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mo insidestory
GP Dr Stephanie Fox is working to beat health illiteracy around TB in Vietnam.

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PfEMP1, enables the parasite to stick to cells on the internal lining of blood vessels, preventing the body from eliminating the infected cells. It also helps the parasite to escape destruction by varying the proteins genetic code. As we better understand the systems that control how the PfEMP1 protein is encoded and produced by the parasite, we will be able to produce targeted treatments that would be more effective in preventing malaria, Professor Cowman says. The teams work on the 60 var genes that encode PfEMP1 has also led them to identify other genes important to the parasites development in the liver and the creation of a vaccine that has passed phase 1 clinical trials. Genes also play an important role in the TB work of Dr Greg Fox, a respiratory physician who moved to Vietnam with his GP wife, Stephanie, and their young son, more than three years ago. The Centenary Institute researcher is conducting a study of the genetic susceptibility of Vietnamese TB patients and their families to the disease. His work is an extension of the institutes research that identified a nucleotide polymorphism in the P2X7R gene, which confers increased susceptibility to Vietnamese and other populations. Its known in the medical literature that there are at least 20 genes likely to be associated with TB, although there a lot that have not yet been identified. The main question that we are asking is, what are the risk factors in Vietnamese people that may make them more susceptible? Dr Fox says. A Vietnamese government TB prevalence survey done in 2006 and 2007 discovered that the problem was far greater than had been previously realised, with a rate of 170 per 100,000 cases and the majority not receiving treatment. Dr Fox is undertaking a 17,000-strong contact-tracing program, which aims to enhance detection of TB cases, create a more proactive health system and reduce the spread of the disease. But he has found that the stumbling blocks to dealing with TB are not just clinical, but also cultural. Understanding of the disease is poor and locals are often not keen to report a disease that has traditionally been stigmatised as indicative of poverty and weak morals. Dr Stephanie Fox, who worked for 18 months in a free clinic for rice farmers outside Hanoi, says health illiteracy makes dealing with TB or any other health issue difficult in Vietnam. They dont know how to describe symptoms very well; they dont remember their past history. They cant tell you what medications they have had... partly because of low education levels and partly because of the way the health system works here. There isnt a sense of importance in educating patients, Dr Fox says. For this reason, it is patient education that forms perhaps the most important role for GPs working in the developing world. Back in PNG, Dr Frankish says education is one of the most powerful tools in her doctors bag. Ive actually found the education of the health workers and the village health volunteers the most rewarding, she says.

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New developments in developing world medicine


RESEARCHERS at the University of California, Irvine, and the Pasteur Institute in Paris have created a transgenic mosquito that impairs the development of the malaria parasite by releasing antibodies that render it harmless. The modified Anopheles stephensi mosquito, which is a major source of malaria in India and the Middle East, cannot transmit the disease through its bite. The method can also be applied to other mosquito types that transmit the Plasmodium falciparum parasite. Australias Burnet Institute, in collaboration with biotechnology company Starpharma, is undertaking the preclinical evaluation of dendrimer microbicides for the inhibition of HIV. Women account for 50% of HIV infection globally but are often in no position to negotiate condom use with sexual partners or to abstain from sex altogether. It is hoped that the topical gel, VivaGel, will offer women a chance to protect themselves.

Tackling poverty and lack of education is just as important for GPs in the field as is medical science, writes Jane Lyons.

GPs making a difference


HEROES
ISSUE
WHEN GP Dr Merrilee Frankish visits her patients, she makes sure to take her satellite phone and marking beacon with her. Based in Papua New Guinea for a six-month placement with Australian Doctors International, Dr Frankish regularly finds herself battling high seas and inclement weather on board one of the local banana boats during her patrols to outlying villages. They are very unpredictable and if you happen to be slightly overloaded, its very unsafe, she says. You just have to do it. Theres nothing heroic about it its just a fact of life. Local people do it all the time while they are sick, when they are in labour. She has witnessed many people face such hell and high water to seek health care, like the mother who carried her malaria-infected baby for a day, often over her head, through flood waters to the clinic where Dr Frankish helped save her child. Once a rural doctor, Dr Frankish has seen many desperately sick people on her patrols, which last an average of seven days and can involve up to 250 patients.
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She has helped many but is challenged because treatable conditions such as malaria, tuberculosis and filariasis are often beyond her care. At least one person in the village a day was dying of TB, and its such a treatable condition. Its a condition of poverty. It needs good drug supply and it needs help financially for them to get into the review, and it needs good lab facilities a whole lot of infrastructure things that PNG is struggling with at the moment. She also sees a lot of permanent damage from cerebral malaria. There are no services to help the kids, so they live a pretty miserable life without any shunts. Malaria and TB, as well as HIV, are considered the three main poverty diseases. Their high prevalence is driven by economic and political instability, poor nutrition, pollution, poor sanitation and lack of access to health education, services and medication. In turn, the burden of these diseases in the developing world drives poverty. PNG, with 1.36 million malaria cases in 2009, is a close second to India, whose 1.56 million malaria cases topped the Asia Pacific region (5.25 million) in the same year. The emergence of malaria in Indias urban areas is of particular concern, as rapid

and haphazard expansion of cities, labour migration from rural areas and increasing numbers of urban poor drive prevalence rates. The burden of TB also continues to be felt in the region with about 5.9 million cases reported in 2009. Meanwhile, an estimated 6.1 million people live with HIV, and AIDS-related deaths sit at about 300,000. However, Associate Professor Ben Marais, head of the Sydney Emerging Infections and Biosecurity Institute, says poor HIV data in South-East Asia could mean that the region has a rapidly growing

In countries such as Indonesia, Cambodia and Malaysia, habitat destruction can lead to cross-species infections like the Nipah virus that emerged in Malaysia in 2009, Professor Marais says. It was discovered that [the virus] was in areas where people had recently cleared forests and the pigs came in close contact with fruit bats and the fruit bats infected the pigs with this Nipah virus, which then infected the farmers and they developed a fatal brain disease and huge numbers of them died, he says. It never spread but its not

Education of the health workers and the village health volunteers [is] the most rewarding Dr Merrilee Frankish
problem that is under-appreciated. There are massive barriers to HIV testing, especially in Muslim countries like Indonesia its hardly discussed, Professor Marais says. He says the Asia-Pacific region is also a hotspot for emerging infectious diseases, as well as those that are multi-drug resistant. Environmental changes, human incursions into animal habitats, population displacement, and uncontrolled use of antibiotics and chemicals have set the scene for their emergence. inconceivable that the organism couldnt develop the ability to spread in humans, like SARS. The advance of multi-drugresistant malaria and tuberculosis across the Asia-Pacific region is also seen as a major threat by international development and health agencies, NGOs, researchers and clinicians. Papua New Guinea, Indonesia, Cambodia, the Philippines, Vietnam they all have massive burdens of drug-resistant TB, says Professor Marais,

a paediatrician who specialises in the disease. A recent study also confirmed the existence of artemisinin-resistant Plasmodium falciparum parasites, the most common and lethal form of malaria, in western Thailand. The first case of artemisininresistant malaria was confirmed in Cambodia in 2006, and suspected cases have also been identified in Vietnam and Myanmar. Resistance to earlier generations of anti-malarial medicines such as chloroquine and sulfadoxine/pyrimethamine is already widespread in most endemic countries, and the artemisinin group of drugs, often used with other drugs as artemisinin-based combination therapies (ACTs), is considered the last line of defence. With anti-malarial drug development a slow process, and the mutating parasite deftly playing tag with the clock, Professor Alan Cowman and his research team at the Walter and Eliza Hall Institute of Medical Research in Melbourne have been focusing on what makes the parasite tick genetically, and on developing a vaccine. In January they announced that they had identified a molecule, PfSET10, which controlled the protein responsible for the parasites invisibility cloak against the immune system. The protein,