Guest post by Karolina Maciag, an MD/PhD student at Harvard Medical School/Harvard-MIT Health Science and Technology Program and Jen Manne, an ScD/MD student at Harvard School of Public Health/BU School of Medicine.
Last month, Boston hosted the inaugural Neglected Tropical Diseases (NTD) meeting of the International Society for Infectious Diseases (ISID). At the request of society members from resource-poor countries, the meeting focused on the NTDs, rather than the “Big Three” of HIV/AIDS, tuberculosis, and malaria. In these countries, disabling and potentially fatal diseases – from schistosomiasis and onchocerciasis to Chagas Disease, lymphatic filariasis and other helminthic infections – are endemic.
While the neglected diseases affect over a billion people, they have been poorly represented in academia as well as industry. Astonishingly, they garner less than 0.5% of global medical research funding. The meeting provided a forum for discussion of both science and policy regarding these traditionally marginalized areas of both practice and research.
Scientific opportunities and the need to innovate
Adel Mahmoud of Princeton opened the meeting by lauding nascent applications of structural, computational, genomic, and metabolomic approaches to NTDs. Dr. Mahmoud also encouraged a multidisciplinary approach, pairing development of new drugs, diagnostics, and vaccines with strict monitoring for the inevitable emergence of drug resistance.
Presentations on microbiology, immunology, and pathology of these diseases were complemented by studies of their interaction with chronic infections and human development. The discussion at the meeting identified key challenges, including a continuously evolving drug pipeline to address resistance, pediatric formulations, vaccines, and a way to target animal reservoirs of disease, such as the livestock that harbor the schistosomiasis parasite.
Leading product development partnerships (PDPs)B
The biomedical industry has traditionally ignored NTDs. Product development partnerships (PDPs) have recently succeeded in capturing a fraction of industrial R&D capacity for NTDs by linking companies with nonprofit funders and academic researchers. ISID–NTD.provided a forum for the leading PDPs in drugs, vaccines, and diagnostics to provide an update on their global R&D portfolios.
On behalf of the Drugs for Neglected Diseases Initiative, Manica Balasegaram described a new treatment for human African trypanosomiasis and announced that a much-needed pediatric formulation of benznidazole would likely be available as early as next year to treat the roughly 14,000 children born each year with Chagas Disease.
The leading consortium in the development of NTD diagnostics, The Foundation for Innovative New Diagnostics, uses revenue from commercially successful platform technologies for pay for NTD research. Specifically, the foundation has adapted lateral flow testing and their novel DNA amplification strategy from (the more lucrative) malaria and TB to diagnostics for HAT, malaria, and leishmaniasis.
Peter Hotez, representing the Sabin Vaccine Institute, spoke to the challenges of developing vaccines against parasitic infections. Sabin and other PDPs increasingly team with scientists and vaccine manufacturers in the innovative developing countries, creating new opportunities for scientific progress and collaboration.
When science, healthcare, and policy align
Will new and existing interventions be implemented, given the structural and cultural difficulties in healthcare delivery in the resource-poor areas in which NTDs are endemic? Speakers at the meeting underscored innovations in public health that are enabling and improving the deployment of medical technologies. Two examples: the scale-up of sanitation and mass administration of existing drugs by national public health systems and nonprofit organizations across the world. Where consumer or governmental markets are too poor for a sustainable demand, drug donation programs and generic manufacture bring costs down. Responsiveness to empirical data creates efficiencies, as illustrated by a comparison of two parallel onchocerciasis (river blindness) eradication efforts in South America. In this case, a simple yet far-reaching change – involvement of local communities – lowered costs and expanded the reach of treatment efforts.
Evidence has also demonstrated that in many settings, “horizontal” health systems that address many diseases, rather than “vertical” disease-specific programs, created effective and sustainable programming while improving other aspects of health care delivery for the “bottom billion.” With the recent demonstration of associations between several NTDs and transmission of HIV/AIDS and malaria (Hotez et al NEJM June 2011), there was also discussion about how to best advance collaboration between these research communities.
A few examples demonstrate the progress possible when concentrated science, healthcare, policy, and funding efforts align. For instance, guinea worm has been eradicated from sixteen out of twenty previously endemic countries, while transmission of river blindness has been halted in Colombia with Mexico and Guatemala predicted to follow suit within a year.
Though millions remain infected with NTDs, these successes have emphasized the capacity and need for further biomedical innovation: poor infrastructure is not an excuse to cease scientific research applied to NTDs.
Closing the resource gap
Both established biomedical centers and programs in endemic countries will need two vital resource inputs in order to capitalize on the opportunities in NTD research: drastic increases in financial support and additional young trainees.
David Molyneaux of the Liverpool Centre for NTDs addressed gaps and sources of research funding, and outlined an advocacy agenda focused on addressing both basic and implementation research, especially in zoonotic diseases and co-morbidities with chronic and noncommunicable disease.
In addition, speakers described the African Network for Drugs and Diagnostics Innovation, an expanding consortium of African regional scientific research collaborations and the newly established Institute for Tropical Disease at the University of Texas-Southwestern, the US response to the UK’s centers of tropical medicine at London and Liverpool.
Recognizing the effect of NTDs on local economies, vaccines against these diseases have been dubbed the “antipoverty vaccines.” The importance of NTD control for foreign aid efficiency in regions where the poor are too sick to work and for “vaccine diplomacy” – of particular relevance in the Middle Eastern countries, which account for nearly half of the world’s tropical disease burden – furthers the compelling case to increase funding in this area. Molyneux called for refined disease burden assessments to strengthen arguments for funding.
While ISID–NTD highlighted progress and challenges ahead for the research community, it was noted that no “magic bullet” drug candidate, sanitation policy, or policy intervention would provide a cure-all. Rather, ministries of health, communities, researchers, physicians, policy experts, and NGOs all play important roles in fighting NTDS.