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.” 

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.

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.

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.

Leading development agency Oxfam is not impressed with the performance of the leaders of the G8 countries, who are meeting in Italy this week. It calls on them to respond to the ‘triple threat’ faced by the world’s poorest people: economic crisis, rising food prices and climate change.

Oxfam’s most scathing criticisms are aimed at Silvio Berlusconi, G8 chair and Italian president, who is accused of attempting to wriggle out of aid commitments to the world’s poorest and of using creative accounting to hide broken promises. According to the OECD, G8 leaders will fall short by as much as $23bn in their 2005 promise to increase annual aid by $50bn over five years. Meanwhile, sub-Saharan Africa is expected to lose $245bn this year as a result of the global slump, but the region will receive only about $5bn in additional aid.

Read the full Oxfam article here.

According to a Reuters report the Global Fund to Fight AIDS, Tuberculosis and Malaria is facing a budget hole of about $3 billion, resulting from the worldwide economic decline.

A spokesperson said the money would have to be found in order to meet commitments to programmes for 2010.

One concern, should the Global Fund not be able to meet its commitments, is that it might mean many TB patients would not be able to continue with their treatment, and this would encourage the development of drug resistance.

As of the end of last year, the Global Fund had provided AIDS treatment to 2 million people and tuberculosis treatment to 4.6 million people, and distributed 70 million insecticide-treated bed nets worldwide.

Ultimately, the aim of control programmes for infectious diseases is global eradication. Smallpox is the only instance of a disease where this has been achieved. Polio (like guinea worm) continues to move towards eradication but frustratingly there have been setbacks, particularly in Nigeria and in India.

An article in the American Journal of Public Health (sadly, not an open-access publication) reminds us that India made little progress against smallpox during the 1950s and 1960s, and was regarded as one of the major barriers on the road towards eradication of the disease worldwide. It took a change in the way the eradication programme was run in India before progress was made.

The article describes how “the campaign was converted from a project in which a handful of officials tried to impose their ideas on a complex health bureaucracy to one in which its components were constantly adapted to the requirements of a variety of social, political, and economic contexts”. The change was achieved in the 1970s mainly through the active participation of workers drawn from local communities.

As the authors point out, there are many differences between smallpox and polio. Nevertheless, there are lessons from the experience of smallpox eradication in India that should not be forgotten in today’s efforts to eradicate polio.

One of the authors of the article, Sanjoy Bhattacharya, is involved in the organization of a series of seminars on the history of tropical diseases that is being broadcast over the internet - see TropIKA.net News.

Reference
1. Bhattacharya S, Dasgupta R (2009). A tale of two global health programs. Smallpox eradication’s lessons for the antipolio campaign in India.Am J Public Health99(7):1176-1184.

US researchers have used computer models to look for established drugs that might be of use in treating resistant forms of TB. They have concluded that two drugs used in the treatment of Parkinson’s disease could also have activity against Mycobacterium tuberculosis.

The two drugs - Comtan and Tasmar - are presently used to boost the effectiveness of the Parkinson’s drug levodopa. They block a brain chemical called COMT, stopping it from breaking down levodpa, but their molecular structure also allows them to block a compound needed by M. tb’s protective cell wall.

One of the researchers, Philip Bourne of the University of California, San Diego, says that Tasmar can damage the liver but Comtan is safer and has the potential to become a TB drug.

The study is published in PLoS Computational Biology and is discussed in a news story from AFP.

Farmabrasilis is a non-governmental, non-profit research network bringing together Brazilian, Chilean, American and European scientists and others whose concern is: “The research and development of new medicines and technologies for the benefit of economically disadvantaged populations and individuals affected by neglected diseases”.

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 it 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.

This proposed new therapeutic approach was presented to delegates at the recent STOP TB Partnership Forum held in Rio de Janeiro. Farmabrasilis welcomes contact with other individuals and organizations interested in the further development of the proposed approach.

A study recently published in the Irish Medical Journal investigates the reasons for an increase in malaria cases in Ireland in recent years. While malaria incidence between 1988 and 1998 was 14 cases per year on average, in 2006 alone there were 91 cases of malaria.

If no malaria mosquitoes have been found flying around in Ireland, how can this increase in malaria incidence be explained? The reason, the study points out, is travelling. However, for malaria to become a problem in Ireland, and in other countries for that matter, the mosquitoes do not need to bother flying continental distances. They can simply wait in their local and endemic regions for the unwary or uninformed traveller who goes to Africa to see friends and family, according to the study.

Between July 2005 and April 2006, five children were diagnosed with malaria caused by Plasmodium falciparum in the Our Lady of Lourdes Hospital Drogheda, in Ireland. Of these five, four were born in Ireland while the fifth was born in Nigeria. They all lived in Ireland but went to Africa in the previous months to the diagnosis to visit friends and family. What the study shows is that travellers to Africa have failed to take appropriate prophylaxis for the correct period of time as a way to be protected against malaria. In this study, none of the children received adequate prophylaxis. The five children were treated with quanine and clindamycin and were able to leave the hospital.

The final message is clear: “Families who intend travelling to endemic areas need to be aware of the potential risks if adequate prophylaxis is not taken or if compliance is inadequate.”

For more information, the full study, Out of Africa: Traveller Malaria in Paediatric Patients Presenting to Our Lady of Lourdes Hospital Drogheda, is freely available.