Image credit: National Archives of Records Administration

In December, PLoS Medicine published a paper by An Pan and colleagues, which focused on shift work and type 2 diabetes. The authors found that working night shifts on rotation over extended periods of time modestly increased the risk of type 2 diabetes and that this appeared to be partly mediated by body weight. The study has been viewed over 8000 times since publication and has attracted a great deal of press attention. Since the study was US-based, it was no surprise that much of this coverage came from American media sites such as USA Today, the Boston Globe and the Huffington Post (who reposted a report by Amanda Gardner at Health.com). Elsewhere in the world, however, the findings also made a significant impact, with the UK’s Daily Mail, Canada’s CBC News and the German magazine Focus all covering the paper.

Many media outlets opted for factual headlines reflecting the study’s findings, such as CNN’s ‘Night shift work may raise diabetes risk’ (also reposted from Health.com), and ‘Irregular Night-Shift Work Associated With Higher Diabetes Risk’ from the Wall Street Journal. The LA Times, however, chose the punchier “Shift work: Good for your pocketbook, bad for your health.” In her piece, reporter Melissa Healy explains that, although “these days, it’s just good to have a job”, if your job involves shift work your physical wellbeing could suffer. Alice Park at TIME also mentions shift work in light of the current economic climate, commenting that “the night shift isn’t usually anyone’s first choice, but in some professions — and in this economy — it can’t be avoided.” In a Perspective article published in PLoS Medicine on the same day as the research paper, Mika Kivimäki, David Batty and Christer Hublin state that “We are increasingly residing in a “24/7” society; thus, the option to eradicate shift working is not realistic.”

Just as the media storm generated around the paper by Pan and colleagues was dying down, at the end of December PLoS Medicine published an editorial related to the topic of how shift work affects health. The PLoS Medicine Editors discussed the link between shift work, diet and type 2 diabetes, arguing that unhealthy eating should be considered a new form of occupational hazard. Their article made international headlines, with some news sites such as TIME, the LA Times and the Huffington Post following up their stories on the Pan paper with coverage of the editorial. PLoS Medicine Chief Editor Dr Ginny Barbour, the lead author of the editorial, received multiple interview requests and is quoted extensively in pieces by ABC News, Toronto Star and The Checkup. A brief podcast reporting on the editorial is available on the Scientific American website.

Hopefully the media coverage that the interlinked papers received will have broadened public awareness that shift work can harm your health. The Checkup asks its readers: ‘Have you ever considered that the hours you work at your job can actually make you sick?” However, as the PLoS Medicine Editors outline, the findings of this study relate to a wider issue. Though we must all take responsibility for what we eat, the onus does not rest solely with the individual: “governments need to legislate to improve the habits of consumers and take specific steps to ensure that it is easier and cheaper to eat healthily than not. Could workplaces, specifically those who employ shift workers, lead the way (or be required to lead the way) in such a drive?”

Image Credit: Jon Rawlinson

This week, PLoS Medicine published four new articles, including a Perspective piece on a new Clostridium difficile Research Article.

A set of cross-sectional surveys by Robert Stewart and colleagues carried out in Cuba, Dominican Republic, Peru, Mexico, Venezuela, Puerto Rico, China, and India reveal the prevalence and between-country variation in mild cognitive impairment at a population level.

To learn morn about the Clostridium difficile infection paper by Sarah Walker and colleagues (and the related Perspective by Stephan Harbath and Matthew Samore) please view our latest Media Release blog post.

Edward Mills and colleagues argue that a more balanced approach to gender is needed so that both men and women are involved in HIV treatment and prevention.

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.

Image Credit: CDC

Contrary to current convention by which infection with the organism Clostridium difficile is regarded as an infection that is acquired by contact with symptomatic patients known to be infected with C. difficile, these may account for only a minority of new cases of the infection. These findings are important as they indicate that C. difficile infection, which can be fatal especially in older people, may not be effectively controlled by current hospital infection strategies.

In a study led by Professor Tim Peto of the John Radcliffe Hospital in Oxford, UK, and published in this week’s PLoS Medicine, almost 30 000 stool samples from nearly 15 000 patients were tested for C. difficile, with 4.4% (n=1282) found to be positive by specialised laboratory tests  (enzyme immunoassay and culture). With further tests (genotyping), the researchers identified 69 types of C. difficile and when linking this information to the clinical situation found that the majority of cases of C. difficile infection were not linked to known cases (66%) and only 23% shared the same type of C. difficile as a ward patient known to be infected.

The authors say: “In this endemic setting with well-implemented infection control measures, up to three-quarters of new [C.difficile infections] are not easily explained by conventional assumptions of ward-based transmission from symptomatic patients and so may not be targeted by current interventions.”

The authors conclude: “A better understanding of other routes of transmission and reservoirs is needed to determine what other types of control interventions are required to reduce the spread of C. difficile.”

However, in an accompanying Perspective article, Stephan Harbarth from the University of Geneva Hospitals and Medical School in Switzerland and Matthew Samore from the University of Utah School of Medicine in Salt Lake City, USA (uninvolved in the research study) note that given the methods used in the study, the research cannot definitively answer some important clinical questions, such as the amount of benefit accrued by blocking transmission from symptomatic C. difficile infection cases and the proportion of the C. difficile infections that are attributed to within-hospital transmission that actually represent already-infected individuals who come into the hospital. Harbarth and Samore say: “The study by Sarah Walker and colleagues cannot provide definitive answers to these questions because it has significant limitations with respect to both issues.” These authors recommend that more studies be conducted to fully answer these questions.

Please contact plosmedicine@plos.org if you would like to get in touch with the authors of this paper.

This media release was distributed to our press list under embargo before the article was published.

Four acts in 90 minutes. A tight script that does not leave time for clapping. Nine men in dark suits and one woman on stage. That one woman is Margaret Chan, Director General of WHO. One of the men is Bill Gates. The stage is Uniting to Combat Neglected Tropical Diseases (NTDs), an event convened by WHO and the Bill and Melinda Gates Foundation.

The first act: ‘Setting the stage’. This is the most comprehensive, coordinated action ever to address NTDs. “I have never seen so many competitors working together”, said Margaret Chan, referring mainly to the 13 large pharmaceutical companies present, but possibly also referring to the bilateral and multilateral donors. The prospect of elimination appeals to many.

An animation lays out what it is we are combating; ten circles, representing ten ancient parasitic infections which affect over 1 billion of the poorest and most neglected people. The ten circles move into two groups; seven versus three. For the seven – Guinea worm (eradication), lymphatic filariasis (elimination), leprosy (elimination), trachoma (elimination), schistosomiasis (control), soil-transmitted helminthes (control) and river blindness (control) – the battle can be geared up relatively easily. The tools and strategies already exist and for most of the seven these are simple and among the most cost-effective interventions in public health: periodic mass drug administration of cheap tablets and improving water and sanitation. But the other three, visceral leishmaniasis, human African trypanosomiasis (sleeping sickness) and Chagas disease, require new tools and strategies to make elimination/control possible.

In Médecins Sans Frontières’ medical programmes we see the need for these new tools and strategies every day: for rapid diagnostic tests, oral effective treatments and support to heavily under-resourced national control programmes. For sleeping sickness in particular, endemic countries are almost all failed and insecure states. ‘Sleeping sickness lives in the last village’, as a member of a national control programme in central Africa once said to my colleague. The national sleeping sickness programmes in most central African countries have few staff members, and worse, they can work only in parts of the year when there is money for fuel, transport and salaries. For sleeping sickness to be eliminated, enhanced research and development (R&D) and programmatic support along with access to current drugs are necessary. The actors at the London conference were offering only the latter. Now is the time to address the reality. It is urgent.

Act two featured making progress with existing tools, while act three ushered in innovation and new tools. ‘There is a today and there is a tomorrow’, said a CEO of a large pharmaceutical company. Today has a huge unmet need. Tomorrow is where R&D comes in. And, as another CEO said, ‘here is where the secrets are’. Indeed. The commitment made at the event by 13 large pharmaceutical companies to share and open up data and compound libraries is welcome news. But more attention went to announcements on branded drug donations; several existing donations will be increased or extended until 2020. Noble and useful actions – that should be seen in perspective. For example, MSD has, since 1981, annual sales of ivermectin for veterinary use of about $1 billion. Perhaps it is only fair to make it free for humans? For a few drugs, generic production would be better. No word on that in the script, though it was generic production (only) that made sustained and dramatic scale-up of access to antiretroviral treatment for HIV possible.

The last act: ‘Realizing the 2020 goals’. The story here was how to connect drugs and people, a simplified version of health systems strengthening; a score card needed to measure progress and impact; how to reach those most in need; the need to engage countries and coordination by ministries of health; creating a critical mass and tipping point. More questions than answers, but fair enough, this is just the start.

So, here is where we are. A common call to action and a road map to elimination and control of ten NTDs by 2020. History in the making, I hope. And I hope that the remaining essential steps will be executed with the same enthusiasm: include companies who develop diagnostic tools, get the political commitment of endemic countries, steer and heavily invest in national NTD control programmes, establish strong leadership of the initiative, measure progress and impact, build capacity to sustain the successes, and keep focus.

Rachel ter Horst, MSF

Rachel ter Horst is a Dutch physician who has worked for Médecins sans Frontières since 2003. She is currently serving as a medical advocacy advisor, based in Amsterdam.

Image Credit: James Gathany, Centers for Disease Control and Prevention

Author: Renata Santillan

The current issue of PLoS Neglected Tropical Diseases presents a new collection of articles on the use of genetically modified (GM) insects for controlling some of the most widespread infectious diseases. Articles from across the PLoS journals describe the technological advances these tools represent, the regulatory framework, and the societal dialogue that is necessary for their wide-scale application for disease control.

Diseases transmitted by insects form a huge burden on human and animal populations. Insect control has historically been one of many strategies for control of diseases such as dengue, malaria, and sleeping sickness. The debate on whether GM insects could be used for disease control began as soon as transgenic insects were first produced in the 1980’s. Since then several experimental releases of GM insects have taken place. These trials show promise for limiting the spread of many vector-borne diseases (most notably Dengue fever). Articles in this collection showcase different aspects of this new technology including development, environmental impact, and regulation. Public discussion of the science and application of GM insects is necessary as new developments bring potential wide releases closer to a reality.

In an Editorial, Drs. Michael J Lehane (Liverpool School of Tropical Medicine) and Serap Aksoy (Yale School of Public Health) state that GM insects “may provide great promise for new means of controlling diseases with a devastating impact on people’s lives. If so, then public acceptance is likely to be a key issue in their implementation.” With many countries considering open field trials of GM insects, a Viewpoint by Guy Reeves et al. examines the regulation process of the first 3 countries that have had field trials of GM insects. Commentary by John Mumford highlights that both national and international regulations are required due to factors regarding each country’s individual environmental risk to GM insects.  In a commentary from an industry perspective, Luke Alphey and Camilla Beech argue that “the agencies tasked to regulate GM insects have appropriately taken a cautious, thorough approach that allows progress towards realisation of the substantial benefits GM insect technology could potentially provide, while rigorously protecting the public and environment.”

The articles in this collection highlight many different points of view surrounding the research into GM insects. As the recent history of GM insect development demonstrates, public discussion is necessary as scientists continue to research GM insect technologies to control some of the world’s most devastating diseases.

Image Credit: Montage created by Pat Margis and Clare Weaver, PLoS

Four new articles published in PLoS Medicine today, starting with the monthly editorial.

In the January editorial, the PLoS Medicine editors review the journal’s contents in light of its mission and scope, and call for papers on specific topics.

In a cross-sectional analysis of WHO-AIMS data, Ryan McBain and colleagues investigate the associations between health system components and access to psychotropic drugs in 63 low- and middle-income countries.

In a before and after study, Johanna Westbrook and colleagues evaluate the change in prescribing error rates after the introduction of two commercial electronic prescribing systems in two Australian hospitals.

Teun Bousema and colleagues argue that targeting malaria “hotspots” is a highly efficient way to reduce malaria transmission at all levels of transmission intensity.

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.

Source: Wikimedia Commons, Janice Carr (CDC)

With 8.8 million new cases and 1.4 million deaths worldwide in 2010, TB remains an unacceptable burden of human suffering and loss, overwhelmingly borne by poor and vulnerable people living in low or middle income countries. The tools available for TB control are old, lack effectiveness, and are not readily accessible in many settings. In most highly affected countries the diagnosis of pulmonary TB still relies on sputum microscopy, a century old technology that only detects half of cases. Current treatment of tuberculosis, which was developed in the 1970s, demands close supervision, is difficult to use in people living with HIV, and cannot be used in patients infected with multi-drug resistant strains. The only TB vaccine (BCG), first used in 1922, is variable in its efficacy to protect adults from pulmonary TB. More effective and widely accessible tools are needed to make a greater impact on the global TB burden in order to reach the goal of eliminating TB by 2050, defined as less than one case per million population in the Global Plan to Stop TB 2011-2015.

Fortunately there is hope, thanks to notable progress in the development of new tools for TB control over the last decade. In diagnostics the recent introduction of Xpert MTB/RIF – a DNA-based molecular assay that can diagnose TB and the presence of rifampicin-resistance in 100 minutes – is a major breakthrough. For treatment, nine new drugs are currently in phases I to III clinical trials. For vaccines, four novel candidates are presently in phase II clinical trials and two have recently entered phase IIb trials.

These advance alone are, however, insufficient. A recent mathematical model suggests that to effectively control and eliminate TB by 2050 a combined and synergistic implementation of several novel strategies is needed. These strategies include improved diagnosis of drug-susceptible and drug-resistant TB, shorter treatment of overt TB cases, scaled-up treatment of latently infected persons, and mass vaccination campaigns using a more effective vaccine. This could be obtained only through massive synergistic efforts in all areas of research and development.

“What research is required to Stop TB?”

Research across the full continuum – from basic science for discovery, to development of new diagnostics, drugs and vaccines, and their optimal uptake for better TB control – is necessary to enable the revolution in TB control technology needed to achieve the goal of TB elimination by 2050. For this, we need to improve our understanding of the basic science that will fuel the development of new diagnostics, drugs and vaccines, and we need to ensure that the newly developed tools are acceptable and affordable to be effectively used where they are needed. To achieve these objectives all aspects of research must be properly addressed and funded in a harmonized way.

To support this, the TB Research Movement engaged in the development of a coherent and comprehensive roadmap for global TB research towards TB elimination that encompasses all aspects of research. This roadmap was developed through a coordinated process including a multidisciplinary Delphi consultation, a series of systematic reviews and an open web-based survey. It involved a multidisciplinary group of more than 150 scientists, TB experts, implementers, funders and community advocates from around the world. Critical research priorities were identified in the areas of epidemiology, fundamental research, research and development of new diagnostics, drugs and vaccines, and operational and public health research.  More than a simple research agenda, the International Roadmap for Tuberculosis Research outlines critical and priority areas for future scientific investment, with the aim of increasing and harmonizing funding across the research spectrum.

This roadmap provides an architecture on which transformational and outcome-oriented research areas can be constructed. It is intended to promote organization of cross-disciplinary teams and attract all research-related constituents to the field, especially those in BRICS countries, who have a vital role to play. It provides a common platform for donors, researchers, implementers, and advocates by identifying the most important research questions.

The roadmap appears at a critical moment, when funding for TB research has flattened for the first time since 2005.  A report released recently by the Treatment Action Group and the Stop TB Partnership found that in 2010 just US$ 617.1 million was spent on TB research and development globally, down 0.3% compared to 2009 funding levels – while the Global Plan to Stop TB 2011-2015 calls for at least US$ 9.8 billion in TB research funds over the plan’s five-year period. It is hoped that the research roadmap will serve as a framework for concrete actions to synergize TB research efforts globally and catalyse the development of new research collaborations to address difficult and as yet unanswered questions in TB.

Dr. Christian Lienhardt is Senior Scientific Advisor at the Stop TB Partnership and WHO and responsible for the TB Research Movement. He has been coordinating the development and production of the International Roadmap for Tuberculosis Research that is presented here.

Related Links:

• The International Roadmap for Tuberculosis Research and other publications from the StopTB Partnership can be downloaded here

• A related PLoS Medicine article describing the TB Research Movement can be accessed here

Image Credit: Sustainable sanitation

This week PLoS Medicine publishes three new articles, including a follow-up to a previously published manuscript.

A systematic review and meta-analysis by Kathrin Ziegelbauer and colleagues finds that sanitation is associated with a reduced risk of transmission of helminthiases to humans.

Learn more about the findings by Nayu Ikeda and colleagues on adult mortality in Japan by reading our most recent Media Release post.

Xavier Bosch and colleagues expand upon a recent analysis by Simon Stern and Trudo Lemmens in PLoS Medicine and outline areas in which authors participating in medical ghostwriting could be held legally liable.

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.

Image Credit: Alisha Vargas

The life expectancy of a person born in Japan is among the highest in the world (82.9 years) yet tobacco smoking and high blood pressure are still the major risk factors for death among adults in Japan, emphasizing the need to reduce tobacco smoking and to improve ongoing programs designed to help people manage multiple cardiovascular risk factors, including high blood pressure, according to a study published in this week’s PLoS Medicine.

In an analysis of available data led by Nayu Ikeda from the University of Tokyo in Japan, the authors found that in Japan in 2007, tobacco smoking and high blood pressure accounted for 129,000 and 104,000 deaths, respectively, among adults aged 30 years and over. Physical inactivity accounted for 52,000 deaths, high blood glucose and high dietary salt intake accounted for 34,000 deaths each, and alcohol use for 31,000 deaths. Furthermore, the authors found that life expectancy at age 40 would have been extended by 1.4 years for both sexes, if exposure to multiple cardiovascular risk factors had been reduced to an optimal level.

According to the authors, in order to sustain the trend of longevity in Japan for the 21st century, additional efforts in a variety of fields are required for decreasing adult mortality from chronic diseases and injuries. They say: “A first step will be to powerfully promote effective programs for smoking cessation.”

Tobacco smoking is deeply rooted in Japanese society, but the authors argue that health professionals can play a big role: “Health care professionals, including physicians, who are highly conscious of the harms of tobacco will play the primary role in treatment of smoking and creating an environment for implementation of stringent tobacco control policies.

As for high blood pressure, the authors say: “it is urgent to establish a monitoring system for management of high blood pressure at the national level. Further investigation through national health surveys will help understand factors that contribute to the inadequate control of blood pressure in the Japanese population.”

The authors conclude: “Measuring the quality of the care that is actually delivered by interventions will be of paramount importance in the assessment of current policies and programs for the treatment of multiple cardiovascular risks including hypertension. These concerted actions in research, public health, clinical practice, and policymaking will be the key for maintaining good population health in the aging society.”

CONTACT:

Nayu Ikeda
Department of Global Health Policy
Graduate School of Medicine
The University of Tokyo
Japan
ikedan@m.u-tokyo.ac.jp

This media release was distributed to our press list under embargo before the article was published.