Eliminating VL – the impact of TDR grants
Bangladeshi scientist Dinesh Mondal rose from modest roots to become one of the country’s leading experts on the control of visceral leishmaniasis. He got his start as an independent Principal Investigator with TDR grants that provided the evidence for insecticide-treated bednets and for testing a new treatment in real-life conditions.
For a boy from rural Bangladesh, the son of a day laborer with never more than a few taka to his name, Dinesh Mondal had seen a great deal of the world. A talented singer in the national youth choir, he was 13 when he first left his rural village to represent Bangladesh at the annual World Children’s Assembly in what was then Soviet Ukraine.
“I used to love to sing,” recalls Mondal, now a senior scientist at the International Center for Diarrhoeal Disease Research (icddr,b), Bangladesh’s leading health research institution. “But I had to give it up,” he says. “I knew that the only way to support myself and my family was to have a good education. So I became very serious about my studies, and I decided to become a doctor.”
“I have 18 published papers, including 3 as principal investigator. And all of these were made possible by my mentorship under Dr Mondal, who engaged me in public health research methodology, data analysis and interpretation and report writing, among other disciplines.”
Mr Mamun Huda, icddr,b
Mondal left Bangladesh a second time to attend medical school in Bulgaria, where he specialized in pediatrics and graduated with honors before pursuing a PhD in pediatric gastroenterology. From there, he might easily have gone on to a research institution in Europe or the United States, but Mondal felt compelled to return home. “I knew I should do something for my people,” he says. “And through the research I do on kala-azar”—or visceral leishmaniasis (VL), as it’s also known — “I’m able to help thousands of them.”
Indeed, since joining icddr,b in 2010, Mondal has established himself as one of the country’s leading experts on the neglected parasitic disease, with 48 peer-reviewed publications to his name, including 15 as principal author and 3 as senior author. And it all started, he says, with a TDR grant he received in 2006 to study VL vector control activities in Bangladesh, along with another TDR grant to assess strategies for case finding and management of kala-azar patients.
“That’s how my career in research at icddr,b first began,” he says. “And it’s all thanks to TDR, which has allowed me to help change the lives of thousands of the poor in Bangladesh’s rural communities.”
Establishing the evidence for insecticide-treated bednets
Last year, Mondal, a member of the WHO expert committee on the control of VL, led a TDR-supported study demonstrating the feasibility, acceptability and effectiveness of a community-based programme to treat existing bed nets in Bangladesh with a slow-release insecticide. First conceived of by TDR scientist Axel Kroeger, that control strategy has since been adopted by the governments of Bangladesh, India, and Nepal, as a central tool in their campaign to eliminate VL from the Indian subcontinent by 2015.
When the countries made that commitment in 2005, there was no ideal treatment that could be deployed to large numbers of patients. One potential option was the liposomal form of Amphotericin B, which effectively kills parasites without the toxic side effects of an earlier treatment but it was prohibitively expensive for use in control programmes. In 2007, the manufacturer, Gilead, announced a price reduction of 90% for all low- and middle-income countries where VL is endemic, and in 2010, the drug was recommended by the WHO’s expert committee on the control of leishmaniasis for first-line use in the Indian subcontinent.
Testing a drug treatment in real life conditions
The question remaining was whether distribution of the drug, which requires regulated temperatures, could be implemented safely, cheaply, and effectively under “real life” conditions in the hot climate of Bangladesh – such as among primary health facilities in remote rural areas. “Until 2 or 3 years ago, 95% of the evidence about the drug was generated in India,” says Dr Byron Arana, who worked for TDR and is now at the Drugs for Neglected Diseases initiative (DNDi). “So one of the requirements of the Bangladesh Ministry of Health was to produce this kind of evidence for the country.”
“Dr Mondal has provided evidence crucial to improving the national guidelines for VL management and control, so that one day soon, Bangladesh can eliminate this terrible disease.”
Dr Byron Arana, Drugs for Neglected Diseases initiative (DNDi)
In an effort to satisfy that requirement, Mondal, Arana and colleagues conducted a feasibility study of the single-dose liposomal amphotericin B in a public hospital in a rural area of Bangladesh. The study, which included 300 patients in one of the country’s most endemic districts, showed that the drug was just as safe and effective in Bangladesh as it was in India. Even before the findings were published in The Lancet Global Health, the Ministry of Health had seen fit to revise its national guidelines in accordance with WHO recommendations for the Indian subcontinent.
“Now single-dose amphotericine B has been adopted as the first-line treatment for VL in Bangladesh,” says Mondal, who adds that the government has so far treated “hundreds of patients with no reports of adverse events.” For more on this treatment and WHO’s donation, read the feature on the elimination programme.
Building national research capacity
The study on single-dose amphotericine B may stand as Mondal’s most important contribution to the literature, but he is equally proud, he says, of his work as a mentor to young researchers in Bangladesh. “I’ve really enjoyed teaching new scientists and helping them as they embark on their careers,” he says, praising the “very talented team” he’s built up over his time at icddr,b. “I started with 4 people, and now there are 32 of us – all working on VL.”
When I was hired on, I didn’t know much about public health research,” says Mr Mamun Huda, a statistician at icddr,b and himself the recipient of two TDR re-entry grants for work on VL control and case management. “Now I have 18 published papers, including 3 as principal author and all of these were made possible by my mentorship under Dr Mondal, who engaged me in public health research methodology, data analysis and interpretation and acientific writing, among other disciplines.”
“The results of Dr Mondal’s studies have vastly improved our understanding of the epidemiological features of VL in Bangladesh,” says Arana. “He has provided evidence crucial to improving the national guidelines for VL management and control, so that one day soon, Bangladesh can eliminate this terrible disease.”
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