By: Nathaniel Wolf, Sabin Vaccine Institute

August 20^th is World Mosquito Day.  In 1897, Sir Ronald Ross looked at a mosquito under a microscope and saw that it looked really cool up close.  He declared August 20^th World Mosquito Day and said we should be nice to mosquitoes, if only one day a year. 

Not really.  What Dr. Ross discovered was the link between mosquitoes and transmission of malaria.  He declared World Mosquito Day so that people would become educated about the life cycle of malaria, and in 1902 he won the Nobel Prize in Medicine for it.   In spite of this discovery, today the disease continues to be a threat to approximately 2.85 billion people, afflicting 250 million people around the world and causing an estimated 1 million deaths annually.   

Dr. Ross’ discovery was made possible by another discovery some 20 years prior.  In China, Sir Patrick Manson discovered that the mosquito is a vector for lymphatic filiariasis (LF), a debilitating parasitic disease that currently afflicts about 120 million people around the world.   LF causes a range of symptoms including elephantiasis, hydrocele and extreme swelling of the scrotum.  The economic and social effects of this disease are enormous.  If you’ve ever read James Michener’s Tales of the South Pacific, wherein he talks about a man who, in order to walk, had to push before him a “rude wheelbarrow” in which “rested his scrotum, a monstrous growth that. . .weighed more than 70 pounds and tied him a prisoner to his barrow,” you probably thought Michener was taking poetic license.  He wasn’t.

The 2.85 billion at risk for malaria are also those most at risk from neglected tropical diseases.   As Alanna Shaikh pointed out in her entry on this blog yesterday, malaria “shares territory, climate, and even modes of transmission with NTDs.”  The clinical outcome of childhood malaria and malaria in pregnant women is dramatically higher when combined with one or more NTD, and there is evidence that even susceptibility to malaria is increased by NTDs.

Furthermore, according to an article published in 2008 in PLoS Neglected Tropical Diseases by Drs. Peter Hotez and David Molyneux, the anemia caused by malaria is increased dramatically when combined with an NTD such as hookworm disease, of which there are almost 200 million cases in Africa alone.  More than anything else, this anemia is what makes malaria and NTDs “diseases of poverty”—adults can’t work when they are very sick, and children can’t learn. 

There is good news out there.  In addition to the positive things mentioned by Ms. Shaikh, UK’s Department of International Development (DFID) states that 11 African countries are “approaching elimination” and Rwanda and Ethopia have seen a 50% decrease in malaria cases.  

The Malaria Vaccine Initiative, a program of PATH, is conducting late-stage clinical trials on a vaccine against malaria.  Also, Sabin Vaccine Institute’s Vaccine Development Program, in partnership with Malaria Vaccine Initiative and Johns Hopkins University’s Bloomberg School of Public Health, is working on the development of a very exciting “transmission-blocking” vaccine (yes, I said “exciting,” “vaccine,” and “development” all in the same sentence).  In other words, if a mosquito “bites” a person who has been inoculated with this vaccine, it may render that mosquito unable to infect any other person with the disease.    So maybe some year in the future on August 20^th we can all roll up our sleeves and stick out our arms and be nice to mosquitoes, if just for one day.

 Nathaniel Wolf is an Information Officer for the Sabin Vaccine Institute. He is a fan of the Washington Nationals and is currently working on his first screenplay.

More good news from me this week. New research shows that more kids in Africa are sleeping under bednets to protect them from mosquito-borne diseases like malaria and dengue. Here’s the big deal: in 1999, only 1.5% of children at risk slept under a net. By 2008 26.6% of children slept under a net. In Djibouti, Ethiopia, and Sao Tome, more than 80% of all children slept under a net. Considering that malaria caused 900,000 deaths in 2006, these kinds of advances really matter.

To make things even more interesting, the countries who did the best job of distributing bed nets and getting people to use them were also the countries that received the most aid for their malaria programs. That’s not exactly 100% proof that health aid works, but it comes awfully close.

Malaria has a lot in common with the NTDs. After all, it’s a tropical disease, too. It’s just not neglected. It shares territory, climate, and even modes of transmission with various NTDs. And, like malaria, we know how to prevent and cure NTDs. What worked for malaria – effective, targeted aid in quantities big enough to have an impact – will work for neglected tropical diseases, too. This research is a reminder and an inspiration. We really can defeat these diseases, bit by bit.

Are you feeling all happy now? I hope so, because I’m about to get cranky and I would like a susceptible audience. You know what else has been proven to work? Humanitarian aid after disasters. As I mentioned last week, the rapid provision of emergency aid – especially drinking water and sanitary facilities – can prevent the wave of water-borne disease that strikes after a disaster.

Pakistan is not getting that aid. There are three and a half million children at risk for disease if they don’t get help quickly, and there just isn’t enough money coming in to fund that help. I don’t know if everyone is tired after the Haiti disasters, if flooding’s not as exciting as an earthquake, or if the world just hates to help Pakistan. But innocent people are about to die from diseases we could prevent. By making sure they had safe drinking water and a decent place to toilet. This isn’t one of those tricky situations where you don’t know if your donation will do any good.

While Pakistan’s leadership isn’t going to win any prizes for good governance, the subsistence farmers who fled the flood waters don’t have much to do with that. We are already starting to see reports of preventable waterborne diseases in among the displaced. And you’re not donating to the government of Pakistan; money given to emergency relief groups doesn’t go to the Pakistani government.

Now is the time to donate for Pakistan aid. You want to pick an NGO that has a history in Pakistan and a lot of experience in emergency response. I mentioned International Medical Corps last week. World Vision, Mercy Corps, and Oxfam are other good choices.

Once you’ve made your donation, contacted your elected officials, and tell them that you support aid to Pakistan’s flood victims. If you don’t want to do it out of sheer altruism, think of it this way. Fifteen million displaced people who aren’t getting the help they need, in an already fragile nation, are a reservoir for diseases that can and will spread globally.

Alanna Shaikh is an expert in health consulting, writing about global health for UN Dispatch and about international relief and development at Blood & Milk. She also serves as a frequently contributing blogger to ‘End the Neglect.’

1.  Launching International Year of Youth, UN urges dialogue, respect across generations, UN News Center
2. Massive scale-up needed in Pakistan flood relief operation, says UN, UN News Center
3. Map reveals global threat from the ‘other malaria’, Rhiannon Smith, SciDev.net
4. India Asks, Should Food Be a Right for the Poor? Jim Yardley, New York Times

Human African trypanosomiasis: number of new cases drops to lowest level in 50 years, WHO
Community-Based Education Strengthens Elimination of Lymphatic Filariasis, Science Daily
Pharmacy students work to close the gap, Charles Sturt University
Foreign Policy Examines GHI, PEPFAR, Kaiser Family Foundation
Researchers In Australia Make Important Malaria Breakthrough, Government of Australia
Do Parasites Make You Dumber?, Cassandra Willyard, ScienceNOW
Dengue Re-emerges in U.S., Spurring Race for Vaccine, Gayathri Vaidyanathan, The New York Times

I just read an impressively scary article about Chagas disease. You should read it too, if you have access. It’s only eight pages long and it provides a clear glimpse into the future of communicable diseases. Once Chagas was a Latin American problem; it is now in the process of becoming global. On the off-chance you don’t have the article, or aren’t up to eight pages of journal reading , I’ll summarize it here for you.

In short, Chagas is spreading across the planet in a surprising way. The cause of this globalization is not, as you might expect, global warming (although that is increasing the natural habitat for Chagas.) Instead, the disease is being spread by emigration from Latin America. The disease has traveled with emigrants to Australia, Europe, Japan, and Canada.

T. cruzi, the protozoan that causes Chagas disease, can stay dormant in the human body for years. So, when emigrants travel, the disease goes with them. It started out as a novelty – a surprise to physicians. It’s now included in standard medical screenings. The article recommends training physicians on the diagnosis and treatment of Chagas disease and that policymakers develop national plans for prevention and treatment.

The article goes into more detail on the statistics of Chagas infection and transmission. They’ve got data on infection rates in Europe and Australia, broken down by the country of immigrant origin. What really interests me, though, is the trend we’re looking at here.

People move around. They travel for vacation, they take business trips, and they leave their homes in search of better prospects elsewhere. And they take their infections with them. Global air travel means the end of region-specific diseases. During the swine flu pandemic, we saw exactly how fast an infection can spread. Geographic distance is not the protection it used to be.

Right now, Chagas is still a Latin American disease, but this article, as discussed, shows that’s changing. The larger point is that other diseases are expanding, too, because of both climate change in the increased accessibility of air travel.

The wealthy world is already stepping up malaria control to stay ahead of the territorial expansion caused by climate change. Yellow fever, dengue, and encephalitis are other likely candidates for growth as the weather becomes more and more to their liking.

And that effect of climate change is exacerbated by the airplanes. Drug resistant TB is brewed in a few hot spots, like Baku, Azerbaijan, and then dispersed by travel and emigration. The WHO reported on this three years ago, looking at infection transmission in airline cabins.

Between human migration, climate change, and actual disease spread in airplanes, the NTDs aren’t going to remain tropical for long. Right now, it’s easy for wealthy countries to ignore their impact since they assume that the diseases won’t come home. That won’t be true for much longer. There is a moral imperative for the countries who can afford it to fight NTDs, but it’s increasingly obvious there is blatant self-interest as well. If we can lower disease rates in the NTD endemic countries, there will be less to transmit to everyone else.

Alanna Shaikh is an expert in health consulting, writing about global health for UN Dispatch and about international relief and development at Blood & Milk. She also serves as a frequently contributing blogger to ‘End the Neglect.”

By: Bill Brieger

Roll Bank Malaria (RBM) was launched in 1998, but actual scale up to universal coverage is only happening in 2010. By Comparison, the African Program for Onchocerciasis Control (APOC) took off in 1996 and has been scaled up for several years in all but a few of its endemic countries. Granted, APOC has a relatively smaller target area, but it now regularly reaches over 127,000 African villages with annual doses of ivermectin.

Both programs have in common the need to sustain their scaled up for many years into the foreseeable future if disease elimination is to be achieved.

This need for a long term perspective causes concern when one reads about a threat to continued funding for APOC’s Borno State, Nigeria project, and raises speculation whether malaria efforts may face the same threat a few years down the line.

Photo Courtesy of http://www.malariafreefuture.org/blog/?p=972

APOC started with a very clear vision of sustainability. APOC, a government entity (state, province, district, or country) and a non-governmental development agency (NGDO) would enter into a financial and programmatic 5-year partnership to establish community directed treatment with ivermectin (CDTI – see photo of CDTI in Cameroon at right). APOC’s financial contribution would be largest in the first year, when the overall budget would be largest because of start up costs.

Over time, program costs were to reduce, as would costs per person treated because of economies of scale. APOC’s share of the budget would decrease relative to that of the government partner, though the overall budget to maintain the program into the future was expected to be smaller and more manageable to the government partner with some continued support from the NGDO.

Free supplies of ivermectin from the Mectizan Donation Program would continue as long as there was need, but by the sixth year of operation, it was hoped that countries could sustain their own CDTI efforts. Apparently this has not been easy.

Evidence of problems with Borno’s CDTI project surfaced in 2007 at a meeting of APOC’s Technical Consultative Committee where the following report was shared. “Borno has maintained a good geographic and therapeutic coverage. However, the project has the following challenges:

* Non-release of funds by state and LGAs
* Inadequate number of FLHF staff
* Selection and training of more CDDs
* Obtaining funds from the government

IRIN now reports that after 11 years of operation “The (Borno State) government was supposed to provide counterpart funds to run the river blindness programme, but it has not done so, (according to) Borno State’s onchocerciasis coordinator Galadima.” Hellen Keller International (HKI) is Borno’s NGDO partner for CDTI and has been trying to make up the slack.

Unfortunately “HKI funding has been hit by the global recession, says (a representative). ‘Since the recession our donors have turned their attention elsewhere with little consideration for Africa and this affects the volume of funds for intervention projects like the onchocerciasis.’

Project staff complained to IRIN that, “We have been crippled financially due to lack of state counterpart funding. We sometimes find it hard to fuel our vehicles and go for supervision in the affected communities.”

There were hopes that another four years of government funding would put Borno within reach of elimination goals, but project staff lament that, “If the project stops at this stage, the effects will be devastating. It will turn the tide of the success we have achieved which will be quite disastrous.”

Let’s move this scenario forward to 2015 and change the disease to malaria. Let’s assume that talk of funding ceilings by donors has become a pressing reality and countries need to contribute more to sustain malaria interventions and achieve elimination. Let’s hope we don’t wind up again like malaria control did in the 1950s and ‘60s – eliminating the programs, not the disease.

PS – The IRIN article does have some potential technical problems. It referred to the CDTI as a program to create ‘immunity’ to onchocerciasis, whereas ivermectin actually is a drug to kill the microfilaria of the parasite and keep infection at a low level until such time as adult worms die and transmission in the community stops. There is also concern about the figure of $18 per person treated. Normally at this advanced stage of the program we should be talking in terms of cents, not dollars. These technical problems with the article do not detract from its serious financial message.

Bill Brieger is currently a Professor in the Health Systems Program of the Department of International Health at Johns Hopkins University as well as the Senior Malaria Adviser for JHPIEGO, JHU’s family and reproductive health affiliate. He was a Professor in Health Education at the African Regional Health Education Centre, University of Ibadan, Nigeria, from 1976 to 2002. His research interests have focused on the social and behavioral aspects of tropical disease control, and in the area of malaria research, funded by the Unicef/UNDP/World Bank/WHO Tropical Disease Research program (TDR) and USAID implementing partners, this has included acceptability of pre-packaged antimalarial drugs, urban malaria, role of patent medicine sellers in malaria treatment, and community and cultural perceptions of malaria as a basis for village health worker training and health education.

The Global Network for Neglected Tropical Diseases, an initiative of the Sabin Vaccine Institute, invites you to a briefing in conjunction with the Congressional Malaria and Neglected Tropical Diseases (NTDs) Caucus.

Can the diseases that have been around since the days of Moses and Pharaoh truly be eliminated? What tools do we now have to successfully control and eliminate NTDs? How does control and elimination of NTDs help the United States and U.S. foreign policy?

This distinguished panel of experts will discuss current and future NTD control and elimination efforts:

Moderator: Mr. Steve Sternberg, Medical Writer, USA TODAY

Panelists:
• Dr. Peter Hotez, President, Sabin Vaccine Institute
• Dr. Christy Hanson, Chief, Infectious Disease Division, Bureau for Global Health, USAID
• Mr. Ken Gustavsen, Director, Global Health Partnerships, Merck & Co., Inc.

NTDs: Can We Take the ‘Neglected’ Out of the Name?, Alan Fenwick, A Global Village
Canada’s Reportedly $1 Billion toward Maternal Mortality, Nandini Oomman, The Huffington Post
iBio Licenses Vaccine Technology to CMB, Drug Discovery & Development
Molecular-Based Assay for Simultaneous Detection, Rajeev K. Mehlotra, Laurie R. Gray, Melinda J. Blood-Zikursh et al., The American Journal of Tropical Medicine and Hygiene

By: Seth Hoffman

Its 2:30am on June 5th, 2010 and I am supposed to “get up” for my flight to Indonesia in about three hours. I’m also not nearly done with my packing.

Hi. My name is Seth Hoffman, and I am going to be a junior at Cornell University. This summer I am setting out for the experience of a lifetime.

I’ll be spending the next 8 weeks working with the University of Indonesia and Leiden University Medical Center at their field sites in Flores, Indonesia. Flores is right smack dab along the path less traveled, and that is my kind of party. The project aims to attend to the issue that in many parts of the developing world, malarial and helminth (i.e. hookworms) infections are co-endemic. Investigation on the immunological associations between helminth infections and malarial parasites in co-endemic areas holds the key to answer the question whether helminths, by downregulating immune responses, increase susceptibility to malarial parasites on the one hand, but protect from cerebral malaria on the other.

The purpose of this blog is to describe the experiences of an undergraduate trying to immerse himself completely in the broad (scientific, socio-political, anthropological, etc.) aspects of the field of Global Health, specifically in regard to neglected transmitted diseases (NTDs). I am going to be helping out the doctors and scientists in the study by conducting blood analyses, stool samples, physicals, PCRs, and much more. I personally am overjoyed at being given such an opportunity to develop my medical/scientific prowess, especially in regard to hookworm, an NTD that prior to becoming involved in the field study I had little knowledge of except for what I had learned in my medical parasitology class. I have done a lot of research with malaria, but helminths and NTDs are a whole new “can of worms.”

I will also be traveling to Flores with my best friend Michael Billingsley (University of Glasgow) and my younger brother Benjamin Hoffman (Stanford University) who both happen to be pursuing medical careers as well.

Furthermore, the three of us are members of a band called Nigeria that has had some local success, and whose debut demo album Mango is currently being passed around several major music labels (fingers crossed!). As a band we plan on writing and recording a lot of music heavily influenced by our exploits in Flores to be released at the end of the summer as a free digital-download mixtape. The three of us have grown up in families fixated on tropical diseases, and work in Global Health, and we have pledged a portion of the proceeds of our album Mango to Share Our Strength’s campaign to end childhood hunger.

I truly hope that this summer¹s experiences will help to enhance my parasitological knowledge and general understanding of the grand scope of Global Health; and that is precisely what I plan to communicate to you all through this blog. If I can impart just 25% of what I hope to learn this summer onto another reader, who will then hopefully pass that new found knowledge onto another, then my blog will have been a success.

More posts, pictures, video, and music to come! Until then…I’m going to go ahead and finish packing.

Seth Hoffman is a pre-med student at Cornell University, majoring in Anthropology and minoring in Global Health. He has worked for a number of years on identifying olfactory genes of Anopheles mosquitoes involved in mate and host seeking, and has published on his work in the scientific literature. He is a singer and guitarist for the band Nigeria.

A common critique of the Global Fund to Fight AIDS, TB and Malaria is that there are other major contributors to the burden of disease in tropical countries.  Some are infectious like pneumonia while others are non-communicable like injuries.

From the standpoint of malaria, integration makes sense. From the start, the Roll Back Malaria Partnership made it clear that malaria control (end eventual elimination) could not succeed unless health systems were strengthened. These are the same systems that are supposed to control filariasis, helminthic diseases, diarrheal diseases, and pneumonia as well as promote maternal health, child growth and development as well as immunization programs. It was a weak health system that contributed to the failure of the first effort to eradicate malaria fifty years ago.

Two recent articles exemplify the need for integrated prevention and control services because tropical communicable diseases themselves are ‘integrated’ into the environment and the human host.

Abraham Degarege and colleagues examined Malaria and helminth co-infections in outpatients at Alaba Kulito Health Center in southern Ethiopia. Fifty-four percent of patients having malaria parasites also had at least one of three helminth infections including hookworm, A. lumbricoides and/or T. trichiura. Those with both worms and malaria (P. falciparum and/or P. vivax) had higher rates of anemia. These negative synergies require an integrated approach to patient management as well as to community prevention programs.

Marcia C. Castro and her co-researchers looked into local water sources for larval development of lymphatic filariasis and malaria vectors in Dar es Salaam, United Republic of Tanzania. Larvae of both anopheles and culex species were found in puddles, swamps, mangrove swamps, drains/ditches, human-made holes, water storage, agriculture, rivers/streams, and ponds.

Polluted urban environments are less conducive to anopheles breeding, and culex were more likely to be found in all these urban sites in Dar es Salaam, especially in drains/ditches, but again in this environment both types were found, meaning that both filariasis and malaria ‘co-existed’. Integrated control through larviciding and ITNs would help prevent both diseases.

If basic health services are well funded, staffed and supplied, no tropical disease needs to be neglected.

Bill Brieger is currently a Professor in the Health Systems Program of the Department of International Health at Johns Hopkins University as well as the Senior Malaria Adviser for JHPIEGO, JHU’s family and reproductive health affiliate. He was a Professor in Health Education at the African Regional Health Education Centre, University of Ibadan, Nigeria, from 1976 to 2002. His research interests have focused on the social and behavioral aspects of tropical disease control, and in the area of malaria research, funded by the Unicef/UNDP/World Bank/WHO Tropical Disease Research program (TDR) and USAID implementing partners, this has included acceptability of pre-packaged antimalarial drugs, urban malaria, role of patent medicine sellers in malaria treatment, and community and cultural perceptions of malaria as a basis for village health worker training and health education