Communicable Diseases and Human Security

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Communicable Diseases and Human Security

• Kelechi Ohiri MD MPH MS
• Health, Nutrition, Population
• Human Development Network
• World Bank

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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 Banks role and involvement

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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.

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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

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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)

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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

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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.

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Communicable Disease Burden Varies Widely Among
Continents
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Communicable disease burden in Europe
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Causes of Death Vary Greatly by Country Income
Level
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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

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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

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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

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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.

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Select Communicable Diseases
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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.
• gt50 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

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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.

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Global Prevalence of TB cases (WHO)
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Tuberculosis
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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

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Malaria

• Every year, 500 million people become severely
  ill with malaria
• causes 30 of Low birth weight in newborns
  Globally.
• gt1 million people die of malaria every year. One
  child dies from it every 30 seconds
• 40 of the worlds 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

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Annual Reported Malaria Cases by Country (WHO
2003)
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Global malaria prevalence
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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

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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.

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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

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Global HIV Burden
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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)

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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.

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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

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Confirmed human cases of HPAI
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Migratory pathway for birds and Avian influenza
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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

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Communicable Disease and Human Security

• Part 2 - Mounting an Effective Global Response

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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

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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.

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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.

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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.

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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)

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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.

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Isnt Donor Collaboration Wonderful?
INT NGO
WHO
CIDA
3/5
UNAIDS
GTZ
RNE
UNICEF
Norad
WB
Sida
MOF
USAID
T-MAP
UNTG
PMO
CF
DAC
GFCCP
PRSP
PEPFAR
HSSP
GFATM
MOEC
MOH
SWAP
CCM
NCTP
CTU
CCAIDS
NACP
PRIVATE SECTOR
CIVIL SOCIETY
LOCALGVT
Source WHO Mbewe
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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.

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Global Mismatch Between Disease Burden and Health
Spending
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Global Mismatch Between Disease Burden and Health
Spending
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Future Population Growth Will be in LICs and MICs
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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

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World Banks 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

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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

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Sources of Development Assistance for Health
Source Michaud 2006
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The World Banks 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.

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Thank You.