Special Programme for Research & Training in Tropical Diseases (TDR) sponsored by UNICEF/UNDP/World B a n k / W H O

Special Programme for Research & Training in Tropical Diseases (TDR) sponsored by UNICEF/UNDP/World B a n k / W H O

No. 82 - M a r c h 2 0 0 9

Making a paradigm shift The Bamako 2008 Global Ministerial Forum on Research for Health | PAGE 12

Also in this issue 29 • Empowerment SAC • ANDI Task Force PAGE 30 • Chagas disease protocol 4 Research briefs 19 • ASTMH and rectal artesunate 7 TDR briefly 32 • DEEP on ineffective diagnostics Liberia diary: 24 HAT research in Uganda • Biosafety courses launched ‘greening’ in Mali M eet i n g s clinical trials in 33 • Sudan adopts HMM strategy 27 • Stewardship SAC a remote site • Environment, agriculture and 34 Publications infectious diseases 36 Grants Letter from the editor

Powering sustainable research

page n TDR we speak a great deal about Solar power generation capacity not only would as- 9 using the research that we do in sure the sustainability of the infrastructure invest- countries not only for a particular drug ment in Bolahun for other trials for neglected tropi- trial or project, but also to build more cal diseases, but it could potentially power existing “sustainable” research and health services facilities of a nearby health centre, and also Bolahun capacity in poorly resourced locales. High School.

Now, a drug trial of moxidectin, a potential drug The high school, founded by monks in 1925 and a for the eradication of onchocerciasis in Africa, to be focus of Peace Corps volunteer activity in the 1960s conducted in Liberia and the Democratic Republic of and 1970s, has an interesting history. It had a national Congo, is adding another dimension to the quest for reputation for academic excellence before the war, sustainability – an environmental dimension. and has recently been rebuilt thanks to the support page I of a network of distinguished alumni. 19 The clinical trial site in Bolahun, Liberia, in a remote northern border region that was once the scene of Kuesel recruited a master’s degree student to make civil war, offers the most dramatic example of the detailed engineering plans for a photo-voltaic system challenges involved (see page 19). sufficient to fuel the research and health centre and the school. Unfortunately, a donor has yet to be The trial site development in Bolahun has involved found. the construction of a major new research centre that will house the Phase III clinical trial activities. Capac- The fact that the sturdy, modern centre was built ity development at the Liberia trial site, as well as with sun-dried mud bricks and that other “green” those in DRC, has largely been funded through a measures have been considered, such as solar- US$ 6 million donation from Wyeth Pharmaceuticals, powered health waste disposal and re-use of biofuel page 24 owner of the moxidectin compound. waste from nearby banana and rice fields, make the Bolahun story a potential case study of efforts to However, despite the generous donation, guarantee- “green” health research facilities in remote locales. ing a power supply to the site has been an ongoing challenge. Charged by our Joint Coordinating Board to address climate change impacts and issues on neglected The centre, soon to begin recruiting patients, cur- diseases, we find the Bolahun story one of the most rently is powered by diesel fuel. However, diesel palpable examples of how TDR can be a leader of power capacity could be unpredictable, due to the Communications innovation in the research sector. Learning from the Manager site’s remote location, (a 10-hour trip from Monrovia, Liberian experience, we can explore how to incorpo- Jamie Guth partly over dirt roads in dry weather). Even though a rate environmental and climate change mitigation Managing Editor backup generator has been installed, any interrup- features into our field and clinical research activities Elaine Fletcher tion in fuel supply or failure of one of the generators – supporting the global drive for sustainable develop- Design and Layout could threaten the successful collection of data es- ment through our research work. Lisa Schwarb sential to the trial. Production Team But becoming a model requires us to first complete Also, once the trial is completed in three years’ time, Jocelyne Bruyère our work in Bolahun. And that means locating donors Pelthia Makgatho there is no guaranteed budget for supply of fuel to for a 15KW solar power generation system. Patrick Adams continue powering the array of laboratory, clinical, (reporter) ophthalmological and computer equipment, which Any takers, please tell us… Ali Bhanpuri (intern) could be used for further research or in the delivery of more routine health services. Cover photo: The Bamako In order to address such issues, TDR’s Annette Kuesel, International Conference who is coordinating the moxidectin research effort Centre in Mali, scene of together with Fatorma Bolay of the Liberia Institute the Global Ministerial Forum on Research for of Biomedical Research, developed a plan to provide Elaine Ruth Fletcher Health, 17-19 November solar power-based electricity to the centre. Managing Editor, TDRnews 2008, which drew 1100 participants from around the world. (Olivier Asselin) Letter from TDR’s director No. 82

Optimizing global health research ‘architecture’

Research policy actors are examining critical ques- cation in activities and administration tions about how the global community can act on needs to be examined. Just as donors recent calls for massive new investment into a global are urged to “harmonize” activities, we R&D effort targeting neglected diseases. need to examine ourselves and see how we are collaborating with our partners. The Global Strategy and Plan of Action on Public Health, However, any proposed reorganization Innovation and Intellectual Property (GSPA), approved must consider that the ultimate goal is by the World Health Assembly in May 2008, has led to improve efficiency, responsiveness to to the creation of a major WHO task force on sustain- scientific opportunity and the needs of able financing of research. This highlights the need to developing countries – and not merely spend much more on such research. superimpose another layer of bureau- cracy. Right now, only 3% of the US$ 160 billion spent glob- ally on health research is invested in neglected dis- TDR is in a pivotal position in this de- eases. Some argue this should quadruple to 12% over bate. TDR’s special programme model the next six years. of governance equally involves both developed and developing country gov- If funds of such an order of magnitude are to be lever- ernments. As TDR’s Joint Coordinating aged then investors, whether private or public donors, Board chairman has remarked, the co-sponsorship of 3 need to be assured that the international organiza- TDR by several UN agencies makes the Programme re- tions and NGOs engaged in research have coordinat- sponsive not to only WHO, but to the UN system more ed mandates for action that optimize their efficient broadly. We believe that the maintenance of this gov- use of funds and can appropriately support regional ernance model is crucial if developing countries are to and national efforts. play a pivotal role in global research for health, and WHO-associated and other health research agencies if research is to remain accountable to high disease have thus been called upon to improve coherence of burden countries. programmes, or even consider a merger of certain in- There will be furthered discussion of TDR’s position ternational research efforts.1 and role in research coordination and alignment at This need to review global health ‘architecture’ was the next Joint Coordinating Board session, 15-17 June. noted in the Bamako call for action at the close of the It is important to bear in mind the good news inher- Global Ministerial Forum on Research for Health in ent to this debate: that is the wave of interest in re- November 2008. search for health, both at the global policy level and from developing countries. At the Bamako Forum, In direct response to the Bamako call, WHO’s Execu- I spoke with the minister of health from Sierra Leone, tive Board, meeting in January, asked actors to “better a country recovering from civil war. He was adamant align and coordinate the global health research archi- that development of research capacity was critical to tecture and its governance through the rationaliza- health and development. tion of existing global health research partnerships, to improve coherence and impact, and to increase ef- TDR is building such capacity on the ground. In this ficiencies and equity.” 2 TDRnews issue, we feature efforts in Liberia and Ugan- da, where research investments are greeted with en- The matter is sure to also arise as the World Health thusiasm and involvement by policy leaders as well Assembly considers approval of a new WHO research as local communities. Engaging and responding to strategy in May. No single programme or agency can country needs has to be kept in the forefront of our remain aloof to the questions being asked and the thinking. It is these efforts that will lay a good founda- challenges posed. There are indeed multiple inter- tion for a research ‘architecture’ that is strong, stable national research initiatives operating from WHO, and durable. involving other partners. And there are multiple NGO initiatives promoting research. Potential dupli-

1 Røttingen JA, Marchiori Buss P, Davies S, Touré O. Global-health research architecture—time for mergers? The Lancet 373: 9659, pp 193-195 Dr Robert Ridley 2 WHO Executive Board resolution: EB124.R12 (http://www.who.int/gb/ ebwha/pdf_files/EB124/B124_R12-en.pdf) TDR Director No. 82

Research briefs

• The Lancet – Rectal artesunate can save lives of severe malaria patients • Gatifloxacin trial: Patient enrolment target is met • New TDR study to evaluate if home management reduces malaria mortality • Glossina genome is 80% sequenced – completion planned in 2009 • Phase 2 of eco-bio-social research launched • WHO/TDR establish Pregnancy Register

malaria new tb treatment Because gatifloxacin has been associated with the problem of hypo- and The Lancet – Rectal Drug trial meets patient hyperglycaemia, patients with a history of artesunate can save lives enrolment target diabetes or abnormal blood glucose levels of severe malaria patients A pivotal Phase III trial of a shorter, have been excluded from the trial. It is “A rectal application of the 4-month course for tuberculosis (TB) expected that the initial analysis of safety inexpensive antimalarial drug treatment has taken a significant step and efficacy will be conducted 1 year forward after the enrolment quota of post-treatment, i.e. in mid-2010, followed artesunate could save the lives of 1836 volunteer patients was reached at by a final 2-year analysis. Should the 4 many people who develop severe African study sites. The trial is testing initial 1-year analysis be positive, it malaria who live in the world’s a 4-month course of TB multidrug is anticipated that a formal file for remotest locations, e.g. rural Africa treatment including gatifloxacin against registration of a gatifloxacin-containing and Asia.” the standard 6-month multidrug TB TB drug combination will be submitted to course. the United States of America’s Food and The trial, launched in 2005, aims to assess Drug Administration and other regulatory whether the new regimen is safe and as authorities in late 2010 or early 2011. effective as the standard 6-month regimen. >> For complete report, see: The achievement of the target sample http://www.who.int/tdr/svc/news-events/ size in October 2008 means that the final news/shorter-tb-drug-trial WHO/TDR/Craggs patients needed for the study will now complete treatment in the second quarter For more info of 2009. Dr Piero Olliaro: TB centres of the national TB control [email protected] programmes in Senegal and Benin together with clinical and research institutions in Guinea, Kenya and South Africa are partners in the study, which is being conducted in collaboration with the European Commission (EC)-funded TDR evaluation Oflotub Consortium. TDR provides co-sponsorship and funding, as well Does HMM reduce malaria as technical oversight in collaboration mortality? with the Institut de Recherche pour le TDR is to evaluate whether distribution Développement (IRD), France. of free artemisinin-combination therapies (ACTs) through home-based management In 2003, TDR and the Oflotub Consortium of malaria (HMM) can reduce malaria began a programme to develop and register These are the conclusions of a TDR- mortality as well as morbidity. supported study published recently in a TB treatment containing gatifloxacin, The Lancet, “Pre-referral rectal artesunate an oral fluoroquinolone antibiotic The TDR research will be carried out in to prevent death and disability in severe with activity against Mycobacterium the context of a major US$ 20 million malaria: a placebo-controlled trial.” tuberculosis. In the Phase III trial involving initiative to extend HMM, including The research was presented at the adults under the age of 65, patients are ACTs offered free-of-charge, to some December 2008 meeting of the American randomly allocated to receive either the 10 million Africans in four countries. The Society of Tropical Medicine and Hygiene standard 6-month TB treatment or the initiative was launched 16 February in shortened tested treatment (rifampicin + (for more details see page 30). Nairobi, by the Canadian International isoniazid + pyrazinamide + gatifloxacin Development Agency (CIDA) and for 2 months, followed by rifampicin + Population Studies International (PSI), a isoniazid + gatifloxacin for 2 months). Washington, DC-based NGO. No.No. 8282

Glossina genome disease-endemic countries (DECs) to exploit the data to develop new vector Sequencing at 80% mark – control strategies. TDR aims to facilitate completion planned in 2009 DEC involvement in genomics research

WHO/TDR/Pagnoni through seed-funding of preparatory Researchers at the Wellcome Trust activities and support for regional training Sanger Institute have sequenced 80% of centers that would offer courses in the Glossina m. morsitans, the tsetse fly bioinformatics and functional genomics. species that is a vector of human African trypanosomiasis (HAT), in the context of For more info a TDR-supported international genomics effort. Dr Yeya Touré: [email protected] Over the next 2-3 years, the TDR The International Glossina Genomics scientists will monitor the impact of the Initiative (IGGI) has now drawn up home-based effort on ACT treatment to an implementation plan for complete determine if indeed it reduces mortality sequencing of the Glossina genome from malaria. eco-bio-social research by 2009, with sequence assembly to What makes the TDR research ground- follow this year as well. The plans were Six countries test dengue breaking is that the effectiveness of the discussed at IGGI’s sixth annual meeting interventions in Mombasa, Kenya, during November home-based approach for delivering ACTs A multi-country research effort in Asia 2008. on child mortality has never before been designed to study dengue transmission monitored. ACTs also are not yet widely and then test social and ecosystem-based IGGI members have proposed that available in Africa, particularly for the interventions is launching its Phase II. completion of the sequencing can be most poor and vulnerable people. Following the completion of the Phase I expedited by using a new sequencing situation analysis, all six sites will initiate Research has, however, demonstrated technology that is more efficient and 5 tests of various community-based that prompt and effective treatment of less expensive than conventional means, management approaches in April. These uncomplicated malaria (usually with providing the estimated US$ 250 000 in are designed to address locally identified chloroquine) prevents an infection’s funding needed for the effort is secured. factors in disease transmission. evolution to severe malaria and death. The new 454 FLX sequencing technology The initiative, funded by the EcoHealth If the health impact of delivering was recently developed by Roche Programme of the Canadian International ACTs (free-of-charge) through HMM Diagnostics. IGGI is an international Development Research Centre (IDRC), is significant, results would serve as a consortium that was convened by TDR involves multi-disciplinary research powerful catalyst for the expansion of in 2004 to accelerate genomics-based teams at universities and research centres such programs across sub-Saharan Africa. research on the Glossina genome. in India, Indonesia, Myanmar, the The CIDA/PSI project will cover some HAT is estimated to infect about 300 000 Philippines, Sri Lanka and Thailand. 2.5 million people in each participating people worldwide, with an additional The initiative has been designed to country. Community selection will be 60 million people in 37 African countries improve dengue prevention through better based on criteria such as high malaria considered to be at risk. The same species understanding of its ecological, biological burden and the existence of community- of tsetse fly also is a carrier of animal and social (“eco-bio-social”) determinants. based health networks. TDR will evaluate African trypanosomiasis (AAT), whose impacts of the programme in a subset of effects on agriculture have hindered Eco-bio-social research is a trans- the trial population in three countries. economic development in rural areas disciplinary research concept that TDR scientist Franco Pagnoni, overseeing and cost African farmers almost US$ 4.5 integrates research on environmental, the evaluation, estimates that the project billion every year. vector-epidemiological (entomological) could potentially avert up to 11 000 child and social factors that make communities According to Yeya Touré, TDR’s deaths in each of the four pilot areas. vulnerable to vector borne diseases such innovative vector control interventions as dengue. The aim of such research is HMM provides a regimen of pre- leader, a fully sequenced genome would to develop inter-sectoral approaches to packaged, unit-dosed antimalarials along represent a significant contribution to disease control, addressing issues that with associated health communication current and future vector control efforts. extend beyond traditional boundaries of materials. WHO has adopted HMM as This would happen in part by helping health-sector activities. a cornerstone of disease-control efforts, particularly in Africa, where half or more In the current study, research teams of all malaria cases are treated at home. are examining both effectiveness and community acceptance of locally developed Yet there remains “inadequate access vector control measures. For instance, in to ACTs for such treatment,” according WHO/TDR/Fischer Yangon, Myanmar, teams will examine to the 2008 World Malaria Report. how use of natural predators and biological larvicides such as dragonfly nymphs and For more info Bacillus thuringiensis serovar israelensis (Bti), as well as water covers, window Dr Franco Pagnoni: curtains and waste control measures, [email protected] may reduce vector densities. Stakeholder No. 82

Drug safety healthy pregnancies and their outcomes, along with data on pregnant women WHO/TDR establish exposed to drug treatment,” Islam said. Pregnancy Register “The women not exposed to the drug of WHO/TDR/Craggs A new Global Pregnancy Register to interest will act as controls, as it were, in collect epidemiological data on the comparison to women exposed to drugs impacts of new drugs for malaria, HIV of interest, enabling identification of any and other major diseases on pregnant increased (or no increased) risk of birth women is being established by the defects due to a drug.” Making Pregnancy Safer Programme of The plans and funding for pilot testing of WHO, TDR and several other WHO the register were approved at an informal departments. The register will provide consultation of the Malaria Pregnancy the evidence on drug safety in pregnancy Register Protocol in Geneva, 7-8 Novem- from resource-poor settings of Africa, ber 2008. This was a joint meeting Asia and Latin America. The register of TDR/MPS, the HIV Programme, will enable assessment of the risks and the Quality and Safety of Medicines Thailand is one of many Southeast Asian benefits of new drugs for HIV, malaria, Programme and the Global Malaria countries implementing new dengue leishmaniasis and other neglected tropical Programme of WHO. prevention projects. diseases, whose safety and efficacy in pregnant women have not been fully Pilot testing of questionnaires and methods to be used in the register are alliances, community partner groups established. being implemented in 2009 in targeted and volunteers will be involved in these Data on outcomes of such drug use are health clinics of at least five African activities. very scanty because pregnant women countries, prior to launching to scale. typically are excluded from clinical trials In Muntinlupa City, Philippines, part Development of systems for effective of new medications in order to protect of the metropolitan Manila region, the tracking of exposures to medicines, them and their unborn children, says Phase II work also aims to evaluate and awareness of its importance, are MO Islam, MPS director. relative acceptance by communities particularly challenging in countries 6 and local governments of community- Thus for major and life-threatening where capacity of antenatal care based vector control efforts involving diseases such as HIV or malaria, pregnant programmes to conduct such monitoring solid waste management, lid covers for women are often treated with safe but is currently weak. key containers, larvicides and health potentially less efficacious medicines until As part of the effort, WHO/TDR also are education measures. The social research cumulative evidence is gathered on the issuing calls to researchers worldwide element will include stakeholder safety of newer first-line drugs, often over for contributions of results from studies, meetings, key informant interviews and many years. reports and patient data sets on maternal focus group discussions. outcomes and prevalence of birth defects in Asia, Africa and Latin America. These Similar projects are taking place in will be included in a planned WHO Gampaha District, Sri Lanka; Chennai, systematic review of the issue (Please see India; Yogyakarta, Indonesia; and

WHO/TDR/Crump Calls on TDRnews back page). Chachoengsao Province, Thailand. The project in Thailand aims to measure >> See also TDR web link: the efficiency of insecticide impregnated safety of artemisinins in pregnancy window curtains and water container http://www.who.int/tdr/svc/research/ covers on the reduction of vector density antimalarial-policy-access/projects#_ measured by standard entomological Safety_of_the indices. EcoHealth volunteers and students will be engaged in applying the vector control methodologies at the For more info community level. Dr Melba Gomes: “The aim is to show that dengue [email protected] transmission can be reduced with an appropriate management of ecosystems, in different ecological environments.” said Dr Olaf Horstick, a TDR technical Yet de facto, many women become officer involved in TDR’s eco-bio-social pregnant while taking such drugs or efforts. “If this concept is successful the may be exposed before they or their studies should underline the importance health care providers are aware of the of inter- and intrasectoral approaches to pregnancy. Better tracking of subsequent the control of vector-borne, but also other pregnancy outcomes in such women, communicable diseases.” and comparison with their unexposed peers, can help establish the safety of new drugs or identify potentially problematic For more info consequences. Dr Johannes Sommerfeld: [email protected] “The important thing about this register is that it will collect data on unexposed No.No. 8282

• STAC commends TDR progress • WHO commends Chinese • Global spending on neglected LF elimination disease research • TDR affiliate is Gambia WR • TDR grantee lauded for TB TDR • ESSENCE pilots activities briefly research • Good clinical laboratory • Top Guatemalan award to practices TDR’s Byron Arana

STAC commends TDR’s as “significant”, and commended the 80% of neglected disease strategy implementation work of the other lines of TDR activity research spending is for as “satisfactory” to “excellent”. However HIV, malaria and TB TDR’s Scientific and Technical Advisory it noted the need to develop clearer Committee (STAC) met in Geneva strategies and indicators to ensure Of the more than US$ 2.5 billion spent on 23-26 February and commended that disease- endemic countries play in 2007 on neglected disease R&D, TDR for the good progress attained a pivotal role in global research, in TDR almost 80% went to HIV/AIDS, malaria over 2008. This was the first year of research in particular, and in setting and tuberculosis (TB), a new report on implementation of TDR’s new strategy, the health research agenda. STAC also global investment in new products for asked TDR to develop longer term which aims to give disease endemic neglected diseases says. indicators of the impacts of various countries a pivotal role in research that The remaining neglected diseases and TDR research activities on the success addresses diseases of poverty. disease groupings, including diarrhoeal of disease control efforts. illnesses, helminth infections and Under the new strategy, approved “Issues that are now coming into bacterial pneumonia and meningitis, by TDR’s Joint Coordinating Board in focus include a need for TDR to not each received less than 5% of global 2007, specific areas of TDR research 7 only better describe what we do but funding, according to the G-Finder focus include the early stages of the processes we use, i.e. how we report by the Australia-based George “discovery” research for new drugs function,” said Director Robert Ridley, Institute for International Health. and diagnostics tools, as well as following the meeting. “There needs In terms of the types of research implementation research aiming to to be a particular emphasis on how funded, the lion’s share of global improve drug, diagnostics and health we are going to help disease-endemic investment went to R&D of drugs and service delivery in real-life settings. Two countries play a pivotal role for vaccines, with very little dedicated key crosscutting TDR functions include research. This means we will be looking to diagnostics. Over 80% of global “stewardship” of research priorities very closely in the coming year at how funding was provided by only 12 aiming to identify research needs we measure and evaluate the impact organizations. The report recommends and gaps and improve knowledge of our work with developing countries, broadening funding so that all sharing, as well as “empowerment” and also how we walk the talk about diseases receive the attention they of research leadership in disease- disease endemic country leadership.” n deserve and more funders become endemic countries. The STAC termed involved in such R&D efforts. progress in TDR’s Stewardship function The G-Finder report, supported by the Bill and Melinda Gates Foundation, surveyed 2007 R&D investments of 134 donors and private as well as public programmes/agencies (including TDR) in 43 countries. The report on WHO/TDR/Schwarb funding trends aims to identify areas in which funding is lacking and where additional funding can potentially have a high impact. Around 20% of global funding was invested by public institutions and private companies into internal programmes, the report found. The remaining 80% was granted to external organizations either directly or via “intermediary” organizations such as TDR as well as product development partnerships (PDPs). Among the intermediary organizations, The STAC board at the 31st session held in February. TDR ranks eighth in terms of funding. No. 82

In making R&D investments, funders Cooperation (NORAD), the Swedish and adapt the guidelines as part of an need to assess the likely health return International Development Cooperation overall effort aiming to help disease against the cost of any investment, Agency (Sida), the Bill and Melinda endemic country laboratories meet discounted for risk, the report Gates Foundation, and the Wellcome international good practice standards. emphasized. This is a complex process Trust. See web link to GCLP guidance in the and factors include burden of disease, Subsequent to the pilot in Tanzania, the Publications section (page 34). n epidemiological trends, product ESSENCE Steering Committee also met shortfalls and the presence of other in concurrence with the Stakeholders funders in a given space. Meeting on Strengthening Research Partnerships for Neglected Diseases of WHO Director-General A complete briefing and link to the Poverty in Berlin March 16-19 to discuss congratulates China on document are available at: a work plan and to agree on partners’ LF elimination www.who.int/tdr/svc/news-events/ responsibilities. news/g-finder-reportn WHO Director-General Margaret Chan An ESSENCE website is being developed; congratulated China for its success in it will be unveiled at the meeting having eliminated lymphatic filariasis and launched shortly thereafter. ESSENCE tested in (LF) as a public health problem in a This website will reinforce the fact country pilot recent ceremony in Beijing to celebrate that although ESSENCE activities the landmark effort. Efforts of the new TDR-based initiative are facilitated by TDR, ESSENCE was initiated during a meeting organized Enhancing Support for Effective Noting China was historically one by the Sida, and it will extend beyond National Capacity Efforts (ESSENCE) of Asia’s countries with the highest LF TDR’s existing sponsors and partners to advanced with the staging of a country burden, Chan said “China has acquired involve other parties. Hannah Akuffo, pilot meeting hosted in March by the vast knowledge and experience over formerly of Sida, has been asked to act Commission for Science and Technology the last five decades and [the country] as executive secretary of the initiative. n capitalized on new strategies and tools (COSTECH) of the United Republic of 8 as it mopped up the remaining trouble Tanzania. Contact: Professor Hannah Akufo at spots in the country.” ESSENCE is an effort by a number of [email protected] international funders to strengthen CP Ramachandran, one of the key research capacity in low-income architects of TDR’s LF research initiative African countries in the spirit of the Good clinical laboratory that led to the development of key Paris Declaration on Aid Effectiveness. practice published by new control tools and strategies in the The effort aims to harmonize their WHO/TDR 1980s and 1990s, was among those respective efforts and improve present at the ceremony on 7 October transparency while increasing the 2008. He provided an update on the involvement of disease-endemic ongoing Global Programme for the countries in combating neglected Elimination of LF, established by WHO diseases. in the wake of a 1997 World Health The Tanzania pilot meeting in Assembly resolution (WHA 50.29) Arusha on 9-10 March established calling for worldwide LF elimination a dialogue between donors and by 2020. country representatives about the An estimated 120 million people undertaking’s collaborative aspects. The globally are infected with the parasite meeting, held under the leadership of From left to right, at the signing ceremony that causes LF, which is often cited as Hassan Mshinda, director general of are Vanessa Grant (GCLP author), Joy Eldridge the second leading cause of disability COSTECH, defined funder priorities and (BARQA Publications Committee) Juntra worldwide. n identified areas where activities may Karbwang-Laothavorn (WHO/TDR), Andy overlap. Participants also agreed on Ramsay (WHO/TDR) and Tim Stiles (GCLP author). mechanisms that could lend synergy to future capacity-strengthening efforts, Longtime TDR affiliate TDR has obtained a copyright according to Fabio Zicker, coordinator appointed WR in Gambia agreement from the British of TDR’s Policy and Development (PAD) Association of Research Quality Dr Thomas TY Sukwa, a longtime TDR portfolio and a TDR liaison to the effort. Assurance (BARQA), permitting WHO affiliate, has been named the WHO Members of the initial ESSENCE to publish and adapt BARQA guidelines Representative (WR) for the Republic steering committee include the on Good Clinical Laboratory Practice of the Gambia, one of Africa’s smallest United Kingdom’s Department for (GCLP). The agreement was signed at countries with a population of International Development (DFID), the Second Global Quality Assurance approximately 1.6 million. The recipient Canada’s International Development Conference in Edinburgh, 29-31 of numerous TDR grants, Sukwa Research Centre, the Ministry of October 2008. GCLP provides guidance completed master’s and doctoral Foreign Affairs of the Netherlands, the to laboratories analyzing samples degrees in public health at Harvard Norwegian Agency for Development from clinical trials. TDR will reproduce University in 1983 and Johns Hopkins No.No. 8282

University in 1992, both supported by of the government’s commitment to TDR’s Byron Arana TDR. strengthening the health sector. n receives top Guatemalan research award

TDR grantee lauded Scientist Byron Arana, part of the TDR for TB research team on research to support visceral TDR grantee Dr Saw Saw, a native leishmaniasis elimination, was the of Myanmar and a newly minted 2008 recipient of Guatemala’s highest PhD, was recognized last October research award, the Science and for outstanding achievements in Technology Medal. tuberculosis research with the Arana, a medical doctor who Melbourne School of Population holds a PhD in tropical medicine, Health’s annual Knowledge Transfer received the award for his work Award. In order to be considered on the epidemiology of cutaneous for the award, researchers must leishmaniasis in Guatemala, studies on demonstrate that their work will In the interim, Sukwa returned to the search for treatment alternatives, change health outcomes, policy or his native Zambia to work as an and for his scientific contribution to professional practice; that it represents epidemiologist with the Tropical national programmes for the control of a novel approach or major discovery; Diseases Research Centre (TDRC), onchocerciasis and Chagas disease. and, that it embodies excellence in then sponsored by TDR. He focused conceptualization, development, on epidemiological and clinical execution and application of research in schistosomiasis, human innovative, high-quality knowledge African trypanosomiasis and malaria, transfer methods. becoming director of the centre in 1994. In 1999, he became senior Through her doctoral work, Saw 9 lecturer in community medicine at Saw examined the role of public- the University of Zambia’s School of private partnerships in controlling Medicine. tuberculosis in vulnerable low-income populations in Myanmar. Her research In 2000, Sukwa joined the WHO findings touched on several knowledge Regional Office for Africa, where transfer issues, including the use of he served as the medical officer for referral letters by general practitioners malaria case management. There, The annual award by the Guatemala and the provision of health education Sukwa developed a framework to National Council of Science and on TB at the township level. guide countries through the adoption Technology (CONCYT) was presented to Arana by the Vice-President of the of new anti-malarial treatment policies Several of her recommendations, such Republic of Guatemala (Dr Rafael incorporating artemisinin-based as disseminating health education Espada), also the CONCYT President, combination therapies (ACTs). He also methods through former TB patients at a ceremony at the Guatemalan developed a regional antimalarial drug and establishing links between all GPs National Congress on 18 November resistance database. and the township health department, 2008. have been adopted by Myanmar’s In 2005, Sukwa set up a Communicable national tuberculosis programme for Diseases Research Unit within WHO/ The award is given to a researcher improving the delivery of DOTS care. AFRO, becoming Regional Advisor for for his or her contributions to the development of the scientific Communicable Diseases Research. While a doctoral student at the knowledge and/or technology, based Following his involvement in TDR- University of Melbourne, Saw Saw on the recommendations of an ad- sponsored high-level ministerial worked with a longtime TDR adviser, hoc committee reviewing candidate meetings in Abuja and Accra in 2006, Professor Lenore Manderson, and nominations. Arana was nominated by he was re-assigned to head the WHO/ co-supervisor Mridula Bandyopadhyay, the Institute of Research, Universidad AFRO Tuberculosis Unit, a position he both of whom nominated her for the del Valle de Guatemala, where he was held until his appointment as WHO award. Representative in the Gambia in July co-director of the Centre for Health Studies prior to coming to TDR in May 2008. “Saw Saw’s research brings together biomedical, social and cultural 2008. n Speaking on behalf of WHO last data and perspectives, ensuring November, Sukwa applauded the its dissemination and translation – Compiled with contributions Gambia’s support and collaboration into public health programs,” says from Patrick Adams with the organization. He cited Vision Manderson. “She continues to work 2020, the recently revised National with the Myanmar Ministry of Health Policy and the new Health Health in controlling TB and has been Master Plan as products of this very successful in securing further collaboration, which he called evidence grants.” n The world of TropIKA.net TropIKA.net is a web portal that aims to foster innovation and knowledge application relating to the infectious diseases of poverty. In recent months, all the sections within TropIKA.net have Selections from recent expanded considerably. The first of our specially TropIKA.net web news commissioned TropIKA Reviews, comprehensively addressing questions of key importance, will be published shortly.

TropIKA.net at the 2008 Global Ministerial News about TropIKA.net Forum on Research for Health

More people are visiting www.TropIKA.net. There has been a steady rise in ‘hits’ over the last year; in a typical

week there are now about 2000 visitors. However, we Olivier Asselin aim to improve on this figure, with the goal of making TropIKA.net the ‘one-stop shop’ for information and 10 debate about infectious diseases of poverty. If you have not visited our knowledge platform yet, please do so. If you are already a regular user, please pass on the word to your colleagues.

TropIKA.net ‘knowledge hub’ expands activities The Global Ministerial Forum on Research for Health, held 17-19 November 2008 in Bamako, Mali, was our latest and most An important new initiative on TropIKA.net is our ‘knowledge extensive knowledge hub effort to date (http://www.tropika. hub’ designed to facilitate sharing of information in a large net/svc/home/bamako2008). international health forum with potential impact on the Our special 22-member TropIKA.net team in Bamako included battle against infectious diseases of poverty. The aim of this six journalists and twelve rapporteurs – from no fewer than ten ‘knowledge hub’ is to provide information both to participants countries. All rapporteurs were postgraduate research fellows and to engage members of the broader community with a from disease-endemic countries – this has been a strategic strong interest in the issues under discussion – so that even if choice of TropIKA.net providing young researchers with an unable to attend you may feel “virtually” present. opportunity to participate in international policy fora. Before the meeting, background documents are made “There is a lot of value in this approach,” said Nicole Biros, who available online and dedicated collaborative workspace is coordinated the TropIKA.net ‘knowledge hub’ for Bamako. “It offered to organizers, presenters and other interested parties/ greatly benefits the team’s reporting that the rapporteurs are communities of practice. not only familiar with the science involved, but also with the During the meeting, daily overviews are posted by a special social and contextual realities that are an integral part of the TropIKA.net team of journalists and rapporteurs. The team puts issues being discussed.” together session reports, comprising analytical summaries The rapporteurs also build up new skills and diversify of issues and viewpoints, as well as links to the formal their interests as they experience these events not only as presentations, session conclusions and recommendations. researchers but as professional communicators who have to Profiles, interviews and a meeting blog are also featured on the provide information on research to a broader public. They website, as are photographs. After meetings are over, TropIKA. thus lend a unique perspective to their collaborations with net continues to maintain the ‘knowledge hub’ for ease of TropIKA.net’s journalists, who are in charge of the reports’ final reference and further follow-up/perspectives on the event and writing and editing. The Bamako team also was well-served the issues. n by these journalists’ diversity (half are based in Africa). Senior researchers from renowned institutions in Brazil, Ghana and Mali also worked with the knowledge hub, acting as arbiters on the review and editing of final reports. They, together with the knowledge hub’s collaborators from another cooperating agency, UNESCO, proved to be major assets to the undertaking, providing the team with valued regional perspectives and policy insights.

For the Bamako meeting, the team produced three daily overviews and 41 session reports. There were also seven news TropIKA.net No. 82 stories, one profile, and four entries to the blog. The final be produced and distributed to interested parties. Through Bamako Call for Action, adopted by 53 countries represented the knowledge hub effort, TropIKA.net offers a space where at ministerial level, is also available on the TropIKA.net website health research forums can open up to real-time universal (http://www.tropika.net/svc/specials/bamako2008/call- participation. On this site information and knowledge can for-action/call). flow back and forth, evolve and be stored, updated and easily retrieved. The network is an independent forum where issues One impact of the ‘knowledge hub’ coverage was a tripling of can be debated and moved forward with equitable access by the number of TropIKA.net website visitors during the period of all stakeholders. the meeting and for days thereafter – evidence of the real need that the service was able to meet. The Bamako ‘knowledge TropIKA.net plans more knowledge-hub participation at hub’ section will remain on the TropIKA.net website as a readily important health forums in 2009 and will post details of such accessible source of information on the event and a place forthcoming events. If you think this knowledge-hub approach where comments can still be posted. The regular TropIKA.net could enhance a planned health forum event on infectious team continues to add information via the blog when reference diseases of poverty in which you are involved, or if you are is made to the meeting in the press or elsewhere. A CD-ROM interested in participating on the knowledge hub initiative as a compilation of all Bamako knowledge hub contributions will rapporteur, please contact: Edith Certain, [email protected].

Selections from other TropIKA.net features

The world can well vector control strategies; appear every month and we we publish a summary, with afford the malaria we will be combining these will soon be increasing this commentary on each report with bednets and diverse number. We have reported and include a link to the vaccine public health measures. The on developments from document itself. This could A distinguished malaria combination will gradually Cambodia to Colombia, and be one of the most important researcher says that a bring this wiliest of foes on diseases that range from functions of our project. shortage of funds should under control.” n dengue to dracunculiasis. Examples of reports we have not stand in the way of Stories involving the http://www.tropika. recently featured include: developing an effective innovative use of technology • Meeting the Malaria net/svc/editorial/gn/ malaria vaccine. In an address are also featured. So if you Treatment Challenge, the Nossal20080331 to the Molecular Approaches want to know the latest Artemisinin Enterprise; to Malaria Conference, Lorne, developments in the fight • Good Practices in Health Victoria, Australia – also People at the top talk against infectious diseases Financing, International published as an Editorial of poverty, browse here: Bank for Reconstruction to TropIKA.net Opinion on TropIKA.net – (http://www.tropika.net/ and Development (World Sir Gustav Nossal said that Our profiles section svc/collection/news/). Bank): researchers have achieved (http://www.tropika.net/ • The World Can’t Wait: things that 25 years ago stakeholders/) features a From the journals More Funding Needed for would have been thought monthly interview with Research on Neglected We select for summary and a leading figure working Infectious Diseases, Families impossible. Research funding comment articles in peer- against infectious diseases USA; has also now reached a high reviewed journals that we of poverty. Our interviewees • Cough up for TB!: The level. He cautioned that it regard as being of particular have included researchers, Underfunding of Research is not only money that is importance. Review and needed, “We need better and clinicians, agency executives, for Tuberculosis and Other academics and people in opinion articles are included more benign governance Neglected Diseases by the industry. We ask them about as well as original research. structures in the developing European Commission, their work, achievements Nearly 400 articles have been countries and a great deal Médecins Sans Frontières. and outstanding included in this coverage. less corruption. We need to challenges. These in-depth forge true partnerships with The TropIKA.net blog interviews often elicit Reports developing countries with The blog offers an surprising information and Journal articles are indexed their scientists and health opportunity to comment on controversial comments. on PubMed and other officials putting major input articles that have appeared Experts profiled recently databases, and therefore into the programmes. We on TropIKA.net and on included Chetan Chitnis of specific topics are easy to need better physical and developments elsewhere. the International Centre for search. However, when human infrastructure in most The editorial team also uses Genetic Engineering and organizations produce of the developing countries.” the blog to alert readers to Biotechnology in India; Claire reports these often go Sir Gustav also warned of the interesting items published Panosian Dunavan, outgoing unread because there is dangers of overpromising; elsewhere on the internet. president of the American no comparable index or it is important to speak A surprising range of topics Society for Tropical Medicine register of such documents. of control rather than have been covered recently, and Hygiene; and Larry Geiter TropIKA.net uses a variety eradication. Nevertheless, he from the inspiring (an and Charles Wells of Otsuka of resources to identify concluded that, “...if malaria Indian project to provide Pharmaceuticals. new reports that relate to researchers do their work employment for leprosy- the infectious diseases of Contacts: well, then over the next cured patients) to the bizarre TropIKA.net news poverty. decade or two we will have a (a campaign to ‘save the Dr Ayaode MJ Oduola, [email protected] malaria vaccine that works; The news section has In our reports section Guinea worm’). Responses to we will have more and better expanded at a remarkable (http://www.tropika.net/ the blog entries are warmly Ms Edith Certain, drugs; we will have smarter pace. At least ten new stories svc/collection/report/) welcomed. n [email protected] No. 82 Cover story | Bamako 2008

The Bamako 2008 Global Ministerial Forum on Research for Health Making a paradigm shift

Health is the product of a complex social and environmental system that requires research and devel- opment spanning many fields – not simply the product of the presence or absence of disease and the medical ability to treat and prevent it. This was the message underlying the Global Ministerial Forum on Research for Health, 17-19 November 2008 in Bamako, Mali. The forum on the theme of “research for health” brought together researchers, policy leaders and civil society representatives from around the world, as well as leaders from other sectors ranging from environment and agriculture to security, sociol- ogy and economics. 12

Row 1: President Amadou Toumani Touré of the Republic of Mali opening the forum. Row 2: Luis Sambo, Regional Director, World Health Organization Regional Office for Africa; Robert Ridley, Director, TDR Row 3 (on left): Ok Pannenborg, Senior Adviser to the World Bank and representative to TDR’s JCB. Cover story | Bamako 2008 No.No. 8282

BAMAKO – In a dusty health centre a few hours south science, agriculture, climate, food security, economics, The Bamako 2008 Global Ministerial Forum of Mali’s capital, Bamako, a health worker pricks the politics, energy and trade. Some 1100 participants from finger of a feverish little boy, squeezes blood into a ma- 75 countries attended, including official delegations on Research for Health laria test strip, and waits until the result appears. It’s a from 53 countries led by ministers of health, education seemingly simple process – and yet 1 million African and technology. children still die every year from malaria because they This broad base of involvement also was reflected in do not get adequate diagnosis and treatment. the joint organization of this year’s forum by six part- The tragedy of malaria is not a new story, rather an old ners: the Council on Health Research for Development one, that nonetheless illustrates the continuing failure (COHRED), the Global Forum for Health Research, the of health systems to influence or manage the complex World Bank, the World Health Organization (WHO), chain of social, cultural, environmental and economic the United Nations Educational, Scientific and Cultural factors required to transfer research knowledge to pol- Organization (UNESCO) and the host country, the Re- icy and practice. public of Mali. Where health researchers and policy-makers have most In a keynote presentation, Luis Sambo, director of often failed is in taking a holistic, systemic approach WHO’s Regional Office for Africa, called for “the right to fighting disease, says George Amofa, Ghana’s deputy kind of research, now more than ever”. He cautioned director-general of health services, speaking at the re- that health research should not be considered a drain cent Global Ministerial Forum on Research for Health on resources but rather a producer of economic gains, in Bamako. citing a 2001 report of the Commission on Macroeco- nomics and Health. “We need research to guide health It was out of this emerging awareness that an agenda system reforms, as we have seen here in Mali. We need for Strengthening Research for Health, Development operational research to help give existing interventions and Equity was formulated as the focus of the Bamako a greater impact. Above all, we need research to per- discussions – bringing together for the first time stake- suade the world that investments in health must con- holders not only from the health sector, but also from tinue as one of the surest and best proven routes to a 13 stable and prosperous global society.”

Multi-disciplinary approaches to health

Photos Olivier Asselin The forum recognized that in order to fight priority diseases and improve the health of the world’s poor, policy-makers and researchers must address the de- terminants of health that lie beyond disease control, prevention and treatment. Sessions on the impacts of pandemics, global warming, food shortages and mili- tary conflicts offered insights into new approaches and models. “Between 40% and 60% of health outcomes can be ex- plained by forces from outside of the immediate health arena,” said Ok Pannenborg, a senior World Bank ad- viser and the World Bank Representative to TDR’s Joint Coordinating Board (JCB). These challenges range from weak supply chains that make it difficult for re- mote populations to access pharmaceuticals and other health tools to lack of reliable and affordable health services, unreliable food sources, poor environmen- tal health conditions related to unsafe drinking water, inadequate sanitation and poor housing, and climate change threats related to increased patterns of drought and flooding. “All these concerns transcend the boundaries of typical health sector parameters,” said Pannenborg. “Neverthe- less, they strongly influence human health.” “Malaria is an example of a health issue that requires a broader, systemic approach, just like HIV/AIDS,” said TDR Director Robert Ridley, chairman of a Bamako session on Pandemics and Infectious Diseases orga- nized by TDR (see Box 1 on next page). No. 82 Cover story | Bamako 2008

BOX 1. Pandemics and infectious diseases

Considering the links between poverty and dis- he said, is to assist countries to build this national ease was the aim of a TDR-sponsored session on capacity. pandemics and infectious diseases at the Bamako Development of regional capacity for clinical R&D 2008 meeting. is also a priority, according to Mark Walport of the George Amofa of Ghana’s health service argued Wellcome Trust. Collaboration, including among that the malaria pandemic has been largely countries in regions sharing common health ignored despite the fact that more than 1 million issues, is essential to successfully overcome the people annually die from the disease, with 90% challenges that infectious diseases and pandem- of those deaths in sub-Saharan Africa. ics present, including scientific challenges (e.g. transmission routes and viral ecology or effec- “We must take a systemic approach to malaria, tive field diagnostics), logistical challenges (e.g. looking at areas of research beyond the typical supply lines and location of stockpiles, large-scale boundaries of health,” said Amofa. He proposed delivery) and communication challenges (e.g. con- a range of measures to take, including develop- veying the risks of the disease to the public). ing a surveillance system for early detection of and response to outbreaks, designing better and Maria Guzman, virology chief at the Pedro Kouri more reliable diagnostics as well as communica- Tropical Medicine Institute, spoke on how Cuba tion strategies to promote behaviour changes, – a country with a low GDP – has found success and improving supply chains for antimalarials, in addressing the problem of pandemics. Cur- insecticide-treated bednets and diagnostic test- rently, infectious diseases only attribute for 8.8% ing kits. of mortality in the country. Cuba’s approach is anchored in the recognition of the universal right It remains important to ensure that research re- 14 to health and education. Elimination campaigns sults are translated into policy and action, Amofa for diseases such as polio, malaria and TB have said. Citing Ghana as an example, he noted that it involved mass immunization programmes and took many years for research demonstrating the distribution of free medications, such as antiret- effectiveness of bednets in preventing malaria rovirals for people with HIV/AIDS, by the public transmission to be translated into policies pro- health system. The keys to success, she said, have moting mass bed-net distribution. been political will, adequate funding, strong TDR Director Robert Ridley said that for research surveillance and epidemiological monitoring, to have an impact on diseases such as malaria, policy support for health and scientific research, and thus on poverty, the global health commu- and strong human research and medical staff nity also must address the gap between scientific capacity, as well as other features found in free- research and product development. Basic knowl- of-charge national health systems. n edge must be translated into usable products and strategies, particularly ones designed for poorly For more details and resources, see: resourced environments. Countries also lack http://www.tropika.net/svc/specials/ capacity to find solutions to their own specific bamako2008/session-reports/ problems, Ridley noted. One of the roles of TDR, pandemics-and-infectious-diseases

He called for available tools and knowledge to be har- vising evidence-based responses, as well as monitoring nessed into workable delivery strategies designed for and measuring those responses’ impacts and benefits. specific environments. Meeting the maternal health Millennium Development Making ‘research for health’ a reality Goal (MDG 5) will require an approach that extends beyond conventional health research, said Catherine For three days, the forum discussed and debated ‘re- Sanga, the United Republic of Tanzania’s assistant di- search for health’ as a way of improving the health of rector for reproductive and child health in the Ministry the world’s poor. The challenge is to turn this “into a of Health and Social Welfare. reality, not just a dream”, said Anthony Mbewu, presi- dent of South Africa’s Medical Research Council. The “Not only do we need to invest in health systems in resulting Bamako Call to Action on Research for Health order to see improvements, we need socio-cultural re- details the forum’s proposed solutions (http://www. search to find out why home delivery rates are so high, tropika.net/svc/specials/bamako2008/call-for-action/ and then how to better support women so that they call), some of which are briefly discussed below. come to hospitals for prenatal care and delivery.” This is where research can play a critical role by showing how Funding – Many conference participants noted that systems impact on health, measuring problems and de- while funding for research and control of particular Cover story | Bamako 2008 No.No. 8282

As part of this national research strategy, countries need to support local research institutions and develop their personnel’s capacity to “undertake, understand, translate and interpret research”, he said. In Mali, for example, there are several centres of ex- cellence for research in health and agriculture, with researchers working on important local issues such as drug resistance in malaria. However, most research for health in Mali is dependent on external funding, and thus at risk of being part of an external organization’s research agenda. Suggestions from the forum included the creation of a national research centre that would set the national From left to right: Stephen Matlin, executive director of the Global Forum for Health Research; Tim Evans, assistant director-general, WHO/ health research agenda and coordinate research ef- IER and Roger Glass, director of Fogarty International Center, National forts. In addition, the Malian government would need Institutes of Health, USA. to significantly increase its budgetary commitment for research. Research receives 0.15% of GDP, well below the 2% of GDP recommended by the Bamako Call to diseases, for example HIV/AIDS, is available and often Action. fairly accessible, funding to develop health systems is less easy to come by. The importance of expanding local health industries was also recognized. Initiatives like the Yaoundé Pro- “Funding is often driven by vertical lines, and if you cess are mapping health innovation activities in Africa want research funding to collaborate across sectors and by looking at specific needs of African countries in de- disciplines, it’s a challenge”, said Stephen Matlin, exec- veloping local R&D, manufacturing and distribution of utive director of the Global Forum for Health Research. vaccines, pharmaceuticals and diagnostic tests. 15 The Call to Action urges national governments to al- Monitoring/evaluation and implementation/oper- locate at least 2% of their health ministry budgets to ational research – Sometimes described as the “poor research. Funders of research and innovation and in- sister” of research, monitoring and evaluation (M&E) is ternational development agencies are asked to invest at a routine evaluation of programme performance based least 5% of development budgets in health research. on pre-established indicators such as coverage, surveil- One Indian initiative is addressing a lack of obstetri- lance, lag time to action and distribution of drugs. A cians in remote areas by paying private practitioners to somewhat related field, implementation/operational provide maternity services to poor women. KV Ramani research (IR/OR), typically examines how to overcome of the Centre for Management of Health Services at the bottlenecks in programme performance and how to Indian Institute of Management said this scheme has scale up programmes more effectively. Health policy- already saved the lives of almost 8000 newborns. makers increasingly recognize these efforts as key to the improvement of health systems. At Bamako, TDR “We also need to address issues of transportation to the and the Global Fund to Fight AIDS, TB and Malaria hospital, national insurance for people living below the co-sponsored special sessions on implementation/op- poverty line, the lack of midwives, poor blood bank erational research (see Box 3) and on monitoring and management and so on”, said Ramani. “All these issues evaluation (see Box 2). represent research questions that require funding”. The United Republic of Tanzania offers a relevant ex- Research priorities Country-led research strategies – ample of how research can lead to policy change, ma- often have been defined by donors. The forum’s Call ternal health expert Sanga noted in a session on the to Action recommended that “the global research for Millennium Development Goals and health. Her gov- health agenda should be determined by national and ernment’s research examined whether Integrated Man- regional agendas and priorities”. agement of Childhood Illness (IMCI) improves pae- “This is the only way we can be sure that the research diatric care quality as well as this care’s affordability questions asked are relevant to the countries them- and child survival rates. IMCI typically is delivered as selves”, said conference participant Fiona Godlee, edi- a package of interventions to address major childhood tor in chief of the British Medical Journal. illnesses (e.g. malaria, pneumonia and diarrhoea). It includes assistance to health workers to improve case “We need research that focuses on the needs of the management, effective drug supply and management, population”, said Martin McKee of the Brussels-based and improved hospital care through better supervision European Observatory on Health Systems and Policies, and timely referrals. a partnership of the WHO Regional Office for Europe and over a dozen governments, development banks The study found that districts using IMCI had a better and academic institutions. “This means doing context- quality of care with a lower cost per child and lower specific research. To do this, countries need a national child mortality than districts that had not implemented research strategy,” McKee said. IMCI. Sanga said, “Looking at these results, you could No. 82 Cover story | Bamako 2008

BOX 2. Monitoring/evaluation for research

A parallel session on monitoring and evaluation The Ethiopia team, however, found that invest- drew a heavy attendance at Bamako, underlining ments in PMTCT services had had a limited the new relevance being attached to the topic by impact in terms of their availability and actual health researchers and policy-makers as a means uptake of services. The team identified a need to to improve health services. collect data on survival rates and quality of life of patients on antiretroviral therapy (ART), the This session, sponsored by the Global Fund to sero-prevalence of HIV in high-risk populations, Fight AIDS, TB and Malaria in partnership with and the incidence and prevalence of TB (the most TDR, described the preliminary outcomes of a current data are five years old). five-year evaluation of disease control activities conducted under the auspices of the Global Fund In Malawi, the evaluation showed that the preva- in disease-endemic countries. lence of HIV had been reduced from 14.7% in 2003 to 12.6% in 2007, and that the number of people on ART had increased from 13 000 in 2004 to 146 000 in 2007. However, the massive focus on ART had diverted attention and funds from other major killers such as malnutrition and mater- nal and child mortality (due to eroding health systems). After completing its evaluation, the Zambia team recommended improving data collection to understand what was driving major trends. 16 Rolf Korte, Technical Evaluation Research Group (TERG), Was the declining child mortality, for example, Gesellschaft fur Technische Zusammenarbeit (GTZ) due to improved health education of mothers, an increase in breastfeeding, or the mass distribu- There were four presenters from Burkina Faso, tion of bednets? Ethiopia, Malawi and Zambia. Each country team All country teams concluded that M+E findings found that routine health information systems must be better disseminated and data/findings were generally very poor, and that more baseline used more effectively in decision-making. The data must be collected in the future. However, final evaluation report is due out in May 2009. n all teams felt that despite gaps in the data, the information they did collect could be used locally to motivate staff to improve health centres. For more details and resources, see: In Burkina Faso the evaluation team identified http://www.tropika.net/svc/specials/bama- particular issues, such as poor access (14%) to ko2008/session-reports/monitoring-evaluation Prevention of Mother to Child Transmission of HIV (PMTCT) services in the country, and rising http://www.theglobalfund.org/documents/ incidences of TB and malaria. me/M_E_Toolkit_lores_en.pdf

argue that IMCI could save the lives of 28 000 children Bamako Call to Action, which stated that “the nature in Tanzania each year.” She said the research already of research and innovation for health improvement ... has resulted in rapid scale-up of IMCI. is not sufficiently inter-disciplinary and inter-sectoral.” Marie Ruel, Food Consumption and Nutrition division The forum sought to improve dialogue between dif- director at the International Food Policy Research Insti- ferent government agencies (e.g. health, finance and tute (IFPRI), noted the importance of using such tools agriculture) on common concerns, as well as between to measure health system performance and to identify policy-makers, research leaders and civil society orga- best practices. “Monitoring and evaluation and imple- nizations. The Call to Action stressed the need for civil mentation research are the types of research where we society and community participation in the research can learn valuable lessons,” she said. “This is the type of process, and in making key decisions to do with re- search and investment. data can be used to scale up and replicate programmes elsewhere.” “Communities need to be empowered through re- search, and not disempowered, as often happens,” said Thelma Narayan, a Society for Community Health Moving intersectorality Awareness, Research and Action (SOCHARA) public ‘Intersectorality’ was another buzz word at the forum. health consultant in India. “Our dependence on ex- The importance of this theme was underlined in the perts needs to give way to a more participatory form Covercover storystory || CDIBamako study 2008 No. 82

of research, where communities are not just objects to be studied, but active participants and subjects in the research process”. Mbewu of South Africa’s Medical Research Council suggested that national AIDS councils in South Africa, which mobilize and coordinate activities across all sec- tors of society in the fight against HIV/AIDS, could be used as an example of effective intersectoral coordina- tion.

Innovation for health The final Bamako communiqué stressed innovation for Gil Samuels, Chair of Global Forum for Health Research and Carel health – not only in the product R&D chain but also in IJsselmuiden, Director, Council on Health Research for Development developing systems, strategies and solutions to address (COHRED). issues ranging from gender equality to patient safety and health communications/education. tion may help engage the African private sector more fully to deliver services, train health workers, manage New ideas in the communiqué included the creation supply chains and manufacture health care tools and of “convergence centres” linking universities, start-up equipment. Yet the forum’s communiqué also appealed companies and venture capital, and the strengthening of to the private sector to engage more proactively with e-health initiatives. Some of these are based on simple other stakeholders. It called upon researchers to improve but innovative software technologies accessible through their translation of research results into commonly un- mobile phones. derstood terms and messages, and for policy-makers New investments by the World Bank Group, the Bill and to use research more effectively to guide decisions on Melinda Gates Foundation and the Rockefeller Founda- health policy. 17

BOX 3. Implementation/0perational research

This special session emphasized the increasing TDR Strategic Alliances Coordinator Jane Frances importance of operational and implementation Keyenga-Kayondo spoke about TDR’s role in build- research (OR/IR) in determining how well health ing in-country research capacity. “This type of programs are working and how they can be im- research is important,” she said, “because proven proved. As one presenter said, “You can distribute disease control tools fail, and often it’s not known bednets, but if you don’t know what’s happening why. You need evidence at every stage and in all to them and if they are being used, your money settings to improve the quality of interventions.” and time is going to waste.” The session recommended that OR/IR play a more The forum heard that OR/IR can help identify and pivotal role in national health services and in solve problems in implementation, help policy- donor-funded disease control programmes. The makers reach evidence-based decisions, improve capacity of researchers to conduct this type of re- program quality, strengthen public health efforts search also should be increased. The Global Fund and help staff understand why and how well has already encouraged the inclusion of OR/IR in their programmes are working. OR/IR can also the programmes it supports, and has produced a identify new directions in health programming. framework available on its and TDR’s websites to guide OR/IR researchers in good practices. n Irene Akua Agyepong, Greater Accra regional di- rector in Ghana’s Health Service, described recent operational research undertaken to find out why, in 2002, bed-net use across Ghana was very low. Initial research showed that bednets were not For more details and resources, see: available for purchase in the markets, which led http://www.tropika.net/svc/specials/bama- to their free provision. However, further research ko2008/session-reports/implementation-opera- revealed that children under five, who are at tional-research high risk from malaria, were still not sleeping http://www.theglobalfund.org/documents/me/ under the nets. This was a powerful indication FrameworkForOperationsResearch.pdf of the need to understand the complex factors that influence bednet use and to adapt interven- http://www.who.int/tdr/svc/publications/ tions accordingly, via education and other social training-guideline-publications/framework- measures. operation-research No. 82 Cover story | Bamako 2008

BOX 4. MRTC is African model for research training

MRTC Co-director Ogobara K Doumbo is also the head of a vaccine-testing programme, oper- ated jointly with the NIH Laboratory of Parasitic Diseases. A staff of more than 50, nearly all from Mali, carries out research on malaria control, as well as on filariasis and leishmaniasis. From 1992- 2008 the MRTC staff published, with internation- al collaborators, more than 240 peer-reviewed articles in highly regarded journals. Yéya Touré, currently leader of TDR’s vector control research activities, was MRTC’s found- ing director and remained there until 2001. The Mamadou Coulibaly of the MRTC, also profiled in the article on center is now co-managed by Doumbo and Sékou biosafety course on page 32. Fantamady Traoré. Mali’s Malaria Research and Training Center The center was one of Africa’s first to develop a (MRTC) was a much-visited site by participants molecular biology unit and focuses on Anopheles at the Bamako 2008 Global Ministerial Forum. gambiae, the region’s main carrier of malaria. The center, dedicated to research on malaria and There are 12 research groups with laboratories, other vector-borne diseases, provides a useful all led by Malian PhDs and funded by research model for other countries. grants. 18 MRTC aims to build capacities in entomology, A bioinformatics unit was established with initial molecular biology and epidemiology; to research funding by TDR for two-week training sessions. malaria control; and to collaborate internation- The NIH now provides computers and sends ally to develop vaccines. It was established in scientists to teach the course. TDR funds 10 to 1992, preceding by two years the founding of the 15 trainees, and then selects and funds two of University of Mali (which changed its name to the the top research proposals coming out of this University of Bamako in 2000). training. Other TDR contributions include support for development of mass treatment and vector The center was established through collaboration control strategies, for characterization of filariasis between the School of Medicine and Pharmacy transmission and for research into schistosomia- (now Faculty); the USA-based National Institutes sis and drug resistance. n of Health (NIH) and the Rockefeller Foundation; and WHO/TDR. NIH remains the main supporter while current partners include Mali’s health – By Jamie Guth in Bamako, with a contribution ministry, TDR, WHO, Institut Pasteur, the Gates from Beverly Stearns Peterson Foundation and universities in the USA, Europe and Africa.

“Research should not substitute for action,” said the dialogue launched at Bamako in the spirit of a common World Bank’s Pannenborg. “We need to ensure that understanding that health is a critical investment in de- countries implement policies as a follow-up to research.” velopment. “All of the ministers of health, research, sci- ence and technology, education, food and agriculture, Clearly, however, international and donor organizations and environment here must continue their dialogue also must play leadership roles. In light of that need, the once they return home and coordinate their efforts in Swedish International Development Agency (Sida) is all programmes that affect health,” Mbewu said. y leading ESSENCE, a new initiative supported by TDR to bring donors together in a more harmonized approach (see TDRbriefly, p. 8). A TDR-led stakeholder meeting For more details from the forum, including session and daily 16-18 March is also addressing the all-important topic reports, profiles of key players, the call to action and communiqué, and coverage of earlier regional meetings that fed into this forum, of donor coordination. see: http://www.who.int/tdr/topics/ir/cdi.htm In November 2009, Bamako’s participants will review progress so far at the Global Forum for Health Re- Contacts: search annual meeting, Forum 2009: Innovating for Dr Jane Kengeya-Kayondo (OR/IR and M&E sessions) the Health of All, in Havana, Cuba. Mbewu of South [email protected] Africa’s Medical Research Council said that until then, Jamie Guth forum participants should continue the intersectoral [email protected] Focus | Capacity building in Liberia No. 82

‘Greening’ a clinical trial site in a remote area Reviving research in Liberia

The TDR-sponsored Phase III clinical trial for moxidectin, a new drug candidate and potential cure for on- chocerciasis, is one of the largest undertakings in TDR’s history. Funded largely by a US$ 6 million donation from Wyeth Pharmaceuticals and contributions from the African Programme for Onchocerciasis Control (APOC), the initiative is not only testing a new drug for river blindness. It is building research capacity and stimulating sustainable development in countries recovering from conflict. In fact, mud brick construction of a modern clinical trial center in a remote corner of Liberia, as well as pursuit of clean solar and hydro- electric energy for the Liberian and Democratic Republic of Congo sites, make the trials potential models of environmental sustainability in the health sector. For TDR scientist Annette Kuesel, the project has been a journey down a road marked by unforeseen challenges and unexpected rewards. AFRO/LBR/Bolay 19

Community manufacturing of the sun-dried mud bricks for the research centre.

It was a muggy mid-November afternoon in 2008 The US$ 8.5-million Phase III clinical trial and capacity when Kuesel arrived at Roberts International Airport, building effort, supported by the US$ 6 million Wyeth 35 miles south of Monrovia. In June 1990, Robertsfield donation and contribution from APOC is due to begin as locals call it, had been the focus of a fierce battle this spring and summer and continue for three years. between rebels and government forces. The badly dam- It is being carried out in remote areas of Africa not yet aged main terminal still stood vacant, while across the reached by the annual ivermectin treatments currently tarmac several UN planes unloaded supplies for the used to combat the disease in much of sub-Saharan Af- 14 000 peacekeepers still scattered throughout the rica. country. Of the study’s four sites, two are in the Democratic Re- Kuesel had come with Varalakshmi Elango, a labora- public of Congo, one is in Ghana, and one is in Bola- tory physician and TDR clinical monitor, to work with hun, Liberia. The latter is a small, battle-scarred vil- a team of researchers from the Liberian Institute of Bio- lage in Lofa County, just a few kilometers from Liberia’s medical Research finalizing preparations for the Phase northern border with Guinea and Sierra Leone. III clinical trial of moxidectin. Moxidectin is a drug Setting up a clinical trial in a remote setting is a com- candidate for onchocerciasis (river blindness) eradica- mon feature of much TDR-supported research. In fact, tion owned by Wyeth Pharmaceuticals. a conscious effort is made to conduct research in areas No. 82 Focus | Capacity building in Liberia

not well served by health or research facilities, so as to ter a few hours, near Zorzor, we came up on a massive improve access to new tools and also strengthen capacity mud hole, a small lake. A minibus traveling in the op- of health and research services. Still, Bolahun, as Kuesel posite direction had become stuck in the middle. We fi- would discover, embodied a kind of extreme. nally managed to pull the bus out with both of our 4x4s hooked one to the other. But before we could go through During the war, Bolahun had been a point of passage for the hole ourselves, another oncoming car drove in and rebels to and from Monrovia. Like much of the area, it had also became stuck. We pulled that one out too, and yet been ravaged. Schools were burned, clinics were looted another blocked our way, and then another, and another. and once-bountiful farmland had been abandoned. Those We pulled one vehicle after another out without getting a who had remained in Bolahun had endured the daily chance to go through ourselves. By then it was dark, we misery of life in a war zone. Yet the area’s relative isolation were not even supposed to be on the road, and Fatorma in postwar Liberia was precisely what recommended its decided we should try going around the hole somehow. election as a moxidectin trial site. Lofa County’s residents He hooked the winch to a tree at the top of a hill by the had not had access to annual ivermectin (Mectizan®) side of the road and tried to drive the car up, to no avail. treatments available in many onchocerciasis-endemic We then considered returning to Monrovia and taking African regions. a helicopter the next day, but we weren’t sure we would These treatments have dramatically reduced oncho- make it back in time. So we stayed put.” cerciasis symptoms and intensity of infection over two Four hours later, there was a break in the ‘flow’ of on- decades. Ivermectin-naïve subjects thus represent the coming traffic, and the WHO convoy finally powered best test of moxidectin’s efficacy. Phase III trial find- through. Kuesel, who had remained with the vehicle ings here, as well as in similar communities in DRC throughout the ordeal says, “that was quite a lesson for and Ghana, would be of great scientific relevance (see me. I’ll never again go in the rainy season without solid box). boots to wade through knee-deep mud to a ‘bathroom’.”

Getting there Capacity building in remote locales 20 In the years since the war, Bolahun has slowly begun to recover. Yet during the dry season, the 220-kilometer As hard as it had been to get to Bolahun, the mud was drive from Monrovia over mostly dirt roads can take up merely a precursor of other hurdles to be overcome be- to 10 hours. In the rainy season, it can take twice that fore the Phase III launch. On her very first visit to Bo- or longer. lahun in April 2007, Kuesel had encountered a place as devoid of infrastructure as any in which she had ever worked. Bolahun had no public transportation, no sew- Guinea age system or sanitation, no phone service or source of Sierra Leone electricity, and not a single concrete building. “We didn’t realize when we planned the budget that we would actually have to build a research centre. We were truly starting from scratch.” When Kuesel asked how building materials would be supplied, Bolay and Salifu explained that sun-dried mud bricks would be Côte d’Ivoire produced locally. “Seeing a question about

Map: Lisa Schwarb • Photo: WHO/TDR/Kuesel WHO/TDR/Kuesel • Photo: Lisa Schwarb Map: the durability of such a building plainly Monrovia Liberia written on my face, they laughed and pointed to the mud-brick church next door,” she says. “It had been there, they observed, since 1942.” By the time Kuesel made her third visit to Bolahun in November 2008, workers were putting the Kuesel well recalls setting off from Monro- finishing touches on a clinical re- via to the village on her second visit there in search centre complete with labora- September 2007. She was traveling with three tories and examination rooms, meeting Liberian colleagues: Fatorma Bolay, disease preven- room and computers. The centre also includ- tion and control officer in WHO’s Liberia office and act- ed several “guest” quarters where, given the poor roads ing director of the Liberian Institute for Biomedical Re- and transport, subjects could spend the night between search (LIBR); Henry Salifu, national coordinator of the daily examinations required by the protocol. health ministry’s Onchocerciasis Control Programme; Outside were parked the three TDR-provided 4x4 ve- and Fred Sirleaf, the study coordinator. hicles to transport subjects and staff to villages, and two “Our two-vehicle convoy had passed Gbarnga, where the 20-foot containers filled with equipment and consum- paved road stops, and from there on you could hardly ables, including 15 motorbikes to ease movement by re- call it a road; it was more like a series of mud holes. Af- search and health centre staff to surrounding villages. Focus | Capacity building in Liberia No. 82

Sites untouched by ivermectin are ideal sites for moxidectin trial

Timing and location of the Phase III moxidectin clinical trial is critical to its success. For the study to provide reliable data on the safety and efficacy of moxidectin, it has to occur before the arrival of ivermectin from the Merck Mectizan® (ivermectin) Donation Program. Donated ivermectin has reached more than 55 mil- lion Africans in 34 African countries over the past two decades, largely through an innovative community- directed treatment strategy developed by TDR and implemented by the African Programme for Onchocer- ciasis Control. In Lofa County, however, ivermectin distribution was delayed due to the civil war, and paradoxically as a result, its residents are ideal candidates for the trial of moxidectin. Kuesel explains: “Ivermectin is a very effective microfilaricide. It kills the small worms that cause the disease symptoms (blindness, skin rash, le- sions) and disease transmission. However, the adult worms, which live in their human host for up to twelve years, continue to produce microfilaria. Therefore you have to provide for the mass distribution of ivermec- tin annually to residents of endemic areas in order to keep the number of microfilaria low.” While low microfilaria levels eliminate or prevent progression of disease symptoms, they make it very difficult to measure the effect of moxidectin on the macrofilaria. This explains the importance of launching the study of moxidectin in areas like Lofa County, before ivermectin treatment is introduced. From the research done so far, it appears that moxidectin is likely to be as effective a microfilaricide as ivermectin. “But it needs to be able kill or sterilize the adult worms, and be safe for large-scale use, to qualify as a potent tool for global eradication of onchocerciasis,” says Kuesel. Should critical Phase III trials show positive results in three years’time, that would be a big step towards the eradication goal – but not the final one. Larger Phase IV trials would then be initiated to ensure that the drug is safe and effective in mass treatment. n 21

(In one DRC site bicycles are being used due to inferior road conditions.) There was still a well to be dug and a water tower to be built, but those tasks would have to wait for the dry season. WHO/TDR/Kuesel

Setting the tone and training the staff On the day Kuesel and Elango arrived, Bolay called the first meeting in the new clinical research centre, where he introduced the TDR team to the Liberian study staff. But Bolay also had to deliver an important message: “He explained that this trial presents a unique opportunity for the team and for Liberia. Many of the trial’s staff members were making a sacrifice by moving to Bolahun from Monrovia, even those who were returning ‘home’ to this area after having fled during the war. “And he stressed that every team member, from driver to Study staff conducting a ‘dry run’ for discussion of the study in physician, had been recruited because of their qualifica- community meetings. tions and capabilities. If they took advantage of the train- ing, worked collaboratively, and established the right “We wouldn’t be where we are now without him.” work habits and attitudes, the trial would be a personal success and a national one.” After the meeting, Kuesel got to work. Along with Elan- go, she conducted staff training sessions on the research An expert in transmission dynamics and control of on- protocol, on Good Clinical Practice (GCP) and Good chocerciasis, malaria and schistosomiasis and a former Clinical Laboratory Practice (GCLP), and on standard TDR grantee, Bolay had stayed in his native Liberia operating procedures (SOPs). throughout the war, passing up higher-paying positions in Europe and the USA to coordinate emergency health “Conduct of clinical trials according to GCP and GCLP action for victims of violence. If there was anyone with ensures that data obtained are accurate, credible and com- the poise and experience to manage a major clinical trial parable across different trial sites,” Kuesel observed. “And in a place like Bolahun, it was Bolay. GCP safeguards the well-being of subjects and respects their rights. No matter how disadvantageous something “Officially, he’s the institutional principal investigator on might be for the study, if it’s better for the subject, it will the study. But in reality, he’s so much more,” says Kuesel. be done.” No. 82 Focus | Capacity building in Liberia WHO/TDR/Kuesel

New clinical trial research centre stands ready for operations.

One of the most important aspects of GCP is the pro- Setting up the equipment cess of informing potential trial subjects about the “In selecting the equipment to be provided both to Bo- study and its risks. Here too, the moxidectin research lahun and to the trial sites in DRC, we had to take their presents unique challenges. In most clinical trials pa- remote locations into account,” Kuesel explains. For in- tient recruitment will be a result of a routine visit to a stance, from Bolahun there is no way to get samples to health centre. But people rarely seek treatment for on- a central, accredited laboratory. So the village research chocerciasis so a more proactive approach is required. 22 centre needed a laboratory with analytical equipment “The study team goes to villages in the area and holds facilitating strict quality control and assurance. community meetings in which they discuss the study For that purpose, Kuesel had purchased some of the plans with the community members,” Kuesel says. more sophisticated machinery on the market, “the kind “They then provide those interested with further detail that would leave minimal room for operator error.” As about risks as well as benefits, alternatives, potential a precautionary measure, Kuesel also had ordered du- compensation for lost work – anything that could influ- plicates of all critical equipment. Getting an engineer ence a person’s decision to participate.” to fix, say, a biochemistry analyzer would be a very time-consuming and expensive endeavor in Bolahun. In order to prepare for such a process, Kuesel and Moreover, were refrigerators to malfunction, even for Elango simulated an informed consent meeting. “We a short period of time, the loss could have devastating gathered the clinical trial staff together,” says Kuesel. consequences for the study: “so we made sure to have “One person read aloud, paragraph by paragraph, from backups.” Finally, since there was neither cell phone the informed consent form, and others pretended to be transmission in Bolahun nor a nearby courier service members of the community, asking questions that they (common in less remote areas of Africa), satellite-based thought people would raise. phones and internet had to be ordered. “It was a lot of fun and it was also instructive. For in- “We had about 80% of the equipment and consumables stance, the study field assistant asked if he could bring that we had purchased for the study and the centre his children to participate in the study. He said, ‘I have shipped to Bolahun in the two 20-foot containers,” she a child of 15, a child of 15-and-a-half, and a child of recalls. “And we spent the first two days of our Novem- 16...’ And I thought to myself, three children born in ber stay in Bolahun unpacking it all.” the space of a year? How is that possible?’ “But then Even so, the satellite dish for internet and phone access I realized my mistake. I had forgotten that in Liberia was yet to be installed. So Kuesel had a unique way of polygamy is practiced.” keeping in touch with the outside world. Together with Learning to understand cultural cues is one of the her driver, Mr Massalay, she would drive some two ki- things Kuesel loves about her job. “That’s also when it lometers out of town everyday and walk up to a hilltop becomes clear how important it is that staff members where she could capture a faint cellular phone signal. are from the study area, and that everybody, including At the pre-appointed time of 4 p.m., her colleague in your field assistants and your drivers who interact with Geneva would phone. the subjects outside the ‘physician-subject’ or ‘nurse- Yet even once the phone and internet connections, as subject’ relationship, understand the study well,” she well as other purchased hardware, are finally up and says. “Local staff understand the customs and beliefs of running this spring, the biggest barrier to a smooth the communities, and they can help explain the study successful clinical trial in Bolahun has yet to be entirely to potential study subjects in a way that is meaningful.” overcome. Focus | Capacity building in Liberia No. 82

Powering a future As the search for a donor of solar technology continues, Kuesel has realized that in fact, what the team has been That barrier does not involve recruiting subjects or im- developing in Bolahun, out of practical need rather than porting equipment or even building a clinical research any deliberate ideology, is a field health research facility centre out of mud bricks. In fact, the trial sites located in that also has the potential to become a model of environ- the Democratic Republic of Congo are in places almost mental sustainability in the health sector. as resource-poor as Bolahun. “We have built the centre for clinical trials to interna- What sets Bolahun apart, however, is the fact that the tional standards using mostly mud-bricks manufactured village, like much of Liberia, lacks a stable source of elec- locally. We designed the building with features that keep tricity and thus a reliable source of power for the equip- the temperature in the rooms relatively low without air ment essential to a study. “Thinking about how our conditioning. This was a cheap yet durable method of convoy had become stuck in the mud on the way to Bo- construction that also has a minimal ecological ‘foot- lahun made me shudder at the thought of having to rely print’,” she says. on diesel fuel generators for the research centre,” Kuesel “We also have sought ways to dispose of the centre’s says. “So when I suggested to Fatorma and Henry that we health waste in a manner that is safe and sanitary, al- try to find a fuel-independent energy source, they loved though we would still like to go further here in terms of the idea. They told me about Liberia’s ambitious pre-war developing a waste disposal system that is more envi- plans to supply all of the country’s health centres with ronmentally friendly. For the diesel power generators, we solar power. The war had stopped them from carrying have explored the possibility of using scrap waste from out the plan, but it’s still alive. surrounding rice fields and banana plants as a source of “By installing solar power at the centre in Bolahun, we biofuels. And then, of course, there is our quest to de- would not only increase the likelihood of success for this velop solar power generation...” trial, but we would also lower the cost of future research On one of their first nights in Bolahun, Kuesel and undertakings here, leveraging even greater benefit from Elango were preparing the next day’s session when they the investment made here in capacity building.” saw a teenage boy carrying two chairs to the street- 23 In her efforts to secure solar power for the clinical trial light newly installed for the research centre’s secu- site, Kuesel talked to Rolf Korte, then chair of TDR’s Joint rity. He sat down on one and placed his books on the Coordinating Board, who put her in contact with Dieter other, and Kuesel snapped a picture. “He was doing Uh, alternative energy head at the German Gesellschaft his homework,” she says with a smile. “It drove home fuer Technische Zusammenarbeit (GTZ). Uh arranged to me the impact a fuel-independent energy source for Matthias Bergmann, a consultant studying renewable would have, way beyond clinical research. I know that energy sources in Berlin, to design a solar power system somebody out there will want to be a part of this.” for the Liberian site. He designed the system with three potential energy gen- eration capacities: 1) to support only the study’s energy needs; 2) to support expansion of the research centre, and 3) to power the health centre and nearby Bolahun WHO/TDR/Kuesel High School. The high school, founded by monks in 1925 and further developed by the Peace Corps in the 1960s and 1970s was the pride of the northern Liberian region prior to the war. Its graduates have included a vice-president of Liberia, university presidents, associ- ate supreme court justices, lawyers, nurses and doctors, including Bolay. Recently, the school has been rebuilt thanks to the contributions of alumni. Under the light of the research centre. “It was clear from the start that the price tag for solar power was too high for our clinical trial budget, despite As with any drug undergoing clinical trials, there is the the fact that it is relatively ample thanks to the Wyeth chance that moxidectin may not succeed. Even so, the donation,” says Kuesel. “But we were optimistic about investment in human and infrastructure capacity will recruiting a donation of solar panels.” remain. “We’re not just building capacity for this clinical Unfortunately, the company initially approached de- trial. We’re helping Liberia recover from war, revive its clined to make a contribution. For the time being, the research track and stimulate sustainable development – y clinic is running on conventional diesel generators, and we’re starting in Bolahun.” while other donors are sought. - Written by Patrick Adams Diesel generators can’t offer peace of mind. “We lose a lot of sleep worrying that both the generator and back-up generator will simultaneously break down,” says Kue- sel. And these provide only enough energy to run the Contact: Dr Annette Kuesel [email protected] research centre. No. 82 Article | Research on new HAT treatment regimens

Clinical trials in northern Uganda TDR explores shorter HAT treatment options

TDR is conducting clinical trials for two new drug treatment regimens for human African trypanosomiasis (HAT). If successful, these would significantly reduce length of treatment for both early and late stages. In 2008, a TDR expert team visited clinical trial sites in northern Uganda. They observed how the trials have strengthened human and infrastructure capacity as well as underlining the need for greater community awareness of HAT symptoms so that people can be treated early. WHO/TDR

24

Screening for HAT in Adjuman, Uganda.

While prevalence is generally on the decline, human Af- stage disease, there is a potential to blunt the emergence rican trypanosomiasis (HAT), or sleeping sickness, re- of resistance to the current monotherapy treatment with mains an important public health risk in many remote eflornithine®, where an increased rate of patient relapse areas of Africa, where it is endemic in 36 sub-Saharan has been observed. countries (see box: About HAT). For late-stage T.b. gambiense, the Uganda trials are com- Yet there are a very limited number of drugs available paring a nifurtimox+eflornithine combination with the for HAT treatment. And their unwanted side effects, as standard eflornithine regimen to see if the combination well as the lack of prospects for the development of new drug treatment can be as at least as safe and effective, products, have prompted TDR-supported researchers to while being delivered in only 10 days, as compared to the examine innovative new modes of treatment using exist- current 14-day regimen. The shortened regimen being ing drugs. These include a new therapeutic drug combi- tested also would require only two infusions daily plus nation for the late stage of the T.b. gambiense form of the oral medication, as compared to the present regimen of disease as well as a shortened drug regimen for its early four infusions. The trial involving 109 patients is due to stage. finish in June, after which results will be analyzed.1 The two treatment regimes hold the potential to reduce A second study, launched in February 2008, assesses a unwanted side-effects of drug toxicity and to simplify three-day course of pentamidine for early-stage HAT (t.b. and lower costs of treatment. Also, in the case of late gambiense) against the current 7-10 day regimen.2 The Article | Research on new HAT treatment regimens No. 82

trial is based upon a review of pharmacokinetic informa- tion and a preliminary study indicating that pentami- dine has a prolonged elimination periodin the individual WHO/TDR treated, so a shorter regimen might be as effective while reducing unwanted adverse effects.3,4

Late-stage gambiense disease Study of the nifurtimox-eflornithine combination for treatment of late-stage HAT is taking place at two clini- cal trial sites in northern Uganda: Omugo Health Cen- tre and Moyo District Hospital. The two sites were selected based on their track record as HAT treatment centres and the availability of staff that could be trained to undertake the study. The study is part of a broader collaborative effort with the Drugs for Neglected Diseases initiative (DNDi) and Epicentre, a Paris-based clinical studies group, to seek alternative Patient in Omugo Health Centre, northern Uganda. treatments for gambiense disease. The drugs used in the study are donations from Sanofi-aventis (eflorni- A shorter drug treatment course would not only vastly thine) and Bayer AG (Nifurtimox - Lampit). simplify treatment and lower its costs, but it would also lessen the risk of pentamidine accumulation in the During the visit to Omugo, the TDR team attended a body and related adverse effects. The trial is of particu- formal handover to the health centre of facilities made lar importance now in light of the fact that the only oth- available for the trial. TDR had helped to renovate and er drug candidate in the pipeline for early stage HAT, equip a 22-bed clinical trial ward at the centre as well pafuramidine (DB289), was placed on clinical hold in 25 as a laboratory, noted the site’s principal investigator, late 2007 by its pharmaceutical developer.6 Freddie Kansiime. With patient recruitment finished and the study nearly completed, these facilities were In this trial, however, recruitment of HAT patients handed back to the health centre for routine uses. This has been a particular challenge. Identification of HAT illustrates how the human and infrastructure capacity victims at early stages of the disease is often difficult, developed for the trial will have long-lasting impacts on and symptoms may be confused with other ailments. health services. Access to area villages, where early-stage cases of HAT may be found, has proven to be a challenge. It is even At the ceremony, a local member of Parliament, E difficult for the health centres at Adjuman and Moyo Wadri, described HAT as a major public health prob- to communicate; even though they are quite close to- lem in that area and emphasized the need to develop gether, they are separated by the Nile. new diagnostics for early diagnosis and treatment as well as more effective drugs. To illustrate the complexity and high resource demands required, Moyo’s principal investigator, Jimmy Opigo, “HAT patients who go undiagnosed only to be treated took the TDR team to observe a mobile screening activ- in the late stages of the disease often suffer from per- ity in one of the area villages. The village was in a very manent physical, neurological, intellectual and/or men- remote area with poor roads and difficult access. But tal disabilities, and they may become a burden to their upon arrival, the TDR observers found that hundreds community,” he said. of villagers had already been screened without a single case of HAT being found. Diagnosing and treating HAT Although HAT certainly lurks in this region, communi- (gambiense) in its early stages ties themselves are generally not aware of the signs and symptoms, and therefore fail to seek treatment early. To In Moyo and Adjuman, another remote Nile River vil- support this observation, Dr Opar of Adjuman’s hospital lage in northern Uganda, a clinical trial of a three-day talked of a divorced patient who had been abandoned course of pentamidine for early-stage HAT is also under by her family and declared as either suffering from HIV way. or mental illness. When the patient went to the hospi- Launched in February 2008, the trial is examining tal, she was diagnosed with very late-stage HAT and whether the current 7-10 day regimen of daily intra- was under treatment at the time of the team’s visit. The muscular injections with pentamidine could be re- doctor promised to step up the sleeping sickness aware- duced to just three days.5 The shorter course is based on ness campaign to ensure that patients seek treatment pharmacokinetic evidence indicating that pentamidine early and avoid the complications of late-stage disease has a prolonged elimination period; the drug remains and its consequences. It was also observed that lack of at therapeutic levels in the body for over 29 hours after awareness may account for the slow rate of recruitment a single IV administration. into the study. Some 80 patients have been recruited, while the target is 200. No. 82 Article | Research on new HAT treatment regimens

WHO/TDR About HAT

Transmitted by tsetse flies, HAT occurs in two forms: a generally acute form caused by Trypanosoma brucei rhodesiense and a usually chronic form caused by Trypanosoma brucei gambiense. Each form of the disease presents as Stage 1 (also called early or haemolymphatic stage) or Stage 2 (late stage or meningo-en- cephalitic phase). Handover of improved health-care facilities to Omugo Health Centre following HAT trial completion. Uganda is the only endemic country where both the acute form and the chronic disease coexist. T.b. rhodesiense is endemic in the south, Rhodesiense HAT endemic in south while T.b. gambiense is endemic to the north. migrates towards gambiense zone The treatment of While new drug treatments for the gambiense form HAT is depen- of HAT are sought, another trend is causing concern: WHO/TDR dent on the form the possibility of an intermingling between the T. b. and stage of the gambiense species endemic in the north and T. b. rho- disease: early desiense, which is endemic in the south but appears to stage gambiense be migrating slowly northward, largely due to the un- disease is treated checked movement of cattle.7 with pentami- dine and late stage with eflornithine or melar- In order to discuss this issue, the TDR team also visited soprol; while early stage rhodesiense disease the Namungalwe Health Centre in southern Uganda. 26 is treated with suramin and late-stage with There, Dr Kakembo, director of the National Sleeping melarsoprol. Sickness Control Programme, and his deputy Dr Wam- boga, described how the health centre, which functions Although molecular methods are available that as a referral centre for patients with sleeping sickness, can distinguish between the two species,8 diag- was built to treat patients during the last large T. b. nostic tools routinely used in the field cannot. rhodesiense epidemic in the 1980s. As a result, mingling of the two parasite species in the same geographic locale would create a He also explained that Uganda is the only country in Af- difficult situation for making decisions regard- rica where both T. b. rhodesiense and T. b. gambiense co- ing treatment options. n exist. The intermingling of the two species in the same geographic region, however, could greatly complicate diagnosis and treatment. If the two diseases converge, a drug treatment effective against the two forms would be required. Potentially, the usefulness of a nifurtimox + eflornithine combination could be examined in a site such as Namungalwe. 1 “Clinical study comparing the nifurtimox-eflornithine combination with the standard eflornithine regimen for the treatment of Kakembo also observed that while prevalence of the trypanosoma brucei gambiense human African trypanosomiasis in rhodesiense form of HAT that is common in the south the meningo-encephalitic phase”: ISRCTN03148609 (see http://www. appears to have declined markedly, this also could controlled-trials.com/ISRCTN03148609) partly be due to lack of active screening and mobili- 2 “Assessing three-day pentamidine for early-stage human African zation of communities. This underlines again the need trypanosomiasis”: ISRCTN35617647 (see http://www.controlled-trials. com/ISRCTN35617647) to stimulate grassroots awareness of the symptoms of early-stage HAT to facilitate treatment that can lead to 3 Expert group meeting, 14-15 April 2004, WHO/TDR. a full recovery. 4 Priotto et al. Clinical Infectious Diseases 2007;45:1443–1445 5 ISRCTN35617647 Along with testing new drug combinations, the TDR 6 Immtech Pharmaceuticals. Script No 3340, p 22, February 2008 trials have helped improve the skill levels of the col- 7 Févre EM et al. A burgeoning epidemic of sleeping sickness in Uganda. laborating medical teams, stimulating them to think Lancet 2005; 366(9487):745-747 about needs for such improved outreach and diagnosis 8 Picozzi K et al. Sleeping sickness in Uganda: a thin line between two of HAT in remote areas, according to Deborah Kioy, the fatal diseases. British Medical Journal 2005 November 26; 331(7527): TDR scientist who has been managing the drug trials. 1238–1241. Available from: http://www.pubmedcentral.nih.gov/ However, there needs to be further follow-up by con- articlerender.fcgi?tool=pmcentrez&artid=1289320 trol officials at country level, and in coordination with WHO, to ensure that activities instituted for the studies continue following their conclusion. y Contact: Dr Deborah Kioy [email protected] - With reporting from Deborah Kioy in Uganda Meetings | Stewardship • Environment and agriculture No. 82

Stewardship’s Strategic Advisory Committee meets

TDR’s newest area of work – the Steward- Infectious Diseases, initiated its activities Stewardship is also developing a high- ship function – held a second Strategic in October 2008, and will be developing level advocacy group to help communi- and Scientific Advisory Committee (SAC) its first annual report in late 2009. That cate recommendations emerging from meeting 12-14 January. One of Steward- group has already developed a struc- the global report. The SAC co-chaired by ship’s key products is the new global ture for its activities that the SAC recom- professor Eyitayo Lambo, former minister report on infectious diseases research. mended as a model for the nine other of health of Nigeria and Gillian Samuel, This is a major new undertaking planned reference groups being established as president of the Foundation Council, for draft review by the end of 2010. The part of the initiative. The annual reports Global Forum for Health Research, rec- report sets out to highlight the top re- of the reference groups will be consoli- ommended that the high-level advocacy search priorities among infectious dis- dated as a technical document that will group be developed in partnership with eases of poverty that can assist policy be used to produce a top level overview other organizations. Possible categories makers, researchers, funders and other of challenges, opportunities and research of members include ministers of health, stakeholders. In the recent SAC meet- priorities in infectious diseases by a “think science and technology, education, opin- ing, committee members discussed the tank” with cross-cutting activities and har- ion leaders and philanthropists. y initiatives under way that would con- monized approaches. The think tank will tribute to this report. These range from include representatives from the refer- the 10 new disease and thematic refer- ence groups. The SAC also recommended ence groups being established by TDR’s inviting people from outside the scientific Stewardship function to examine global groups with diverse backgrounds who For more information on SAC membership research gaps and needs in specific ar- can help identify fresh ideas and ap- and a list of the disease-specific and eas, to the expansion of TropIKA.net as a proaches to framing the challenges iden- thematic reference groups, visit: ‘one stop shop’ platform for research on www.who.int/tdr/svc/stewardship tified by each of the reference groups in 27 infectious diseases of poverty. a global context – including socioeco- The first such thematic reference group nomic, political, national and regional Contact: Dr Ayoade MJ Oduola [email protected] (TRG), on Environment, Agriculture and perspectives.

Environment, Agriculture and Infectious Diseases Thematic Reference Group launches activities

Changes in global environmental and in 2009 and 2010 as part of its Steward- While the group will focus on global agricultural systems are among the ship function for infectious diseases of issues and trends, its outputs are also major overlooked factors in the persis- poverty. The TRG/DRGs aim to evaluate expected to address public health chal- tence, emergence and re-emergence of and synthesize scientific information on lenges in China. “Collaborations with infectious diseases. These also interact Chinese research institutions and China- with trends of economic development, specific global health issues, providing population growth, urbanization, mi- guidance on priority research gaps and based international agencies will be of gration and pollution. Climate change needs that should be addressed. critical importance to the expert group’s and variability add new factors to this analysis and findings,” says Johannes conglomerate of driving forces, as do Appearing at the Beijing meeting, Ayo- Sommerfeld, TDR manager of the refer- related trends of over- and under-nu- ade MJ Oduola, TDR’s Stewardship leader, ence group. trition. stressed that the new China-based effort reflects TDR’s increasing commitment to Stakeholder consultation paves addressing how global environmental These are among the issues to be ad- way for meeting dressed by a new Thematic Reference change, including climate change, im- A stakeholders’ consultation convened Group (TRG) of international experts pacts the epidemiology and control of in Beijing on 21 October to discuss the on Environment, Agriculture and In- infectious diseases of poverty. planned framework for the TRG’s activi- fectious Diseases (TRG-4), which held He noted that the expert group will be ties. The consultation, co-organized by its first meeting 22-23 October 2008 in based in China for a minimum of four the WHO Representative Office in China, Beijing, China. years (2008-2012). It will operate in col- TDR and the Chinese Center for Disease The expert group is one of 10 such the- laboration with the WHO Representative Control and Prevention (China CDC), matic and disease-specific reference Office in China and with approval of the brought together Chinese health offi- groups efforts being launched by TDR Chinese Ministry of Health. cials and regional representatives of in- No. 82 Meetings | Environment and agriculture

Thematic Reference Group on Environment, Agriculture and Infectious Diseases: stakeholder consultation and meeting in Beijing.

ternational agencies. Presentations were tute of Parasitic Diseases in Shanghai, Members of the Thematic Reference made by the China Council for Interna- also discussed trends related to climate Group (TRG) tional Cooperation on Environment and change and agriculture with Lin Erda Dr Anthony McMichael, TRG chairperson, National Centre for Epidemiology and Popula- Development and the United Nations of the Chinese Academy of Agricultural tion Health, The Australian National University, Food and Agriculture Organization. Chris Sciences. Canberra, Australia. Tunon described WHO activities on be- Dr Xiao-Nong Zhou, TRG co-chair, CDC National Although China has made significant Institute of Parasitic Diseases in Shanghai, China. half of the WHO Representative in China. progress in combating infectious diseas- Dr Corey Bradshaw, Research Institute for Stakeholders stressed the need for pro- Climate Change & Sustainability, School of Earth es, many persist and re-emerge, noted & Environmental Sciences, University of Adelaide, spective, systemic and ecological ap- Kai JianLi director, Office for Epidemiol- Australia. proaches to the issues. Interdisciplinary ogy, China CDC. Public health challeng- Dr Stuart Gillespie, Agriculture and Health Research Platform, International Food Policy 28 and inter-sectoral research are needed es include dysentery, gonorrhea, viral Research Institute (IFPRI), Geneva, Switzerland to address complex linkages that exist hepatitis, HIV/AIDS, malaria, measles, Dr Felipe Guhl, Centro de Investigaciones en between environments, agriculture and schistosomiasis, syphilis, tuberculosis Microbiologia y Parrasitologia Tropical - CIMPAT, Bogota, Colombia. infectious diseases, and those linkages and typhoid and paratyphoid fevers. Dr Anthony Okon Nyong, Agriculture and to poverty. TRG analysis and recommen- Emerging diseases include SARS (2003), Agro-Industries Department, Environment and dations should be expressed in practical Natural Resources Division, African Development avian influenza (2004), angiostrongyli- Bank, Tunis Belvedere, Tunisia. terms relevant to policy-makers’ actions. asis (2006) and EV71 (2008). Dr Suad M Sulaiman, Environment Advisor, Khartoum, Sudan. The expert meeting featured overview Why China? Dr James A Trostle, Anthropology Department, presentations on how environmental Trinity College, Hartford, USA. change, climate change, agriculture, food As China is undergoing rapid eco- Dr Jürg Utzinger, Department of Public Health security and disease prevalence/trans- and Epidemiology, Swiss Tropical Institute, Basel, nomic, agricultural and environmental Switzerland. mission interrelate. Discussion also fo- changes, it is well placed to harness Dr Bruce Wilcox, Center for Infectious Disease cused on the need to also consider pov- the TRG’s findings to challenges of in- Ecology, Asia-Pacific Institute for Tropical Medi- erty linkages and economic systems that cine and Infectious Disease, John A. Burns School fectious diseases of poverty, observed of Medicine, University of Hawai’i, Honolulu, USA. better incorporate relevant “externalities.” Zhou, an internationally recognized ex- Dr A Lee Willingham III, WHO/FAO Collaborat- ing Center for Parasitic Zoonose, Faculty of Life Chairperson Anthony McMichael, an Aus- pert on schistosomiasis, a disease with Sciences, University of Copenhagen, Frederiks- tralian National University professor, de- multiple environmental dimensions. berg C, Denmark. scribed some of the environmental and China has recently been challenged by Dr Yang Guojing, Jiangsu Institute of Parasitic Diseases, Wuxi, China. agricultural factors enhancing infectious both human-caused and natural envi- disease emergence and spread, includ- ronmental changes, including flooding Related resources: ing intensified livestock production, live and drought as well as the 2008 Sichuan WHO Department for Public Health animal retail markets, changes to ecosys- Province earthquake. Climate change and Environment (PHE) tems (e.g. dam construction, deforesta- impacts on agricultural productivity and http://www.who.int/phe/en/ tion) and global climate change. “Often vector-borne disease transmission also WHO/UNEP Health and Environment Linkage Initiative factors act in concert in changing the are of concern. http://www.who.int/heli/en/ range, seasonality and intensity of in- Earlier in October, McMichael also IFPRI Agriculture and Health Research fectious diseases transmission,” he said. chaired a meeting of experts on climate Platform “Climate change, for example, is amplify- http://www.ifpri.org/ahrp/ahrp.asp change and public health convened by ing environmental stresses from human * WHO Expert Meeting on Climate Change the WHO and hosted by Spain’s Ministry pressures on water systems, land cover and Public Health of Health. The meeting, 6-8 October in and displacement of reservoir host spe- http://www.who.int/phe/climate/ Madrid, agreed on a research agenda to meeting_madrid/en/index.html cies.” develop an evidence-based framework Co-chairperson Xiao-Nong Zhou, a pro- for action on the human health implica- Contact: Dr Johannes Sommerfeld [email protected] fessor at the China CDC’s National Insti- tions of climate change*. y Meetings | Empowerment • ANDI No. 82

Empowerment SAC reviews ‘centres of excellence’

At least ten health research institutes are Research: New funding should be sought and research leaders as well as centres of to be designated centres of excellence in to support research empowerment excellence. infectious diseases research as a result of grants to scientists and institutions, par- Quality management: SAC commended TDR’s Empowerment function (BL2) ac- ticularly in small, poor countries that have the progress made by Empowerment tivities. a high disease burden. More emphasis on developing programmes for Qual- should be given to translation of research Empowerment’s Strategic and Scientific ity Management training, coordination results into policies and practices, includ- Advisory Committee (SAC) endorsed and institutional recognition in 2008. As ing strategies for publications and pack- the plans in a meeting, 6-7 November of 2009, quality management activities aging of results for various audiences. 2008 in Geneva. The SAC also urged are to be transferred to TDR’s team on that TDR will develop criteria for the Training: Significant progress had been Neglected Research Priorities, operating selection of candidate centres of excel- made on harmonization and standardiza- there as an independent function. This is lence, as well as indicators to determine tion of short courses and development to ensure that quality management cuts if centres meet research excellence of indicators and mentorship systems across all TDR health research and train- goals. TDR also plans to develop cross- for TDR’s new stepwise programme of ing activities. Links between TDR’s qual- cutting indicators measuring progress leadership training including: Leadership ity management activities and those of on the broader strategic goal of having Training Grants, Leadership Development internationally recognized accreditation “disease-endemic countries play a piv- Fellows and Career Development Fellows. programmes also are being deepened otal global role in research on infectious and developed. y Networks: Progress also was made on de- diseases of poverty.” velopment of a data base of previous TDR In terms of other specific Empowerment grantees. SAC encouraged TDR to further activities supporting research, training, explore how its range of networks could networks and quality management, SAC be harnessed to support training, men- Contact: Dr Glenn Laverack 29 [email protected] recommended the following: torship and grooming health researchers

ANDI Task Force plans follow-up to Abuja launch

A Task Force of the new African Network Funding: e.g. encourage African gov- WHO/AFRO regional office in Brazzaville, for Drugs and Diagnostics Innovation ernments to support R&D; provide the Democratic Republic of Congo, 3-4 Au- (ANDI), held its first meeting on 10 Feb- platform for African product R&D fund- gust. A second stakeholders meeting ruary to plan concrete actions for turn- ing and investment; promote establish- is scheduled for the week of 5 October ing the R&D initiative into a reality. This ment of venture capitalists that focus on 2009 in Cape Town, South Africa, where follows the launch of ANDI in October health innovations; establish and man- the Task Force final report will be pre- 2008 at a stakeholders’ meeting in Abuja, age an African Innovation Fund. sented. Nigeria. Advocacy for product R&D at all levels: The first ANDI stakeholders’ meeting and The ANDI Task Force is charged with e.g. advocate for increased investment launch of the initiative in October 2008 developing a strategic blueprint and in product R&D by various stakeholders drew over 200 participants from Africa business plan for the network. Meeting including African governments, phil- and around the world, including health in Geneva, the group reviewed the po- anthropic agencies, and international/ ministers and private sector and inter- tential scope of ANDI’s work, options for development bodies; establish a mecha- governmental organization representa- organizational structure and selection nism to take African traditional medicines tives. criteria for African countries interested in to international market standards; seek ANDI aims to promote African-led R&D hosting the secretariat. recognition of diagnostics/drugs registra- innovation, and to support capacity and tion among African member states. The proposed scope of work for ANDI infrastructure development, accord- include activities related to: Task Force participants agreed to recruit ing to Solomon Nwaka, TDR’s leader of a consultant to aid in developing a five- drug discovery and innovation. It follows Product R&D coordination and man- year strategic and business plan. The upon WHO’s recent approval of a Glob- agement: e.g. a framework for scientific group scheduled two more meetings, as al strategy and plan of action on public coordination and R&D priority-setting; well as teleconferences, in order to pre- health, innovation and intellectual prop- collaboration with regional and western pare for delivery of a business plan in the erty (WHA 61.21). y partners; management of intellectual fourth quarter of 2009. property to protect local knowledge and Contact: Dr Solomon Nwaka promote innovation; and linkages of in- Those will be at the African Devel- [email protected] vestors with entrepreneurs. opment Bank in Tunis, 7-8 May, and the No. 82 Meetings | PCR for Chagas • ASTMH

Standardized protocol for PCR analysis of Chagas disease

setting and establishing the limitations of the course of that week allowed for the PCR technology as a diagnostic tool. establishment of a standard operating procedure (SOP) for the use of PCR as a While PCR has been employed for clini- diagnostic tool. cal diagnosis and assessment of T. cruzi infection for more than a decade, there “In the absence of a validated commer- exist numerous and widely varying labo- cial product, we have this,” says Janis ratory protocols for its use. The effect has Lazdins-Helds, TDR’s leader of research been to render unreliable comparisons on drug development for helminth and of PCR-based findings between groups, other neglected diseases and one of the A workshop and symposium on the use thereby slowing the pace of research. Buenos Aires workshop’s planners. “It has of polymerase chain reaction (PCR) for to be made in one’s own laboratory, but Recognizing the need for a standard PCR T. cruzi DNA detection has resulted in a it’s a start. And it’s a wonderful example protocol for T. cruzi DNA detection, a single standardized protocol for PCR- of how basic biomedical research find- consortium of researchers from Brazil, Co- ings can be used clinically for the benefit based clinical analysis of the disease. lombia and Argentina drafted a project of both practitioners and patients.” Sponsored by TDR, INGEBI-Conicet UBA proposal in 2007 and sought TDR sup- According to INGEBI-Conicet’s Alejandro and the United Nations University’s BIO- port. Months later, the research began. Schijman, the initiative’s coordinator, the LAC programme, the workshop involved Blinded blood samples with a known new SOP can serve as a point of refer- 32 biomedical researchers and medical number of parasites, purified DNA from ence not only for medical practitioners practitioners from 14 countries – whose T. cruzi strains of different lineages and interested in disease diagnosis but also convening in a single forum also repre- relevant controls were prepared by the for clinical researchers using PCR to eval- 30 sented a significant achievement. coordinating center and sent to 29 par- uate new therapies for Chagas in clinical ticipating laboratories. Most of the participants at the meeting, studies. y 17-22 November 2008 in Buenos Aires, Ar- Those laboratories that achieved a mini- gentina, were from Latin America where mum of concordance with the blood Chagas remains endemic. Over four days, samples were invited to participate in the group defined PCR best practices, the workshop and symposium in Bue- Contact: Dr Janis Lazdins-Helds [email protected] outlining their applicability in a clinical nos Aires. The information gathered over

Rectal artesunate session draws big turnout at American Society of Tropical Medicine and Hygiene (ASTMH)

Tropical medicine experts discussed re- sults of randomized controlled trials of a life-saving, one-dose regime in rural African and Asian communities. The Emran Bin Yunus Bin Emran 57th annual meeting of ASTMH in New Orleans also covered logistics, ethics, adherence to referral advice and clini- cal research practices.

A rectal application of an inexpensive drug could save lives of patients with severe malaria in some of the remotest locations of rural Africa and Asia.

A TDR-supported study promoting the treatment, Use of rectal artesunate at the community level in African rural settings, was presented to a packed session at the 57th American Society of Tropical Medicine and Hygiene (ASTMH) annual meeting in New Orleans, USA, 7-11 De- cember 2008. Some Study 13 and Study 18 team members at the ASTMH. Meetings | ASTMH No. 82

Standardized protocol for PCR analysis of Chagas disease Researchers from all over the world gathered to hear the conclusions from a Other TDR sessions at ASTMH panel including TDR coordinator of the research Melba Gomes and researchers TDR sponsored a total of five major symposium sessions, several Emran Bin Yunus from Bangladesh, John papers and posters on malaria, and a presentation on TDR’s Gyapong from Ghana, Marian Warsame Helminth Drug Initiative at the 57th ASTMH meeting in New from Tanzania, and Tom Peto, Rita Baiden Orleans. In addition to the session detailed above, TDR’s major and other colleagues from the Study 13 sessions discussed: Research Group. • Accelerating the development and deployment of diagnostic tools That same morning, The Lancet published into the developing world: promises and challenges. Due to the lack the study online.1 Lorenz von Seidlein of laboratory capacity in the developing world, high-quality diagnos- and Jacqueline L Deen also wrote in a tic tests for infectious diseases are neither affordable nor accessible commentary there, “If there are a handful to the majority of patients. Moreover, owing to the lax regulatory of important papers every decade that oversight of diagnostics, those tests that are available are often sold and used with little evidence of their effectiveness. This symposium will influence the way malaria is treated, described the path from diagnostic target discovery to test develop- this study is one of them.” ment and deployment, identifying challenges and opportunities That same enthusiasm was evident at the along the way. ASTMH session, which drew supportive TDR contact: Dr Rosanna Peeling, [email protected] comments and questions about how to move forward with the results. Use of fluorescent probes and transgenic parasites to enhance drug The study sought to determine in very screening. This symposium highlighted progress made by a network remote settings whether rectal arte- of investigators from disease-endemic and non-endemic countries sunate plus referral to a clinic reduced using new genomic technology for drug screening. 31 mortality and permanent disability TDR contact: Dr Ayoade MJ Oduola, [email protected] compared with rectal placebo plus re- ferral. The multi-country study included over 17 000 patients, and showed that Home Management of Malaria (HMM) in 2008: Improving access to ACTs and diagnostics at the community level in sub-Saharan Africa. a single dose given rectally can be safe This session provided a summary of how HMM is incorporating new and effective as an initial treatment for tools like artemisinin-based combination therapy (ACT) and rapid patients with severe malaria who are diagnostic tests (RDT) for malaria and addressing new challenges too sick to take medication by mouth, posed by communities in urban settings and integrated disease man- and who do not have immediate ac- agement. See also: http://www.who.int/tdr/research/antimalarial- cess to an injectable treatment. Rectal policy-access/ppt/HMM-Antwerp-Apr08.ppt artesunate is administered at a rural TDR contact: Dr Franco Pagnoni, [email protected] health centre or by a trained commu- nity member or caregiver in order to “buy time” while the patient is referred Measurement and prediction of malaria treatment outcomes: Para- for definitive treatment. site, drug and host factors. Leading experts reviewed the protocols for in vitro and molecular measurements of antimalarial drug resis- tance, their limitations, and how these relate to treatment outcomes What is new? TDR contact: Dr Olumide Ogundahunsi, [email protected]. n The trial was the first randomized-con- trolled study to assess the value of rectal artesunate in community-based settings in remote rural areas. It was undertaken The study noted remarkably high com- in malaria-endemic areas of Bangladesh, 1 MF Gomes, MA Faiz, JO Gyapong, M Warsame et pliance with the advice to go immedi- al from the Study 13 Research Group. The Lancet, Ghana and the United Republic of Tan- 373:557-566. zania. ately to a clinic, partly because there was a recruiter in each village and com- In their Lancet commentary, Seidlein and munities received sustained malaria Deen said that the trial results provide education. Before the study began in “a strategy for patients with severe ma- For more information and The Lancet each village, the process was explained article, see www.who.int/tdr/svc/news- laria who cannot access parenteral drugs to leaders, traditional healers and the events/news/rectal-artesunate-lancet quickly.” The survival benefit is signifi- For archives of ASTMH meetings, see: cant in the communities where travel to community. The trials were approved www.astmh.org get care takes at least six hours. Mortality by WHO and national ethics committees was halved in longer travel, a particularly and reviewed by an independent data Contact: Dr Melba Gomes [email protected] acute problem in Africa. monitoring committee. y No. 82 Meetings | DEEP • Innovative vector control in Mali

DEEP discusses costs of ineffective diagnostics

The fifth annual meeting of the Diag- line on accessible quality-assured diag- (STIs), to estimate the costs/benefits of nostics Evaluation Expert Panel (DEEP) nostics, results from work on the human poor quality/improved diagnostics, in- 3-4 November 2008 offered TDR scien- and economic costs of low-quality diag- cluding tests for drug resistance; the en- tists a chance to engage potential col- nostics could generate advocacy materi- couragement of regulatory authorities laborators in estimating the human and als about their consequences. to work with health ministry and control economic costs of low-quality diagnos- programmes; the establishment by TDR The meeting in Geneva opened with tics for infectious diseases. of a session on diagnostics regulation at an overview of the global diagnostics the annual International Conference for Owing to the lack of regulatory oversight landscape and the process by which di- Drug Regulatory Authorities (ICDRA); and in the developing world, many diagnos- agnostics are regulated and approved in greater collaboration with partner organi- tics are sold and used without evidence South Africa, Thailand, the United States zations in advocacy efforts. of effectiveness. There is usually little in- of America and India. Speaking on behalf formation available on test performance. of the European Diagnostics Manufac- A website devoted to diagnostic tests for As a result, cost is often the overriding turers Association (EDMA), Jean-François priority diseases was also proposed as an consideration in test procurement. This de Lavison stressed the need for inter- effective means of disseminating infor- situation has led to the marketing of national cooperation in the regulation of mation to health authorities, funders and cheap tests with low performance char- diagnostic tests. He called for the estab- the public. The website would include in- acteristics, which has in turn discouraged lishment of an International Diagnostics formation on product evaluation, includ- reputable manufacturers of high-quality Manufacturers’ Association to comprise ing unpublished evaluations by WHO, diagnostics from competing in these companies from developed and devel- FIND and FDA, among others, and tool markets. oping countries. kits describing how to evaluate diagnos- tic tests. y Assembled in 2004, DEEP has a mandate Advocacy recommendations included 32 to advise TDR and the Foundation for In- the use of case studies of problems or novative New Diagnostics (FIND) on rec- benefits associated with poor-quality or ommendations for best practices in di- improved diagnostics; the use of math- Contact: Dr Rosanna Peeling agnostic trials. According to TDR scientist ematical models, such as those currently [email protected] Rosanna Peeling, leader of TDR’s business used for sexually transmitted infections

Biosafety course in vector control launched in Mali

to develop material for further biosafety training and assessment of GM research in Africa, Latin America and Asia. That was Olivier Asselin followed by a TDR-supported “train the trainers” course on laboratory biosafety and biosecurity, 3-8 December, aimed to consolidate and expand the initiative in Africa, Asia and Latin America.

Standing on an open concrete terrace at the University of Bamako on a break from the first African training course, Couliba- ly described how his PhD studies had The year was 2002, the setting was Notre Now, Coulibaly believes, that dialogue is stimulated questions that he and other Dame University in the USA, and a young advancing, thanks partly to several new researchers now seek to address more Malian PhD student named Mamadou initiatives by WHO and TDR. systematically. Coulibaly was engaged in research re- Coulibaly was a member of the first TDR- lated to the genetic modification (GM) “I have a lot of theoretical knowledge in supported course for Africa on Biosafety the technology,” Coulibaly said, “but the of mosquitoes. for human health and the environment, most interesting thing to me is: what do 17-28 November 2008 at the University of As he considered both the potential of countries and ethics boards think about Bamako, Mali. such research to fight disease and also the release of transgenic mosquitoes into the social and environmental issues it On 29 November - 2 December, coor- nature? How do neighbouring countries inevitably raised, Coulibaly recalls asking dinators of three new TDR-supported interconnect with each other? And what his professor and mentor, “Isn’t it better biosafety training centres in Africa, Latin is the response of communities where to start talking about ethics issues now?” America and Asia also met in Bamako GM deployment is planned? Meetings | Home management of malaria No. 82

“We, the scientists, as well as policy-mak- tion [AFBSA: www.afbsa.org]. “I applied train-the-trainers course on laboratory DEEP discusses costs of ineffective diagnostics ers and the public, need to be assured for this course because I wanted to learn biosafety and bio-security, 3-8 Decem- that the genes we’ll be putting into mos- more about GM insect vectors and about ber, was organized by the Biorisk Re- quitoes are not going to have negative ef- laboratory safety. I want to be able to re- duction for Dangerous Pathogens unit fects on other organisms or on communi- view and evaluate proposals coming to of WHO’s Department of Epidemic and ties and their environment.” me within my institution. I want to net- Pandemic Alert and Response (EPR). It involved 11 participants from Africa, The biosafety training course, at the Uni- work and grow my association.” Latin America and Asia, and took place versity’s new TDR-supported Regional The second event , a meeting of coordi- at the same University of Bamako Fac- Biosafety Training Centre, was organized nators of the three new TDR-supported ulty of Sciences and Technology venue by Dr Madama Bouaré of the Faculty of biosafety centres in Africa, Asia and Latin as the African biosafety course. Sciences and Technologies. The course America, discussed long-term plans involved 20 participants from 11 Afri- for development of courses and good These meetings pave the way for ex- can countries. Similar courses are set for practice guidance in ethical review and panding biosafety training courses from Africa to Asia and Latin America over the soon-to-be-opened regional centres in risk assessment of GM research/deploy- coming three years. Researchers such Asia and Latin America in 2009. ment. Meeting participants also included as Coulibaly from around the world will Willy Kiprotich Tonui was another bio- the investigators involved in a TDR proj- thus be able to delve into the ethical and safety course member. He is based in ect on best guidance principles for the biosafety issues related to new scientific Kenya and has written a laboratory safety use of GM vectors. The meeting was co- endeavours. y handbook. ordinated by TDR’s Yeya Touré, formerly of the Faculty of Medicine, Pharmacy and “Not many Africans have been exposed Dentistry, University of Bamako. Contact: Dr Yeya Touré to biosafety,” said Tonui who is the found- [email protected] er of an African Biological Safety Associa- The third TDR-supported event, the 33 Sudan to develop a national HMM strategy

Khaled Elmardi of the National Malaria Control programme. A second such proj- ect was then initiated in 2007-08 in North Kordofan state, funded by the Federal Ministry of Health. Positive results of these two projects inspired the Ministry to con- vene the workshop to develop a national HMM strategy across Sudan’s northern region in zones where malaria is endemic.

The February workshop was facilitated by Hoda Atta, regional adviser for malaria in Field visit to community medicine distributor in North Kordofan state, Sudan. Foreground, left to right: EMRO, Marian Warsame of WHO’s Global Mai M Alhilo, coordinator, Malaria Control Programme, North Kordofan, Sudan; Franco Pagnoni, TDR; Malaria Programme and Franco Pagnoni Tarig Abdelgadir, coordinator, National Malaria Control Programme, Federal Ministry of Health; Marian of TDR. Warsame (WHO/GMP); and Hoda Atta, regional advisor for malaria in WHO’s Eastern Mediterranean Regional Office.In background, left to right: Khalid A Elmardi, case management director, National The approximately 50 participants in- Malaria Control Programme; Elrasheed M Ali, Partnership desk in National Malaria Control Programme. cluded representatives of high malaria- burden states as well as health officials Sudan’s national malaria programme is ganized a two-day policy development from South and North Kordofan, where developing a large-scale home manage- workshop in Khartoum, 3-4 February. the two pilot projects had taken place, ment of malaria programme (HMM) for its The workshop follows in the wake of a and several high level officials from the malaria-endemic zones in the country’s Federal Ministry of Health. The workshop northern region as a result of implemen- TDR implementation research project was preceded by a field visit to North tation research stimulated by TDR. testing HMM strategies adapted to the country’s epidemiological and socio- Kordofan, where participants were able Sudan, the country in WHO’s Eastern cultural context. to see first-hand how the home manage- Mediterranean Region (EMRO) with the ment of malaria project had been imple- highest malaria burden, will thus be- The study was carried out in 2006 in the mented. y come the first country in the region to state of South Kordofan, in collabora- develop and implement such an effort. tion with TDR/HQ, TDR/EMRO, Roll Back Contact: Dr Franco Pagnoni In preparation for the new initiative, the Malaria/EMRO and the Istituto Superiore [email protected] national malaria control programme or- di Sanità in Rome, Italy. It was led by No. 82

Print and multimedia publications now available from TDR

will allow clinical laboratories to ensure that safety and All TDR publications may be downloaded efficacy data is repeatable, reliable, auditable and easily from the TDR website: reconstructed in a research setting. GCLP guidelines set www.who.int/tdr/publications a standard for compliance by laboratories involved in the To order hard copies free of charge, please fax analysis of samples from TDR-supported clinical trials. or mail us the attached publications order To download: http://www.who.int/tdr/svc/publications/ form, or e-mail your request to: [email protected]. tdr-research-publications/gclp-web

Second edition: Good laboratory practice Evaluation of commercially available (GLP) handbook and training manuals anti-dengue virus immunoglobulin (Trainer and Trainee) M tests Web version only Diagnostics evaluation series, No. 3 Handbook, 325 pp., 2009 (ISBN 978 92 4 154755 0) 52 pp., 2008 Trainer manual, 270 pp., 2009 (ISBN 978 92 4 154756 7) Trainee manual 271 pp., (ISBN 978 Serological assays that can detect virus-specific immunoglobulin First published in 2001 to assist countries in conducting 34 antibodies to dengue virus non-clinical research and drug development, the GLP are widely available and can series, including a GLP Handbook and GLP Training provide an alternative to more manuals for trainers and trainees, has been revised and costly, labour-intensive methods updated in line with World Health Assembly Resolution of diagnosing dengue fever. 61.21, Global strategy and plan of action on public health, However, due to the wide variety innovation and intellectual property. Since the publication of IgM response patterns to of the first GLP series, TDR-fostered GLP training efforts infection, there is a need to have resulted in a network of GLP trainers whose input evaluate the sensitivity and specificity of available tests. shaped the development of this second edition. This This report describes the results of a TDR-sponsored revised GLP series will support TDR in empowering laboratory-based evaluation of nine commercially disease endemic countries to develop and lead research available anti-DENV IgM tests. activities with internationally recognized standards of quality. To download: http://www.who.int/tdr/svc/publications/ Good clinical laboratory practice (GCLP) tdr-research-publications/glp-handbook09-web Web version only 28 pp., 2008 (ISBN 978 92 4 159785 2) In 2006, WHO/TDR convened a meeting of organizations Available through TDR engaged in clinical trials in disease-endemic countries to discuss the applicability of GCLP guidelines to their Evaluating diagnostics: the CD4 guide Nature Reviews Supplement: Microbiology work. It was agreed that GCLP would be a valuable tool for improving quality laboratory practice. In line with Vol. 6, No.11, November 2008 that agreement, TDR/WHO recently acquired copyright Accurate CD4 counts are crucial laboratory markers for to GCLP guidelines that were originally published in assessing immunodeficiency and the risk of disease 2003 by a working party of progression in HIV-1 infection. HIV-1 causes a huge burden the Clinical Committee of the of morbidity and mortality, particularly in developing British Association of Research countries. This fourth supplement in the series focuses on Quality Assurance (BARQA), CD4 immunodiagnostics, which can be used to monitor with the aim of disseminating CD4 counts and to decide when to treat individuals with them widely in developing antivirals and whether treatments are effective. countries and developing To download: http://www.nature.com/nrmicro/ related training materials. These supplements/index.html GCLP guidelines are presented here. Compliance with them No. 82

Framework for operations and procedures such as informed consent and confidentiality. implementation research in health and Those presentations formed the basis for this book, disease control programmes subsequently distributed to all of Brazil’s 550 institutional Expert group report ethics review committees as well as the National 37 pp., 2008 (ISBN 92 9224 110 9) Commission on Ethics in Research (CONEP). For copies please contact: Dr Iara Coelho Zito Guerriero at: The product of a joint effort by the Global Fund to [email protected] Fight AIDS, Tuberculosis and Malaria, TDR and an inter-agency technical working group, this IR/OR framework, first published in 2008, is now available A human rights-based approach in both French and Spanish along with the initial to neglected tropical diseases English version. The overall goal of the framework is to WHO information sheet/web version standardize the practice of OR across the international Neglected tropical diseases (NTDs) affect one billion health community and to stimulate the integration of people around the world, often the most vulnerable OR into health programmes. Limited number of hard populations living in poor rural areas. A source of social copies available in English, French and Spanish. stigma and poverty, NTDs can result in lifelong disability To download all three versions: and even death. Affected populations often do not http://www.who.int/tdr/svc/publications/training- have access to treatment and preventive measures, and guideline-publications/listpubs research and development have been insufficient. This http://www.theglobalfund.org/en/me/?lang=en WHO information sheet, developed jointly with TDR andWHO’s Department of Health, Ethics and Trade, aims Joint TDR/EC expert consultation on to improve understanding about NTDs among health biomarkers in tuberculosis planners, human rights groups, development partners and civil society organizations. Available in English, French and Expert group report, TDR and the European Spanish. Commission 35 143 pp., 2008 To download: http://www.who.int/tdr/svc/publications/ tdr-research-publications/human-rights The emergence of multi- and extensively drug resistant tuberculosis has aggravated the impact of New laboratory diagnostic tools for TB, especially on HIV-infected individuals, and added tuberculosis control urgency to the search for new vaccines, diagnostics Stop TB Partnership: Retooling Task Force and New and drugs. However the lack of suitable and validated Diagnostic Working Group biomarkers to assess areas of clinical management January 2009 of TB patients remains a major obstacle to these efforts. This report provides an overview of biomarkers There is a lack of easily digestible information available to currently under study, treatment response and national tuberculosis programmes, as well as to funding outcomes, technological platform s, and collaborations and technical agencies, regarding new TB diagnostic tools between researchers and funding agencies. in the development and implementation pipeline.

With this in mind, this brochure describes 19 new or Ethics in human and social sciences improved diagnostic tools, among the many such research in the health field initiatives under way worldwide. Three of the tools Iara Coelho Zito Guerriero, Maria Luisa Sandoval described in this document have already been endorsed Schmidt and Fabio Zicker by WHO and are being implemented by countries, while Sao Paulo: Editora Hucitec the others are still under development or in piloting phase, 308 pp., 2008 (ISBN 978 85 60438 63 1) and are expected to be ready for review for scaled-up use in the coming years. Ethical guidelines issued by the Council for International Organizations of Medical Sciences The brochure represents as an interim document until (CIOMS) have long established norms for the conduct a more complete blueprint of current R&D efforts can of biomedical research. However, when it comes to the be developed. The purpose is not to recommend specific social sciences, the guidance has never been so clear. tools, but rather to provide summary information about Thanks to a TDR-supported initiative by the Health tools being developed and becoming available, so that Secretary of Sao Paulo, Brazil, this may soon change all who play a part in TB control, especially in national TB in Brazil. A 2007 seminar in Sao Paulo addressed the programmes, can make well-informed decisions when ethical challenges unique to qualitative social sciences retooling. research, particularly in developing countries. More To download: http://www.who.int/tdr/svc/publications/ than 150 participants presented on issues ranging non-tdr-publications/diagnostic-tool-tb from the ethics of ethnographic studies involving vulnerable populations to issues related to specific No. 82

Call for contributions The call includes requests for contributions of: • Studies, publications or reports that Call for contributions to a WHO systematic monitored pregnant women in Africa, Asia review of information on maternal outcomes or Latin America, and assessed the newborn and prevalence of birth defects in Asia, Africa at birth. and Latin-America. • Individual patient data from research in WHO/TDR are issuing two calls for Africa, Asia or Latin America, where pregnant contributions to this planned systematic women were prospectively followed to term, review, which is part of a broader WHO effort and where the newborn has undergone a to establish a Global Pregnancy Register (see systematic physical examination. is published three page 6). times a year by the Special Pro- gramme for Research and Training in Tropical Diseases (TDR), spon- sored by UNICEF/UNDP/World Bank Please contact Dr Melba Gomes ([email protected]) with either “Systematic review of pregnancy and WHO. outcomes -reports” or “Systematic review of pregnancy outcomes – Individual Patient Data” in the subject line of the message if you have information to contribute. Both html and PDF versions of the newsletter are available on the TDR Reprints of relevant publications/reports can be mailed to: website. All material submitted to TDRNews undergoes editorial Dr Melba Gomes, scientist, review. Articles and illustrations Special Programme for Research and Training in Tropical Diseases (TDR) published in TDRNews which are World Health Organization, not copyrighted may be reproduced, 20 Avenue Appia, 1211 Geneva, Switzerland provided credit is given to TDR and provided such reproduction is not used for commercial purposes. Articles do not necessarily reflect the views of WHO. 36

Grant awards To our readers: We want to hear from you. A80309 A80344 including genetic diversity Innovative vector Please send us your feedback, control interventions Brij Kishore TYAGI Hiba Mohamed ABDALLA of dengue virus serotypes as well as letters and ideas on (BL5) Centre for Research in Blue Nile National from dengue cases. possible stories for TDRNews Medical Entomology, Institute for A80331 and on TDR-related tropical TDR’s Strategic and ICMR, Madurai, INDIA. Communicable Diseases, Amare Deribew TADEGGE disease research issues, events, Scientific Advisory institutions, publications and Asian centre for training Wad Medani, SUDAN. Jimma University, Committee on in biosafety assessment personalities. Thank you! Insecticide resistance in Jimma, ETHIOPIA. Innovative Vector for human health and malaria vectors in central Evaluation of operational Control Interventions environment using Sudan. performance of the revised recommended the genetically modified recommendations & following projects vectors. A80345 for funding in 2008 algorithms of WHO for US$ 50 000 Mariam ALLY in response to calls Ministry of Health and improving diagnosis of TB. for proposals from A80310 Social Welfare, Dar es A80328 investigators worldwide. Ivan Dario Salaam, TANZANIA. Tashi TOBGAY VELEZ-BERNAL A80361 Equity in health financing Vector Borne Disease Universidad de Antioquia, Seydou DOUMBIA and beneift incidence Control Programme, PECET, Medellin, University of Bamako, in Tanzania: Could Ministry of Public Health, Faculty of Medicine, COLOMBIA. prepayment schemes be a Thimphu, BHUTAN. Pharmacy and dentistry, Latin American biosafety solution? Reaching malaria MALI. training centre in relation Address A80382 treatment in the remote to potential release of TDR Evidence-basis for the malarious areas of Bhutan. Ivan EMIL World Health Organization improvement of integrated genetically modified Kigali Health Institute, A80338 20, Avenue Appia malaria vector control disease vectors. Kigali, RWANDA. Fadima YAYA BOCOUM 1211 Geneva 27 strategies in East, Central US$ 50 000 Switzerland and West Africa. Impact of de-worming & Institut de Recherche prevalence of helminths en Sciences de la Santé, US$ 200 000 Fax: (+41) 22 791-4854 Empowerment & HIV co-infections Ouagadougou, [email protected] A80360 Function (BL2) in pregnant women BURKINA FASO. Maria Inés PICOLLO www.who.int/tdr TDR’s Strategic and attending antenatal Scaling up the antenatal Centro de Investigaciones Scientific Advisory services. syphilis screening in de Plagas e Insecticidas, Committee for A80350 Burkina Faso. Villa Martelli, ARGENTINA. Empowerment Shyam Prakash DUMRE Design and evaluation recommended the National Public Health of complementary or following Leadership Special Programme for Research & Training alternative strategies for Training Grants to Laboratory, Kathmandu in Tropical Diseases (TDR) sponsored by UNICEF/UNDP/World B a n k / W H O the control of Chagas researchers in 2008, in Teku, NEPAL. disease vectors. response to a global call To determine the US$ 193 000 for LTG proposals. molecular epidemiology ISSN 1028-5911

SpecialDOI: Programme 10.2471/TDR.09.TNL.82.1028-5911 for Research & Training in Tropical Diseases (TDR) sponsored by UNICEF/UNDP/World B a n k / W H O