Lessons from Global Health Activities

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Lessons from Global Health Activities

• Timothy Jones, M.D.
• Tennessee Department of Health

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If the rest of the world is not healthy, we will
not be healthy
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Smallpox Eradication

• Program launched in 1967
• 10 - 15 million cases annually
• Last case diagnosed 10 years later
• Program cost 300 million
• Recouped every 26 days

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What makes it possible?
What makesit difficult?

• No animal reservoir
• Effective vaccine
• No chronic carrier state
• Survives poorly in environment

• Inapparent infection (2001 ratio)
• Other diseases withsimilar symptoms

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Challenges of EradicationPolio Contrasted with
Smallpox

• Smallpox
• Single dose vaccine
• Stable vaccine
• Clinically apparent disease

• Polio
• 4 doses required
• Cold chain required
• gt99 subclinical

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Poliomyelitis- United States, 1930-1995
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Benefits of the Polio Eradication

• Reduction in morbidity mortality
• Polio leading cause of disability
• Also Vitamin A, measles
• Health systems
• Enhanced surveillance systems lab network
• Revitalized immunization programs
• Economic savings 1.5 billion/year

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Strategies for Polio Eradication

• Strong routine immunization program
• National Immunization Days (NIDs)
• Acute flaccid paralysis surveillance
• "Mopping-up" immunization

• Then.
• Polio-free certification
• Laboratory containment of polioviruses
• Stopping polio immunization

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Polio Eradication InitiativeRepublic of Yemen
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Yemen

• Per capita GNP
• 1991 485
• 1997 306
• Average monthly wage 43
• gt80 rural

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Yemen

• 17 million population
• Registered births
• 198,000 males
• 85,000 females
• Secondary students
• 225,000 males
• 61,000 females

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Health Care in Yemen

• Budget
• Defense 320 million
• Health 70 million
• Population per physician 4300
• In Ibb
• 160 primary health centers
• 62 functioning

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transverse myelitis
other enteroviruses
traumatic neuritis
Acute Flaccid Paralysis
Coxsackie virus
Echovirus
Guillain-Barre Syndrome
Poliovirus
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Reported AFP Cases STOP Target Governorates
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STOP Team Activities
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STOP Team Activities
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Other STOP Team Activities

• Revised National Plan
• Developed budgets
• Translated teaching materials
• Developed posters
• Distributed educational letters
• Conducted computer training

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Food SafetyShort-Term Consultancy
WHO Western Pacific Regional Office Manila,
Philippines October, 2005

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Asian Foodborne Disease Network

• Feasibility
• Feedback
• Model
• Recommendations

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Goals

• Strengthen capacities
• Establish Centers of Excellence
• Foster collaboration
• Enhance reporting
• Promote communication

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Barriers

• Free communication
• Trade, politics
• Capacity diversity
• Organizational inconsistency
• Confidentiality
• Resources
• Priorities

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Recommendations

• List-serve
• OzFoodNet moderates
• Hybrid selection process
• Epi / lab / food safety
• Confidentiality guidelines
• Working group
• In-person meeting
• Evaluation

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Barriers

• Free communication
• Trade, politics
• Capacity diversity
• Organizational inconsistency
• Confidentiality
• Resources
• Priorities

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Thai Phage-Typing Project

• 2002
• WHO National Salm and Shigella Centre, Thailand
• Danish Institute Food Vet Research
• 79 S. Typhimurium isolates
• Understand phage type prevalence

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Thai Campylobacter Project

• 2004
• 50 isolates
• GSS member asked for testing
• Armed Forces Research Institute, Thailand
• All multi-resistant

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Democratic Republic of Congo

• 2002-2004
• Salmonella serotyping and susceptibility
• 28 isolates
• Tested in Denmark
• Presented at conference in Denmark

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Nepal Project

• 2005
• Drinking water and clinical samples
• 65 Salmonella isolates serotypes
• 29 (45) S. Typhi
• 8 (12) S. Paratyphi
• Presented at WHO conference, China

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Sudan Project

• 2005
• Salmonella serotyping
• 40 isolates
• Thesis project

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Burden of Illness Studies

• Jordan
• Salmonella, Shigella, Brucella
• Slovenia
• Campylobacter, Salmonella
• Caribbean
• Gastroenteritis, respiratory, fever
• Population survey
• Lab survey
• Physician Survey

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ZambiaInfluenza Sentinel Surveillance (ISS)
Consultancy

• Jennifer K. MacFarquhar, RN, MPH, CIC
• Tennessee Department of Health
• Communicable and Environmental Disease Services

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Scope of Consultancy

• Materials Developed
• Sentinel surveillance protocol
• Case Definitions
• SOPs for UTH
• Questionnaire
• Case Definition Poster
• Specimen ID Form
• Report template
• Work-flow diagram

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Scope of Consultancy

• Guidance provided
• Laboratory procedures
• Database development
• Infection Control measures (training/Isolation
  Unit)

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If the rest of the world is not healthy, we will
not be healthy
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West Nile virus 1999
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West Nile virus 2004
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West Nile Virus Outbreaks

• Israel 1941, 1951-1954, 1957, 1980
• South Africa, 1974
• Algeria, 1994
• Romania, 1996
• Tunisia, 1997
• Russia, 1999, 2000, 2001
• Israel, 2000
• Sudan, 2002
• United States, 1999-2007

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Dengue/dengue hemorrhagic fever, average annual
number of cases reported to WHO, 1955-2005
Number of Cases
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Dengue in the Continental US and Hawaii

• Dengue epidemics occurred in the US in the late
  1700s to the first half of the 1900s
• 7 outbreaks in TX since 1980
• 1 outbreak in Hawaii in 2001

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U.S. Imports of Used Tires (millions),1970-85
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Lucky Bamboo Dracaena sanderanaand the
importation of the Asian Tiger Mosquito Aedes
albopictus

• Bamboo associated with strength and good fortune
  in China
• Bamboo associated with Feng Shui traditional
  Chinese method of ordering ones life to attract
  positive force
• Feng Shui becomes popular in California and a new
  global market for bamboo is born

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Ten Great Public Health Achievements -- United
States, 1900-1999

• Vaccination
• Motor-vehicle safety
• Safer workplaces
• Control of infectious diseases
• Decline in deaths from coronary heart disease and
  stroke
• Safer and healthier foods
• Healthier mothers and babies
• Family planning
• Fluoridation of drinking water
• Recognition of tobacco use as a health hazard

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Life Expectancy

• US
• 1900 47 years
• 2000 76 years (62 increase)
• Former Soviet Union
• Fell by 6 years
• Increased poverty, social disintegration,
  environmental problems, alcohol, smoking

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Comparison of 20th Century Annual Morbidity and
Current Morbidity, Vaccine-Preventable Diseases
Recod lows
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Multistate Outbreak of Mumps --- United States,
January 1--May 2, 2006

• 2,597 cases
• Largest number cases reported to CDC since 1991
• Delayed diagnosis of cases might have
  contributed to spread
• Younger physicians likely have not seen mumps
• Physicians might not consider diagnosis in
  vaccinated persons

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Industrialization

• Benefits
• Increased material well-being
• Improved healthcare for many
• Flood of new goods and services
• More choices for consumers

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Potential Impacts of Climate Change on Human
Health
Morbidity/mortality
Heat
Storms, coastal flooding
Morbidity/mortality/ displacement

• Climate change effects
• Temperature
• Sea level
• Precipitation

Vector biology
Infectious diseases
Air pollutants
Respiratory diseases
Food supply
Malnutrition
Civil conflict
Morbidity/mortality/displacement
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Produce Imported from Mexico
-Hedberg, CID, 1994
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Global International Tourist Arrivals
-Altekruse, EID, 1997
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Burch Farms Faison, NC
DeLeon Farms Homestead, FL
Produce Exchange Livermore, CA
Intl Trade Marketing Bronx, NY
Fresh Tex Produce Alamo, TX
Seminole Produce Sanford, FL
Little River Produce Lake Park, GA
Leone Produce Minotola, NJ
Brandt Produce Edinburg, TX
CD Fruit Veg Bradenton, FL
Crown Harvest Plant City, FL
McRae Produce Darien, IL
Moore Porter Thomasville, GA
Chapman Fruit Co. Immokalee, FL
Nogales Central Dallas, TX
Frontora Produce San Antonio, TX
United Distributors Los Angeles, CA
Bailey Farms Oxford, NC
Delfino Marketing Plant City, FL
Sid Goodman Jessup, MD
LM Companies Raleigh, NC
Marker 29 Produce Plant City, FL
Harvest Central Fresno, CA
Coastal Sunbelt Savage, MD
Class Produce Group Jessup, MD
E.A. Parker Sons Oak Grove, VA
Quality Produce Tifton, GA
Chevys Fresh Mex Annapolis, MD
MOL Produce The Netherlands
Parade Produce Jessup, MD
Bengard Ranch Salinas, CA
U.S. Food Jessup, MD
Gowers Express San Francisco, CA
Ger-Nis Intl Brooklyn, NY
Edward G. Rahl Jessup, MD
Salyer American Fresh Foods Pittsburgh, PA
Food Co. Laurel, MD
The Nunes Co. Salinas, CA
Goodson Farms Balm, FL
Coastline/Sunridge Farms Salinas, CA
G. Cefalu Bros. Jessup, MD
Severt Sons St. Augustine, FL
First Class Fruit Veg Fresno, CA
River Ranch Fresh Foods Los Angeles, CA
L. Holloway Bros. Jessup, MD
Goodson Farms Balm, FL
Amco Produce Leamington, ON
Castellair Farms Vineland, NJ
Ger-Nis Intl Brooklyn, NY
Sorantino Produce Vineland, NJ
Cresci Farms Vineland, NJ
Pismo-Oceano Veg Exchange Oceano, CA
CB Farms Clewiston, FL
Voyager Farms Balm, FL
Boskovich Farms Los Angeles, CA
All jalapeno shipments sold to Edward G. Rahll
Pacific Collier Immokalee, FL
Suppliers of jalapenos (April-July 2008)
Six Ls Packing Co. Immokalee, FL
First Fruits Vegetables Dillsburg, PA
Last updated July 10, 2008
The Greenery Philadelphia, PA
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Investigation

• Mangoes
• OR21.6
• One Brazilian farm
• Only US affected

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Mango Handling

• Mediterranean fruit fly
• US-bound only
• New disinfestation procedure
• Hot-water dip
• Salmonella internalized

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Outbreak

• December 1999
• Salmonella newport
• 78 patients in 13 states
• 15 hospitalized 2 deaths

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The healthier the rest of the world is, the
healthier we will be