1. Communicable Diseases and Human Security
Kelechi Ohiri MD MPH MS
Health, Nutrition, Population
Human Development Network
World Bank
Review the choice of the title

2. 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
Introduction and Definition
Definition:
Modes of transmission
Examples of CDs
Common Infectious diseases
Neglected diseases
History of Communicable Diseases
Burden of Disease
Global burden of disease and communicable diseases, by region, gender and income levels
Importance of CDs
Sheer Burden
Economic impact
Rate of spread
Recurrence of diseases
Security and CDs
Interventions
Why intervene? Why should policy makers care about CDs?
History of interventions and policy issues
What is needed for effective control of CDs
Global Approaches
Global responsibility
International law
Partnerships and collaboration
Financial support
World Bank’s role and involvement
Total lending in health
Special programs the Bank is involved in.
Conclusions and Way forward

3. 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.

4. 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
These have become more important given the modern means of transportation and increased interaction across countries that makes it easy for an infectious pathogen to spread from one part of the world to another

5. 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)

6. 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

7. 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.
Even with the projected rise in the burden of NCDs, CDs are expected to account for 26% of the BoD in 2015 globally, and 56% in Africa. (Global Burden of Disease

8. Communicable Disease Burden Varies Widely Among Continents

9. Communicable disease burden in Europe

10. Causes of Death Vary Greatly by Country Income Level
In Sierra Leone most deaths occur in the U5 age group, whereas in Denmark it is among those over 65.

11. 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
Global importance of Communicable Diseases
Enormous burden and impact globally
Economic impact
Constrain health and development of infants and children and affect their schooling
Stigma and discrimination against people with certain communicable diseases such as HIV/AIDS, TB. Leprosy
Disruption of social networks and family structure e.g. with Orphans and other vulnerable children who have lost their parents or other care gives due to HIV/AIDS
TB-
Malaria
HIV/AIDS etc

12. 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
Reduction in revenue for the country
India example during the bubonic plague outbreak
Substantial loss in productivity and income
In Tanzania, men with AIDS lost an average of 197 days of work over an 18 month period.
Catastrophic costs of treating illness

13. 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
In history, attempts at stopping communicable diseases from entering a country often proved ineffective

14. 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.

15. Select Communicable Diseases

16. 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
Two billion people – one third of the world’s total population–are infected with the microbes that cause TB.
Of these, 10% will become sick with active TB in their lifetime. Risks are higher in those with HIV infection.
A total of 1.6 million people died from TB in 2005, equal to about 4400 deaths a day. TB is a disease of poverty, affecting mostly young adults in their most productive years. The vast majority of TB deaths are in the developing world, with more than half occurring in Asia
TB/HIV- About people with HIV die from TB every year, most of them in Africa.
TB is a worldwide pandemic. Although the highest rates per capita are in Africa (28% of all TB cases), half of all new cases are in six Asian countries (Bangladesh, China, India, Indonesia, Pakistan and the Philippines).
Multidrug-resistant TB (MDR-TB) is a form of TB that does not respond to the standard treatments using first-line drugs. MDR-TB is present in virtually all countries recently surveyed by WHO and its partners.
About new MDR-TB cases are estimated to occur every year. The highest occurrence rates of MDR-TB are in China and the countries of the former Soviet Union. Extensively drug-resistant TB (XDR-TB) occurs when resistance to second-line drugs develops. It is extremely difficult to treat and cases have been confirmed in South Africa and worldwide.
WHO’s Stop TB Strategy aims to reach all patients and achieve the target under the Millennium Development Goals (MDG): to reduce by 2015 the prevalence of and deaths due to TB by 50% relative to 1990 and reverse the trend in incidence.
The Global Plan to Stop TB , launched January 2006, aims to achieve the MDG target with an investment of US$ 56 billion. This represents a three-fold increase in investment from The estimated funding gap is US$ 31 billion.

17. 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.
Most cases of XDR-TB were in HIV infected individuals.

18. Global Prevalence of TB cases (WHO)

19. Tuberculosis

21. Tuberculosis Control Challenges for tuberculosis control
MDR-TB - In most countries. About new cases annually.
XDR-TB cases confirmed in South Africa.
Weak health systems
TB and HIV
The Global Plan to Stop TB
an investment of US$ 56 billion, a three-fold increase from 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

22. 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
More than one million people die of malaria every year, mostly infants, young children and pregnant women and most of them in Africa
Approximately, 40% of the world’s population, mostly those living in the world’s poorest countries, are at risk of malaria. Every year, more than 500 million people become severely ill with malaria. Most cases and deaths are in sub-Saharan Africa.

23. Annual Reported Malaria Cases by Country (WHO 2003)

24. Global malaria prevalence

25. Malaria Control Malaria control Challenges in 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
With full LLITN coverage, child mortality from all causes is reduced by 18%

26. 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 age group.
Previously unknown about 25 years ago. Has affected over 60 million people so far.
One of the most devastating conditions of the 21st century
An estimated 38.6 million [33.4 million–46.0 million] people worldwide were
living with HIV in An estimated 4.1 million [3.4 million–6.2 million]
became newly infected with HIV and an estimated 2.8 million [2.4
million–3.3 million] lost their lives to AIDS.

27. HIV Co-infections Impact of TB on HIV HIV and Malaria
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
Growing body of evidence on the interactions between both conditions
Both are diseases of poverty

28. Global HIV Burden

29. HIV/AIDS Interventions depend on Elements of an effective intervention
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)

30. Avian Influenza
Seasonal influenza causes severe illness in 3-5 million people and – deaths yearly
1st H5N1 avian influenza case in Hong Kong in 1997.
By October 2007 – 331 human cases, 202 deaths.

31. 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
Limited evidence suggests that some antiviral drugs, notably oseltamivir (commercially known as Tamiflu), can reduce the duration of viral replication and improve prospects of survival, provided they are administered within 48 hours following symptom onset.

32. Confirmed human cases of HPAI

33. Migratory pathway for birds and Avian influenza

34. 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

35. Communicable Disease and Human Security
Part 2 - Mounting an Effective Global Response

36. 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

37. 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.
Improved hygiene and sanitation
Hand washing, proper waste disposal, sewage system, cooking methods and boiling water
Information, education and behavior change including household practices
Livestock handling, knowledge about contagion,
Cultural norms
Poultry and farming methods, …..
Self reporting of illnesses and compliance with interventions and treatment
Unexplained fevers, ARI symptoms, etc
Compliance with medications to reduce potential for drug resistance. – hasn’t always worked - DOTS

38. 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.
Utilitarian Approaches – “Greatest good for the greatest number” – Sort of cost benefit analyses, where the benefits of the intervention such as the lives saved or years of live gained, etc, exceed the costs which could range from just the prick of a needle to a minority developing side effects of the vaccine.
Social Isolation and Quarantine measures
Home treatment
Isolation
Mass Vaccination programs
Polio in Nigeira

39. 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.
Regulations and Laws-
Challenge of enforceability, as it often relies on international cooperation and pressure

40. 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)
Notification - The IHR (2005) require States to notify WHO of all events that may constitute a public health emergency of international concern and to respond to requests for verification of information regarding such events.
Under the WHO Constitution, all WHO Member States are automatically bound by the new IHR (2005) unless they affirmatively opt out within a limited time period, namely by 15 December No WHO Member State has completely opted out, and only a very small number made reservations.

41. 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.
Effectiveness of global response is based on the principle of collaboration
The Global Outbreak Alert and Response Network (GOARN) is a technical collaboration of existing institutions and networks who pool human and technical resources for the rapid identification, confirmation and response to outbreaks of international importance.

42. Isn’t Donor Collaboration Wonderful?
WHO
INT NGO
CIDA
3/5
UNAIDS
GTZ
RNE
UNICEF
Norad WB
Sida
USAID
T-MAP
MOF
UNTG
PMO CF
DAC
GFCCP
PRSP
PEPFAR
HSSP
GFATM
MOEC
MOH
SWAP
CCM
NCTP
CTU
CCAIDS
NACP
LOCALGVT
CIVIL SOCIETY
PRIVATE SECTOR
Source: WHO: Mbewe

43. 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.
The need to move beyond charity-model.
Non-rival –The benefits from the Interventions can be enjoyed simultaneously by all in the community.
Lack of access to TB drugs may fuel resistance and the development of MDR-TB

44. Global Mismatch Between Disease Burden and Health Spending

45. Global Mismatch Between Disease Burden and Health Spending

46. Future Population Growth Will be in LICs and MICs
Therefore by the percentage of the global population susceptible to CDs will increase significantly.

47. 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
Respect for the value of each life – Behind the numbers of those affected by CDs are individuals, with hopes dashed and who make complex decisions, the context of which we are not very familiar with.
The person who refuses an HIV test, against the background of stigma
The mother in northern Nigeria who prevents her child from accessing polio vaccines because of the outbreak of vaccine-derived polio

48. 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

49. 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
more than 21 million LLINs and over 42 million doses of ACT will be distributed under projects in the Booster Program’s first phase ending in 2008.

50. Sources of Development Assistance for Health
Source: Michaud 2006

51. 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.

52. Thank You.
The World Bank has committed more than $430 million to Booster projects. A nine-fold increase in IDA funding for malaria control in Africa.