Designing Strategies for Neglected Disease
Research:
What Innovations Do We Need?
Julia Walsh MD MSc
UCB School of Public Health
jwalsh@berkeley.edu
What Innovations Do We Need?
Health Interventions
Products & Services that promote health
How do we promote R&D for New
Interventions for the Major Diseases of
Poor Countries?
Types of Interventions 1
Health care dependent
• Drugs
• Diagnostics
• Vaccines
• Others (e.g. male circumcision, behavior
change)
Types of Interventions 2
Health care Independent
• Environment
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Water, Sanitation
Air pollution - Indoor & Outdoor
Safety
Vector Control
• Behavior Change
• Others?
Types of Health Interventions 3
Mechanisms for Health Care Independent
Interventions
– Budget allocation
– Tax incentives/Disincentives
– Subsidies
– Regulations/Laws
– Information, Education, Communication
– Research
Myriad Possible Interventions:
How set Priorities
• Goal of the health system - maximize health
of the population
• Limits - scarce resources
• Decisions and choices necessary
• Best choice - maximize health with fewest
resources
• Therefore - must compare costs of strategies
with outcomes
Cost-Effectiveness Analysis
Examples of Cost-Effectiveness
Analysis
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Population 1Million people
$10Million available for health investment
Two Research Programs A & B both cost $10M
Program A will potentially avert 10,000 deaths or
$1,000/death averted ($10M/1000deaths)
• Program B 25,000 deaths or $400/death
averted ($10M/25,000)
• Which is More Cost-effective?
The Amount of Health $1Million Will
Buy - Reducing Under-Five Mortality
Service or
Intervention
Cost/
DALY
DALYs per
$1M spent
Neonatal care Age
10-400
2.5– 100,000
2-20
40-250
50 – 500,000
4 – 24,000
8-20
50 – 100,000
<28days
Vaccines
Expand coverage
Add new vaccines
H.flu, Hep B, rotavirus
Improved Rx Malaria
SubSaharan Africa
The Amount of Health $1Million Will
Buy – HIV Prevention & Treatment
Service or
Intervention
Cost/
DALY
DALYs per $1M
spent
Prevention Mother to
Child Transmission
50-200
5 – 20,000
STI Treatment *
10-100
10 – 100,000
ARV Treatment
10-500
2 – 100,000
Source: DCP2.org
Male Circumcision
Source: Fieno J; 2008 AIDS Care
0-7.50 10-40,000
The Amount of Health $1Million Will
Buy – Noncommunicable Disease
Service or Intervention Cost/
DALY
Tobacco Tax
3-50
DALYs per
US$1M spent
Generic Rx Acute
Myocardial Infarction
+ Streptokinase
Bypass Surgery
40-100,000
10-25
20-330,000
+600-750 +1,300-1,600
Cervical CA Dx & Rx
>25,000 <400
15-50
20-60,000
Basic Surgical Ward
70-250
4-15,000
What makes an intervention costeffective?
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Averts large number of deaths +/or DALYs
Highly Efficacious
Very Inexpensive
Health care - Easy to use & distribute
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One or small # doses
Heat stable
No electricity, technology, maintenance, pure water
Use by unskilled health workers
Lightweight, easily carried to homes or rural clinics
Feasible in poor countries (?regulations against use of trans
fats?)
• More cost-effective than the next best intervention for
that condition
From Yach et al., The Global Burden of Chronic Diseases, 291 JAMA 2616 (2004).
For what causes of death are better
interventions needed in LDC:
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Respiratory Infections
HIV
Perinatal Conditions
Diarrheal Diseases
TB
Childhood Diseases ????
Malaria
Maternal Conditions
Health Care Interventions
Infectious Diseases & childhood illness
control usually most cost-effective
Biotechnologies
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Diagnostic tests
Vaccines
Treatments
Others – e.g., preventive measures
• Microbicides
• Female condoms
Priorities for Development of New
Diagnostics
Gates Process:
Health impact
Market potential & demand
Willingness to Pay – Clients, donors,
governments
Gates Priorities for New Diagnostics
Health Impact - No DALYs!
• Tuberculosis
• Sexually transmitted Infections in women
– In Comercial Sex Workers: Gonorrhea & Chlamydia
– In antenatal care: Syphilis
• Malaria in Children
• Acute Lower Repiratory Tract Infections in Children
– Bacterial etiology & needing antibiotics
– Severe disease requiring hospitalization
• HIV in infants
• Stunting in children: Enteroaggregative E.coli, Giardia
lamblia, Cryptosporidium parvum
Source: Nature 2006; Determining the Global Health Impact of Improved
Diagnostic Technologies for the Developing World
Vaccines for the 21st Century:
A Tool for DecisionMaking
Institute of Medicine 2000
US Based
Method:
Cost-effectiveness assessment of
health benefits vs. costs of care
Assumption of availability within
20 years
Results IOM Vaccines for 21st
Century
Level I Most Favorable –Saves $ & QALYs
• Cytomegalovirus administered to 12 year olds
• Influenza virus vaccine for the general population (once per
person every 5 year or 20% of the population per year)
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Insulin-dependent diabetes mellitus therapeutic vaccine
Multiples sclerosis therapeutic vaccine
Rheumatoid arthritis therapeutic vaccine
Group B Strep vaccine for pregnant women and high risk
Streptococcus pneumonia vaccine for infants and elderly
Health Impact of Tropical Diseases
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trypanosomiasis,
Chagas disease,
schistosomiasis,
leishmaniasis,
lymphatic filariasis,
onchocerciasis,
intestinal nematode infections,
Japanese encephalitis,
dengue, and
leprosy
TOTAL 177,000 deaths worldwide in 2002, mostly in sub-Saharan
Africa,
20 million DALYs, or 1.3% of the global burden of disease and injuries.
Conclusion
Many new health innovations will save lives
and DALYs/QALYs
Work on the big problems