The new Panama canal facing the reemergence of old and still NTD related to the old Panama Canal

Dr. Esteban A Morales m.d; mph; msc

DENGUEGROWING PUBLIC HEALTH PROBLEM

MACROFACTORES

climate change - such as global warming, phenomena of the child/of the Southern Oscillation (ENSO) and the girl (AENOS),

population growth unprecedented in the region and not always with an appropriate health infrastructure (not controlled or planned urbanization)),

microfactores

VECTOR HABITS HUMAN

BEING

CURRENT SITUATION OF DENGUE FEVER

Last year, in Panama, the largest number of deaths from dengue hemorrhagic fever since the last reinfestation by Aedes mosquito aegypti in 1985.

Around 2000 cases of classic dengue

¿Why is this and what can we do?

BACK AT THE MACROFACTORES

What happened two centuries ago

Two megaprojects of the time 1850 The Panamá railroad discovery of gold in California in the

latter part of 1848 1914. the Panama Canal.

What happened two centuries ago

The French started to build the canal in 1850 until they fell into the historical financial disaster that led into bankruptcy in 1885;

after a second attempt with another French company started in 1989, they decided to sell the rights for the building of the canal to the United States, for 40 million dollars in 1902.

FERDINAND DE LESSEPS

but the health aspects were especially important. Death and suffering and disease were the principal characteristics in this period of time

They had to face many difficulties

The workers were constantly attacked with fever and malaria, and, though the whole working party was changed every week, it was necessary to keep constantly importing others to take the places of those who fell sick or died. 

La Folie Dingler

It was the prospective home of M. Jules Dingler director-general of the first French companyhe never occupied it. cost including the grounds is said to have been about $50,000. one of the saddest incidents in French canal history.  he is credited with having said, "I am going to show them, that only drunkards and the dissipated contract yellow fever and die."  Afterwards his son, daughter and wife died of yellow fever. Then he relinquished his post and went back to France

It was the era of the megaconstruction of the Panama canal

The great transformation faced deteriorated due to rapid immigration, the concentration of this population in the cities. The response of the institutions of the State were not at the same speed.

But the process itself, also produced risk situations, such as the proliferation of excavations and large ditches, which were important under the epidemiological point of view

HOSPITAL ANCÓN. PANAMÁ. 1900

NICE HOSPITALS ARE NOT ALWAYS THE ANSWER

But... the French failed in its mission. What happened then?

But... the hospitals are also needed

Hospitals, then as now are not the initial response, neither the spearhead of the public health problems.

DESPITE THE PRESENCE OF PRESTIGIOUS FRENCH DOCTORS, FIRST CLASS NURSES AND HOSPITALS AS DESCRIBED, THE DISEASE BEAT

US CANAL

US CANAL

When the United States started into build the Panama Canal, the first duty was the sanitation of the area. Col. William Gorgas was in charge of it

US CANAL

He was fresh from his successes in Cuba, where he had, applied the lessons of sanitation that had been learned by Dr. Carlos Finlay in their remarkable series of experiments with yellow fever, who found out that a mosquito was the transmitter of this disease.

US CANAL

he was assisted by a number of experienced surgeons, as well as by Major Roland Ross, the man who had proven the mosquito theory of the causation of malaria

Gorgas bases his strategy on a mass sanitation.

He proposes the construction of 10 clinics (outpatient) along all the waterway, between Panama and Colon

BRIEF REVIEW OF THE HISTORY

100 Years ago there was a rapid transformation of a hamlet into a city.

100 Years ago were used modern prevention strategies and innovative care and control.

WAS A TIME OF GREAT CONSTRUCTIONS

Distribution of the workers for 1913 :

Antillanos 29667

Chinos 15000

Españoles 8722

Italianos 1941

Colombianos 1403

Panameños 357

Ticos 244

Franceses 19

Armenios 14

No Clasificados

69

Time of big changes

WHEN IT MOVED FROM THIS…

AND GRADUALLY CAME TO THIS…

100 years ago…

THE RAPID POPULATION GROWTH WAS FACED

WITH REORGANISATION MEASURES, WHICH WAS INNOVATIVE

¿what is happenning now?

they are repeated, but magnified tremendously, events of that first Republic. We are living in an era with similar characteristics

The extension works, initiated since September 2007, with a value of 5,250 million dollars of which 3.2 billion are aimed at the design and construction of a third set of locks, work that has advanced 22%

The

new C

ANAL OF

PANAMA

PHYSICAL AND GEOGRAPHICAL CONTEXT

EL CONTEXTO GEOGRÁFICO

cuentan con la mayoría de los recursos naturales yambientales disponibles en el territorio nacional.

Climate Intertropical Region

high rainy season precipitation temperatures

Tropical diseases:Malaria.Dengue.

Leishmaniasis.Enf. de Chagas

PANAMA ESTE, PARTE DE LA CUENCA DEL CANAL

The province of Panama is the receiving province for excellence, followed by the province of Colon. Panama collects 70% of immigrants in the country. The immigrant men represent the 28.0% and females the 31.6%. Between these two migration flows, the percentage of emigrants is greater than immigrants. To differentiate this percentage according to provinces in the Panama immigrants accounted for the 31.6 per cent, while migrants only 5.6%, from there that one is born in another province of each 4 persons residing in the province of Panama.

AEDES AEGYPTI Y DENGUE

Rhodnius pallescens

Is the main vector - trypanosoma cruzi in Panama and the single triatomineo transimisor Trypanosoma rangeli here in Panama

It is a hematophagous insect of the order diptera, family Reduviidae, subfamily Triatominae

great ability to invade and colonize human habitation.

Hábitat

Main reservoirs are the mammals (90%), mainly zariguellas.

47% Collected triatomine were positive by trypanosomes of which 85% corresponded to T. cruzi and the rest to T. rangeli. Héctor Paz

DONANTES72.2%

I. CAMPO20.4%

Dx. CLÍNICOS1.9%

IF5.6%

39

11

13

ENFERMEDAD DE CHAGAS SEGÚN CONDICIÓN PANAMA, AÑO 2002*

* CIFRAS PRELIMINARESFUENTE: DVFPRSE- LCR ecaw Captación

activa

Leishmaniasis

The regions most affected are Colon, Bocas del Toro, Coclé, Darien, Panama. East and Western Panama recorded incidence rates, during all the period, rates higher than the national rate.

The presence of livestock in the basin has left deep marks on its natural resources. Firstly, it has caused the Elimination of important forest areas. The loss of plant cover, in turn, increases levels of sediment entering the Lakes of the channel, influencing the quality of its waters. Studies on water quality in different points of the basin indicate that direct animal contact with bodies of water affects the concentration of micro-organisms harmful to human health.

PEOPLE MOVEMENT

DEFORESTATION

NTD´SConcept and importance

Probably the first formal discussion about ND was held in 1977, with the Rockefeller Foundation, establishing the “Great Neglected Diseases of Man Kind Program”, focusing in collaborative researches on malaria in poor countries.

Then, in 2000 WHO took over the subject and conducted by the Millennium objectives established at that time by 147 chiefs of states, decided to frontally confront these diseases.

One of the first authors that defined the criteria for NTD was Ehrenberg (Ehrenberg & Ault 2005).

In general terms the so called ND are those related to the also called, neglected population. are communicable diseases from the tropical areas of the world.

They pose a major challenge to the fulfillment of the Millennium Development Goals; hence, there is involved an ethical and strategic component in the control of these diseases.

NDs AND GLOBAL HEALTH a changing world where borders between countries

are disappearing Global communication and technology make global

communities migratory movements have increased Typology of population movement according to the

characteristics of onset, cause, direction and motivation. Lechat (1976); Shears (1991); and others

mega projects need the contribution of human resources from many different part of the globe

new transport infrastructure allows parasites and vectors to travel greater distances

population resettlement may introduce parasite carriers to receptive areas or to those who are not immune to pathogens transmitted by vectors.

Which are the principal NTD´S

There is a great variety of diseases considered as NTD´s depending of the region of the world, history and resources (Weekly epidemiological record, No. 13, 25 march 2011)

Dengue. A mosquito-borne viral disease.

Rabies. A viral zoonotic disease. Trachoma. A bacterial infection

of the eye caused by Chlamydia trachomatis.

Buruli ulcer. A severe sken disorder caused by the bacterium Mycobacterium.

Endemic treponematoses. (yaws, endemic syphilis and pinta.

Leprosy. A chronic bacterial infection caused by the bacillus Mycobacterium.

Chagas disease (American trypanosomiasis) .

Human African trypanosomiasis

(sleeping sickness). Leismaniasis Cysticercosis. A severe helmint

infection. Dracunculiasis. (guinea-worm

disease) A helminth infection. Food borne trematode infections.

A group of parasitic worm infection.

Lymfatic filariasis. Onchocerciasis. (river blindness) Shistosomiasis (bilharziasis) Soil transmited helminthiases.

Some others (Hermann Feldmeiera & Jorg Heukelbach b) consider the Epidermal parasitic skin diseases (EPSD) that occur worldwide and have been known since ancient times. Despite the considerable has been widely neglected by the scientific community and health-care providers.

other author (N. Akritidis ) considers Parasitic, fungal and prion zoonoses as other less classic ND. a list that is likely to expand in the future as novel human immune compromised

Although prions cannot strictly be considered to be infectious agents, as they are not pathogens as such, BSE possesses all the typical characteristics of a zoonotic infection. the disease induced in humans, variant Creutzfeldt–Jakob disease behave as a typical zoonosis.

For our purpose, in our case, I

am emphasizing in leismaniasis

and I will be presenting an

specific proposal for this

WHY IS NECCESARY TO CONTROL NTD´S

high financial burden to the individual, the family, the community, the country and even the region – impairing its development.

Since most are zoonosis, they represent a serious menace to food security, and adversely affect opportunities for income generation.

long-lasting sequels' and cause persisting symptoms if the infestation remains untreated.

causes significantly more accumulated morbidity (anemia, chronic diarrhea and pain, undernutrition from protein loss, exercise intolerance, infertility, poor school performance) than previously thought (King CH, Dickman K, Tisch DJ

affect the most vulnerable people (women, children, eldest, migrant, inmuno supressed, indigenous population, minority ethnic groups, refugees. This confers the attention of NTD an ethical component

When all the NTD are put together in a single rate, these represent the second cause of death after HIV.

Are responsible of 27% of lost disability-adjusted life years. According to WHO (2006) ranked sixth among the ten leading causes of Disability Adjusted Life Years (DALYS) is the aggregated measure of 11 of the NTDs

SOME NDs IN THE US

Hotez et.al(2010) consider that such diseases are not confined to developing nations. He estimates that millions of Americans living in poverty also suffer from NTD-like infections. Parasitic diseases such as cysticercosis, Chagas disease, trichomoniasis and toxocariasis occur with high frequency in our inner cities, post-Katrina Louisiana, other parts of the Mississippi Delta, the border region with Mexico, and Appalachia

CHAGAS DISEASE afflicts an estimated 300,000 people in the U.S. Screening of donated blood, started in 2007, finds that cases are concentrated in areas with large numbers of immigrants from Latin America living in substandard housing.(Hotez et.al 2010)

LEISHMANIASIS

leishmaniasis

It consists of a group of parasitic diseases, caused by different species of Leishmania

It is a zoonosis Discovered by Brazilian scientists in

1909 In Panama the first indigenous case

was reported by Dr. S. T. Darling in 1910.

VISION TO SMEAR MICROSCOPY

In the host vertebrate intracellular amastigotes (aflagelado))

promastigota (flagellate)) found in digestive tract of thr flies

Areas de Leishmaniasis Endémicas

Cuatro tipos de síndromes clínicos

Leishmaniasis Visceral Leishmaniasis Cutánea del Viejo

Mundo Leishmaniasis Cutánea del Nuevo

Mundo (América) Leishmaniasis mucocutánea.

Delicate and tiny flies only about 2-4 mm long, these flies belong to the subfamily phlebotominae, family Psychodidae

Especies vectoras en Panamá

Luztomia panamensis. Luztomia trapidoi. Luztomia Gomezi Luztomia ylephileptor. Luztomia sanguinarialis Luztomia olmeca.

RESERVORIO

“perezoso colorado” of two nails (choloepus hoffmanni)

Tratamiento

pentavalent antimony compounds have remained the principal solution for nearly 75 years

As a conclusion

Globalization, Population movements, as crucial factors related to neglected tropical diseases

Globalization has led to massive migratory movements; unplanned urbanization and the fast conexion between massive transport media have made more dangerous these diseases since many of them are zoonosis and vector transmitted diseases.

According to the International Organization for Migration (IOM) (2009), more than 200 million people are estimated to be international migrants; another 26 million are internally displaced in at least 52 countries as a result of conflict. Overall migrants comprise 3% of the world’s population (IOM 2009).

Migration, poverty and disease is many times a funest triangle that leads to more disease, more poverty and more under develope.

For example, some authors found that leismaniasis is four times more frequent among people with protein-energy malnutrition (Machado-Coelho et al. 2005)

Since the focus is given to the international heath, then the strategies derived from it suggest a strong international cooperation.

Following the initative proposed in the first Universities allied for esential medicines neglected diseases and innovation symposium.

Finally, I consider that one of the main issues related to the problem of NTDs in general and to leishmaniasis in particular is the one related to vaccination and medication.