No. 84 - D e c e m b e r 2 0 0 9 TB or not TB? The latest in TDR’s research from diagnosis to disease treatment | PAGE 14 Also in this issue M E ET I N G S 32 • Quality management PAGE 4 RESEARCH BRIEFS • New tools for VL elimination 4 7 TDRbriefly 33 • Community-based interventions 11 Stewardship 34 • Strategic alliances Targeting 22 MIM Pan-African conference 35 • Empowerment visceral 24 ANDI leishmaniasis 25 Global Health Histories • Diagnostics 28 Artemisinin’s discovery 36 • Tropical medicine conventions eradication 30 World of TropIKA.net 37 PUBLICATIONS Editor’s corner The meaning of meetings Take the interview by one of the Chinese scientists pagepage hen I set off 244 for Dar es Salaam who was a leader in the international development to write about TDR of the first artemisinin combination therapy, the research into earlier fastest-acting antimalarial available today. initiation of anti-retroviral In an interview on page 28, Professor Zhou Yiqing re- therapy in HIV-positive TB pa- counts how a TDR-organized 1981 meeting in Beijing tients, I had no idea that I would was the turning point that introduced artemisinin be spending so much of my time in the tropics in an to the world. over-air-conditioned hotel conference room. From there, the rest is history. But along with field visits to hospitals, laboratories and clinics, our group of clinical trial team members In 2009 and 2010, TDR’s Stewardship function is convening meetings all over the world to take a fresh page28 from four countries also sat for several days in a 28 darkened room exhaustively reviewing slide presen- look at target diseases and thematic issues with tations. The team analysed in painstaking detail the critical relevance to control of infectious diseases Communications critical steps related to good clinical practice (GCP) most prevalent in poor countries (see article, page 11). manager Jamie Guth and good clinical laboratory practices (GCLP) that This series of meetings adds another dimension to are essential to any clinical trial. Managing editor the discussion of research gaps and priorities. Elaine Fletcher While meetings in some instances can be perceived On the eve of each meeting of these “disease and Contributing writers as bureaucratic encumbrances, in fact they have im- thematic reference groups”, an even wider range of Julie Reza, portant consequences, and can shape what happens stakeholders gathers. Representatives of govern- scientific editor in health research and hospital services. ment, NGOs, the private sector and academia Patrick Adams, meet with the expert group to share knowledge reporter While the glamour of research may be associated page and views about the diseases or themes being Design and 31 with huddling over a microscope or a field sample of examined. coordination insect vectors, meetings are important too. They are LisaCommunications Schwarb manager essential for training and improving field services There, history is yet to be written. Perhaps the JamieLayout Guth and procedures, as well as for sharing knowledge next artemisinin will emerge from one of those Simon Fenwick Managing editor and discoveries among expert peers. meetings. ElaineProduction Fletcher team Patricia Codyre, webDesign editor PelthiaLisa Schwarb Makgatho, Layoutadministration CopySimon editor Fenwick ProductionVallaurie Crawford team Pelthia Makgatho Elaine Ruth Fletcher Ali Bhanpuri Cover photo: Managing Editor, TDRnews TB(intern) diagnostic samples Copyawait analysiseditor at VallaurieMuhimbili CrawfordNational Hospital Laboratory Coverin United photo: Republic of ATanzania. rapid malaria Photo credit: diagnosticMuhidin Issa in MichuziAfrica. CoverCredit: Foundationbox photo: TDR’sfor Innovative Soumya New SwaminathanDiagnostics. in Goanpura village, Bihar, India, as part of a joint TDR-Indian health services exploration of research initiatives to support VL elimination. Photo credit: Greg Matlashewski Letter from TDR’s director No. 84 Innovation in action Innovation is the first time that you put a new idea Meanwhile, innovation in health into practice – that was a theme sounded in the systems and in access to health service recent Global Forum for Health Research meeting delivery are other topics receiving in- Forum 2009 in Havana, Cuba. creasing focus within WHO and among donor agencies. The term innovation typically conjures up im- ages of new tools, new products and new patents. Major donors such as the GAVI However, our understanding of the concept as it Alliance (Global Alliance for Vaccines applies to global health has become much more and Immunisation) and the Global broad in recent years. Fund to fight AIDS, Tuberculosis and Malaria are examining how they In fact, there can be many different facets of might direct new resources into innovation. health systems strengthening. As our cover story reflects, TDR has been on the cut- ting edge of efforts to develop and assess new forms Here too, TDR is involved. We are work- of TB diagnosis and treatment. Some of these involve ing with others in WHO to organize new tools, such as the use of light-emitting diode the first Global Symposium on Health (LED) microscopes in TB diagnosis. Some efforts test Systems Research, 16-19 November 2011 3 strategies for the improved use of existing tools – for in Montreux, Switzerland. instance, the earlier initiation of ARV therapy for HIV- In the widening discussion around innovation, the positive TB patients. competition can at times become intense between Innovative institutional networks and groupings can diverse groups pitching for innovative new tools; also be part of the innovation drive. Over the past approaches to networking and knowledge manage- year, TDR has been involved in the development of ment; and investments in health systems innovation. a new African Network on Drugs and Diagnostics In TDR’s view, the entire continuum of innovation is Innovation (ANDI), which held its second stakehold- important and should be viewed holistically. Those ers’ meeting on 4-7 October in Cape Town, South actors concerned with R&D and those concerned Africa. Inspired by ANDI, a new China Network on with health systems and access are working Drugs and Diagnostics Innovation (China-NDI) held together towards a mutual goal – the elimination its initial meeting, 24-25 October, in Shanghai. of diseases of poverty and the improved welfare of These are both important contributions to the Global people globally. Strategy on Public Health, Innovation and Intellectual Property approved at the World Health Assembly in 2008. Dr Robert Ridley TDR Director No. 84 RESEArcH BRIEFS • New TB smear diagnostic procedures on the horizon • Shorter, easier visceral leishmaniasis treatment shows promise • Vector control can play critical role in visceral leishmaniasis elimination • Researchers uncover DNA blueprint of Schistosoma mansoni • TDR initiates model public health PhD programmes TB DIAGNOSIS becoming popular in developing country VISCERAL LEISHMANIASIS settings. Expert review, as well as More rapid and accurate controlled trials, indicates that the LED Shorter, easier treatment smear microscopy microscopes make the analysis of TB shows promise in India smears faster and easier. New techniques to make diagnosis of For nearly a century, the standard TB much faster and easier in developing The Scientific and Technical Advisory treatment for visceral leishmaniasis (VL), countries have shown good results in Group of WHO’s STOP TB Department or kala azar, has been a painful 30-day TDR-supported trials, and are likely to reviewed experiences with both course of intramuscular injections with be endorsed soon by WHO. front-loading and LED fluorescence sodium stibogluconate. In addition to the prolonged regimen, the treatment One procedure is a new “front-loading” microscopy in a November meeting 4 and will issue findings shortly. Nearly is associated with serious side effects smear sampling technique that would including pancreatitis, myalgia (muscle half of suspected TB patients do not get permit same-day TB smear diagnosis pain) and cardiac failure. with two sputum smear samples. a confirmed TB diagnosis currently. A Currently, sampling over two or three major factor is the dropout rate of poor Over the past decade, TDR and days is required, imposing a burden patients who cannot afford the travel partners in India successfully brought not only on laboratories but on patients and time off work for repeated clinic to registration a 28-day oral drug, having to make repeated clinic visits. visits. (See TB update, p. 14). miltefosine, for VL. The only existing oral treatment, miltefosine has proven TDR also recently sponsored clinical trials highly effective in both children and of low-cost LED (light-emitting diode) FOR MORE INFO adults. However, at roughly US$ 72 per fluorescent adapters to microscopes. Dr Andy Ramsay: [email protected] treatment, miltefosine is costly. LED fluorescence microscopy is rapidly Now it appears that a shorter, easier and lower-cost treatment for VL may be on the horizon. Preliminary results of a TDR-sponsored clinical trial of Gilead’s AmBisome® (liposomal amphotericin B) followed by 14 days of oral miltefosine WHO/TDR/Crump treatment are very promising. Publication of final results is expected in 2010. The trial, led by Banaras Hindu University and Rajendra Memorial Research Institute of Medical Sciences, is being conducted in two sites in India, one in Varanasi and the other in Patna. The latter is the capital of Bihar, where close to 50% of the Indian subcontinent’s VL cases occur. According to TDR scientist Byron Arana, combining one injection of AmBisome® with the 14-day miltefosine course appears highly effective as a treatment. This regime also improves patient adherence to the therapy, which helps stave off parasite resistance to the new VL drugs. “Patients tend to feel much better after a short time of taking miltefosine – and then they often stop taking the pills. That’s a recipe for resistance,” Arana says, Microscopic examination of a TB specimen at St Peter’s TB Clinic, Addis Ababa, Ethiopia. “and the patient is never cured.” No.