Comment
CNRI/Science Photo Library
Evidence to implementation continuum for universal health coverage
Published Online January 12, 2015 http://dx.doi.org/10.1016/ S1473-3099(14)71090-4 See Articles page 277
250
Globally, more than 1 billion people are estimated to be infected with soil-transmitted helminthiasis, of whom 300 million end up with severe disabilities.1 Despite the availability of one-dose preventive chemotherapy as global practice to control soil-transmitted helminthiasis, the national prevalence of such infections in 2010 was in the range of 20–50%, and most of the burden was in Asia and sub-Saharan Africa.2 A key challenge to the control and elimination of these diseases is a shortage of broad-spectrum preventive chemotherapies, which is compounded by the low prioritisation of research for new therapeutics for neglected diseases; so much so that, until 2011, only 1% of all therapeutic products developed were for neglected diseases, even though the burden due to these diseases is much higher.3,4 In The Lancet Infectious Diseases, Benjamin Speich and colleagues5 report the results of a four-arm, randomised clinical trial comparing combinations of different anthelmintics in children infected with Trichuris trichiura and other soil-transmitted helminth infections. They assigned 440 infected children to receive one oral dose of albendazole (400 mg) plus ivermectin (200 μg/kg), albendazole (400 mg) plus mebendazole (500 mg), albendazole (400 mg) plus oxantel pamoate (20 mg/ kg), or mebendazole (500 mg) alone. Albendazole plus oxantel pamoate cured a significantly greater proportion of children of T trichiura (74 of 108 children cured [68·5%, 95% CI 59·6–77·4]) and a greater reduction in eggs (99·2%, 98·7–99·6) than the other treatments. This trial emphasises the potential and possibilities of tackling prevalent diseases with available therapeutics, and that health research need not be restricted to finding new technologies and methods, and could focus on making better use of existing knowledge. More research will be needed to achieve the universal health coverage as outlined in WHO’s flagship 2013 world health report.6 Speich and colleagues’ findings5 could contribute to improved treatment outcomes and reduced burden of soil-transmitted helminthiasis in endemic countries and advance the agenda of universal health coverage in these countries. However, serious challenges are posed in the translation of existing
evidence and new research findings into practice. A more effective drug (or effective combination of drugs) is only a part of the solution and does not mean it would enter practice. One side of the challenge is that health coverage with existing interventions remain suboptimal—ie, in 2008, only 16% of targeted school children received regular treatment for soiltransmitted helminthiasis and coverage was variable across the regions.7 The other aspect is that new research findings have an additional challenge of a long lag time from the availability of evidence to programmelevel implementation—ie, Haemophilus influenzae type b vaccines only became available in the national programmes of many low-income and middle-income countries almost 15–20 years after they first became licensed.8,9 The situation becomes even more complex because the lessons from the past are not sufficient for faster adoption of other newer vaccines, and uptake of the rotavirus and pneumococcal vaccines has been only slightly faster.10 Universal health coverage needs increased coverage with health interventions, by translating scientific research from academic discourse to programmatic implementation. Partnerships between groups of institutions and subject experts have emerged to generate evidence, as shown in Speich and colleagues’ study,5 where researchers from four different settings and countries collaborated. Focus on research and the creation of an evidence base at a national level has increased and partnerships and collaborations are evolving. However, such collaborations are yet to become a norm for policy making and implementation processes to effectively bridge the evidence-toimplementation gap, and optimise the benefits of research findings. The global discourse on universal health coverage and sustainable development goals as part of the post-2015 agenda provides an opportunity to create a continuum from evidence to policy formulation to implementation and bridge the gap. The solutions could be innovative, and the settings specific—institutional mechanisms for closer engagement between researchers, policymakers, or programme managers; sustained partnership among www.thelancet.com/infection Vol 15 March 2015
Comment
the key stakeholders (academics, policymakers, donors, research institutions, and international agencies); or setting up policy and implementation units in ministries of health to help the process. The delay in evidence to implementation should be minimised, and if researchers identify a combination therapy that is more effective than currently available standard treatment, then institutional mechanisms should already be in place to initiate the next natural step for further assessment, feeding into the policy process and programme implementation. The advancement towards universal health coverage needs the creation of an evidence-to-implementation continuum by development of sustained partnerships and institutional mechanisms at a national and global level. All countries should work together in this direction to ensure that research findings are used in the shortest possible time to improve health outcomes.
© 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
*Chandrakant Lahariya, Nata Menabde
9
WHO Country Office for India, New Delhi 110 011, India (CL, NM) [email protected] We are staff members of WHO. We are responsible for the views expressed in this Comment, which do not necessarily represent the decisions, policy, or views of WHO. We declare no competing interests.
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Hotez PJ, Fenwick A, Savioli L, Molyneux DH. Rescuing the bottom billion through control of neglected tropical diseases. Lancet 2009; 373: 1570–75. Pullan RL, Smith JL, Jasrasaria R, Brooker SJ. Global numbers of infection and disease burden of soil transmitted helminth infections in 2010. Parasit Vectors 2014; 7: 37. Trouiller P, Olliaro P, Torreele E, Orbinski J, Laing R, Ford N. Drug development for neglected diseases: a deficient market and a public-health policy failure. Lancet 2002; 359: 2188–94. Pedrique B, Strub-Wourgaft N, Some C, et al. The drug and vaccine landscape for neglected diseases (2000–11): a systematic assessment. Lancet Glob Health 2013; 1: e371–79. Speich B, Said MA, Shaali MA, et al. Efficacy and safety of albendazole plus ivermectin, albendazole plus mebendazole, albendazole plus oxantel pamoate, and mebendazole alone against Trichuris trichiura and concomitant soil-transmitted helminth infections: a four-arm, randomised controlled trial. Lancet Infect Dis 2015; published online Jan 12. http://dx. doi.org/10.1016/S1473-3099(14)71050-3. WHO. The world health report 2013: research for universal health coverage. Geneva: World Health Organization, 2013. http://who.int/whr/2013/report (accessed Dec 14, 2014). WHO. First WHO report on neglected tropical diseases: working to overcome the global impact of neglected tropical diseases. Geneva: World Health Organization, 2010. http://who.int/neglected_diseases/2010report/ en/ (accessed Dec 14, 2014). Shearer JC, Stack ML, Richmond MR, et al. Accelerating policy decisions to adopt Haemophilus influenzae type b vaccine: a global, multivariable analysis. PLoS Med 2010; 7: e1000249. Hajjeh RA, Privor-Dumm L, Edmond K, et al. Supporting new vaccine introduction decisions: lessons learned from the Hib initiative experience. Vaccine 2010; 28: 7123–29. Anon. Vaccine Information Management System report on global introduction. September, 2014. http://www.jhsph.edu/research/centersand-institutes/ivac/vims/ (accessed Dec 14, 2014).
An addition to treatment options for avian influenza A H5N1? Despite rare human-to-human transmission,1 highly pathogenic avian influenza A H5N1 viruses are a major public health concern because sporadic infections associated with severe morbidity and mortality continue to occur.2 In The Lancet Infectious Diseases, Céline Bal and colleagues3 report the results from their randomised, double-blind, placebo-controlled, phase 1 study in 16 healthy Asian male volunteers, assessing the safety and pharmacokinetics of one or five daily intravenous doses of 0·85 U/kg of equine F(ab’)2 fragments raised against an influenza A H5N1 virus (FBF001). Although antiviral drugs are useful for treatment of influenza, they must be given early in the course of disease. Additionally, the emergence of drugresistant strains of avian influenza A H5N1 viruses has been reported.4–6 A 2008 review7 of uncontrolled clinical experience showed that patients who had not www.thelancet.com/infection Vol 15 March 2015
received antiviral treatment for clade 1 and 2 H5N1 infections had 77% and 97% mortality, respectively. Although oseltamivir treatment increased survival, mortality was still 45% and 59%, respectively, in patients with clade 1 and 2 H5N1 infections treated with this drug,7 which underscores the important need for additional therapeutic strategies for the treatment of avian influenza A H5N1. Passive immunotherapy could be an effective alternative or adjunct to antiviral therapy. Some critically ill patients infected with an H5N1 virus have reportedly recovered after being given convalescent human plasma with neutralising anti-H5N1 activity.8,9 Polyclonal immunoglobulins from hyperimmune animal or human serum samples have been successfully used in the management of other clinical emergencies, including snakebite envenomation, severe poisoning,
Published Online February 5, 2015 http://dx.doi.org/10.1016/ S1473-3099(15)70019-8 This online publication has been corrected. The corrected version first appeared at thelancet.com/infection on March 23, 2014 See Articles page 285
251
CNRI/Science Photo Library
Evidence to implementation continuum for universal health coverage
Published Online January 12, 2015 http://dx.doi.org/10.1016/ S1473-3099(14)71090-4 See Articles page 277
250
Globally, more than 1 billion people are estimated to be infected with soil-transmitted helminthiasis, of whom 300 million end up with severe disabilities.1 Despite the availability of one-dose preventive chemotherapy as global practice to control soil-transmitted helminthiasis, the national prevalence of such infections in 2010 was in the range of 20–50%, and most of the burden was in Asia and sub-Saharan Africa.2 A key challenge to the control and elimination of these diseases is a shortage of broad-spectrum preventive chemotherapies, which is compounded by the low prioritisation of research for new therapeutics for neglected diseases; so much so that, until 2011, only 1% of all therapeutic products developed were for neglected diseases, even though the burden due to these diseases is much higher.3,4 In The Lancet Infectious Diseases, Benjamin Speich and colleagues5 report the results of a four-arm, randomised clinical trial comparing combinations of different anthelmintics in children infected with Trichuris trichiura and other soil-transmitted helminth infections. They assigned 440 infected children to receive one oral dose of albendazole (400 mg) plus ivermectin (200 μg/kg), albendazole (400 mg) plus mebendazole (500 mg), albendazole (400 mg) plus oxantel pamoate (20 mg/ kg), or mebendazole (500 mg) alone. Albendazole plus oxantel pamoate cured a significantly greater proportion of children of T trichiura (74 of 108 children cured [68·5%, 95% CI 59·6–77·4]) and a greater reduction in eggs (99·2%, 98·7–99·6) than the other treatments. This trial emphasises the potential and possibilities of tackling prevalent diseases with available therapeutics, and that health research need not be restricted to finding new technologies and methods, and could focus on making better use of existing knowledge. More research will be needed to achieve the universal health coverage as outlined in WHO’s flagship 2013 world health report.6 Speich and colleagues’ findings5 could contribute to improved treatment outcomes and reduced burden of soil-transmitted helminthiasis in endemic countries and advance the agenda of universal health coverage in these countries. However, serious challenges are posed in the translation of existing
evidence and new research findings into practice. A more effective drug (or effective combination of drugs) is only a part of the solution and does not mean it would enter practice. One side of the challenge is that health coverage with existing interventions remain suboptimal—ie, in 2008, only 16% of targeted school children received regular treatment for soiltransmitted helminthiasis and coverage was variable across the regions.7 The other aspect is that new research findings have an additional challenge of a long lag time from the availability of evidence to programmelevel implementation—ie, Haemophilus influenzae type b vaccines only became available in the national programmes of many low-income and middle-income countries almost 15–20 years after they first became licensed.8,9 The situation becomes even more complex because the lessons from the past are not sufficient for faster adoption of other newer vaccines, and uptake of the rotavirus and pneumococcal vaccines has been only slightly faster.10 Universal health coverage needs increased coverage with health interventions, by translating scientific research from academic discourse to programmatic implementation. Partnerships between groups of institutions and subject experts have emerged to generate evidence, as shown in Speich and colleagues’ study,5 where researchers from four different settings and countries collaborated. Focus on research and the creation of an evidence base at a national level has increased and partnerships and collaborations are evolving. However, such collaborations are yet to become a norm for policy making and implementation processes to effectively bridge the evidence-toimplementation gap, and optimise the benefits of research findings. The global discourse on universal health coverage and sustainable development goals as part of the post-2015 agenda provides an opportunity to create a continuum from evidence to policy formulation to implementation and bridge the gap. The solutions could be innovative, and the settings specific—institutional mechanisms for closer engagement between researchers, policymakers, or programme managers; sustained partnership among www.thelancet.com/infection Vol 15 March 2015
Comment
the key stakeholders (academics, policymakers, donors, research institutions, and international agencies); or setting up policy and implementation units in ministries of health to help the process. The delay in evidence to implementation should be minimised, and if researchers identify a combination therapy that is more effective than currently available standard treatment, then institutional mechanisms should already be in place to initiate the next natural step for further assessment, feeding into the policy process and programme implementation. The advancement towards universal health coverage needs the creation of an evidence-to-implementation continuum by development of sustained partnerships and institutional mechanisms at a national and global level. All countries should work together in this direction to ensure that research findings are used in the shortest possible time to improve health outcomes.
© 2014. World Health Organization. Published by Elsevier Ltd/Inc/BV. All rights reserved.
*Chandrakant Lahariya, Nata Menabde
9
WHO Country Office for India, New Delhi 110 011, India (CL, NM) [email protected] We are staff members of WHO. We are responsible for the views expressed in this Comment, which do not necessarily represent the decisions, policy, or views of WHO. We declare no competing interests.
1 2
3
4
5
6
7
8
10
Hotez PJ, Fenwick A, Savioli L, Molyneux DH. Rescuing the bottom billion through control of neglected tropical diseases. Lancet 2009; 373: 1570–75. Pullan RL, Smith JL, Jasrasaria R, Brooker SJ. Global numbers of infection and disease burden of soil transmitted helminth infections in 2010. Parasit Vectors 2014; 7: 37. Trouiller P, Olliaro P, Torreele E, Orbinski J, Laing R, Ford N. Drug development for neglected diseases: a deficient market and a public-health policy failure. Lancet 2002; 359: 2188–94. Pedrique B, Strub-Wourgaft N, Some C, et al. The drug and vaccine landscape for neglected diseases (2000–11): a systematic assessment. Lancet Glob Health 2013; 1: e371–79. Speich B, Said MA, Shaali MA, et al. Efficacy and safety of albendazole plus ivermectin, albendazole plus mebendazole, albendazole plus oxantel pamoate, and mebendazole alone against Trichuris trichiura and concomitant soil-transmitted helminth infections: a four-arm, randomised controlled trial. Lancet Infect Dis 2015; published online Jan 12. http://dx. doi.org/10.1016/S1473-3099(14)71050-3. WHO. The world health report 2013: research for universal health coverage. Geneva: World Health Organization, 2013. http://who.int/whr/2013/report (accessed Dec 14, 2014). WHO. First WHO report on neglected tropical diseases: working to overcome the global impact of neglected tropical diseases. Geneva: World Health Organization, 2010. http://who.int/neglected_diseases/2010report/ en/ (accessed Dec 14, 2014). Shearer JC, Stack ML, Richmond MR, et al. Accelerating policy decisions to adopt Haemophilus influenzae type b vaccine: a global, multivariable analysis. PLoS Med 2010; 7: e1000249. Hajjeh RA, Privor-Dumm L, Edmond K, et al. Supporting new vaccine introduction decisions: lessons learned from the Hib initiative experience. Vaccine 2010; 28: 7123–29. Anon. Vaccine Information Management System report on global introduction. September, 2014. http://www.jhsph.edu/research/centersand-institutes/ivac/vims/ (accessed Dec 14, 2014).
An addition to treatment options for avian influenza A H5N1? Despite rare human-to-human transmission,1 highly pathogenic avian influenza A H5N1 viruses are a major public health concern because sporadic infections associated with severe morbidity and mortality continue to occur.2 In The Lancet Infectious Diseases, Céline Bal and colleagues3 report the results from their randomised, double-blind, placebo-controlled, phase 1 study in 16 healthy Asian male volunteers, assessing the safety and pharmacokinetics of one or five daily intravenous doses of 0·85 U/kg of equine F(ab’)2 fragments raised against an influenza A H5N1 virus (FBF001). Although antiviral drugs are useful for treatment of influenza, they must be given early in the course of disease. Additionally, the emergence of drugresistant strains of avian influenza A H5N1 viruses has been reported.4–6 A 2008 review7 of uncontrolled clinical experience showed that patients who had not www.thelancet.com/infection Vol 15 March 2015
received antiviral treatment for clade 1 and 2 H5N1 infections had 77% and 97% mortality, respectively. Although oseltamivir treatment increased survival, mortality was still 45% and 59%, respectively, in patients with clade 1 and 2 H5N1 infections treated with this drug,7 which underscores the important need for additional therapeutic strategies for the treatment of avian influenza A H5N1. Passive immunotherapy could be an effective alternative or adjunct to antiviral therapy. Some critically ill patients infected with an H5N1 virus have reportedly recovered after being given convalescent human plasma with neutralising anti-H5N1 activity.8,9 Polyclonal immunoglobulins from hyperimmune animal or human serum samples have been successfully used in the management of other clinical emergencies, including snakebite envenomation, severe poisoning,
Published Online February 5, 2015 http://dx.doi.org/10.1016/ S1473-3099(15)70019-8 This online publication has been corrected. The corrected version first appeared at thelancet.com/infection on March 23, 2014 See Articles page 285
251
