Poverty-related Diseases Research Articles

The Linguistic-Cultural Mediation Service of the National Institute for the promotion of Health of Migrant populations and the control of Poverty related-diseases (NIHMP)

The paper presents the experience of the linguistic-cultural mediation service of the National Institute for Health, Migration and Poverty (NIHMP), a public structure that carries out clinical research, assistance, prevention, treatment and training activities. A team of linguistic-cultural mediators is involved in the numerous services and activities working with different disciplines and professionals. The paper aims at describing how the linguistic-cultural mediators serve as facilitators in terms of migrant populations’ access to social and healthcare services and showing their involvement in a multidisciplinary setting.

Knowledge, attitude and practices related to visceral leishmaniasis among residents in Addis Zemen town, South Gondar, Northwest Ethiopia.

BackgroundVisceral leishmaniasis (VL), commonly known as kala-azar is a systemic disease caused by parasitic protozoan species of genus Leishmania and transmitted by species of Phlebotomus (sand flies). It is a poverty-related disease and associated with malnutrition, displacement, poor housing, weakness of the immune system and lack of resources. For the success of prevention and control programs of any disease, the most important prerequisite is community participation. Therefore, this study was aimed to assess the knowledge, attitude and practice of residents towards VL in Addis Zemen town, south Gondar, Northwest Ethiopia.MethodsCommunity based cross-sectional study was conducted among residents in Addis Zemen town from February to March 2012. A total of 346 households were selected by using simple random sampling techniques from three kebeles in the town. Data was collected using structured Questionnaire. For knowledge, attitude and practice variables each right response was given a score of 1 while a wrong or unsure response was scored 0. Data were double entered and analyzed using SPSS-15 statistical software. The frequency distribution of both dependent and independent variables were worked out.ResultsFrom a total of 346 study participants (136 males and 210 females), 87.6% heard of the disease kala-azar. From participants who heard about kala-azar 93.5% males and 86.7% females had awareness about the disease. The majority (95.7%) of participants had favourable attitude towards the treatment of kala-azar whereas 14.8% didn’t use anything to prevent it. More than half of the respondents (68.6%) did practice proper methods for the prevention and control of kala-azar in the study area.ConclusionIn general our findings showed that the residents had good awareness and favourable attitude about the disease, but their overall practice about prevention and control of the disease was low. Therefore, our investigation call for continued and strengthened behavioral change communication and social mobilization related activities.

EDCTP regional networks of excellence: initial merits for planned clinical trials in Africa.

BackgroundAchieving the Millennium Development Goals (MDGs) and combating hotspots with escalating but preventable communicable diseases remain major challenges in Africa. The European and Developing Countries Clinical Trials Partnership (EDCTP) intervened to combat poverty-related diseases including malaria, tuberculosis and HIV/AIDS, and to conduct multi-centre clinical trials and multi-disciplinary health research through an innovative model of regional Networks of Excellence (NoEs).MethodsWe participated in a quasi-formative evaluation between October and December 2011 on the 4 regional-led research networks. These included the: Central Africa Network on Tuberculosis, HIV/AIDS and Malaria (CANTAM); East African Consortium for Clinical Research (EACCR); West African Network of Excellence for TB, AIDS and Malaria (WANETAM), and the Trials of Excellence for Southern Africa (TESA) launched between 2009 and 2010. We shared a participatory appraisal of field reports, progress reports and presentations from each network to jointly outline the initial experiences of the merits, outputs and lessons learnt.ResultsThe self-regulating democratic networks, with 64 institutions in 21 African countries, have trained over 1, 000 African scientists, upgraded 36 sites for clinical trials, leveraged additional € 24 million and generated 38 peer-reviewed publications through networking and partnerships.ConclusionsThe shared initial merits and lessons learnt portray in part the strengthened capacity of these networks for improved research coordination and conduct of planned multi-center clinical trials in Africa. Increased funding by African agencies, governments and international health partners will ensure sustainability of these networks for research capacity development and demonstrate their commitment to achieving the MDGs in Africa.

Epitopic analysis of Potential Vaccine Candidate in Leishmania infantum for Development of Human Vaccine

Leishmaniasis is a poverty related disease caused by protozoan parasites belonging to the genus Leishmania. No effective vaccine is presently available to treat this disease. The present study identifies specific epitopes in highly antigenic peptides of Leishmania infantum. Interestingly we found amastin like surface proteins as relevant markers for vaccine development for design of epitopes. A major glycoprotein GP63 leishmanolysin which directly binds to human natural killer cells (NK cells) was also selected as highly antigenic and considered for the analysis. Overall two different amastin like surface proteins were found as relevant for designing 9-mer epitopes for vaccine development against L. infantum and the best identified antigenic segments interacted with at least 8 alleles of each MHC classes. These epitopes are potential candidates to induce both T cell and B cell mediated immune responses. Keywords: Amastin, Antigenic, Epitopic analysis, Human, In silico, Leishmania, Vaccine development, L. infantum, NK cells, Leishmania donovani, HIV/AIDS, VL, Helicobacter pylori, GP63 leishmanolysin, Amastin, fold-level analysis, CD-HIT

A research agenda for helminth diseases of humans: health research and capacity building in disease-endemic countries for helminthiases control.

Capacity building in health research generally, and helminthiasis research particularly, is pivotal to the implementation of the research and development agenda for the control and elimination of human helminthiases that has been proposed thematically in the preceding reviews of this collection. Since helminth infections affect human populations particularly in marginalised and low-income regions of the world, they belong to the group of poverty-related infectious diseases, and their alleviation through research, policy, and practice is a sine qua non condition for the achievement of the United Nations Millennium Development Goals. Current efforts supporting research capacity building specifically for the control of helminthiases have been devised and funded, almost in their entirety, by international donor agencies, major funding bodies, and academic institutions from the developed world, contributing to the creation of (not always equitable) North–South “partnerships”. There is an urgent need to shift this paradigm in disease-endemic countries (DECs) by refocusing political will, and harnessing unshakeable commitment by the countries' governments, towards health research and capacity building policies to ensure long-term investment in combating and sustaining the control and eventual elimination of infectious diseases of poverty. The Disease Reference Group on Helminth Infections (DRG4), established in 2009 by the Special Programme for Research and Training in Tropical Diseases (TDR), was given the mandate to review helminthiases research and identify research priorities and gaps. This paper discusses the challenges confronting capacity building for parasitic disease research in DECs, describes current capacity building strategies with particular reference to neglected tropical diseases and human helminthiases, and outlines recommendations to redress the balance of alliances and partnerships for health research between the developed countries of the “North” and the developing countries of the “South”. We argue that investing in South–South collaborative research policies and capacity is as important as their North–South counterparts and is essential for scaled-up and improved control of helminthic diseases and ultimately for regional elimination.

Taming the Burgeoning Stroke Epidemic in Africa: Stroke Quadrangle to the Rescue (P01.002)

Objective: This is a systematic review of the existing literature to examine the burden and profile of stroke in the WHO African region and proffer coordinated and responsive means of tackling the epidemic. Background Africa is currently experiencing epidemiological transition with growing burden of stroke and other non-communicable diseases, initially adding to the infectious and poverty-related disease burden and later becoming the dominant causes of death and disability. There is inadequate pooled data describing the total burden of stroke in Africa. Design/Methods: A systematic review of the literature was conducted according to the Centre for Reviews and Dissemination Guidelines using Pubmed, African Journals On-Line and Google Scholar databases. Over 1300 articles were obtained. All abstracts were screened, and every article that might have contained relevant information was read in full. Their heterogeneity made meta-analysis impossible. So a critical assessment of the data with a narrative review was conducted. Results: Stroke has an annual incidence rate of up to 316 per 100 000, a prevalence rate of up to 315 per 100 000 and a 3-year fatality of up to 84% in Africa. In 2002, model-based estimated age-adjusted stroke mortality rates ranged between 168 and 179 per 100 000 population for countries in the African region. There is severe scarcity of facilities and human resources for prevention, investigations, acute care and rehabilitation of stroke patients in Africa. Conclusions: Africa bears a heavy burden of stroke. I propose a stroke quadrangle comprising a concerted network of four pillars: demographic surveillance and stroke research network; integrated community-based primary and secondary prevention programs; easily accessible and well-equipped acute stroke care services; and neurorehabilitation centres and services. This network could be reinforced using information and communication technologies, telemedicine facilities and linked health information systems. Disclosure: Dr. Owolabi has nothing to disclose.

Global health in 2012: development to sustainability

In 2012 there will be a major strategic shift in global health, away from development and towards sustainability. Since 2000, the Millennium Development Goals (MDGs), driven by a macroeconomic diagnosis of global poverty, have focused on investment in a small number of diseases as the most effective approach to decrease poverty. Institutions such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, Roll Back Malaria, and GAVI have been created to respond to that diagnosis. But this approach is now delivering diminishing returns. The AIDS epidemic has peaked, both in terms of deaths and new infections, non-communicable diseases (NCDs) are increasing, and the climate change crisis is an ever present threat. India is a good example of a country facing these new challenges. It has an NCD epidemic and yet still endures the highest number of maternal and child deaths in the world. The old macroeconomic approach to solving poverty-related disease is simply insufficient to meet the demand of countries. At the same time, institutional tensions are growing—the Global Fund is in difficulty and WHO is facing a financial emergency. And there are new concepts forcing their way into global health agendas—such as integration and accountability. There is a view among some development experts that health has had its decade. It is time now for other sectors to take centre stage, such as agriculture or energy. All these issues will come into sharp focus later this year at Rio+20, the UN Conference on Sustainable Development in Rio de Janeiro, Brazil (June 20–22). The summit marks the 20th anniversary of the 1992 UN Conference on Environment and Development and the tenth anniversary of the 2002 World Summit on Sustainable Development. World leaders, stakeholders from the public and private sectors, as well as representatives from environment and development communities will convene to define a new roadmap towards economic growth, social equity, and environmental protection. The objectives of Rio+20 will be to review progress on sustainable development from previous summits, identify gaps in implementation, renew political commitment on past action plans, and find ways to safeguard the planet from future destruction from emerging threats. The two core themes will be a move towards a green economy (in the context of sustainable development and poverty eradication) and strengthening the institutional framework for sustainable development, which to date has not fulfilled its potential because of a lack of coordination and coherence. The zero draft outcome document published last week lists seven priority areas for Rio+20. They are: job creation, food security, water, energy, sustainable cities, oceans, and disasters. There will be ten new sustainable development goals to be decided by governments just before the meeting—and introduced in 2015 as part of the post-2015 UN development agenda. There will be no legally binding agreements and countries will set their own targets, working voluntarily towards them. Disappointingly, health is hardly mentioned in this draft. It is vital that this major shift from development to sustainability is governed by a clear set of principles and values. One report to draw from is The Lancet's 2010 Commission titled: The Millennium Development Goals: a cross-sectoral analysis and principles for goal setting after 2015. The authors of this multidisciplinary analysis represent many different sectors, and explain that much more could have been achieved if the MDGs were better integrated. They conclude that future goals should be built on a shared vision of development across the lifecourse, and suggest five principles: holism, equity, sustainability, ownership, and global obligation. Their report exemplifies the positive contribution the health community can make to sustainability after 2015. The health sector has a vital part to play during the next 12 months. We need to make a strong case for health as part of sustainable development and future sustainable development goals—to protect the gains of the past decade and ensure that the unfinished agenda of the past decade is continued. However, we also need to embrace a new and emerging health agenda—one that includes NCDs and climate change. And we must sharpen our advocacy for health as we rightly integrate other sectors into this broader vision. We have an extraordinary opportunity to re-vivify global health. But we are unprepared to do so. We must identify the lessons learned from the MDGs, as well as bringing to the fore evidence for new threats and emerging challenges. The Lancet plans to be a strong partner in shaping this future health and sustainability agenda—towards finding equitable solutions to improve the health and lives of people worldwide.

Towards a world free from HIV and AIDS?

Approximately 30 years ago, in June 1981, it was reported from theCenter forDiseaseControl andPrevention (CDC) that five, otherwise healthy, homosexual men in California had presented with pneumonia caused by Pneumocystis jiroveci pneumonia, a rare disease seen exclusively in individualswith a severely suppressed immune system. Several reports confirmed the initial observation and lent support to the possibility that a new sexually transmitted, infectious agent was circulating within the gay community in the United States. The clinical condition was named acquired immunodeficiency syndrome (AIDS). Two years later, a research team at the Institut Pasteur under the guidance of Francoise Barre-Sinoussi and Luc Montagnier isolated human immunodeficiency virus (HIV), the causative agent of AIDS, from a lymph node biopsy of a French patient. The isolation and characterization of HIV paved the way for the design of diagnosticmethods to identify the virus in blood andbloodproducts and towards the development of novel antiretroviral treatment (ART) to control HIV replication in infected patients. For their discoveries, Barre-Sinoussi and Montagnier were awarded the Nobel Prize in Physiology and Medicine in 2008.

A recombinant Bacille Calmette–Guérin construct expressing the Plasmodium falciparum circumsporozoite protein enhances dendritic cell activation and primes for circumsporozoite-specific memory cells in BALB/c mice

A protective malaria vaccine may induce both high levels of neutralising antibodies and strong T-cell responses. The Plasmodium falciparum circumsporozoite protein (CSp) is a leading pre-erythrocytic vaccine candidate. CSp is a week immunogen per se, but Mycobacterium bovis Bacille Calmette–Guérin (BCG) has excellent adjuvant activity and has been utilized as a vector to deliver heterologous vaccine candidate antigens. It is safe in immunocompetent individuals and inexpensive to produce.We assessed in vitro and in vivo a recombinant BCG-expressing CSp (BCG-CS) as malaria vaccine candidate. Immunisation of BALB/c mice with BCG-CS augmented numbers of dendritic cells (DCs) in draining lymph nodes and in the spleen. The activation markers MHC-class-II, CD40, CD80 and CD86 on DCs were significantly upregulated by BCG-CS as compared to wild-type BCG (wt-BCG). In vitro stimulation of bone marrow-derived DCs and macrophages with BCG-CS induced IL-12 and TNF-α production. BCG-CS induced higher phagocytic activity in macrophages as compared to wt-BCG. Immunogenicity studies show that BCG-CS induced CS-specific antibodies and IFN-γ-producing memory cells.In conclusion, BCG-CS is highly efficient in activating antigen-presenting cells (APCs) for priming of adaptive immunity. Implications for the rational design of novel vaccines against malaria and TB, the two major devastating poverty-related diseases, are discussed.

Innovative public-private partnerships to maximize the delivery of anti-malarial medicines: lessons learned from the ASAQ Winthrop experience

BackgroundThis case study describes how a public-private partnership initiated to develop a new anti-malarial combination, ASAQ Winthrop, has evolved over time to address issues posed by its effective deployment in the field.Case descriptionIn 2002, DNDi created the FACT project to develop two fixed-dose combinations, artesunate-amodiaquine and artesunate-mefloquine, to meet the WHO anti-malarial treatment recommendations and international regulatory agencies approval standards. In 2002, Sanofi-aventis had started a development programme for a fixed-dose combination of artesunate and amodiaquine, to replace its co-blister combination. DNDi and sanofi-aventis joined forces in 2004, with the objective of developing within the shortest possible time frame a non-patented, affordable and easy to use fixed-dose combination of artesunate and amodiaquine adapted to the needs of patients, in particular, those of children. The partners developed Coarsucam®/Artesunate Amodiaquine Winthrop® ("ASAQ Winthrop") which was prequalified by the WHO in 2008. Additional partnerships have since been established by DNDi and sanofi-aventis to ensure: 1) the adoption of this new medicine by malaria-endemic countries, 2) its appropriate usage through a broad range of information tools, and 3) the monitoring of its safety and efficacy in the field through an innovative Risk Management Plan.Discussion and evaluationThe partnership between DNDi and sanofi-aventis has enabled the development and pre-qualification of ASAQ Winthrop in a short timeframe. As a result of the multiple collaborations established by the two partners, as of late 2010, ASAQ Winthrop was registered in 30 sub-Saharan African countries and in India, with over 80 million treatments distributed in 21 countries. To date, 10 clinical studies, involving 3432 patients with ASAQ Winthrop were completed to document efficacy and safety issues identified in the Risk Management Plan.ConclusionsThe speed at which ASAQ Winthrop was adopted in the field shows that this drug fits the needs of patients and health authorities. It also demonstrates the power of partnerships that combine different sets of strengths and skills, and that evolve to include additional actors to meet new global health challenges for poverty-related diseases.

Prevention of soil-transmitted helminth infection

Soil-transmitted helminths (STHs) form one of the most important groups of infectious agents and are the cause of serious global health problems. The most important STHs are roundworms (Ascaris lumbricoides), whipworms (Trichuris trichiura) and hookworms (Necator americanus or Ancylostoma duodenale); on a global level, more than a billion people have been infected by at least one species of this group of pathogens. This review explores the general concepts of transmission dynamics and the environment and intensity of infection and morbidity of STHs. The global strategy for the control of soil-transmitted helminthiasis is based on (i) regular anthelminthic treatment, (ii) health education, (iii) sanitation and personal hygiene and (iv) other means of prevention with vaccines and remote sensoring. The reasons for the development of a control strategy based on population intervention rather than on individual treatment are discussed, as well as the costs of the prevention of STHs, although these cannot always be calculated because interventions in health education are difficult to measure. An efficient sanitation infrastructure can reduce the morbidity of STHs and eliminates the underlying cause of most poverty-related diseases and thus supports the economic development of a country.

Highly effective generic adjuvant systems for orphan or poverty-related vaccines

Safe and effective adjuvants are needed for many vaccines with limited commercial appeal, such as vaccines to infrequent (orphan) diseases or to neglected and poverty-related diseases. Here we found that three nonproprietary liposome formulations containing monophosphoryl lipid A each induced 3-fold to 5-fold increased titers of binding and neutralizing antibodies to anthrax protective antigen compared to aluminum hydroxide-adsorbed antigen in monkeys. All vaccinated monkeys were protected against lethal challenge with aerosolized Ames strain spores.

Fighting HIV/AIDS, tuberculosis and malaria: one world, one partnership

keywords poverty-related diseases, clinical trials, partnership, EDCTPThe European and Developing Countries Clinical TrialsPartnership (EDCTP) was founded in 2003 in response tothe global burden of HIV/AIDS, tuberculosis and malaria.Its mission is to accelerate the development of new orimproved clinical interventions against these diseases witha focus on supporting phase II and III clinical trialsincluding capacity development. EDCTP organises biennialforums that bring together researchers, programme man-agers, policy makers, funders and other stakeholdersworking on poverty-related diseases. These forums havebecome a major platform for discussing matters pertainingto poverty-related diseases in Africa. The theme of the FifthEDCTP Forum, held in Arusha, Tanzania, from 12 to 14October 2009, was ‘Fighting HIV/AIDS, tuberculosis andmalaria – one world, one partnership’. This underpinnedthe principle of EDCTP of working in partnerships.Four hundred and fifty participants from 49 countriesincluding 26 from Africa, 15 from Europe and others fromAustralia, Cambodia, China, Cuba, Indonesia, Nepal, Peruand the United States attended. There were presentationsfrom many partners from the African AIDS VaccineProgramme (AAVP), the African Malaria Network Trust(AMANET), AERAS Global TB Vaccine Foundation, theBill & Melinda Gates Foundation (BMGF), the EuropeanVaccines Initiative (EVI), the Enhancing Support forStrengthening the Effectiveness of National CapacityEfforts (ESSENCE), the International Partnership forMicrobicides (IPM), the Medicines for Malaria Venture(MMV) and the Wellcome Trust. There were also foursatellite meetings and workshops on Ownership ofResearch Outcomes in sub-Saharan Africa; UniversalStandards for Clinical Trials in Practice; ESSENCE fundersmeeting to explore synergy; and a Round-table Meeting ofAfrican Regional Economic Communities on the Africanrepresentation to EDCTP-EEIG General Assembly. EDCTPlaunched awards for outstanding African scientists: thesenior scientist award went to Alexis Nzila of KenyaMedical Research Institute, Wellcome Trust ResearchCentre. Dominique Pepper from the Institute of InfectiousDiseases and Molecular Medicine, University of CapeTown, South Africa, won the junior scientist award.The forum comprised plenary and parallel sessionsduring which 58 oral presentations, 81 short electronicpresentations and 69 posters were presented, covering awide range of topics. Keynote addresses were delivered onthe current state of affairs in research and control of HIV/AIDS by Dr Anatoli Kamali, of malaria by ProfessorAbdoulaye Djimde´ and of tuberculosis by Professor WillemHanekom. Articles based on these are published as reviewsin this issue of the journal.Forum participants met in the penultimate plenarysession to identify research gaps and needs and madeseveral recommendations to EDCTP. These were asfollows:HIV/AIDS• Continue with research on preventive HIV vaccinesand microbicides including exploring efficacy of anti-retroviral-based combinations.• Conduct more research to answer treatment strategyissues. These should include when to start treatment;effect of treatment on immune reconstitution inflam-matory syndrome (IRIS); when to switch and what toswitch to; management of HIV-TB co-infectionsincluding strategies on prophylaxis, vaccines, diagno-sis and treatment and reduction in mortality prior toand soon after treatment initiation.• High priority should be given to customised inter-ventions and the needs of specific populations such asdiscordant couples.• High priority should be given to research on imple-menting and scaling up interventions of proven

Health Impacts of Floods

Floods are the most common hazard to cause disasters and have led to extensive morbidity and mortality throughout the world. The impact of floods on the human community is related directly to the location and topography of the area, as well as human demographics and characteristics of the built environment. The aim of this study is to identify the health impacts of disasters and the underlying causes of health impacts associated with floods. A conceptual framework is developed that may assist with the development of a rational and comprehensive approach to prevention, mitigation, and management. This study involved an extensive literature review that located >500 references, which were analyzed to identify common themes, findings, and expert views. The findings then were distilled into common themes. The health impacts of floods are wide ranging, and depend on a number of factors. However, the health impacts of a particular flood are specific to the particular context. The immediate health impacts of floods include drowning, injuries, hypothermia, and animal bites. Health risks also are associated with the evacuation of patients, loss of health workers, and loss of health infrastructure including essential drugs and supplies. In the medium-term, infected wounds, complications of injury, poisoning, poor mental health, communicable diseases, and starvation are indirect effects of flooding. In the long-term, chronic disease, disability, poor mental health, and poverty-related diseases including malnutrition are the potential legacy. This article proposes a structured approach to the classification of the health impacts of floods and a conceptual framework that demonstrates the relationships between floods and the direct and indirect health consequences.

Health Systems Exist for Real People

Action always leads to reaction, a fundamental law of nature. The recent unprecedented investment in combating the HIV/AIDS pandemic has led to marvel at the effects of antiretroviral therapy, to constructive questioning about impact on health systems and, at one extreme, to frank hostility. Central to the debate has been the question of whether the disease-specific efforts of initiatives such as the United States President’s Emergency Plan for AIDS Relief (PEPFAR) and the Global Fund to Fight AIDS, Tuberculosis and Malaria have strengthened or undermined national health systems in lowand middle-income countries. Regrettably, discussions have sometimes become polarized and antagonistic, drawing attention from the specifics of the enormous tasks at hand in global health. This supplement of the Journal examines the impact of HIV scale-up on health systems in a diverse array of countries and contexts, building on discussions that took place at a meeting at the Rockefeller Foundation Bellagio Center in September 2008 that focused on these issues. These discussions are rooted in documents now decades old: the 1978 Declaration of Alma-Ata and the 1993 World Development Report entitled ‘‘Investing in Health.’’ These important documents illustrate that discussions about health systems have been ongoing at the highest levels for some time but that bringing the necessary financing to bear lagged far behind. In 2001, the Commission on Macroeconomics and Health published its conclusion that better health for the world’s poor is not only a right but an important priority for development and poverty reduction. Influential academics had been speaking out since the 1990s on sub-Saharan Africa’s disproportionate burden of infectious and poverty-related diseases, and more specifically on the dominant impact of malaria, tuberculosis, and HIV. The stage was set for major donor initiatives, their nature and political origins unpredictable and themselves worthy of historical analysis. These global health initiatives reflected the interplay of multilateral and national politics, and involved the faith-based sector, perhaps for the first time. Investment in countries of the south by the Global Fund and PEPFAR began to be felt in 2003, the year that WHO launched its 3 3 5 initiative, which provided normative and policy guidance for scale-up of HIV/AIDS prevention, treatment, and care in lowand middle-income countries. Ironically, it was the evaluation of the 3 3 5 initiative that first warned that health system constraints, especially the shortage of human resources, was a rate-limiting step to scale-up toward universal access to essential HIV/AIDS services. Two other themes fueled the emerging debate about prioritization of disease-specific initiatives versus the strengthening of health systems: the growing recognition that other major health challenges, including enhancing maternal and child health, access to safe water and sanitation, and addressing non-communicable diseases, were under-resourced (and, by inference, that HIV/AIDS received ‘‘too much’’ funding); and skepticism around epidemiologic estimates of the severity of the HIV/AIDS pandemic. Against this background, a variety of studies and programs have recently examined the question of whether health systems have been strengthened or weakened by diseasespecific initiatives, and significant review articles have been published this year. That these discussions are not just academic is illustrated by their implications for programmatic funding. The Obama administration is committed to spending US$63 billion over 6 years

EDCTP: a genuine north–south partnership

EDCTP: a genuine north–south partnership

Intervention studies for improving global health and health care: An important arena for epidemiologists

Marginalised populations in many low- and middle-income countries experience an increasing burden of disease, in sub-Saharan Africa to a large extent due to faltering health systems and serious HIV epidemics. Also other poverty related diseases (PRDs) are prevalent, especially respiratory and diarrhoeal diseases in children, malnutrition, maternal and perinatal health problems, tuberculosis and malaria. Daily, nearly 30,000 children under the age of 5 die, most from preventable causes, and 8,000 people die from HIV infections. In spite of the availability of powerful preventive and therapeutic tools for combating these PRDs, their implementation, especially in terms of equitable delivery, leaves much to be desired. The research community must address this tragic gap between knowledge and implementation. Epidemiologists have a very important role to play in conducting studies on diseases that account for the largest share of the global disease burden. A shift of focus of epidemiologic research towards intervention studies addressing health problems of major public health importance for disadvantaged population groups is needed. There is a need to generate an evidence-base for interventions that can be implemented on a large scale; this can result in increased funding of health promotion programs as well as enable rational prioritization and integration between different health interventions. This will require close and synergetic teamwork between epidemiologists and other professions across disciplines and sectors. In this way epidemiologists can contribute significantly to improve health and optimise health care delivery for marginalized populations.

The 10/90 gap in sub-Saharan Africa: Resolving inequities in health research

Sub-Saharan Africa (SSA) is worse off in terms of health indicators than any other region of the world, and suffers badly from the 10/90 gap, whereby 90% of the world's investment in health research addresses only 10% of the global health problems. This anomaly in health research investment in SSA is mainly attributed to rampant poverty, weak educational institutions, deficient health research capacity, feeble communications systems and isolation. Translating research results into action, manufacturing and access are also weak. Furthermore, many diseases of poverty are neglected diseases, they receive scanty research attention; there are no new drugs or vaccines for their treatment or prevention. The situation in SSA is made worse by the surge in noncommunicable diseases and injuries. The paper reviews actions taken over the last two decades to resolve the 10/90 gap through: (i) policies prioritizing funding for health research, (ii) developing capacities of credible public and private SSA health research institutions, (iii) activities of international NGOs undertaking research aimed at resolving the gap, and (iv) the setting up of research based mechanisms to ensure access to new effective products for the treatment and prevention of poverty-related diseases. The paper highlights examples for each of the above, and discusses the overall situation. We conclude that despite the many capacity strengthening actions, and achievements made towards resolving the 10/90 gap, the disequilibrium still persists; there is need for greater investments aimed at closing it.

Heterologous prime–boost vaccinations for poverty-related diseases: advantages and future prospects

Classical vaccination approaches, based on a single vaccine administered in a homologous prime–boost schedule and optimized to induce primarily neutralizing antibodies, are unlikely to be sufficiently efficacious to prevent TB, malaria or HIV infections. Novel vaccines, capable of inducing a more powerful immune response, in particular T-cell immunity, are desperately needed. Combining different vaccine modalities that are able to complement each other and induce broad and sustainable immunity is a promising approach. This review provides an overview of heterologous prime–boost vaccination modalities currently in development for the ‘big three’ poverty-related diseases and emphasizes the need for innovative vaccination approaches.

Microfluidic approaches to malaria pathogenesis

Malaria is a major poverty-related human infectious disease of the world. Over a billion individuals are under threat and several million die from malaria every year. The nature of disease, especially fatal disease, has been the subject of many studies. The consensus is that parasite-induced cytoadherance of red blood cells precipitates capillary blockage and inflammatory responses in affected organs. Reduced deformability of infected erythrocytes may also contribute to disease. What is not very clear is why people with significant parasite burdens display large variations in disease outcomes. Technologies which allow a detailed description of the cytoadherance properties of infected erythrocytes in individual patients, and which allow a complete description of the flow capabilities of red blood cell populations in that patient, would be very useful. Here we review the recent introduction of microfluidic technology to study malaria pathogenesis, including the fabrication processes. The devices are cheap, versatile, portable and require very small patient samples. With greater use in research laboratories and field sites, we eventually expect microfluidic methods to play important roles in malaria diagnosis, as well as prognosis.