol assistance provided by the EMA throughout the drug development process, direct access to the European centralized procedure to register the medicinal product in Europe, reduced fees for filing drug approval and marketing exclusivity in the approved orphan indication for a period of 10 years in the European market. Further details are available from Sanofi-aventis.

Tuberculosis "not just a disease of the poor"

A columnist in India's Hindustan Times alerts readers to the fact that "tuberculosis is resurging among the affluent, urban young professionals". Sanchita Sharma alerts readers to some often appreciated facts about TB: it does not always cause the classic symptoms of hacking cough etc., and most of the [at least] one in three people who are infected worldwide do not have the active disease. Sanchita Sharma blames stress, late nights, smoking and dieting for turning a latent infection into active disease, when it appears in young professionals. That's not something everyone would agree with but the columnist does well to remind us that TB should never be considered to be a disease that doesn't happen to "people like us".

Drug giant pursues new Chagas disease treatment

Merck & Co is investigating the potential use of one its existing drugs as a treatment for Chagas disease. The drug, Posaconazole, is already registered for use against fungal infections. The company says it will carry out a "Phase II mid-stage investigational proof-of-concept clinical study" with the drug and plans to report the results in 2012. Although the infection affects some eight million people in Latin America, of whom approximately 30-40 percent will develop serious cardiac or digestive disease, it is one of the most neglected infections and has attracted little attention from the pharmaceutical industry. This new development is therefore to be welcomed. More details are on the company's website.

US FDA looks for new ways to stimulate private-sector development of drugs for neglected infections

A Reuter's report says that, later this year, a US Food and Drug Administration (FDA) panel will discuss how to make it easier and cheaper for drug companies to develop treatments for "neglected diseases such as malaria and tuberculosis". It's deliberations will be along similar lines to those of a panel that is looking at the development of treatments for rare conditions such as cystic fibrosis and Huntington's disease. In both cases, the underlying issue is that the market for new treatments is relatively small and offers the companies very few opportunities for profit. As reported on TropIKA.net, FDA has already tried to stimulate private-sector research on neglected infections through its priority review voucher scheme but, as we have also reported, this has proved to be controversial. The panel's ideas for further initiatives in this area will be awaited with interest.

Most paediatric fevers not caused by malaria

More than half the paediatric fevers treated in public health clinics in Africa are caused by diseases other than malaria, according to a study by Oxford University and other research groups, whose authors caution against the "continued indiscriminate use of anti-malarials for all fevers across Africa." Of the 183 million children with malaria symptoms treated by public health clinics in 2007, only 43 percent were diagnosed with malaria, but many more most likely received anti-malarial medication. "Malaria is still routinely made as the diagnosis of convenience in response to paediatric fever," the study's lead researcher, Peter Gething, told IRIN. "This in part stems fromofficial guidelines that have only recently been updated, and in part because often the only treatments available in front-line clinics are anti-malarials." In 2006 the World Health Organization (WHO) recommended that health workers in countries with a high number of suspected cases of malaria treat children with fevers - the main clinical symptom of malaria - for the disease, even without a diagnosis. There was little else to do at the time, said WHO expert Peter Olumese. "The probability was high that the fevers were from malaria, the disease could turn fatal quickly and there was no time to lose, and there were no proven diagnostic tools," he told IRIN. Since then, rapid diagnostic testing for malaria has become available, making it possible to confirm diagnoses without health workers, a microscope or a laboratory. In 2008, 11.5 million of these tests were distributed in Africa; in 2009, the Global Fund to Fight AIDS, Tuberculosis and Malaria financed 74 million tests, and another 105 million in 2010, according to the Roll Back Malaria Partnership. People in communities have been trained to test one another for malaria. In Senegal, people of all ages are treated for malaria in government-funded health centres only once there is a positive result from a laboratory or rapid test. In sub-Saharan Africa 31 countries have a policy of "universal diagnostic testing", while another 15 countries in the region have set a goal of testing before treatment in children aged five and older, judging it too risky to delay treatment in younger patients.

More on malaria from IRIN

BURKINA FASO: When is malaria not malaria?

GLOBAL: Spoonfuls of sugar could save malaria patients

MALI: Combating malaria misdiagnosis

TIMOR-LESTE: Rebuilding infrastructure poses challenge to tackling malaria

Yet it can be equally risky to treat someone for malaria based only on the assumption that they have the disease, the director of WHO's global malaria programme, Robert Newman, told IRIN. "You might be wasting ACT [anti-malarial artemisinin-based Combination Therapy], while increasing the risk for drug resistance; also, you are not treating the underlying febrile disease and the drug delay can be fatal. If you treat bacterial pneumonia with anti-malarials, you still have a problem." On Kinaserom, one of the islands in Lake Chad, health workers recently started using rapid tests to check patients suspected of having malaria. Mahamat Boukar Moussa, the head nurse at a clinic on the island, told IRIN he gave patients malaria medication even when test results were negative. "The tests are not accurate and we cannot risk inaction." Raoul Ngarhounoum, the regional health director overseeing the rollout of malaria rapid testing, told IRIN he agreed with the health workers' scepticism. "These are malaria-endemic areas, and just because a test says it is not malaria does not mean it is not." Gething said that besides quality control, "Simply supplying RDT [rapid diagnostic testing] universally is likely to be less effective if it is not accompanied by sufficient training for front-line health workers." The Foundation for Innovative New Diagnostics, which works with WHO to create quality control standards for rapid tests, recommends spot checking in each batch of tests ordered to ensure the tests were not poorly manufactured, or had been damaged in transit or storage. Malaria treatment would not change overnight, said Gething. "In an ideal world, all fevers reaching clinics in Africa would be tested for malaria, using a reliable diagnostic test ... As always, the reality on the ground is more complex. For years the advice has been to treat all fevers as malaria, and changing that dogma is likely to take time."

Source: IRIN

EU wants more research collaboration with Africa

The European Union has published a report calling for more collaboration and coordination with researchers in Africa. Health research is one of the areas considered. According to the Foreword of the 64-page report The Changing Face of EU-African Cooperation in Science and Technology: Past Achievements and Looking Ahead to the Future::

"Africa is a continent with a great pool of untapped scientific talent. The brain-power is there, but the means to translate it into scientific input for socio-economic development need further enhancement."

The report continues:

"Europe’s objective is to support Africans in the development of their own scientific and technical skills and capacity, mastering the knowledge and technology needed for their development and the implementation of their own research agenda. It aims to achieve this by opening up the European Research Area (ERA) and developing equitable and effective research partnerships between the European Union (EU) and African institutions and their researchers." After a look at how policies have developed over the years, the report promises "a new beginning". Appendices on specific areas of collaboration include descriptions of the European and Developing Countries Clinical Trials Partnership (EDCTP) and health system research.

mHealth for mothers

Andrew Whitworth of the Fleishman-Hillard communications consultancy writes... A consortium of international groups (health Alliance, the WHO’s Partnership for Maternal, Newborn and Child Health, White Ribbon Alliance, Family Care International, the GSM Association, Johns Hopkins School of Nursing, Bloomberg School of Public Health and PATH) will be developing a Joint Action Plan to accelerate the use of wireless technology to improve maternal and newborn health in the developing world. This announcement made at the consortium’s first working meeting in London last month and follows a report released by UN Secretary-General Ban Ki-Moon which highlighted that efforts to boost maternal and child health are currently falling short of the goals set against MDG 5 (maternal health). For further details contact Andrew on: Andrew.Whitworth@fleishmaneurope.com

Guinea worm: movements of pastoralists hold back progress in Sudan

The prospects for the total global eradication of guinea worm disease (dracunculiasis) are looking good but Sudan, where 85%, of the world's remaining cases are to be found, is proving a hard nut to crack. An article in Sudan Tribune says one problem is that many people in the south of the country, where most cases are located, are pastoralists and during the dry season move from their "base villages" to temporary camps in search of water for their cattle. It is hard for health teams to retain contact with the pastoralists whilst they are on the move. This makes it difficult to provide treatment or to maintain adequate surveillance. The article quotes the director of the Southern Sudan Guinea Worm Eradication Program, Makoy Samuel who says: "There’s no way we can succeed in interrupting transmission of Guinea worm disease without taking into account the movements of the cattle, and thus of villagers, between their permanent locations and the cattle camps". The campaign to eradicate Guinea worm began in 1986, when there were an estimated 3.5 million cases of the disease in 20 countries in Africa and Asia. Last year there were 3,190 cases in just four countries, all of them in Africa: Sudan, Ghana, Mali, and Ethiopia. The US Carter Center continues to play the leading role in the campaign: http://www.cartercenter.org/health/guinea_worm/index.html

Dengue, not malaria, is Sri Lanka's most serious mosquito-borne disease

As discussed in a recent TropIKA.net article, which focused on Zanzibar, some malaria-endemic areas have now reached a position where it would be technical feasible to eliminate the disease as a public health within the next few years. Now, Sri Lanka's health minister Maithripala Sirisena is reported by the country's Daily News as saying that malaria will be eradicated* there by 2015. The minister pointed out that annual malaria case numbers have declined in recent years, whereas ten years ago 200,000 cases per year were reported. He went on, however, to comment on the Sri Lanka's growing problems with dengue - like malaria a disease transmitted by mosquitoes: "We are facing another problem. That is the dengue fever. Over 35,000 dengue patients were reported in 2009 and 360 people died due to this. The present dengue situation is similar to that of 2009. Over 16,000 dengue cases were reported and over 90 people have died in 2010. This is very serious problem." He said that dengue control could not be achieved by the government alone; it was a "social responsibility". *The term disease "eradication" is usually taken to mean a complete absence of cases, whereas reducing locally-acquired cases to zero is described as "elimination". It is likely that Sri Lanka has set elimination as a target.

Blinding infections a major issue for Nigeria's Bornu State

It is increasingly recognized that one way of preventing trachoma, an infectious disease of poverty that causes blindness, is to provide communities with clean toilets. (The bacterial disease is often transmitted by flies and inadequate toilets provide them with a place to breed.) An IRIN News report describes the situation in Bornu State, Nigeria, which has the highest rate of trachoma in the country. A survey by Helen Keller International (HKI) concluded that, “Poor sanitation, lack of personal hygiene and acute water shortages are major causes of this disturbing health problem”. HKI staff have constructed ventilated pit latrines for primary schools in 10 villages and trained teachers to detect early signs of trachoma. Trachoma rates in these schools have since declined, but HKI is worried that the children are still at risk when they are at home. The government is said to be doing little to combat trachoma in Bornu, which also has the misfortune to have Nigeria's highest prevalence of another infectious cause of blindness - onchocerciasis or river blindness.

The Bay Area Global Health Summit

Heidi Moseson, an epidemiology student at the University of California, San Francisco, writes to TropIKA.net.. I’m writing regarding the Bay Area Global Health Summit, scheduled for October 13, 2010 at the University of California, San Francisco. Hosted by the UCSF Global Health Group, this Summit will bring together a unique array of leading health and development experts to discuss new aid models, promising innovations for expanding access to care, public-private partnerships for health, priorities arising from the 2010 Canadian G8 meeting and UN MDG Summit, malaria elimination and eradication, and more. I’m writing in the hope that TropIKA.net might be interested in posting information about the Summit in your online event calendar, and/or on your website. I’ve pasted a brief description of the event below that you are free to use if helpful, and there is also much more information on the Summit website (www.UCSFGlobalHealthSummit.org) including a confirmed speakers list, agenda, and registration information. We would very much appreciate it if you could spread the word, and we think that many of your readers will have a strong interest in the summit focus. Please feel free to email or call with any questions: hmoseson@gmail.com Many thanks for your time, Heidi

Be a part of a groundbreaking discussion on global health action for the next decade. Join us for the first Bay Area Global Health Summit where leading health and development experts will discuss new aid models, promising innovations for expanding access to care, public-private partnerships for health, malaria elimination and eradication, and more. Hosted by the Global Health Group of UCSF Global Health Sciences, the summit will bring together leaders of foundations, universities, government and industry from around the world on October 13, 2010 at UCSF’s new Mission Bay Campus. Register now! Visit www.UCSFGlobalHealthSummit.org for more information.

Buruli ulcer: treatment guidelines should be "urgently changed"

The Institute of Tropical Medicine (ITM) in Antwerp, Belgium says that the World Health Organization must, as a matter of urgency, change its guidelines on the management of Buruli ulcer. In a press release, the ITM calls for faster surgery of large ulcerating lesions, without the currently recommended four-week "waiting period", in which only antibiotics are used. ITM says that using antibiotics only makes large ulcers worse. The ITM bases its views on research carried out, in the Democratic Republic of Congo, for a PhD thesis by Dr Anatole Kibadi Kapay. (The press release provides only an outline of Dr Kapay's findings; TropIKA.net has contacted ITM to inquire where further details might be found but has received no reply as yet.) According to the press release, Dr Kapay found that: "WHO guidelines for clinical diagnosis lead to a correct diagnosis in only 2 cases out of 3. As opposed to a Ziehl-Neelsen smear, a microscopic technique that is within reach of poor countries – and that, through a better diagnosis, prevents the needless use of antibiotics. But when large wounds have to be treated, from a microscopically confirmed Buruli case, antibiotics are indeed useful. With surgery only, 15% of patients relapse; with parallel use of antibiotics, less than 2% relapse. But antibiotics only, without surgery, make large wounds worse". Another outcome from Dr Kapay's work was the discovery of new focus of infection close to the Angolan border. He suggests this could be connected to the poor working conditions in the illegal diamond mines there. Note: The findings of a recent trial published in the Lancet (and highlighted on TropIKA.net) were said to have “...established beyond reasonable doubt that early and limited Buruli ulcer can be effectively treated with antibiotics without surgery”.

Disease elimination: when is it a realistic prospect?

Some of our recent articles on TropIKA.net have involved use of the E word – elimination. There comes a time when it becomes realistic for a control programme that seeks merely to reduce case numbers to progress to the more ambitious goal of eliminating an infectious disease as a public health problem. The elimination of malaria from some of the territories where it is endemic is now technically feasible, though many barriers will still have to be overcome. 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.

mHealth project will focus on dengue and Chagas disease

The Science and Technology Division of the Inter-American Development Bank has launched a Mobile Citizen Program that will "support the development of citizen-centric mobile services targeted to low-income groups in urban and rural areas in Latin America and the Caribbean region". Infectious diseases are amongst the issues that will be addressed. A project based in Argentina will focus on Chagas disease and dengue. Current epidemiological surveillance of Chagas and dengue is largely based on manual records, which leads to poor information management and lack of coordination. The project aims to strengthen surveillance and response through mobile and internet-based systems, shortening the time between notification and decision making. Further details are available here.

The H3 Africa Project

Ten years after the Human Genome Project's completion only one genome study has been based on an African population, and startlingly few African scientists have been involved in genome research on any population. With the announcement this week of the new Human Heredity and Health in Africa Project (H3 Africa), that may soon change. The $38 million project, established by the US National Institutes of Health (NIH)and the Wellcome Trust, will employ African scientists in the search for new insights into genes, environment and health among African populations, which have been found to contain greater genetic diversity than those of Europe and Asia [1]. The project's aim is to find out more about how genes affect the way the human body responds to environmental factors, such as diet, and how this lowers or elevates risk for both non-communicable and infectious diseases. In the past, many research projects simply took samples from Africa and conducted the studies back in Western labs," said Dr Charles N Rotimi, President of the African Society and Director of the Center for Research on Genomics and Global Health at the National Human Genome Research Institute in the USA. "H3 Africa will build the capacity for African researchers to study African populations to solve African problems and will create strong collaborations between African researchers and those in Europe, the US, and other parts of the world." Reference 1. LB Jorde, et al (200). The distribution of human genetic diversity: a comparison of mitochondrial, autosomal, and Y-Chromosome data. American Journal of Human Genetics; 66(3): 979-988.

US support for global health - an update

A press release from USAID says that the US government is continuing "to lay the groundwork" for its Global Health Initiative (GHI). GHI is a six-year, $63 billion initiative to help developing countries improve health outcomes by strengthening health systems and building upon proven results. It places a particular focus on improving the health of women, newborns and children. Pursuing a comprehensive approach, GHI includes programmes addressing HIV/AIDS, malaria, tuberculosis, maternal and child health, nutrition, family planning and reproductive health, and neglected tropical diseases. The first round of "GHI Plus" countries and the programme's governance structure have now been agreed.

Nurses know little about multidrug-resistant strains of TB

The increasing number of cases of multidrug-resistant tuberculosis is one of the leading global health concerns. One country where MDR-TB is now common is South Africa, but a study has shown that nurses know little about the condition and its treatment. The study was presented at a recent conference in Durban. Many nurses considered MDR-TB a rare problem, even those in KwaZulu-Natal, which has the highest incidence of drug-resistant TB in the country. Only about 19% of the 16 health facilities surveyed in rural and urban areas of Limpopo and KwaZulu-Natal provinces had nurses with formal training in MDR-TB management. Worryingly, it was found that some nurses who had been trained to handle MDR-TB demonstrated similar levels of knowledge as those who were untrained. More details are available from IRIN News.

More on neurocysticercosis

TropIKA.net recently highlighted a review article about an infectious disease of poverty that is an important cause of epilepsy. The disease in question is neurocysticercosis and it is good to see that it is starting to attract more attention from both researchers and donors. Members of the Cysticercosis Working Groups in Europe and East and Southern Africa have been invited by the Bill and Melinda Gates Foundation (BMGF) to develop a proposal to investigate the efficacy and safety of mass administration of praziquantel and albendazole for the control of schistosomiasis and soil transmitted helminths in areas co-endemic for cysticercosis. Northern Uganda and the Southern Highlands of Tanzania have been selected as suitable study areas. To facilitate the development of this proposal the Schistosomiaisis Control Initiative (SCI) is convening a workshop of key stakeholders supported by the BMGF to ensure that the study design builds on the work of existing programmes preventing duplication and promoting efficient use of resources, makes use of lessons learned from previous studies and strengthens the cysticercosis working group network of researcher and implementers who will be able to take forward the control of cysticercosis in the future. The half-day workshop will be taking place in the week of the 12th July in Entebbe, Uganda. For details contact Dr Wendy E Harrison Deputy Director of SCI.

Fish for mosquito control

Dr Jonathan Matias of Poseidon Sciences writes... "I just wanted to update you on our recent publication on biological control using fish that can be disseminated in the form of hibernating eggs to control mosquitoes in temporary pools. Here is the link to this new article: http://www.malariaworld.org/article/open-access-use-annual-killifish-biocontrol-aquatic-stages-mosquitoes-temporary-bodies-fresh Hoping that this stimulates interest and collaboration to move this project towards more practical use."

mHealth summit coming in November

The use of mobile phone technology in health care is a topic that has often been dealt with on TropIKA.net - for example see a review article on the topic published in February this year. A major conference on the issue is planned for November this year and a call for presentations and abstracts has been issued. The 2010 mHealth Summit, organized by the Foundation for the National Institutes of Health (FNIH), the mHealth Alliance and the US National Institutes of Health, will be held 8-10th November in Washington DC. It aims to connect leaders in government, private sector/industry, academia and not-for-profit organizations to advance decision-making related to the intersection of mobile technology, health research, and policy in the United States and abroad. For more information, visit http://www.mhealthsummit.org.

Sock scent could lure mosquitoes in malaria control

It has often been noted that mosquito species that transmit malaria are attracted by human sweat. A Dutch scientist has noted that the smell of sweaty socks seems to be particularly attractive and she is hoping to use the odour to lure the mosquitoes into traps. The aim is to reduce mosquito numbers as a part of malaria control programmes. Dr Renate Smallegange of the University of Wageningen says she is working to create a synthetic odour suitable for use in such traps. However, there are several components to human sweat and she has not yet been able to identify them all. More details on AfricaNews.com.

Philippines reports progress against lymphatic filariasis

Over one billion people live in areas where they are at risk of lymphatic filariasis (elephantiasis), a disfiguring and disabling disease that is caused by microscopic worms and carried by mosquitoes. Programmes are now under way in many countries, seeking to eliminate the disease as a public health problem. One such country, the Philippines, has been making encouraging progress. The Philippine Information Agency (PIA) reports that WHO has declared Bukidnon Province as being "Filaria-Free". For a region to earn this description, the WHO criteria are that the prevalence rate of the disease should be less than 1%, no positives should be found among children aged 2-4 years, and there should be no positives among new school entrants. "We are celebrating this milestone to show the world that filariasis can be beaten," says Provincial Health Officer Dr Teresita Damasco. Mass drug administration is the central element of efforts to control LF, and PIA reports that another province, Aklan, is "moving in for the total elimination of filariasis" with the launch of a drug administration programme that will initially run for five years. In Aklan, LF infection is said to be particularly common amongst workers who harvest the abaca plant (from which 'hemp' fibre is extracted). But, with certain exclusions the whole population will receive drugs (diethylcarbamazine and albendazole) once a year.

Global Fund freezes its funding for Zambia

The Global Fund to fight AIDS, Tuberculosis and Malaria has frozen its grants to the Zambian health ministry. A Global Fund press release states: "The freeze in disbursement came after Zambian authorities last year uncovered fraud within its own Ministry of Health. Further investigations by the Global Fund showed that the Ministry of Health was not able to safely manage grants. The organization has demanded the return of US$8 million in unspent funds from the Ministry of Health. The Global Fund has also demanded that Zambia takes action against individuals found to be involved in the unaccounted expenditures that led to the freezing of grant disbursements". The Fund hopes to recommence its Zambian funding programme within a few months, but through the UN Development Programme instead of the health ministry. Other African countries, including Kenya and Uganda, have previously seen their grants from the Fund suspended for similar reasons. The Fund recently announced its mid-year results, which show that it has so far provided seven million people with effective TB drugs treatment. This is a 30% increase from mid-2009. Progress is also reported in the fight against malaria, with a cumulative total of 122 million insecticide-treated bed nets delivered with Fund support - a rise of 39% from 88 million nets distributed one year ago. However, the Fund has made it clear that it can only maintain activities at this level if donor nations can be persuaded to continue their support, despite the continuing global economic problems. The Fund estimates that it will need $17-20 billion to respond to demand from developing countries for resources to fight the three diseases during the next three years. In October, UN Secretary-General Ban Ki-moon will chair a meeting of the Fund’s donors where they will pledge resources for this period.

Resistance to key antimalarial is said to be spreading

The progress that is being made against malaria in several parts of the world could be derailed if the parasite becomes resistant to the drug that is now the mainstay of treatment - artemisinin. Such resistance is already known to be present along the borders of Cambodia and Thailand. (First detected in 2007, this was confirmed in research published last year - see TropIKA.net article.) Now, a US expert says it has spread to other parts of Southeast Asia. According to a report from AFP, Timothy Ziemer, the US government's global coordinator against malaria, signs of resistance to artemisinin have been found in southern Myanmar and possibly on the Chinese-Myanmar border, and in southern Vietnam near Cambodia. Ziemer, who was speaking at a regional conference in Hanoi, said that, nevertheless, malaria case numbers are down in several parts of the region. In Vietnam, for example, they had fallen from about 190,000 in 1991 to 15,000 by 2008. WHO is overseeing a programme that seeks to hold the spread of artemisinin resistance in check (see TropIKA.net article). One of the key elements of this programme will be to act against the spread of fake and substandard antimalarials.

Researchers show deforestation is associated with malaria risk

US and Brazilian researchers[1] have found a significant association between the destruction of the rain forest and the incidence of malaria. They used satellite data showing changes in tree cover in one county in Brazil's Amazon region, together with health records showing diagnosed cases of malaria. Over a four-year period, 4.2% of the county's tree cover was cleared and there was a 48% increase in cases of malaria. The deforestation was a result of both logging and subsistence farming. To explain the association, the researchers point out that: "Human-altered landscapes provide a milieu of suitable larval habitats for Anopheles darlingi mosquitoes, including road ditches, dams, mining pits, culverts, vehicle ruts, and areas of poor clearing". An increase in the number of fish farms may also have led to a rise in the number of breeding sites for mosquitoes. The research team propose that that land use measures may be one method to employ in malaria control. It has been estimated that that 19,000 square km of forest are cleared in Brazil each year. Reference 1. Olson SH, Gangnon R, Silveira G, Patz JA. Deforestation and malaria in Mâncio Lima County, Brazil. Emerg Infect Dis. 2010 Jul; [Epub ahead of print]. Accessible here.

Filariasis in the news

Lymphatic filariasis (LF) is an infectious disease of poverty that rarely makes it into the mainstream media, but in an article in the Guardian (UK) Dr Mwele Malecela, of the Global Alliance to Eliminate Lymphatic Filariasis describes the work of the Alliance and says that progress against the disease is now being made. More information on LF is available here.

Chagas disease said to be increasing in Venezuela

A report on GlobalPost.com says that Venezuela is experiencing an increase in cases of Chagas disease. The report focuses on the infection of 100 students and staff in a high school. They are believed to have contracted the parasite responsible for the disease (Trypanosoma cruzi) through drinking contaminated fruit juice. Two other 'major incidents' are said to have occurred in the country since 2007. The Venezuelan Parasitological Society says that cases of Chagas have tripled in the past two decades and that its prevalence has increased from 0.5% of the population to 1.6%. More information on Chagas disease, which affects some eight million people across the Americas, is available here.

Leishmaniasis: nanotechnology used to create potential new treatment

Brazilian scientists have used the methods of nanotechnology to produce a new formulation of an existing drug (currently used to treat gastric ulcers) that they have used to reduce the number of leishmaniasis parasites in infected hamsters. Their findings, using a liposomal formulation of furazolidone, are reported in the International Journal of Antimicrobial Agents [1]. A summary (in Spanish) is available on SciDev.net. Reference 1. Tempone AG, Mortara RA, de Andrade HF Jr, Reimão JQ (2010). Therapeutic evaluation of free and liposome-loaded furazolidone in experimental visceral leishmaniasis. Int J Antimicrob Agents; 27 May. [Epub ahead of print]. Accessible here: http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B6T7H-506H0PH-2&_user=10&_coverDate=05%2F31%2F2010&_rdoc=1&_fmt=high&_orig=search&_sort=d&_docanchor=&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=43b53f7b55ff405458cf97af98d729d4

Aid dollars and malaria

A feature story in the current issue of Time Magazine looks at the massive increase in aid for malaria over the past five years and the pivotal role UN special envoy Ray Chambers has played in prodding Western governments to open their wallets. The writer suggests that Chambers' group, Malaria No More, which he founded in 2006 and which has the official endorsement of the WHO, represents "a new way of giving. "With its ethos that "aid should be seen not as a noble act of charity but as something that's in everyone's interest," Malaria No More "stands as a case study that aid can change," argues the writer, Alex Perry, Time's Africa bureau chief. But can that progress be sustained? That may be the true test of aid's effectiveness - especially given that, short of eradication, nothing is permanent when it comes to controlling malaria. Perry points to Zanzibar as a prime example of the need to maintain momentum; the Tanzanian island, which is now on the cusp of launching a malaria elimination campaign, has twice before eliminated malaria - not "eradicated" it, as Perry stresses - only to reimport it from the heavily-infected mainland. "Kenya has slipped," he adds. Dambisa Moyo, author of the 2009 best-seller "Dead Aid: Why Aid is Not Working and How", popularized the notion that charity hasn't worked. Moyo's message echoes the late race-bating, gay-bashing senator of North Carolina, Jesse Helms, infamous for his tirades against greater funding for AIDS research, who once dismissed foreign aid as "money down a rat hole." Moyo has been criticized for being light on the facts and for glossing over positive trends directly attributable to health and humanitarian aid, among them the halving of malaria deaths in nine African countries since 2000. But if Moyo questions Africa's progress against malaria and what it actually means, she isn't alone. "Roll Back Malaria claims its interventions have had an impact in places like Eritrea, Sao Tome and The Gambia, where there's either a history of bed net use or, in the case of Eritrea, there's been a drought for four years," says David Molyneux, director of the Lymphatic Filariasis Support Centre at the Liverpool School of Tropical Medicine. "So surprise, surprise, you have an impact on malaria." Molyneux adds that when it comes to malaria's success, one has to ask, "How long have we got?" Bed net efficacy, he says, is already being eroded by resistance to pyrethroids. "We know there's quite a lot of resistance already in West Africa. And there's nothing in the pipeline to replace them." Indeed, rather than joining the chorus of applause, Molyneux asks why the world isn't holding the malaria community accountable: "They have failed to reach targets they set themselves," he says. "It wasn't that other people set the targets. They set the target of universal bed nets by 2010. Of course you fail when you set that kind of target." A veteran researcher and vocal advocate for the control of lymphatic filariasis (LF), Molyneux has often criticized what he calls a "siloed" malaria community. "They don't have the structures or ability or interest in engaging with other people who have different ideas," he says. "That's the point I've been making and will continue to make: why are you ignoring LF? It's not a question of whether I'm technically correct: free drugs and mass drug administration have been shown to increase bed net uptake. So why don't they look at that and say, 'What can we learn from this? It's not going to cost us anything.' I don't understand it."

Protein that protects against TB is identified

According to a new study [1] a protein, CCL5, plays a protective role in helping the body ward off tuberculosis in the early stages of infection. CCL5 is a member of a large family of proteins responsible for immune cell migration toward infection sites. The work on this molecule suggests that CCL5 and/or related proteins may lead to new therapies that help the immune system resist TB. Gillian Beamer, a researcher from the Center for Microbial Interface Biology at Ohio State University in Columbus, Ohio who was involved in the work has said, "We hope this study will spark interest in understanding the mechanisms which control cell migration to sites of infection, help define the protective immune response to Mycobacterium tuberculosis, and ultimately improve our capacity to predict and/or treat patients with TB". The research team discovered the role and potential benefits of CCL5 by studying mice lacking the gene to make the CCL5 protein and mice with the CCL5 gene. When both groups of mice were infected with Mycobacterium tuberculosis, those lacking CCL5 accumulated fewer protective cells and had more bacteria in their lungs over three to five weeks of infection when compared to the normal mice. After five weeks, differences between the groups were not apparent, leading researchers to conclude that CCL5 did not play a role in long-term infection, but rather in the onset and early protection against infection. Additionally, in humans, altered CCL5 expression may be a predisposing factor leading to TB disease progression. Reference 1. Vesosky B, Rottinghaus EK, Stromberg P, Turner J, Beamer G (2010). CCL5 participates in early protection against Mycobacterium tuberculosis. J Leukoc Biol; 87(6):1153-1165.

Advocacy group under fire

The organization Africa Fighting Malaria, which is run from an office in Washington DC, continues to come in for criticism. Since its launch in 2000, this advocacy group has focused most of its attention on one issue - the desirability of using DDT in mosquito control programmes. Blogger Ed Darrell adds another critical voice, asking "Can anyone tell me, what has Africa Fighting Malaria ever done to seriously fight malaria?" He points out that while the organization portrays itself as a lonely voice struggling to promote the use of indoor residual insecticide spraying, the practice is already supported by WHO, the Gates Foundation, African governments and others.

Sector-wide approach fails to improve health

A Comment article in the Guardian (UK) criticises the performance of "sector-wide" aid programmes (SWAps) in addressing health issues. The article defines the approach, now much favoured by the World Bank and other donors, as follows: "Instead of funding a development project with a very specific focus, like tuberculosis (TB) or malaria, SWAps channel donor funds to broad health initiatives in a developing country. For instance, instead of financing the delivery of HIV medicines or bed nets in Ghana, SWAps money is provided to the government to spend toward broader goals like 'improving the public health sector' and a number of health services". However, the Guardian writers, using tuberculosis as one example, say that only limited improvements in health have been achieved through SWAps. Many governments in the North, such as the UK, have recently stated that agencies like the World Bank must improve their performance in order to justify continued funding. A close look at the sector-wide approach is therefore now needed. The article quotes the Bank as stating that the current economic downturn will increase the number of child deaths in the South by around 400,000 this year.

As promised, GSK makes chemical structures of antimalarials freely available

GlaxoSmithKline has deposited the chemical structures for more than 13,500 anti-malaria compounds in the European Bioinformatics Institute's freely available ChEMBL chemical database. In January, GSK announced its plans to make the structures freely available but did not disclose at the time how it planned to make the compounds available. More information is available on the Free Library and on the ChEMBL-NTD web page.

Kenya researchers predict malaria incidence rates

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%. In research conducted across East Africa over the last nine years, scientists of the Kenya Medical Research Institute, the Kenya Meteorological Department, and the International Centre for Insect Physiology & Ecology have made use of weather predictions, information about the reproductive mechanisms of mosquitoes, and data on the geographical formations of particular areas. Being able to predict when epidemic levels of malaria will strike would be of great assistance to health authorities. For example, indoor residual spraying of insecticide programmes can be focused on areas where outbreaks are imminent. The full story is reported on AlertNet.

Angola suspends sleeping sickness research efforts

Disappointing news is reported from Angola where the Institute to Fight and Control Trypanosomiasis has announced that it will be suspending its programme of research this year. According to the Angolan News Agency, the Institute had been hoping to screen more people for the disease this year. However, after screening just 3.7% of the population at risk, activities were halted due to a lack of funds. In 2008, 12% of the population were screened and the goal was set to raise this figure to 80% by 2012.

South Africa will make use of patent pool for infectious diseases of poverty

GlaxoSmithKline announced last year (see TropIKA.net News) that it would create a "patent pool" into which it would put any chemicals or processes over which it has intellectual property rights relevant to finding drugs for malaria, tuberculosis and the neglected tropical diseases. Other researchers would be free to make use of anything within the pool. Alnylam Pharmaceuticals, the Emory Institute for Drug Discovery, and the Massachusetts Institute of Technology have since added to the patent pool, which is administered by BIO Ventures for Global Health. And in the latest development, South Africa has become the first country where the government has announced that it will draw upon the resources that have been made freely available. Mamphela Ramphele, chairwoman of the South African Technology Innovation Agency, said that finding new drugs for tuberculosis would be a particular priority. Her agency will coordinate and nurture drug development among local companies, including the South African firm iThemba Pharmaceuticals, which has already announced plans to use the pool to do research into new TB drugs. More on this development is available from Reuters. Other TropIKA.net articles focussing on the patent pool may be accessed here.

Charting the bottom ten

By Margaret Harris This is a first attempt to chart the distribution of these neglected diseases and is based on published epidemiological data. Let the maps cycle, or click on each disease name at the top to see where in the world that disease can be found. We welcome feedback, updates and suggestions on ways to improve the information provided. The interactive map on the TropIKA.net home page shows 10 diseases - some with names few can pronounce- that have been identified by the Unicef/UNDP/World Bank/WHO Special Programme for Research & Training (TDR) as the most neglected of infectious diseases, hampering the health and development of the world's poorest people. The diseases: Chagas, dengue fever, human African trypanosomiasis (HAT) onchocerciasis, leishmaniasis, leprosy, lymphatic filariasis, malaria, tuberculosis and schistosomiasis are still endemic in much of the world, particularly tropical regions. Their distribution and effects differ from disease to disease but their burden remains heavy. Africa, South America and Asia all contain countries affected by at least one of these neglected diseases of poverty. Not only do these diseases disproportionately affect impoverished populations, they reduce economic activity. The annual economic loss in Africa due to malaria has been estimated as $12 billion, representing a crippling 1.3 percent annual loss in GDP growth in endemic countries. Schistosomiasis and malaria lower child survival, while onchocerciasis and schistosomiasis hamper children's school performance. Lymphatic filariasis interferes with agricultural productivity as does onchocerciasis and schistosomiasis [1]. Leishmaniasis, human African trypanosomiasis and lymphatic filariasis are associated with an economic burden of a different kind as infected people pay excessive amounts for treatment and seek inappropriate of ineffective care [1]. Leprosy leads to social isolation and stigmatization, particularly among women who may not present for diagnosis due to fear of loss of marriage opportunities. TDR is working to identify the needs, gaps and potential for action in research for infectious diseases of poverty, including the ten that appear on this map. A think tank made of 125 experts from around the world is examining the research, debating the issues and developing options for action. Their findings will feed into the Global Report for research on infectious diseases of poverty, due to be published in 2011. Reference 1. Hotez PJ, Fenwick A, Savioli L, Molyneux DH (2009). Rescuing the bottom billion through control of neglected tropical diseases. Lancet; 373:1570-1575

Malaria cases diagnosed in Venezuela double this year

So far this year, twice as many cases of malaria have been diagnosed in Venezuela compared with the same period in 2009. A report on Times Newsline says there have been nearly 22,000 cases this year. The rise is believed to be due to government's eviction of "hundreds of thousands" of miners working illegally in forest areas. The evicted miners have moved to urban areas, where they would be more likely to be tested for malaria and more likely to spread the disease. While Venezuelans face much lower risks from malaria than the populations of most African countries, the forest zones in the south, which is rich in mineral resources, do seem to pose a significant hazards to those who are drawn there in search of work.

Brazil findings suggest diabetes and allergies increase risk of dengue haemorrhagic fever

Most people who develop dengue recover from the fever and severe joint pains caused by this mosquito-borne viral infection. A minority, however, (variously estimated between 0.5 and 4.0%) progress to more serious and potentially fatal forms of the disease - dengue haemorrhagic fever (DHF) and dengue shock syndrome (DSS). Finding out why some individuals are at risk of DHF and DSS has become a priority for dengue researchers. Researchers working in Brazil used a case-control approach to test the hypothesis that diabetes, hypertension and allergies all raise the DHF/DSS risk level [1]. They compared 170 DHF patients with controls who tested positive for dengue but had not progressed to DHF. For each DHF patient, there were seven controls. Significant associations were found between DHF and white ethnicity, high income, higher education, reported diabetes, and reported allergy treated with steroids. Hypertension was also more common in DHF cases but the association was not significant. (However, black individuals who reported being treated for hypertension had 13 times higher risk of DHF then black individuals reporting no hypertension.) A case-control study (with only 170 cases) would not be considered strong evidence in favour of the associations investigated, but these findings are of great interest. The authors argue that: "...the evidence produced in this study, when confirmed in other studies, suggests that screening criteria might be used to identify adult patients at a greater risk of developing DHF with a recommendation that they remain under observation and monitoring in hospital". Reference 1. Figueiredo MAA, Rodrigues LC, Barreto ML, Lima JWO, Costa MCN, et al. (2010) Allergies and Diabetes as Risk Factors for Dengue Hemorrhagic Fever: Results of a Case Control Study. PLoS Negl Trop Dis 4(6): e699. Available online: http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000699

Dengue drug claimed to be showing promise

US company NanoViricides has released a press statement saying that an anti-dengue drug has shown "efficacy in the recently completed preliminary cell culture studies". The drug is said to have successfully inhibited two of the four types of viruses that cause dengue. NanoViricide's researchers believe the drugs "mimic a common natural host cell receptor by which the four different dengue virus serotypes bind to the body's host cells, thus causing disease". They have hopes that the drug will help overcome the phenomenon known as "antibody-dependent enhancement" in which a person who has recovered from infection with one dengue virus faces a heightened risk of developing the more serious condition dengue haemorrhagic fever (DHF) should they subsequently be infected by another strain of the virus. More details on Vaccine News Daily.

LSTM named WHO Collaborating Centre

The World Health Organization, in consultation with the government of the United Kingdom, has named the Liverpool School of Tropical Medicine a WHO Collaborating Centre for Evidence Synthesis for Infectious and Tropical Diseases. "This designation firmly establishes LSTM as a reference centre for WHO in bringing together the best available research evidence on infectious tropical diseases," said Dr Hans Hogerzeil, Director of Essential Medicines and pharmaceutical policies at WHO. "LSTM has made valuable contributions on the WHO Model List of Essential medicines and the recently released malaria treatment guidelines. We look forward to our continued collaboration as we work towards better quality, safety and use of medicines." LSTM will support WHO in developing recommendations for health care policy, developing guidelines for the management of infectious diseases, organizing training in research methods and assisting in the communication of research results to policy makers, clinicians, teachers and the public in developing countries.LSTM's Professor Paul Garner said, Head of the new Centre, said: "We are really delighted to have been designated a WHO Collaborating Centre. This will allow us to build on our existing work with WHO--part of which is to provide top quality health evidence to assist with work in developing countries and to contribute towards achieving the Millennium Development Goals." The designation builds on an extensive work programme already in existence through the Cochrane Infectious Diseases Group, an international network of 200 people coordinated from LSTM.

Research and development of new tuberculosis vaccines: conference update

Babs Verblackt of Citizen News Service writes further from the conference "Research and development of new tuberculosis vaccines" in Zaragoza, Spain. Professor Stefan Kaufmann of the Max-Planck-Institute for Infection Biology in Berlin, Germany, illustrated that TB infection is a vicious circle: Each day about 125,000 infections result in roughly 25,000 TB cases, or 10 million new cases of TB disease a year. Around 5,000 people die of tuberculosis every day. Drug resistant TB strains, and HIV/TB co-infection further challenge global TB control. Kaufmann emphasized that vaccines can play an important role in turning the tide. He referred to studies showing that a 40-50% reduction in TB could be achieved by new vaccines. Improved drugs could lead to a 10-27% reduction and better diagnostics to a 13-42% drop. He elaborated on the development of the VPM1002 vaccine candidate by his team. VPM has successfully completed tests on safety and immunogenicity in Germany. Further trials (phase Ib) are taking place in South Africa at the moment. Also in Spain progress is made. "It is a difficult process from research to development," Professor Carlos Martin of the University of Zaragoza said, describing the development of the MTBVAC01 vaccine candidate discovered by him and his colleagues. After more than ten years of discovery and proof of concept and now four years of development, the vaccine is taking its first steps out of the lab: The vaccine is scheduled to be tested in people (phase I safety trials) the end of next year. Dr Jelle Thole, director of Tuberculosis Vaccine Initiative (TBVI), in a meeting with Spanish journalists called MTBVAC01 a leading vaccine in its kind. "It is the only candidate derived from the actual bug that starts tuberculosis. All other vaccine candidates either are based on improving or boosting BCG," he explained. TBVI, a European research consortium for the development of new TB vaccines, aims to have eight vaccines in phase II safety and efficacy trials in ten years. New vaccines are aimed to improve or replace BCG, the only currently available vaccine against tuberculosis, which "does not protect against the most prevalent form of the disease, and therefore has little - if any - impact on the epidemiology of TB," Kaufmann said. However, Martin stressed that BCG, developed in the 1920s, is "...still in use because it is protective in children. In this regard, new vaccines should be at least as good as BCG in protecting against severe diseases as meningitis and miliary tuberculosis, and better in protecting against respiratory forms of the disease." Worldwide, new tools against tuberculosis are in several stages of development. Jan Gheuens, a senior programme officer on the tuberculosis team at the Bill & Melinda Gates Foundation, summarized at the symposium: "Two vaccines are in large clinical trials, lots of vaccines are in other phases. Furthermore, eight drugs are in pre-clinical development or further. And there is much excitement on the performance of a TB molecular diagnostic test". Gheuens briefly mentioned strategic challenges to be considered. "What will be the next generation of new vaccines? New antigens or a new approach to vaccines? What about the cost of progress, can we raise the funds for larger clinical studies?" he questioned, adding that fundraising is 'tough' and that not just greater awareness of the challenges in TB, but also (public/political) commitment is needed". The two day symposium (3-4 June 2010) was organized by the University of Zaragoza, the foundation Ramon Areces and TBVI. Babs Verblackt's report on the first day of the conference is available on TropIKA.net News.

Burkina Faso tests indoor residual spraying

Indoor residual spraying with insecticide is seen as an important part of malaria control efforts in endemic areas. A report on IRIN News describes the launch of Burkina Faso's first trial of the technique. Funded by the US Agency for International Development (USAID), the project is expected to cover 25,000 households in the district of Diébougou – using the insecticide bendiocarb – for one season at a cost of US$1.4 million. In 2009 Diébougou experienced more than 20,000 cases of malaria, with 110 deaths.

Peter Piot will be new head of London School

The London School of Hygiene & Tropical Medicine has announced that, from September this year, its new Director will be the former Executive Director of UNAIDS, Professor Peter Piot. Prior to his time at UNAIDS Professor Piot, who co-discovered the Ebola virus in Zaire in 1976, held senior positions at the Institute of Tropical Medicine in Antwerp, the University of Nairobi, and WHO. He is currently Director of the Institute for Global Health and Professor of Global Health at Imperial College London. Professor Piot said, “I am delighted and honoured to accept the role of Director of the prime global public health institution in the world. I look forward to bringing my combined background of research, teaching, policy and management to the School, and to working with staff and students to improve health in the UK and globally.” Amongst those who have congratulated Peter Piot on his new appointment has been Julio Montaner, President of the International AIDS Society who said, “The IAS is delighted with this week’s announcement. We congratulate Professor Piot on a great personal achievement, he will no doubt bring unique vision and experience to this new position”. He replaces the current Director of the School Sir Andy Haines.

Vietnam's Deputy PM calls for more tools to control TB

The need for improved tools to fight tuberculosis has been stressed by Vietnam's Deputy Prime Minister, Nguyen Thien Nhan. Speaking at the 18th Coordinating Board Meeting of the Stop TB Partnership, held in the Vietnamese capital Ha Noi, he said: "In order to control tuberculosis successfully, we need new diagnostic tools, new vaccines and new drugs. Moreover, we need new fundraising systems and the involvement of more partners and the entire society." In his address to the meeting, reported in VietNam News, the Deputy PM also called for more international support to help control TB in Viet Nam. More information on the meeting of the coordinating board is available in a Stop TB press release.

MSF attacks Chagas in Colombia

Médecins Sans Frontières is one of the few international humanitarian agencies that takes a specific interest in Chagas disease. The organization has recently published an article describing its programme against the disease in Colombia. At the end of 2009, MSF integrated Chagas screening and treatment into its primary healthcare services already carried out though mobile clinics in Arauca, a conflict-affected region bordering Venezuela. This is the first time that MSF has carried out Chagas treatment in a conflict context. MSF has welcomed the passing of the resolution "Chagas Disease: Control and Elimination" during the World Health Assembly, which includes the integration of treatment and diagnosis at primary healthcare level for patients in both acute and chronic phases of the disease. However, it says the Assembly failed to stress an important point: "the need to promote alternative mechanisms of financing the research and development for better rapid diagnostic tests, new treatments and a test of cure".

WHO's Research for Health Strategy approved by the 63rd World Health Assembly

May 2010 saw the first organization-wide strategy on research approved by the World Health Assembly. The strategy - Research for Health - defines a common framework for how research is approached in the World Health Organization and the role WHO is taking in global research. It has five main goals: Capacity - building capacity to strengthen health research systems. Priorities - supporting the setting of research priorities that meet health needs particularly in low and middle income countries. Standards - creating an environment to create good research practice and enable the greater sharing of research evidence, tools and materials. Translation - ensuring quality evidence is turned into products and policy. Organization - action to strengthen the research culture within WHO and improve the management and coordination of WHO research activities. Further information can be found at: http://www.who.int/rpc/research_strategy/en/index.html

TropIKA.net launches review series

Efforts to control the infectious diseases of poverty (IDPs) must be based on an objective consideration of all the evidence available. Policy makers, funding agencies, researchers and practitioners all need access to rigorous reviews of this evidence. We are therefore launching a series of such reviews, the first of which is now available: Dengue outbreak response: documented effective interventions and evidence gaps.
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:

Major mHealth report is published

One of TropIKA.net's most-read recent articles has been our review of initiatives in “mHealth” – the use of mobile phones in improving the health care available to people in the world’s poorest countries. Our article referred to a forthcoming report, sponsored by the mHealth Alliance, of the progress that has so far been made. The 79-page report - "Barriers and Gaps Affecting mHealth in Low and Middle-Income Countries: Policy White Paper" - has now been published. It concludes that there is a lack of information as to whether the burgeoning number of mHealth projects are proving effective in improving health care delivery. The authors say that, "the current evidence base ... is not sufficient to inform and influence governments and industry partners to invest resources in nationally scaled mHealth initiatives". They argue that, "the current single‐solution focus of mHealth needs to be replaced by using mHealth as an extension and integrator of underlying health information systems along the continuum of care". The conclusion of the report is that mHealth technology does have the potential to contribute towards improvements in health but that this potential, "...will only be realized if a systematic approach is taken to integrate all its moving parts and direct them toward concrete measurable health objectives and desired outcomes". The complete report may be downloaded from the United Nations Foundation's Global Problems-Global Solutions website.

A "manifesto" for combatting NTDs

Despite evidence that the global burden of neglected diseases is as great as that of any other serious disease, financial support for elimination efforts and R&D has been inadequate, say the authors of a new "Manifesto for Advancing the Control and Elimination of Neglected Tropical Diseases", published this week. Writing in PLoS Neglected Tropical Diseases, Peter Hotez, President of the Sabin Vaccine Institute and Distinguished Research Professor of The George Washington University Medical Center, and Bernard Pecoul, Executive Director of Drugs for Neglected Diseases initiative (DNDi), outline in eight points why the global community should increase financial support for NTD control and elimination efforts and research and development. The manifesto states that:

· All NTDs are "tool ready" with cost-efficient and effective interventions that could be implemented now, even if for some diseases such tools are far from being perfect or complete.

· At the same time that NTDs are tool ready they are also tool deficient, signifying that the tools are incomplete, or inadequate, to sustain elimination efforts.

· NTDs have received little attention from the international community during the past ten years despite their large disease burden.

· Increasing evidence indicates an association between NTD prevalence and conflict and violation of human rights.

· NTDs can be particularly destabilizing and disrupt agricultural productivity and food security. Many poor societies with high NTD burdens have been recently engaged in a civil or international conflict or are currently at war.

· Sustained involvement by the WHO and other international health agencies is crucial for current and future NTD control and elimination efforts.

· Nothing is more important to the success of global NTD control than the involvement of communities themselves and disease-endemic countries' health ministries.

· Achievement of Millennium Development Goal 8 ("develop a global partnership for development") will rest with stakeholders — health ministries, affected communities, public–private partnerships, large and small non-governmental organizations, etc. — establishing a well-functioning international strategy for NTD control.

While acknowledging that policymakers are “slowly beginning to appreciate the importance of NTDs” — evidenced by the creation of a new department of Neglected Tropical Diseases at the World Health Organization; TDR’s 10-year strategic plan; and the identification, by NIH’s Francis Collins, of neglected diseases as a research priority, among other developments — Hotez and Pecoul argue that the challenge of NTDs calls for a manifesto — “a public declaration of motives by a government or by a person or group regarded as having some public importance.”

Moreover, they add, by doing more to tackle NTDs, the global health community can make progress toward Millennium Development Goals.

"[NTD control] activities have facilitated the delivery of additional interventions such as insecticide-treated bed nets, antimalarial drugs, micronutrients, and childhood immunizations," they write.

The authors urge scientists working on NTDs to increase collaboration and identify funding opportunities and cost-efficient interventions.

"By highlighting important challenges in the fight against NTDs, this 'manifesto' calls on the global community for urgent, renewed, and innovative efforts."

Antibiotic resistance discussed

The threat of antibiotic resistance to efforts to improve control of infectious diseases such as tuberculosis is highlighted in a Voice of America report that includes a podcast and video. Issues raised include the part played by the misuse of antibiotics in promoting the development of resistance, and the reluctance of pharmaceutical companies to include infectious diseases in their research and development activities.

Can hungry plants control malarial mosquitoes?

Uganda's New Vision newspaper reports on a research project that is testing whether insectivorous plants planted around homes can decrease mosquito numbers and cut malaria transmission. The project, which is backed by funding from the Gates Foundation, is being run by Professor Jasper Okeng of the Pharmacology Department of Makerere University. Professor Okeng says this is the first time such an approach to malaria control has been attempted anywhere in the world. The New Vision article describes the project and also looks at Jasper Okeng's career as a pharmacologist.

Texting to fight fakes

The number of fake drugs on the market continues to rise. It has been estimated, for example, that over half of the antimalarials on sale in Africa are fake or substandard. Individuals who take these drugs do not receive the effective treatment they need. Also those fakes that contain a small amount of the active compound (as is often the case) promote the development of drug resistance. A new plan to help consumers identify fake products makes use of the fact that mobile telephones are now found widely across the developed world, even in rural areas. Under the plan, legitimate drugs will come with a scratch- off panel hiding 10 digits. Anyone who has purchased a drug with one of these labels can text the code to a widely advertised number, and receive a reply confirming or disputing the product’s authenticity. There is no charge. The scheme is operated by a non-profit group, mPedigree Network, in partnership with computer giant Hewlett Packard. GlaxoSmithKiline is interested in participating in the initiative and discussions are said to be taking place. Initially the focus will be on Africa. It is intended to introduce the system with malaria pills in Ghana and Nigeria by December, with expansion later to Kenya, Tanzania, Liberia, Benin and Uganda. (Full story on the Bloomberg website.)

Implementing the Global Strategy and Plan of Action on Public Health, Innovation and Intellectual Property

A side event at the World Health Assembly on 19th May, 2010, explored how different European Union-supported initiatives are being used to implement the Global Strategy and Plan of Action on Public Health, Innovation and Intellectual property. The European Commission's Kevin McCarthy [Presentation 1 ] outlined the European Union's involvement in developing a range of initiatives, in collaboration with WHO, to implement the Global Strategy. Dr Elias Sory [Presentation 2], Director General of the Ghana Health Service explained how the Global Report on Infectious Diseases of Poverty, now being produced by TDR, will implement element 1 of the Global Strategy by setting research priorities for diseases of poverty. Dr Anthony MBewu [Presentation 3] then showed how the African Network for Drugs and Diagnostics Innovation (ANDI) is implementing element 3 of the strategy by building a research and development network in the most disease-affected countries. Robinson Esalimba [Presentation 4], of WHO's Public Health Innovations and Intellectual Property department, described strategies to improve access to medicines by promoting local production and related technology transfer. Other presentations discussed the local pharmaceutical manufacturing landscape in the most disease affected countries.

Filtration of water through saris retains popularity

The most effective way of preventing cholera is through the provision of safe water supplies. But what can families with no access to safe water do to reduce their risk of infection? Research conducted in Bangladesh in 2003 [1] concluded that, when some 70,000 village women responsible for collecting water were taught to filter it through folded cotton sari cloth, the incidence of cholera was halved. There were concerns that the women might not continue with the practice in the longer term. A follow-up study [2] now reports that, five years later, 31% of the women continued to filter their water, of whom 60% used a sari. Additionally, the researchers found that 26% of women in a control group, who did not receive any education or training in the first study, also filtered their water. Filtration has clearly impressed not only many of the women who were trained but also a good number of their neighbours. Nevertheless, it is clear that without a continuing programme to promote the use of 'sari filtration', many women will abandon the practice. The researchers looked at the incidence of cholera in households during the five-year follow-up period; the incidence of hospitalizations for cholera during the period reduced by 25% but this decline was not statistically significant. The mechanism through which sari cloth seems to filter out Vibrio cholerae bacteria is likely to depend on the removal of particulate matter and zooplankton with which V. cholerae is associated. The follow-up study appears in mBio, a new open access online journal published by the American Society for Microbiology. A summary also appears on the Society's website. Reference 1. Colwell R, Huq A, Islam M, Aziz K, Yunus M, Khan N, Mahmud A, Sack R, Nair G, Chakraborti J, Sack D, Russek-Cohen E (2003). Reduction of cholera in Bangladesh villages by simple filtration. Proc Natl Acad Sci USA; 100:1051-1055. 2. Huq A, Yunus M, Sohel SS, Bhuiya A, Emch M, Luby S, Russek-Cohen E, Nair B, Sack RB, Colwell R (2010). Simple Sari Cloth Filtration of Water Is Sustainable and Continues To Protect Villagers from Cholera in Matlab, Bangladesh. mBio; 1(1):e00034-10. Available from: http://mbio.asm.org/content/1/1/e00034-10.full?sid=fa50f8ec-e969-40b1-b30e-4c2710039a72

Advance in Giardia research: could it help progress against malaria?

It is often hoped that a research advance against one parasitic infection may prove helpful in efforts to combat another. Scientists seeking to develop a vaccine for the intestinal parasite Giardia lamblia believe that their latest findings [1] may help in research targeted on other parasitic diseases, including malaria. The research team, in Argentina, noted that G. lamblia is able to make changes in the proteins on its surface and that this "antigenic variation" allows it to evade the host's immune response. They went on to show that parasites engineered to express all their surface proteins worked as vaccines that could help prevent or mitigate future infections. They conclude that, "These results constitute, to our knowledge, the first experimental evidence that antigenic variation is essential for parasite survival within hosts and that artificial disruption of this mechanism might be useful in generating vaccines against major pathogens that show similar behavior". In an interview on ScienceLive.com, the leader of the research team, Professor Hugo Luján, said that the surface proteins of parasites were needed to help them survive the acid conditions of the host gut and that the new understanding could lead to vaccines that would disrupt this protective mechanism. Vaccines against other parasites, including malaria, could be possible following the same principle. Giardia is a common cause of diarrhoea in many countries and a vaccine against it would therefore be helpful, but it is already possible to prevent infection by through the provision of safe water supplies and good hygienic practices. Reference 1. Rivero FD, Saura A, Prucca CG, Carranza PG, Torri A, Lujan HD (2010). Disruption of antigenic variation is crucial for effective parasite vaccine. Nat Med; 16(5):551-557.

Madagascar will benefit from new initiative to subsidize malaria drugs

Following the announcement that the Affordable Medicines Facility-malaria (AMFm) will "go live" this month (see TropIKA.net Interview), AMFm says that first-line buyers from the public, NGO and private sectors in Madagascar can now place orders for ACTs that will be subsidized under the initiative. Madagascar has completed all of AMFm's requirements and, in a letter sent to TropIKA.net, AMFm Director Dr Olusoji Adeyi says, "Depending on how soon buyers place orders and how long it takes manufacturers to deliver, the first subsidized ACTs may reach the country in August. Eligible buyers from other countries can place orders once each country has completed the requirements; most are close to completion". The Global Fund has signed master supply agreements with five of the six eligible manufacturers of ACTs (Ajanta Pharma Ltd, Cipla, Guilin Pharmaceutical Co Ltd, Ipca Laboratories Ltd and Sanofi-Aventis), and will very soon conclude an agreement with the sixth (Novartis).

Neglected tropical diseases: debating the best way forward

An article [1] in PLoS Medicine's Debate series examines the different approaches that can be taken to tackle neglected tropical diseases (NTDs). Some commentators, such as Jerry Spiegel and colleagues from the University of British Columbia, feel there has been too much focus on the biomedical mechanisms and drug development for NTDs, at the expense of attention to the social determinants of disease. Burton Singer argues that this represents another example of the inappropriate “overmedicalization” of contemporary tropical disease control. Peter Hotez and colleagues, in contrast, argue that the best return on investment will continue to be mass drug administration for NTDs. Reference 1. Spiegel JM, Dharamsi S, Wasan KM, Yassi A, Singer B, et al. (2010) Which New Approaches to Tackling Neglected Tropical Diseases Show Promise? PLoS Med 7(5): e1000255. Available from: http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000255

To prevent Chagas' is not enough

At the 63rd World Health Assembly (WHA) held in Geneva last week, health ministers adopted a resolution on Chagas' disease that focuses too narrowly on prevention and fails to include language promoting diagnosis and treatment, both of which are essential to tackling the neglected parasitic disease, say health charities Médicins sans Frontières (MSF) and the Drugs for Neglected Diseases Initiative (DNDi). Together, the organizations have called on Member States to integrate treatment and diagnosis at the primary healthcare level, to promote research and development, and to reinforce the supply chains of existing treatments so that they are available to health workers and national programmes. While control programmes have traditionally focused on prevention, MSF experience in Honduras, Nicaragua, Guatemala and Bolivia has shown the organization that prevention alone is not an adequate response. “The focus on prevention ignores the needs of those who are already infected and are suffering in silence. In endemic countries, governments should actively screen, diagnose, and treat many more patients,” said Gemma Ortiz, senior advocacy officer for Chagas at MSF. “Access to diagnostics and treatment must be made a priority." "Chagas' patients have been forgotten because they are poor and fall outside the mainstream market interest, but science exists to develop better treatments and diagnostic tools for all," says Bernard Pecoul, executive director of DNDi. "The first steps to making progress at an international level are through sustainable, predictable funding and strong public support."

Ever the advocate, Peter Hotez takes a new tack

The New York Times has an Op-Ed today by Peter Hotez, professor at George Washington University and president of the Sabin Vaccine Institute. Perhaps the world's most vocal advocate for the control of neglected diseases, Hotez is constantly coming up with creative arguments to engage and connect with a US audience far removed from the diseases in question. Writing in Scientific American last December, for example, he appealed to Americans' consumption savvy by making the case for a global economic incentive for defeating NTDs and by marketing an investment in their control as a public health "best buy". "Now Hotez is trying a different tack to make Americans care. Writing in the Times ("Parasites in Paradise"), he points out that, in fact, Americans are not as far removed from neglected diseases of poverty as many of them might have thought. Leptospirosis lurks in their own big cities, and close to three million African-Americans suffer from toxocariasis, a parasitic worm infection transmitted by dogs. And then there's the Caribbean, where a host of other parasites all but unknown in "paradise" - Chagas' disease, schistosomiasis, and hookworm to name just a few - have thrived ever since the slave trade. And here, Hotez introduces yet another angle, this one sure to resonate with American readers on both sides of the political aisle: disease as vestige of slavery and racism. Indeed, if there's one thing with the potential to raise awareness through the roof - even for something as obscure and forgettable as "trichomoniasis" - it's the notion that racism is in some way responsible. Hotez says most of the neglected diseases in the Caribbean could be controlled or eliminated for an estimated $20 million a year, "a total that is roughly equivalent to one dollar for every tourist who visits there ever year". He adds that the Sabin Vaccine Institute, in collaboration with the World Health Organization and the Interamerican Development Bank, is working to find that funding. [Prof Hotez was also the subject of a recent TropIKA.net Profile article.]

Regulating new TB drugs

Ethiopia's capital, Addis Ababa, will host the latest in a series of meetings organized by the Global Alliance for TB Drug Development to examine regulatory issues surrounding the development of new TB drugs. After many years in which there was little support for efforts to find new drugs for TB, progress is now being made but there are concerns that national and international processes for drug regulation could lead to unnecessary delays in getting new treatments to all those who need them. The Alliance is therefore seeking to develop new guidelines for TB drug registration and approval. The next meeting in the Alliance's "Open Forum" series to discuss this issue will feature presentations by leaders in TB drug development, regulators, and public health policy-makers. It will focus on regulatory challenges specifically relevant to the African region. The meeting will take place 18-19th August 2010 at Addis Ababa's Hilton Hotel. Registration for the event is free and currently open. The draft agenda is also available.

TB prevalence underestimated by passive case finding

Many patients with active tuberculosis are not diagnosed until a late stage. Further confirmation of this situation comes in a recently published study [1] from Guinea Bissau, West Africa. Routine TB surveillance in the area studied is based on passive case finding. Researchers made household visits and employed a standard questionnaire to screen for symptoms of pulmonary TB; suspected cases were then investigated with sputum smear microscopy and X-ray. Four cases cases were found among a cohort of 2,989 adults of all ages, and in a second cohort of 571 adults over 50 years of age a further four cases were identified. Of the eight cases found, two were unknown to the local TB programme. (Five cases were HIV uninfected while three were of unknown HIV status.) Previous studies [e.g. 2, 3, 4] have often found that active case finding leads to a higher proportional increase in the number of known TB cases. However, this study is also useful because information on TB prevalence in Africa is sparse. The researchers have shown prevalence to be moderately high in the area studied, with a higher rate of prevalence in older individuals. Late diagnosis can worsen the prognosis for patients and left untreated they can go on to infect many other people. Delays can also increase the costs to patients, which can pose serious demands on people with low incomes. A new study [5] from Ethiopia interviewed recently diagnosed patients about their healthcare seeking behaviour at the time of diagnosis, the delays which occurred, and the costs they had to meet. The researchers concluded that costs arising from time lost in seeking care comprises a major portion of the total cost of diagnosis, and may worsen the economic position of patients and their families. Factors responsible for delays in diagnosis include patients seeking care outside the health system and a low index of suspicion public health providers. These studies provide further evidence of the need for improved screening for TB, greater TB awareness amongst the public and health care providers, and better referral systems. References 1. Bjerregaard-Andersen M, da Silva ZJ, Ravn P, Ruhwald M, Andersen PL, Sodemann M, Gustafson P, Aaby P, Wejse C (2010). Tuberculosis burden in an urban population: a cross sectional tuberculosis survey from Guinea Bissau. BMC Infect Dis;10:96. 2. Zachariah R, Spielmann MP, Harries AD, Gomani P, Graham SM, Bakali E, Humblet P (2003). Passive Versus Active Tuberculosis Case Finding and Isoniazid Preventive Therapy Among Household Contacts in a Rural District of Malawi. Int. J. Tuberc. Lung Dis; 7(11):1033-1039. 3. Shargie EB, Yassin MA, Lindtjorn B (2006). Prevalence of smear-positive pulmonary tuberculosis in a rural district of Ethiopia. Int J Tuberc Lung Dis; 10(1):87-92. 4. 14.Wood R, Middelkoop K, Myer L, Grant AD, Whitelaw A, Lawn SD, et al. (2007). Undiagnosed tuberculosis in a community with high HIV prevalence: implications for tuberculosis control. Am J Respir Crit Care Med; 175(1):87-93. 5. Mesfin MM, Newell JN, Madeley RJ, Mirzoev TN, Tareke IG, Kifle YT, Gessessew A, Walley JD (2010). Cost implications of delays to tuberculosis diagnosis among pulmonary tuberculosis patients in Ethiopia.BMC Public Health; 10:173.

Shrinking the malaria map

The Emerging Health Threats Forum has an interesting piece on efforts to “shrink the malaria map.” The article highlights a new study (1) by researchers at the London School of Hygiene and Tropical Medicine (LSHTM) who have developed a reliable way to accurately identify so-called “hot spots” of malaria transmission. According to the authors, the heterogeneity of risk of malaria within populations “creates opportunities for targeted interventions, but only if hot spots of malaria transmission can be identified.” By looking at serological markers of antibody levels, which had been obtained through a pin-prick blood test of people attending health facilities in a district in Tanzania’s Korogwe region, the researchers were able to detect spatial variation in malaria transmission at the micro-epidemiological level. “Serological markers of exposure to malaria showed a tight correlation with malaria incidence and predicted transmission hot spots with high precision,” they write. As debate continues over how best to allocate funds for disease control — to programmes aimed at eliminating malaria in areas already on the verge of doing so or into those designed to reduce the burden of disease where it is greatest — the new findings represent a potent new tool and one the researchers believe could pave the way for eliminating malaria in areas where the disease has been brought under control. References 1. Bousema T et al. (2010). Identification of hot spots of malaria transmission for targeted malaria control. J Infect Dis.

Chikungunya: a timely update on a worrying infection

The mosquito-borne viral infection Chikungunya is not a new disease but the last few years have seen it spread to many new parts of the world. Case numbers are increasing and the disease may be more common that we think, as its symptoms are easily confused with those of dengue. An epidemic in India in 2007 is believed to have infected 1.3 million people. It is not a trivial infection. As the authors of a newly published review [1] point out: "Ninety-five percent of infected adults are symptomatic after infection, and of these, most become disabled for weeks to months as a result of decreased dexterity, loss of mobility, and delayed reaction". The publication of the review is therefore timely. It provides a comprehensive summary of what is known about Chikungunya. The authors detail the epidemiology and global expansion of the disease and go on to describe its clinical features, pathogenesis, symptoms, and complications. They point out that Chikungunya has many of the characteristics necessary to make an ideal biological weapon. This further underlines the need to step up the efforts that are under way to develop a vaccine. Reference 1. Thiboutot MM, Kannan S, Kawalekar OU, Shedlock DJ, Khan AS, et al. (2010) Chikungunya: A Potentially Emerging Epidemic? PLoS Negl Trop Dis 4(4): e623. Available from: http://www.plosntds.org/article/info%3Adoi%2F10.1371%2Fjournal.pntd.0000623;jsessionid=7573D03E82C8350515E5E4FB062C3C58

Mosquito nets go unused

Insecticide-treated bednets (ITNs) are widely recognised as an effective means of reducing malaria transmission. Massive distribution programmes are under way in many parts of Africa, and in the developed world a growing number of charities (some backed by celebrities) have been established to raise support for these programmes. However, several media outlets, for example the Los Angeles Times, have lately pointed out that many ITNs go unused; some fail to reach those who need them and it is claimed that up to half of Africans refuse to use nets. ITNs are a relatively low-cost intervention. If - after all the distribution efforts - only half of the population in malaria-endemic areas is protected by a net then it is disappointing, but many lives will still be saved. The distribution programmes will still be worthwhile. And if more attention is devoted to education and promotion of net use then, in time, more people will be willing to sleep under them. We can only hope that articles like that in the LA Times do not reduce the commitment of those who have provided support to ITN programmes.

Neglected protozoan diseases to be the subject of Paris conference

Three of the most neglected infectious diseases of poverty are caused by related protozoan parasites. Human African trypanosomiasis (HAT, sleeping sickness), Chagas disease and leishmaniasis are all caused by kinetoplastid species. Although millions of people are affected by these conditions and many more are at risk, there continues to be very little funding available for research. In consequence, there are no vaccines and the drugs used to treat these diseases are of limited effectiveness and cause serious adverse effects. Welcome news therefore is that a colloquium "Neglected Protozoan Diseases" is to be held in Paris on 24th September 2010. The meeting, to be held at the Institut Pasteur, will discuss the prevention, treatment and control of all three diseases. Conference sessions will be as follows: • vaccines for leishmaniasis • new diagnostic for protozoan diseases • innovative drug discovery • control of leishmaniasis • epidemiology of neglected protozoan diseases. Further details of the event are available on the Insitut Pasteur website. The deadline for registration is 30th June.

Malaria and primary education in Mali

One reason why the infectious diseases of poverty do so much damage to individuals, communities and nations is that they can prevent people from achieving their full physical and mental potential. The impact of malaria on cognitive ability is an area in which there has been increasing interest. It is recognised that cerebral malaria or severe anaemia as the result of infection can effect a child's developing brain, and that the fetus is similarly vulnerable to malaria during pregnancy. But evidence has been lacking as to whether (and through what mechanisms) uncomplicated malaria or asymptomatic infection can damage cognition, particularly in children who suffer repeated attacks. Researchers working with children in a village primary school in Mali [1] have attempted to improve knowledge in this area. The authors, whose published paper begins with helpful tables summarising previous work on this issue, looked for an association between malaria and variation in cognitive abilities, teachers’ evaluation scores, school progression and absences. Malaria was the main cause of absence from school. In addition, asymptomatic malaria and the presence of malaria parasites were found to have a direct correlation with educational achievement and cognitive performance. The higher the level of parasites present in the blood, the lower the cognitive score. Children with clinical malaria and asymptomatic malaria both had significantly lower achievement test scores, but asymptomatic malaria had less effect on cognitive abilities than clinical malaria. (The cognitive function score used in the study was highly correlated with routine school marks given by teachers.) The authors acknowledge that it is impossible in such studies to prove beyond doubt that an observed association is causal, and the data of course come only from one village school, but these findings offer strong evidence in favour of the view that malaria parasites affect educational achievement. Everything possible should be done to reduce the risk of infection faced by children of this age in endemic areas. Reference 1. Thuilliez J, Sissoko MS, Toure OB, Kamate P, Berthélemy JC, Doumbo OK (2010) Malaria and primary education in Mali: A longitudinal study in the village of Donéguébougou. Soc Sci Med; Mar 17 [Epub ahead of print]. Available from http://bit.ly/9tydZ9.

Sourcing medicines for children

The very young are especially vulnerable to the infectious diseases of poverty but health programme managers face a challenge in sourcing appropriate and affordable medicines for children. A guide produced by UNICEF and WHO seeks to provide guidance. The second edition of Sources and prices of selected medicines for children lists sources and prices for 75% of the 612 formulations needed for the 240 medicines in the Essential Medicines List for Children. WHO and UNICEF note that more than half of the nine million preventable deaths in children annually are caused by diseases which could be treated with safe essential child-specific medicines: acute respiratory infections - pneumonia (17%), diarrhoeal diseases (17%), neonatal severe infections (9%), malaria (7%), and HIV/AIDS (2%). The number of sources for the paediatric treatment of diarrhoea and HIV/AIDS is, however, limited and there is a serious challenge to obtain child-specific medicines to treat tropical infections endemic in Africa and Asia. There are few manufacturers who produce child-specific medicines to treat infections such as filariasis, schistosomiasis and soil-transmitted helminthiases. A commentator on the website Essentialdrugs.org notes that, "UNICEF and WHO could not find a manufacturer for 144 of the 612 needed formulations. Is it lack of commercial markets? Or is it that there is not yet enough demand? Here is a good opportunity for the pharmaceutical industry to show some corporate social responsibility!"

Whither the EDCTP?

As described in a recent article in TropIKA.net News, the European Commission is conducting a consultation to help decide whether the European and Developing Countries Clinical Trials Partnership (EDCTP) should continue and what form it might take. It is important that as many people as possible should contribute to the debate on the future of this important but sometimes controversial initiative, established in 2003 “to accelerate the development of new or improved drugs, vaccines and microbicides against HIV/AIDS, malaria and tuberculosis, with a focus on phase II and III clinical trials in sub-Saharan Africa”. Perhaps TropIKA.net could provide a forum for this debate? Readers with an opinion to express may use the Leave a Reply facility at the end of this blog. Before doing so, it might be helpful to look at some of our other articles in which the role of EDCTP has featured. Also worth reading is a paper [1] published in BMC Public Health a few months ago, in which a group of African scientists described EDCTP as a "success story of true partnership". We shall look forward to hearing your views. Reference 1. Matee MI, Manyando C, Ndumbe PM, Corrah T, Jaoko WG, Kitua AY, Ambene HP, Ndounga M, Zijenah L, Ofori-Adjei D, Agwale S, Shongwe S, Nyirenda T, Makanga M (2010). European and Developing Countries Clinical Trials Partnership (EDCTP): the path towards a true partnership. BMC Public Health; 9:249.

New study will help develop dengue vaccines that do not increase the risk of severe disease

New research explains the observation that people who have been infected by one of the four dengue fever viruses are likely to suffer a more severe attack of the disease if they are subsequently infected by another of these viruses. The findings could also help design vaccines against the disease that are both effective and safe. Over the last 50 years, there has been a remarkable rise in cases of this mosquito-borne disease for which there is no vaccine and no specific treatment. Several potential vaccines are under development (see recent TropIKA.net article) but there is an underlying concern - might a vaccine that is effective against one of the four serotypes of the dengue virus actually make matters worse by increasing vulnerability to the other three? Dengue is unpleasant while it lasts but most patients do recover; only a small minority develop the potentially fatal complication dengue haemorrhagic fever (DHF). It is widely accepted that most DHF victims have already had (and recovered) from dengue; their first episode of the disease might leave them with a reduced ability to fight off the other three serotypes. (This concept is described as "antibody-dependent enhancement"). One of the challenges that vaccine developers face is, therefore, to create a vaccine that works against all four versions of the dengue virus. The new study [1]) was conducted by researchers at Imperial College London (UK) and Mahidol University, Khon Kaen Hospital and Songkhla Hospital in Thailand. Using blood samples from infected volunteers, they showed that a set of antibodies produced in response to the virus did enhance the ability of other serotypes to enter cells. The antibodies in question - precursor membrane protein (prM) antibodies - constitute a large part of the immune response that dengue patients make to the virus. The researchers conclude from their findings that it would be "advisable" to design dengue vaccines that minimize the production of antibodies to prM. Professor Gavin Screaton who led the study told BBC News that, "Our new research gives us some key information about what is and what is not likely to work when trying to combat the dengue virus. We hope that our findings will bring scientists one step closer to creating an effective vaccine." Reference 1. Dejnirattisai W, Jumnainsong A, Onsirisakul N, Fitton P, Vasanawathana S, Limpitikul W, Puttikhunt C, Edwards C, Duangchinda T, Supasa S, Chawansuntati K, Malasit P, Mongkolsapaya J, Screaton G (2010). Cross-reacting antibodies enhance dengue virus infection in humans. Science; 328(5979):745-748.

Zambian scientists to study human resources for health

Researchers at the Zambia Forum for Health Research (ZAMFOHR) have received funding for a 3-year Human Resources for Health (HRH) project aimed at evaluating past and current strategies used to stem the flow of health care providers out of the country and improve service delivery. In 2000, it was estimated that 1.5 million health care professionals from developing countries had emigrated to industrialized countries, primarily the US, UK, New Zealand and Australia. These countries derive significant proportions of their health workforce from poorer countries. And as human resources are integral to the delivery of health services, that loss has severely reduced the capacity of developing country health systems to deliver care in an equitable manner. The US and UK in particular have a long history of recruiting health workers from the developing world. In 2004/5, more than half of the 12,000 nurses entering the UK were from India and the Phillippines. And although the UK's National Health System stopped active recruitment in 2005/6, the private sector continues to recruit trained nurses. In the US, 23% of doctors trained overseas and 64% came from low and middle-income countries. And taken together, the approximately 11,000 doctors from sub-Saharan African working in the US, UK and Canada represent 12% of all currently employed African-educated physicians. Figuring out how to effectively retain and recruit health care workers in low-income countries is critical to strengthening health care systems in the developing world. The ZAMFOHR's HRH project aims to evaluate strategies currently in use in two rural districts (Gwembe and Chibombo). The project is funded by the Global Health Research Initiative (GHRI), a research funding partnership of five agencies and departments of the Government of Canada, including the Canadian International Development Agency (CIDA); the Canadian Institute for Health Research (IHR); Health Canada (HC); the International Development Research Centre (IDRC); and the Public Health Agency of Canada (PHAC). ZAMFOHR is also the recipient of a grant from the Alliance for Health Policy and Systems Research, an international collaboration of more than 300 partners based in the WHO Health Systems and Services Cluster. The grant was used to develop the Zambia Fellowship Programme (ZFP), a 3-year "knowledge translation" initiative providing education and training for Zambian health researchers. Established in 2005, ZAMFOHR is a not-for-profit NGO dedicated to fostering the development of scientifically and ethically-sound health research and ensuring that health research evidence forms the basis for the policies and practices that drive Zambia's health care system. "The majority of health research that is being carried out in Zambia is inaccessible," says the website. "ZAMFORH endeavors to contribute to building capacity to produce, manage, translate and use research."

Yaws returns to Vanuatu

Yaws is an infectious disease of poverty that attracts extremely little research. Indeed it is best described as a "forgotten" rather than a "neglected" tropical disease. A rare research paper [1] that has just been published on this chronic infection of the skin, bone and cartilage is, sadly, a report of a resurgence of the condition. The report comes from the Pacific nation of Vanuatu, where the disease had been thought to have been eradicated. Tests by researchers have, however, indicated that it is once again present, though perhaps in a milder form than previously. The authors of the study suggest that use of oral azithromycin to treat cases would be appropriate, as such treatment could easily be incorporated into primary health care activities. Reference 1. Fegan D, Glennon MJ, Thami Y, Pakoa G (2010). Resurgence of yaws in Tanna, Vanuatu: time for a new approach? Trop Doct; 40(2):68-69.

Preventing malaria during pregnancy: trials planned of a new treatment option

Every year an estimated 30 million pregnant women in Africa are at risk of malaria. Intermittent preventive treatment in pregnancy (IPTp) is one of the new tools available to help control the disease but there is a need to increase the range of drug treatments suitable for use in IPTp programmes. A collaboration has been announced that will result, later this year, in African trials of a new combination treatment. The agreement extends to the further development and delivery of the treatment, which is a fixed-dose combination of azithromycin dihydrate (AZ) and chloroquine phosphate (CQ). Partners in the collaboration are Pfizer Inc, the Medicines for Malaria Venture (MMV) and the London School of Hygiene & Tropical Medicine. The three organizations have already been working on the project, on an informal basis, for the last two years. Further details are available in a London School press release. In another new development, MMV and California based Anacor Pharmaceuticals have agreed to explore Anacor’s novel boron chemistry platform for developing new therapeutics for the treatment of malaria - see MMV press release.

Ovale malaria caused by two distinct species

Scientists investigating ovale malaria, a form of the disease thought to be caused by a single species of parasite, have confirmed that the parasite is actually two similar but distinct species which do not reproduce with each other, according to research published in the Journal of Infectious Diseases [1]. Researchers from the London School of Hygiene & Tropical Medicine, the Hospital for Tropical Diseases (London) and Mahidol University, Bangkok collaborated last year in order to share their research after noticing that the single parasite Plasmodium ovale, though visible through a microscope, was not detected by forensic DNA tests designed to identify the species. Dr Colin Sutherland, lead researcher at the London School of Hygiene & Tropical Medicine, said "We used DNA technology to compare the parasites from 56 patients with ovale malaria, from across the tropical world. It was a great surprise to find that, not only are these two species completely distinct from each other by every test we carried out, they actually occur in people living side by side in the same African and Asian countries, and even in the same towns and villages. We hope to continue our work so we can unravel the mysterious differences between these two newly recognised human pathogens." Reference 1. Sutherland CJ, Tanomsing N, Nolder D, Oguike M, Jennison C, Pukrittayakamee S et al (2010). Two nonrecombining sympatric forms of the human malaria parasite Plasmodium ovale occur globally. J Infect Dis; 201(10):1544-1550.

Bangladesh's success against diarrhoea

A recent article in USA Today looks at Bangladesh's success over the past 30 years in combatting diarrhoeal diseases using the so-called "Poor man's Gatorade," a homemade concoction of salt, sugar and water that led to the development, in the late 1960s, of oral rehydration solution (ORS). In 1971, during a cholera outbreak in West Bengal among refugees of the Bangladesh "War of Liberation", ORS proved itself a highly effective intervention, slashing the death rate from 50% to 3% of those infected. The article discusses the International Centre for Diarrhoeal Diseases Research (ICDDR,B) located in Dhaka, Bangladesh. Founded in 1978, ICDDR,B has trained more than 27,000 health professionals from more than 78 countries in the control of diarrhoeal diseases, epidemiology, biostatistics, family planning, demographic surveillance and child survival strategies. Current ICDDR,B projects encompass a broad range of issues, including child health and nutrition, HIV/AIDS and chronic and infectious diseases. In collaboration with Massachusetts General Hospital (MGH) in the US, ICDDR,B clinical researchers are investigating the differences between naturally-acquired immunity from infection with cholera and immunity conferred by vaccination in the hopes that findings will lead to a vaccine protective for longer than those currently on the market. A recent article in Mass General Magazine describes the collaborative effort in detail, tracing it from its origins in the mid-1990s to the present day.

Papua New Guinea makes progress against cholera

Many countries have experienced serious cholera outbreaks in the last few years. The appearance of the disease in Papua New Guinea (PNG) in August 2009 has been of particular interest, as it was previously unknown in this Pacific nation; reports have described instances of public panic and of stigma against cholera patients. Now, however, IRIN News says that the outbreak appears to be almost over, after nearly 3,000 cases and 60 deaths. Victor Golpak, the government’s national response coordinator for cholera says that only a few cases are now being seen each week. He noted the importance of the assistance provided by international agencies in bringing the disease under control. Nevertheless, 58% of PNG’s six million inhabitants still lack access to safe drinking water and experts have cautioned that until this situation is addressed the country will be at risk of further outbreaks.

Ethiopia's trachoma burden

The online journal Ethiopian Review discusses the high prevalence of trachoma in the country in a recent article. More people have been blinded by this infectious disease of poverty in Ethiopia than in any other country. The article describes a trachoma programme focused on the country’s most affected region, the northwestern state of Amhara. Launched in 2001, the initiative is a partnership between the federal government and the US Carter Center, which is running similar programmes in Ghana, Mali, Niger, Sudan and Nigeria. A predominantly rural region, Amhara carries 45% of the country’s trachoma burden. The programme seeks to bring the disease under effective control by 2012. The provision of adequate latrines to reduce numbers of the flies that transmit the infection is seen as a priority area.

Zoonotic diseases: Ugandan experts' warning

The President of the Uganda Veterinary Association, Dr Sam Okech, has warned of the increasing risks of zoonotic diseases, transmitted from animals to humans. Speaking to journalists, he used brucellosis and bovine tuberculosis as examples. He also warned against eating meat that had not been inspected by veterinary officers. Professor Ruth Muwazi from the Faculty of Veterinary Medicine at Makerere University added that zoonoses could be contracted through direct contact with infected animals and through poor hygiene in the home. See report on NewVision.

New funding to support research leaders in sub-Saharan Africa

The UK's Medical Research Council has launched a new initiative to support African research leaders. Intended as a highly prestigious award for non-clinical and clinical researchers of exceptional ability, the scheme is jointly funded by the MRC and the UK's Department for International Development (DfID). The aim is to strengthen research leadership and capacity in sub-Saharan Africa, by attracting and retaining researchers of high ability. The scheme will be launched as a pilot in the first instance, aiming to award support for two or three research leaders. Further details are available from the MRC wesbsite: http://www.mrc.ac.uk/Fundingopportunities/Calls/index.htm

Dengue success in Vietnam uses predatory crustacean

Successes in the battle against dengue fever are rare but an Australian Government-funded project to eradicate the mosquito-borne viral disease in the Cuu Long (Mekong) Delta over the last five years has achieved its goal, says a report on VietNam News. Viet Nam joins only two other countries, Cuba and Singapore, that have managed to reduce dengue prevalence. The Viet Nam success was achieved through introduction of the non-indigenous predatory crustacean Mesocyclops, which reduced mosquito numbers by 80-90%. It is claimed that the 90,000 inhabitants of the 12 communes where Mesocyclops was introduced no longer face any risk of dengue infection. Some 100,000 Vietnamese people live in other parts of the country where the risk remains. AusAID, the Australian government's development agency, believes that introduction of Mesocyclops and the use of a community-based approach could also be effective in other dengue-endemic areas across the tropical world. Meanwhile, news reports continue to suggest that 2010 will be a bad year for dengue case numbers. Some Central American and Caribbean countries have declared epidemics, which is unusual for this time of year, according to a report from the Center for Infectious Disease Research and Policy, USA.

Multidrug-resistant TB: a report from Ethiopia

Multidrug-resistant tuberculosis is a growing problem in Africa but a lack of diagnostic facilities creates problems for individual patients and makes it hard to get a clear picture of how the situation is developing. A report from IRIN News looks at the situation in Ethiopia, where 1.6% of new TB cases and 11.8% of re-treatment cases are MDR-TB. Only one hospital in the country, St Peter TB Specialized Hospital situated to the north of the capital Addis Ababa, is able to treat MDR-TB. Over 100 patients are known to have died whilst on the St Peter's waiting list. The IRIN report describes the country's efforts to strengthen its TB treatment system and to address such problems as poor adherence to treatment.

Indian cholera vaccine to be available soon

India's Department of Biotechnology (DBT) has invited applications to commercialise a new oral vaccine for cholera, according to the Vaccine India website. The vaccine has been developed by the Institute for Microbial Technology, Chandigarh, and National Institute of Cholera and Enteric Diseases, Kolkata. Phase III trials of the vaccine are planned and the DBT believes that it could be available for use before the end of 2010.

Potential new TB treatment identified

A compound that could form the basis of a treatment for tuberculosis has been discovered by a team led by the University of Strathclyde, UK. Although so far tested only in vitro, the research could lead to the development of a new class of anti-TB agents - 2-aminothiazole-4-carboxylate derivatives - based on the naturally occurring but "synthetically challenging" antibiotic thiolactomycin. The study [1] was published in PLoS ONE and has recently been described in a BBC News report. The advance is a result of a new collaboration between British scientists - Tuberculosis Drug Discovery UK (TBD-UK). The group receives support from the UK Medical Research Council and the Global Alliance for TB Drug Development. Reference 1. Al-Balas Q, Anthony NG, Al-Jaidi B, Alnimr A, Abbott G, Brown AK, Taylor RC, Besra GS, McHugh TD, Gillespie SH, Johnston BF, Mackay SP, Coxon GD (2009). Identification of 2-aminothiazole-4-carboxylate derivatives active against Mycobacterium tuberculosis H37Rv and the beta-ketoacyl-ACP synthase mtFabH. PLoS One. 2009;4(5):e5617.

A new tool for Chagas' disease diagnosis

A rapid and reliable tool for the diagnosis of Chagas' disease (CD) has long been atop the wish list of control programmes in the developing world, particularly those in the poorest parts of the Americas, where approximately 10 million people are affected and the disease remains endemic. That's because, unlike most parasites that causes disease in human beings, Trypansoma cruzi conceals itself in the body long before the victim realizes he or she has been infected. Most subjects remain asymptomatic for decades. And because only 15-30% develop terminal complications, the disease has managed to wreak havoc on poor communities without generating anything close to the amount of research funding needed to discover and develop novel drugs and diagnostics. Last week, however, Canadian researchers reported a major breakthrough: the discovery of a highly sensitive biomarker capable of identifying CD in asymptomatic patients and of being screened using high-throughput mass spectometry or mass profiling. The study [1], published in the Journal of Clinical Microbiology, was co-authored by Momar Ndao and Brian Ward at the Research Institute of McGill University Health Center in Montreal, Canada. "The use of these biomarkers is a revolution in diagnostic confidence and protection of possible contamination of blood banks," says Ndao, who believes that the biomarkers could provide researchers with important clues for the development of a vaccine for Chagas and possibly other parasitic diseases. "It's as if the parasite left its signature in the infected person," he told the the Montreal Gazette. Reference 1. Ndao M et al. 2010. Identification of novel diagnostic serum biomarkers for Chagas' disease in asymptomatic subjects by mass spectrometric profiling. J Clin Microbiol; 48(4):1139-1149.

The importance of local volunteers in disease surveillance

New York Times journalist Nicholas Kristof has a column today looking at the US-based Carter Center's highly successful campaign to eradicate Guinea-worm disease and the important contributions made by local volunteers, especially in terms of surveillance. Kristof focuses the column on a village in southern Sudan, one of the few remaining places the disease still exists. "In recent decades, the world has learned that fighting poverty is harder than it looks," he writes. "But the Guinea worm campaign underscores that a determined effort, with local people playing a central role, can overcome a scourge that has plagued humanity for thousands of years." According to WHO, Guinea worm is endemic in only three other countries – Ethiopia, Mali and Ghana – and that as the eradication campaign nears the final mile, heightened surveillance is crucial to containing the last cases and interrupting transmission.

Illustrating infectious diseases of poverty: how infographics can inform and engage

Over the past decade, technology has transformed the media system and along with it the nature of science communication. Whereas “science writers” were once the sole conduit for the dissemination of information to a lay audience, today’s plethora of outlets, including cable television, the Internet, and digital resources, has made scientific information both accessible and user-friendly, allowing for public engagement with the issues through a variety of formats. Still, the mere availability of scientific information does not ensure its uptake. As an interdisciplinary workshop on the changing nature of science communication recently concluded, “communication is both an art and a science.” (1) And how scientific information is packaged—how the message is “framed”—plays a major role in how audiences interpret it. “Individuals are ‘cognitive misers’,” write the authors. “If they lack a motivation to pay close attention to science debates, they will rely on mental shortcuts, values and emotions to make sense of an issue, often in the absence of knowledge.” (2) Infographics, including charts, graphs, diagrams, maps and other forms of multimedia, offer an interactive frame. As visual representations of data, they often supplement written material to quickly and clearly communicate complex ideas or processes. As such, they are particularly useful for the dissemination of scientific information. Indeed, infographics abound throughout the scientific literature, appearing in scholarly journals and popular news accounts alike. With their power to magnify the microscopic, to illustrate the invisible and freeze processes in time, infographics succeed where words alone fail, particularly when their design is informed by empirical research. Indeed, studies indicate that, more than decorative elements only good for grabbing readers’ attention, infographics can help strengthen higher-level cognitive functions such as comprehension and inference making. One recent example is the Bill & Melinda Gates Foundation’s “The Living Proof Project”, a multimedia initiative aimed at showcasing some of the positive developments in U.S.-funded global health initiatives; these include new progress against Polio and the successful utilization of trained health care workers in extending care to rural areas of Ethiopia. While the photographs arrest and engage, the infographics allow readers “to delve into some of the facts behind the global health success.” In carrying out its mission to be a clearinghouse for research on infectious diseases of poverty (IDP), TropIKA.net will produce a series of infographics exploring these diseases and their pathology. The diagrams will portray the processes at the molecular level, illustrating in detail how infection occurs, how and why it produces symptoms, and how drugs and vaccines work to cure or prevent infection. To kick off the new series, TropIKA.net will feature a set of infographics exploring H1N1 on the main homepage. These infographics were developed by BIREME/PAHO/WHO and published in its H1N1 portal. This portal provides scientific and technical information on H1N1 available in the Virtual Health Library information sources. Combining written text and detailed illustrations, the H1N1 series provides readers with a detailed overview of the disease, including everything from historical information about previous flu epidemics and current efforts to contain outbreaks of the flu around the world. 1. Bubela, T. Science communication reconsidered (2009). Nature Biotechnology 27:6; 514-8. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19513051 2. Popkin, S. The Reasoning Voter (University of ChicagoPress, Chicago, 1991). Available from: http://tinyurl.com/2fmtrv2

TropIKA.net named as a top 50 international health care and nursing blog

TropIKA.net has found favour with "The Practical Nurse", a useful web site that describes itself as "your go-to source for nursing information from around the world wide web". They consider us to be one of the top 50 international health care and nursing blogs. TropIKA.net readers should take a look at the list, which is available on http://lvntobsn.org/2010/top-50-international-health-care-and-nursing-blogs/. Unlike TropIKA.net, which is of course a full-scale knowledge platform, the other sources selected by The Practical Nurse are indeed just blogs but some interesting views on global health issues are to be found there. We are very pleased to be on this list and hope that new readers discovering us via this route will find our content to their liking. All of our readers are of course welcome to use our comment function to share their own views on TropIKA.net articles and the issues that they cover.

A wider view

One of the best-read sections on TropIKA.net is “Profiles”, in which we feature in-depth interviews with influential figures in research and policy whose work concerns the infectious diseases of poverty. Our latest interviewee is one of the most charismatic individuals in this field – Peter Hotez of the Sabin Vaccine Initiative and the Global Network for Neglected Tropical Diseases (NTDs). No one has done more than Professor Hotez to raise the profile of the NTDs. Speaking to TropIKA.net’s Tatum Anderson, he describes the career path that led him to specialize in this area. 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.

Fellowship programme announced for malaria elimination in Asia-Pacific region

A message from Cara Smith Gueye, Program Coordinator, Malaria Elimination Initiative, Global Health Group, University of California. The Asia Pacific Malaria Elimination Network (APMEN) commemorates the third World Malaria Day, on April 25th, 2010, with the launch of the APMEN Fellowship Program. The Asia Pacific Malaria Elimination Network brings together ten founding countries in the Asia Pacific region who are working to eliminate malaria. The APMEN Fellowship Program aims to help to equip the next generation of leaders and health workers from the Asia Pacific region with the tools and training to guide malaria elimination in the critical coming decades. The Fellowships will strengthen the exchanges and lesson sharing among APMEN Country Malaria Control Programs and research institutions in the region. Up to five Fellows from the ten APMEN partner countries will be selected each year for one to three month, short-term training opportunities with a partner country malaria program or institution. Malaria elimination in the Asia Pacific will require a multi-pronged strategy involving diverse interventions and numerous communities, organizations, companies and governments. A commentary in the Lancet, to be released April 24th, describes the role of APMEN in the region’s efforts toward malaria elimination, highlighting the special challenge of Plasmodium vivax in the region. Further information regarding APMEN, the Fellowship Program, and the Lancet commentary can be viewed at apmen.org.

News from Farmabrasilis

Iseu Nunes, CEO of Farmabrasilis, writes... Farmabrasilis is a non-governmental, non-profit research network bringing together Brazilian, Chilean, American and European scientists and people devoted to the research and development of new medicines and technologies for the benefit of economically disadvantaged populations and individuals affected by neglected diseases. Our goals are: 1) Build a new model for pharmaceuticals 2) Create and disseminate new strategies for research and development of medicines and related technologies in favour of economically disadvantaged populations 3) Expand and ensure the development of technologies to support translational research 4)Transfer the production technology of our products free of charge for use by neglected diseases and populations. The main focus of the work of Farmabrasilis has been the development of the immunomodulator P-MAPA. Although this compound was originally intended for cancer treatment and has been shown to have anti-tumour activity, P-MAPA also modulates the production of interferon-gamma and interleukin-10, known to be key substances in the body’s defences against TB, malaria and other infectious diseases. This had led Farmabrasilis to put forward a new approach to treating patients with these conditions - including those co-infected with HIV - which would involve attempting to re-establish patients’ immunocompetence by adjuvant immunotherapy with P-MAPA. Farmabrasilis welcomes contact with other individuals and organizations interested in the further development of the proposed approach. Tests carried out by Tuberculosis Antimicrobial Acquisition and Coordinating Facility (TAACF) under contract signed by Farmabrasilis and US NIAID has shown that P-MAPA is active against M. tuberculosis in vivo. The results are detailed at: http://www.farmabrasilis.org.br/todos_conteudos_interna.php?idioma=eng&id=276. This information supports the Farmabrasilis proposal to fight TB and other infectious diseases, launched in 2009 at Stop TB Partners Forum. The new therapeutic approach to treating patients with diseases such as tuberculosis and malaria, including those co-infected with HIV, consists of re-establishing the patients’ immunocompetence by adjuvant immunotherapy with P-MAPA. The proposal is detailed at: http://www.farmabrasilis.org.br/pesquisa_desenvolvimento_interna.php?idioma=eng&id=255 We are open to new collaborations in order to conclude the development of P-MAPA (a detailed description of this compound’s biological properties is at: http://www.farmabrasilis.org.br/interna_periodicos_publicacoes.php?idioma=eng&id=149). An article about Farmabrasilis in the TropIKA.net blog last year produced several highly supportive comments.

Is this the best we can do?

There are four strains of the virus that causes dengue fever, a disease transmitted by a mosquito – Aedes aegypti – that is present in many parts of the tropical world, including Africa. So how common is dengue in Africa? Quite incredibly, we just don’t know. Data on case numbers in South America and Asia are reasonably informative but, for the African continent, no figures are available. New research provides evidence that one dengue strain, DENV-3, has spread to West Africa during the last few years. The scientists in several European labs who have contributed to this new study are to be congratulated for adding to what is known about dengue in Africa. But sadly, their findings are the result of tests on Europeans who have visited the region and returned home with a fever – see TropIKA.net News. It is simply unacceptable that diagnostic facilities are so poor in Africa that we know more about an infectious disease in returning foreigners than we do about its prevalence in the indigenous population. Surely we can do better than this? In both the research and control of neglected tropical diseases, diagnostic testing is a neglected issue. WHO’s updated guidelines on the treatment of malaria (see TropIKA.net News in Brief) stress that more attention should be given to testing for malaria before beginning treatment. Another WHO report (on the growing prevalence of drug-resistant strains of tuberculosis) notes that because of inadequate testing facilities in most parts of Africa there is considerable uncertainty as to how many cases of drug-resistant TB are to be found there. As for dengue, this looks likely to be a bad year. Cases of the disease have increased steadily since the 1950s but years where the El Niño phenomenon occurs are known to lead to dramatic spikes in incidence – and 2010 is such a year. See TropIKA.net News. On a more positive note, we report on progress with research that may lead to more effective ways of controlling the Aedes aegypti vector. A much debated question is whether the rise of dengue and other vector-borne diseases is related to climate change. A review article that has been highlighted on TropIKA.net concludes that we do not yet know enough about the ecology of diseases such as malaria and dengue to be able to make accurate predictions. Nevertheless, the article concludes, despite our lack of knowledge there is still appropriate action that can be taken now to reduce the impact of these diseases. World TB Day In our report on World TB Day we note the opinion of TB specialists who believe the gains that have been made are “fragile” and the list of challenges is growing. And a TropIKA.net editorial describes the event as the day when, “the world confronts its collective failure to use medical advances to stop the spread of tuberculosis among the poor”. Nevertheless there are some promising new initiatives on TB, one of which – the Critical Path to TB Drug Regimens (CPTR) – we describe in some detail in a TropIKA.net Profile. Another development which could lead to new treatments for TB is the growth of the “open source” approach to drug discovery. A TropIKA.net article on this topic has already created considerable interest. Initiatives such as those reported in this article are an example of innovative thinking in this area. But much more is needed if we are indeed to do better in the fight against the infectious diseases of poverty. Paul Chinnock Editor, TropIKA.net

Antimicrobial screening of medicinal plants in Nigeria

Esther Adelakun of the University of Jos' Natural Products Group writes... The Natural Products Group in the Department of Chemistry, University of Jos, Nigeria have been involved in the survey, phytochemical and antimicrobial screening of medicinal plants in the Plateau area of Nigeria. An abstract on the findings of plants used in the Nasarawa Senatorial zone of Nasarawa State was presented in Abuja, Nigeria, at the Symposium on Natural Products Research in May 2009. This is ongoing research and presently one of my PhD students has gone to the University of Illinois, Chicago as a visiting research student to determine the potency and possibly isolate the anti-tuberculosis agent of three plants. The three plants had actually been used by traditional medical practitioners successfully. My student knows one of the patients, who has been certified by an orthodox medical practitioner as being healed completely from tuberculosis which had plagued him for some years. We will keep you informed as the results come.

Tuberculosis: facing up to the issues

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. Paul Chinnock Editor, TropIKA.net

Innovation and interpretation

TropIKA.net has often reported on projects involving the use of mobile phones in health care delivery – or “mHealth” as this has become known. These projects, most of which are small pilots, are encouraging examples of the innovative use of technology for the improvement of health, but care must be taken in the interpretation of what has so far been published about these projects. 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

Most war deaths are due to infectious disease

War kills. It does so by a variety of means, including infectious disease. Belgian researchers studying deaths occurring as a result of conflict in Sudan's Dafur region [1] found that while in 2004 violence was the biggest cause of death, in the years that followed more people died as the result of the increased rate of infections. During the whole period studied (2004-2008), infections were estimated to have killed 80% of the approximately 300 000 people who died as a result of the Dafur war. An editorial comment [2] on the research was written by Francesco Checchi of the London School of Hygiene & Tropical Medicine. He discusses the study further in a podcast now available from the School. He speaks of an "excess mortality that won't go away" that follows conflicts such as that in Dafur. People have reduced access to health care (including immunization programmes), safe water and food, all of which make them more vulnerable to infection. He calls for an "expanded range of interventions" to be used in relief efforts with the aim of reducing the number of infectious deaths. References 1. Degomme O, Guha-Sapir D (2010). Patterns of mortality rates in Darfur conflict. Lancet; 375(9711):294-300. 2. Checchi F (2010). Estimating the number of civilian deaths from armed conflicts. Lancet; 375(9711):255-257.

Leprosy: has "elimination" been misunderstod?

The elimination of a disease as a public health problem is a very different matter from eradication. The latter means wiping it off the face of the earth - a feat that has so far only been achieved with smallpox. Nevertheless, even at high levels of policy making, there can be some confusion between the two terms. A Lancet article, written to mark World Leprosy Day, raises the question as to whether a misunderstanding of the concept of elimination has hampered leprosy control efforts. The World Health Organization defines leprosy elimination as reducing the level of prevalence to below one in 10,000 of the population. Most of the countries that were formerly highly endemic for leprosy have now achieved elimination by this definition, but many of those same countries (most notably India) still have many cases of leprosy. According to the article, many countries stepped down their efforts against leprosy once the elimination target had been reached. In consequence progress against the disease, of which there are still around a quarter of a million new cases every year, has thus suffered. The article also refers to a new report from WHO's Southeast Asian Regional Office (SEARO) which puts forward a new strategy for further reducing the disease burden due to leprosy. Most notably, under this strategy, the rate of new cases with grade-2 disabilities among new cases per 100,000 population would be used as a key indicator to monitor progress. TropIKA.net's own coverage of World Leprosy Day 2010, which emphasized the role of research, may be accessed here.

Has Australian research revealed malaria's "Achilles heel"?

The transcript is available of a short ABC radio interview with Australian scientist Professor Alan Cowman who describes his recent study [1] on the so-called effector proteins that the malaria parasite uses in order to successfully invade red blood cells. Professor Cowman believes that there is one protein that "decides" how all of these proteins are to be exported. He hopes that this protein - plasmepsin V - will turn out to be the Achilles heel of malaria and that a new type of malaria drug can be developed that works by targeting plasmepsin V. The study appears in Nature in the same issue as a paper by US malaria researchers who report [2] they have found more than two dozen smell receptors in the malaria-transmitting mosquito Anopheles gambiae that enables the insect to home in on human sweat. They believe that some of the receptors "could be excellent targets" for chemicals to snare mosquitoes or repel them, References 1. Boddey JA, Hodder AN, Günther S, Gilson PR, Patsiouras H, Kapp EA, Pearce JA, de Koning-Ward TF, Simpson RJ, Crabb BS, Cowman AF (2010). An aspartyl protease directs malaria effector proteins to the host cell. Nature; 463(7281):627-631. 2. Carey AF, Wang G, Su CY, Zwiebel LJ, Carlson JR (2010). Odorant reception in the malaria mosquito Anopheles gambiae. Nature; Feb 3. [Epub ahead of print]

Dengue's march across the Americas

The last 30 years have seen a five-fold increase in cases of dengue fever in the Americas. Transmission of this mosquito-borne viral disease now occurs in almost all Caribbean and Latin American countries. There were 4.8 million reported dengue cases in the Americas between 2000 and 2007, compared with 2.7 million in the 1990s and one million in the 1980s. Cases of the potentially fatal complication dengue haemorrhagic fever have also increased — from just more than 13,000 cases in the 1980s to more than 100,000 cases between 2000 and 2007. There is no vaccine and no specific treatment for dengue. Olivia Braithwaite, a researcher at the PAHO Regional Program on Dengue says that, "The pattern of dengue in the Americas is changing, becoming more similar to the Asian profile, with more paediatric cases rather than adult cases." Dr Braithwaite is an author of a recently published study [1] on which a SciDev.Net article is based. Reference 1. San Martín JL, Brathwaite O, Zambrano B, Solórzano JO, Bouckenooghe A, Dayan GH, Guzmán MG (2010).The epidemiology of dengue in the americas over the last three decades: a worrisome reality. Am J Trop Med Hyg; 82(1):128-135.

Further warnings on resistance to key antimalarial

The World Health Organization's representative to Myanmar (Burma) has repeated warnings that resistance to artemisinin (now the mainstay of treatment to malaria) is spreading in the region. Speaking to IRIN News, Leonard Ortega highlighted the role of increased movement of individuals and populations, and of the widespread use of fake or substandard drugs, in spreading resistant strains of malaria. He referred to studies, presented late last year at a WHO regional workshop of health officials, indicating that artemisinin resistance is present in areas along the Myanmar-Thailand, Myanmar-China and Cambodia-Vietnam borders.

Living proof: investments made in global health deliver success

There is a widespread view in the USA that funding for health programmes in developing countries is wasted, as the initiatives supported generally fail. To counteract this view, and to give examples of projects that have worked, the Bill & Melinda Gates Foundation has launched a website called Living Proof that shows video clips and provides other information about Gates-supported projects and those backed by other US government or private donations. “Living Proof is a multimedia communications effort that uses the power of individual stories to show the success of investments made by America to developing countries for global health,” said Cyndi Lewis, senior programme officer in global health at the Gates Foundation in an interview with USAID's Frontlines newsletter. “We listened to many regular and influential Americans, and what we heard was a lack of reporting on progress—lack of connection to individuals. But that’s not what you see in the field where there is so much progress and results.” In a series of short "Progress sheets" available on the Living Proof website, tuberculosis, malaria and neglected tropical diseases are amongst the topics covered. Though aimed specifically at a US audience and featuring exclusively US-supported success stories, Living Proof makes a compelling argument for further investments in global health

New techniques needed to stop the flow of fake drugs

A meeting in the Togolese capital Lomé has discussed the urgent need to find new ways to address the growing problem of fake and substandard drugs. Fake products continue to sell well in developing countries because they are cheap. Some of the most widely faked drugs are antibiotics and antimalarials. Many contain low (but ineffective) doses of the active ingredient, and exposure of the disease-causing organisms to such low doses encourages the development of resistant strains. Delegates at the meeting agreed on the need for a united public-private front to overcome people's resistance to health warnings and to dismantle increasingly sophisticated trafficking networks. The event was organized by Leem, a body representing French pharmaceutical companies, and brought together government health officials from francophone African countries. A report on the meeting from IRIN News also includes links to other recent IRIN stories on the issue of fake drugs.

mHealth much in vogue

Coinciding with the publication of a major TropIKA.net article on mHealth (the use of mobile phones in health care), the journal Health Affairs has published an interesting contribution on the topic that focuses on one example of mHealth in action - Mexico's VidaNET (LifeNET) system which sends text messages and e-mail to patients, reminding them to take their anti-HIV drugs, keep their doctors’ appointments, and stay up to date on their lab tests. (This article is freely available online.) The latest issue of Health Affairs is devoted to the wider topic of eHealth - the use of modern information and communications technology to transform health and health care. The other articles - on a range of potentially interesting eHealth topics - are, however, only available in full to the journal's paying subscribers. Reference 1. Lester Feder J (2010). Cell-Phone Medicine Brings Care To Patients In Developing Nations. Health Affairs; 29(2):259-263.

Importance of health information emphasized in Bangkok call to action

"The current state of country health information systems are inadequate and fail to meet the needs of decision-makers globally, nationally and locally." This was the conclusion of delegates to the Global Health Information Forum held in Bangkok in January. The meeting ended with the publication of a call to action that stressed the need for: transparency, good governance, adequate investment, capacity building, harmonization and integration, and planning for the future. The Bangkok call to action follows a recent statement on health information systems from WHO, the World Bank, the Global Fund, UNICEF, UNAIDS, UNFPA, GAVI and the Bill & Melinda Gates Foundation that called for "new ways of working and a more systematic approach by all partners ... to better monitor and evaluate progress and performance" [1]. Reference 1. Chan M, Kazatchkine M, Lob-Levyt J, Obaid T, Schweizer J, et al. (2010). Meeting the Demand for Results and Accountability: A Call for Action on Health Data from Eight Global Health Agencies. PLoS Med 7(1): e1000223.

Malaria vaccines could earn $ billions for manufacturers

A leading market research company forecasts that global market for malaria vaccines will reach $1.05 billion by 2017. The predictions are based on likely sales of products that are currently in the pipeline, including GlaxoSmithKline's Mosquiri (RTS,S), which continues to be investigated in several large scale Phase III trials in Africa. Mosquirix is at a more advanced stage than any other malaria vaccine but is expected to produce protection rates of only around 50%. More information available from MarketWire.

Encouraging trial of TB vaccine in HIV-infected patients

A new vaccine to protect against tuberculosis is urgently needed. Nowhere is the need greater than for HIV-infected people, who face very high risks of developing TB. A clinical trial in Tanzania has found that a new TB vaccine reduced TB infection rates by 39% amongst 2,000 HIV-infected patients. The seven-year trial - a collaboration between Dartmouth Medical School, USA and Muhimbili Medical School, Dar es Salaam - employed a whole cell vaccine of the organism Mycobacterium vaccae, closely related to M. tuberculosis the disease agent responsible for TB. Patients in the trial had already received the standard BCG vaccination for TB. The trial - known as the DarDar Study (Dartmouth-Dar es Salaam) - has already created considerable interest. The next steps are to improve manufacturing methods to support the production of the larger quantities of the vaccine needed for further studies and subsequent clinical use. Development work on manufacturing will be conducted by the Aeras Global TB Vaccine Foundation in Maryland, USA, in conjunction with the London-based manufacturer, Immodulon Therapeutics. Reference 1. von Reyn CF, Mtei L, Arbeit RD, Waddell R, Cole B, Mackenzie T, Matee M, Bakari M, Tvaroha S, Adams LV, Horsburgh CR, Pallangyo K; the DarDar Study Group (2010). Prevention of tuberculosis in Bacille Calmette-Guérin-primed, HIV-infected adults boosted with an inactivated whole-cell mycobacterial vaccine. AIDS; 2010 Jan 28. [Epub ahead of print]

Malaria control programme in Angola comes under fire

The Internet allows open discussion to take place on a huge range of topics, including the implementation of programmes to control the infectious diseases of poverty. The excellent Topnaman blog on malaria presents a discussion of an article [1] in the Bulletin of WHO that criticised some aspects of the President’s Malaria Initiative’s (PMI) work in Angola. The intervention in question was the use of indoor residual spraying (IRS) of insecticide. The core of the criticisms made is that intervention areas were selected on the basis of reported clinical diagnoses of malaria, unsupported by laboratory findings, and that this led to expensive control efforts taking place in areas where they were not necessary. Published on the blog are a response from PMI to the original Bulletin article, followed by a comment on this from one of the article's authors, Bill Jobin. PMI say that the work conducted in a low-transmission area provided "experience and confidence" to enable subsequent activities in higher transmission areas. But Bill Jobin argues the case for programmes that are based on data from microscopic diagnoses in appropriate sentinel populations. "Then we will know what the problem really is, and where to put our efforts", says Jobin. Reference 1. Somandjinga M, Lluberas M, Jobin WR (2009). Difficulties in organizing first indoor spray programme against malaria in Angola under the President's Malaria Initiative. Bull World Health; 87(11):871-874.

They think it’s all over ...but it isn’t

One of the barriers to increasing the level of support for research and control of the infectious diseases of poverty (IDPs) is a widespread view that many of these infections are already in decline, and that little more needs to be done before they are eliminated. Leprosy is a case in point; this year’s World Leprosy Day has already been and gone, but attracted little media attention. Here on TropIKA.net, however, we have argued [1] that the battle against leprosy is far from over and that there is a need for further research; we seek to identify the research gaps that need filling. Thankfully, some other IDPs are now receiving increased attention and there is good news to report. New findings from southern Africa and from Mexico [2] provide further evidence that the introduction of rotavirus vaccines into immunization programmes can lead to substantial reductions in diarrhoeal morbidity and mortality. (Diarrhoeal disease is, after pneumonia, the second biggest killer of children in poor countries.) Getting the vaccine to all those who need it is now the challenge. The search for a vaccine that will protect against dengue fever [3] has been stepped up, with another candidate vaccine entering Phase 1 trials. There are now at least five potential dengue vaccines under development. Some of the countries in Asia and South America reporting increased numbers of dengue cases are amongst the world’s most rapidly growing economies. There will certainly be a significant market for products that prevent or treat dengue and thus there is an economic incentive for research and development efforts that is lacking for many other IDPs. Many infectious diseases have now been studied using the techniques of mathematical modelling but it remains a controversial area of research. In one of our regular series of Profile interviews, Tatum Anderson speaks with one of the leaders in this field – Professor Sir Roy Anderson [4]. But probably the most influential figure in IDP research is now Bill Gates, who has been much in the news in recent days. The publication of his Annual Letter is likely to come to be regarded as a yearly landmark, as it sets out – in an informal fashion – the Gates Foundation’s own current plans and priorities, and it will have an influence on the actions taken by other donor organizations. The letter – and the announcement of major new Gates funding for vaccine research that followed a few days later – are discussed in TropIKA.net News [5]. The TropIKA.net Blog [6] continues to highlight new developments that have been reported elsewhere on the Internet. China has been reported to have made good progress against tuberculosis [7] and market research has shown it to offer enormous potential for the sale of TB drugs [8]. The achievements of China contrast with the situation in South Africa where TB rates in children are claimed to be the highest ever reported [9]. Another item of interest on the blog is the news that drug giant Novartis has been trying to create a fund that companies and institutions could draw upon to finance the development of drugs against neglected diseases. But after two years of approaching potential donors Novartis says it has not raised a cent for its proposal [10]. Industry has a major role to play in the development of new tools to control the infectious diseases of poverty and it is to be hoped that Novartis will find other ways in which it can make a contribution. Paul Chinnock Editor, TropIKA.net

Doctor in South Africa makes a plea for more TB research

A US doctor working in Cape Town, South Africa says that TB infection rates of children are "at the highest levels ever recorded since the onset of TB chemotherapy in the middle of the last century". He calls for more research to develop new ways of treating the disease. Dr Robin Wood is Director of the Desmond Tutu HIV Centre at the University of Cape Town. In a blog in the Huffington Post he speaks of the high TB rates his research team have identified during a clinical trial: "By the time children enter school at age 5, 20 percent are already infected with TB. By the time they reach the age of sexual maturity, 13 years, 50 percent are infected. And between the ages of 24 and 28 - the years of peak prevalence of HIV - 80 percent are infected". Also serious is the growing number of cases of drug-resistant forms of TB. He contrasts current funding for TB with efforts being made against H1N1 and expresses concern that the global economic crisis could lead to cuts in research budgets. He want to see "increased research of all the stages of TB development".

Malaria: what drug should we take?

In the good old days, most cases of malaria responded to chloroquine (CQ) treatment and there was a high level of public awareness as to the name of this drug. However, as an editorial in the Tanzanian online newspaper ThisDay points out, in this era of CQ resistance, very few people have a clear idea of what drug they or their children need when they suspect they have malaria. Referring to a 2008 study [1] the article stresses that a high proportion of the antimalarials on sale in Africa are likely to be ineffective. The situation is confusing and people need guidance. ThisDay says, "There is need for the government to make an aggressive effort to remove all inappropriate and ineffective drugs (most of which are counterfeit products) from the shelves, while at the same time we look into the way of bringing down the costs of other effective drugs". Governments also need to provide more information to assist the public in their efforts to choose effective drugs from the range of products now available to them. Reference 1. Bate R, Coticelli P, Tren R, Attaran A (2008) Antimalarial Drug Quality in the Most Severely Malarious Parts of Africa – A Six Country Study. PLoS ONE 3(5): e2132.

Drugs for infectious diseases can make a profit

Research aimed at developing new treatments for the infectious diseases of poverty (IDPs) has generally been of very little interest to the pharmaceutical industry. The people with these diseases are, by definition, poor and would be unable to afford expensive new drugs. Hence there is no profit to be made. However, the economies of some of some countries with high rates of IDP incidence are now growing rapidly. China is a case in point. Tuberculosis is the country's number one infectious cause of death, claiming some 160,000 lives annually. China has the world's second highest number of TB cases, after India. But thanks to its economic success China can now pay for TB drugs. A study by the market research group ResearchAndMarkets says that China's demand for TB drugs has grown at a fast pace in the past decade. It predicts that, in the next five years, both production and demand will continue to grow. The study examines China's economic trends, investment environment, industry development, supply and demand, industry capacity, industry structure, marketing channels and major industry participants. (Unfortunately the full report is only available for a very high fee - around $6,000.) What impact will economic growth in IDP-endemic countries have on the research priorities of the pharmaceutical industry? Certainly countries that have both IDPs and money become a more interesting prospect. Many countries with growing economies are, for example, afflicted by dengue fever and by malaria. Will industry come to regard these as more attractive areas for research than previously? Some of the highest rates of infectious diseases, however, are in Africa where economies are still struggling. The profit motive for addressing their disease burden is still lacking.

Drug company wants to research neglected infections but "doesn't have a cent"

A report in Business News says that drug giant Novartis has had no success in trying to raise funds from the public and philanthropic sectors to to finance development of drugs against neglected illnesses including dracunculiasis (guinea-worm disease), malaria and tuberculosis. Novartis wants to raise about $1 billion annually for 10 years to create a fund that companies and institutions could draw on to develop treatments for diseases that get little drug-development interest because they wouldn’t be profitable. The US and European governments, the Bill & Melinda Gates Foundation and the Wellcome Trust have all apparently been approached without success. Paul Herrling, head of Novartis corporate research says, “It’s two years I’ve been working on this thing, and I don’t have a cent”.

Can yellow fever vaccine be modified to protect against malaria and dengue?

An intriguing report from Ecuador says that scientists have been given government backing to attempt to transform a vaccine used to protect against yellow fever so that it becomes active against malaria and dengue. Researchers from the University of Guayaquil will apparently use the transformed vaccine in a study based in a military hospital - see report from SperoNews.

Fake antimalarials seized in Nigeria

One reason why research is needed to develop new antimalaria drugs is the the appearance of resistance to drugs currently in use. The mainstay of malaria treatment is now artemisinin combination therapy (ACT) but many ACTs in circulation are faked or substandard versions. These products tend to contain low doses of active drugs, and when the malaria parasite is exposed to such doses the development of resistant strains is more likely to occur. Action against fakes has generally been inadequate. News that fakes have been intercepted and seized by the authorities is always welcome therefore. AllAfrica.com reports that Nigeria's National Agency of Food and Drugs Administration and Control (NAFDAC) has impounded a consignment of nine packages of the antimalarial Lonart (artemether plus lumafantrine) valued at Naira 10 million ($67 million). NAFDAC made the discovery during routine checks at Lagos airport and employed their recently acquired drug testing equipment to establish that the drugs were faked. While the story is encouraging, one can only speculate as to how many fake antimalarials (and other drugs) are still entering countries like Nigeria undetected.

China reports massive progress against TB

Tuberculosis control efforts in China are claimed to have saved over three-quarters of a million deaths and prevented 20 million new cases of the disease over the last eight years. According to the Xinhua.net news service, the figures were given at a joint meeting of China's health ministry with the World Bank and the UK Department for International Development, which supported the TB control programme based on DOTS (directly observed treatment, short course). China's population of TB patients was estimated as 4.5 million in 2009, the world's second largest after India.

Tropical diseases exist in the Arctic - poverty is responsible

Arguing that the burden of neglected tropical diseases (NTDs) is not just dependent on climate, but mainly related to incidence of poverty, an editorial [1] in PLoS Neglected Tropical Diseases details the large number of neglected infections of poverty in the Arctic region and calls for greater research into these devastating, debilitating and sometimes deadly diseases. “One of the most dramatic illustrations of poverty as the single most important determinant of neglected infections among human populations is the observation that these conditions occur among the poorest people in the Arctic region,” states the paper’s author, Dr Peter Hotez, President of the Sabin Vaccine Institute and Distinguished Research Professor at George Washington University. He says there are a dozen neglected infections of poverty in the region, most of which are food-borne. There are seven countries with significant territory in the Arctic, including Canada, Finland, Greenland, Norway, Russia, Sweden and the United States (Alaska). Iceland is also sometimes included in the definition of the Arctic. Approximately two million people live north of the Arctic Circle, with 60% living in Arctic Russia. A high percentage of these populations represent aboriginal or indigenous peoples. In Canada, the most indigenous people of the Arctic are the roughly 50,000-60,000 Inuit. Dr Hotez notes that it is not surprising that neglected infections of poverty are found in the Arctic given the region’s socioeconomic deprivation, stress, and environmental degradation. Indigenous people living in the Arctic region suffer disproportionately from high rates of chronic conditions such as smoking, drinking and obesity and have a life expectancy 8-12 years shorter than the non-indigenous population. “Indeed, overall the world’s indigenous people in general suffer from high rates of infections such as ectoparasitic skin infestations, upper and lower respiratory track infections, and central nervous system infections from bacterial invasive organisms and tuberculosis, childhood illnesses, diarrheal and intestinal helminth infections, urinary tract infections, bone and musculoskeletal infection and in some cases, HIV/AIDS and malaria,” Hotez writes. Many of the parasitic infections are food-borne and transmitted through uncooked or inadequately prepared meats from polar bear and sea mammals such as walrus or seal. Other infections are zoonoses (diseases that can be transmitted from animals to humans) transmitted from livestock unique to the Arctic region such as reindeer and elk. Toxoplasmosis is one of the neglected infections of poverty endemic to the Arctic region. In terms of prevalence and diseases burden, toxoplasmosis is probably the most important parasitic infection in the North American Arctic. Toxoplasmosis can seriously impact people with a weakened immune system. The parasite can also cause encephalitis, neurologic diseases and can also affect the heart, liver and eyes. “Given the high rates of toxoplasmosis, a program of newborn screening for these populations would identify at-risk infants eligible for antiprotozoan chemotherapy,” Hotez concludes. Dr Hotez also calls for further study of neglected infections of poverty throughout the Arctic region, including among the indigenous populations living in Russia and Siberia. “Ultimately, programs for prevention of neglected infections may need implementation for all of the indigenous people living in the Arctic region,” Hotez states. Reference 1. Hotez PJ (2010) Neglected Infections of Poverty among the Indigenous Peoples of the Arctic. PLoS Negl Trop Dis 4(1): e606.

Science and innovation for development

A call for governments and universities to embrace new and sometimes risky scientific research was made at the launch of a ground-breaking book about international development. In their book Science and Innovation for Development Professors Jeff Waage and Gordon Conway challenge policy-makers worldwide to raise the profile of science and maximise the benefits of scientific progress for people living in poor countries. They emphasise the potential of new technologies – information and communication Ttechnology (ICT), nanotechnology and biotechnology – in poverty reduction. Their recommendations include better training for scientists, stronger science innovation systems in developing countries, and designing and delivering research for impact. Sections of the book deal with biotechnology research for health, participatory research for health, and the role of public-private partnerships in health research. A chapter devoted to health includes a discussion on infectious disease that focuses on four areas of innovation: • environmental and behavioural modification: • the quest for vaccines • the role of treatment and drugs • emerging infectious diseases. The book 380-page is published by the UK Collaborative on Development Sciences (UKCDS) which seeks to bring together key government departments and UK research funders who support development sciences. The book may be read freely online here.

Neglected tropical diseases in the Lancet

A couple of weeks ago we alerted readers of TropIKA.net to the publication of an important series of articles on neglected tropical diseases in the Lancet. The series continues and the following articles are now freely available (registration required). Programmes, partnerships, and governance for elimination and control of neglected tropical diseases Bernhard Liese, Mark Rosenberg, Alexander Schratz Integration of control of neglected tropical diseases into health-care systems: challenges and opportunities John O Gyapong, Margaret Gyapong, Nathaniel Yellu, Kwadwo Anakwah, George Amofah, Moses Bockarie, Sam Adjei Mapping, monitoring, and surveillance of neglected tropical diseases: towards a policy framework MC Baker, E Mathieu, FM Fleming, M Deming, JD King, A Garba, JB Koroma, M Bockarie, A Kabore, DP Sankara, DH Molyneux Socioeconomic aspects of neglected tropical diseases Lesong Conteh, Thomas Engels, David H Molyneux Also recently published in the journal's Seminar section is an update on human African trypanosomiasis (sleeping sickness).

Malaria and the global health system

"Support for and inclusion of local research institutions in global health research is essential to develop well-adapted health tools". This is the conclusion of an article in PLoS Medicine [1] which uses efforts to research and control efforts malaria as a case study. The article is the third in a series of articles on the changing nature of global health institutions. The authors review a century of malaria and research control activities. They note that there has been a shift from centralized. short-term programmes efforts, often relying on single interventions, toward more decentralized, continuous efforts using multiple approaches: "Malaria is no longer seen primarily as a biomedical problem, but rather as a complex ecological system in which humans, mosquitoes, and parasites are interconnected. Malaria has also increasingly been characterized as a “global” and regional rather than a national or local problem. This has led to changed concepts of governance". Reference 1. Keusch GT, Kilama WL, Moon S, Szlezák NA, Michaud CM (2010). The Global Health System: Linking Knowledge with Action - Learning from Malaria. PLoS Med 7(1): e1000179.

Malaria and more

The first month of 2010 has seen important developments in the world of malaria research. GlaxoSmithKline is putting into the public domain details of 13,500 “confirmed-hit structures” – compounds that other researchers will be free to screen for their potential use as antimalarials [1]. Meanwhile, the genome has been mapped of the plant from which the key antimalarial artemisinin is produced [2], which should pay the way for the development of higher yielding varieties. Also announced has been an extension of efforts to develop a so-called transmission blocking vaccine [3] active against the sexual stages of the malaria parasite. 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

Tanzania's ambitious malaria goals

There can be no doubt that the government of Tanzania regards malaria as one of its top health priorities. It has announced that it plans to reduce case numbers by at least 80 percent over the next two years. Afrique en Ligne quotes Health and Social Welfare minister Professor David Mwakyusa as saying that the use of rapid diagnostic tests (RDTs) will play a major part in efforts against the disease. RDT kits will be used on a pilot basis in three selected regions (Coast, Iringa and Kagera) before their distribution to all parts of the country. Speaking at a launch event for the kits, Professor Mwakyusa said, "Malaria poses a great challenge, but if we play a collective role as individuals and do not leave the fight to the government alone, we will make malaria a history". Malaria is still Tanzania's leading killer, claiming 60,000-80,000 lives per year, mainly those of children under age five. Under-five malaria-related deaths have, however, already been much reduced, from 147 per 1000 live births a few years ago to 91 per 1000 in 2008. Meanwhile, Tanzania's Citizen newspaper reports that Tanzania spends over Sh850 billion (US$ 850 million) annually in fighting malaria. David Mwakyusa told the Citizen that the country spends 3.4 % of its gross domestic product on the disease. Around 29% of this is government expenditure, the rest of the figure is what individuals spend on drugs, coils, sprays and bed nets. The US President's Malaria Initiative (PMI) is amongst the biggest donors assisting Tanzania's malaria control efforts. This year the country will receive $52 million from PMI. The Tanzania mainland will be allocated $46.77 million of the total, while the remaining $5.23 million will be spent in Zanzibar where the war against malaria has already shown positive results.

Cholera surveillance will be improved in Africa

The last two years have seen outbreaks of cholera in many parts of Africa but surveillance systems for the disease there nevertheless remain poor. French organization Agence de Medecine Preventive (AMP) has received a three-year grant of $4.9 million from the Bill & Melinda Gates Foundation to create a consortium that will establish an African Cholera Surveillance Network (AFRICHOL) to strengthen cholera surveillance and outbreak response in at least eight African countries. AMP and the African Field Epidemiology Network (AFENET) will be the core members of the consortium, which will also include several other leading health organizations from around the world. AMP will expand cholera surveillance by actively mobilizing regional and international organizations. AFENET will be responsible for overseeing project implementation in several countries. "AMP will rely on its extensive global network to bring to the table the most important organizations working on cholera prevention in resource-poor settings," said Alfred da Silva, executive director of AMP. "It is only through such a collective effort that we will be able to establish the true burden of disease in sub-Saharan Africa." Further details are available in an AMP press release. APM has also recently received a Gates grant to improve advocacy for vaccines and immunization systems in West Africa (press release). Agence de Medecine Preventive The Agency for Preventive Medicine is a nonprofit organization that aims to improve the quality of health service delivery in developing countries. It describes its mission as follows: • to contribute to the analysis of the health problems of developing countries through operational and scientific research • to participate in scientific and technical programmes based on the results of action research • to collaborate with developing countries, research institutions and international organizations for effective implementation of recommendations • to strengthening country capacity in health activities for the population, particularly mothers and children.

"Malaria spreading in East African highlands": Where is the evidence?

A recent press release from the UK Department for International Development (DFID) suggested that millions more people in Kenya are now at risk of malaria as a result of mosquitoes colonising higher ground as global temperatures rise. But columnist and environmental campaigner Chris Goodall says that DFID has produced no evidence to back up this assertion. Chris Goodall approached DFID for details of the research on which the press release was based and was sent three papers. In his CarbonCommentary blog Goodall concludes that: "The specific claim that the Mount Kenya area has recently become vulnerable to malaria was backed up by interview data of a few years ago from a small number of families who declared a total of eight cases of malaria in the past five years compared to only three in the period of five to ten years ago. No medical analysis appears to have been carried out to determine whether the disease recorded was or was not malaria". He says that the evidence regarding the presence of mosquitoes at higher altitudes is equally insubstantial. Goodall adds that other research shows that "...the DFID assertion that malaria is increasing in highland regions of Kenya is highly questionable and that overall malaria rates are probably decreasing, although the geographic picture is complex". Climate change denialists - of whom there are many - are eager to jump on any unfounded claims made by those who advocate for action to hold back the threat. A warmer world is indeed likely to see rising rates of many infectious diseases and we must be prepared to adapt to this challenge. But unsubstantiated assertions are unhelpful and could well prove counter-productive.

Leadership roles in tuberculosis research

The Global Alliance for TB Drug Development (TB Alliance) is a not-for-profit, product development partnership accelerating the discovery and development of new tuberculosis drugs. The Alliance has recently announced the appointment of three TB specialists to key positions within the organization. Dr Carl Mendel, is the new Senior Vice President of Research and Development. Dr Mendel comes to the TB Alliance from Synvista Therapeutics. In his new position he will guide all research and development activities as the organization advances the largest portfolio of potential new tuberculosis TB in history, which includes three clinical-stage compounds. Dr Maarten van Cleeff has become President of the Alliance's Stakeholders Association. He has nearly three decades of international experience in TB , and currently works in the Netherlands at KNCV Tuberculosis Foundation as Project Director of The Tuberculosis Coalition for Technical Assistance (TBCTA). Dr Carlos Morel has also been appointed to the TB Alliance Board of Directors. Dr. Morel is the Director of the Center for Technological Development in Health (CDTS) of FIOCRUZ, a scientific institution dedicated to biomedical research and development located in Brazil.

Malaria transmission-blocking vaccine

The first steps have been taken toward the development of a malaria transmission-blocking vaccine (TBV). The PATH Malaria Vaccine Initiative (MVI) today announced a new collaboration with the Johns Hopkins Bloomberg School of Public Health (JHSPH) and the Sabin Vaccine Institute (Sabin) that marks MVI’s first investment in TBVs. This vaccine approach aims to stop the malaria parasite from developing in the mosquito, effectively blocking transmission of malaria from mosquitoes to humans. Malaria kills nearly 900,000 people per year, most of them children younger than age five. “The heart-breaking devastation caused by malaria cannot be overstated,” according to Dr Peter Agre, Nobel Laureate and Director of the Johns Hopkins Malaria Research Institute (JHMRI). “Blocking transmission by novel vaccines may provide the approach needed to stop the epidemic. MVI deserves great credit for supporting potentially exciting research that would otherwise be abandoned due to lack of precedent.” “Although eradication is a very long-term and aspirational goal, we are excited by the potential of transmission-blocking vaccines to significantly limit the spread of malaria infection,” noted Dr Christian Loucq, Director of MVI. “In combination with other interventions, we believe a successful TBV would provide another important tool in the fight against malaria.” Over the next 18 months, MVI’s partners will collaborate to produce and characterize an antigen that can activate the body’s defences to disrupt the complex human-mosquito transmission cycle of malaria. An antigen is any substance that triggers the immune system to produce antibodies against it. The development team will identify the optimal conditions needed to manufacture clinical supplies of AnAPN1, a mosquito antigen that appears to play a major role in parasite establishment within the mosquito. Preliminary field research has shown that antibodies induced by this antigen are capable of blocking transmission of the two deadliest malaria parasites, Plasmodium falciparum and P. vivax. When a mosquito takes blood from a vaccinated person, these antibodies prevent the parasite from attaching to and invading the mosquito’s gut. “The antibodies that we have produced are effective against multiple malaria parasites and, therefore, this antigen may constitute the basis for a future ‘universal’ or pan-malaria transmission-blocking vaccine.” said Dr Rhoel Dinglasan, lead researcher on this project and faculty member at JHSPH. “This could have a tremendous impact on malaria transmission, even extending beyond those individuals we can reach through a vaccination campaign.” “We look forward to supporting MVI’s innovative efforts in the development of transmission-blocking vaccines for malaria,” said Dr. Ami Shah Brown, Director of Vaccine Operations for the Sabin Vaccine Institute. “Together with our partners at The George Washington University, we are very excited to utilize our existing vaccine development capabilities and work with MVI and JHSPH to develop the AnAPN1 antigen.” The collaboration reflects MVI’s redesigned research and development strategy. The new strategy encompasses a broader outlook on malaria vaccine development and promotes early investment in a variety of approaches that have the potential to reach the malaria community’s long-term goal of a vaccine that is at least 80 percent effective against clinical disease for more than four years by 2025. Further, MVI is increasing support for vaccines targeting clinical disease caused by P.vivax, as well as vaccines that could interrupt the cycle of transmission of malaria parasites; two aspects of malaria vaccine development that have historically been poorly funded. These efforts are spurred by a renewed long-term commitment within the malaria community to eradicate the disease. An article in Time looks further at this new initiative. Time spoke to the Rhoel Dinglasan, an entomologist and biologist from the Philippines, now at Johns Hopkins University Hospital, USA, about his role in the development of the vaccine

Tobacco use common amongst Malaysians with TB

2010 is the Year of the Lung. It is interesting to see such a broad view taken of health conditions that affect the lung, for they are many and various - both infectious and non-infectious. In many cases different health threats conspire to attack the lungs. The use of tobacco can worsen infectious conditions, for example tuberculosis. Analyses have suggested that a considerable proportion of the global burden of TB may be attributable to smoking. It seems likely that the recovery of patients receiving TB treatment will be held back if they use tobacco. Surprisingly little is known as to how many TB patients use tobacco. Researchers in Malaysia (1) asked over 800 people receiving TB treatment whether they were users of tobacco. They found that 40% were current users and 14% had used tobacco at some point in their lives. They estimate the prevalence of ever-smoking among patients with TB to be 54,220 per 100,000 population. From conversations with the TB patients the researchers conclude that most of them had "deficiencies in knowledge of tobacco use and its health dangers". Efforts to control tuberculosis must clearly include action to discourage smoking. Reference 1. Awaisu A et al. (2010). Tobacco use prevalence, knowledge, and attitudes among newly diagnosed tuberculosis patients in Penang State and Wilayah Persekutuan Kuala Lumpur, Malaysia. Tobacco Induced Diseases; 8:3. http://www.tobaccoinduceddiseases.com/content/8/1/3

Networks that will boost Africa's capacity in clinical research

A Nature Medicine news article discusses the European Clinical Development Partnership (EDCTP) and its recent achievement in contracting four regional networks that will facilitate the conducting of multicentre phase 2 and 3 clinical trials on AIDS, tuberculosis and malaria in sub-Saharan Africa. Africa hosts an increasing number of clinical trials but, for the most part, the continent lacks the basic infrastructure and expertise to conduct trials that meet international standards. EDCTP's networks are intended to improve the situation by upgrading the quality and capacity of local hospitals and research centres. EDCTP is a partnership between 47 sub-Saharan African countries and 14 European Union member states plus Norway and Switzerland. Since its launch in 2003, it has provided over $300 million to fund 45 clinical trials in 21 African countries. The fourth of its regional networks, the southern African group, was contracted in November 2009. According to Thomas Nyirenda, EDCTP’s networking and capacity development manager in Cape Town, "There are centres that are good here and there, but there’s a lack of critical mass of researchers on the continent. The driving force is to really put a structure in place that will be sustainable". Ruxandra Draghia-Akli, the European Commission’s director of health research says it is hoped to extend the trials conducted under the initiative to cover also other more neglected infectious diseases. EDCTP has also featured in other recent articles on TropIKA.net.

Novel financing mechanisms for global health

Last week’s Economist magazine takes a look at innovation in global health financing with a feature article on UNITAID and the Massive Good movement of the Millennium Foundation, among other novel mechanisms designed to leverage the wealth of populations to fund medical care for TB, AIDS, and malaria. In the 1990s, more than two-thirds of the $5.6 billion spent on global health assistance came from governments. In 2007, the Gates Foundation and other major philanthropies accounted for the bulk of total funding for health. While those models relied on a small number of large donations, UNITAID is targeting entire populations by introducing so-called “solidarity tax” on purchases of airline tickets. Founded by France and Brazil in 2006, UNITAID is hosted by the WHO and has raised more than $1.5 billion over the past four years. The organization’s primary goal is to ensure access to drugs against the most deadly global diseases by negotiating low prices for the bulk purchase of medications and to incite the development and mass production of special drugs (such as pediatric treatment for HIV/AIDS-infected children). In January, a private foundation linked to UNITAID called MassiveGood, started raising money from the public directly with the help of the Tourism and Travel industry. In his new book, “Power in Numbers: UNITAID, Innovative Financing, and the Quest for Massive Good”, UNITAID president Phillippe Douste-Blazy argues that “building solidarity” will be essential to any effort to combat disease. The article goes on to describe other new approaches, including the GAVI alliance’s strategy of issuing bonds backed by sovereign pledges of aid money in future years; the Global Fund’s exchange-traded fund aimed at both traditional investors and “socially responsible” ones; and the WHO’s effort’s to pressure the drug industry to relax patent protection and for large drug makers to share patents with more modest institutions. By pooling patents, the cost of development can be lowered and the pace accelerated. GlaxoSmithKline and Pfizer have announced they would combine their patents for HIV into a joint research effort called ViiV. Also profiled is the Affordable Medicines Facility-Malaria (AMFm) to be rolled out by the Global Fund by mid-2010. Spending $216 million over two years to subsidise the cost of ACT to wholesale buyers, the Global Fund intends to reduce the retail price to between 20 and 50 cents, although 50 cents may still be too expensive. “The flurry of innovative schemes should help,” write the authors, “but the developing world will have to mobilise its own money and willpower to tackle humanity’s great scourges.”

Deep Springs International works to provide clean water in Haiti

Three days after an earthquake struck Haiti, time is running out for survivors desperate for food and clean drinking water. While rescue teams are now arriving on the scene, aid efforts have largely faltered and major shipments of water and food have been unable to reach those in greatest need. As survivors succumb to thirst and dehydration, they'll likely turn to water distribution systems that have been compromised by the damage to infrastructure and the lack of sanitation in crowded camps. That can lead to massive outbreaks of water-borne diseases like cholera, a disease capable of ravaging refugee camps in a matter of hours. In the wake of the 1994 Rwandan genocide, for example, cholera killed some 45,000 people in less than three weeks. Among the organizations responding to the crisis is the Haiti-based Deep Springs International (DSI). In collaboration with the US Centers for Disease Control and Prevention (CDC), DSI is working to develop an immediate implementation plan to respond to the country's myriad clean water needs. DSI President and in-country director, Michael Ritter is based in Baudin, 30 miles southwest of Port-au-Prince, and is in contact with CDC's Daniele Lantagne, a leading expert in diarrheal diseases. To learn more about what Deep Springs International does, visit their site. Updates will follow as they become available.

"Hero" of neglected tropical diseases is interviewed

Narcis Kabatereine has steadily built a career as both an academic and a highly trusted technical expert whose advice on tropical disease control is greatly in demand across Africa. He has been described as "the unsung hero of NTDs [neglected tropical diseases]". PLoS NTDs has interviewed Dr Kabatereine in his office at the Vector Control Division (VCD) of Uganda's Ministry of Health in Kampala, where he spoke to the journal about his career - including his work on schistosomiasis and soil-transmitted helminthiases - and his enthusiasm for the integrated approach to NTD control.

New digital TB test looks for "structural fingerprint"

New methods to diagnose tuberculosis are desperately needed, as existing techniques are slow and inaccurate. One test at the development stage uses the same technology that is employed in security testing at airports. South African researchers at the Aurum Institute describe, in a SciDev.Net news story, their TBDx test which takes digital images of patients' sputum samples and looks for TB's structural "fingerprint". The Aurum Insitute scientists say that TDX is 10% more accurate than conventional testing and could be useful for pre-screening samples to determine which need further analysis. It will also be more affordable than other TB diagnostic technologies also under development.

Leptospirosis increasing in northern India

Leptospirosis is a bacterial disease of animals that can also affect humans. Exposure through water contaminated by urine from infected animals (most commonly rats) is the most common route of infection. Outdoor and agricultural workers (rice-paddy and sugarcane workers for example) are particularly at risk. In India it is recognized as being one of the most common causes of fever in many parts of the country but not in the north, where it is regarded as being "non-endemic". New research (1), however, confirms that it has become much more common in this part of India in recent years. During the period 2004 to 2008 the Post-Graduate Institute of Medical Education and Research (PGIMER) in Chandigarh received 1391 blood samples from suspected patients with fever of unknown origin, from several parts of northern India, which they tested for leptospirosis. They found there was a sustained rise of leptospirosis cases from 11.7% to 20.5% across the period. The researchers followed up 86 of the leptospirosis cases in more detail. Infestation of dwellings with rats (53.7%), working in farm lands (44.2%), and contact with animals (62.1%) emerged as the most common risk factors. Five of the 86 patients died and many more suffered severe complications: kidney failure (60.5%), respiratory failure (20.9%), blood clotting (11.6%), and damage to the nervous system (11.6%). Leptospirosis, say the researchers, is often not suspected by physicians in patients with fever in supposedly non-endemic areas. They argue that doctors in northern India should be more aware of the possibility of the disease in their patients, as early diagnosis and treatment may reduce the number of complications and the death rate. Reference 1. Sethi S, Sharma N, Kakkar N, Taneja J, Chatterjee SS, et al. (2010). Increasing Trends of Leptospirosis in Northern India: A Clinico-Epidemiological Study. PLoS Negl Trop Dis 4(1): e579

Partnership meeting will bring together researchers, industry and funders

BIO Ventures for Global Health, a non-profit organization, aims to "harnesses the resources of the biotechnology industry to create new medicines for neglected diseases of the developing world". The organization has announced details of its 2010 Partnering for Global Health Forum which will take place in Chicago beginning 3rd May. The meeting will feature one day of panel discussions, followed by two days of partnering and networking opportunities intended to bring together the perspectives of the biopharmaceutical industry, potential funders, and international health experts.

“You Idiots”

Patrick Adams writes... That’s the cover quote of the current issue of Rolling Stone, which kicks the New Year off with a cover piece on “The Climate Killers,” by Tom Dickson. The story, a series of rap sheets on the 17 “deniers and polluters who are derailing efforts to curb global warming,” starts off with Warren Buffett, CEO of Berkshire Hathaway and – after Bill Gates – the second richest man in the world. In 2008, he was indeed in the top spot. Buffet, who’s promised to donate roughly 85% of his fortune to the Bill & Melinda Gates Foundation and four other philanthropies, has called the climate bill passed by the US House of Representatives a “huge tax” that would mean, “very poor people are going to pay a lot more for their electricity”. But Buffett isn’t just bad-mouthing climate legislation, writes Dickson. “He’s literally banking on its failure,” with millions invested in carbon-polluting industries. Berkshire Hathaway bought 1.28 million shares of America’s biggest climate polluter ExxonMobile, and last November purchased the Burlington Northern Santa Fe railroad for $26 billion. “As a savvy investor, Buffett would only buy a coal-shipping railroad if he felt certain that Congress will fail to crack down on climate pollution,” writes Dickson. Labelled the “The Profiteer,” by Rolling Stone, Buffett’s investments certainly reflect his opinion that “capitalism is the greatest growth engine ever invented”. But is it the greatest invention for population health in developing countries? For all of his admiration for the Gates Foundation, Buffett most likely wasn’t investing with malaria in mind – or for that matter any of the diseases for which climate change represents a major risk factor. When Buffett’s donation to the Gates Foundation was first announced, back in June 2006, it was reported that whereas most people with this amount of money would typically try to create a foundation in their own image, the then-75-year-old Buffett was humbly entrusting it to a close friend 25 years his junior, who would know how to use it properly. Given that Buffett’s investments have the power to move entire markets, and that the effects of climate change on infectious diseases of poverty are likely to be rather large, one might have hoped that the “Oracle of Omaha” (as Buffet has been nicknamed) would have sought out his friend Gates – who has been highly vocal about the life-or-death consequences of climate change for the poor – for some sound advice.

Call to new USAID chief to do more on infectious killers of children

USAID - the US government's overseas development assistance agency - has a new chief. Dr Rajiv Shah was sworn in on 7th January - see USAID press release. Dr Shah is sure to be hearing from many people who would like to see changes in USAID policy, particularly as regards health. Amongst them will be Dr Orin Levine Executive Director of the International Vaccine Access Center at Johns Hopkins University. Writing in the Huffington Post, Dr Levine says USAID's health policies should be more "child friendly". He refers in particular to the two biggest killers of children, both of them the result of infections - pneumonia and diarrhoea. He notes that USAID funding has tended to focus more on diseases that kill adults, particularly AIDS. Interventions are available, proven by research to be effective, that USAID should fund in order to save children's lives.

New dengue guidelines show how policy is informed by research

Recently published new guidelines for the diagnosis, treatment, prevention and control of dengue (see TropIKA.net report) have been hailed by the Wellcome Trust as an example of how research can shape policy - see Trust press release. The Wellcome Trust funded some of the research on which the new guidelines are based, particularly research conducted in Viet Nam. The press release also describes how malaria policy in Kenya has been influenced by Trust-funded work.

TB infection worsens quality of life for people with HIV

For patients with chronic infectious disease, quality of life (QoL) is arguably the most important issue, but it is often not considered in research. An Ethiopian study (1) has looked at the QoL of patients coinfected with TB and HIV. The research team interviewed 591 HIV-positive patients, of whom 124 (21%) were TB/HIV co-infected. Use was made of a short version of WHO's QoL scoring system. Depression was also assessed. TB/HIV co-infected patients had lower scores on all aspects of QoL, compared with HIV-infected patients without active TB. Depression, having a source of income and family support emerged as particular problems. In co-infected patients, individuals who had depression were 8.8 times more likely to have poor physical health as compared with individuals who had no depression. Self-stigma was also associated with poor QoL. The authors of the study recommend that TB programmes should design strategies to improve the QoL of TB/HIV co-infected patients. Depression and self-stigma should be given particular consideration and families of the patients should be counselled and educated. Reference 1. Deribew A, Tesfay M, Hailemichael Y, Negussu N, Daba S, Woji A, Belachew T, Apers L, Robert C (2009). Health Qual Life Outcomes; 7(1):105.

Expert Indian group will study Chikungunya

A report in the Hindu newspaper says that the Indian Council of Medical Research (ICMR) will be setting up an expert group to examine the increasing number of cases of the infectious disease Chikungunya. ICMR also intends to create a National Virology Network to monitor the outbreak of all viral diseases throughout India. Chikungunya - viral disease, carried by Aedes aegypti mosquitoes - was first reported in the 1950s and in recent years has steadily become more common in Africa, Asia and the Pacific islands, with the first European cases seen in 2007. It has similar symptoms to dengue, making diagnosis difficult. The fever lasts only a few days but severe joint pains and fatigue can persist for many months. The disease has also recently been shown to cause severe blistering of the skin of infected children (1). No vaccine or specific treatment exists for Chikungunya. There are concerns that the increasing frequency of the infection will cause problems for blood transfusion services in many parts of the world (2), although improved blood tests are under development (3). References 1. Robin S, Ramful D, Zettor J, Benhamou L, Jaffar-Bandjee MC, Rivière JP, Marichy J, Ezzedine K, Alessandri JL (2010). Severe bullous skin lesions associated with Chikungunya virus infection in small infants. Eur J Pediatr; 169(1):67-72. 2. Petersen LR, Stramer SL, Powers AM (2010). Chikungunya virus: possible impact on transfusion medicine. Transfus Med Rev. 2010 Jan;24(1):15-21. 3. Sharma S, Dash PK, Santhosh SR, Shukla J, Parida M, Lakshmana Rao PV (2010). Development of a Quantitative Competitive Reverse Transcription Polymerase Chain Reaction (QC-RT-PCR) for Detection and Quantitation of Chikungunya Virus.

Improving access to vaccines

From Patrick Adams Public vaccination programmes have made huge strides in recent years in extending coverage to vulnerable, hard-to-reach populations. Measles mortality, for one, was reduced from 750,000 cases in 2000 to 197,000 in 2007, and an estimated two-to-three million child deaths are now averted annually through vaccination against diphtheria, tetanus, pertussis and measles combined. Still, vaccine preventable diseases are responsible for close to a quarter of the 10 million annual deaths among children under five. Thanks in large part to GAVI Alliance financing, the last decade has seen a number of new life-saving vaccines – for rotavirus and pneumococcal diseases – become available, but at prices too high for most low-income countries. And as more vaccines become available over the next decade, Ministries of Health will have to make difficult decisions about which life-saving tools they should finance and use on a routine basis (1). As Ruth Levine points out on the Center for Global Development blog, several important factors play into that decision, including disease burden, vaccine efficacy, costs and benefits of different introduction strategies, and financing approaches, among others. The inability of MOHs to access and synthesize that data in a timely and credible manner is one of the barriers to distribution and usage of new vaccines. Which is why the newly created International Vaccine Access Center at the Johns Hopkins Bloomberg School of Public Health has the potential to play an important role in public health worldwide. Launched in December 2009, the IVAC is led by Dr Orin Levine, associate professor in the Bloomberg School’s Department of International Health and executive director of PneumoADIP, a GAVI-supported programme at Johns Hopkins devoted to accelerating the uptake of pneumococcal conjugate vaccines. “Orin, who did landmark research in the Gambia and elsewhere, can amplify his team’s positive impact immeasurably through its collaborations,” writes Ruth Levine. Drawing on its experience with PneumoADIP, IVAC aims to accelerate access to vaccines for children worldwide through data-driven policymaking and by targeting the results of rigorous studies at key decision-makers—both donors and policymakers. “I’m hoping IVAC’s excellent team find optimal ways to work with WHO,” adds Ruth Levine, referring to WHO’s Immunization, Vaccines and Biologicals group. “The IVB has a vital role to play in creating the normative guidance and providing information and support to Ministries of Health.” 1. Phillipe, D (2009). Global immunization: status, progress, challenges and future. BMC Int Health Hum Rights. 9(Suppl 1): S2.

Where would Nigerians like to get their malaria treatment?

Prompt access to appropriate and affordable treatment is a critical component of efforts to improve the control of malaria. But in low-resource nations, the limited healthcare facilities available make it difficult to provide good quality malaria management services. In seeking to improve these services in such a way that patients will make good use of them, it is important to take account of where and how people in malaria-endemic countries themselves would like to have their treatment provided. A team of Nigerian researchers has conducted a questionnaire survey of 2,250 randomly selected householders in the southeast of the country, in both rural and urban areas (1). They also recorded information to enable them to determine the socioeconomic status of their interviewees. Their findings are of some interest. The questionnaire offered respondents a choice of different sources of treatment, including public and private hospitals, public primary healthcare (PHC) centres, pharmacy shops, patent medicine dealers, home-based care by trained mothers, herbalists or community health workers (CHWs). The most preferred sources of treatment were public hospitals (30.5%), trained mothers (19%) and PHC (18.1%). Traditional healers (4.8%) and patent medicine dealers (4.2%) were the least preferred sources. Many studies have shown that it is extremely common people with a fever (or with a child who has a fever) to seek treatment first from a traditional healer or to self-medicate with drugs bought in pharmacy or other shops. In this part of Nigeria, it seems that most people doing so only take such action because of the poor availability of current health services, rather than because it is what they would actually prefer to do. The findings showed that traditional healers were more popular in rural areas, probably because rural dwellers have more familiarity with them. Other findings included a greater level of preference for hospital treatment in respondents with higher levels of SES. The authors rightly note that other factors, such as occupation and age, might also affect preferences of different sources of treatment. It is also important to emphasize that these findings apply only to the part of Nigeria in which the survey was conducted. Similar studies in other malaria-endemic areas where it is intended upgrade treatment services would be of considerable help in policy and planning. Reference 1. Uguru NP, Onwujekwe OE, Tasie NG, Uzochukwu BS, Ezeoke UE (2010). Do consumers' preferences for improved provision of malaria treatment services differ by their socio-economic status and geographic location? A study in southeast Nigeria. BMC Public Health. 2010 Jan 5;10(1):7.

Late presentation of TB: Liberian programme encourages patients to seek treatment sooner

It is common for patients with tuberculosis not to seek treatment until quite late in the progress of their condition. This is particularly the case in developing countries, where access to health care is often limited. Finding ways to improve treatment seeking behaviour has long been recognised as a priority. Progress achieved in Liberia in recent years therefore comes as welcome news. Government and NGO awareness campaigns have taken place in the capital Monrovia and surrounding areas, encouraging sufferers to come forward for treatment. So-called “TB hubs” have als been set up throughout the capital to encourage people with consistent coughing to be tested. One of the aims of the awareness programme is to overcome the widespread belief in Liberia that TB is fatal and incurable. As a result, there have been increases in the number of people receiving treatment. But beyond the capital less progress has been made. Solomon Addison, TB project coordinator with the International Committee of the Red Cross says, “We are still seeing very low caseloads in smaller towns, which we do not think necessarily reflects the [real number of infections]. We need to expand our treatment and our [education campaigns] there”. Further details on IRIN News.

Commitment and collaboration

At the turn of the year, it is always heartening to be able to report some good news. WHO’s new certification of no less than seven countries as being free of dracunculiasis (guinea worm disease) provides a demonstration of what can be achieved against an infectious diseases of poverty when there is commitment and international collaboration. The progress made against dracunculiasis is quite remarkable; it is estimated that there are now fewer than 3,500 cases of the disease worldwide when, just 20 years ago, the total was approaching three million. 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

Gates funding will support clinical product development of malaria vaccine

The Fraunhofer USA Center for Molecular Biotechnology (CMB) says it has been awarded $9.85 million by the Bill & Melinda Gates Foundation for clinical development of a transmission blocking vaccine to combat malaria. Fraunhofer USA CMB, a division of Fraunhofer USA, Inc., is a not-for-profit research organization which seeks to develop safe and effective vaccines targeting infectious diseases and autoimmune disorders. Dr Vidadi Yusibov, CMB’s Executive Director, says, "We are looking forward to beginning clinical product development following up on the exciting pre-clinical results we have achieved to date". The award has also been welcomed by Dr.Philip Russell of the Sabin Vaccine Institute, who commented, “The technology has the potential to provide the capacity and cost effectiveness required to deal with the health and economic problems caused by malaria in developing countries”. Further details are available in a Fraunhofer USA CMB press release.

Neglected tropical diseases featured in Lancet

Recent months have seen an increasing level of interest in the infectious diseases of poverty, including those that have till now been the most neglected - for example, filarial diseases, schistosomiasis and soil-transmitted helminthiasis. The Lancet is one publication that has increased the coverage it devotes to such conditions. The journal has just begun a new series of articles on neglected tropical diseases (NTDs). The first of four papers reviews elimination and control programmes. Subsequent papers will describe the integration, mapping, and financing of international control initiatives. The series is introduced by a commentary article from David Molyneux of the Centre for Neglected Tropical Diseases, Liverpool School of Tropical Medicine, who is well known as an active campaigner for action against NTDs to be stepped up. A podcast and a profile of Professor Molyneux also form part of the series. The Lancet is not an open-access journal. However, as with many of its articles on global health topics, the series may be viewed freely online. (Registration is required.)

Automated TB diagnosis to enter Phase II

A promising new TB diagnostic test, soon to enter Phase II trials in South Africa, could make screening for the disease faster, cheaper and more accurate than anything currently on the market, reports IRIN/PlusNews Signature Mapping TBDx, an automated diagnostic solution that uses sophisticated detection algorithms to identify TB under microscopy in sputum samples, recently concluded Phase I clinical evaluations at South Africa's National Health Laboratory Service(NHLS) Recheck Program. Phase II clinical trials are set to begin early this year. SM TBDx takes digital pictures of sputum samples and searches those images for TB’s signature structural “fingerprint.” The test works on the same principles as airport scanners, which search digital images of luggage for the structural fingerprint of plastic explosives. According to David Clark, deputy CEO of the Aurum Institute the health research organization partnering with the NHLS to develop the tool, SM TBDx is the first TB diagnostic to combine advanced imaging technology with digital microscopy. If approved for use, the automated technology could dramatically reduce the labor involved in diagnosing TB. Guardian Technologies International, the test's maker, was invited by the Government of India to present SM TBDx to a group of government ministers last October. By automating the diagnostic process, SM TBDx obviates the need for skilled lab technicians; the test can be operated by personnel with no special skills and can run independently around the clock. And the test appears to be more efficient than conventional methods; a prototype has already proven 10 percent more effective at identifying TB bacilli than laboratory technicians hunched over a microscope. Sputum microscopy, the most commonly used TB diagnostic test, relies on technology first developed by Robert Koch, the German physicist who discovered TB more than 100 years ago. In recent years, a number of newer and more sophisticated genetic TB diagnostics have come on the market, but all have their limitations, and the need remains for a rapid, cost-effective, and highly accurate method of diagnosing both latent and active TB infection (1). SM TBDx may well fulfill those criteria. But the technology has yet to be costed, and despite promising signs that the test will be able to increase lab productivity and improve diagnosis, determining cost-effectiveness is a particular challenge for TB tests. There are currently no widely accepted standards for evaluating the costs of a TB test, and few studies have investigated the issue. (2) Declaring, as PlusNews does, that the test could "revolutionise TB diagnosis" may be premature, especially given that rollout on a national level would not occur for at least another 3 years. But if, as its makers say, the SM pathology platform can be applied to other laboratory-diagnosed diseases, such as malaria, leprosy and cancer, this may be just the beginning of the good news. References 1. Pai M et al. (2009). Novel and improved technologies for tuberculosis diagnosis: progress and challenges. Clin Chest Med; 30(4):701-716. 2. Sohn H. et al. (2009) TB diagnostic tests: how do we figure out their costs? Expert Rev Anti Infect Ther; 7(6):723-733.

Seven more countries are now guinea worm free

WHO has certified seven more nations as being free of guinea-worm disease (dracunculiasis). The countries are: Benin, Cambodia, Guinea, Mauritania, the Marshall Islands, Palau and Uganda. This brings the number of countries and territories now certified free of the disease to 187, compared with 21 in 1997. It is necessary for at least three years to pass without notification of a case before WHO will certify a country as being guinea worm free. As recently reported on TropIKA.net, over a year has gone by since a case was seen in Nigeria. Neighbouring Niger is in a similar position. WHO considers that both nations have interrupted transmission and it is hoped that they are well on the way towards elimination of the disease. Ethiopia, Ghana, Mali and Sudan are the four remaining ountries where transmission has yet to be interrupted. Further details are available in a WHO press note.

China's search for new TB drugs

Chinese scientists are working on a new class of tuberculosis drugs based on clofazimine, according to a Reuters' report. Clofazimine itself is an old drug, used at one time in the treatment of leprosy. New ways to prevent and treat tuberculosis are a priority globally but China's needs are particularly acute. After India, the country has the second largest number of people with TB. Every year 1.4 million people in China fall ill with the disease; in 2008 there were 160,000 TB deaths. Drug-resistant forms of TB are also becoming more common. In 2000, 28% of China's TB cases were drug resistant, compared with typically around 5% in developed nations. Lin Yan, director of the China office of the non-profit International Union Against TB and Lung Disease, told Reuters that: "If there are more drug-resistant cases, the cost of TB treatment will rise by a lot, that's for sure. With drug resistance, we can't use first-line drugs and other drugs cost a lot more". Zhong Qiu, who heads the Anti-TB Research Institute in Guangdong province and is a member of of China's TB Expert Consultative Committee, explained that regular TB costs 1,000 yuan to treat in China but drug-resistant TB ranges from 100,000 to 300,000 yuan per person.

Moving forward against malaria: contrasting experiences in two African countries

During the course of 2009, falls in the number of malaria cases were reported from several parts of Africa. It is widely believed, but yet to be proved, that the introduction of new tools for malaria control such as artemisinin-combination therapies (ACTs) and insecticide-treated bednets (ITNs), have been responsible for these encouraging declines. According to a report from AllAfrica.com, Zambia has reached the goal of a 50% reduction in malaria case numbers. The National Malaria Control Centre's acting coordinator, Mulakwa Kamuliwo says malaria deaths in children under the age of five prevalence levels of the malarial parasite have both been reduced, as have cases of children with severe anaemia. Dr Kamuliwo attributes the decline particularly to ITNs and indoor residual spraying (IRS). An important role has been played by the Konkola Copper Mines (KCM) initiative on which the national anti-malaria drive has been based. The support of communities for the new interventions is also regarded as crucial. Zambia continues to expand its malaria control programmes and seems set to be used as an example of what an African country can achieve against the disease. In contrast, Sierra Leone is said to be experiencing increasing numbers of cases of malaria - see report from IRIN News. The situation in Sierra Leone is blamed by WHO and UNICEF largely on a drug procurement problem. Prevention and rapid response also need to be strengthened. Just 26% of children sleep under ITNs (although this represents a five-fold increase over the last five years), and only30% of children with malaria receive treatment within 24 hours of onset. WHO and UNICEF have issued an emergency appeal for 1.3 million bednets and antimalarials for Sierra Leone, at a cost of $16.9 million. The contrasting experiences of these two African countries demonstrate the need for intervention research. We must establish just what it is that leads to success when new tools for malaria control are introduced in one country and to failure when the same measures are tried elsewhere. There is much to be learned from what is taking place in both these countries.

TB research findings raise concerns

Could some tuberculosis bacteria have evolved so that they have actually become dependent on one of the key drugs used in TB treatment? A case study (1) in China raises this disturbing possibility. Bacteria isolated from a TB patient in whom treatment had failed were found to grow poorly without the antibiotic rifampicin and to grow better in its presence. The authors of the report say that this case demonstrates the importance of drug susceptibility testing, and that doctors should be prepared to remove rifampicin from a patient's treatment regimen if resistance to the drug has been demonstrated. Another TB research article published in recent days reports disappointing findings. One of the reasons why it is so difficult to control this disease is the ability of the bacterium Mycobacterium tuberculosis to lie dormant for many years, then suddenly emerge to cause serious disease. It was proposed a few months ago by Swedish researchers that M. tb. might have the ability to turn into dormant, highly-resistant spores. If true, this would provide promising new avenues of research in the fight against TB. However, a new study (2) by US scientists has found no evidence that M. tb can actually form spores. Working with the organism Mycobacterium marinum, often used in TB research, the researchers used genomic techniques to demonstrate that mycobacteria are unlikely to be able to form spores. They were also unable to detect the presence of spores by light microscopy or by testing for heat-resistant, colony-forming units in aged cultures of M. marinum. And they failed to recover heat-resistant colony-forming units from frogs chronically infected with M. marinum. So it may be back to the drawing board to find an explanation for TB dormancy. References 1. Zhong M, Zhang X, Wang Y, Zhang C, Chen G, Hu P, Li M, Zhu B, Zhang W, Zhang Y (2010). An interesting case of rifampicin-dependent/-enhanced multidrug-resistant tuberculosis. Int J Tuberc Lung Dis; 14(1):40-44. Abstract on PubMed. (Full paper not open access.) 2. Traaga BA Driks A, Stragier P, Bitter W, Broussard G, Hatfull G, Chu F, Adams KN, Ramakrishnan L, Losick R (2009). Do mycobacteria produce endospores? Proc Natl Acad Sci USA; Abstract published online before print (Full paper not open access.) A summary is available on EurekAlert.

Malaria vaccine uses nasal route

Japanese researchers have claimed to be the first to use a nasal vaccine to successfully block transmission of the malaria parasite from mosquitoes to mice. Their finding may lead on to the development of such a vaccine for use in the prevention of malaria in humans. Malaria vaccines based on ookinete surface proteins (OSPs) of the malaria parasite are known to block oocyst development within feeding mosquitoes, thus disrupting the parasite's life cycle. The Japanese team - based at the Tropical Biosphere Research Center, University of the Ryukyus - set out to investigate whether a nasally administered OSP vaccine could effectively block parasite transmission in vivo. Writing in the journal Infection and Immunology, they report that mosquitoes that took a blood meal from nasally vaccinated mice were subsequently unable to pass on the parasite to other mice as the fertilization cycle had been interrupted. Reference Arakawa T, Tachibana M, Miyata T, Harakuni T, Kohama H, Matsumoto Y, Tsuji N, Hisaeda H, Stowers A, Torii M, Tsuboi T (2009). Malaria ookinete surface protein-based vaccination via the intranasal route completely blocks parasite transmission in both passive and active vaccination regimens in a rodent model of malaria infection.Infect Immun; 5496-500. Abstract on PubMed. (Full paper is not open access.)

Dwindling funds for malaria could reverse recent gains

Patrick Adams writes... A number of countries have made great strides in terms of malaria control, resulting in reductions of over 50% in the number of malaria cases in more than a third of affected countries. According to the World Malaria Report 2009, the progress was made possible by major increases in donor country contributions to the Global Fund, leading WHO Director General Dr Margaret Chan to declare that “development aid for health is working”. The report notes, however, that funds for malaria “are disproportionately concentrated on smaller countries with lower diseases burdens”. The report recommends that, in order to maintain the gains made to date, “more attention be given to ensuring success in large countries that account for most malaria cases and deaths”. Yet more worrying, some experts say, is the possibility that donor contributions may have peaked. Last February, it was announced that the Global Fund faces a $5 billion shortfall through 2010. In order to address the gap, the fund would impose a series of “efficiency cuts”, “uncertainty cuts” and “delays”. Reporting on the Global Fund’s 20th board meeting in Addis Ababa last month, policy analyst David Wendt speculated that these measures could put at risk more than US$ 1 billion of the US$ 2.64 billion of approved Round 9 budgets. “The prospects for increasing donor contributions to the Global Fund are small,” says Dr Matthew Lynch, director of the Global Program on Malaria at the Johns Hopkins Bloomberg School of Public Health. “Given the delays associated with Rounds 9 and 10, even maintaining the current GFATM funding levels is going to be a stretch.” And though the funding level for Round 10 has yet to be determined, he says, “it’s not likely to be huge”. Lynch adds that while the US government “is doing a lot,” and the President’s Malaria Initiative (PMI) is “fully-funded and doing a very good job,” these bilateral contributions represent just a fraction of Global Fund amounts. The global recession may be partly to blame, he says. But even so, the basic donor-recipient paradigm has to change. “I do still believe ‘cautious optimism’ is appropriate,” says Lynch, referring to WHO Director General Dr Margaret Chan’s reaction to the global report findings. “Mortality levels are declining. There are two more years to run on Round 8 funds. And I think we will demonstrate some substantial returns-on-investment. But countries are going to have to recognize those returns-on-investment and start shouldering more of the financial load.” Richard Tren, director of Africa Fighting Malaria, has been among the more vocal advocates calling for more domestic funding for malaria. He has said that external funding alone will not be sufficient, and, along with many others, he’s questioned the distribution of limited aid dollars on wealthy countries like China and India. China is the third-richest nation overall, India the fifth. In the Global Fund’s 9th round of funding since 2002, China’s total funding request for a malaria “National Strategy Application” (NSA) was roughly $ 176.5 million. (An NSA is a funding channel that allows countries to request support for strong existing national HIV/AIDS, TB and/or malaria strategies). Meanwhile, India requested more than US$ 113 million for malaria. But are these countries indeed “rich”? In per person terms, China is poorer than 132 countries; India is poorer than 166. Both have space programmes, but both also have extreme poverty. Regardless, says Lynch, it’s clear that relying on donors will be increasingly risky for endemic country governments. It’s also likely, he says, that even households will need to make contributions as well. “Malaria elimination is a long-term goal, which means a long haul for maintaining high net coverage. The era of the free nets campaign may be rapidly drawing to a close.”

Nigeria's "last case" of guinea worm

Earlier this year, as reported on TropIKA.net, former Nigerian head of state Yakubu Gowon, who has been intensely involved in the campaign to rid his country of dracunculiasis (guinea worm disease) predicted that 2009 would be the first year in which no guinea worm cases were reported there. As the year draws to a close, it looks like he was right. The US Carter Center which has been at the heart of guinea worm eradication efforts says there have been no known cases since November 2008. According to the Center, the last person to have had the disease (a villager in the southeast of the country) has become a "minor celebrity". Two more years must pass without further cases before Nigeria is officially accredited as being free of the disease. Nevertheless, the achievement of the eradication efforts, which began in 1988, have been nothing short of astonishing. According to 1987 figures, there were 650,000 guinea worm cases in some 6,000 villages across Nigeria. Nigeria joins 15 other countries that have rid themselves of Guinea worm disease since 1986. It is estimated that in 2009, fewer than 3,500 cases of the disease remain in four African countries: Ethiopia, Ghana, Mali and Sudan. It has hard to believe that just 20 years ago the total number of cases worldwide was approaching three million. In Ghana there have been calls for opinion leaders to support community-based surveillance volunteers who are a key part of the plan to eradicate the disease there by 2014 - see Ghana News Agency report. A recent report on Afrika.com notes that it is now six years since Uganda had any cases; WHO's country director there has handed over an official certificate saying the coutry is guinea worm free.

The role of temperature in infectious disease: a call for more research

The TropIKA.net Blog welcomes contributions from guest bloggers. We publish below a viewpoint from Guey Chuen (Oscar) Perng, Associate Professor, Department of Pathology and Laboratory Medicine, Emory Vaccine Center, Emory University School of Medicine, USA: gperng@emory.edu. As always, we encourage comments on the views expressed in the blog. Please use the 'Leave a Reply' function at the end of the blog. ------------------------------------- Inconsistent results are common in investigations of human diseases. In addition to differences attributable to individuals' genetic background, environment or food consumption, temperature may also be an important factor. Temperature plays a critical role in the macro-environment; trees or flowers grow in defined geographical zones, and so do infectious diseases. Temperature also plays, perhaps, an even more critical role in the micro-environment, such as in the physiology of a cell. Fever is a form of body response to a change in physiology. This may be the reason why most pathogenic infections are febrile - i.e. they induce a fever. In some infections, fever can last for several days and occasionally up to a week. In reality, such a long duration of fever is rare as, upon sensing fever, most people self-medicate or seek professional medical help; the majority of patients seek help when their fever lasts more than two or three days. Most parents seek help for their febrile children promptly but, due to inattentiveness, some children may be feverish for several days before assistance is sought. In adults, tolerance levels for fever may be stronger and delays in seeking help are common. Thus, investigations on samples collected during the febrile period and results derived from these specimens must be interpreted cautiously. Fruitful and important information may be gained, especially when searching for biomarkers with a system biology approach, in structure-based drug design, or in the evaluation of diagnostic kits, but such investigations are based on normal temperature conditions. Yes, fever involves only a change in body temperature of a couple of Celsius degrees. However, if we feel our body temperature rising to 38 degrees C, we may feel a little too hot; at 39 C we feel unwell, feverish and anxious; and at 40 C we we feel very concerned, even desperate. Thus, a change of a few degrees is sufficient to cause a noticeable effect on our physiology, which may have a much greater impact on cells or pathogens within our body. Cell physiology may have been changed significantly, the structure of proteins from host or pathogens may alter, and the specific antigens used for diagnostic kits (which are mainly based on the detection of antigen at normal temperature) may not be present. Additionally, temperature is among the most important of the parameters that free-living microbes monitor. Microbial physiology needs to be readjusted in response to sudden temperature changes. Virtually every biomolecule responds to temperature shifts by performing conformational changes, and this can be exploited for direct temperature sensing mechanisms to control the expression of heat shock, cold shock or virulence genes. Importantly - since the tertiary and quaternary structures of proteins are susceptible to temperature changes, and particularly to heat - several protein-dependent thermometers have evolved in nature. Perhaps we need to give serious attention to the importance of temperature in the drug treatment of infectious diseases. Most drugs for pathogenic infections are given to the patient within febrile periods. The crystal structure of a particular pathogen protein derived at normal temperature may be similar to that derived at a higher temperature. However, it is possible that the dynamic space on which the drug is targeted may differ significantly. Drugs are designed to fit within gaps in crystal structure at normal temperature; they may not fit perfectly in structures at a higher temperature. Consequently, the efficacy of drug treatment may not live up to expectation. This may also favour the selection of parasite strains resistant to the drug and consequently the development of more virulent pathogens. I urge a thorough and systemic investigation of the role that temperature plays in the search for specific biomarkers with a system biology approach, in structured-based drug design, and perhaps in the re-evaluation the diagnostic kits with antigens prepared at different temperatures.

Leishmaniasis research in Ethiopia

One of the most neglected of the infectious diseases of poverty, visceral leishmaniasis (kala azar), will be the subject of a new research project in Ethiopia. The project, entitled "Studies on the ecology and transmission dynamics of visceral leishmaniasis in Ethiopia", will seek to determine the drivers of transmission of the disease, of which there an estimated 500,000 cases worldwide annually. The worst affected region in Africa is southern Sudan and northwest Ethiopia. The research will be carried out by the Hebrew University of Jerusalem Kuvin Center for the Study of Infectious and Tropical Diseases, supported by a $5 million grant from the Bill & Melinda Gates Foundation. For further information see press release.

Call to introduce vaccine that could cut child death rates

Extensive research has demonstrated the effectiveness of rotavirus vaccination in reducing death rates in children. It is believed that rotavirus is the most common cause of severe diarrhoea and dehydration in under-fives, leading to some 527,000 deaths every year – 85% of them in Africa and Asia. WHO has recommended the inclusion of the vaccine in national immunization programmes worldwide. So far, however, many governments have been slow to act. A report from IRIN News describes a meeting - held earlier this month in Dakar, Senegal - of the West African Rotavirus Advisory Board, at which health experts urged national governments in the region to introduce the vaccine with minimum delay. Professor George Armah,of Ghana’s Noguchi Memorial Institute for Medical Research, said that the evidence from research was clear and policymakers should now act: “Rotavirus is one of the major causes of diarrhoea deaths and hospital admissions. There are vaccines that are very effective and can radically reduce mortality and morbidity from rotavirus infection”. Two rotavirus vaccines are available - one of them from GlaxoSmithKline which sponsored the Dakar meeting. Following a similar meeting in Kenya, a number of countries in southern and eastern Africa applied to the GAVI Alliance - the global public-private partnership to increase vaccine access – for assistance in introducing both rotavirus and pneumococcal vaccines.

Good news from Ghana: TB treatment and cure rates are approaching target levels

By 2015, as part of the Millennium Development Goals, 85% of new cases of pulmonary tuberculosis should be successfully treated (using directly-observed treatment, short course [DOTS]). There are fears that many developing countries, particularly in Africa, will fail to hit this target. But Ghana is nearly there according to a report from the Ghana Broadcasting Corporation. A forum in Kumasi heard that the present coverage rate is "almost 80%".

Dengue vaccine research expands in Latin America

Dengue fever was considered to be virtually absent from most parts of Latin America until the late 1960s, but since then case numbers have increased and the region is now one of the most badly affected parts of the world for this mosquito-borne viral disease. Sanofi Pasteur, the vaccines division of the sanofi-aventis Group, has announced that it will be expanding its dengue vaccine clinical programme in Latin America with a new multicentre study in children and adolescents in Mexico, Colombia, Honduras and Puerto Rico. The company's candidate vaccine has been evaluated in clinical trials (Phase I, II) in adults and children from non-endemic (US) and endemic countries (Mexico, Philippines). Sanofi Pasteur reports that a balanced immune response against all four dengue serotypes was observed after three doses, and that the vaccine appears to be well tolerated. There are ongoing clinical studies with adults and children in Mexico, Colombia, Honduras, Puerto Rico, Peru, the Philippines, Vietnam, Singapore, and Thailand. Further details are available in a company press release.

Tanzanian project seeks to hold back spread of diseases from animals to humans

Zoonoses are diseases of animals that can be transmitted to people. Examples include anthrax, bovine tuberculosis, brucellosis, fascioliasis, hydatid disease and rabies. Collectively they are significant causes of sickness and death in humans, particularly in poor communities, but very little funding is devoted to research or control programmes that focus on zoonotic diseases. Most infections are undiagnosed. Explosive human population growth and environmental changes have resulted in increased numbers of people living in close contact with wild and domestic animals and there is growing concern that such people face a high risk of zoonoses. An article in PLoS Medicine describes a pilot project conducted in Tanzania to test the feasibility of a new approach to “reducing risks of infectious diseases at the animal–human–ecosystems interface”. Details of this approach, known as One Health, are available in a UN document published earlier this year. Essentially One Health involves integrated and multidisciplinary interventions that address multiple and interacting causes of poor human health, including unsafe and scarce water, lack of sanitation, food insecurity, and close proximity between animals and humans. Tanzania’s Health for Animals and Livelihood Improvement (HALI) project was launched in 2006 to test the feasibility of the approach in a rural area notable for the abundance and diversity of its wildlife. Activities included: testing of wildlife, livestock, and their water sources for zoonotic pathogens and disease; environmental monitoring of water quality, availability, and use; assessing wildlife population health and demography; evaluating livestock and human disease impacts on livelihoods of pastoralist households; examining land and water use impacts on daily workloads and village economies; introducing new diagnostic techniques for disease detection; training people of all education levels about zoonotic diseases; and developing new health and environmental policy interventions to mitigate the impacts of zoonotic diseases. The authors of the article identify three lessons that can be learned from the progress of HALI so far: - First, it is crucial to recognize that zoonotic pathogens are present and emerging in rural communities and that their emergence is spatially and temporally variable within. Nevertheless, most people living in high-risk areas are not aware of the danger or what can be done to reduce it. - Second, the role of water in disease transmission and zoonosis emergence requires particular attention and more research is called for. - Thirdly, effective surveillance, assessments, and interventions are possible only by bridging the organizational gaps among institutions studying and managing wildlife, livestock, water, and public health.

Moving forward from Copenhagen: we must campaign for more research

Most observers have described the Copenhagen climate change conference as a failure. A limited and non-binding agreement – the Copenhagen Accord – has been signed but there is little doubt that, within a few years, we shall all be living in a much warmer world and suffering many adverse consequences. These will include increases in water-borne and vector-borne infectious diseases. (For more details see TropIKA.net News.) 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!

Scientists speak in podcast on the health benefits of tackling climate change

A podcast from the London School of Hygiene and Tropical Medicine features interviews with Andy Haines, Paul Wilkinson, James Woodcock and Alan Dangour from the School, and Anil Markandya from the Basque Centre for Climate Change in Bilbao, Spain. All of the researchers contributed to the recent special issue of the Lancet which examined the consequences to human health of mitigating the effects of greenhouse gas emissions. In the interview the researchers argue that large positive effects on human health are possible over the next few decades if we choose the right strategies to reduce greenhouse gas emissions.

Ethiopia will receive US funding for malaria

The USA will be making a three-year, $40 million grant to the United Nations Children’s Fund (UNICEF) to assist Ethiopia's Oromia Region in the delivery of appropriate malaria prevention, diagnosis, and treatment services. Ethiopia is one of the focus countries under the US President's Malaria Initiative (PMI), which aims to reduce by half the number of malaria deaths in 15 African countries using proven malaria interventions. Oromia is the Ethiopia's largest administrative region and bears the brunt of the country’s malaria burden.The programme, called "Sustaining Malaria Reduction Interventions in Oromia”, will increase access to effective diagnostic tests and medicines to manage malaria cases and promote household ownership and proper use of insecticide-treated bednets. Through UNICEF, USAID will procure and distribute 3.7 million rapid diagnostic tests for use by health staff and health extension workers; distribute 9.4 million treatments of medicines to fully treat confirmed malaria infections in Oromia; and procure and distribute 3.9 million bednets and support the distribution of nets from other sources such as the Global Fund to Fight Aids, Tuberculosis and Malaria, the World Bank, the Carter Center and other partners. See US Embassy press release for more details.

Ghana steps up efforts against neglected infections

Dr Nana Kwadwo Biritwum, Programme Manager of the Neglected Tropical Disease Control Programme of the Ghana Health Service, has spoken of the government's plans to improve the control of neglected infections, including buruli ulcer, lymphatic filariasis (elephantiasis), schistosomiasis, soil-transmitted helminthiases and yaws. The main emphasis will be on prevention. Partnership will be emphasized, including partnership with endemic communities themselves. The interview with Dr Biritwum is available on GhanaWeb.

Human Hookworm Vaccine Initiative

Work continues to develop the first ever vaccine against hookworm - a parasite that infects half a billion people worldwide. Chronic hookworm infections are a leading global cause of malnutrition and can lead to poor school performance and learning disabilities. Effective treatments are available but - because of re-infection - must be given at regular intervals. Many children and adults who need treatment do not receive it. A vaccine to prevent infection would greatly assist disease control efforts. Established in 2002, the Human Hookworm Vaccine Initiative (HHVI) is an international product development partnership based at the Sabin Vaccine Institute. The Institute's website includes a section devoted to HHVI, which provides comprehensive information on the initiative. The initiative is also described in an article published last month Case Studies for Global Health. (Thirty-one other case studies are also featured in this publication, all of them related to diseases that have a disproportionate impact on developing countries.)

Development of R&D capacity of the South needed to hold back rise of infectious diseases due to climate change

Zambian microbiologist George Kasali argues that developing countries must invest in their own research to tackle the increase in infectious diseases that will result from climate change. In an article on SciDev.Net, he focuses on vector-borne infections, saying that the "top priority" in the fight against these diseases is the development of R&D capacity in developing countries. George Kasali's view is that, "...it is wrong for the governments of developing counties to relinquish their own R&D responsibilities in favour of research driven by donor organisations". Climate change will also have a major impact on water-borne infections.

Flu in Africa: how little we know

A PLoS Medicine essay points out that very little information is available about influenza in Africa. As in other parts of the tropical world, flu can occur at any time of the year but there are no reliable figures on its prevalence and incidence. As it may be hard to distinguish flu from other diseases that cause fever, gathering such information in Africa, where there are many such diseases, is problematic. Also lacking is information as to the efficacy of flu vaccines in Africa. The article concludes that: "...data from sporadic studies suggest that influenza is prevalent in Africa and the disease may have considerable impact on morbidity and mortality on the continent. A raised awareness of the presence of common febrile diseases such as influenza is essential for the clinical management of patients". The author call for surveillance programmes to be introduced (as is already happening in parts of Southeast Asia and Latin America) and for clinical trials of flu vaccines to be conducted in Africa.

No bednet? Pay a fine

In one part of Senegal, local women now conduct "bednet patrols". They have the power to fine anyone who has a bed that is not protected by an insecticide-treated net (ITN). This surprising, and many would say unduly harsh, approach to increasing the use of ITNs as part of malaria control activities, is one of the strategies employed in community initiative in the rural community of Tiénaba in the Thiès region of Senegal. An association launched in 2000 comprises 65 public health committees headed by village women who run education and awareness campaigns, and impose penalties when people do not follow "hygiene rules". The fine for not having an ITN is equivalent to US55 cents. According to IRIN News, 15 cases of malaria were reported among the 4,000 residents of Tiénaba in 2009, compared to 1,140 in 2004.

Mobile phones track where Zanzibaris travel, as part of malaria elimination programme

Zanzibar has made huge strides in its efforts to control malaria and is now seeking to eliminate the disease as a public health problem. US researchers from the University of Florida are aiding the elimination campaign by following where Zanzibar people travel. Analysing the records of mobile phone calls made by Zanzibaris, the Florida team found that most people did not leave the island; should malaria be eliminated, such people would not play a part in any subsequent re-introduction of the disease. Of those who do travel further afield, most only went as far as Dar es Salaam on the Tanzanian mainland, where they stayed just a few days. They are considered to be at relatively low risk of acquiring malaria during their travels. However, "a few hundred" Zanzibaris travel to inland parts of Tanzania which are highly endemic for the disease. They would be the most likely people to reintroduce malaria to Zanzibar. The Florida scientists say that the Zanzibar government could choose to give residents prophylactics against malaria before they travel, or it could screen all residents as they return, both very expensive propositions. Or it could launch a targeted information and/or screening campaign aimed at the high-risk travellers. (More details in University of Florida News.) Some of us feel uncomfortable about our mobile phone records being accessed without our permission to find out who we talk to and where we go. In this case, of course the information has been put to good use.

"World faces epidemiological transition"

Climate change is identified as one factor in the growing number of cases of zoonoses (diseases of animals that can be transmitted to humans.) in an article in Emerging Health Threats Forum. The article quotes Montira Pongsiri, of the US Environmental Protection Agency, who says, "We appear to be undergoing a distinct change in global disease ecology". She and her colleagues argue that the loss of animal and plant species, together with the destruction of their habitats, brings people into closer contact with animal diseases, particularly those transmitted by vectors such as mosquitoes. Also interviewed is Jan Slingenbergh, of the UN Food and Agriculture Organization. He says that at least 45 diseases have jumped the human-animal species barrier over the last two decades. Increasing globalization is also cited as a factor.

Climate change: Africans are already learning to adapt

An article in South Africa's Globe and Mail claims that innovations already under way in Africa are helping people to keep pace with the effects of climate change. New energy sources, more efficient farming methods and malaria research are all examples cited by author Geoffrey York.

Funding provided to study impact of environmental change on infections

To better understand the ecological mechanisms that govern relationships between human-induced environmental changes and the emergence and transmission of infectious diseases, the US National Science Foundation (NSF) and National Institutes of Health (NIH) have awarded 10 grants through the Ecology of Infectious Diseases (EID) programme. Details of the awards are available in an NSF press release.

US increases funds for neglected tropical diseases

The United States Senate has approved $65 million new funding for action against neglected tropical diseases. The figure is less than the $70m proposed by President Obama but it has nevertheless been welcomed by the Global Network for Neglected Tropical Diseases as a "positive step forward".

Uganda takes action against trypanosomiasis

The impact of sleeping sickness (human African trypanosomiasis, HAT) on ordinary families is brought home in a BBC news story that focuses on the barriers a Ugandan mother had to surmount in order to get treatment for her young daughter. The story also describes a veterinary project in Uganda which seeks to reduce levels of infection with the trypanosome parasite in cattle. (In this part of Africa, cattle are the main reservoir of the parasite responsible for sleeping sickness in humans.) The innovative project involves private, community-based vets.

Saving lives with zinc: Bangladesh programme evaluated

After pneumonia, the biggest cause of childhood death is diarrhoeal disease. Many children's lives have been saved with oral rehydration therapy, although it is still not reaching all those who need it, but the value of treatment with zinc is also now well established. Much of the research doing so was conducted in Bangladesh, which in 2003 embarked on an ambitious national programme - Scaling Up of Zinc for Young Children” (SUZY) - to provide zinc treatment for diarrhoea in all children under five years of age. Research is also needed to evaluate how implementation programmes are performing. It is necessary to identify any problem areas, so that the programmes can be improved. This was the aim of a study evaluating SUZY published in PLoS Medicine. Many of the findings are encouraging. Four areas, each representing different segments of the population across Bangladesh were surveyed; urban slums, urban non-slums, municipal (small city), and rural. In total 1.5 million under-fives live in the areas surveyed. Two years after SUZY was launched, 25% of urban non-slum, 20% of municipal and urban slum, and 10% of rural children under five years of age were being given zinc for childhood diarrhoea. Use of zinc was shown to be safe, with few side-effects, and did not affect the use of oral rehydration therapy. However, many children did not receive the full course of treatment; their parents had been sold the wrong number of pills. While a national campaign to create awareness of zinc treatment was extremely successful, high levels of awareness did not always result in high levels of zinc use. The detailed results of the study will provide the SUZY programme, and similar efforts in other countries, with information that will help improve its implementation and level of effectiveness.

Malaria: is elimination a useful concept?

Can we hope to eliminate malaria as a public health problem? 'Elimination', in this context, would mean the interruption of disease transmission, creating zero incidence of locally contracted cases. Or is it more realistic to think in terms of improved control and reductions in case numbers? The issue is hotly debated. A short Lancet Editorial reports the recent comments of Nick White at the UK Academy of Medical Sciences' annual international health lecture. He believes that there is now an opportunity to eliminate malaria in many parts of the world. He made reference to the Malaria Elimination Group's efforts to identify countries where national or subnational elimination strategies could deliver zero transmission. But at the same meeting another leading malaria specialist, Kevin Marsh said that focusing on elimination could be harmful by causing false hopes.

Climate change and health: new impetus for better understanding of the linkages between climate variability and disease outcomes

The publication of the IPCC’s 4th Assessment Report led to a rapid escalation of interest among the Global Health Community. In recognition of this, the community has begun to explore and advocate for strategies to “climate proof” health, as a means to protect and further hard-won development gains. Climate and Health was the focus of World Health Day in 2008 and a Special Resolution on Protecting Human Health from Climate Change was ratified by the 61st World Health Assembly. Follow-on reports include a Lancet commissioned study carried out by University College London (1) and another from WHO (2). The authors call for a wide-sweeping coalition of socio-economic development agencies ready to take forward the agenda of a new public health movement appropriate to managing to the scale of the problem, coupled with applied interdisciplinary research to help maximize the public health benefits of decisions taken outside the health sector. In furthering these research requirements, a meeting was held in Geneva last week to elucidate the relative importance of climate-environmental-social drivers of the major vector-borne diseases that impact on the health of the world’s poor. The meeting: “Effects of Environmental and Climate Change on Major Disease Vectors and Vector-Borne Diseases: Current Evidence and Research Priorities” was an informal expert consultation convened by the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR). It was apparent from the discussions that the climate-environmental-social determinants of major vector-borne diseases vary greatly over time, by disease and by region. If health services are to be adaptive to climate change, then they must be enabled to better understand the linkages between the drivers of disease and their outcomes, in order to design and implement more effective and responsive control strategies. This will require concerted research capacity building and training. Such initiatives will need to be truly interdisciplinary and must enable effective partnership across climate and environmental services and public health services. Climate services are increasingly open to joint research into societal benefit areas, such as public health. This was clearly evident at the World Climate Conference held in Geneva in September 2009, where WHO and WMO gathered their partners to promote the development of Climate Services for Public Health. Recognition of these vital research requirements and the benefits they will have for more effective health care are vitally important considerations for the discussions in Copenhagen this week and we look forward to concerted multilateral support to such initiatives. Stephen J. Connor is a Senior Research Scientist based at the International Research Institute for Climate and Society at Columbia University, New York – a WHO Collaborating Centre on Climate Sensitive Diseases. References 1. Costello A et al (2009). Managing the health effects of climate change: Lancet and University College London Institute for Global Health Commission. Lancet; 373(9676):1693-1733. 2. World Health Organization (2009). Protecting health from climate change: Global research priorities. WHO, Geneva. Available online: http://www.who.int/globalchange/publications/9789241598187/en/index.html.

Nigerian fears of insecticide resistance

A worrying report from news agency AFP says that delegates at a conference in Abuja, Nigeria have expressed that mosquitoes are becoming less sensitive to insecticides. According to Peter Clearyof Vestergaard Frandsen, manufacturers of insecticide-impregnated bednets, "There is concern that the malarial vectors are becoming resistant to the entire class of insecticides the WHO approves". Amongst others interviewed by AFP was Yayo Abdulsalam, a researcher and lecturer in medical entomology. He points out that, "In cases where there is high resistance of mosquitoes to insecticides, there is high usage of agricultural pesticides". Resistance is the "first warning sign that you have to take necessary measures to ensure that the few insecticides we have... will be effective," says Sam Awolola, a scientist with Nigerian Institute of Medical Research. The impact of climate change on malarial mosquitoes was also discussed at the conference.

Health needs of women and children

World Vision Australia has published a 36-page report Climate Change Threats to Health that highlights the impact of climate change on the health of women and children. The NGO says that: "Climate change poses unprecedented threats to the health and well-being of children through the incidence and spread of diseases, and through growing pressures on the availability and quality of air, food and water." The report goes on to call for urgent action to build climate resilience into existing health programmes to improve the health and nutrition of women and children under five

Loss of biodiversity linked to rise of infections

ScienceNews reports on a study, published in BioScience that is claimed to be the first to demonstrate the link between the loss of species (due to climate change) and the increase in the incidence of certain infectious diseases including: malaria, schistosomiasis Lyme disease and hantavirus.

Changing climate and isotherms shifts diseases to new heights in East African highlands

It is fascinating just how nature has the ability to maintain the stability of natural systems, including climate. Whereas seasons change, the general climate has been fairly stable, with just a few hiccups along the way. On an odd occasion extreme events occur but gradually things get back to normal. Now, however, we may have to redefine what is normal under the regime of climate change. Apart from what the eye can see – for example, melting glaciers or early blossoms – there are other events that are not obvious to the eye, such as relocating isotherms. These are lines that connect areas with the same temperature. Particular animals and plants are constrained to exist within certain isotherms where their physiology has been adapted. A shift in an isotherm will lead to a shift in animal and plant species as new areas become suitable habitats. Unfortunately, the animals that are shifting include arthropods that transmit diseases to humans. One of the effects of climate change is to shift isotherms altitudinally and longitudinally. While scientists continue to debate the impacts of climate change, other species are busy adapting to climate change and this includes colonizing new, warmer habitats. A couple of examples have been observed in the East African highlands. In addition to the melting glaciers of Mount Kilimanjaro and Mount Kenya, malaria and schistosomiasis are shifting to new areas in the highlands. Malaria has now become established in the Central Kenya highlands, where it did not exist prior to 1990. In 1993 the mean annual temperature rose permanently above 18oC, the isotherm that is a barrier to malaria transmission. In the highlands of Western Uganda, intestinal schistosomiasis (Schistosoma mansoni) has been reported at higher altitudes. Earlier records indicate that intestinal schistosomiasis occurred only at altitudes below 1,400 metres above sea level. However, recent data indicate that the disease now occurs at 1,682 metres above sea level. Areas that were historically free of major tropical diseases in East Africa are very likely to become endemic for malaria and schistosomiasis, diseases that cause serious morbidity and mortality at lower altitudes. It is more than likely that other infectious disease will follow suit. Heavy investments are required to control these diseases since prevention is better and probably cheaper than cure. Adapt now! Dr Andrew K Githeko PhD, Climate and Human Health Research Unit, Kenya Medical Research Institute.

Learning to adapt: why we need research on the health impact of climate change

Climate change provokes heated debate. Opinion polls repeatedly show that many people doubt that the world’s climate is changing and, of those who accept reality, many do not believe that the changes are man-made. The lack of public support for efforts to address climate change seems likely to hinder the progress of these efforts. As discussed in a TropIKA.net editorial, governments have focused on the impact of climate change on economies and not on the threat it poses to the health and wellbeing of individuals. Perhaps this is one reason why the public at large has yet to grasp the seriousness of the situation. 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

Short-term temperature variations could influnce malaria risk

The climate change debate has largely focussed on the steady rise in average temperatures. A mathematical modelling study suggests that diurnal temperature variation (the difference between the daytime high and the night-time low) could also be a major factor in determining malaria transmission rates. The findings of the study, published in the Proceedings of the National Academy of Science, indicate that temperature fluctuation reduces the impact of increases in mean temperature. When mean diurnal variation is over 21°C, parasite development is slower than at constant temperatures. Lower levels of variation speed parasite development. The researchers conclude that, "...models which ignore diurnal variation overestimate malaria risk in warmer environments and underestimate risk in cooler environments".

Health threats to Africa's slum dwellers

The health of the growing number of people living in the slum areas of Africa's expanding cities is already of great concern. The residents of these areas face a chronic lack of basic services, including safe water and sanitation and basic health care. Now, warns an editorial in the Bulletin of the World Health Organization, things could get worse. Author Brodie Ramin of the University of Ottawa, Canada points out that, paradoxically, water shortages and severe flooding events are both likely to be features of climate change. Slum dwellers will be at increased risk of malnutrition, diarrhoeal disease and respiratory infections, amongst other health threats. The article concludes with a call for further research to understand the impacts of climate change on the health of slum dwellers and to help design appropriate adaptation policies. Meanwhile, the population of Africa's slum districts continues to rise.

Meningitis and climate

Meningococcal meningitis is one of the biggest infectious killers of poverty in the countries within Africa's 'meningitis belt'. The disease has rarely been considered within the context of climate change. The International Research Institute for Climate and Society, working with the philanthropic arm of Google, has produced an online video "guided tour" discussing the relationship between climate change and meningitis. Epidemics of the disease are now occurring over a wider range, as for example in Ethiopia. The tour is narrated by IRI's Judy Omumbo and lasts about six minutes.

How climate change will hurt Uganda

Africa's media are taking a keen interest in the Copenhagen climate change. See, as an example, an excellent article on AllAfrica.com, which examines the likely impact of climate change on human and animal diseases in Uganda. Author Frederick Womakuyu spoke to experts on health and environment based in Uganda, including WHO representative Joaquim Saweka who said that malaria, cholera, swine flu and hepatitis E were amongst the diseases that could become more common in the country.

Copenhagen conference must help the poor to cope with climate change

The poorest people in the poorest countries will be the most affected by climate change. They are more vulnerable to the increased risks to health, including the likely rise in many of the infectious diseases of poverty. The Least Developed Countries Fund (LDCF) was set up in 2001 under the UN Framework Convention on Climate Change (UNFCCC) to help low-income nations adapt to rising temperatures and other changes in the climate. An article on IRIN News, timed to coincide with today's opening of the UN climate change conference in Copenhagen (COP15), reviews the progress made with LDCF so far. As of May this year, 426 projects had been identified as priorities by the Fund but only one, in Bhutan, had begun to be implemented.

Health must be a priority at climate change conference, says European Parliament

As the climate change conference begins in Copenhagen, the European Parliament has said that “large immediate co-benefits to global health” would result from a binding international framework to reduce emissions of greenhouse gases. The Parliament has also stated that, “due consideration needs to be given to the public health aspects of climate change”. A news article in the BMJ says that activists concerned with the health impact of climate change have been heartened by support from the Parliament. Robin Stott, co-chairman of the Climate and Health Council, which aims to mobilise health professionals worldwide to act against climate change, told the BMJ that health rather than economics should be regarded as the key issue in Copenhagen.

Journal will mark Copenhagen conference with special issue

The International Journal of Public Health is timing a special issue on climate change to be published just after the close of the Copenhagen conference. An editorial describing the contents of the issue is already available online. Epidemiologist Francesco Forastiere of the Regional Health Service, Lazio, Italy, stresses that public health professionals have an important role to play in action against climate change.

Call for action to end malaria drug "stock-outs"

Artemisinin combination therapy (ACT) is the recommended treatment for malaria and its use has been, officially, adopted in most Africa countries. But, as we have often reported on TropIKA.net (e.g. 1, 2) health care facilities, particularly in the rural areas, are frequently out of stock of this much needed treatment. Patients only have access to older ineffective drugs and/or counterfeit products. The increasingly influential journal PLoS Medicine has added its voice to calls for a new wave of malaria activism to raise awareness of the "ACT stock-out crisis". An editorial quotes leading malaria specialist Bob Snow of the KEMRI-Wellcome Trust Research Centre in Nairobi, who says: “We abandoned chloroquine when it failed to cure one in four patients and was available everywhere.We now have a drug that cures 100% of patients but is not available in one in four clinics.” Dr Snow blames the problem on health systems issues including inadequate ordering, distribution and supply. Addressing such issues is a complex matter. The editorial's discussion of how best to proceed represents an important contribution to the debate. An initiative devoted to stock-outs does already exist. Stop Stockouts deals with all essential medicines (not just antimalarials) and its focus is on East and southern Africa.

Navrongo Health Research Centre celebrates 20 years

Ghana's internationally known Navrongo Health Research Centre, situated in the far north of the country reached its 20th anniversary on 30th November 2009. Research at the centre has included studies on many of the infectious diseases of poverty. While originally the focus was on the health problems of the Sahelian ecological belt, the centre's remit has since broadened to include issues of national and international significance. Infectious diseases currently under study at Navrongo include malaria, schistosomiasis and meningitis. For a report on the birthday celebrations see Peace FM Online. TropIKA.net wishes the Navrongo centre many happy returns!

Reporting the debate – Testing the tests

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

Making the link between neglected infections and maternal health

Neglected infections are a major disease burden for people in the world's poorest countries. Maternal morbidity and mortality and other reproductive health issues are also of great concern in the same communities. It is customary to think of the two problems as being entirely separate but the indefatigable Peter Hotez - Editor of PLoS Neglected Tropical Diseases and President of the Sabin Vaccine Institute - makes a persuasive case that controlling neglected tropical diseases (NTDs) in developing countries would help improve the reproductive health and rights of girls and women. In a PLoS NTDs editorial, Professor Hotez points out that an estimated 20% of maternal deaths in Africa are attributed to anaemia, which is also a key risk factor for infant mortality and low birth weight. Schistosomiasis is an important contributor to anaemia and infertility, and likely contributes to increased maternal morbidity and low birth weight. Human hookworm infection, one of the most common NTDs, adds significantly to iron loss and anaemia in pregnancy, and also contributes to infertility. An estimated 44 million pregnant women are infected with hookworm at any one time. Some NTDs are sexually transmitted and others promote susceptibility to sexually-transmitted infections. Female genital schistosomiasis has been identified as an important co-factor in HIV transmission in rural areas of Africa. And the stigma of many NTDs carries social and economic consequences; many women are ostracised and sometimes prevented from seeking medical attention due to their disfigurations. Hotez concludes that, "because of the dramatic impact of NTDs on the health of women, especially girls and women in their child-bearing years, it is critically important that these populations are included in current and proposed large-scale interventions for NTDs," and calls for specific actions to help control and eliminate NTDs and improve the health of women.

"How did the leading killers end up at the bottom of the global health agenda?"

Speaking at a meeting in Hanoi of the GAVI Alliance, John Wecker, of the Program for Appropriate Technology in Health said, "How did the leading killers end up at the bottom of the global health agenda? I don't know". The GAVI Alliance aims to save children’s lives and protect people’s health by increasing access to immunisation in poor countries. At its recent meeting, according to Associated Press, much of the discussion focussed on pneumonia and diarrhoea and their near eclipse from the health agenda, which has been a consequence of the global emphasis on HIV/AIDS. Pneumonia and diarrhoea together claim some 3.5 million children's lives annually. Vaccines are now available for pneumococcal and HiB infections (the cause of most childhood pneumonia) and for rotavirus (which is the biggest cause of diarrhoeal deaths). The Alliance wants to see the vaccines made available to those who most need them. See recent TropIKA.net articles on pneumonia and diarrhoea.

Malaria researchers "losing their way"

A Dutch malariologist, Bart Knols, has accused his fellow researchers of being more interested in subsidies and getting articles in prestigious journals than in solving the problem of malaria. Dr Knols told Radio Netherlands Worldwide that too much research is now focussed on genomics and not enough on improving mosquito control. In his view: "... you turn a gene on or off in the malarial parasite and then you observe what happens to it: that’s ‘hot science’. Then, you’ll maybe get data that you can publish in Nature or Science. This, in turn, gets you your next research grant. It’s turned malaria research into a kind of industry". He points out that mosquitoes are expanding their range and, "If we’re not prepared to do everything in our power, including the use of computer technology, GPS systems, four-wheel drive trucks, and lots of money… the mosquito [will win], without a doubt." What do TropIKA.net readers think of Dr Knols' views? Use our Leave a Reply facility below to share your opinions.

Could dog fleas transmit leishmaniasis?

The parasite that causes leishmaniasis is in most cases transmitted by the bite of the sandfly. However, in Brazil - where the disease is becoming more common - sandflies show low rates of infection with the parasite. Does this mean that other disease vectors are responsible? Dogs are known to be a reservoir of the infection and researchers at Paulista State University suggest that dog fleas may be implicated in leishmaniasis transmission. In a study - published in Veterinary Parasitology and discussed on SciDev.Net - they took fleas from 22 leishamania-infected dogs and injected samples of the fleas into 22 hamsters. This led to the development of infection in four or six (depending on the test method used) of the hamsters. This is a small study and it has not established whether the fleas pass on the parasite between dogs. It does not yet provide any indication of whether the dog fleas then pass transmit the disease to humans. But it indicates that this possibility should be investigated further.

Yaws outbreak suspected in the Philippines

Health authorities in the Philippines report high rates of an infection, which could either be syphilis or the serious skin disease yaws, amongst women fleeing civil conflict on the island of Mindanao - see IRIN News. Further tests will, however, be needed to determine the precise identity of the infection. Médecins Sans Frontières (MSF), which is working in the conflict zone, says a quarter of women undergoing antenatal and post-natal care have tested positive for treponematosis. This group of infections includes both syphilis and other non-sexually transmitted diseases such as yaws. Provincial health officer Elizabeth Samama said the women could have yaws as it is known to exist in the area. Given that yaws most commonly infects children, it does seem likely that most of these women are infected with syphilis. Nevertheless, MSF has stressed the importance of further testing. Yaws can progress to cause major damage to bone and cartilage and is known to be re-emerging in poor, rural and marginalised populations in Africa, Asia and South America.

Biggest ever yellow fever vaccination effort

Which are the most important infectious diseases of poverty? The answer depends on which poor people, in which countries. For many of the world's poorest countries yellow fever is not a threat but, in 44 endemic countries with a combined population of 897 million, this disease remains a significant concern. Thirty-two of the endemic countries (population 508 million) are in Africa; the others are in Latin America, with Bolivia, Brazil, Colombia, Ecuador and Peru at greatest risk. In total there are an estimated 200 000 cases of yellow fever (causing 30,000 deaths) each year. While there is no specific treatment for yellow fever, a safe effective and affordable vaccine has been available for over 50 years. A single dose provides protection for 30–35 years or more, and probably for life. Tragically, many people in endemic countries have still not been vaccinated and the disease is now reappearing in countries that have not reported cases for many years. The World Health Organization - in collaboration with UNICEF, national Red Cross and Red Crescent Societies, Médecins sans Frontières and other partners - is this week conducting the largest-ever yellow fever mass vaccination campaign, targeting 11.9 million people across Benin, Liberia and Sierra Leone. The aim is not to eliminate yellow fever - there are too many infected Aedes mosquitoes in urban areas to make that possible - but to greatly reduce the number of people getting sick with the disease. The plan is to complete mass vaccinations in all high-risk African countries by 2015, but WHO warns there is currently a gap in the funding needed to fulfil this goal. For further information see WHO press release and BBC News report.

Portuguese-speaking health community will benefit from new email forum

It is increasingly apparent that, while the internet has given a huge boost to efforts to exchange health news and information around the world, most of the information sources available are still in just one language - English. There are some encouraging programmes in operation to improve the situation. For example, BIREME exists to "contribute to the development of the health in the countries of the Latin America and the Caribbean by the promotion of the use of the scientific and technical health information". More, however, needs to be done and it is very pleasing to note the launch of a new initiative for Portuguese speakers by HIFA2015. HIFA2015 is a global campaign with the goal that "By 2015, every person worldwide will have access to an informed healthcare provider". The HIFA2015 Email Forum is the main communication tool to bring all HIFA2015 members together. Staff at the World Health Organization and elsewhere have emphasised to HIFA2015 the need for parallel HIFA2015 forums in different languages, with linkages between them. As a result, HIFA-pt was launched last week at a meeting in Maputo, Mozambique. The focus of HIFA-pt is on the 240 million people who live in the eight Portuguese-speaking countries: Angola, Brazil, Cape Verde, Guinea Bissau, Mozambique, Portugal, Sao Tome e Principe, and Timor Leste. Within days of its launch, over 350 people have joined. For more information and how to join, see www.hifa2015.org/hifa-pt. For information HIFA2015 and its other activities (including the CHILD2015 email forum) see http://www.hifa2015.org/about/.

A biotechnology platform for South Africa: an interview with Anthony Mbewu

An interview with Anthony Mbewu, President of the Medical Research Council, South Africa and next Executive Director of the Global Forum for Health Research Q: South Africa is currently considering acquisition of a high-throughput screening (HTS) facility that would allow it scale up the screening of natural compounds. At this stage in the development of its biotechnology platform, do you think an investment in HTS is appropriate? A: I think there is a role for HTS along with other sorts of high-tech technology. What we have done in South Africa in terms of looking for the molecules is to take the approach of looking at natural compounds. The mistake we made in the past was we said, Well there are 2,000 plants that are unique to South Africa; we put them all through HTS and we found nothing. Now, you know, it really doesn’t work that way. So since 1997, South Africa has followed a twin track: one, the classical drug discovery route of taking a plant, getting alcohol and water extracts, putting it through HLPC and trying to find the compounds. But then also having a parallel approach of saying let’s look at the medical folklore, African traditional medicine, where these plants have been used for centuries, often in combination. And let’s get clues from that. For instance, the clue for one antimalarial that we have characterized came from a plant that was used as an antipiretic. And so we guessed that if this was used as an antipiretic in Kwa Zulu Natal, where malaria was once endemic, perhaps it’s an antimalarial. And behold, we were able to extract three molecules from the plant, and characterize them by NMR. And of course the problem now is how to commercialize them, because we don’t have the funds. The venture capital is not there. The other thing we realized was that perhaps when these drugs are used in combination, they act more as biologic drugs than chemical entities that follow the ‘Lipinski Rule of 5. ‘And indeed, we found for instance in plants used by traditional healers compounds that are active against mycobacterium tuberculosis, but when you try and extract them and isolate them they fall apart. They’re large molecules, they don’t obey Lipinski’s rules, how they work we don’t know. But clearly studying them is a whole new discipline. Q: Cuba has been very successful in developing a biopharmaceutical industry despite limited resources. Has it served as a model for South Africa? A: Yes, President Mbeki sent me as part of a delegation back in 1998. The question was if Cuba could do this in ten years, why can’t South Africa? Well, one problem is venture capital. I’m a trustee of the only biotech venture capital fund in South Africa, Bioventures. We’ve had a successful first round. But there isn’t money for a second round. And then the most important single factor is human resources. We don’t have an educated population, we don’t have the PhDs and post docs that you need for a national biotech industry. Q:There are some innovative approaches to drug development taking place in South Africa. One of them is iThemba Pharmaceuticals, a biotech startup with a high-volume, low-margins approach to developing and commercializing new treatments. Without venture capital, can iThemba or any such effort ever be successful? A: I think it depends on where you are along the value chain. You need VC at some point because although you can do preclinical Phase I and II without major funding, when you get to Phase III it can be very expensive. It costs between $100 and $500 million in the West. In South Africa, we could probably do Phase III clinical trials for about $50 million. So it’s cheaper, but it’s still hugely expensive, and you have to have venture capital to pay for it. Q: Without HTS, South Africa must rely on pharma to screen its natural compounds, the therapeutic potential of which is unknown. Does this pose a risk to the country’s intellectual property? Yes, but the South African government has passed legislation with regard to IP rights. So the latest act stipulates that if the R&D has been done in South Africa, the IP can not be sold overseas. One thing that has done is force pharma to forge collaborations with South African R&D institutions, so rather than simply taking the compound back to a lab in New Jersey, they have to work with a company like iThemba Labs and take the molecule to the market together.

Artemisinin resistance has spread to China, Myanmar and Vietnam

The greatest threat to efforts to improve the control of malaria, with the longer term aim of disease elimination, is the appearance of resistance to the treatment drug artemisinin. The first reports of resistance, confirmed in a study published in August, came from the Thailand-Cambodia border. But the Malaria Consortium says that signs of resistance have also been noted in China, Myanmar and Vietnam. As the Consortium explains: "The proportion of patients who still carry malaria parasites on the third day of treatment is currently the best measure available of slow parasite clearance and can be used as a warning system for confirmation of artemisinin resistance. Currently, the alert point for resistance is at 10% of patients retaining the parasite after day three. Levels of day three positives in Myanmar with ACT treatment, and China and Vietnam with artesunate treatment range from 12-31% in recent studies". The Consortium also reminds us that the biggest fear is that resistance will spread to Africa, which is where most of the world's malaria cases and deaths occur.

Mexican researchers working against neglected infections

A fascinating account of research on leishmaniasis and Chagas disease has been published on the website of Mexico's Universidad Autonoma de Nuevo Leon (UANL). The focus of medical entomologist Doctor Eduardo A. Rebollar Tellez and his colleagues is on the insect vectors of leishmaniasis and Chagas disease. Both of these kinetoplastid diseaseses are present in Mexico. The work of Dr Tellez is part of an inter-disciplinary project, “Complex ecological networks: applications to the emerging diseases and biodiversity”. The UANL article may be accessed here.

Podcasts from Nairobi

The London School of Hygiene & Tropical Medicine has made available a series of podcasts from the MIM conference. They may be accessed on the School's Audio News site. The podcasts include the following. Professor Brian Greenwood discusses the presentation he gave to the conference, in which he explained that combined prophylactic and therapeutic use of malarial drugs can play an important part in programmes to control the disease. Epidemiologist Diadier Diallo, co-ordinator of a trial of intermittent preventive treatment (IPT) for children in Burkina Faso and Mali, discusses what has been learned from this project. In another podcast, Dr Harry Tagbor describes his IPT work in Ghana. Geoffrey Targett Professor of Parasitology says the prospects for malaria elimination are good in many regions. There is also an interview with Bianca D'Souza, Manager of the ACT Consortium. Other interviews focussing on the Consortium involve Ugandan Health Ministry Commissioner Dr Anthony Mbonye and - from the School - Professor David Schellenberg and Dr Harparkash Kaur.

Joining up GIS with health information systems

Integrating different knowledge systems has been a recurring theme at this conference. In a session yesterday on climate change and health equity, Dziedzom de Souza of the Noguchi Memorial Institute for Medical Research in Ghana offered up an intriguing idea to make the most of data gathered via geographical information systems (GIS). De Souza wants to see GIS data integrated into health information systems. This seems obvious, but many countries don’t do this. Countries like the USA are top of the list in using such data when looking at how climate change affects the health of the poor, but regions like West Africa are barely using GIS data in this way at all. Why does this matter? 80% of health data is intricately linked to geography, de Souza said. This has implications for health generally, but especially when we look at how climate change affects disease. For example, tropical diseases vary with climate variations in terms of their intensity and spread. Climate change is also altering the geographical spread of vector-borne diseases. Countries in West Africa, for instance, will much more vulnerable to these shifts in disease patterns than the USA. None of this has to cost poor countries a lot of money. There is a wealth of free GIS data available in WHO’s Health Mapper and Google Earth, for example. Developing countries will need all the data they can get to fight climate change. It’s time they start making use of these tools.

What will happen to primary care in Cuba when the U.S. embargo comes down?

Speaking in Thursday’s plenary session, the author Laurie Garrett raised the point that when the U.S. embargo comes down—“and it will during the Obama administration”—Cuba’s primary health care system will be threatened as never before. “Hundreds of U.S. and Canadian health care providers are going to swoop down to grab up Cuba’s doctors,” she said. Garrett also said that in addition to poaching Cuban doctors, U.S. medical tourism to Cuba could siphon medical talent from the country’s primary health care system and into cosmetic surgery. We welcome your comments…

Are brain drains essentially unfair trade?

In Thursday’s plenary session, Dr David Samuels of the University of the Western Cape argued that poor countries’ loss of human resources to richer ones should be compensated by the latter. “More than 60 percent of health systems spending is on human resources, and in Africa the ratios are just abominable,” Samuels said. “We’re losing human resources in the brain drain, and it amounts to unfair trade. People shouldn’t be restricted from moving, but the countries that receive the professionals should reimburse the sending countries.” Samuels added that while capacity building is imperative to stem this loss, “you can’t do that in the long run without rebuilding the training institutions.” Over the past couple of decades, African training institutions have suffered from ill-informed policies and economic crises. “For instance, the World Bank, 15 or so years ago, said that countries should not invest in tertiary education, only in primary. And actually we need investment in both. Right now, we don’t have the basis to actually build capacity. So all this talk of money going into capacity building, we’re not seeing it in African universities.” One reason for that, he said, is that much of the money spent on capacity building is absorbed by the actors conducting the transaction. “PEPFAR claims to be spending $3 billion on capacity building, but how much of that is going to U.S. contractors, who come to Africa to run short training courses and then leave? That money should go directly to the African institutions. We can have partnerships with U.S. contractors, but as it is, the great majority of that money returns to the U.S.” We welcome your comments…

Digital health care in rural India—the costs and benefits of broadband

What if a patient in rural Gujarat could see a doctor in downtown New Delhi without waiting in line? Without leaving her village? And what if it only cost her $1.00? According to Al Hammond, Senior Entrepreneur in Residence at Ashoka, that isn’t just the future of health care distribution in remote rural areas. It’s the present. “These things are beginning to be put on the ground right now in rural India,” he said in a plenary session speech on Wednesday. “And they’re all driven by social entrepreneurs.” Hammond was talking about telemedicine—new technology capable of linking medical professionals with patients in areas plagued by chronic shortages of health care personnel. “It’s not widely understood that within 5 years rural broadband will be available practically everywhere there is cell phone coverage,” he said. “That will allow for video links between a doctor and a patient.” It would also allow for so-called telepharmacy, a potential solution to the lack of licensed pharmacists and the abundance of counterfeit drugs in many rural areas. “Machines that dispense pills in an automated fashion already exist in many developed world hospitals,” said Hammond. “They’re called ‘Med Stations.’ We need to develop the Internet controlled rural version of these devices that can reliably dispense medicines under the control of the pharmacist from any urban center.” It’s just the kind of cutting-edge technology that many people associate with the word innovation, a flick-of-the-switch gadget that promises to sweep away the problems of the past. But is it the right innovation for the rural poor? Claudio Schuftan of the People’s Health Movement in Vietnam doesn’t thinks so. “I want to congratulate Mr. Hammond for bringing high tech equipment to rural areas where there is no electricity, and no way to repair the equipment that has broken down,” he said. “And last but not least for creating a system of dependency in an environment where most of us sitting in this room are trying to resolve the problems of health distribution from a completely different angle.” Hammond replied that Ashoka is aware of the hostility from some quarters to private sector approaches. “But we want to emphasize that this work is being carried out by social enterprises, which have been launched by NGOs. It uses market techniques, because that’s how you get efficiency in the distribution system.” Ashoka has carefully surveyed the families participating in the pilot study, Hammond added, “and they like the service. They think it treats them better than the other services available to them, and they consider it very affordable.” Perhaps more important, he said, was the fact that, on the basis of the pilot study to date, the Indian government has requested 600 additional units. No innovation is a panacea. But if telemedicine is truly able to bridge the urban-rural divide, it would address an issue at the heart of health care in the developing world. Should it be implemented? Is it sustainable? And who should decide? We invite your comments…

Toilets to tackle trachoma

Tomorrow (19 Nov) is another Day - this time it is World Toilet Day*. One organisation that will be marking the event is the Canadian charity Operation Eyesight. Inadequate sanitation is responsible for many diseases but it is seldom linked with trachoma - the world's biggest infectious cause of blindness. Operation Eyesight says in a news release that it has funded a study (no details provided) in Zambia which found that trachoma was 28% more likely to occur in households without proper toilet facilities. The study, which covered five districts in, found that up to 80 per cent of the households surveyed did not have toilets. Since trachoma is spread by flies and flies feed on human waste, the finding is perhaps not surprising but the provision of toilets has not been regarded as a key part of trachoma prevention efforts. Operation Eyesight says, however, that toilets will play an important role in its work in both Zambia and Kenya, where it is also active. --------- *World Toilet Day is organised by the World Toilet Organization, a global non-profit organization committed to improving toilet and sanitation conditions worldwide. Based in Singapore, it is one of the few organizations to focus on toilets instead of water, which receives more attention and resources under the common subject of sanitation. Founded in 2001 with 15 members, it now has 215 member organizations in 57 countries working towards delivering sustainable sanitation.

Scientific American publishes malaria update

The journal Scientific American has published a short article on malaria research that includes an interesting slide show examining some of the new tools being developed for control of the disease. The article also links to a video presentation shown during a recent conference held at the Johns Hopkins Malaria Research Institute (JHMRI). The article may be accessed here.

Affordable antimalarials may help hold back spread of fake products

Arguably the greatest threat to international efforts to improve malaria control, with elimination of the disease as the ultimate goal, is the appearance of resistance to the recommended treatment drug - artemisinin. As with earlier antimalarials, resistance has first appeared in Southeast Asia. Initial reports of resistant strains of the parasite in the border regions of Cambodia and Thailand in 2008 were confirmed in a research article published in August this year. Whilst it is not yet fully understood why resistance is most likely to develop in this part of the world, the ready availability of fake and substandard drugs is undoubtedly a factor. Of particular concern is the number of drugs on sale which contain low doses of artemisinin as monotherapy; the World Health Organization and other authorities say that artemisinin must only be used if combined with one of the older antimalarials, as combination therapy delays the development of resistance. People buy substandard and fake drugs because they are cheap and easy to obtain. It is therefore excellent news that, according to media reports, distribution of an affordable artemisinin combination therapy has now begun in Cambodia - see UPI report. The drug is available for around 5 US cents per dose. "No one will want to sell counterfeits when the real doses are 5 cents," says Duong Socheat, director of Cambodia's National Malaria Centre. The distribution of the drugs at this cost has been made possible as a result of the Affordable Medicines for Facility - malaria (AMFm). The Facility also plans to provide similar support to Benin, Ghana, Kenya, Madagascar, Niger, Nigeria, Rwanda, Senegal, Tanzania and Uganda.

Dengue concerns rise across the tropical world

Public alarm over rising case numbers of dengue fever is evident in newspaper reports from cities throughout the tropical world. In addition to Asia and Latin America, where dengue epidemics are now commonplace during the rainy season, Africa and Australia are also affected. As reported in TropIKA.net News, the biggest ever dengue epidemic in West Africa has afflicted thousands in the island nation of Cape Verde, including the prime minister. The nearest point on the African mainland is the Senegalese capital, Dakar, where there are now 55 reported cases. A national campaign against the disease is apparently at the planning stage. Queensland in northern Australia experienced its biggest dengue outbreak in 50 years earlier in 2009. Officials are said to be surprised that, so early in the rainy season and only three months after the earlier epidemic ended, new cases are already being reported. India's capital Delhi is more used to dengue epidemics but this year's case numbers - already approaching 1000 - are causing alarm. Many patients have been hospitalised and some require blood transfusion. Reports say that blood supplies are running low. There have been confirmed reports from several countries (including Barbados and Vietnam) of patients with both dengue fever and H1N1 ("swine") flu. The implications of such coinfection are not yet clear.

Virtual participation

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

Lectures on global health available on line

A series of lectures, prepared for US nurses but of great interest to others involved in global health matters, is available free online from Online Nursing Programs.net. Topics include: epidemiology, malariology and hepatitis.

Re-tooling the malaria kit for elimination in the long term

Dr Roma Chilengi, head of clinical trials at the KEMRI/Wellcome Trust Research Programme in Kilifi, Kenya discusses the way forward for malaria elimination Elimination means reducing to zero the incidence of a specified disease in a defined geographical area as a result of deliberate efforts. For malaria, this means a situation where incidence of the disease is reduced to zero in a given area, and this should be demonstrable by sensitive diagnostic tests. The accepted definition of elimination is however a sobering reality for the bulk of sub-Saharan Africa. The depth from which certain places have to be lifted is daunting, as they are still way behind in malaria "control" benchmarks. Unfortunately, the health systems infrastructure, which is critical to achievement of malaria elimination, is very poor or non-existent in most places. Since the problem of malaria also does not follow political borders, variation in the burden and transmission intensity cuts across national boundaries. For example, the malaria burden within Kenya varies, such that the problem is declining on the coast while it is still a substantial problem in the western parts. Therefore, to attain elimination, health systems need to be sufficiently capable of establishing the correct burden, identifying proper interventions, deploying them, and monitoring and evaluating the process. This is why many may be pessimistic about malaria elimination as a target, believing it to be way beyond the reach of some places. Some countries will realise elimination, while others may not be able to do so within the foreseeable future, given the currently available tools. There is therefore a great need to sharpen and develop new tools altogether to help in the fight against malaria. A malaria vaccine offers a great hope of achieving significantly improved malaria control, particularly in Africa, where the ecological habitat is such that effective mosquito control has proved difficult or impossible to maintain. The success of other vaccination campaigns within Africa demonstrate that the control of major infectious diseases is achievable on a global scale: smallpox has been eradicated as a result of vaccination, polio seems close to being eliminated, and measles is virtually under control in many African countries.

Towards equality in health: the role of research

Inequalities in health are vast and closing the gaps between nations, socioeconomic groups and individuals has long been seen as a priority. What is the role of research in helping to make this possible? In 2004, the World Health Organization (WHO) established a Task Force on Research Priorities for Equity in Health to provide expert advice on research priorities to take forward the health equity policy agenda. The recommendations of the task force contributed to the report of the Commission on Social Determinants of Health (CSDH), published last year. (The report was featured on TropIKA.net.) Since the publication of the CSDH, WHO has commissioned a group of 14 researchers to update the earlier recommendations. The group recently released a discussion paper: Priorities for research on equity and health: Implications for global and national priority setting and the role of WHO to take the health equity research agenda forward. According to the paper: “The bulk of global health research has focused on biological disciplines, to develop medical solutions, to be provided through clinical, individual patient care. The past two decades have witnessed a rise in a new public health paradigm, enlarging disciplinary perspectives, stakeholder analysis, and recognition that health systems can be designed more effectively through new knowledge. This paradigm shift represents a second wave of global health research. With the 10/90 gap embraced by many organisations as an objective to be reversed and the CSDH's report widely distributed, among other contemporary efforts, this paper argues that we are on the cusp of a third wave in global health research, one that explicitly links broader social, political and economic determinants with improvements in equity in health, within and across countries.” The themes examined in the paper are highly relevant to the infectious diseases of poverty (IDPs). The majority of the research featured on TropIKA.net does indeed focus on medical solutions! However, we welcome contributions from other disciplines and we urge our readers to alert us to the publication of non-medical papers that they consider to be relevant to the IDPs.

Malaria Week for southern Africa

The nations belonging to the Southern African Development Community (SADC) have set themselves the goal of eliminating malaria from the region by 2015. To focus attention on the disease and on elimination efforts, next week (beginning 16th November) will be Malaria Week in the region. Events are planned in all the SADC countries and health ministers will be meeting in Limpopo, South Africa to discuss what now needs to be done to reach the elimination goal. Are you involved in Malaria Week? Let TropIKA.net readers know about the activities in which you are participating. Contact us using the 'Leave a Reply' feature below.

Highlighting public-private partnerships

Chemical & Engineering News may not sound like a publication where one would expect to find an article describing the phenomenon of public-private partnerships (PPPs) in the development of new technologies to address the infectious diseases of poverty. But the latest issue of C&EN does have, as its cover story, a very comprehensive article on this important topic. As author Lisa Jarvis rightly says, a decade ago the private sector had almost entirely abandoned research efforts on diseases like malaria, tuberculosis and the neglected tropical diseases. The advent of PPPs - "conceived of as a way to address the gulf between drug need and availability by bringing together resources across the public, private, and philanthropic sectors" - has brought industry back into the picture. Between 2000 and 2004, PPPs spent $112 million to develop a combined 46 drug projects. The article describes projects including the Novartis Institute for Tropical Diseases, the TB Alliance and the recently launched MSD Wellcome Trust Hilleman Laboratories. It also includes interviews with some of the key people involved in these initiatives. The article is highly recommended and may be accessed in full here.

Filariasis: where did the day go?

TropIKA.net constantly scours the news media for reports on the infectious diseases of poverty. We have come across several passing references, all of them in Indian newspapers, to "World Filariasis Day". Apparently this was to be held yesterday - 11th November. But we can find no further references to the existence of World Filariasis Day. TropIKA.net readers who have heard something about it are asked to let us know. The TropIKA.net blog has often commented on the rapidly growing number of special "Days" held in an attempt to focus attention on particular diseases. (The most recent was World Pneumonia Day - 2nd Nov.) It could be argued that there are already more than enough such Days. But lymphatic filariasis (and onchocerciasis, which is also caused by filarial worms) are severely neglected diseases. Would a World Filariasis Day help to bring an end to this neglect?

TB remains South Africa's greatest killer

Newly published statistics from South Africa confirm that tuberculosis is the country's biggest cause of death. The Statistics SA organisation said, "Other diseases that appeared as leading were influenza and pneumonia; intestinal infectious diseases; other diseases of the respiratory system; ischaemic heart diseases; and HIV disease." Within some provinces pneumonia and influenza accounted for more fatalities than TB. HIV disease is South Africa's ninth largest cause of death. Overall death rates in South Africa have showed a small decline, this fall being greatest in the 1-4 age group and among adult women. A summary of the new statistics may be found on Health24.

Local intiatives for TB treatment: proof of concept

This year's Canadian Conference on International Health heard an update on progress with the FIDELIS project (Fund for Innovative DOTS [Directly Observed Treatment, Short-course] Expansion Through Local Initiatives to Stop TB. A report in the Canadian Medical Association Journal sums up a presentation by Dr I D Rusen, director of the Tuberculosis Control and Prevention Department of the International Union Against Tuberculosis and Lung Disease. He told the meeting that FIDELIS had so far funded 51 projects in 18 countries, mostly in regions with the highest burden of tuberculosis. The projects range from training school children in China how to detect possible tuberculosis cases in their families, to creating a radio call-in show in Pakistan for tuberculosis patients to explain how they were diagnosed and treated. So far, the projects have resulted in the detection of 272,216 new cases of tuberculosis. Interestingly, most of the projects have been funded as short-term "proof-of-concept" initiatives. These are popular with funding agencies who need to feel confident that a project is going to work before committing longer term support. An article describing the launch of FIDELIS was published in 2006 in the American Journal of Public Health.

BBC's dengue reports

The BBC website has a short video report on dengue fever featuring images of insecticide spraying in Jakarta and brief expert comment. The report focuses on the role of climate change in the increase of dengue case numbers. There is no discussion of the role played by the increasing number of people living in poor quality urban environments. A BBC video report from Manilla a few weeks ago did mention this issue and also the growth of international travel.

The genetic basis of mosquito resistance to malaria

The ability of Anopheles gambiae mosquitoes to transmit malaria parasites is highly variable and mosquito strains have been found that are entirely resistant to the parasite. The mosquitoes' immune response to malaria is of more than academic interest; it could offer possibilities for cutting the risk of transmission from mosquito to human. Researchers of the European Molecular Biology Laboratory (EMBL) in Germany and INSERM in France set out to identify the genes that control A. gambiae's resistance to the rodent malaria parasite Plasmodium berghei. Their results, published in Science, show that that variations in a single gene explain a substantial part of the variability in parasite killing. Confirmation is needed that resistance to P. falciparum and other parasite species that attack humans is similarly determined. Nevertheless, this could be an important advance. As the researchers say, "Understanding the genetic basis of resistance to malaria parasites, as well as how the determinant polymorphisms are maintained and selected in field populations, will be of tremendous importance for the control of malaria transmission". They also state that the methods they developed to conduct this research could also be useful in moving from a whole region of DNA to an actual causative gene. While Science is not an open access publication, the PubMed abstract and commentaries from EurekAlert and GenomeWeb provide further information about the research.

An interesting proposal: a "global health accelerator" to support biotechnology industries in the South

There are now, in some developing countries, a growing number of health biotechnology firms, seeking to develop and sell vaccines, diagnostics, and therapeutics for local markets. These companies of the South could play a crucial part in the development of new technologies to be used in the control of the infectious diseases of poverty. The authors of a recent article say they have identified a pipeline of 62 NTD [neglected tropical disease] products from 78 such companies. They go on to propose creation of "... a Global Health Accelerator—a new nonprofit organization whose mission would be to support and help grow this Southern source of affordable innovation for NTDs". Strangely, the authors have chosen to publish this article in a publication, Health Affairs, that is not open access. None of the sources we use at TropIKA.net allows us to read the full article and we are thus unable to comment more fully on this interesting proposal. The abstract may be accessed here. Also of interest in the same issue (Nov/Dec 2009; Vol 28, No 6) of the journal, for those who can see it, there are a number of other articles on the infectious diseases of poverty. The contents list may be viewed here.

Miners and TB: now is the time for South Africa to act

Not only poverty but also specific occupations can raise the risk of infectious disease. As long ago as 1903 it was first recognised in South Africa that miners were more likely to develop tuberculosis than other people in the country. The same has been noted in other countries and it is believed that damage to the lungs through the inhalation of silica dust makes it easier for the infection to develop. But South Africa's miners now experience such very high levels of TB infection - around 7,000 cases per 100,000, ten times that of the rest of the population and very much higher than that found in miners in developed countries - that silica dust cannot be the only risk factor involved. Living and working conditions are also a cause for concern. Mine shafts are crowded and poorly-ventilated, and so are hostels where over a dozen men can share a small room. These conditions are highly conducive to the spread of infection. The issue is discussed in a "Debate" article in the journal Globalization and Health. The authors state that, "The problem is not simply one of differential occupational hazards, but of the social context for transmission and the interaction between miners and the rest of the population". The article goes on to discuss the measures that can be taken to reduce miners' TB risks, noting that - as South Africa's mining industry is currently experiencing a boom - this is the time for such measures to be introduced.

Factors in transmission-blocking malaria vaccines

Ashley Birkett, director of pre-clinical development at the PATH Malaria Vaccine Initiative discusses their strategy towards new vaccine development . We’re eager at MVI to build on the progress that we’ve achieved with RTS,S. Even as we look forward to taking this first vaccine candidate through a large Phase 3 clinical trial with GlaxoSmithKline Biologicals and African scientists, we’re also moving ahead with a strategy for developing a next-generation vaccine that includes candidates that can block transmission of the parasite. A key part of our strategy is to build on current progress. RTS,S, which is a pre-erythrocytic candidate that aims to protect against the early stage of Plasmodium falciparum malaria infection, was found to be 53 percent effective against clinical disease in Phase 2 trials. As we test this candidate in phase 3 trials at 11 sites in seven African countries, we’re already working on approaches that should help us to achieve the 2025 goal of a product that is at least 80 percent effective against clinical malaria for at least four years. How do we plan to do this? Our approach involves a number of aspects. Our focus on pre-erythrocytic vaccine candidates—those that target the parasite on its journey to the liver or while it matures in an infected person’s liver cells—will continue. However, we plan to target other stages of the parasite’s development as well.  In addition to widening our focus to include transmission-blocking vaccines and other approaches, we’re also pursuing candidates that target the less deadly but more widespread P. vivax malaria. These steps to further diversify our portfolio of vaccine candidates are helping to set the stage for the malaria community’s push to control malaria and to eliminate the disease in the long term. Transmission-blocking vaccine candidates typically seek to interrupt the life cycle of the parasite by inducing antibodies that prevent the parasite from maturing in the mosquito after being taken up during a blood meal from a vaccinated person. Further, MVI has had an increasing interest in multi-stage, multi-antigen vaccines. We believe that a highly effective pre-erythrocytic, transmission-blocking vaccine that could block the parasite’s lifecycle, to reduce transmission in endemic areas, as well as provide protection from clinical disease would be a key tool in the global effort to beat back the disease.

MRI scans could advance understanding of cerebral malaria

Cerebral malaria, where the parasite breaches the blood-brain barrier and damages the central nervous system, is a life-threatening condition. Many studies have also established that children who survive cerebral malaria are left with persistent problems with memory, attention and other cognitive skills. The nature of the damage inflicted on the brain by cerebral malaria is not clear but US scientists aim to improve understanding of the problem with the use of magnetic resonance imaging (MRI) scans. They have already begun their project in Thailand. MRI scans are of course an extremely expensive technology but there are now some machines available in malaria-endemic areas. In an interview with SciDev.Net Gary Brittenham from Columbia University says that MRI research could transform understanding of cerebral malaria and lead to new therapies. He notes, however, that adapting MRI scanners to conduct malaria research in the field would present "an array of technical and logistic challenges".

Death of TB treatment pioneer

Sir John Crofton, recognised as a leading pioneer in the treatment of tuberculosis has died aged 97. He first came to international prominence in 1948 with a paper reporting a trial of the use of streptomycin with TB patients (1). This study is now regarded as a major contribution in the development of clinical trial methods, as well as being a key advance in TB treatment. He went on to develop the "Edinburgh method" involving the combination of three drugs to cure TB. The method still forms the mainstay of TB treatment half a century later. This reflects the relative lack of research into the disease during most of that period. Thankfully, the last few years have seen an end to the neglect of TB research. An obituary of Sir John has been published in the Independent newspaper. Reference 1. Medical Research Council (1948). Streptomycin treatment of pulmonary tuberculosis. Br Med J; 2(4582):769-782.

The wallpaper that prevents malaria

Insecticide-treated bednets (ITNs) and indoor residual spraying (IRS) are the currently recommended methods of reducing the risk of being bitten by malarial mosquitoes. IRS, which normally involves the use of DDT, has been controversial. A new approach, tested in a study in Benin, may prove more acceptable - insecticide-treated "wallpaper". When experimental huts were wallpapered with plastic sheeting treated with carbamate insecticide, all mosquitoes died and none took a blood meal. Even when only the top third of walls was covered by the sheeting, which would prevent contact with children, 80%t of mosquitoes were killed. The researchers say that retreatment of the sheeting would only be needed every two years. An article about the research, which was formally published in Malaria Journal, can be found on SciDev.net.

Eradication - is the ‘e’ word really too risky to contemplate?

Eradication was on everybody’s lips yesterday, though not everyone agrees on how to move forward with this enormous challenge. Some, like the Malaria Eradication Agenda’s (malERA) Pedro Alonso believe we must look beyond the short-term goal of control and shift our focus to eradication (see TropIKA’s Q&A with Pedro Alonso on this topic). Alonso also has the backing of several key players in malaria: Fred Binka of the INDEPTH –Network/MCTA, Ghana; Brian Greenwood at the London School of Hygiene and Tropical Medicine, UK; and Marcel Tanner of the Swiss Tropical Institute, Switzerland, to name a few. Alonso and others are rightly worried about repeating the mistakes of the past, when over-optimism and complacency led to a subsequent massive resurgence of the disease. Those fighting against malaria, as with other diseases of the poor, must continuously battle for funding that is not only sufficient but sustainable. Understandably then, some MIM delegates told TropIKA that they were concerned that a push towards eradication – especially with the might of the Gates foundation, which often drives the direction of research, behind it – would divert funds from urgent control measures. But it should be possible to focus both on control and access to drugs as well as the long-term prize of eradication. After all, the global health community now has more funding and support than ever before; if we don’t move towards eradication, or at least think about how and when we might achieve it, when will we? It seems the least that those suffering with the burden of malaria on a daily basis deserve.

New findings: a personal selection

As Editor of TropIKA.net, I read many new research papers on the infectious diseases of poverty, the majority of which are about malaria. Identifying which are the most important is no easy task, but some do attract my particular attention. I have just written an article about seven such papers. Issues raised in my personal selection include: - the need to protect older children (i.e. those aged 5-18 years) from mosquito bites - what is the best way to prevent malaria in children with sickle cell disease - the growing popularity of window screens and ceilings as a way to prevent mosquito entry to homes - the factors that determine what sort of treatment mothers seek when their child has malaria. You can read my article here and use the TropIKA.net "Comment" facility to add your own views on my selection. (Six of the seven papers I have chosen are available with open access, so you can also read the full papers yourself.) Paul Chinnock Editor, TropIKA.net

How to decide when to take a malaria vaccine to Africa

Kevin Marsh, director of the Wellcome-KEMRI-Oxford Collaborative Research Programme, discusses malaria vaccines on this MVI guest blog: Deciding when it’s a good time to take a malaria vaccine into African countries for testing in children is not always straightforward. It’s a real issue for vaccine developers and funders and one that is the subject of debate here at MIM and in the wider malaria vaccine community. There are no absolute criteria for these decisions. For malaria vaccines, the ability to challenge—with the bites of infected mosquitoes—healthy adult volunteers who have not previously been exposed to malaria is a critical way for developers to decide whether or not a candidate vaccine has potential and should therefore move to African trials. For pre-erythrocytic vaccine candidates—those designed to prevent the parasite from getting past the liver and into the blood stream—this model has proven to be extremely valuable. One good example is RTS,S, the vaccine candidate developed by GlaxoSmithKline Biologicals and supported by the PATH Malaria Vaccine Initiative that is now being tested in the region. On the other hand, for vaccines that target the parasite later in its life cycle, during its development in human red blood cells, the human challenge model has been seen to have limitations. However, many researchers now believe these limitations can be overcome and that challenge models should form part of the selection pathway for blood-stage vaccines. Without this crucial decision point, a major question is, how do developers decide which blood-stage vaccines should go into the field? An added complication for these blood-stage vaccine candidates is the fact that adults tend to develop immunity as a result of previous exposure to the parasite. Therefore, young children who have had limited exposure and limited immunity to malaria are really the best population for evaluating whether these vaccines work. These factors create ethical dilemmas for developers and funders, given that vaccine candidates that have limited human proof-of-concept data may need to be evaluated in large numbers of children. All the important challenge models exist in developed countries. So it’s time to ask why such models are not found in developing regions, such as Africa. In Kenya, there are active discussions among ethical and research institutions to examine whether this country could take a lead in developing challenge models. There’s a strong positive feeling that this is important. In the meantime, there needs to be broad consensus among scientists, including African scientists, about when vaccines should be tested in Africa. It’s also important that African institutions and scientists are meaningfully involved throughout the process of vaccine development.

Malaria Ethics

Research ethics occupies an uncomfortable place in investigators’ hearts. On one hand, it’s at the core of their work – no clinical trial could, or should, be conducted without a strong ethical framework. But researchers also want to get their trials up and running as soon as possible, and waiting for ethics review can be immensely frustrating. In a small basement room at the MIM conference today, it became clear just how relevant these issues are for a disease like malaria. Malaria trials often involve the vulnerable segments of a population –pregnant women and children and so there are sensitive ethics issues. But the trials are almost always done in Africa, where ethics review is patchy across the region. Clearly, there is a need to mesh these conflicting factors. The members of review panels, however, have a hard time of things. They are often volunteers who have full-time jobs, few resources, and little training. So what’s the solution? Collaborative efforts by organisations like PABIN/SIDCER help tremendously by offering much needed training and funding. For their part, African scientists involved in bioethics will have to think about the issues in a broad, perhaps moral, context, rather than just ticking ethics review boxes. This is a tough challenge, but one that African scientists are more than capable of. Watch this space for a Q&A with Aceme Nyika, AMANET’s ethics coordinator.

Global health histories

Another in a series of "webinars" on the history of tropical diseases will be broadcast over the internet this week, when two leading specialists will speak on the theme "How malaria became a vector borne disease". The series, launched in April this year, was described in an article in TropIKA.net News. In the latest session, Dr Axel Kroeger of TDR (the UN Special Programme on Tropical Disease Research & Training) will be joined by Professor Randall Packard, of the Institute of the History of Medicine at Johns Hopkins University. Dr Kroeger will discuss “institutional memory loss” in the history of vector control efforts, citing the example of indoor residual spraying with insecticides. Professor Packard's focus will be on the limitations of the Roll Back Malaria approach and the consequences for the prospects of malaria elimination. The webinar will be held Wednesday 4th November 2009 (12:30 PM - 14:00 PM CET). Participation is freely available to anyone who pre-registers and has the necessary system requirements. To register and join the next webinar, go to: https://www1.gotomeeting.com/register/877471673 More about the sessions can be found at: http://lnk.nu/who.int/124x.html

What Africans need from product development partnerships

Yvette Collymore of the Malaria Vaccine Initiative talks to MIM Professor Wen Kilama, AMANET: Managing Trustee, African Malaria Network Trust (host of MIM): The Product Development Partnership model has seen a number of achievements since they began developing drugs, vaccines, and vector control solutions in 1999. However, from an African perspective, these product development partnerships (PDPs) that receive funding to address neglected diseases create a number of challenges. As I said at a session on PDPs organized by the PATH Malaria Vaccine Initiative as well as the Medicines for Malaria Venture and the Innovative Vector Control Consortiumm at the MIM conference, the PDP model addresses one disease problem with one approach. The model does not take a holistic approach to the development of these products. But a product on its own does not solve the problem. You need to go beyond that and make a product accessible. There may be hindrances to do with weak public health systems, lack of political will, poor infrastructure, corruption, traditional norms and beliefs, and prescribing practices. All these issues impinge on access. Some argue that the PDP model cannot do all things. I agree. At the same time, these PDPs can build good working relations with national and local researchers and scientists instead of relying on so-called CROs (contract research organizations)—small companies perhaps contracted through ads on the Internet who come in, do the job, and leave without contributing whatsoever to local capacity building. They come back, do the same thing, over and over again. We need to work hand-in-hand with PDPs: plan together, implement together, build up local capacity, so that local researchers can eventually carry on, without much outside input. I do not see PDPs carrying on implementation research, long-term follow-up, for example, of chronic adverse events, or disease rebound effects, pharmacovigilance—following a study population to detect rare adverse events. Another area of concern is that PDPs are not likely to analyze data inside the country of testing. The issue of data sharing is crucially important, as is that of transferring materials or specimens for analysis abroad. And when results are obtained, they are often not fed back to the country of origin, in order to benefit the national health care system. Local manufacturing and related aspects such as technological transfer are also major concerns. The local researchers and research participants might inadvertently be creating markets for foreign products.

The toll of counterfeit medicines

Would you take a drug not knowing whether it was safe or not? Whether it could kill you? For a whole host of reasons, this is exactly what many people with malaria do. The reasons are not as simple as ignorance or a lack of education. In a session on ‘pharmacovigilance’ today, Ogobara Doumbo, the director of the Malaria Research and Training at Bamako talked about some of the reasons why people still take drugs that are unsafe, and what can be done to prevent it. Some people are so used to getting medicine from their local pharmacies or shops that they don’t question the validity of the medicines. Fake drugs can enter the market in many ways; in some countries with no local manufacturers, imported drug can have questionable provenance. Some companies sell antimalarials even when after the expiration date. The consequences are serious. Some fake drugs do contain some active ingredient, but not being prescribed properly, the drugs can lead to the development of resistance in parasites – effectively working as an immunization for the parasite. In the worst cases, the drugs kill people. Doumbo said, for example, that 2500 people died in Niger in 1995. So what is the solution? Regions need to coordinate on quality assurance, and they need to educate people about the importance of getting hold of safe drugs. More importantly, and something that will be a challenge for policymakers and governments, is to ensure that safe antimalarials are available to those who need them. Until then, people with malaria may well feel that desperate times call for desperate measures.

A place to confer: TropIKA.net

As I write this blog, some 1,500 malaria specialists are taking part in the first day of a major conference being held in Nairobi this week. Many important presentations on malaria research will be delivered during the event, but a conference is a place to confer and should not be merely a series of lectures delivered to passive audiences. To help make the 5th Multilateral Initiative on Malaria Pan-African Malaria Conference a more interactive affair, TropIKA.net has established a “knowledge hub” for the meeting, where we are providing background documents, news, summaries and blogs. Everything we publish on the site allows registered users to add their own observations and opinions on the latest developments in Nairobi. TropIKA.net spoke, before the conference began, to ten researchers making presentations of particular importance. These interviews have been published within the knowledge hub. We will be conducting further interviews, in which we ask young African scientists and senior figures in malaria control for their reactions to these presentations. Some of the presenters we spoke to have views that could prove highly controversial. Frank Baiden from Ghana says we need to take a long, hard look at the data on malaria in Africa: “Do we have the numbers right?” he asks, “How confident are we that these cases are all malaria?” He and others we spoke to query whether the declines now being seen in case numbers in several parts of Africa are the result of new interventions, or whether something else is going on. James Tibenderana (Uganda) alleges that previous efforts to promote the integrated management of childhood infections have “died a natural death”. Paul Milligan (UK) says that the way in which data from vaccine trials are analysed should be changed, in order to provide better measures of their impact on disease burden. And Hilary Ranson (UK) says “alarmingly high” levels of insecticide resistance are now being recorded. Let other TropIKA.net readers know your opinion on what these researchers have told us. Thanks to the Internet, there are now also virtual places to confer and TropIKA.net provides such a facility throughout the year – not just in the present ‘conference season’. We continue to report on major new developments relating to the infectious disease of poverty. A recent example is the publication of new estimates showing that Streptococcus pneumoniae and Haemophilus influenzae type B are responsible for as many child deaths as AIDS, malaria, and tuberculosis combined. Epidemics of other infectious diseases have also featured in our pages. This has been a very serious year for meningococcal meningitis in Africa’s meningitis belt, and cholera outbreaks have afflicted many parts of the African continent, including Nairobi – a city in which ironically malaria is not actually transmitted, according to new findings. We have also highlighted reviews that provide updates on what is known about cholera and about fascioliasis, and a major report on global progress with vaccination programmes. But we do not neglect the basic end of research. It will be interesting to see whether some very preliminary findings recently reported may one day lead to a role for chocolate in malaria treatment or for anti-obesity drugs to treat dengue fever. What do you think? Let us know. Paul Chinnock Editor, TropIKA.net

US charity steps up its programme on neglected infections

A news report highlights the activities of Medical Assistance Programs International (MAP) a US Christian group which is supplying drugs for the treatment of neglected infectious diseases in developing countries. Drugs worth $400 million were dispatched last year alone. The group is also involved in community health programmes. The group plans to step up its activities against neglected infections, including Chagas disease, Buruli ulcer, cholera, dengue fever, sleeping sickness, lymphatic filariasis, trachoma and soil-transmitted helminths. Information is also available on the MAP International website.