By: Dr. Suman Rijal
Published on: 17 October, 2017
The neglected tropical diseases are fighting for attention despite the fact that these diseases are major chronic infectious diseases that affect the world’s poorest population. In an interview to Health Analytics India, Dr Suman Rijal, Director of Drugs for Neglected Diseases initiative (India) spoke about challenges of eliminating the diseases, role of tools and data and why are there little investments in the area of neglected tropical diseases.
Q: What is the biggest challenge that India is facing currently in order to eliminate the neglected diseases?
Neglected diseases affect populations in mainly low-income countries and are a leading cause of mortality, chronic disability, and poverty. There are lots of challenges for India to eliminate the neglected diseases. First, it’s a vast country with large number of states having different level of competencies. We need a lot of planning, resources and monitoring to manage the state of health in India. Public health delivery systems are not very strong in all states. Since health is a state subject, all states tackle these problems according to their capabilities and resources. We have strong strategies in order to eliminate the neglected diseases but we don’t have strong operational plan.
We use partners at local and national levels to supplements areas where there is a need and mobilise communities.
Q: You have extensively worked on Kala-azar. Do you think India will be able to completely eliminate kala azar?
Elimination programme for kala azar in India is basically targeting to eliminate kala azar as a public health problem, that means bringing the number of cases down in blocks to less than 1 case in 10,0000 population.
In 2016, 85 % blocks (regions) achieved the elimination target. In 2017, the number of reported cases is further reducing; however, it may take longer than 2017 to meet the elimination target in all the affected blocks. The bigger challenge in future is, once the elimination is achieved, how to sustain this elimination.
There is a need for continued efforts in terms of more intensive surveillance along with vector control and availability of treatments. For complete elimination, there is a need for better scientific understanding and better tools for diagnostics and treatments.
Q: Globally donors and drug firms are co-operating to fight NTDs. How is the situation in India? Are drug firms in India coming forward as well to collaborate and fight against the neglected diseases?
If you see generally, there are little investments in the area of neglected tropical diseases. Globally there has been some momentum, for example, in 2012, pharmaceutical companies, donors, endemic countries and non-government organisations came together to sign the London Declaration on Neglected Tropical Diseases. Together, they committed to control, eliminate or eradicate 10 diseases including Leishmaniasis by 2020.
In India, some of the drug firms are actively participating in fight against neglected diseases and this momentum will grow slowly. National Filaria Control Programme is procuring drugs from Indian pharma companies. Dengue testing kits are being manufactured in India.
Gilead is donating Ambisome for treating Kala-azar in India through WHO but there are India pharma companies looking into making generic version of miltefosine as this is the only oral drug which is effective when combined with other treatments.
Q: You have launched a joint initiative with WHO to treat bacterial infections where drug resistance is present or emerging. What do you think should be the key public health priorities for India in terms of dealing with antimicrobial resistance?
Antimicrobial resistance (AMR) has become a core political, social, and economic problem of our time. It is a serious threat to global public health that requires action across all government sectors and is driven by many interconnected factors. India has also made its National Action Plan on AMR. The overarching goal of the National Action Plan is to effectively combat antimicrobial resistance in India, and contribute towards the global efforts to tackle this public health threat. It shall establish and strengthen governance mechanisms as well as the capacity of all stakeholders to reduce the impact of AMR in India.
A joint initiative of DNDi and WHO, the Global Antibiotic Research and Development Partnership (GARDP) aims to develop and deliver new treatments for bacterial infections where drug resistance is present or emerging, or for which inadequate treatment exists. In India, our work will be focussed on neo natal sepsis infections. Our programme aims to provide an evidence base for the use of antibiotics, both old and new, in neonates with serious bacterial infections (SBIs), as the currently available standard of care in many countries is increasingly becoming less effective due to antimicrobial resistance.
Q: Despite important progress in research and development for global health, only a small fraction of new medicines developed are for the treatment of neglected diseases. Why?
NTDs are neglected tropical diseases that disproportionately affect the very poor. These diseases have been neglected for decades by pharmaceutical R&D because there is no return on investment to incentivize pharmaceuticals to find solutions for these patients.
In 2012, an analysis conducted by the Drugs for Neglected Diseases initiative (DNDi), Medicines Sans Frontières (MSF) and others found that of the 850 new drugs and vaccines approved for all diseases between 2000 and 2011, just 4% (37) were for neglected diseases. In addition, of the nearly 150,000 registered clinical trials for new therapeutic products in development as of December 2011, only 1% was for neglected diseases. This highlights the persistence of the ‘fatal imbalance’, described between global disease burden – and thus patients’ needs – and therapeutic product development.
The major reasons are firstly, global public health needs are not in the driving seat when it comes to R&D priority-setting. Regardless of how great the needs may be, where commercial potential is weak, there is little “pull” to develop new technologies. Secondly, patients in low- and middle-income countries must often “make do” with innovations that primarily cater to patients in high-income countries. Medical tools are too often developed first for these patients, with roll-out in resource-limited settings an afterthought, at best. And finally, even when there is enough of a profit incentive to drive innovation – for example when diseases affect both developed and developing countries alike – the resulting products are too often priced out of reach.
Q: What are the current focus areas of DNDi in India in eliminating and controlling the spread of neglected diseases?
Over the last decade, DNDi’s focus area of work in India has been kala azar. Our approach has been to develop new treatments by combining existing drugs and/or shortening treatment duration in order to increase tolerability, reduce burden on health systems, and offer greater affordability for patients.
At present, DNDi is prioritising the management of PKDL (Post-kala-azar dermal leishmaniasis) patients who are believed to constitute a potential reservoir of infection for VL in the Indian Sub-continent. Early treatment of PKDL patients could be critical elements of any VL public health and elimination strategy. A Phase II study is underway in India to assess the safety and efficacy for patients with PKDL. With this study, DNDi aims to reduce PKDL treatment to two to three weeks which is three months long at present. New drugs for PKDL treatment is required because present line of treatment drug Miltefosine is teratogenic (cannot be given to pregnant and lactating women).
Another study we are implementing in partnership with MSF in Bihar that aims to identify and deliver a safe and highly effective treatment for VL in HIV co-infected patients that will improve long-term survival of these patients.
Along with these studies, we are implementing a capacity building project that is supporting the National programme by strengthening the capacity of health care facilities and development of public health systems. The aim is to develop combinations of drugs that are effective against visceral leishmaniasis in all foci of the disease.
Q: In an environment where data collection is not robust in India, how lack of data about neglected diseases impacts the fight against these diseases?
The role of data is very imperative in fight against neglected diseases. In fact, some of these diseases are neglected because there is dearth of data on it. There are diseases where you need to show data for funds to the donor. If there is no data, there is no investment. It is difficult to convince people that there is a problem. For any programme project to happen effectively, data is the primary requirement.