Communicable Diseases and Human
Security
Kelechi Ohiri MD MPH MS
Health, Nutrition, Population
Human Development Network
World Bank
Outline of Presentation
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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 Bank’s role and involvement
Human Security in a globalized world
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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.
Communicable Diseases: Definition
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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
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Change in human demographics and behavior
Economic development and land use patterns
CD- Modes of transmission
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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)
Importance of Communicable Diseases
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Significant burden of disease especially in low and middle
income countries
Social impact
Economic impact
Potential for rapid spread
Human security concerns
Intentional use
Communicable Diseases account for a significant
global disease burden
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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.
Communicable Disease Burden Varies Widely Among
Continents
Communicable disease burden in Europe
Causes of Death Vary Greatly by Country Income Level
CDs have a significant social impact
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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
CDs have a significant economic impact in affected
countries
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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
International boundaries are disappearing
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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
Human Security concerns
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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
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Bioterrorism and intentional outbreaks
Anthrax, Small pox
New and re-emerging diseases
Ebola, TB (MDR-TB and XDR-TB), HPAI, Rift valley fever.
Tuberculosis
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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.
>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 disease
Tuberculosis and HIV
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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
TB
TB
TB
is harder to diagnose in HIV-positive people.
progresses faster in HIV-infected people.
in HIV-positive people is almost certain to be fatal if undiagnosed or left untreated.
occurs earlier in the course of HIV infection than many other opportunistic infections.
Global Prevalence of TB cases (WHO)
Tuberculosis
Tuberculosis Control
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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
Malaria
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Every year, 500 million people become severely ill with malaria
causes 30% of Low birth weight in newborns Globally.
>1 million people die of malaria every year. One child dies from it every 30
seconds
40% 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 MICs
11% of childhood deaths worldwide attributable to malaria
SSA children account for 82% of malaria deaths worldwide
Annual Reported Malaria Cases by Country (WHO 2003)
Global malaria prevalence
Malaria Control
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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
HIV/AIDS
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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.
HIV Co-infections
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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
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Acute malaria episodes temporarily increase HIV viral load
Adults with low CD4 count more susceptible to treatment failure
Global HIV Burden
HIV/AIDS
Interventions depend on
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Epidemiology – mode of transmission, age group
Stage of epidemic –concentrated vs. generalized
Elements of an effective intervention
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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
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Constraints to access to care and treatment
Stigma and discrimination
Inadequate prevention measures.
Co-infections (TB, Malaria)
Avian Influenza
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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.
Avian Influenza
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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
Confirmed human cases of HPAI
Migratory pathway for birds and Avian influenza
Neglected diseases
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Cause over 500,000 deaths and 57 million DALYs annually.
Include the following
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Helminthic infections
Hookworm (Ascaris, trichuris), lymphatic filariasis, onchocerciasis, schistosomiasis,
dracunculiasis
Protozoan infections
Leishmaniasis, African trypanosomiasis, Chagas disease
Bacterial infections
Leprosy, trachoma, buruli ulcer
Communicable Disease and Human Security
Part 2 - Mounting an Effective Global Response
Approaches to Interventions
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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
Personal Responsibility and action
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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.
Utilitarian Approaches – “Greatest good for the greatest
number”
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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.
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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.
Regulations and Laws
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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
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Minor changes in 1973 and 1981
cholera, plague, yellow fever, smallpox, relapsing fever and typhus
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2005 – Revised International Health Regulation
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Challenge of enforceability of international agreements.
Regulation and laws – WHO 2005 International
health regulation
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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)
Partnerships and Collaboration
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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.
A paradigm shift - Enlightened Self interest
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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.
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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.
Global Mismatch Between Disease Burden and Health
Spending
Global Mismatch Between Disease Burden and Health
Spending
Future Population Growth Will be in LICs and MICs
Key principles of an Effective Global Response
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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
World Bank’s involvement
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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
World Bank
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$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
Sources of Development Assistance for Health
The World Bank’s new HNP strategy
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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.
Thank You.