Global Health and infectious diseasechallenging and rethinking the paradigms

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Global Health and infectious disease-challenging
and rethinking the paradigms

• Professor David H Molyneux
• Liverpool School of Tropical Medicine

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The changing global environment

• Millennium Development Goals
• Commission for Africa
• Global Health Initiatives
• The Partnership agenda
• The rise of the NGDOs
• Financing

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The Millennium Development Goals
Addressing the Poverty Agenda

• MDG 1 Eliminate extreme poverty and hunger
• MDG 4 Reduce child mortality
• MDG 5 Reduce maternal mortality
• MDG 6 Combat HIV/AIDS,TB and Malaria and
  other diseases
• MDG 8 Develop a global partnership for
  development

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Health Policy

• Financing
• Partnerships
• Global initiatives
• Conflict/post conflict
• Chronic disease burden
• Poverty/health/MDGs
• Emerging diseases

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Financing Policies

• SWAps
• PRSP
• HIPC
• Global Fund
• User Fees
• Insurance Systems

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Global Health Initiatives

• GAVI
• RBM
• Tobacco Free Initiative
• 3 x 5
• Stop TB
• IMCI
• Etc

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Public-Private Partnerships for Health

• Around 100 PPPs
• Different objectives
• Different governance
• Different geographical focus

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Globalisation and disease-drivers of change

• Water resources management
• Deforestation
• Agricultural development
• Urbanisation
• Global trade
• Conflict and instability-fragile states
• HIV/AIDS pandemic

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Epidemiological TransitionClimate
ChangeIncrease in Non Communicable Disease
BurdenNutritional StatusConflictVaccine
CoverageEducation LevelWomens
StatusEpidemiological Transition
Health System Resourcing and ChangeControl
Programme ImpactImpact on other Sectors
Affecting HealthInsecticide and Antimicrobial
ResistanceNatural DisastersHuman Resources
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Burden of Neglected Diseases
Comparison with HIV/TB/Malaria
Neglected Diseases20
Other infectiousdiseases29
Neglected Diseases24
Other infectiousdiseases30
HIV/TB/Malaria46
HIV/TB/Malaria51
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Impact/Benefit- LF transmission - Oncho
transmission and morbidity- Deworming and
morbidity- Hookworm anaemia- Skin diseases-
Schistosomiasis morbidity- Trachoma prevalence/
incidence- Growth- Nutrition- School
attendance- Malaria fever- Malaria morbidity-
Anaemia- ITN distribution- Vitamin A
International Agencies
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Guinea WormGlobal1989 - 2002
SchistosomiasisEgypt1988 - 2001
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(No Transcript)
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Impact of MDA on Lymphatic Filariasis
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Malaria
HIV/AIDs
Unit cost per episode5-107-10
episodes/child/year35-100/yearcirca 30
household expenditure
Minimum 150/person/yearLow cost ART
TB
Cost per patient treatment65-1824 (Russian
Federation)Median 199South Africa 700
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Target 2005
Status 2003/2004
Malaria ITNs 60 coverage
HIV/AIDs 3 x 53 million under treatment with
ARVs by end 2005
150,000 Africans on ART of 28 million infected
440,000 of 40 million globally
TBAfrica2.26m estimated cases992,000
notifiedTarget case detection rates 70 by 2005
Case detection rate 2003 37
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Clinical Presumptive Malaria
Incorrect Diagnosis Incorrect Treatment
Correct Diagnosis Correct Treatment Full
Compliance
Private/Informal Traditional Healers Chemical
Sellers Shopkeepers Relatives Pharmacies
Cure
50
80
Correct Diagnosis Incorrect/ Inappropriate Treatme
nt Full or Incomplete Compliance
Drug Resistance
90
Fever Cases
CounterfeitFakeExpired
Progress to severe malaria Death
Correct Diagnosis Right drug, time and place
Correct Diagnosis Correct Treatment Incomplete
Compliance
50
Drug Resistance
PublicHospital Clinics Health Centres
20
10
Microscope ve
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Inefficiency and waste in the supply of drugs
from budget allocation to consumer
Budget allocation for drugs
Value received by consumer
U.S. Dollars
100
90
80
76
60
49
40
30
20
15
12
0
Quantification problems
Inefficient procurement
Inefficient distribution
Irrational prescription
Non-compliance by patients
Inadequate buying practices
Remaining value
Cumulative losses
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0.40 for packaged intervention
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Microparasites v. Macroparasites

• Emergence and rapid dissemination
• Drug and insecticide resistance
• Rapid rate of reproduction
• Biological processes faster than political

• Slow rate of reproduction
• Limited risk of drug resistance
• Stable biology enables effective programme based
  on consistent strategy
• Donated products

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Human Hookworm Infection 740 million
cases Necator americanus is the major
hookworm 22.1 million DALYs and 65,000 deaths
 
De Silva et al Trend Parasitol 2003 19 547-51
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REASON 2. NEW AND IMPROVED CONTROL
TOOLS Development and Evaluation of The Na-ASP-2
Hookworm Vaccine An Orphan Product for a
Neglected Disease
THE HUMAN HOOKWORM VACCINE INITIATIVE
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Anthelminthic Rx Does Not Prevent Hookworm
Infection
1. Mebendazole Cure Rates 21
Village A
120
120
Zanzibar, Tanzania
100
100
Village B
80
80
60
60
pre-treatment EPG
40
40
20
20
20 40 60 80 100
120
140 160 180
Days Since Treatment
2. Hookworm infected patients reacquire hookworm
to pretreatment levels within 4-12 months
following anthelminthic chemotherapy (Albonico M
et al. Trans R Soc Trop Med Hyg,
1995) 3. Efficacy of BZAs diminishes with
increasing use (Albonico M et al. Bull WHO, 2003)
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Anthelminthic VaccinationsNa-ASP-2 Hookworm
Vaccine

• Strategy that complements periodic deworming
• Combined use of chemotherapy and vaccination is
  the basis of a novel, more-versatile approach to
  control
• Prolong the intervals between treatments
• Reduce the likelihood of emerging drug resistance

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Conclusions

• Evidence based health policies
• Globalisation forces have a profound impact on
  emerging infectious diseases and non-
  communicable diseases
• Focus on the big three driven by politics and
  activism at expense of equity for the poorest
• Big three need attention but policy makers must
  recognise current strategies will not impact on
  transmission

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Conclusions

• Biology and public health dimension in target
  setting is essential
• Objectivity versus subjectivity
• Partnerships-more cross talk essential
• Target setting by international agencies seems a
  prelude to failure
• Cost effectiveness and cost benefit
• Focus on proven, achievable approaches which
  bring most benefit to the poorest at least cost
• Create governance processes compatible with goals
  not existing structures