Presentation on theme: "Communicable Diseases and Human Security"— Presentation transcript:
1Communicable Diseases and Human Security Kelechi Ohiri MD MPH MSHealth, Nutrition, PopulationHuman Development NetworkWorld BankReview the choice of the title
2Outline of Presentation Part 1 – Overview of Communicable Diseases (CDs)Introduction and DefinitionImportance of CDsSelected CDs of Public Health ConcernPart 2- Mounting a Global ResponseApproaches to interventionKey elements of a global responseWorld Bank’s role and involvementIntroduction and DefinitionDefinition:Modes of transmissionExamples of CDsCommon Infectious diseasesNeglected diseasesHistory of Communicable DiseasesBurden of DiseaseGlobal burden of disease and communicable diseases, by region, gender and income levelsImportance of CDsSheer BurdenEconomic impactRate of spreadRecurrence of diseasesSecurity and CDsInterventionsWhy intervene? Why should policy makers care about CDs?History of interventions and policy issuesWhat is needed for effective control of CDsGlobal ApproachesGlobal responsibilityInternational lawPartnerships and collaborationFinancial supportWorld Bank’s role and involvementTotal lending in healthSpecial programs the Bank is involved in.Conclusions and Way forward
3Human Security in a globalized world The changing role of policy makers in an increasingly globalized worldShared space = Shared DestinyLocal actions have global consequencesGlobal interventions can achieve positive local impactAs long as human interactions exist, Communicable diseases will remain an issue.
4Communicable 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 toIncrease in the volume and means of transportation (affordable international air travel),globalization (increased trade and contact)Microbial adaptation and changeBreakdown of public health capacity at various levelsChange in human demographics and behaviorEconomic development and land use patternsThese 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
5CD- Modes of transmission DirectBlood-borne or sexual – HIV, Hepatitis B,CInhalation – Tuberculosis, influenza, anthraxFood-borne – E.coli, Salmonella,Contaminated water- Cholera, rotavirus, Hepatitis AIndirectVector-borne- malaria, onchocerciasis, trypanosomiasisFormitesZoonotic diseases – animal handling and feeding practices (Mad cow disease, Avian Influenza)
6Importance of Communicable Diseases Significant burden of disease especially in low and middle income countriesSocial impactEconomic impactPotential for rapid spreadHuman security concernsIntentional use
7Communicable 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 countriesMost 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
8Communicable Disease Burden Varies Widely Among Continents
10Causes 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.
11CDs have a significant social impact Disruption of family and social networksChild-headed households, social exclusionWidespread stigma and discriminationTB, HIV/AIDS, LeprosyDiscrimination in employment, schools, migration policiesOrphans and vulnerable childrenLoss of primary care giversSusceptibility to exploitation and traffickingInterventions such as quarantine measures may aggravate the social disruptionGlobal importance of Communicable DiseasesEnormous burden and impact globallyEconomic impactConstrain health and development of infants and children and affect their schoolingStigma and discrimination against people with certain communicable diseases such as HIV/AIDS, TB. LeprosyDisruption 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/AIDSTB-MalariaHIV/AIDS etc
12CDs have a significant economic impact in affected countries At the macro levelReduction 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 transmissionThe plague outbreak in India cost the economy over $1 billion from travel restrictions and embargoesAt the household levelPoorer households are disproportionately affectedSubstantial loss in productivity and income for the infirmed and caregiverCatastrophic costs of treating illnessReduction in revenue for the countryIndia example during the bubonic plague outbreakSubstantial loss in productivity and incomeIn Tanzania, men with AIDS lost an average of 197 days of work over an 18 month period.Catastrophic costs of treating illness
13International boundaries are disappearing Borders are not very effective at stopping communicable diseases.With increasing globalizationinterdependence of countries – more trade and human/animal interactionsThe rise in international traffic and commerce makes challenges even more dauntingOther global issues affect or are affected by communicable diseases.climate changemigrationChange in biodiversityIn history, attempts at stopping communicable diseases from entering a country often proved ineffective
14Human Security concerns Potential magnitude and rapid spread of outbreaks/pandemics. e.g. SARS outbreakNo country or region can contain a full blown outbreak of Avian influenzaBioterrorism and intentional outbreaksAnthrax, Small poxNew and re-emerging diseasesEbola, TB (MDR-TB and XDR-TB), HPAI, Rift valley fever.
16Tuberculosis 2 billion people infected with microbes that cause TB. Not everyone develops active diseaseA person is infected every second globally22 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 diseaseTwo 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 AsiaTB/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.
17Tuberculosis and HIVA third of those living with HIV are co-infected with TBAbout 200,000 people with HIV die annually from TB.Most common opportunistic infection in Africa70% of TB patients are co-infected with HIV in some countries in AfricaImpact of HIV on TBTB 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.
21Tuberculosis Control Challenges for tuberculosis control MDR-TB - In most countries. About new cases annually.XDR-TB cases confirmed in South Africa.Weak health systemsTB and HIVThe Global Plan to Stop TBan 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
22MalariaEvery year, 500 million people become severely ill with malariacauses 30% of Low birth weight in newborns Globally.>1 million people die of malaria every year. One child dies from it every 30 seconds40% 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 MICs11% of childhood deaths worldwide attributable to malariaSSA children account for 82% of malaria deaths worldwideMore than one million people die of malaria every year, mostly infants, young children and pregnant women and most of them in AfricaApproximately, 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.
23Annual Reported Malaria Cases by Country (WHO 2003)
25Malaria Control Malaria control Challenges in malaria control Early diagnosis and prompt treatment to cure patients and reduce parasite reservoirVector control:Indoor residual sprayingLong lasting Insecticide treated bed netsIntermittent preventive treatment of pregnant womenChallenges in malaria controlWidespread resistance to conventional anti-malaria drugsMalaria and HIVHealth Systems ConstraintsAccess to servicesCoverage of prevention interventionsWith full LLITN coverage, child mortality from all causes is reduced by 18%
26HIV/AIDSIn 2005, 38.6 million people worldwide were living with HIV, of which 24.7 million (two-thirds) lived in SSA4.1 million people worldwide became newly infected2.8 million people lost their lives to AIDSNew 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 centuryAn estimated 38.6 million [33.4 million–46.0 million] people worldwide wereliving 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 [2.4million–3.3 million] lost their lives to AIDS.
27HIV 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 patientHIV and MalariaDiseases of povertyHIV infected adults are at risk of developing severe malariaAcute malaria episodes temporarily increase HIV viral loadAdults with low CD4 count more susceptible to treatment failureGrowing body of evidence on the interactions between both conditionsBoth are diseases of poverty
29HIV/AIDS Interventions depend on Elements of an effective intervention Epidemiology – mode of transmission, age groupStage of epidemic –concentrated vs. generalizedElements of an effective interventionStrong political support and enabling environment.Linking prevention to care and access to care and treatmentIntegrate it into poverty reduction and address gender inequalityEffective monitoring and evaluationStrengthening the health system and Multisectoral approachesChallenges in prevention and scaling up treatment globally includeConstraints to access to care and treatmentStigma and discriminationInadequate prevention measures.Co-infections (TB, Malaria)
30Avian InfluenzaSeasonal influenza causes severe illness in 3-5 million people and – deaths yearly1st H5N1 avian influenza case in Hong Kong in 1997.By October 2007 – 331 human cases, 202 deaths.
31Avian Influenza Control depends on the phase of the epidemic Pre-Pandemic PhaseReduce opportunity for human infectionStrengthen early warning systemEmergence of Pandemic virusContain and/or delay the spread at sourcePandemic DeclaredReduce mortality, morbidity and social disruptionConduct research to guide response measuresAntiviral medications – Oseltamivir, AmantadineVaccine – still experimental under development.Can only be produced in significant quantity after an outbreakLimited 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.
34Neglected diseasesCause over 500,000 deaths and 57 million DALYs annually.Include the followingHelminthic infectionsHookworm (Ascaris, trichuris), lymphatic filariasis, onchocerciasis, schistosomiasis, dracunculiasisProtozoan infectionsLeishmaniasis, African trypanosomiasis, Chagas diseaseBacterial infectionsLeprosy, trachoma, buruli ulcer
35Communicable Disease and Human Security Part 2 - Mounting an Effective Global Response
36Approaches to Interventions Personal Responsibility and actionUtilitarian Approaches – “Greatest good for the greatest number”Including non Health Systems Interventions.Regulations and LawsPartnerships and CollaborationEnlightened Self Interest
37Personal Responsibility and action Improved hygiene and sanitationHand washing, proper waste disposal, food preparation and handling.Information, education and behavior changeChanging harmful household practicesLivestock handling, knowledge about contagionCultural and social normsSelf reporting of illnesses and compliance with interventions and treatment.Improved hygiene and sanitationHand washing, proper waste disposal, sewage system, cooking methods and boiling waterInformation, education and behavior change including household practicesLivestock handling, knowledge about contagion,Cultural normsPoultry and farming methods, …..Self reporting of illnesses and compliance with interventions and treatmentUnexplained fevers, ARI symptoms, etcCompliance with medications to reduce potential for drug resistance. – hasn’t always worked - DOTS
38Utilitarian Approaches – “Greatest good for the greatest number” Reliance on personal responsibilitynot always the optimal option given different knowledge levels and values.Public good nature of the interventionsSocial Isolation and Quarantine measuresHome treatment; IsolationMass vaccination programs and campaignsPolio, small pox, DPT, Hepatitis, Yellow feverMass treatment programs –Onchocerciasis, de-worming programs.For some CDs, intervention in other sectors is requiredEnvironmental health – elimination of breeding sites, sprayingAgricultural 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 measuresHome treatmentIsolationMass Vaccination programsPolio in Nigeira
39Regulations and LawsNational response remains the bedrock of interventionNational laws and capacities vary.International Regulations and laws introduced1851 – International Sanitary regulations in Europe following cholera outbreak1951- international sanitary regulation by WHO.1969- Replaced by the International Health regulationMinor changes in 1973 and 1981cholera, plague, yellow fever, smallpox, relapsing fever and typhus2005 – Revised International Health RegulationChallenge of enforceability of international agreements.Regulations and Laws-Challenge of enforceability, as it often relies on international cooperation and pressure
40Regulation 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 mechanismsIts elements includeNotification:National IHR Focal Points and WHO IHR Contact PointsRequirements for national core capacitiesRecommended measuresExternal 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.
41Partnerships and Collaboration Collaboration vs. coercionImportance of partnerships –MDG 8: “Develop global partnerships for development”Comparative advantage of partnersInclusivenessExamples of partnershipsOver 70 Global health partnerships availableExamples 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 collaborationThe 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.
43A paradigm shift - Enlightened Self interest Communicable diseases have no borders.Predominantly affect the poor, and poor countriesAlso 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 developmentMismatch between global health need and health spendingGlobal 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
44Global Mismatch Between Disease Burden and Health Spending
45Global Mismatch Between Disease Burden and Health Spending
46Future Population Growth Will be in LICs and MICs Therefore by the percentage of the global population susceptible to CDs will increase significantly.
47Key principles of an Effective Global Response Respect for the value of each lifeBehind every statistic is an individualUnderstanding of the social context that govern individual decision makingDisease Surveillance and reportingManagement and containment of outbreaksStrong legal and regulatory frameworkSustained and predictable financingBuilding national health systemsRespect 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 stigmaThe mother in northern Nigeria who prevents her child from accessing polio vaccines because of the outbreak of vaccine-derived polio
48World Bank’s involvement Relevance to our mandateCDs disproportionately affect the poor and LICs and MICsEnormous economic consequencesMajor constraint to achieving the MDGsMajor source of financing for poor countriesThis position is rapidly changing with the entrance of newer players in DAH such as Gates foundation, Bilaterals, multilaterals.Call for innovative financing schemes
49World Bank$430 million committed to malaria booster projects in AfricaBy 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 influenzaCumulative WB commitment to HIV/AIDS is over $2.5 billionmore 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.
50Sources of Development Assistance for Health Source: Michaud 2006
51The World Bank’s new HNP strategy Five broad strategic directions of the World bankFocus on HNP ResultsStrengthening health systemsEnsuring synergies between Health Systems strengthening and priority disease interventionsIntersectoral approach to HNP resultsIncrease strategic and selective engagement with development partners.
52Thank 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.