Global Infectious Disease

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Global Infectious Disease

• Dr. Cynthia Schneider
• Life Science Seminar
• October 21, 2004

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The Facts
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The Facts
Leading Causes of Death Due to Infectious Diseases 2002
Lower respiratory infections 3.9 million
HIV/AIDS 2.8 million
Diarrheal diseases 1.8 million
Tuberculosis 1.6 million
Malaria 1.2 million
Measles 0.6 million
Source World Health Report, 2004WHO
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The Facts

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Infectious Disease and the Developing World
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90/10

• 90 of global health care focus on 10 of the
  population
• 90 of global population receives 10 of health
  care

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Malaria a Case Study in Infectious Disease
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Malaria the Silent Holocaust
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And Its Getting Worse

• Average number of cases per year has quadrupled
  since 1980s
• Malaria deaths among children in eastern and
  southern Africa has doubled
• In some areas rate of increase of malaria deaths
  as high as 11-fold
• 95-100 of population of tropical Africa at risk
  of malaria
• At present rate of increase, half of the worlds
  population soon will live in malaria infected
  areas

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Poverty and Malaria
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Malaria-endemic Countries in Africa, the Middle
East, Asia, and the South Pacific, 2002
www.cdc.gov
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Malaria-endemic Countries in the Americas, 2002
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History of Battling Malaria

• Malaria eliminated in US by draining swamps
• Early 20th century, organized malaria control
• Global eradication campaign 1956-1973 failed
• Chloroquine - cheap, effective treatment (5
  cents per dose) until evolution of chloroquine
  resistant mosquitoes
• From 1990 onwards, increasing problem in Africa
• Multi-pronged approach vector, prevention
  (vaccine, spraying, nets) , drugs for treatment

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Battling Malaria Today the Players

• Gates Foundation, Malaria Vaccine Initiative
• Assumptions (source Gates Foundation web site)
• A strong foundation of malaria research already
  exists
• Progress along the malaria vaccine development
  pathway will be measurable
• Current market forces requiring a return on
  investment cannot drive malaria vaccine
  development alone, requiring a balance of push
  and pull mechanisms for success and
• Effective disease prevention will ultimately
  require combination vaccines that include several
  antigens from different stages of the Plasmodium
  life cycle and elicit a breadth of immune
  responses.

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Gates Foundation MVI

• Approach
• Partnerships
• Vaccine Development, not Discovery
• Pursues multiple vaccine candidates
  simultaneously
• Uses industrial model of management with goal of
  ensuring that MVI funding results in net increase
  in funding for vaccine development

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Gates Partners

• PATH international NGO for sustainable,
  culturally sensitive solutions to health problems
  in developing world
• Glaxo Smith Kline (GSK)
• GAVI Global Alliance for Vaccines and
  Immunization
• Mozambique GSK Biologicals, Mozambique Ministry
  of Health, Centro de Investigacao em Saude da
  Manhica (CISM), Hospital Clinic of the University
  of Barcelona

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Gates Funding for Malaria

• MVI at PATH 50 million over 4 years (4/1/99)
• 100 million over 4 years (9/21/2003)
• Other grants, such as to One World Health 1.4
  million
• Compared to total funding for malaria about 80
  million in 2004

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The Players

• MMV Medicines for Malaria
• Swiss Foundation established 1999
• Public Private Partnership
• WHO, IFPMA (International Federation of
  Pharmaceutical Manufacturers Association), Global
  Forum for Health Research, Rockefeller
  Foundation, World Bank, Swiss Agency for
  Development and Cooperation, Association of the
  British Pharmaceutical Industry, Wellcome Trust
• Formed as alternative to market mechanisms,
  which have not led to vaccine development

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RBM Roll Back Malaria

• 1998- WHO, UNICEF, UNDP, World Bank, plus 90
  other partners
• Goal to halve malaria by 2010
• Multi-faceted Strategy, with emphasis on low
  tech interventions
• Preventive treatment during pregnancy
• Artemisinin-based combination therapy for
  treatment
• Vector control
• Insect-treated nets
• Indoor residual spraying

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Low Tech Weapons Against Malaria

• Artemisinin
• Mosquito nets
• DDT

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Artemisinin an organic antidote to chloroquine
resistance

• Artemisinin and artesunate come from an herb
  used in traditional Chinese medicine
• Combat chloroquine resistance
• Works best when combined with another
  anti-malarial
• Artemisinin in combination with other
  anti-malarials has cure rate of 90
• PROBLEM Artemisinin currently grown in Tanzania,
  exported to Europe for processing, re-imported to
  Africa at prohibitive cost of 5-7 per dose

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Policy Choices Whose Standards Are They Anyway?

• DDT -- arguably readiest, cheapest means to
  combat malaria
• Not used in developing world because of
  regulatory standards in developed world
• Northern/western driven environmental standards
  have (inadvertent) impact on health in developing
  world
• How to balance environmental safety and human
  health?
• Risk evaluation that incorporates risk of doing
  nothing

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• Another approach -- modify the vector
• Genetically alter mosquito so that it cannot
  transmit disease (prevents malaria parasite from
  binding onto mosquitos gut interrupts malaria
  life cycle)
• Genetically alter mosquito so that it produces
  more defensin, which kills malaria bacteria
  (like a vaccine imbedded in mosquito)
• Problems How to regulate? How to ensure
  environmental safety?

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Role of Department of Defense

• New vaccine recently tested in Mozambique was
  developed at Walter Reed
• DOD operates largest malaria drug development
  program in world, emphasis on drug resistance
  (IOM Emerging Infectious Diseases from the Global
  to the Local Perspective, 1999)
• DOD has large network of state-of-art labs all
  over world -- 700 staff, with 800 in DOD who
  work with them on infectious diseases
• Focus on safety of troops has led to
  comprehensive surveillance/monitoring system
• Links to WHO and other health agencies

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Flu Vaccine Crisis Reveals U.S. Vulnerability

• Systemic problems with vaccines
• 1) high cost of manufacturing and passing
  regulatory hurdles
• 2) limited U.S. and foreign markets
• 3) Product liability exposure.

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Towards a Different Model

• Need to create incentives for more private
  companies to develop vaccines
• Requires creative rethinking of public/private
  balance and roles
• How to create incentives for more public and
  private entities to tackle infectious diseases
  in developing world
• How to balance western/northern regulation
  standards with needs and capacities of
  developing world