1. Containing Infectious Disease State of the World Worldwatch Institute Image: CDC

2. Infectious Disease A security threat Outbreak dynamics Current threats Economic Impact Managing future outbreaks © PAHO

3. Security Threats Infectious diseases remain a security challenge—the dreaded Fourth Horseman of the Apocalypse –Diseases rank with wars and famine as major security threats –Diseases are a leading cause of death and disability worldwide Jean Colombo, The Horsemen of Death, Musee Conde, Chantilly

4. Security Threats –the emergence of new infectious diseases –a resurgence of older diseases –a spread of resistance to a growing number of antibiotic drugs What are the global threats? © WHO

5. Historical Context Infectious diseases have been called pestilences, pests and plagues since ancient times –Plague of Athens heralded end of Greece' Golden Age –1300s Black Death in Europe killed 40% of the population –1500s smallpox in Latin America killed 10-15 million –1918 Influenza pandemic during WWI took 20-40 million lives

6. A War Not Won By the 1960s, with improved sanitation, medicine and drugs, the U.S. Surgeon General stated, "the war against infectious diseases has been won." The war continues today: –The campaign to eradicate infectious disease is ongoing –Pathogens are exhibiting remarkable resilience and flexibility

7. A War Not Won At least 30 diseases not previously known such as Ebola, hepatitis C, hantavirus, SARS and HIV have emerged Twenty well-known maladies such as TB, malaria, cholera and influenza have re-emerged or spread © WHO

8. Dynamics of Outbreaks Which causes more deaths -- military combat or diseases? –All the wars of the 20th century killed an average of about 1.1 million combatants and civilians a year –Communicable diseases are now killing 14 times as many people annually –A new influenza pandemic could kill millions © Digital Vision

9. Dynamics of Outbreaks What factors can disturb the balance between people and pathogens resulting in a large-scale disease outbreak? –changes in human behavior or circumstances –mutations in or movement of pathogens –changes in shared environments © Digital Vision

10. Historical Outbreaks Changes in relationships between people and microbes have facilitated disease outbreaks in three recent historical periods 10,000 years ago –domestication brought people and animals together –settlements brought people into close contact with accumulated wastes © WHO

11. Historical Outbreaks 2,500 years ago –the Roman Empire in the West and the Han Dynasty in the East expanded trade and germs were swapped in both directions 14 th and 15 th centuries –transoceanic exploration and trade brought the bubonic plague to Europe and smallpox, measles, influenza and other diseases to indigenous peoples in the western hemisphere

12. Contemporary Outbreaks Today population growth, industrialization, globalization, migration and urbanization have created a fourth wave of outbreaks 20 th and 21 st centuries –1957 Asian flu and the 1968 Hong Kong flu pandemics killed 4 million worldwide –1981-2003 AIDS deaths total more than 20 million © Digital Vision

13. Globalization What effect has the globalization of travel and commerce had on the spread of diseases? –In the 1300 the Black Death took several years to spread across Europe –In 2002 in remote China, SARS, a new respiratory disease, jumped from animals to people and within 6 months was reported in 29 countries around the world © CDC

14. Population Growth What can we expect as the world population grows to over 7 billion people? Billion people

15. Urbanization As populations become more densely packed it is easier for pathogens to spread rapidly In 1965 36% of world's population lived in cities, today it is almost 50% By 2030 the U.N. predicts 2 billion people may live in urban slums © stock.xchng

16. Urbanization Most growth will be in developing countries Billions of people Developing Nations—Urban Developing Nations—Rural More Developed Nations—Total

17. Migration What happens when people are displaced due to population growth or ethnic violence in developing countries? Crowed refugee camps around the world become ideal incubators for diseases © UN New settlements push into forested areas where microbes in wild animals can spread to humans © Yosef Hadar/World Bank

18. Rich or Poor Does affluence or poverty make a difference? –In poor nations, many people suffer from infectious diseases of the underfed –In affluent nations, an increasing number of people are afflicted with chronic diseases of the overfed © UN/DPI© stock.xchng

19. Poverty –An estimated 2.8 billion people now live on less than $2 per day with little access to health care –In Africa, infectious and parasitic diseases account for about 50% of all deaths, while in Europe they account for only 2% Persistent Poverty © FAO

20. Technology How has technology transformed the way in which people and pathogens interact? –Speed and pervasiveness of international travel means people and pathogens move swiftly across borders –Imports of agricultural commodities increase the risk of infectious microbes on food © USDA

21. Technology –Urban sewage systems in developing areas often pollute water encouraging waterborne diseases –Industrial and auto pollution contribute to global warming allowing tropical pathogens to expand their range –Increased use and misuse of antibiotics creates drug resistant microbes © Digital Vision

22. Current Status Of an estimated 57 million people who died worldwide in 2002, infectious diseases caused 14.9 million deaths –20 previously well-known diseases have reemerged or spread geographically –30 diseases not previously known to be infectious have been identified in the last three decades

23. Global Deaths from Major Communicable Diseases Diseases Worldwide 2000 (million) 2002 (million) Share of all Deaths in 2002 (percent) Respiratory infections 3.94.06.9 HIV/AIDS2.92.84.9 Diarrhea2.11.83.2 Tuberculosis1.71.62.7 Malaria1.11.32.2

24. HALE HALE = the number of healthy years that a newborn can expect to live based on current rates of ill health and mortality –The HALE for Japan is 75 (75 healthy years and 6.9 years of disability due to infectious or chronic diseases) –In Sierra Leone the HALE is only 28.6 years Big gap between the HALE of rich and poor countries

25. HALE Highest CountryHALE Japan75.0 Sweden73.3 Switzerland73.2 Italy72.7 Australia72.6 Spain72.6 Canada72.0 France72.0 Norway72.0 Germany71.8 Lowest CountryHALE Sierra Leone28.6 Lesotho31.4 Angola33.4 Zimbabwe33.6 Swaziland34.2 Malawi34.9 Zambia34.9 Burundi35.1 Liberia35.3 Afghanistan35.5

26. Drugs and Developing Countries Between 1975-1997 only 13 out of 1,233 drugs on the global market were for tropical diseases Each year, more than 2.3 million people, primarily in poor countries, die from 8 diseases that could be prevented by vaccinations Why are drugs not available in developing countries? © WHO

27. Drugs and Developing Countries Pharmaceutical companies are concerned about intellectual property rights and profits Poor countries lack money and enough health care workers to distribute needed drugs © WHO

28. HIV/AIDS In the near future, what is the most pressing global health issue? –Worldwide more than 20 million people have died from HIV/AIDS –Seven sub-Saharan African countries have HALEs of less than 35 years due to poverty and the rampage of HIV/AIDS –34-46 million people are now living with HIV/AIDS © WHO

29. HIV/AIDS Source: UNAIDS Millions AIDS Deaths HIV Infections

30. HIV/AIDS Future Impact India, China, Nigeria, Ethiopia and Russia are likely to see rapid growth of infections with 50-70 million infected by 2010 –India is expected to have 20-25 million cases and an adult prevalence rate of 3- 4% –China is expected to have 10-15 million victims and an adult prevalence rate near 2% © FAO

31. HIV/AIDS in the Military HIV/AIDS is higher in many armed forces than in civilian populations, particularly in developing countries –In Zimbabwe and Malawi the infection rate among armed forces is 70-75% –Active duty military, combatants and peacekeeping forces are contributing to the spread of the disease © UN

32. HIV/AIDS in the Military How does AIDS in the military affect national security in developing countries ? –Diminished efficiency of troops –Demoralization among troops –Effectiveness and discipline are threatened –Medical treatment is costly –Loss of leadership and professional standards –Destabilized governments © UN

33. Influenza What is influenza? It is a common virus that continually undergoes small changes, evading human immunity throughout the world –Periodically the virus shifts to new, more deadly forms that can spread from person to person –Deadly pandemics occurred in 1988, 1918, 1957 and 1968 –WHO estimates a new outbreak could kill 650,000 and hospitalize 2.3 million in industrial countries alone Courtesy of National Museum of Health and Medicine

34. Animal-Human Connection People and animal interactions have a history of disease transmissions –West Nile virus passes from birds to people via mosquitoes –Lyme disease from mice to people via deer ticks –SARS virus jumped to people from palm civets –Avian flu in chickens transferred to humans © CDC © ebi bioinformatics

35. Avian Flu in Asia

36. Recent avian influenza cases occurred when the virus jumped from poultry to humans In late 2004 the first case of human-to-human infection was documented Infected international travelers could rapidly spread the disease creating a pandemic © FAO

37. Human Infections with Avian Influenza Viruses, 1997-2004 1997 H5N1 Hong Kong 18 cases 6 deaths 1.4 million chickens slaughtered 1999 H9N2 Hong Kong 2 cases 2003 H5N1 Hong Kong 2 cases 1 death H7N7 Netherlands 84 cases 30 million chickens slaughtered in Europe 1 death H9N2 Hong Kong 1 case 2004 H5N1 8 Asian countries including Thailand & Vietnam 34 cases 23 deaths 100 million fowl culled H7N3 Canada and US 2 cases Late 2004 first probable case of human to human transmission Source: WHO

38. Genetic Mixing and Transmission What is interspecies genetic mixing? –Back-switches of human viruses have emerged in pigs –Both doubly mixed (pig- human) and triply mixed (pig- human-avian) viruses have been isolated –Mixing is suspected to have occurred in the 1918 influenza pandemic © FAO

39. Bioterrorism Are bioterrorism and biowarfare new concepts? –1346 historians suggest plague-ridden corpses were catapulted over enemy walls in siege of Caffa (Ukraine) –1754-1763 during the Seven Years War, officers may have given smallpox impregnated blankets to Indians –1984 Oregon religious cult spiked restaurant salad bars with Salmonellae –2001 terrorists mailed letters filled with anthrax spores to prominent U.S. citizens © stock.xchng

40. Economic Consequences Governments often attempt to keep disease outbreaks under wraps because of the economic consequences –Nine countries in sub- Saharan Africa are losing more than 10% of working- age population every five years, largely due to HIV –A 1994 outbreak of pneumonic plague in India resulted in $1.7 billion in lost exports and tourism African AIDS quilt © FAO

41. Economic Consequences In 2003 a SARS outbreak in East Asia had major effects on travel and exports –China's tourism industry lost an estimated $7.6 billion and 2.8 million jobs –Overall loss to the travel economy was thought to be $20.4 billion –Economists shaved about 1.5 percentage points off 2003 growth estimates for the economies of Hong Kong, Singapore, and Malaysia

42. Economic Consequences In the world's poorest countries HIV prevalence among the most productive working-age adults is above 20% causing significant economic tolls –Retards industrial development –Reduces agricultural production –Devastates education –Weakens the military –Undermines political stability © FAO

43. Economic Consequences How has HIV/AIDS affected the GDP of African countries? –GDP declined by an average of 1.1 % per year between 1992 and 2002 in 33 countries –By 2020 estimates of the collective loss in economic growth is 18% or roughly $144 billion © UN

44. Managing Future Outbreaks Infectious diseases will continue to emerge and re-emerge, leading to unpredictable epidemics and difficult challenges to public health and science International security priorities need to include revised expenditures to reflect the threat of infectious diseases in our increasingly interconnected world

45. Managing Future Outbreaks 1.Increase surveillance on a global scale to detect new disease outbreaks quickly 2.Use anticipatory thinking and action to prepare for and avoid rapidly moving future pandemics 3.Start campaigns to eradicate serious illness among the world's poor 4.Develop better mechanisms to distribute antiretroviral drugs and other pharmaceuticals to poverty stricken disease victims

46. Managing Future Outbreaks 5.Create innovative ways to provide affordable drugs to victims in poor countries 6.Encourage greater transparency by governments where disease outbreaks are likely to occur 7.Redefine security priorities and funding to reflect the serious challenges of new and resurgent disease in a globalized world 8.Address economic liability issues arising from the rapid development of vaccines for swiftly moving diseases

47. Managing Future Disease Outbreaks 9.Provide incentives for the development of new vaccines and medicines for endemic diseases in developing countries 10.Fund and build effective public health systems © WHO

48. Worldwatch Institute Further information and references for the material in this presentation are available in the Worldwatch Institute’s publication “State of the World 2005” This presentation is based on Chapter 3 “Containing Infectious Disease” authored by: Dennis Pirages www.worldwatch.org