What Works Best in Fighting Neglected Tropical Diseases

I don't know if Mark Hanna ate in the New York City restaurant where Mary Mallon (Typhoid Mary) cooked, but he is among the prominent American political figures (they include Abigail Adams and Stephen A. Douglas) who succumbed to typhoid fever. The disease is caused by the bacteria Salmonella enterica serovar typhi, which is spread through water or food contaminated with the fecal matter of infected persons. S. typhi causes a three-to-four week fever, which, if left untreated, is fatal ln up to a third of patients. School-age children are especially vulnerable.

The disease has largely been banished from the advanced industrial world through improved sanitation and prompt treatment with antibiotics. But occasional outbreaks still occur, often among people who have traveled in the developing world or live in precincts of the U.S. that approximate third world conditions. Last year, the Centers for Disease Control rushed to the Marshall Islands to help contain an outbreak of at least 22 confirmed cases.

Today, the disease remains common in the developing world's rural areas and urban slums, where typhoid strikes an estimated 16 million to 33 million people a year, and kills anywhere from 216,000 to 600,000. And, unlike the middle part of the last century when typhoid was licked in the U.S., most current strains of S. typhi have developed resistance to antibiotics, including powerful new ones like ciprofloxacin.

But, like most other drug-resistant diseases, this is one that can still be licked through effective public health measures. According to a timely wake-up call published in today's New England Journal of Medicine, there are vaccines that can provide immunity to typhoid fever. The vaccines could have an almost immediate impact because the most vulnerable population -- school-age kids -- are easily reached through public schools. And best of all, the vaccines are cheap -- about 50 cents a dose from the Indian generic companies that manufacture them.

But as with so many technology-driven solutions, the global public health community hasn't figured out a way to get children inoculated in the countries where it would matter most. In last week's NEJM, Peter Hotez and a host of colleagues associated with the Global Network for Neglected Tropical Diseases called for a comprehensive public health approach to treating and preventing the most common diseases that are ravaging the developing world.

What that would entail is equipping health care workers in developing countries with the tools needed to fight the health problems faced by the world's poorest citizens. This should include the proven generic drugs for fighting common infectious like hookworm or elephantiasis (the GNNTD identifies 13 diseases that need immediate attention in addition to the "big three," HIV/AIDS, tuberculosis and malaria). Though they don't mention it in their article, this piggy-back approach could also include proven vaccines like the one that is available for typhoid fever.

This is a very different approach from the current efforts of the Global Fund, the President's Malaria Initiative or bilateral aid organizations the the U.S's Agency for International Development. Their programs are aimed at specific diseases like HIV/AIDS, malaria or onchocerciasis (river blindness). Very often, this leads to different emissaries from various aid organizations concerned about different diseases knocking on the door of the same rural health clinic or government ministry. No doubt the one offering the most money and resources gets the most attention.

But is this what is best for achieving the greatest gains in public health in that area? The silo mentality fostered by the specialist approach to medicine is widely recognized as a major flaw in the U.S. health care delivery system. That failed model shouldn't be exported to the developing world.

Posted by gooznews at September 13, 2007 11:43 AM