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Research Focus
Bringing neglected tropical diseases into the spotlight
Lara Payne
1
and Joseph R. Fitchett
2
1
Imperial College London, Sir Alexander Fleming Building, South Kensington, London, UK, SW7 2AZ
2
London School of Hygiene & Tropical Medicine, Keppel Street, London, UK, WC1E 7HT
The correlation between poverty and the neglected tro-pical disease (NTD) burden is undeniable. NTDs are abrand without copyright; an international movementgathering momentum towards a common goal of tack-ling major causes of preventable illness in low-incomecountries.NewreportsbyLieseandSchubertandMoran
et. al.
act as a call to arms, highlighting a need forresearchintoNTDtreatmentandcontrolthatisessentialto improving the lives of the ‘bottom billion.’Shifting the focus to the neglected diseases
One billion of the world’s poorest people are infected withatleastone neglectedtropicaldisease (NTD)[1], a groupof diseases that can lead to severe disability or even death.Furthermore, 2.7 billion people living on less than US $2per day are at risk of contracting NTDs and are withouteconomic means to access treatment or prevent infection[2]. These conditions can be both the cause and effect of poverty and must be addressed with urgency if we are tohave any hope in achieving the Millennium DevelopmentGoals (MDG) by 2015[3,4].Definitions of what classifies an NTD vary, the mostcomprehensive account is a list of 37 NTDs by Hotez
et al.
with 13core NTDs comprisingthe highestdiseaseburdens(Table 1)[1]. Cumulative factors such as geographical isolation, lack of education, lack of political voice of thosemostaffectedandthelimitedthreattothedevelopedworldhavepreventedthesediseasesfromreceivingexposureandfunding relative to their burden[5]. Until recently, theexact extent of this burden has been unclear as many of these diseases are characterised by a chronic course thatcan reduce life expectancy, or significantly decreaseeconomic capability and quality of life without necessarilycausing death[6]. NTDs such as schistosomiasis, trichur-iasis,ascariasisandhookworminfectioncandirectly causemalnutrition and anaemia and are within the top tencauses worldwide of disability adjusted life years (DALYs)[2]. There is some suggestion these diseases might havebeen overlooked due to the focus on tackling ‘the big three’,namely HIV/AIDS[7], tuberculosis and malaria[4]. The emphasisnowshouldbeonusingthestructureandlessonslearned from these programmes and applying them to theNTD cause[8,9].Severalrecentlypublishedpapershaveledtoanincreas-ing awareness of NTDs, by outlining the progress being made and challenges that remain[10
–
12]. In addition,the recent ‘Spotlight On: Neglected Tropical Diseases’ con-ference (http://www.rstmh.org/news/rstmh-news/spotlight-neglected-tropical-diseases-report) at the Royal Society of Medicinein Londonsetout toraise awarenessandtransferknowledge from NTD experts to young members of theclinical and academic communities. The aim was to inspirethenextgenerationtoreversethetrendofneglect,raisetheprofile of NTDs and make the ‘bottom billion’ a priority interms of investing in some of the ‘other diseases’ of MDG6,whichhaveproven,cost-effectivestrategiesforcontrol[1,4].
How neglected are NTDs?
It is widely recognised that NTDs are overlooked in termsof funding provided for health programmes and research.Without an exact figure on the extent of ‘neglect’ it isdifficult to catalyse change and demand further supportfrom governmental and non-governmental bodies. Lieseand Schubert[13]set out to quantify empirically theamount of Official Development Assistance (ODA) allo-cated to all the diseases most commonly included in theNTD criteria and compared this with disease burdenagainstotherinfectiousdiseases,usingdataobtainedfromthe Organisation for Economic Co-operation and Develop-ment (OECD) creditor reporting system database from2003 to 2007. All commitments for Health and PopulationPolicies/Programmes and Reproductive Health by individ-ual donors in the Development Assistance Committee(DAC)werenotedandinformationconcerningmultilateralorganisations was collected on a voluntary basis. Commit-ments for infectious disease control were subsequentlyanalysed in detail and those relating to diseases classifiedas an NTD[1]were summated. Programmes were dividedaccording to whether they were NTD related, NTD andnon-NTD related and non-NTD related.Overall, the results indicated a 10% increase in ODA commitments between 2003 and 2007, although themajority of funding was received for programmes relatedto HIV/AIDS (30 to 40%), tuberculosis (1.3 to 3.4%) andmalaria (2.4 to 5.3%)[13]. NTD control received relativelyconstant funding at around 0.6% of all ODA. However, thisshareofODAisdisproportionatetotheDALYsresultantof NTDs, and this balance needs to be addressed.TheG-FINDERdata(http://www.thegeorgeinstitute.org/ prpppubs), commissioned by the Bill and Melinda GatesFoundation,corroboratedandelaboratedontheobservationthatpneumonia,diarrhoealdiseaseandhelminthinfectionsare insufficiently funded for research and development inrelation to the DALYs caused[14]. In this report, ‘the big three’receive80%oftheresearchanddevelopmentfunding for infectious diseases, with NTDs collectively being allo-cated 10.5%. To date, it is primarily philanthropic donorsand public organizations, along with some pharmaceuticalcompanies, that are providing the funding.
Update
Corresponding author:
Payne, L. (lara.payne08@imperial.ac.uk ).
TREPAR-964; No. of Pages 3
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To achieve any success in reducing the burden of NTDsthere must be more appropriate ODA funding to supportongoing programmes and for research and development of new tools, drugs, diagnostics and vaccines. In addition togovernments, changing this bias is the responsibility of both prospective recipients and donors.
Issues in health policy and the impact on NTDs
NTDs have received more drug donations from pharma-ceuticalcompaniesthananyotherpublichealthinitiatives[9]. Public
–
private partnerships have successfully distrib-uted donated ivermectin in onchocerciasis eliminationefforts since 1987, and this method has now been appliedto provide albendazole, donated by GlaxoSmithKline andMectizan, donated by Merck and Co. Inc., for lymphaticfilariasis through the Mectizan Donation Programme.Numerous charities, pharmaceutical companies, inter-national programmes and non-governmental organis-ations (NGOs) are involved with various NTDs, eachoffering different opinions on the best strategies to tackletheseproblems.TheGlobalNetworkforNeglectedTropicalDiseasesandtheWHODepartmentforControlofNeglectedTropical Diseases have been set up recently to focus onadvocacy and integrating control efforts[15]. Mass drug administration (MDA) through preventive chemotherapyis the recommended method for helminth management,but at present programmes are inadequately coordinatedto ensure efficient delivery. Drugs to control NTDs throughMDA have been found to be safe in specific combinations(albendazole, mectizan and praziquantel) and coadminis-tration is less expensive, potentially increasing coverage[16]. Combining NTD interventions with existing malariaprogrammes can reduce duplication of work and unecono-mical management[15], especially where there is geo-graphical overlap in disease distribution. Increased vectorcontrol can reduce transmission of lymphatic filariasis inareas where
Anopheles
is the main vector[17]. For inte-grated control methods to be effective there must also beconcurrentmappingofareasatrisk,monitoringtoevaluatethe impact of programmes and surveillance after the inter-vention has been discontinued[18].
No magic bullet
To achieve integrative control, it is essential that differentgroups, such as health services, communities, pharmaceu-ticalcompaniesandNGOscooperateandformpartnershipsin order to work together effectively[17]. Furthermore, inrural areas with poor infrastructure we must prioritiseaccess to essential medicines. Interventions for these con-ditionshavebeendescribedasthe‘lowhangingfruit’[19],asmany NTDs have existing, efficacious treatments that aredonatedbypharmaceuticalcompaniesona long-term basis(Table 2)[13]. Theseare highly cost effectiveand lead to an increase in economic productivity and decrease suscepti-bility to other diseases[8,11]. The treatment of NTDs inschool children is a top priority to avoid the subsequentimpact on education and growth restriction. We must buildonrelationshipswithdrugcompaniessuchasMerckandCo.who have donated ivermectin to treat onchocerciasis forover 20 years, GlaxoSmithKline’s long-term pledge of albendazoleforlymphaticfilariasisandJohnson&Johnsonwho have come forward and promised donations to treat
Table 1. The 37 key NTDs
a
Helminthinfections:Ascariasis
b
, trichuriasis
b
, hookworm infection
b
, strongyloidiasis,toxocariasis and larva migrans, lymphaticfilariasis
b
, onchocerciasis
b
,loiasis, dracunculiasis
b
, schistosomiasis
b
, food-borne trematodiases,taeniasis cysticercosis, echinococcosisBacterial infections:Bartonellosis, bovine tuberculosis, buruli ulcer
b
, leprosy
b
,leptospirosis, relapsing fever, rheumatic fever, trachoma
b
,treponematosesFungal infections:mycetoma, paracoccidiomycosisProtozoan infections:leishmaniasis
b
, Chagas disease
b
, human African trypanosomiasis
b
,amoebiasis, giardiasis, balantidiasisViral infections:dengue fever, yellow fever, Japanese encephalitis, rabies,haemorrhagic feversEctoparasitic infections:scabies, myiasis, tungiasis
a
See Ref.[1].
b
13 core neglected tropical diseases.
Table 2. Overview of NTD drug donation programs active 2003 to 2007
a
Disease Donated drug Donor company Duration of program Amount of drugs donated 2003 to 2007
Onchocerciasisivermectin Merck & Co., Inc. 1987 to open-ended 990 million tablets
c
Lymphatic filariasisivermectin Merck & Co., Inc. 1998 to 2020 385 million tablets
d
Lymphatic filariasisalbendazole GlaxoSmith-Kline 1998 to 2020 602 million tabletsTrachomaazithromycin Pfizer 1998 to open-ended 266 million tablets
e
Leprosymultidrug therapy Novartis 2000 to 2010 NAHuman Africantrypanosomiasispentamidine, melarsoprol,eflornithineSanofi-Aventis 2001 to 2011 NA (total of 940 000 vials 2001 to 2006)Human Africantrypanosomiasissuramin Bayer Healthcare 2002 to 2012 NASchistosomiasispraziquantel MedPharm NA
b
NA (14 million tablets 2004)Chagas diseasenifurtimox Bayer Healthcare 2004 to 2012 NA (500 000 tablets 2004 to 2005;2.5 million tablets pledged 2007 to 2012)Soil-transmittedhelminthiasismebendazole Johnson & Johnson 2006 to open-ended NA (30 million tablets 2006)
a
See Ref.[13].
b
NA, not available.
c
330 million treatments, 3 tablets per treatment.
d
195 million treatments, 3 tablets per treatment.
e
70 million treatments, 3.8 tablets per treatment.
Update
Trends in Parasitology 
Vol.xxx No.x
TREPAR-964; No. of Pages 3
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