Distinguished scientists do not always follow a traditional academic path. That is certainly true for Maryline Bonnet who just received the Christophe Mérieux Prize for her work fighting tuberculosis and HIV. She began her career as a practising pulmonologist travelling the globe to care for people in the regions ravaged by these diseases. It was only later that she turned towards research to solve diagnostic and clinical issues she saw in the field.
Vocation and practicality can come together in advantageous ways. Maryline Bonnet found the first of these very early on. "I don’t come from a family of doctors like so many of my colleagues, but by the time I was seven or eight years old, I knew that was what I would be." She began her medical studies at the Grenoble Medical School and common sense motivated her choice of speciality when she began her residency in Toulouse: "I wanted to work in the Global South and so I specialised in infectious diseases. More pragmatically, however, I wanted to be able to easily find work as a substitute in France between missions abroad." She therefore opted for pulmonology, one of the few specialities to fill these two criteria. "The lungs are a filter and infectious diseases play an important role in pulmonology." And so she became a specialist at the infectious disease and pulmonology units of the university hospital centres of Purpan and Rangueil in Toulouse.
A young intern in Rwanda
The desire to serve populations who most needed her skills was an early calling for her. As a young intern, she took an extended leave to join a Doctors Without Borders mission in Rwanda during the middle of the Tutsi genocide. She then participated in several emergency medicine missions. "Once I became a pulmonologist, I naturally took an interest in infectious pulmonary pathologies in the Global South such as tuberculosis, especially in the context of a HIV infection (which is often accompanied by tuberculosis)."
Over time and after many missions, as her clinical and humanitarian experience grew, so did her responsibilities. "Between 1998 and 2002, I rose up the ranks of my profession within Doctors Without Borders, first as a practitioner on tuberculosis care projects, then as a coordinator for these projects, and finally as a technical advisor." Her missions drew her to countries like Georgia, Armenia, and Russia where tuberculosis and treatment resistance are major epidemiological problems.
Towards operational epidemiology
Confronted with the flagrant limitations of treatment and diagnostic tools for these disadvantaged diseases, she then began focusing on operational research. "I had a good understanding of the clinical challenges for tuberculosis and the basics of epidemiology, so I went to Epicentre, the Doctors Without Borders epidemiological research centre." Since she never does anything half way, she simultaneously led work on the possibility of better administering anti-tuberculosis and antiretroviral treatments for HIV-tuberculosis coinfections and improving techniques for diagnosing tuberculosis. At the same time, she undertook thesis work in public health at the Institut Pasteur in Paris on the subject of tuberculosis diagnostics(1). In concrete terms, this research led to evolutions in diagnostic tools for hospitals and primary healthcare centres ?structures that are less well equipped for diagnosis than regional and national hospitalsin the Global South where most tuberculosis patients are found. Her work also helped establish new WHO recommendations on optimising microscopic diagnosis of pulmonary tuberculosis in Kenya and on the use of antiretrovirals in patients with HIV and tuberculosis coinfections (the ANRS Carinemo trial(2)). Furthermore, she participated in therapeutic trials aiming to optimise dosage for anti-tuberculosis treatments to reduce the length of treatment and improve observance. "With the Rifshort trial?funded by the Medical Research Council and the Wellcome Trust currently under way in Uganda, we are trying to show that you can decrease the length of treatment from six to four months by doubling or even tripling the dose of rifampicin, the major drug for treating tuberculosis."
Serving scientific capabilities
In 2013, she joined the TransVIHMI unit at IRD as research director and went to the Epicentre research base in Mbarara in Uganda in September 2014. She helped develop multi-centre (or multi-location) research projects in Uganda and Cameroon where scientists with the TransVIHMI unit are already very involved in HIV research. "With the ANRS Statis trial in Uganda, we assessed various approaches to care for tuberculosis in patients at an advanced stage of HIV infection." At the same time, she co-coordinated an important project for IRD with the University of Bordeaux and the University of Makerere in Uganda. The project, spanning seven countries in Sub-Saharan Africa and Southeast Asia, aims to improve the diagnosis of tuberculosis (TB-Speed project funded by UNITAID and the 5% Initiative3)in children fact, less than have of the one million cases of paediatric tuberculosis estimated by the WHO have access to treatment. The underlying causes of this gap include the difficulty of diagnosing this condition in children and the lack of screening and prevention in those living in close contact with affected adults in countries with a high prevalence of tuberculosis. "We have already demonstrated the benefits of placing children who live with adults affected by tuberculosis on prophylactic anti-tuberculosis drugs. When this is done, none develop the disease." This research will eventually also explore the benefits improving access to these preventative treatments by providing care for children at home rather than at the hospital since they are not always taken to the hospital when necessary.
Finally, it is significant that in the framework of the Christophe Mérieux Prize that encourages promoting the development of infectious disease research capacities in the Global South, she dedicates a significant proportion of her activities to sharing knowledge by teaching at the Mbarara University of Science and Technology (MUST). Specifically, she works with the Public Health Masters program and supervises doctoral work in Uganda. "We have increasingly strong Ugandan and Cameroonian scientific teams. That’s a good sign for the future!"
A custom prize for IRD
The Christophe Mérieux Prize awarded by the Fondation Christophe et Rodolphe Mérieux of the Institut de France is intended to promote research into infectious diseases in developing countries. It exclusively recognises research teams that are working permanently on the ground in these countries. The prize is worth 500,000 euros distributed as follows: 100,000 euros given to the recipient & research team leader personally and 400,000 to fund the development of the team’s research.
1. Under the direction of Professor Arnaud Fontanet
2. Carinemo. A clinical trial comparing the nevirapine-base antiretroviral triple therapy (which has no teratogenic effect) to the efavirenz-based drug (the drug that is usually recommended) for treating patients with HIV infections undergoing anti-tuberculosis treatment with rifampicin. Though it does not establish the equivalence of the first antiretroviral drug tested, the trial nevertheless leads to a recommendation that it be used in women in their childbearing years with no contraceptive coverage.
3. The 5% Initiative is the second largest way France contributes to the Global Fund to Fight AIDS, Tuberculosis and Malaria
Margaret Nansumba, Elias Kumbakumba, Patrick Orikiriza, Yolanda Muller, Fabienne Nackers, Pierre Debeaudrap, Yap Boum, Maryline Bonnet, Detection Yield and Tolerability of String Test for Diagnosis of Childhood Intrathoracic Tuberculosis, Pediatr Infectious Diseases Journal, 1 février 2016 ; doi: 10.1097/INF.0000000000000956
Andrew Ramsay, Willie Githui, Laramie Gagnidze, Francis Varaine, Philippe J. Guerin, Bleach sedimentation: an opportunity to optimize smear microscopy for tuberculosis diagnosis in settings of high prevalence of HIV, Clinical Infectious Diseases, 1 juin 2008 ; doi : 10.1086/587891
Maryline Bonnet, Nilesh Bhatt, Elisabeth Baudin, Carlota Silva, Christophe Michon, Anne-Marie Taburet, Laura Ciaffi, Agnès Sobry, Rui Bastos, Elizabete Nunes, Christine Rouzioux, Ilesh Jani, Alexandra Calmy, Nevirapine versus efavirenz for patients co-infected with HIV and tuberculosis: a randomised non-inferiority trial, The Lancet Infectious Diseases, 13 avril 2013 ; doi : 10.1016/S1473-3099(13)70007-0
Contact : Maryline Bonnet