Archive for the ‘Tropical Medicine’ Category

Growing reports of cholera in Pakistan add urgency to funding appeals

August 20, 2010

U.N. Secretary-General Ban Ki Moon called the flooding in Pakistan a “slow-motion tsunami” and the worst natural disaster he had ever witnessed. Ban today urged the United Nations General Assembly to speed up assistance to the war-ravaged country.

According to the UN, about 47 percent of the $460 million in relief aid needed has been delivered.

About 20 million people have been affected by the floods which has so far claimed at least 1,200 lives. The World Health Organization (WHO) says that said relief efforts have been stymied by monsoonal rains and flood waters that have damaged or destroyed more than 200 hospitals and clinics.

With floodwaters covering more than 600 miles, or about one-quarter of Pakistan, disaster relief organizations are warning that millions are at risk for cholera and other deadly water-borne diseases.

“We are extremely concerned by reports of cholera in the Swat Valley,” Brendan Gormley, head of the UK-based Disasters Emergency Committee (DEC), said today in a released statement.

About 86,000 suspected cases of acute watery diarrhea have been reported so far, according to UN officials. The UN Office of Humanitarian Affairs confirmed the first case of cholera in the Swat Valley last weekend. Acute watery diarrhea is one of the main symptoms of cholera although it can also be caused by other water-borne diseases.

“Aid workers greatly fear cholera after a disaster because, without treatment, more than half those infected are likely to die,” said Gormley. “Cholera can be prevented by providing clean drinking water, good sanitation and rapid treatment of those affected.”

DEC member organizations, including Oxfam, Save the Children and Merlin, are “redoubling their efforts” to truck in clean water, clean contaminated wells, provide diarrhea treatment, and generally improve sanitation in an effort to contain infectious disease outbreaks among the millions affected by Pakistan’s floods that began more than two weeks ago in the mountainous northwest.

Merlin reports that it has seen a significant rise in cases of acute watery diarrhea in the worst affected areas, particularly in young children.

“If left untreated, the rapid loss of fluids caused by acute watery diarrhea, such as with cholera, can prove fatal within hours,” according to Linda Doull, Merlin’s director of health and policy. “We need to ensure patients have access to medical staff, that enough diarrhea treatment units are set up swiftly and that the delivery of safe water is made an absolute priority.”

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Malaria-Resistant Drugs

April 24, 2010

What will happen if the current treatment for malaria continues to be less effective in the next few years? What will be the ripple effect in Asia, Africa (the two continents most plagued by malaria), and the rest of the world? Resistance of Plasmodium falciparum to choloroquine, the cheapest and the most used drug is spreading in almost all the endemic countries.

Here is an alarming report of increasing resistance in the Thailand-Cambodia area

And an article in The Telegraph about our ongoing war with a clever, evolving parasite…

Malaria’s resistance to drugs is truly bad news
Using the latest drugs against malaria sparingly where resistance is present could make them useful for decades, says Andrew Read.

By Andrew Read
Published: 7:31AM BST 30 May 2009

So it looks like the malaria parasite wins again. Two research teams in Cambodia have discovered parasites resistant to the only fully effective malaria drug we have left. This is truly bad news. Resistance has already arisen to all other classes of front line drug, and many early generations of wonder drugs are now rendered useless. The new discovery is of resistance to the artemisinins, the latest drugs. These form the backbone of plans to globally eradicate malaria.

For most of us in the business, the discovery is depressing news, but no great surprise. It was a matter of when, not if. We can easily make resistant parasites in the laboratory, simply by throwing drugs at the parasites, and artemisinin is no exception. There is an ongoing arms race between the drug developers and the parasites. Just to stand still will cost $US2.5 billion over the next decade. Evolution is a very costly business.

The new discovery, if confirmed, signals the beginning of the end for artemisinin, but the end itself is a long way off. For one thing, the resistant parasites are still being killed by the drug – it is just takes longer. High-level resistance has yet to appear. For another, the resistance has a long way to go before it is common even in Cambodia, let alone the world. There is talk of trying to eradicate malaria in this region of South East Asia before the resistance is exported to Africa. I frankly doubt that is feasible, but I hope I am wrong.

But something else can be done. Resistant parasites spread because of drug use. If artemisinin is used sparingly where resistance is present, it could remain globally useful for decades. Easily enough time to get next-generation drugs deployed. Let the sequel begin.

In Katine, a Coke is easy to buy. Medicine isn’t

April 2, 2010

In Uganda and across Africa people are dying of diseases such as malaria and TB because they can't get the drugs to treat them

Sarah Boseley
The Guardian, Thursday 20 August 2009

Emanuel Opengam has the listless look in his large eyes of the habitually ill. The three-year-old sits passively on his mother’s lap, and sometimes his seven-year-old sister’s, in a corner of a drug shop in north-eastern Uganda. It’s just a small room in a hut, dominated by a table covered with a dirty gingham cloth on which are stacked plastic tubs of pills that are sold loose, in twos and threes or as many as the patient can afford.

Taped to Emanuel’s hand is a needle to allow fluid from a plastic bag hanging on the mud wall to drip into one of his veins. He has malaria, the commonest killer in Uganda, which takes more than 300 lives every day, mostly under-fives and pregnant women. Emanuel has been ill for most of the past year, recovering from one bout of the disease only to succumb to another.

There are pills that can stop malaria in its tracks at an early stage before the sufferer succumbs to a high fever, delirium and, in the worst cases, coma. But go to any health centre in Katine sub-county, where Emanuel lives, and you will be disappointed. Nursing staff shake their heads. “We don’t have,” they say.

On other similar gingham-covered tables in huts in Uganda and all over Africa, they sell Coca-Cola. The drinks giant has reached into the darkest corners of the continent. Coke is everywhere. Essential medicines, many of them paid for by governments such as ours, are not.

Tiriri health centre, which should have the capacity of a small hospital, has no Coartem, an anti-malarial and the most needed drug in the region. Frequently it has virtually no medicines at all, even paracetamol. Stock-outs are the norm all over Africa. You can get Coke but you can’t get a painkiller, an antibiotic or a drug to save your child from malaria.

A few miles away in Obiol village, Gusberito Eremu, 49, brings out an empty foil blister pack that once contained a week’s supply of TB drugs. He was prescribed the standard three-drug combination that has to be taken daily for two months, followed by four months of other drugs. Tiriri health centre’s staff could give him only enough for seven days. They told him to go to the clinic at Kaberamaido for more. He got up early in the morning and caught a local minibus, arriving at 9pm that night. But the government health centre shelves were empty there, too.

“When I cough, my chest is very painful,” says Eremu, a subsistence farmer. “It is very difficult because when I start digging there is dust and it makes me cough.” He knows TB is a potential killer. He has always lived in the same place – he gestures to where his father is buried behind the house – and hopes not to end up in the earth soon himself. “There is nothing I can do except pray to God that maybe, if they send the medicines, it will save my life. I get weak, but I keep on praying.”

Another farmer, Peter Ogira, 43, was diagnosed with pulmonary TB and, three months later, also has no drugs. “I have been going back to the health centre but the drugs are not there,” he says. “I have been told to stay home and they will let me know when they come.”

In a dusty exercise book, Ogira’s medical record is handwritten: “Sleep in a well-ventilated room. High protein diet. Bed rest.” None of that is possible. He sleeps in a windowless mud hut with his wife, his mother and most of his nine children, putting all of them at risk of TB. Protein is a luxury here, and he must work hard at his smallholding if his family is not to starve.

Ogira lives simply, digs the land, grazes his cattle and has aspirations for his children. He pays for the two eldest, both girls, to attend boarding school, where they stand a better chance of leaving with qualifications. “If I don’t get the medicine and I die, you will see how this family will suffer,” he says.

Tiriri health centre is short of many other drugs – antibiotics, paracetamol, aspirin, quinine injections (a second-line treatment for malaria too severe to be treated by Coartem), diclofenac for pain and inflammation. The empty shelves in government clinics drive people to private drug shops, which have mushroomed in the villages and towns. But because they have to pay and are poor, families can only buy a small handful of pills – not necessarily the right ones and, quite possibly, fakes. Poor people may buy six pills when they need 30, or they will buy 20 and stop after 10 when they feel better, saving the rest for another crisis. That’s how resistance grows to antibiotics and to TB and Aids drugs, which can then spread around the globe. In this way, poverty and the inadequacies of public sector drug supply in Africa threaten us all.

Both Eremu and Ogira tried going to private drug shops to buy the pills they need. Eremu took his empty foil pack to show the proprietor. “Ah, no,” said the owner, “those are donor-funded TB drugs that can only be supplied in government clinics. Have these instead.”

“I bought some pills for 2,000 shillings [57p],” says Eremu. “They were red and poured out of a container. I was told to swallow one in the morning and one in the evening. There were about 12 of them.”

Ogira, meanwhile, was sold 30 capsules for 6,000 shillings (£1.72) and told to take three a day. “I got no improvement. It seems I have just wasted my money,” he says.

Little Emanuel is in the private drug shop for much the same reason. Trained volunteer village health workers are supposed to carry government-supplied Coartem to give to babies at the first feverish signs of malaria. Only they haven’t got any. Emanuel has had malaria six times in the past year – but his mother, Grace Ayeso, tells me there is no point going to the health workers. And so, early-stage malaria becomes severe malaria.

The Ayesos have been in and out of government hospitals and health centres. The closest is Ojom, which is four hours’ walk away. So she ends up in the hut with the gingham tablecloth. Locals call this private drug shop a clinic because the owner employs a trainee nursing assistant, Betty Achakarat, to sell pills and put up drips. She wants to work in a government hospital. “I’m waiting for interviews,” she says. “I’m supposed to start in July.” She’s keen and bright, but her training is minimal and the drug shop doesn’t have a treatment licence.

Emanuel arrived three days ago. “He was really badly off, really sick,” Achakarat says. “Jaundiced, with yellow eyes, swelling legs and vomiting.” First she gave him a quinine injection, then she put him on a quinine drip. The three days’ treatment has cost Emanuel’s mother 13,500 shillings (about £4.50). That’s a lot of money here, but she was desperate. Emanuel was too sick for the long walk to the free hospital.

Is he any better? “I see some improvement,” says his mother. “Today, at least he has tried to eat something. But whenever he tries to eat, his stomach swells.”

The medicine Emanuel needs originates a long way from here. In central China, farmers tend a fern-like crop that used to be a weed. Artemesia annua (known also as sweet wormwood) has been long used by the Chinese as a fever medicine, but in 2002 the WHO recommended its use, in combination with other drugs, as the first-line treatment for malaria across Africa. ACT (artemisinin combination therapy), along with bed nets, is central to the campaign to reduce malaria deaths around the world.

Novartis, the huge Swiss drug company based in a state-of-the art glass block in Basel, owns the market-leading anti-malarial Coartem (an extract of the artemether plant combined with another drug, lumefantrine). Novartis has dropped its price over the years from $1.57 to 80 cents, but that’s still too much in countries such as Uganda.

To improve the situation, the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM) in Geneva channels money donated by affluent governments including the UK and US to poor nations to buy supplies of the drug. But in Uganda in 2005, it all went wrong. GFATM suspended all its grants to the country: money was being siphoned off and officials in the ministry of health were blamed. The scandal has had a massive fallout, with corruption trials ongoing.

People in Uganda blame GFATM for the drug shortages, but the money was stopped for only two and a half months. Unfortunately, future grants were conditional on annual audit reports being produced by the Ugandan government – something it failed to do until last October. So a malaria grant was approved more than a year ago, but no money could be paid out. It was finally signed off in April.

The GFATM scandal has had a huge impact in Uganda. While few doubt the fund had to act to stop its money being diverted into people’s pockets, the people who really suffered are those living in places like Katine, where the anti-malarials ran out. No Coartem was delivered to Tiriri health centre for 10 months. Soroti hospital has been full of pregnant women, sick with malaria. “Patients have suffered,” says Moses Kamabare, general manager of the National Medical Stores (NMS) in Entebbe, voicing the feelings of many Ugandans. “It is sad [GFATM] had to punish the patients because things were not done right by the government.”

Malaria is such a serious problem in Uganda that the government eventually found the money to buy 2.3m anti-malarial tablets – a cheap copycat version of Coartem called Lumartem, made by Indian generics company Cipla.

For Kamabare, the cardboard mountain of Lumartem in his warehouse is a triumph. He has been in the job not much more than a year, and when he began, the stores had only 45% of the drugs on Uganda’s essential list in stock. That’s now up to 75%, and rising. “Look around,” he says. “Paracetamol, aspirin, diclofenac, ciprofloxacin are all here.” But will they get to the health centres? Even when the money is found, there is another mountain to climb to get drugs out to the people.

Talk to health-centre staff and district officials, and they blame the NMS for stock-outs. They put in an order, they say, but it doesn’t arrive. In the press and parliament, there has been outrage at the mass destruction of drugs – including Aids drugs – at the NMS that had gone past their sell-by date.

For his part, Kamabare blames a combination of the government funding structure, the ordering system, a lack of distribution vehicles (and petrol in their tanks), and theft. “When you reach the health facility,” he explains, “the health workers open the boxes and help themselves to the supplies, either because they are running a private clinic to compensate themselves for their low salaries, or for a rainy day. Take Coartem. You know your aunties or uncles or cousins may need it. So you take 10 doses to your home. And you may give some to your neighbour, either for free or for a charge.”

Hospital doctors, Kamabare claims, have other ways of making money out of the system. “They may prescribe six or 10 medicines, knowing that the medicines are not in their government centre but a private pharmacy 200m away. Perhaps it is even owned by themselves, or by a friend. They say the drug is out of stock, but you can get it there.”

Back in Katine, Samuel Agom, the clinical officer in charge of Tiriri health centre, who must treat patients and run the place in the absence of a doctor (he left to earn more money in the city), concedes that deliveries have improved somewhat. But still, not all the drugs they order arrive.

“There is a medicine that stops bleeding called ergometrin,” he says. “That is finished.” It’s a critical drug in Tiriri, which deals with large numbers of women giving birth. Entering the rainy season, they also need stronger antibiotics for dysentery. But it is ACTs for malaria they need most. The generic Coartem duly arrived from the NMS in May, but within two months it was again finished.

“Drug costs have got higher,” says Agom. “A tablet of quinine is 200 shillings. You need 30 tablets for an adult – six a day. They may buy four and take two in the morning and two in the evening. It will not make them recover. They continue to be in a constant state of sickness.” Like little Emanuel, they will get one bout after another until they end up on a quinine drip in hospital, or a mud hut drug shop.

At the Soroti district health authority that oversees treatment in Katine, a man sits in a tiny office with a door that won’t close and a collection of tubs and packets on his desk. This is drug inspector Max Imata, and the drugs on his desk have expired. “The big problem is late delivery, or the drugs may not be in the NMS,” he says. It is his job to check the orders that arrive from Agom before passing them for signature to the district health officer.

Dr Charles Okadhi, the district health officer, is a much bigger man in a much bigger office. “The challenges are an inadequate budget for drugs,” he says. “We deal mainly with communicable diseases. Many people are infected and drug consumption is high.” The primary healthcare money arrives a month or two later than it should, he explains. Some forms don’t arrive, and all invoices and drug orders must be signed off after him by the chief accounting officer. Bad prescribing and pilferage add to this bureaucratic quagmire.

It’s not like this at the roadside shacks selling Coca-Cola, nor at the private pharmacies. At the Mandela pharmacy in Soroti town, the manager stares in scorn. “I can make a phone call to Kampala in the morning and have the drugs delivered by the evening,” he says. Private pharmacists say their supply chain works because people’s livelihoods depend on it. Shop owners have to invest their own cash.

Like water running round a blockage in a river, people in Africa give up on the government health centres and head for private drug shops and pharmacies – and even the local markets, where they risk being sold fakes. They don’t understand that a drug is not a magic bullet, and that taking one or two may be worse than useless, because they haven’t been told. So the fragile efficacy of antibiotics and antimalarials is damaged. Uganda is typical of most African countries. The same sorry story of shortages, inefficiency, sickness and growing worries over drug resistance are told across the continent.

At Uganda’s Ministry of Health, the permanent secretary Mary Nannono maintains that the system should be good enough to ensure rural health centres have the medicines they need. “Where you have a good manager, you will never find stock-outs of essential drugs,” she says. And yet she readily concedes the money Uganda sets aside for buying and distributing medicines is too little.

“The budget is not enough,” she says. “We can argue our case, but so will agriculture and energy and so on.”

Sadly, where people with HIV relapse and die without Aids drugs, where TB could resurge and even become drug-resistant, where precious new anti-malarials are not available and where people take only half a course of antibiotics because they cannot afford the whole lot, money for drugs is a deadly serious issue.

The new battle is now not just to get HIV medicines to people with Aids, but to get a consistent, affordable supply of essential drugs to all who need them. That means that governments in the west, as well as in developing countries, need to make money available, and turn their attention to supply systems. It can’t be left to Coca-Cola barons. It’s too important to leave to the market. Not just for Uganda, or Africa, but for all of us.

Exotic Pursuits: Issues in Tropical Medicine

March 30, 2010

One of many tropical field clinics all over the world; a physician tending to a young boy with malaria-related fever in Malawi

The hot, sweltering climate of the countries around the equatorial world bounded by the tropics of Cancer and Capricorn, are a breeding ground for variety of infections

The hot, sweltering climates of tropical countries are a breeding ground for a variety of infections that plague millions.  According to The World Health Organization, over 13 million deaths a year in developing countries are caused by a tropical disease, which accounts for nearly 45 percent of all deaths in the world.

Tropical diseases are challenging to deal with because they vary the gamut in terms of their causative agent: bacteria, virus, parasite–and each agent operates and infiltrates its host in a unique, adaptive way.

The pioneers of tropical medicine were the Brits. The original designation of certain diseases as being tropical can be dated back to the 1898 publication of Sir Patrick Manson’s Tropical Diseases: A Manual of the Diseases of Warm Climates.  Manson’s field guide identified twelve tropical infectious diseases, as well as a few other noninfectious diseases such as pellagra. The book was tailor made for British physicians who were Empire builders, working in the warmer climates of many of the British colonies. Since then, the list of tropical infections has expanded to include well over one hundred infections

Part of the persistence of tropical diseases depends of systemic and societal failures in a country’s health care system.  Good sanitation, hygiene, and vector-control methods, as well as a rise in the standard of living, were responsible for the virtual eradication of these diseases from North America and Europe. The fact that many of the diseases that are considered to be “tropical,” are found in poorer, developing countries is more a result of economics than it is of climate. There are several countries with high rates of “tropical” infections that do not have hot, sweltering climates associated with the tropics (for example, Iraq, Iran, and Afghanistan).

Over the next few weeks, I’ll take a look at some of the diseases in particular, their cultural and historical significance, and various other aspects of tropical medicine that come up in the news.