The good, the bad, and the neglected.

Abstract

There is a lot to celebrate and applaud in this month's issue of The Lancet Global Health, but also some sobering findings and a clear demonstration of the need for more research. To start with the positive, Osman Sankoh and fellow INDEPTH Network colleagues announce a new freely accessible repository of Health and Demographic Surveillance System data generated by its member centres across Africa, Asia, and the Pacific. This triumph of dedication, which currently holds data on around 800 000 individuals and more than 3·7 million person-years of observation, represents the first harmonised database of longitudinal population-based data from low-income and middle-income countries. The Network also launched INDEPTHStats, a publicly accessible source of summary statistics generated from the data repository. The INDEPTH team should be congratulated on this effort, which can only improve as more data are added and more centres sign up to the Network.Continuing the spirit of sharing, US National Institutes of Health Director Francis Collins and colleagues from eight other research funding bodies announce the launch of a freely accessible online map (World RePORT) showing the location of research programmes funded by these organisations in sub-Saharan Africa over the past year. It's a welcome step towards a more collaborative approach to the funding of research in lower-income countries by high-income-country organisations, and a ready way to identify gaps and inequities. We encourage other governmental, non-governmental, and private funding agencies to join the effort.One of the funding gaps identified by the World RePORT is, perhaps unsurprisingly, the field of neglected tropical diseases. Collins and colleagues pick out Buruli ulcer and yaws—two infectious diseases that cause highly disfiguring skin, tissue, and bone lesions—but another such disorder is possibly even more neglected. That disorder is noma. The devastating nature of this condition, which mainly affects young children, is grossly out of proportion with the state of what is known about the illness. As Klaas Marck notes in his Comment in this issue, the exact cause and disease mechanism are unknown, no proper antibiotic treatment studies have been done, and there is no effective treatment for one of the common sequelae—complete trismus. Although the ultimate “cure” for the disease might be the elimination of the extreme poverty of which it is characteristic, the fact that so little research has been done is shameful.This sentiment is echoed by Denise Baratti-Mayer and colleagues in their Article. Baratti-Mayer and colleagues did an ambitious case-control study in southeastern Niger to try to identify sociodemographic and microbiological risk factors for the disease. They found that severe wasting and stunting, recent respiratory or diarrhoeal disease, a high number of past pregnancies in the mother, and the absence of chickens at home (a surrogate for poverty) were significant risk factors for noma. The authors also found a different pattern of oral microbial flora compared with controls, which resembled the composition found in patients with periodontal diseases. Frustratingly, the authors did not find a specific causative agent. Nevertheless, the study shows that noma research is possible, and suggests that educating parents about oral care and how to recognise symptoms could be novel preventive approaches to add to ongoing programmes to eliminate poverty and undernutrition.In other research in this issue, Sant-Rayn Pasricha and colleagues' systematic review and meta-analysis shows that, although daily iron supplements reduce anaemia in children aged 4–23 months, they seem to impair length and weight gain, possibly as a result of increased vomiting. There was also no evidence of a beneficial effect on cognitive development, contrary to previous research. The authors highlight the paucity of data on the non-haematological effects of iron supplementation in this vulnerable age group and stress the need for further research before any guidelines can be developed.Finally, Heather Zar and colleagues explore the value of a rapid PCR-based test (Xpert MTB/RIF) in diagnosing tuberculosis in children attending a primary care clinic. Although a formal assessment of sensitivity and specificity could not be done owing to the absence of a gold standard diagnostic for paediatric tuberculosis, the authors conclude that the test is “feasible and useful” in children in primary care. In her linked Comment, Annelies Van Rie is not so sure. But tell us what you think by starting a discussion on this or any of the other items in this month's issue on The Lancet Global Health Blog.For INDEPTH data repository see http://www.indepth-ishare.org/index.php/homeFor INDEPTHStats see http://www.indepth-ishare.org/indepthstats/For the World RePORT see http://worldreport.nih.gov/For The Lancet Global Health Blog see http://globalhealth.thelancet.com/ There is a lot to celebrate and applaud in this month's issue of The Lancet Global Health, but also some sobering findings and a clear demonstration of the need for more research. To start with the positive, Osman Sankoh and fellow INDEPTH Network colleagues announce a new freely accessible repository of Health and Demographic Surveillance System data generated by its member centres across Africa, Asia, and the Pacific. This triumph of dedication, which currently holds data on around 800 000 individuals and more than 3·7 million person-years of observation, represents the first harmonised database of longitudinal population-based data from low-income and middle-income countries. The Network also launched INDEPTHStats, a publicly accessible source of summary statistics generated from the data repository. The INDEPTH team should be congratulated on this effort, which can only improve as more data are added and more centres sign up to the Network. Continuing the spirit of sharing, US National Institutes of Health Director Francis Collins and colleagues from eight other research funding bodies announce the launch of a freely accessible online map (World RePORT) showing the location of research programmes funded by these organisations in sub-Saharan Africa over the past year. It's a welcome step towards a more collaborative approach to the funding of research in lower-income countries by high-income-country organisations, and a ready way to identify gaps and inequities. We encourage other governmental, non-governmental, and private funding agencies to join the effort. One of the funding gaps identified by the World RePORT is, perhaps unsurprisingly, the field of neglected tropical diseases. Collins and colleagues pick out Buruli ulcer and yaws—two infectious diseases that cause highly disfiguring skin, tissue, and bone lesions—but another such disorder is possibly even more neglected. That disorder is noma. The devastating nature of this condition, which mainly affects young children, is grossly out of proportion with the state of what is known about the illness. As Klaas Marck notes in his Comment in this issue, the exact cause and disease mechanism are unknown, no proper antibiotic treatment studies have been done, and there is no effective treatment for one of the common sequelae—complete trismus. Although the ultimate “cure” for the disease might be the elimination of the extreme poverty of which it is characteristic, the fact that so little research has been done is shameful. This sentiment is echoed by Denise Baratti-Mayer and colleagues in their Article. Baratti-Mayer and colleagues did an ambitious case-control study in southeastern Niger to try to identify sociodemographic and microbiological risk factors for the disease. They found that severe wasting and stunting, recent respiratory or diarrhoeal disease, a high number of past pregnancies in the mother, and the absence of chickens at home (a surrogate for poverty) were significant risk factors for noma. The authors also found a different pattern of oral microbial flora compared with controls, which resembled the composition found in patients with periodontal diseases. Frustratingly, the authors did not find a specific causative agent. Nevertheless, the study shows that noma research is possible, and suggests that educating parents about oral care and how to recognise symptoms could be novel preventive approaches to add to ongoing programmes to eliminate poverty and undernutrition. In other research in this issue, Sant-Rayn Pasricha and colleagues' systematic review and meta-analysis shows that, although daily iron supplements reduce anaemia in children aged 4–23 months, they seem to impair length and weight gain, possibly as a result of increased vomiting. There was also no evidence of a beneficial effect on cognitive development, contrary to previous research. The authors highlight the paucity of data on the non-haematological effects of iron supplementation in this vulnerable age group and stress the need for further research before any guidelines can be developed. Finally, Heather Zar and colleagues explore the value of a rapid PCR-based test (Xpert MTB/RIF) in diagnosing tuberculosis in children attending a primary care clinic. Although a formal assessment of sensitivity and specificity could not be done owing to the absence of a gold standard diagnostic for paediatric tuberculosis, the authors conclude that the test is “feasible and useful” in children in primary care. In her linked Comment, Annelies Van Rie is not so sure. But tell us what you think by starting a discussion on this or any of the other items in this month's issue on The Lancet Global Health Blog. For INDEPTH data repository see http://www.indepth-ishare.org/index.php/homeFor INDEPTHStats see http://www.indepth-ishare.org/indepthstats/For the World RePORT see http://worldreport.nih.gov/For The Lancet Global Health Blog see http://globalhealth.thelancet.com/ For INDEPTH data repository see http://www.indepth-ishare.org/index.php/homeFor INDEPTHStats see http://www.indepth-ishare.org/indepthstats/For the World RePORT see http://worldreport.nih.gov/For The Lancet Global Health Blog see http://globalhealth.thelancet.com/ For INDEPTH data repository see http://www.indepth-ishare.org/index.php/home For INDEPTHStats see http://www.indepth-ishare.org/indepthstats/ For the World RePORT see http://worldreport.nih.gov/ For The Lancet Global Health Blog see http://globalhealth.thelancet.com/ Noma: a neglected enigmaNoma is a disease surrounded by riddles. It manifests itself only in the poorest populations in developing countries, enclosed by ignorance and extreme poverty. The worldwide prevalence of noma is unknown—estimates range from 30 000 to 140 000 cases.1 Most cases of noma worldwide occur in the so-called noma belt, which is situated directly south of the Sahara and runs across Africa from Senegal to Ethiopia. Another puzzle is that child mortality and malnutrition are prevalent on the Indian subcontinent, but noma is not reported there. Full-Text PDF Open AccessXpert MTB/RIF: a game changer for the diagnosis of pulmonary tuberculosis in children?The diagnosis of pulmonary tuberculosis in young children is challenging because clinical and radiological features are often non-specific.1 Achieving a definite diagnosis through microbiological confirmation is especially problematic in this population owing to the typically low bacillary burden and the difficulty in obtaining a quality respiratory specimen. For adults, WHO has endorsed a single Xpert MTB/RIF assay for initial diagnosis, especially in people with HIV and in those with suspected drug-resistant tuberculosis. Full-Text PDF Open AccessA database on global health research in AfricaOver the past decade, global concern about the disproportionate burden of disease and mortality in low-income countries, especially in sub-Saharan Africa, has led to a substantial influx of funding for research by many donor and research agencies.1 This investment has energised in-country research; advanced the discovery and the use of new treatments for HIV/AIDS, tuberculosis, and malaria; and stimulated new research strategies for the prevention and control of these and other diseases. Questions have been raised about whether these international efforts could be better coordinated to increase efficiency and improve outcomes, while ensuring that research institutions and universities are supported with these funds. Full-Text PDF Open AccessINDEPTH launches a data repository and INDEPTHStatsOn July 1, 2013, the INDEPTH Network1 will launch the first online data repository that specialises in longitudinal individual exposure and cause-specific mortality data from health and demographic surveillance systems located in low-income and middle-income countries, including in Africa, Asia, and Oceania. These are regions where such high-quality, particularly longitudinal, data, are traditionally very difficult to obtain. Each dataset in the repository is documented according to internationally accepted metadata standard by the Data Documentation Initiative, which enables users to quickly identify and download the data they need. Full-Text PDF Open AccessEffect of daily iron supplementation on health in children aged 4–23 months: a systematic review and meta-analysis of randomised controlled trialsIn children aged 4–23 months, daily iron supplementation effectively reduces anaemia. However, the adverse effect profile of iron supplements and effects on development and growth are uncertain. Adequately powered trials are needed to establish the non-haematological benefits and risks from iron supplementation in this group. Full-Text PDF Open AccessRisk factors for noma disease: a 6-year, prospective, matched case-control study in NigerNoma is associated with indicators of severe poverty and altered oral microbiota. The predominance of specific bacterial commensals is indicative of a modification of the oral microbiota associated with reduced bacterial diversity. Full-Text PDF Open AccessRapid diagnosis of pulmonary tuberculosis in African children in a primary care setting by use of Xpert MTB/RIF on respiratory specimens: a prospective studyOur findings suggest that Xpert MTB/RIF on respiratory secretions is a useful test for rapid diagnosis of paediatric pulmonary tuberculosis in primary care. Full-Text PDF Open Access