Communicable diseases and the genome revolution
Authors: Fujie Xu, Yan Guo
Journal: The Lancet Global Health (2018)

The greatest global health achievements in the previous century are population-level interventions, including reductions in child mortality and vaccine-preventable diseases, and these achievements have contributed to shifts in the major causes of death.1CDCTen great public health achievements worldwide, 2001–2010.MMWR Morb Mortal Wkly Rep. 2011; 60: 814-818PubMed Google Scholar Chronic, non-infectious causes of death are prevalent and increasing, not only in affluent countries but also in low-income and middle-income countries.2Stanaway JD Flaxman AD Naghavi M et al.The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study 2013.Lancet. 2016; 388: 1081-1088Summary Full Text Full Text PDF PubMed Scopus (908) Google Scholar When The Lancet Global Health was launched in 2013, lower respiratory diseases, viral hepatitis, and AIDS were the only three remaining communicable and neonatal causes of death among the top ten worldwide, and viral hepatitis was the only one that had seen an increase in incidence since 1990.2Stanaway JD Flaxman AD Naghavi M et al.The global burden of viral hepatitis from 1990 to 2013: findings from the Global Burden of Disease Study 2013.Lancet. 2016; 388: 1081-1088Summary Full Text Full Text PDF PubMed Scopus (908) Google Scholar In the past 5 years, better tools have become available to tackle the remaining infectious diseases, including breakthrough treatments and vaccines. However, formidable challenges are encountered in bridging the gap between these interventions and their large-scale use. Pneumococcal vaccines have been shown to be both safe and effective in preventing lower respiratory diseases, but for those living in low-income and middle-income countries, the path from vaccine licensure to vaccination has been long and uncertain, and the potential of the vaccines have not been fully realised because of poor widespread use.3O'Brien KL Binka F Marsh K Abramson JS Mind the gap: jumping from vaccine licensure to routine use.Lancet. 2016; 387: 1887-1889Summary Full Text Full Text PDF PubMed Scopus (15) Google Scholar Since 2014, treatments for hepatitis C have achieved cure rates of more than 90%, but there are questions about whether curing patients is a sustainable business model because the success of hepatitis C treatment gradually exhausted the available pool of treatable patients, and curing existing patients also decreased onward transmission to new people, thus the incident pool has also declined. In this situation, the challenge for sustained cash flow for the industry is greater than vaccine products because for vaccines, the size of birth cohorts is relatively stable, and the stable user pool poses less risk to the sustainability of a franchise. Historically, tiered pricing of vaccines for global coverage in children is often a triple-win for the industry, high-income countries, and low-income and middle-income countries,4Plahte J Tiered pricing of vaccines: a win-win-win situation, not a subsidy.Lancet Infect Dis. 2005; 5: 58-63Summary Full Text Full Text PDF PubMed Scopus (32) Google Scholar but questions about business success in the long run might decrease the interests in finding cures for hepatitis B and AIDS. Human papillomavirus (HPV) vaccines represent medical advances that require trade-offs between short-term and long-term priorities. Today in China, HPV vaccines are self-pay vaccines. Because of out-of-pocket expenditure, the vaccines are more commonly used in affluent areas. However, cervical cancer is often a disease of the poor.5Zeng H Chen W Zheng R et al.Changing cancer survival in China during 2003–15: a pooled analysis of 17 population-based cancer registries.Lancet Glob Health. 2018; 6: e555-e567Summary Full Text Full Text PDF PubMed Scopus (644) Google Scholar This mismatch between vaccine use and disease burden has emerged in other countries, and in due time, could exacerbate health disparity within countries. Solutions for more equitable access to HPV vaccines are not easy to find because of high vaccine costs and the large population (ie, children, adolescents, and women aged ≤45 years) that can benefit from vaccination. Although self-pay can protect only individuals who can afford the vaccine, this self-pay policy is preferable to shifting public resources away from cervical cancer screening, which is more likely to reduce mortality in the short term. Since 2013, gene therapy has ushered in the so-called genome revolution.6Dunbar CE High KA Joung JK Kohn DB Ozawa K Sadelain M Gene therapy comes of age.Science. 2018; 359: 6372Crossref Scopus (678) Google Scholar Gene therapy in various forms has produced clinical benefits in patients with cancer and genetic disorders including blindness, neuromuscular disease, and haemophilia.6Dunbar CE High KA Joung JK Kohn DB Ozawa K Sadelain M Gene therapy comes of age.Science. 2018; 359: 6372Crossref Scopus (678) Google Scholar In the coming decade, multiple clinical genome editing techniques are expected to deliver therapies for a variety of inherited genetic diseases, so the practical challenges in getting these therapies to patients who need them in low-income and middle-income countries are not just a hypothetical issue for global health. Treatment of genetic disorders might not necessarily prevent deaths in large numbers, but it will still provide tremendous value for patients, and societies have to prioritise among options. In this era of unprecedented optimism and increasing efforts towards making advanced therapies standard treatment that can cost patients more than US$300 000 per year, how can the silent gap between vaccine and vaccination for children in developing countries get attention, when so-called wonder drugs such as ivacaftor for cystic fibrosis and imiglucerase for Gaucher's disease are celebrated in the news and are supported by law in courts?7Settlement reached over medicaid coverage of cystic fibrosis drug: Arkansas federal court case highlights medical necessity, high cost of targeted therapies.Am J Med Genet A. 2015; 167A: 8-9Google Scholar How can global health funding be secured when the expenses from advanced therapies are placing increasing pressure on wealthy countries, and challenge the capacity of the publicly funded health-care system in the USA, the most affluent country?7Settlement reached over medicaid coverage of cystic fibrosis drug: Arkansas federal court case highlights medical necessity, high cost of targeted therapies.Am J Med Genet A. 2015; 167A: 8-9Google Scholar Could pharmaceutical companies' interests in wonder drugs displace the search for hepatitis B or AIDS cures? Medicine is entering an era where rapid scientific advances are adding novel but often expensive options. Global health has come to new thresholds of values in setting priorities and sustaining past achievements. Greater efforts are needed to secure resources for global health, and to allocate limited resources to improve health ethically. The Lancet Global Health should keep reminding policy makers and the pubic in donor countries that the threats and consequences from communicable diseases are often shared across borders and continents. We declare no competing interests. 5 years laterA lot can happen in 5 years. In many parts of the world, so much can happen that a child's reaching that milestone age is a cause for celebration. In 5 years, a medical student can receive her basic training and start treating patients. 5-year action plans are common components of global health programmes, this timeframe being considered adequate to optimise the use of available funds and implement strategies. 5 years is also the amount of time granted a newly-elected WHO Director-General to reform the institution, set priorities, and orient the global health agenda to make a difference. Full-Text PDF Open Access