Mother and child health

Symposium organized by Guy de Thé, from 16 – 20 March 2001

Participants

Françoise Barré-Sinoussi (Institut Pasteur, Paris), Nathalie Charpak (Fundacion Canguro, Bogota, Colombie), Michel Cohen-Solal (Académie des sciences, Paris), Aissatou Laye Diallo (University Cheikh Anat Diop, Dakar, Sénégal), Glenda Gray (Chris Hani Baragwanath Hospital, Soweto, Afrique du Sud), Richard Hamilton (Mc Gill University Health Centre, Montréal, Canada), Elisabeth Heseltine (Communication in Science, Saint-Léon-sur Vezère), Leang Sim Kruy (Hôpital Calmette, Phnom Penh, Cambodge), Diane Labruyère-Guilleret (Directeur marketing Carrefour, Paris), Bo Lindblad (Karolinska Hospital, Stockholm, Suède), Philippe Moingeon (Aventis Pasteur, Marcy-L’Étoile), Marina Rea (Instituto de Saude, Sao Paulo, Brésil), Gabriella Scarlatti (San Raffaele Scientific Institute, Milan, Italie), Guy de Thé (Institut Pasteur, Paris), Roger Whitehead (Dunn nutrition Centre, Cambridge, Grande-Bretagne), Rolf Zetterström (Karolinska Hospital, Stockholm, Suède).

Summary

Catherine Bachy welcomed the participants on behalf of the Fondation des Treilles. Prof. Guy de Thé expressed the regrets of François Gros not to be able to participate in this workshop, as well as his confi­dence in the progress we will accomplish together.

The participants from the different continents and disciplines intro­duced themselves. A round-table progress report followed, covering the 18 months sine the last workshop at Tourtour, 17-20 October 1999.

Prof. Rolf Zetterström had aсtively participated in a meeting organ­ized by Prof. Oral Atanyazovа on the dramatic environmental and health situation in Central Asia, espeсially for mothers, the new-born and chil­dren. A report of the meeting is to be published in Acta Paediatrica.

Report

Prof. Guy de Thé reported on:

• the establishment of the “mother-child.org” web site to be presented by Dr Michel Cohen-Solal,
• the Erice workshop on Mother-to-Child Transmission of HIV (MTCT/HIV) organized with the World Federation of Scientists (a report was published in Acta Paediatrica). He stressed the impact of conclusions of the Erice workshop on the views expressed by UNAIDS on the prevention of mother-to-child transmission of HIV, the problem of alternatives to breast feeding for HIV+ mothers, and the respect of local cultures and local hygiene habits.

Dr Philippe Moingeon from Aventis-Pasteur presented their Research and Development Program on vaccine development, including vaccines against cancer, infectious diseases, vector-borne diseases and HIV AIDS.

He mentioned the interest of Aventis Pasteur in sponsoring this prom­ising Network and in promoting clinical research training courses in the developing world. In the discussion, Roger Whitehead and Dick Hamilton stressed the need to investigate potential ill-effects of combi­nation vaccines in malnourished children in developing countries.

Prof. Ayоu Gayle-Diallo presented the African AIDS Research Net-work (AARN) winch includes 200 clinicians and researchers from West and Central Africa (Senegal, Gambia, Ivory Coast, Nigeria, Sierra Leone, Guinea Bissau, Ghana, Niger, Cameroon). She reported that 15 workshops had been organized in the last few years and mentioned that the AARN has a web site. The secretary of AARN is Dr Abdula Hane, Prof. S. M’Boup being the chairman of AARN in Dakar. A hypertеxt link will have to be established with our “mother-child.org” web site. The AARN is ready to join a regional prevalence and behavioural survey and to organize a scientific communication course.

Prof. Françoise Barré-Sinoussi presented the activities of the ANRS/НIV perinatal group with its scientific board including Dr Blanche, paediatrician, Jean-François Delfraissy, internal medicine; Marie-Jeanne Maуаux, epidemiologist; Christine Rouzioux, virologist; and Dr Tardieu, neuropaediatrician. The philosophy of the group is to promote capacity-building by paralleling interventions and research activ­ities. Their target countries include Cambodia, Ivory Coast, Cameroon and India.

Prof. Кruy Leang Sim from Phnom Penh (Cambodia) presented her MCTC/HIV Perikam program involving Nevirapine, with three months’ follow-up for both mother and child.

Dr Nathalie Charpak reported the progress made on the Kangaroo Mother Care (KMC) Program which was exported to, and adapted by, many countries in Africa, the Ukraine, in India, etc.

Dr Gabriella Scarlatti presented her input in the ANRS perinatal group which involves inotial research in the field of basic virological tools necessary for monotoring clinical trials. She is interested in the immunovi­rology of HIV infection in the placenta. The placenta appears as an effec­tive barrier to the transmission of HIV to the offspring, in contrast to the breast.

Prof. Glenda Gray stressed the urgent need to develop biomedical research in South Africa. She reported on the comparative results of breast feeding (BF) versus foster feeding (FF) in either NVP- or zidovu­dine plus 3тС- treated pregnant mothers. She showed that at four weeks after birth BF resulted in 4.5% of babies infected versus 2% with bottle feeding, the difference being even greater at 8 weeks post-natal. She men­tioned that NVP will be given for 60,000 new-born deliveries in South Africa.

Dr Michel Cohen-Solal gave a live demonstration of the “mother­-child.org” web site. Participants made several comments and suggestions, namely to include pictures in the members’ data sheets, date of registra­tion, details on publications, followed by up to 20 keywords.

In the discussion concerning the Directory of scientists being part of the mother-child.org site, Prof. Dick Hamilton from Montreal raised three questions:

• which researchers should be included: child health, nutrition, infec­tion?
• which data should be included?
• who would finance the site and how much would it cost?

He stressed the fact that the Canadian International Development Agency at present was not too keen to promote research, but wished to concentrate its efforts on education in developing countries. Hе con­cluded by saying that he would contact key personalities to assess how Canada could help the development of RIME.

Prof. Roger Whitehead expressed his enthusiasm for the web site as the оnly site entirely devoted to research promotion in developing coun­tries. This is very important for Young scientists returning to their home country.  For him, the objective of helping Young scientists from develop­ing countries must be one of the top priorities, and should be clearly stated in all our documents, as well as on the home page of the web site.

Hе expressed regret that the Nestlé Foundation did not receive any proposal from the Network, but he confirmed its interest in our endeav­our. He thought that the promotion of ethics and of the quality of research in developing countries was essential, and suggested the cre­ation of a special forum site for matters of ethics. All participants agreed that this was a major task for the Network.

Dr Nathalie Charpack suggested that the web site list the funding agencies and that the logo on the front page of the site be replaced by the sole list of sponsors.

Dr Marina Ferreira Rea from Brazil mentioned that she was preparing a manual for gynaecologists and midwives, and she reported on the Brazilian human milk-bank network involving 140 individual branches, 40 of them being in Sao Paulo. There is no pooling of samples, but there is pasteurisation. She takes part in a group of 11 countries, repeating the Coutsoudis study on exclusive breast feeding versus mixеd feeding, andorganized a post graduate course on BF, with the participation of Rolf Zetterström.

Prof. Bо Lindblad presented his program of collaboration between the Karolinska Institutet (KI), Pakistan and India, financed by the Linne­Palmer Foundation. The program includes the annual exchange of 11 teachers or scientists between KI and Pakistan/India together with research training courses and sandwich fellowships for students from India and Pakistan as well as Sweden.

He underlined the importance that interested Young Swedish scien­tists work on subjects relevant to developing countries.

Hе suggested that the “mother-child.org” should establish hypertext links with 4 web sites:

Mother and Child Health

• sasnet.lu.se (the aboye Swedish program),
• globalforumhealth.org (WHO),
• www.childresearch.net (Japan),
• www.cas.com (US, with huge number of scientists in many différ­ent disciplines).

Hе also stressed the need to develop close relations between the Karolinska Institutet (flans Rossling, Steffan Bergstrom, Ingemar Ernberg, Gunnel Biberfeld and himself) and the Pasteur Institute (Pierre André Cazenave, E Barré-Sinoussi, etc.).

Sunday 18 March

At the beginning of the session, Dr Ayou Gayle Diallo presented her project on 11V8 and Kaposi’s sarcoma in Senegal.

Prof. Rolf Zetterström summarized the Saturday 17 session and stressed the importance of scientific education in the developing world, taking into account the historical and the cultural backgrounds and the need to rebuild centres of excellence.

The participants then divided into two groups: one to discuss web site issues and research training, the other the “post-Erice follow up” and spe­cific actions to be taken.

During the afternoon session, the web site issues were extensively dis­cussed:

Prof. Bо Lindblad presented in details the sasnet web site of Lund University and pointed out the need to have a “mirror site” of “mother­-child.org” located in Lund University.

On the home page of the web site, the specific airs of the Network should clearly be stated : i.e. to support Young researchers from develop­ing countries and to promote research in the biomedical field in develop­ing countries.

Elisabeth Heseltine, who arrived in the morning, presented an outline of her Research Training Courses which focus on how to write scientific proposals, progress reports and manuscripts, or prepare oral presenta­tions, in English. The main lines of such courses were explained. She emphasized the importance of training the teachers, i.e. training the trainers, who in turn will teach later in their mother tongue. She insisted that the course should be integrated in a research program. Anу given course involved no more than twelve students. The cost was 10,000 FRF honorarium plus travel expenses and accommodation for four days. Very little equipment was required: a round table, a blackboard, an overhead projector and a photocopier.

Rolf Zetterström, a scientific editor for many years, strongly sup­ported such courses on scientific writing since in тanуinstances submit­ted manuscripts were rather poor. Hе also stressed the need for such courses in the Central Asia region with the help of Oral Ataniyazova, who has a good confection with the Gates Foundation.

Françoise Barré-Sinoussi said that ‘sandwich’ research training and courses on scientific writing were in line with the prime duties of the Pasteur International Network, comprising 22 centres around the world.

Aуou Gayle Diallo confirmеd the interest of the African AIDS research network AARN to organize a course in scientific writing. It was suggested that an an advisory committee be established for these research training andscientific writing courses. The first two members should be Rolf Zetterström and Elisabeth Heseltine.

Мonday 19 March

POST-ЕRIСЕ МТСТ (MOTHER-TO-CHILD TRANSMISSION) RESEARCH ACTIVITIES Following two sessions of discussions yes­tеrday and early this morning, Françoise Barré-Sinoussi, Gabriela Scarlatti, Ауоu Gaye-Diallo, Glenda Gray, Marina E Rea and Nathalie Charpak reported on what thеу considered to be top priorities for syn­ergy and support in relation to МТСТ of 1IV–1 and oncogenic viruses.

The first expressed priority was the great need to improve the com­munication between clinicians and laboratory scientists. This became par­ticularly evident during the last AIDS international Conference in Durban (South Africa).

Gabriela Scarlatti presented a proposal for an international workshop on HIV-1/MTCT Integration of clinical studies and research. The inten­tion is to invite 50 to 60 people from different countries, half of them from developing countries. She had contacted ECCO in Brussels, and stressed that the Network could help in fund raising activities. For the follow-up of such a workshop, the web site would be extremely useful.

In the same context E Barré-Sinoussi presented in detail the ANRS activities on MTCT/НIV, and suggested that the ANRS group be described and listed in the site “mother-child.org”. This network consists of two groups: clinical research and basic research in Paris, with colleagues in Italy (G. Scarlatti) and Sweden (G. Biberfeld), and the field centres in Burkina Faso, Ivory Coast, Cameroon, Cambodia, Thailand, South Africa, India.

The second major priority concerns the necessity to monitor HIV ­related clinical interventions and trials in the laboratory.  The discussion group pointed out that therapeutic interventions without laboratory monotoring were extremely dangerous and ran the risk of developing mutant viruses which may have delеtеrious effects on individuals as well as on the general population. This implies that both laboratory and clin­ical monotoring must be part of therapeutic interventions but often are implemented in a hurry and under political pressure. Training local labo­ratory technicians with scientists is therefore vital, as is the setting up of testing field laboratories and reference regional laboratories by the health authorities concerned.

It was stressed over and over that social scientists must be integrated with clinical and laboratory research projects in interdisciplinary initia­tives, especially for interventions involving breast feeding alternatives.

The third priority considered by the discussion group was to apply the same interdisciplinary research approach for other diseases that are an increasing burden, such as tuberculosis and HIV malaria and HIV, and rotaviruses and HCV. Again the web site was considered to be a unique tool for communication, cooperation and cross-information, and a unique pressure group of scientists and clinicians to lobby the govern­ments and large drug companies in favour of the needs of developing countries.

The fourth priority discussed was the need for Ethical Research, tak­ing into consideration both universal and local rules of ethics, stressing the need to consider some cultural ethical rules. For example, India has now mandatory ethical guidelines everybody has to соmplу with before entering into collaboration with an Indian research group.

Within the aboye priorities the critical need for training teams involved in clinicat trials, as well as laboratory research in developing countries was stressed by all participants.

Clinical epidemiology being very weak in the developing countries, special training efforts must be carried out in that field.

Returning to the web site:

The consequences of the aboye discussions are important for the web site forums. The aims as discussed yesterday have to be redefined as well as the forum masters’ responsibilities. It was agreed that each forum mas­ter should:

• list active working groups in the discipline concerned, using the for­mat of the directory;
• propose consensus research priorities in their field of endeavour;
• regularly present key publications in the field including a summary and, if neсessary, indications on how to get the full text from the Internet;
• promote lobbying in favour of advancing research in the developing world.

Then the list of forums (restricted list of communications) and master teams, proposed yesterday bу Bo Lindblad, were reviewed. The follow­ing was agreed:

1. Nutrition and diarrhoea:

Mother and Child Health

Zulfigar Bhutta, R. Hamilton (МcGill, Montreal), Dilip Mahalanabis.

2. MTCT (HIV transmission):

Glenda Gray, Souleymane M’Boup, Gabriela Scarlatti.

3. Lab Monotoring of HIV interventions:

Gunnel Biberfeld, Elizabeth Menu, Christine Rouzioux, Gabriella Scarlatti.

4. MTCT/Oncoviruses:

Ingemar Ernberg, Аyоu Gaye-DialIo, Guy de Thé.

5. Kangaroo:

Nathalie Charpak: hypertext link with their web site.

6. Breast feeding:

Marina Ferreira Rea, Ted Grainer (h)Tpertext link), Rolf Zetterström.

7. Micronutrients, nutrition:

Peter Aggoff (UK), Roger Whitehead (UK).

8. Nutrition/Immunology/Neonatalogy: L.A. Hanson (Göteborg), Bo Lindblad.
9. Reproductive health: Steffav Bergstrom.
10. Research training, study design, data collection and analysis, research management

Sven Cnattingius (Karshushe Institutet Stockholm), Johan Karlberg (hosp. HongKong), Michael Kramer (МcGill, Montreal), Rolf Zetterström.

11. Scientific publications and writing: H. Heseltine, Rolf Zetterström.
12. Ethics and International Research involving developing countries: Nathalie Charpak, Guy de Thé, Rolf Zetterström

Publication:

Guy de Thé reminded the group that a publication was usually required by the Fondation des Treilles at the end of a series of workshops.

There are three alternatives: the first would be to prepare a book with different chapters as proposed during the last workshop, including the web site and its applications.

A second possibility would be to produce a volume on research needs and impediments for low income countries. This should include three major challenges:

• HIV and its consequences,
• environmental pollution with the mother-child tragedies as seen in Central Asia, and
• inadequate food for children resulting in poor résistance to infec­tions.

A major proposition in this book will be the promotion of Sandwich Research Training Fellowship as carried out by Sweden for some time.

A third alternative would be to hold such a publication until an inter­national meeting devoted to the promotion of biomedical research in developing countries takes place. The web site will be a good place fur­ther to discuss optimal and viable alternatives. The group regretted the decision of the Nobel Foundation not to organize a conference on Research Promotion in Developing Countries as was discussed during the last Tourtour workshop.

Then a long discussion took place between Diane Labruyère, Nathalie Charpak, Marina Ferreira Rea and Bo Lindblad on the safe alternative to breast feeding for HIV positive mothers, necessary before the availability of a preventive НIV vaccine. The group restated the value of breast feed­ing in developing countries as the best chance for the new-born to develop properly. But it is clear that the risk breast feeding carries for newborns to НIV positive mothers is a major challenge to which scien­tists and clinicians must respond.

The question of safe bottle feeding, including fabrication, packaging, processing in local factories and distribution of ready-to-use cartons is a huge challenge, presented by Diane Labruyère. The implementation of breast feeding alternatives raises social problems to be evaluated by social scientists and economists and is a good example of a multidisciplinary in­tiative. This gave way to the idea of labelling, such as a “complement to ART therapy prevention”.

Three years ago WHO-UNICEF launched a breast feeding alternative program by bottle feeding in seven countries but results are difficult to obtain for reasons unknown. Roger Whitehead will try to get informa­tion from London UNICEF headquarters.

Possibilities other than bottle feeding were discussed like a human milk bank network as established in Brazil, involving yearly collection of 12,000 litres of breast milk from home, followed by pasteurisation and storage of individual samples. No pooling is carried out. The second cul­tural alternative being used in South East Asia is the soybean milk and rice coup supernatant, which mаy raise malnutrition problems, as pointed out by Bo Lindblad and Rolf Zetterström.

In conclusions of the afternoon, the group recognized:

• the urgent need for multidisciplinary studies and evaluation of the present situation of BF and FF for НIV positive mothers in different geo­graphical and cultural areas,
• the need to evaluate safe and feasible alternatives to BF for HIV+ mothers in different cultural areas,
• proper measures of the reduction rates of MTCT/IfV when alter­natives to BF by milk substitutes are implemented. The workshop ended at around 7 p.m.

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