communicable diseases and human security ======================================== kelechi ohiri md mph ms ----------------------- h

Communicable Diseases and Human Security
========================================
Kelechi Ohiri MD MPH MS
-----------------------
Health, Nutrition, Population
-----------------------------
Human 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
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*
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 Varies Widely Among Continents
==========================================================
Communicable disease burden in Europe
=====================================
Causes of Death Vary Greatly by Country Income Level
====================================================
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.
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.
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 Burden and Health Spending
==========================================================
Global Mismatch Between Disease Burden and Health Spending
==========================================================
Future Population Growth Will be in LICs and MICs
=================================================
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 Assistance for Health
============================================
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.
==========

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