IDM-NTDs: challenges for health systems (case study: tri-tryps) Julien Potet Médecins Sans Frontières / Doctors without Borders Washington, November 17th 2012
Human African Trypanosomiasis (HAT – sleeping sickness) Visceral Leishmaniasis (VL – kala azar) Chagas Disease (American Trypanosomiasis)
Dx (inc.test for cure) - Sensitive -Specific
Rx - Safe - Effective
Measuring both the efficacy of tools and their adaptedness to health systems in resourcelimited settings
SAFE EFFECTIVE ACCURATE
Dx (inc. test for cure) - Affordable - User-friendly - Rapid - Robust - Equipment-free - Deliverable to those who need them Rx - Affordable - Short-course - Oral - No cold chain - Minimal monitoring - Outpatient
ADAPTED TO HEALTH SYSTEMS IN RLS
Measuring both the efficacy of tools and their adaptedness to health systems in resourcelimited settings SAFE EFFECTIVE ACCURATE
Rx: Safe, effective, oral, short-course Dx: ‘ASSURED’ Toolreadiness
Tooldeficiency ADAPTED TO HEALTH SYSTEMS IN RLS
Available tools for Human African Trypanosomiasis
SAFE EFFECTIVE ACCURATE
CATT Microscopy on CSF
1
NECT
Pentamidine
2 Microscopy on blood and CSF
Melarsoprol (phasing out)
ADAPTED TO HEALTH SYSTEMS IN RLS
Rx
1st-line ttt (stage one) 1st-line ttt (stage two)
1
Screening test
2
Confirmation test and determination of stage
Dx
Post-ttt follow-up
Test for cure
Available tools for Human African Trypanosomiasis
SAFE EFFECTIVE ACCURATE
CATT Microscopy on CSF
1
NECT
1 2013?
Pentamidine
2 Microscopy on blood and CSF
Rapid lateral flow tests
Rapid screening tests open the door to new approaches to case-finding: door-to-door screening by CHWs, passive screening at PHC level
ADAPTED TO HEALTH SYSTEMS IN RLS
Rx
1st-line ttt (stage one) 1st-line ttt (stage two)
1
Screening test
2
Confirmation test and determination of stage
Dx
Post-ttt follow-up
Test for cure
SAFE EFFECTIVE ACCURATE
Available tools for chronic Chagas Disease
Serological lab tests
Benznidazole
Negativization of Ab
Nifurtimox
ADAPTED TO HEALTH SYSTEMS IN RLS
Rx
1st-line antiparasitic ttt
Dx
Diagnostic test
Post-ttt follow-up
Test for cure
SAFE EFFECTIVE ACCURATE
Available tools for chronic Chagas Disease
Serological lab tests
2013? RDTs
A better drug than benznidazole and a test for cure are needed to treat the millions of patients who could be diagnosed with RDTs Benznidazole
Negativization of Ab
Nifurtimox
ADAPTED TO HEALTH SYSTEMS IN RLS
Rx
1st-line antiparasitic ttt
Dx
Diagnostic test
Post-ttt follow-up
Test for cure
Available tools for Visceral Leishmaniasis in South Asia
SAFE EFFECTIVE ACCURATE
L-AmB & combination therapies
Rk39 RDT
Microscopy on aspirates
Conventional AmB
Miltefosine
SSG (phasing out)
ADAPTED TO HEALTH SYSTEMS IN RLS
Rx
Treatment
Dx
Diagnostic test
Post-ttt follow-up
Test for cure/relapse
Available tools for Visceral Leishmaniasis in South Asia
SAFE EFFECTIVE ACCURATE
L-AmB & combination therapies
Rk39 RDT
Microscopy on aspirates
Uptake of best treatments in 2013?
Conventional AmB
Miltefosine
(phasing-out?)
(phasing-out?)
L-AmB is likely to become a pivotal drug for kala azar in South Asia. Efforts for access to L-AmB, including support to generics, will be needed.
ADAPTED TO HEALTH SYSTEMS IN RLS
Rx
Treatment
Dx
Diagnostic test
Post-ttt follow-up
Test for cure/relapse
Conclusion •
So-called ‘tool-deficiency’ was an excuse for inaction. Scale-up available treatments now !
•
Mass active screening through mobile teams can be considered as an opportunity for other outreach public health services.
•
The ‘RDT revolution’ has started for tri-tryps and opens door to taskshifting onto lay workers.
•
More R&D with NCEs is needed to develop treatments that can be easily rolled-out at lowest levels of care.
Thank you !