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Transcript of Communicable Diseases and Human Security Kelechi Ohiri MD MPH MS Health, Nutrition, Population Human...
Communicable Diseases and Human Security
Kelechi Ohiri MD MPH MS
Health, Nutrition, PopulationHuman Development Network
World Bank
Outline of Presentation Part 1 – Overview of Communicable
Diseases (CDs) Introduction and Definition Importance of CDs Selected CDs of Public Health Concern
Part 2- Mounting a Global Response Approaches to intervention Key elements of a global response World Bank’s role and involvement
Human Security in a globalized world
The changing role of policy makers in an increasingly globalized world
Shared space = Shared Destiny Local actions have global consequences Global interventions can achieve positive
local impact As long as human interactions exist,
Communicable diseases will remain an issue.
Communicable Diseases: Definition
Defined as “any condition which is transmitted directly or indirectly to a
person from an infected person or animal through the agency of an intermediate animal, host, or vector, or through the inanimate environment”.
Transmission is facilitated by the following (IOM) more frequent human contact due to
Increase in the volume and means of transportation (affordable international air travel),
globalization (increased trade and contact) Microbial adaptation and change Breakdown of public health capacity at various levels Change in human demographics and behavior Economic development and land use patterns
CD- Modes of transmission
Direct Blood-borne or sexual – HIV, Hepatitis B,C Inhalation – Tuberculosis, influenza, anthrax Food-borne – E.coli, Salmonella, Contaminated water- Cholera, rotavirus, Hepatitis A
Indirect Vector-borne- malaria, onchocerciasis, trypanosomiasis Formites
Zoonotic diseases – animal handling and feeding practices (Mad cow disease, Avian Influenza)
Importance of Communicable Diseases
Significant burden of disease especially in low and middle income countries
Social impact Economic impact Potential for rapid spread Human security concerns
Intentional use
Communicable Diseases account for a significant global disease burden
In 2005, CDs accounted for about 30% of the global BoD and 60% of the BoD in Africa.
CDs typically affect LIC and MICs disproportionately.
Account for 40% of the disease burden in low and middle income countries
Most communicable diseases are preventable or treatable.
Communicable Disease Burden Communicable Disease Burden Varies Widely Among ContinentsVaries Widely Among Continents
Communicable disease burden in Europe
Causes of Death Vary Greatly by Causes of Death Vary Greatly by Country Income LevelCountry Income Level
Age distribution of death in Denmark around 2005
Male Female
80 60 40 20 0 20 40 60 80
0 - 4
15 - 19
30 - 34
45 - 49
60 - 64
75 - 79
90 - 94
Age g
roup
Percent of total deaths
Age distribution of death in Sierra Leone around 2005
Male Female
80 60 40 20 0 20 40 60 80
0 - 4
15 - 19
30 - 34
45 - 49
60 - 64
75 - 79
90 - 94
Age g
roup
Percent of total of deaths
CDs have a significant social impact
Disruption of family and social networks Child-headed households, social exclusion
Widespread stigma and discrimination TB, HIV/AIDS, Leprosy Discrimination in employment, schools,
migration policies
Orphans and vulnerable children Loss of primary care givers Susceptibility to exploitation and trafficking
Interventions such as quarantine measures may aggravate the social disruption
CDs have a significant economic impact in affected countries
At the macro level Reduction in revenue for the country (e.g. tourism)
Estimated cost of SARS epidemic to Asian countries: $20 billion (2003) or $2 million per case.
Drop in international travel to affected countries by 50-70% Malaria causes an average loss of 1.3% annual GDP in
countries with intense transmission The plague outbreak in India cost the economy over $1 billion
from travel restrictions and embargoes
At the household level Poorer households are disproportionately affected Substantial loss in productivity and income for the infirmed
and caregiver Catastrophic costs of treating illness
International boundaries are disappearing Borders are not very effective at stopping
communicable diseases. With increasing globalization
interdependence of countries – more trade and human/animal interactions
The rise in international traffic and commerce makes challenges even more daunting
Other global issues affect or are affected by communicable diseases.
climate change migration Change in biodiversity
Human Security concerns
Potential magnitude and rapid spread of outbreaks/pandemics. e.g. SARS outbreak No country or region can contain a full blown
outbreak of Avian influenza Bioterrorism and intentional outbreaks
Anthrax, Small pox New and re-emerging diseases
Ebola, TB (MDR-TB and XDR-TB), HPAI, Rift valley fever.
Select Communicable Diseases
Tuberculosis 2 billion people infected with microbes that
cause TB. Not everyone develops active disease A person is infected every second globally
22 countries account for 80% of TB cases. >50% cases in Asia, 28% in Africa (which
also has the highest per capita prevalence) In 2005, there were 8.8 million new TB cases;
1.6 million deaths from TB (about 4400 a day) Highly stigmatizing disease
Tuberculosis and HIV A third of those living with HIV are co-infected
with TB About 200,000 people with HIV die annually from TB. Most common opportunistic infection in Africa 70% of TB patients are co-infected with HIV in some
countries in Africa Impact of HIV on TB
TB is harder to diagnose in HIV-positive people. TB progresses faster in HIV-infected people. TB in HIV-positive people is almost certain to be fatal
if undiagnosed or left untreated. TB occurs earlier in the course of HIV infection than
many other opportunistic infections.
Global Prevalence of TB cases (WHO)
Tuberculosis
Tuberculosis Control Challenges for tuberculosis control
MDR-TB - In most countries. About 450000 new cases annually. XDR-TB cases confirmed in South Africa. Weak health systems TB and HIV
The Global Plan to Stop TB 2006-2015. an investment of US$ 56 billion, a three-fold increase from
2005. The estimated funding gap is US$ 31 billion. Six step strategy: Expanding DOTS treatment; Health Systems
Strengthening; Engaging all care providers; Empowering patients and communities; Addressing MDR TB, Supporting research
Malaria Every year, 500 million people become severely
ill with malaria causes 30% of Low birth weight in newborns Globally.
>1 million people die of malaria every year. One child dies from it every 30 seconds
40% of the world’s population is at risk of malaria. Most cases and deaths occur in SSA.
Malaria is the 9th leading cause of death in LICs and MICs
11% of childhood deaths worldwide attributable to malaria
SSA children account for 82% of malaria deaths worldwide
Annual Reported Malaria Cases by Country (WHO 2003)
Global malaria prevalence
Malaria Control Malaria control
Early diagnosis and prompt treatment to cure patients and reduce parasite reservoir
Vector control: Indoor residual spraying Long lasting Insecticide treated bed nets
Intermittent preventive treatment of pregnant women Challenges in malaria control
Widespread resistance to conventional anti-malaria drugs Malaria and HIV Health Systems Constraints
Access to services Coverage of prevention interventions
HIV/AIDS
In 2005, 38.6 million people worldwide were living with HIV, of which 24.7 million (two-thirds) lived in SSA 4.1 million people worldwide became newly
infected 2.8 million people lost their lives to AIDS
New infections occur predominantly among the 15-24 age group.
Previously unknown about 25 years ago. Has affected over 60 million people so far.
HIV Co-infections Impact of TB on HIV
TB considerably shortens the survival of people with HIV/AIDS.
TB kills up to half of all AIDS patients worldwide. TB bacteria accelerate the progress of AIDS infection in
the patient HIV and Malaria
Diseases of poverty HIV infected adults are at risk of developing severe
malaria Acute malaria episodes temporarily increase HIV viral
load Adults with low CD4 count more susceptible to treatment
failure
Global HIV Burden
HIV/AIDS Interventions depend on
Epidemiology – mode of transmission, age group Stage of epidemic –concentrated vs. generalized
Elements of an effective intervention Strong political support and enabling environment. Linking prevention to care and access to care and treatment Integrate it into poverty reduction and address gender inequality Effective monitoring and evaluation Strengthening the health system and Multisectoral approaches
Challenges in prevention and scaling up treatment globally include
Constraints to access to care and treatment Stigma and discrimination Inadequate prevention measures. Co-infections (TB, Malaria)
Avian Influenza
Seasonal influenza causes severe illness in 3-5 million people and 250000 – 500000 deaths yearly
1st H5N1 avian influenza case in Hong Kong in 1997.
By October 2007 – 331 human cases, 202 deaths.
Avian Influenza Control depends on the phase of the epidemic
Pre-Pandemic Phase Reduce opportunity for human infection Strengthen early warning system
Emergence of Pandemic virus Contain and/or delay the spread at source
Pandemic Declared Reduce mortality, morbidity and social disruption Conduct research to guide response measures
Antiviral medications – Oseltamivir, Amantadine Vaccine – still experimental under development.
Can only be produced in significant quantity after an outbreak
Confirmed human cases of HPAI
Migratory pathway for birds and Avian influenza
Neglected diseases Cause over 500,000 deaths and 57 million
DALYs annually. Include the following
Helminthic infections Hookworm (Ascaris, trichuris), lymphatic filariasis,
onchocerciasis, schistosomiasis, dracunculiasis Protozoan infections
Leishmaniasis, African trypanosomiasis, Chagas disease
Bacterial infections Leprosy, trachoma, buruli ulcer
Communicable Disease and Human Security
Part 2 - Mounting an Effective Global Response
Approaches to Interventions
Personal Responsibility and action Utilitarian Approaches – “Greatest
good for the greatest number” Including non Health Systems
Interventions. Regulations and Laws Partnerships and Collaboration Enlightened Self Interest
Personal Responsibility and action
Improved hygiene and sanitation Hand washing, proper waste disposal, food
preparation and handling. Information, education and behavior
change Changing harmful household practices Livestock handling, knowledge about contagion
Cultural and social norms Self reporting of illnesses and compliance
with interventions and treatment.
Utilitarian Approaches – “Greatest good for the greatest number”
Reliance on personal responsibility not always the optimal option given different knowledge levels
and values. Public good nature of the interventions
Social Isolation and Quarantine measures Home treatment; Isolation
Mass vaccination programs and campaigns Polio, small pox, DPT, Hepatitis, Yellow fever
Mass treatment programs – Onchocerciasis, de-worming programs.
For some CDs, intervention in other sectors is required
Environmental health – elimination of breeding sites, spraying Agricultural practices such as poultry handling and exposure to
soil pathogens during farming.
Regulations and Laws National response remains the bedrock of
intervention National laws and capacities vary.
International Regulations and laws introduced 1851 – International Sanitary regulations in Europe
following cholera outbreak 1951- international sanitary regulation by WHO. 1969- Replaced by the International Health regulation
Minor changes in 1973 and 1981 cholera, plague, yellow fever, smallpox, relapsing fever
and typhus 2005 – Revised International Health Regulation
Challenge of enforceability of international agreements.
Regulation and laws – WHO 2005 International health regulation IHR (2005) is a legally binding agreement among
member states of WHO to cooperate on a set of defined areas of public health importance.
Arrived at by consensus of all member countries of WHO, with clear arbitration mechanisms
Its elements include Notification: National IHR Focal Points and WHO IHR Contact Points Requirements for national core capacities Recommended measures External advice regarding the IHR (2005)
Partnerships and Collaboration Collaboration vs. coercion Importance of partnerships –
MDG 8: “Develop global partnerships for development”
Comparative advantage of partners Inclusiveness
Examples of partnerships Over 70 Global health partnerships available
Examples include the Stop-TB program, GFATM, RBM, UNAIDS, GAVI, Global Outbreak Alert and Response Network, GAIN, bilateral and multilateral organizations.
MOH MOEC
MOF
PMO
PRIVATE SECTORCIVIL SOCIETYLOCALGVT
NACP
CTU
CCAIDS
INT NGO
PEPFAR
Norad
CIDA
RNE
GTZ
SidaWB
UNICEF
UNAIDSWHO
CF
GFATM
USAID
NCTP
NCTP
HSSP
HSSP
GFCCPGFCCPDAC
CCM
T-MAP
3/5
SWAPSWAP
UNTG
PRSP PRSP
Isn’t Donor Collaboration Wonderful?Isn’t Donor Collaboration Wonderful?
Source: WHO: Mbewe
A paradigm shift - Enlightened Self interest Communicable diseases have no borders.
Predominantly affect the poor, and poor countries Also affect richer households and countries.
Interventions are non-rival, non-exclusive and have positive externalities.
Elimination and control of certain communicable diseases increases global health security.
Limited financial incentives for the market to drive needed innovation in research and drug development
Mismatch between global health need and health spending
Global health security is therefore inextricably tied to the effective control of CDs in developing world.
Global Mismatch Between Disease Global Mismatch Between Disease Burden and Health SpendingBurden and Health Spending
Burden of disease in disability adjusted life years by income category
9.7%55.9%
34.4%
% DALYs in LIC % DALYs in MIC % DALYs in HIC
Global Mismatch Between Global Mismatch Between Disease Burden and Health Disease Burden and Health SpendingSpending
Distribution of Total Global Expenditures on Health by Income Category
10%
2%
88%
Low income Middle income High income
Future Population Growth Will be Future Population Growth Will be in LICs and MICsin LICs and MICs
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
9,000
10,000
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
Year
Tota
l popula
tion (
millions)
Developing countries
Developed countries
Key principles of an Effective Global Response
Respect for the value of each life Behind every statistic is an individual Understanding of the social context that govern
individual decision making Disease Surveillance and reporting Management and containment of outbreaks Strong legal and regulatory framework Sustained and predictable financing Building national health systems
World Bank’s involvement Relevance to our mandate
CDs disproportionately affect the poor and LICs and MICs
Enormous economic consequences Major constraint to achieving the MDGs
Major source of financing for poor countries This position is rapidly changing with the
entrance of newer players in DAH such as Gates foundation, Bilaterals, multilaterals.
Call for innovative financing schemes
World Bank $430 million committed to malaria
booster projects in Africa By 2008, 21 million bed nets and 42
million ACT doses would have been distributed.
As of June 2007, the World Bank had approved financing of $377 million for 40 projects in 45 countries in all six geographic regions to combat Avian influenza
Cumulative WB commitment to HIV/AIDS is over $2.5 billion
Sources of Development Sources of Development Assistance for HealthAssistance for Health
0
2,000
4,000
6,000
8,000
10,000
12,000
Average 1997-99 2003Year
US$ (
in m
illio
ns)
Private Non-profit
Other Multilateral
Development Banks
UN System
Bilateral
Source: Michaud 2006
The World Bank’s new HNP strategy
Five broad strategic directions of the World bank Focus on HNP Results Strengthening health systems Ensuring synergies between Health Systems
strengthening and priority disease interventions
Intersectoral approach to HNP results Increase strategic and selective
engagement with development partners.
Thank You.