Roll Back Malaria issue first global report

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Influenza A H2N2 saga remains unexplained issue any type of explanatory statement. Until then, says Schwartz, we can only speculate: “They probably switched it because the other virus wasn’t growing well in tissue culture and this one did. That’s my guess.”

Rights were not granted to include this image in electronic media. Please refer to the printed journal. AP Photo

All of the influenza A H2N2 samples that were distributed to laboratories and health-care facilities in 18 countries as part of influenza proficiency testing panels have been accounted for and destroyed, according to the US Centers for Disease Control and Prevention (CDC). There have also been no confirmed reports of H2N2related illness associated with possible exposure to the test samples. However, it still remains unclear as to why manufacturer Meridien Bioscience Inc (Newtown, Ohio, USA) added this particular strain to the samples. The flu strain sent out by Meridien is known as H2N2A/Japan, which first appeared in 1957 and killed up to 4 million people worldwide. But by 1968, the strain had mysteriously vanished. “Meridien informed us back in October that they were including H3N2 A/Shanghai in the sample kits”, explained Jared Schwartz, secretarytreasurer of the College of American Pathologists. “The early shipments did contain the Shanghai virus, but then they switched it at some point.” The reasons for switching the virus have not been explained by the manufacturer. A meeting has been arranged with Meridien, who have thus far refused to comment on the incident or

Treating influenza in 1957

The CDC has formed a multi-agency task force that is conducting an investigation into the circumstances that led to the inclusion of H2N2 samples in the proficiency testing kits. The findings of this task force will be used to improve the testing system and help prevent similar occurrences in the future. The risk to the public was always extraordinarily low, but it was very difficult to get the media to understand

that, explains Schwartz. “Many of these samples had been sent out in September [2004], and there has not been a single reported clinical case of the flu. And these are virology laboratories, which are very experienced in handling viruses.” Furthermore, viruses used in sample kits are what virologists refer to as reference reagents. They are highly attenuated, having gone through processes that considerably weaken their virulence. Christine Pearson, a spokesperson from the CDC, agrees that the risk to both the public and to laboratory workers was not great. “But even though it posed a very low threat, we still needed to err on the side of caution”, she says. “The irony is that this incident may turn out to do more good for the public-health system and lab system than anything else”, contends Schwartz, “as it relates to our ability to identify novel proficiency testing samples. We sent out a virus whose subtype hadn’t been seen in decades, and we didn’t identify it. This is a wake-up call. No one attempted to subtype it, even though the strain was sent to public health and state labs, who have the equipment necessary to do so.”

Roxanne Nelson

Roll Back Malaria issue first global report The much-delayed World malaria report was finally published on May 3, 2005. In addition to providing the most detailed information to date on the scale of the global malaria burden, the report—prepared by Roll Back Malaria (RBM), the WHO, and UNICEF—also gives the first real insight into the progress of the RBM project towards control, treatment, and prevention of the disease since it was set up in 1998. The malarial regions of the world are split into three groups by the report— 332

Africa, Asia, and the Americas. Although Africa accounts for just about 60% of the global burden of malaria in terms of the number of cases, the report stresses the problems faced in Asia as an area of concern. Southeast Asia has the highest levels of drug resistance in the world. Multidrug resistance, particularly prevalent along international borders has caused a resurgence of malaria— eg, in Thailand and Burma, among others. Furthermore, malaria remains a substantial problem in the eastern

Mediterranean subregion—particularly Afghanistan and Yemen, which are described as having “severe malaria”. The report attributes these problems to “complex emergencies and the associated destruction of health systems.” The estimated incidence of malarial episodes is revised slightly from the previous figure published in 2000, stating that there are about 350–500 million clinical malaria episodes globally per annum, up from 300–500 million. http://infection.thelancet.com Vol 5 June 2005

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cases in Africa, blaming poor and unavailable African data. But the data were just as poor and unavailable in 1998 when the WHO promised to halve malaria deaths, so why did they promise that?” He speculates that, with only 5 years to go until 2010, we are now seeing the current leadership’s exit strategy.

WHO/UNICEF

Despite the growing problem in Asia, the report makes it clear that the burden of disease lies in Africa. Allan Schapira, coordinator of the Strategy and Policy Team at RBM, concurs: ”We need to take the burden in Africa very seriously. The potential for improvement is greatest in Africa, where [malaria] is highly concentrated, in an at-risk population of around 600 million people.” In terms of giving an overview of the progress made by RBM towards its goal—halving the global burden of malaria by 2010—the report is harder to interpret. The authors write in optimistic terms: “significant progress in the battle against malaria has been made in all malaria-affected regions . . . most countries have begun to implement the recommended tools and strategies to reach those most at risk of malaria”. But later on they state that: “In Africa, several countries will reach at least some of the targets set . . . in 2000”. So is the RBM project still on track? Amir Attaran (Institute for Population Health and Faculty of Law, University of Ottawa, Canada) believes the project is almost “certain to fail”, and that the RBM partnership “plans to ‘massage’ the data to show they succeeded at halving malaria deaths in 2010”. He continues: “The most outrageous thing is that, in 2005, the WHO says it cannot ascertain trends in malaria

Distribution of malaria vectors

Christa Hook of Médecins sans Frontières told TLID that she is “not convinced about some of the statements” in the report. “The report talks about the initiatives in the last 2 years, but there is very little implementation yet, and certainly no scaling up. I would question the coverage [with insecticide-treated bednets] achieved 2 years ago has been maintained by re-impregnation. I think it very doubtful that all these nets are long-lasting nets.” Furthermore, she sees “very little scaling up of artemisinin-based combination therapy [ACT] . . . because there was a lot of muddle and confusion until

very recently in the RBM recommendations on the use of ACT”. And this is despite ACT being the only effective drug regimen in most countries worldwide. For instance,“Ethiopia has to use the ACT Coartem because of resistance to all other available first-line antimalarials, but has only received a small proportion of the drugs needed, and will not receive more until next year at the earliest”, she says. Schapira believes that RBM is learning from its experiences. For example, the use of insecticide-treated bednets “is the intervention that [RBM has] learnt can be scaled up more quickly and efficiently than we thought before, and it is becoming less costly than it was, because we have longlasting insecticidal nets.” He also agrees that ACT should be the drug treatment of choice. “People can discuss forever that there may be places in Africa where other treatments may work, but the cost of a treatment with ACT is ridiculously low for a lifethreatening disease, and the fact that it costs something means that health services are more likely to really focus on the job of getting it to function well and to use it in the right way.” Hopefully, the experience gained by RBM over the past few years will allow the project to meet its ambitious objectives.

Rob Brierley

Ethics of AIDS drug trials on foster children questioned The New York City Administration for Children’s Services (ACS) has commissioned an independent research firm —the Vera Institute of Justice—to investigate if a series of experimental studies on more than 450 HIV-infected children under ACS foster care during 1988–2001 violated ethical standards. “In our [in-house] review of the records so far, we have seen no evidence of any wrong-doing but we look forward to the Vera Institute’s indepth investigation so that we can http://infection.thelancet.com Vol 5 June 2005

answer questions from the community we serve”, Sharman Stein, a spokesperson for ACS told TLID. “We want to answer the public’s questions but this type of investigation requires time and expertise we do not have inhouse”, she said. Although the investigation by the Vera Institute is likely to take several months, its first interim report will be released in about 3 months, she said. But Vera Sherav of the Alliance for Human Research Protection questions the credibility of any investiga-

tion called for by ACS. “ACS lied about the number of children involved, stating in April 2004 that only 76 children were involved; later the number increased to 100, and now 465 ”, Sherav said. She accused the agency of failing to meet its surrogate parental obligation to the children and of circumventing federal regulations that prohibit the use of children who are wards of the state from being used in experiments involving greater than minimal risk. “The agency has yet to 333