Exploring the History of Malaria Transmission Modeling

By Liz Flavall
Posted: April 5, 2012

Image Credit: Original image Grassi, B. Studi di uno zoologo sulla malaria (1901), featured courtesy of the Biodiversity Heritage Library. Permission to use the CCAL license granted by the Smithsonian Institution Libraries.

Mosquitoes are responsible for the transmission of a multitude of pathogens including malaria, dengue and West Nile virus. Modeling the transmission patterns of mosquito-borne pathogens can inform public policy in the efforts to eradicate these diseases. I had a quick Q&A with David Smith, Professor of Epidemiology at the Johns Hopkins Malaria Research Institute, about his recent review, published in PLoS Pathogens, that pulls together the first 70 years of mathematical modeling of malaria transmission by exploring the work of Ronald Ross and George Macdonald.

What was your motivation to start studying malaria epidemiology?

It was a slippery slope.  My academic interest was first sparked as a graduate student in mathematics. Malaria is a large, important problem with an interesting history.  The epidemiology is very complex.  It presents a durable intellectual challenge. I wanted to study it, but I resisted the urge because the complexity seemed overwhelming. I got pulled into it over the years by lots of people, but the most important ones were probably Ellis McKenzie, Simon Levin, and Ramanan Laxminarayan.

Sir Ronald Ross. Image Credit: NIH

When did you become aware of the Ross-Macdonald model of mosquito-borne pathogen transmission?

It was one of the first things I learned about malaria. I’m not sure I can recall the first time I heard of it — probably in a class in population biology at Brigham Young University, or possibly when I first arrived at Princeton and started learning about mathematical epidemiology.

What prompted you and your co-authors to write a historical review of this model?

Earlier this year, PLoS Medicine published the malERA series, including a paper describing a research agenda for mathematical modeling for malaria eradication. As we wrote the historical review for the MalERA publication it became clear that there were limitations to previous commentaries and reviews describing the development of the Ross-Macdonald model.

We wanted to do a comprehensive review of mathematical models of mosquito-transmitted pathogens, so we compiled a comprehensive bibliography.  The “Ross-Macdonald model” and its progeny now include approximately 600 peer-reviewed manuscripts and we had a hard time organizing the analysis. We recognized informally that many papers had influenced the Ross-Macdonald model, so we decided to devise a metric that we could use to measure similarity. That decision precipitated a need to define the Ross-Macdonald model in very rigorous terms, and it was then that we realized the “Ross-Macdonald” model was not any one thing. It is a “scientific theory” in the classical sense: a deliberately simplified set of concepts, abstractions, and quantities that conform to available data to explain a certain class of phenomena.

Do you think there is room to further build upon these theories?

I think so, but not by doing more of the same.  Mathematical epidemiologists need to spend more time trying to break their models and see how they stand up to serious scrutiny.  One of the things I think current models do very poorly is to consider the properties of transmission — how is the pathogen dispersed in space and time by mosquitoes and their human (or other vertebrate animal) hosts?  We have some clues that this is one of the things that the models get wrong, but this is one of the most neglected areas for mosquito-transmitted pathogen models.

What do you see as next direction for this area of epidemiology?

I’d like to see the models integrated and applied in vector-borne disease control programs — and I mean really used to design and evaluate intervention protocols — but there are a lot of intellectual problems yet to be solved.  How do you integrate all the information streams about mosquito-borne pathogen transmission and use that information to improve the efficiency of a control program?  It’s a formidable intellectual problem, but it’s an even bigger human problem.  The people and institutions that work to control malaria and dengue are as complex as the epidemiological and ecological problems it poses.  But the main message is that it is an urgent problem, especially in light of the evolution of antimalarial drug resistance, insecticide resistance, and the volatile funding environment.

What impresses me most, despite all of the complexity and failures, is that malaria has been in retreat for a century.  I think we can continue to make it retreat — I think that’s the task for scientists in my lifetime — how can we eliminate malaria from half the countries where it now exists?  As long as it keeps shrinking, the end of malaria is inevitable.

Read the review: Ross, Macdonald, and a Theory for the Dynamics and Control of Mosquito-Transmitted Pathogens.

More information on malERA – a research agenda for malaria eradication.


Share|
Category: Collections, General, malERA | Leave a comment

Conflicted: The War for Health

By Medsin
Posted: April 4, 2012


CONFLICTED: THE WAR FOR GLOBAL HEALTH

MEDSIN GLOBAL HEALTH CONFERENCE

14th-15th April 2012 King’s College London


As National Coordinator of Medsin, I am fortunate enough to have had the opportunity to attend a number of excellent conferences this year.

But I don’t think I’ve ever looked  forward to one as much as CONFLICTED, this year’s global health conference which will be held at King’s College London on the 14th and 15th of April.

I’m trying to think about what excites me most. Perhaps it’s the amazing set of speakers.  Robin Coupland, medical adviser to the International Committee of the Red Cross (ICRC) will be opening the conference, followed by speakers including Director of MedAct, Marion Birch,  Surgeon Lieutenant Henry Dowlen, and another Red Cross expert, Gilles Thal Larsen. The debate is sure to be fantastic, as the four plenaries will grapple with challenging multisectoral issues that I can’t wait to engage with. The conference will consider the causes of conflict, the emergency humanitarian response and how to achieve sustainable development and peace.

The range of workshops on offer is also pretty stimulating, and since choices don’t have to be made till the start of next week, I’m still wrestling with which to pick. For the Saturday morning I’m trying to decide whether to attend the extremely popular super-workshop on Post-Traumatic Stress Disorder, “Addressing the Mental Health Gap in Low and Middle Income Countries” by Dr. Graham Thornicroft, whom I’ve heard so much about and have yet to meet, or a workshop by Dr Rhona McDonald. Dr McDonald will be manoeuvring an ethical maze by considering the blatant disregard of the Geneva Conventions in recent conflicts, and the provocative question of whether the enforcement of healthcare protection is a realistic option in the 21st century. It’s no easy decision, and there’s also a whole range of excellent, primarily student-led, workshops on the Sunday afternoon for me to choose between. That’s not to mention needing to plan my own workshop, on transformative medical education, a particular interest of mine.

All-in-all the workshops are undoubtedly going to be a highlight of the weekend.

Most of all, however, I’m looking forward to meeting the other delegates. The organising committee tell me that there are already students registered from every medical school in the UK, and the number of professionals, both from within and outside of the medical world is also rising. Such a mix of individuals from different disciplines, and right across the UK is sure to fuel interesting discussions in the coffee breaks, as well as within plenaries and workshops, and like any seasoned conference attendee I know that some of the best connections are made over a shortbread biscuit and cup of tea, rather than a crowded lecture theatre.

Along with a Global Health Question Time including Simon Hughes, Deputy Leader of the Lib Dems, numerous stall fairs, and national poster and photo competitions, it’s going to be quite a weekend!

There’s still tickets left for both professionals and students, but early bird ticket rates end today so snap yours up now! And if you can’t attend but want to engage with the discussion, follow us on twitter (@medsinuk); we’ll be using #medsinghc!

Book your tickets now at http://www.medsin.org/news-and-events/ghc12/booking

From £21.50 for a student weekend ticket & £39.50 for a non-student.

Felicity Jones

Felicity Jones is a fourth year medical student at King’s College London. She is currently Joint National Coordinator of Medsin-UK, along with Dan Knights. Follow her on twitter: @faejones.

Share|
Category: Conference news, General, Students | Tagged , , , | Leave a comment

This Week in PLoS Medicine: Human rights in Darfur; Body size & ovarian cancer & more

By Michael Morris
Posted: April 3, 2012

Image Credit: Jeramey Jannene

Three new articles published this week in PLoS Medicine, with two Research Articles and a Policy Forum.

Alexander Tsai and colleagues review medical records from the Amel Centre, Sudan, to assess consistency between recorded medical evidence and patient reports of human rights violations by the Government of Sudan and Janjaweed forces.

A reanalysis by the Collaborative Group on Epidemiological Studies of Ovarian Cancer of published and unpublished data from epidemiological studies examines the association between height, body mass index, and the risk of developing ovarian cancer.

Peter Bloland and colleagues from the US CDC lay out the agency’s priorities for health systems strengthening efforts.

Remember you can comment on, annotate and rate any PLoS Medicine article and see the views, citations and other indications of impact of an article on that articles metrics tab.

Share|
Category: PLoS Medicine Week by Week | Tagged , , | Leave a comment

Why Do We Create Clinical Practice Guidelines?

By PLoS Guest Blogger
Posted: April 2, 2012

Guest blogger, Jessie McGowan, ponders why there are so many barriers to using, adapting and implementing clinical practice guidelines.

I have been working on a project of clinical practice guideline (CPG) adaptation with the Canadian Society for International Health in Kazakhstan. However, it became clear that the size of the project was too large for creating de novo CPGs (they requested the development of 100 CPGs in 2.5 years). We decided to be pragmatic and adapt CPGs using ADAPTE and CAN-IMPLEMENT.  I personally, love the philosophy of adaptation because it is evidence-based medicine at its best.  Why reinvent the wheel and use precious resources and duplicate efforts?  If an excellent CPG exists, why not try to tailor it to your local situation?

The solution of adaptation seemed so beautiful and simple. However, as the project progressed it became clear that permission to translate and copyright would become major issues.  The first issue is to translate the CPG into Russian for use by the local Kazakh working groups; the second is to adapt the CPG into the Kazakh context and to produce a new adapted CPG for dissemination and implementation in Kazakhstan.

As I worked with publishers and guideline producers, I found that there is no one process to receive permission to translate.  It is time consuming (up to 5 months and many emails) and sometimes there are fees.  Frequently, when I tried to request permission through a third party, the option for translation wasn’t available and I have had to personally contact the publisher.

Old and new in Astana, Kazakhstan. Image Credit: Jessie McGowan

When I have requested permission to “adapt” I found that most publishers and producers did not know how to deal with the request. Technically, one can view adaptation as an academic activity.  If this is so, then, I believe, as long as you follow correct citation rules, you should be okay.  However, if large parts of the CPG are being reprinted, then it is necessary to seek permission.  However, what does “large parts of content” mean and how does “fair dealing” work in Kazakhstan?  ADAPTE and CAN-IMPLEMENT both recommend consulting with the source developers, but actual process guidance is not included (and I can certainly understand why).

One silver lining is with open access. Articles published under an open-access license are not only free to read, but all reuse is permitted provided only that the original article is properly cited. However, the vast majority of CPGs I have been dealing with are not available through an open-access license.

After all of this, I find myself going back to some basic questions.  Why do we produce CPGs?  How do CPG producers expect the CPG to be used or implemented?

If CPGs are important tools for clinical decision makers to make the best decision for their patients, then why are there so many barriers to the use, adaptation and implementation?

Should there be an effort to raise the awareness of the importance of using CPGs? Should journal publishers and CPG producers try to create policies to ensure that the CPGs can be used broadly? Should CPG producers be encouraged to publish in open-access publications?  Leave me a comment a let me know what you think!

Jessie McGowan has a PhD in information science and is a library and health consultant from Toronto, Canada.  She also holds adjunct faculty appointments in medicine and family medicine from the University of Ottawa.  Contact:  jmcgowan@uottawa.ca

Share|
Category: Access, General | Tagged , , , | Leave a comment

It’s Good to Talk: Reflections from the IFMSA General Assembly in Ghana

By Medsin
Posted: March 30, 2012

The medical community is a global one – probably an obvious statement, particularly if you read this PLoS blog!  However, as a medical student, it doesn’t always seem that way.  Meeting the global medical community is something you hope for when you’re a “Real” Doctor.

Which is why it is so exciting for this second blog on behalf of Medsin-UK to reflect on the recent International Federation of Medical Student Associations (IFMSA) General Assembly (GA) in Accra, Ghana, attended by a 12-strong Medsin-UK delegation of medical students from all over the UK.   I direct you to the brilliant series of blogs written by the delegates during their week there (http://www.medsin.org/blogs,) and pick out some highlights to share with you here from their blog entries.  The IFMSA conducts its activities through its six Standing Committees (SC), and I’ll briefly take you through some of the achievements of the UK delegation.

Kevin Garrity and Marion Matheson sat on the SC for Medical Education, where they developed policy statements on Widening Access to Medical Education.  Whilst this is something the British Medical Association (BMA) has been promoting in the UK, it is great to have an international statement on this important issue.  In addition, they ran a workshop with another country’s delegation on advocacy and government lobbying.  Having attended an IFMSA last year, I think it’s easy for us to take for granted the advocacy work we can freely do in the UK, and as Marion’s blog entry explains, this sharing of ideas means we can work together to improve student representation and lobbying work all over the world.

The Medsin-UK delegation at IFMSA 2012 Accra, Ghana

Matthew Tuck and Hollie Kluczewski, representing the UK on the SC for Reproductive Health and AIDs, explored issues surrounding healthcare for HIV positive patients in different countries and for other stigmatized groups within healthcare systems around the world.  As Hollie puts it ‘ there’s a positive hum and it’s buzzing about the youth voice… they want to know your opinions, how our education system works, how we advocate… and they want to know how to do it too’.

Medsin-UK National Coordinators Felicity Jones and Dan Knights will have had an exhausting week in their daily Presidential sessions, which went on well into the early hours of the morning.  But Felicity’s blog notes how the diverse social and cultural differences between different countries and their representative organisations demonstrates how it is possible to ‘adapt to unique challenges’ to the same greater goal of a better world through collaboration.

The rest of the delegation (Jonny Meldrum, Nathan Highton, Juliet Drummond, Sarah-Jane Lang, Leon Cohen and Mike Kalmus-Eliasz) who worked in the other SCs (Professional Exchanges, Research Exchanges, Public Health, and Human Rights and Peace) contributed significantly to the assembly, running transnational projects, running discussion groups, presentations, workshops and training sessions, and developing international policy statements.  In particular, Mike and Jonny did an incredible job promoting ‘Think Global’, facilitating Think Global training and information sessions at both the pre-GA meeting and throughout the GA.  Mike is now the Coordinator for Think Global, and will continue to take the Global Health message to students all over the world.

Medsin-UK and international medical students during small group working

Reading the blogs, there are two overwhelming messages that come across from the delegates – the first was converting the feelings of trepidation (will I have anything to say?  Do I know enough?) into those of confidence (as Hollie says – ‘I’ve managed to find my voice’).  Being part of a vibrant, knowledgeable gathering of hundreds of medical students is a great opportunity to share and learn.  It is exciting to think both of the ideas shared by Medsin-UK which have now travelled to various corners of the world, and conversely what our delegation have brought back to the UK.

The second message is one of friendship and community.  Medicine is often perceived as a career of high achieving, powerful forces.  But it’s also a career of people, and it is clear that the delegation only learned and achieved what they did through the inspirational delegates the met from the global medical student community.

Did you go to the IFMSA General Assembly? Leave a comment and tell us about your experience!

Karin Purshouse

Karin Purshouse is a final year medical student at Newcastle University and was Chair of the British Medical Association’s Medical Students Committee (BMA MSC) 2010-11.  She has been involved with Sexpression and Medsin since 2006, and was part of the Medsin-UK delegation to the International Federation of Medical Student Associations (IFMSA) August Meeting 2011. She also blogs here: www.kpurshouse.blogspot.com

Share|
Category: General, Students | Tagged , , | Leave a comment

Candid Corrections and Responsible Retractions: Lessons Learned from COPE 2012

By Cecy Marden
Posted: March 29, 2012

Several PLoS staff attended the Committee on Publication Ethics (COPE) European Seminar 2012 in London on Friday 16th March. Not only was the theme of the day “Correcting the Literature”, something which usually turns a good publishing day to bad, but the refrain was of retractions.  The programme was filled with several presentations around the theme of corrections, retractions and article versioning. Some of the attendees have commented on what caught their attention.

Retractions and misconduct: Lessons from Science

Rachel Jarmy, Publications Assistant, PLoS Biology

The first presentation of the day was from Deputy Editor and International Managing Editor of Science, Dr Andrew Sugden, who began with the reassuring reminder that most retractions are ‘good’, in that the authors voluntarily report an honest error to the journal, and co-operate fully to rectify the issue.

However, it is the ‘bad’ and ‘ugly’ cases of misconduct, authors refusing to co-operate, institutional investigations and mass retractions across multiple journals that have led to Science reassessing some of their policies.  As a direct result of famous cases such as Hwang in 2004 and2005, the journal has implemented new protocols, such as all authors confirming their authorship on a paper and all figures being checked for manipulation, with the aim of stunting the growth of retractions.

Dr Sugden also highlighted the difficulties faced by editors, such as large multi-author manuscripts from many labs and countries with potential language barriers, and the intense media scrutiny that can surround corrections to the literature.

The presentation closed by voicing a need for an analysis of the pressures that cause misconduct and significant error amongst authors, as well as a balance between observation and accusation.

CrossMark: There is no final version

Cecy Marden, Publications Manager (Sponsored Supplements and Collections), PLoS Medicine

CrossRef are adding to their arsenal of tools for scholarly research and publication with the introduction of CrossMark. Ed Pentz, the Executive Director of CrossRef, made the case that as much as publishers like to think that a published article is fixed in time forever, in fact articles are frequently enhanced, updated, corrected and even occasionally retracted. CrossMark is proposed as a way for readers to easily identify that they are reading a publisher-maintained version of an article, and for publishers themselves to consistently and publicly record any changes that are made to an article post-publication, by adding the CrossMark logo and version information to their content.

It seemed to me that the biggest hurdle CrossMark faces is the requirement for readers to click on the logo in order to see whether an article has been altered. Whilst publishers vary in how they flag up corrections, the word “correction” is usually visible, no clicks required, on the html version of the article. The CrossMark logo will be unchanging so to reach version information you must click, but will readers take that step? Perhaps more usefully, CrossMark will allow PDF users to click on its logo months after download to receive confirmation of whether or not a correction has been made to the article, which is something publishers currently have no means of doing. Even so, I remain most excited about the freely available and searchable dataset which will be part of CrossMark, and its associated possibilities. For example, other services like Mendeley and CiteULike could work with CrossMark to ensure their users’ reference lists were kept updated, or readers could sign up to be notified if a particular article they were using was modified.

There’s no arguing against the importance of ensuring that changes made to an article are consistently available to readers, and it’s great to see CrossRef stepping into that space, but it felt like perhaps CrossMark’s logo isn’t quite big enough to fill it – yet.

You can view the slides, or even a pre-recorded webinar, at http://www.crossref.org/crossmark/index.html

Legal issues in corrections and retractions

Rosemary Dickin, Publications Manager, PLoS Computational Biology

Joss Saunders, from Blake Lapthorn Solicitors, gave an engaging introduction to “Legal issues in corrections and retractions”. As online publishers, we operate under a particularly broad definition of “publication” and Joss provided some useful tips on navigating the legal jungle this can create. Wherever they are based geographically, online publishers actually publish internationally via the internet, and may be answerable to the legal codes of other countries. Publication also occurs with each fresh download, so publishers must be committed to ensuring that corrections and amendments are applied as broadly as possible and are visible to future readers. Given the cultural divides separating the legal codes of different nations, even the simplest of topics can quickly become very complex – for example, “moral rights” (such as the right to be identified as an author), which exist on a scale from highly important to near non-existent and everything in between.

While juggling the legal and ethical considerations of implementing corrections and retractions can be a tricky business, some general principles did emerge: stating only facts, not opinions; making sure all authors are aware of manuscript submission and changes; keeping sensitive information on a “need to know basis”; and acting swiftly, but wisely, when any problems arise.

Breakout Sessions

Paul Simpson, Associate Editor, PLoS Medicine

I found that one of the most useful and interesting parts of the day was the workshop breakout sessions. This gave participants the chance to discuss case studies that have previously been presented at COPE meetings. It was fascinating to hear different perspectives from editors working for journals publishing across diverse scientific specialties. It is was valuable to learn from other people’s experiences without having to go through the difficult process yourself; I was surprised how often I wasn’t sure how best to deal with the situations that were presented and how discordant the group in which I participated were when it came to deciding what to do.

COPE publishes previous case reports on their website and they can make a fascinating read. In addition to the case reports the COPE website contains best practice guidelines and flow charts to help editors cope (excuse the pun) with sticky situations so you don’t have to have attended a meeting to benefit from COPE’s advice. The website also hosts an eLearning course for COPE members.

Did you attend COPE European Seminar 2012? Leave a comment and tell us what caught your ear.

Share|
Category: Research Ethics | Tagged , | Leave a comment

This Week in PLoS Medicine: VBAC; cART during PHI; IPTi & more

By Michael Morris
Posted: March 27, 2012

Image Credit: Petteri Sulonen

This week wraps up the publishing month of March with our monthly editorial and three other new articles.

The PLoS Medicine Editors discuss new research studies on the risks associated with mode of childbirth following caesarean section.

In a three-arm randomized trial conducted among adult patients in HIV treatment centers in The Netherlands, Marlous Grijsen and colleagues examine the effects of temporary combination antiretroviral therapy during primary HIV infection.

A three-arm randomized trial conducted by Ivo Mueller and colleagues among infants in Papua New Guinea estimates the preventive effect against malaria episodes of intermittent preventive treatment in an area where children are exposed to both falciparum and vivax malaria.

Alex London and colleagues propose new ethical frameworks for evaluating the risks associated with research in which financial or other incentives are used to promote healthy behavior.

Remember you can comment on, annotate and rate any PLoS Medicine article and see the views, citations and other indications of impact of an article on that articles metrics tab.

Share|
Category: PLoS Medicine's Daily Click | Tagged , , , , , , , , | Leave a comment

Announcing PLoS Currents: Disasters

By Virginia Barbour
Posted: March 27, 2012

Today, there are ever more pressing needs for up-to-date information to be quickly available and easily accessible. This has never been more true than in the field of disasters, where slowness in sharing knowledge can be the difference between life or death for thousands of people, or the avoidance or mitigation of catastrophic outcomes for an ecosystem.

Despite the breadth of technological possibilities available, publishers and scientific journals  have not provided adequate solutions for publication during fast moving emergencies. One study, published in 2009 showed that the majority of the epidemiological articles on the SARS epidemic of 2003 were submitted after the epidemic had ended, many several years after – and this for an emergency that lasted just a few months. The UNIDSR has identified that, “the sharing of research findings, lessons learned and best practices” are a priority in its Hyogo Framework for Action 2005-2015.

PLoS is proud therefore to announce the launch of PLoS Currents: Disasters, a new, innovative open-access publication for the rapid communication of new research results and operational analyses derived from the study or management of all types of disasters. All research is citable and permanently archived in PubMed Central as well as indexed in Scopus and PubMed.

Our primary aim is rapid dissemination to make essential, and in many cases otherwise hard to publish, findings as widely available as possible as quickly as possible, so they can be used and built upon.  We have implemented an integrated authoring, editorial, and peer-review system called Annotum, a new publishing platform, which we believe can cut the publishing time down to a few weeks, or even days. Authors directly compose or insert their manuscript in the web-based application and peer review occurs within it.  All of the content is published under a Creative Commons Attribution License (CCBY), which means that articles are immediately free to read but more importantly can then be reused in any way, provided that the authors are attributed correctly.

PLoS Currents is a flexible publishing channel, which responds to the particular needs of the community of disasters-related researchers and practitioners.  In addition to the decreased publishing time through a streamlined review and production process, it offers:

  • Flexibility: open article formats to reflect the diverse types of disasters-related research
  • Revisions: updated versions of articles that document the latest results or analyses.

The most recent article,  from 16 international experts in the fields of research, education, ethics and operational aspects of disaster medical management, highlights a critical issue in disaster management and describes  a template for uniform data reporting of acute medical response in disasters.

PLoS Currents: Disasters is supported by an international group of  researchers, practitioners,  who serve on its editorial and review board.

Professor Virginia Murray, an Editor for PLoS Currents: Disasters, and the Head of Extreme Events and Health Protection at the Health Protection Agency, said “evidence based advice is essential for providing relevant up-to-date evidence based information to support the development of planning for extreme events – PLoS Currents: Disasters is a valuable publication resource to help to build the information that is so vitally needed for this purpose.”

Professor Mike Clarke, also an Editor for PLoS Currents: Disasters, and the current Chair of the MRC Network of Hubs for Trials Methodology Research and one of the founders of Evidence Aid, said “We are increasingly aware of the problems caused by research not being published in a timely and accessible way, and the damage this does to decision making and, consequently, to health care and health. The arrival of PLoS Currents: Disasters will help ensure that we learn from those lessons, by improving access to the knowledge needed in disasters. Evidence Aid is trying to make it easier for people to use systematic reviews of relevant information, and this new resource is a landmark step in making this information available.”

Fabrice Renaud, Head of the Environmental Vulnerability and Ecosystems Services Section, United Nations University Institute for Environment and Human Security, Bonn, Germany and an Editor of PLoS Currents: Disasters said: “PLoS Currents: Disasters will enable scientists and practitioners who directly work on the many facets of disaster prevention, disaster management and disaster response to rapidly share their on the ground expertise, observations and research results with a wide range of stakeholders.

Professor David Sanderson, Director, Centre for Development and Emergency Practice (CENDEP) and an Editor of PLoS Currents: Disasters said: “PLoS Currents: Disasters aims to fill an important gap – that of getting good evidence-based research out fast to those working in disasters.”

PLoS Currents started with its first section, Influenza, in 2009. Today, we continue the spirit of innovation with the launch of our sixth and newest member, PLoS Currents: Disasters, which will be developing over the next few months. Contact us at disasters@plos.org with any questions, comments, or suggestions on further developments or leave a comment below.

PLoS Currents: Disasters welcomes your submissions.

Share|
Category: Access, General | Tagged , , , , , , , | 2 Comments

Conflicts of interest and DSM-5: the media reaction

By Clare Weaver
Posted: March 26, 2012

Image Credit: Ano Lobb

The fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-5) will be published next year, but concerns surround its financial competing interest disclosure policy and the ties its panel members have to drug companies. Last week PLoS Medicine published an analysis by Lisa Cosgrove and Sheldon Krimsky , who examined the disclosure policy and the panel members’ conflicts of interest, and call for the APA to make changes to increase transparency before the manual’s publication.

Within three days of publication the paper had been viewed over 4000 times, and several major media outlets reported on the authors’ findings and the wider issues they relate to. In the news section of Nature, Heidi Ledford drew attention to the fact that panel members with competing interests are not evenly distributed throughout the panel work groups, commenting that “the committees with the highest number of industrial links are those evaluating conditions for which drugs are the first-line treatment.” She also described the failure of the policy to require its panel members to specify participation in speakers’ bureaus, arrangements “in which a company hires someone to give a presentation about its product.”

The DSM-5 is unpopular for reasons other than its panel members’ competing interests. Peter Aldhous at New Scientist reported on the controversial changes to certain diagnostic categories, such as the mood disorders group, “which proposes including bereaved people in the definition of major depression,” and adds that, according to critics, “definitions of psychiatric illnesses have broadened over successive editions of the manual as a result of pressure from the pharmaceutical industry.” He also discusses the criticism the DSM proposals have attracted from psychologists, who “tend to favour counselling over the drug treatments that dominate modern psychiatry,” and links to an online petition calling for greater involvement from psychologists in the DSM-5. Katie Moisse at ABC News quotes David Elkins, president of the American Psychological Association’s society for humanistic psychology and chairman of the committee responsible for the petition, who is “”dismayed” that seven in 10 DSM-5 task force members have drug company ties.”

Writing for California Watch, Bernice Young highlighted the authors’ findings – that the proportion of the DSM-5 panel with financial conflicts of interest between 2006 and 2011 stands at 69% – and provided a link to the APA’s refutation of the paper’s conclusions. This includes a statement saying that many members have now divested themselves of previously declared competing interests, and that in fact, for 2012, 72% of panel members declare no financial ties to industry.

But what about the authors? Though Cosgrove and Krimsky’s own competing interests are listed on their paper, as per the PLoS Medicine competing interest policy, some journalists still couldn’t help asking questions.  Bernice Yeung of Californa Watch reports: “When asked about their connections to the pharmaceutical or medical device industries, Cosgrove reported having no ties, and Krimsky said he had once given a speech before pharmaceutical industry lawyers for which he was not paid, and he does take “medications every so often.”

Share|
Category: General, Media, Mental Health | Tagged , | 1 Comment

Zero MDR-TB deaths in children in my lifetime?

By Médecins Sans Frontières
Posted: March 23, 2012

Global aspirations

I like this year’s STOP TB partnership World TB Day campaign approach. It is ambitious, but I, for one, have been inspired by the hope that I will see ZERO DRUG-RESISTANT TB DEATHS IN CHILDREN in my lifetime.

As long as there is still no effective vaccine to stop TB, the same nurturing relationship on which children thrive puts them at risk of catching TB from their parents in low and middle-income countries. Last year Médecins Sans Frontières (MSF) released ‘Out of the dark’, a report highlighting some of the bottlenecks in managing TB in children. Most of these diagnostic and treatment challenges are multiplied tenfold or more when dealing with paediatric multidrug-resistant TB (MDR-TB) in the former Soviet Union countries.

Tajikistan is such a country, with a TB incidence of 206 per 100,000 people; the highest in the WHO European region. According to the latest country-wide survey, 17% of new and 61% of retreatment TB cases are resistant to both isoniazid and rifampicin (two of the most potent TB drugs). A high number of children are therefore also likely to be infected with resistant strains. Unfortunately, although children are as affected by MDR-TB as adults, the actual numbers are not easily available even at local level.

As a TB action guy for MSF, I help teams advance from such hopes as “ZERO DR-TB DEATHS IN CHILDREN in my lifetime” to the practicalities of trying to avert just one paediatric DR-TB death this month. The unfortunate story of a child can reflect the challenges faced by many children who tread the same path around the world.

A child’s story

Picture a small child, lying in bed, with her spine arched backwards in pain, her mother confused and worried by her side. She has just been referred to the hospital by her district polyclinic, 60 km away. She is weak, with the symptoms and signs of meningitis.

This child had first been diagnosed with TB a few years earlier, and treated for extrapulmonary disease with first-line treatment for eight months. An outcome of ‘cured’ had been registered. The child was later re-started on the same treatment for another eight months, after which an outcome of ‘cured’ was again registered. A month later, she received antibiotics for a presumed infection, but continued to deteriorate and was finally referred to a paediatric TB hospital.

There is no reported history of contact with TB and we still don’t know whether her family members have been screened. Her diagnosis is presumed as MDR-TB meningitis, and she is then started on treatment for MDR-TB.

Unfortunately, the child dies a week later.

This kind of story and the barriers that children face in getting the right treatment are unfortunately all too common in Tajikistan and many other countries around the world.

Delayed diagnosis

It can take months, or even years before the diagnosis of MDR-TB is considered. The problem is that there often is no proof. Children, especially those under the age of seven, are very unlikely to produce sputum spontaneously. Though methods to induce sputum exist, lack of experience means these are not used. With the poor availability of new molecular techniques and culture with drug susceptibility testing (DST), confirmation of the diagnosis of MDR-TB is often impossible.

At the same time, no protocols exist to guide doctors towards earlier diagnosis in children who are sputum-negative.

Difficulties in treatment

Once the diagnosis is accepted, a prescription is usually written based on the child’s weight. However, there are no internationally recognised guidelines that help determine the most appropriate drugs at the best dosages. Given that there are no pharmacokinetic studies that help us understand how these drugs will work in children, we base the drugs and dosages only on expert opinion and local experience.

For children who weigh 11 kg or less, the medications themselves present further challenges: PAS (para-aminosalicylate sodium) granules, which come in a sachet of 4g, are very difficult to accurately split; Cycloserine administration involves improvising suspensions from capsules; and Levofloxacin has to be split, despite the manufacturer strictly forbidding it.

Politics

We have to fight hard to get such children accepted for MDR-TB treatment. Given the diagnostic dilemmas, and the length and difficulty of taking the treatment, it is understandable why physicians are often reluctant to start treatment.

ZERO PAEDIATRIC DEATHS FROM MDR TB?

TB is a neglected area of infant and child health, and MDR-TB even more so. There are no paved roads to the implementation of paediatric MDR-TB treatment programmes but the trodden path can only be created by walking it.

National TB programmes, with the support of civil society, should be bold and take on the challenge of diagnosing and treating MDR-TB in children. It is only with numbers that pharmaceutical companies will be obliged to produce appropriate drug formulations and define dosages, and that the international community will standardise guidance on treatment of DR-TB in children.

If all this is done, then maybe we really will see ZERO PAEDIATRIC DEATHS FROM MDR TB in our lifetimes.

Bern-Thomas Nyang'wa

Bern-Thomas Nyang’wa, a Malawian public health doctor working as a TB Implementer for Médecins Sans Frontières (MSF). Bern provides clinical and programmatic field support to start or improve MSF drug-resistant tuberculosis programmes in Africa, Latin America, central Asia and the Caucasus.

Kartik Chandaria

Kartik Chandaria, a paediatric doctor interested in international child health. Kartik is currently working on an MSF project in Tajikistan helping to improve the diagnosis and treatment of children with TB with specific reference to drug-resistant disease. He also writes an MSF blog sharing his experiences in Tajikistan.

Related links:

  • MSF’s press release for World TB Day entitled “World TB Day:emerging global crisis” can be be read here.
  • TB&ME is a collaborative blogging project run MSF where patients being treated for multidrug-resistant tuberculosis  in locations all around the world tell their stories. The website can be accessed here.
Share|
Category: General, MSF | Tagged , , | Leave a comment