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Neglected tropical diseases: The London declaration

31 Jan, 2012

Neglected tropical diseases - Wellcome News cover artworkIn London yesterday morning, an extraordinary gathering of international politicians, pharmaceutical chief executives and global health organisation heads threatened to take the ‘neglect’ out of ‘neglected tropical diseases’ (NTDs). Together they made a number of significant commitments to provide treatments, research and development funding and cooperation to control, eliminate or even eradicate ten NTDs by 2020.

At an event called Uniting to combat NTDs, the World Health Organization (WHO) launched a new roadmap for reducing the burden of NTDs between now and 2020, while 13 pharmaceutical companies announced donations of billions of tablets each year to treat the most common NTDs in endemic countries.

The UK’s Minister for International Development, Stephen O’Brien, said: “The world has come together to end the neglect of these horrific diseases which needlessly disable, blind and kill millions of the world’s poorest…. [We will] provide critical treatments to millions of people, which allow children to attend school and parents to provide for their families so that they can help themselves out of poverty and eventually no longer rely on aid.”

Tough targets

The companies and organisations represented at the event endorsed the London Declaration on NTDs, committing to take advantage of a “tremendous opportunity to control or eliminate at least ten of these devastating diseases by the end of the decade.” This statement reflects the targets in the WHO roadmap, which are to eradicate dracunculiasis (Guinea worm disease) by 2015 and endemic treponematoses (yaws) by 2020; the global elimination of trachoma, leprosy, human African trypanosomiasis (sleeping sickness) and lymphatic filariasis (elephantiasis) by 2020; and to bring under control by 2020 schistosomiasis, onchocerciasis (river blindness), soil-transmitted helminthiases (hookworm, roundworm and whipworm infections), Chagas’ disease and visceral leishmaniasis.

The next post in our NTDs series will be looking at the differences between control, elimination and eradication in more detail next week but, briefly, eradication means no more cases of a disease: this has been achieved only once before in human history when smallpox was eradicated last century – dracunculiasis could be the next to disappear (although polio is also getting close to extinction).

Elimination can be achieved regionally, which means that the transmission of a disease no longer takes place. Global elimination is when a disease has been eliminated from all regions. Control reduces the transmission of a disease to such an extent that it is no longer a major public health issue.

Other NTDs are included in the roadmap but without specific targets. These include dengue fever, Buruli ulcer, cutaneous leishmaniasis, trematode infections, cysticercosis and echinococcosis.

All of the NTDs in the WHO’s official list of 17 are accounted for in the roadmap. There are several other diseases that could also claim to be neglected and what happens to tackle these remains to be seen, but controlling or eliminating at least ten NTDs in the next eight years would be a historic achievement.

Not the only solution

Opening the event, Dr Margaret Chan, director of the WHO, said that in the past we may have relied too much on drug donation alone. “It is one solution,” she said, “but it is not the only solution.”

This point was echoed throughout the day as participants discussed the roadmap and the undeniably impressive drug donation commitments from the world’s pharmaceutical sector. A common issue was the urgent need for clean water and sanitation in the communities at risk from NTDs. And, of course, while treatments have been made available for numerous diseases, there is still the considerable challenge of delivering the pills to the people who need them and ensuring they produce the desired effect – better health and reduced burden of these diseases.

But as Haruo Naito, the president and CEO of Eisai, indicated, having these commitments from the pharma companies removes one obstacle from finding long-term solutions to NTDs. “Supply of drugs will not be the bottleneck,” he said.

Building the future of NTDs together

In the afternoon, a second event examined in more detail the WHO targets and what will be needed to achieve them. Many participants spoke of their emotional response to the news of the morning – Professor Alan Fenwick, director of the Schistosomiasis Control Initiative described it as a “transformational commitment” – but we were also reminded of the need to be cautious and not to forget all the other parts of the equation that need to be in place to achieve the WHO’s “stretching” goals.

Dr Lorenzo Savioli of the WHO explained that the roadmap was designed to provide guidance and technical insight to encourage countries and communities to act against NTDs. The drug companies’ donations had changed the situation: “Business is not as usual,” he said.

The World Bank is a major supporter of improving countries’ healthcare infrastructure and has funded NTD control programmes since the first such programme to control onchocerciasis in Africa launched in 1974. Dr Caroline Anstey, a Managing Director of the World Bank, said: “Part of the reason NTDs are neglected is because the people are neglected. They don’t have a voice so this is about shining a light. We have to create a lobby group for the voiceless.”

Professor Chris Witty from the UK Department for International Development, which announced a significant increase in funding for treating four NTDs last week, said that elimination and eradication get harder the closer you get to achieving them because you are left with territories in which it is more difficult to monitor and coordinate the effort. “A very difficult endgame will be a sign of success,” he concluded.

We also heard more from the pharmaceutical companies about their commitments beyond drug donation. Dr Jutta Reinhard-Rupp from Merck KGaA – which donates praziquantel for schistosomiasis – explained that her company is working on a formulation of praziquantel suitable for children. The current tablets are large and taste bitter if broken up.

Several pharmaceutical companies are now working together, or at least sharing libraries of compounds, to speed up development of better drugs for certain NTDs. Several industry people spoke of new drugs that needed to be reformulated so they could be given orally rather than by injection, which is impractical in poor rural areas. Many participants also described the need for more operational research – to understand the best ways to deliver drugs in the communities where they are needed.

Professor Sir Roy Anderson of Imperial College London set out several areas where scientific tools are available but not currently being sufficiently used. These covered treatment strategies, electronic monitoring of diseases, and the need for demographic analysis as well as epidemiology.

Sir Roy also said we will have to monitor very carefully any evolutionary changes in the parasites given they will be subjected to the most intense selective pressures in their long histories. Mass drug administration could potentially drive the development of resistance mechanisms and as we are currently reliant on just one or two drugs for so many NTDs, that could be disastrous.

Still neglected?

The global health community – including governments, public and private partnerships – has taken a huge step forwards in the task of reducing the burden of disease among the world’s poorest people. However, even if we have the resources and capacity to deliver the donated drugs and implement effective disease control strategies, the tools we currently have will not be enough to combat all NTDs in the next eight years. Looking beyond 2020, the tools of the future will come from basic and applied research being done today – research such as that funded by the Wellcome Trust, the Gates Foundation and others.

As reported in the Guardian yesterday, Bill Gates – who played a major role in bringing together the pharmaceutical companies in yesterday’s announcement – said: “Maybe as the decade goes on, people will wonder if these should be called neglected diseases. Maybe as the milestones go on, we will call them just tropical diseases.”

Of course, the name ‘neglected tropical diseases’ has not been around that long. It is a testament to the strength of the campaigners and advocates who have been extolling the need for action that people are already talking – albeit tentatively – about the term becoming obsolete.

11 Comments leave one →
  1. 31 Jan, 2012 5:14 pm

    Sir Roy touched on the issue already so all I can do is emphasise once again the need to maintain a research agenda. Upscaling of drugs to remove that one bottleneck will make a huge difference of course. But that does not in itself remove numerous other bottlenecks that can only be addressed through properly targeted research. I recently attended a presentation from Don de Savingy of the Swiss Tropical and Public Health Institute where he demonstrated one bottleneck in the supply of antimalarials across the whole of Tanzania. Research on the best way to strengthen health systems even in the face of available drugs is therefore needed. The social context of NTDs is woefully lacking in terms of information available. We still are unsure of the effects of removing certain species on health (e.g non-infectious inflammation diseases) or transmission of other parasites (helminths vs malaria, helminths vs HIV etc). Climate change is likely to affect everything, including the economic priorities of countries suffering from NTDs. For example, we need to consider how population migration related to the impact of climate change wil affect the spread of disease.

    There is a lively discussion at the Guardian website on this declaration with varying viewpoints that should be considerered, in my opinion:

    • 1 Feb, 2012 2:35 pm

      Thanks for your comment, Mark. It is great that the pharmaceutical companies have donated so many drugs to treat NTDs and it is appropriate for resources to go on delivering those treatments to sick people. But it is vital that we don’t think having the drugs available means the end of the problem.

      Your comment about climate change and its potential impact on health chimes strongly with one of the Wellcome Trust’s five ‘research challenges’ for this decade: Connecting environment, nutrition and health – we’re funding research in that area as well as on the basic biology of NTD pathogens and new tools for tackling them. We also support capacity-building in many low-income countries around the world to bolster both the scientific base and the clinical / health service base in these areas.

      As you say, research has to continue to monitor NTDs and the contexts in which they occur, the impact of mass drug administration programmes, and to ensure there are more tools (drugs, vaccines, vector control, social and environmental policies etc) in the pipeline.

    • 3 Feb, 2012 2:19 pm

      Mark has gone into more detail on these points in the New Statesman – an article well worth reading if you want to understand the many potential challenges that NTDs present now and in the future:

  2. 25 Jan, 2013 10:50 am

    Reblogged this on Science on the Land and commented:
    argylesock says… This happened a year ago. Why wasn’t it all over the mainstream news here in Britain, and around the world?


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