Download International spread of disease threatens public health security

International spread of disease threatens public health security
The world health report 2007 focuses on building a safer future
23 AUGUST 2007 | GENEVA -- More than at any previous time in history, global public health security depends
on international cooperation and the willingness of all countries to act effectively in tackling new and emerging
threats. That is the clear message of this year’s World health report entitled A safer future: global public health
security in the 21st century, which concludes with six key recommendations to secure the highest level of global
public health security:
* full implementation of the revised International Health Regulations (IHR 2005) by all countries;
* global cooperation in surveillance and outbreak alert and response;
* open sharing of knowledge, technologies and materials, including viruses and other laboratory samples,
necessary to optimize secure global public health;
* global responsibility for capacity building within the public health infrastructure of all countries;
* cross-sector collaboration within governments; and
* increased global and national resources for training, surveillance, laboratory capacity, response networks, and
prevention campaigns.
In our increasingly interconnected world, new diseases are emerging at an unprecedented rate, often with the
ability to cross borders rapidly and spread. Since 1967, at least 39 new pathogens have been identified, including
HIV, Ebola haemorrhagic fever, Marburg fever and SARS. Other centuries-old threats, such as pandemic influenza,
malaria and tuberculosis, continue to pose a threat to health through a combination of mutation, rising resistance
to antimicrobial medicines and weak health systems.
Universal vulnerability
“Given today’s universal vulnerability to these threats, better security calls for global solidarity,” said Dr Margaret
Chan, Director-General of WHO. “International public health security is both a collective aspiration and a mutual
responsibility. The new watchwords are diplomacy, cooperation, transparency and preparedness.”
The need for global solidarity is especially clear in the response to outbreaks of infectious diseases. This month,
WHO has been closely involved in the response to an outbreak of Marburg fever in Uganda. Together with
partners in the Global Outbreak Alert and Response Network (GOARN) -- including the United States Centers
for Disease Control and Prevention (CDC), Médecins sans Frontières, the Uganda Virus Research Institute, and
African Field Epidemiology Network and local NGOs -- WHO is supporting the Ministry of Health to strengthen
active surveillance, contact tracing, infection control, logistics, and social mobilization activities in an effort to
contain the outbreak.
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The team is carefully studying conditions surrounding the initial transmission, in the hope of improving
understanding of where the virus resides in nature and how it passes to humans, improving the ability to predict
and prevent outbreaks in the future.
WHO and its partners are closely involved in the global response to H5N1 avian influenza, which has caused huge
outbreaks in poultry and at least 308 human deaths since it was first isolated in humans in 1997.
Evolution of outbreak surveillance and response
This World health report traces the history of efforts to contain infectious diseases (including plague, cholera and
smallpox). It describes the evolution of outbreak surveillance and response activities of international partnerships of
agencies and technical institutions. These include GOARN, the chemical and environmental health incident alert
and response system, and the Global Polio Eradication Initiative, which is supporting surveillance of many other
vaccine-preventable diseases.
The report shows how and why diseases are increasingly threatening global public health security. High and rapid
mobility of people is one factor. Airlines now carry more than 2 billion passengers a year, enabling people and the
diseases that travel with them to pass from one country to another in a matter of hours. The potential health and
economic impact was seen in 2003 with SARS, which cost Asian countries an estimated US$ 60 billion of gross
expenditure and business losses.
The report outlines some of the human factors behind public health insecurity, including:
* inadequate investment in public health resulting from a false sense of security in the absence of infectious
disease outbreaks;
* unexpected policy changes such as a decision temporarily to halt immunization in Nigeria, which led to the
re-emergence of polio cases;
* conflict situations when forced migration obliges people to live in overcrowded, unhygienic and impoverished
conditions heightening the risk of epidemics;
* microbial evolution and antibiotic resistance; and
* and animal husbandry and food processing threats such as the human form of bovine spongiform
encephalopathy (BSE) and Nipah virus.
Strategy to tackle pandemic influenza
Pandemic influenza is described as the most feared threat to health security in our times. The report sets out the
WHO strategic action plan to respond to a pandemic, draws attention to the need for stronger health systems
and for continued vigilance in managing the risks and consequences of the international spread of polio and the
newly emerging strain of extensively drug-resistant TB (XDR-TB). New health threats have also emerged, linked
to potential terrorist attacks, chemical incidents and radionuclear accidents.
The revised International Health Regulations (2005) are based on the premise that no country can fully protect
its citizens in isolation or through traditional border controls. The IHR 2005 is a set of rules that governs how
countries should assess and report to WHO public health emergencies of potential international concern. The broad
definitions of “public health risk”, “disease” and “event” ensure that risks caused by the accidental or intentional
release of pathogens or chemical or radionuclear materials are covered by the Regulations.
Since the IHR 2005 entered into force, almost all of the 193 WHO Member States have established their national
IHR focal points, with 179 designations. Since then, WHO has been receiving alerts of health events on a regular
basis, conducting joint risk assessments with the notifying State(s) and sharing real-time information with other
Member States.
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New WHO pocket-charts will save lives by predicting heart attack and stroke
12 SEPTEMBER 2007 | GENEVA -- A new book of pocket-charts that will help health workers to identify people
at risk of heart attacks and strokes and save lives by prescribing the most appropriate treatment is published today
by the World Health Organization (WHO). The charts can be adapted for use in any setting, in any country, with
any patient.
The “Pocket Guidelines for Assessment and Management of Cardiovascular Risk” can be carried and used by any
health care worker and is available in six languages. The guide contains easy-to-use charts that can predict the risk
of a heart attack or a stroke and could help health workers to save and improve the lives of people in all countries.
“This is a real breakthrough. Now, health care workers everywhere - whether they are in a high-tech medical center
in a big city, or riding a bicycle to visit patients in the countryside - can use a simple assessment and treatment
tool to prevent heart attacks and strokes,” said the WHO Director-General, Dr Margaret Chan. “Primary health
care workers now have a new tool to assess and manage people at risk of heart attacks and strokes. This brings
cardiovascular care to the places and people who need it most.”
This is the first cardiovascular disease risk-prediction system that can be used worldwide and is also specially
designed for use with people everywhere, including in low-resource settings. It is an important innovation that
will help health workers to target limited health care resources at people who are at higher risk of developing heart
attacks and strokes.
These guidelines will be distributed to health workers in the form of pocket guides that have been produced for each
of the WHO regions (risk profiles are different for different parts of the world).
“We are never prepared for the sudden death of a family member or a friend from a heart attack or stroke”, said
Dr Catherine Le Galès-Camus, WHO Assistant Director-General for Noncommunicable Diseases and Mental
Health. “Cardiovascular diseases are increasing towards epidemic proportions in developing countries - they already
account for one-third of global deaths, and almost 10 percent of the global burden of disease, and are likely to
become the developing world’s leading cause of death in 2010. There is reason for hope, however, given that huge
potential exists to control this emerging epidemic. These risk charts are a major new tool for providing the best
health care to all the world’s people”.
To ensure that the pocket guide gets into the hands of the health care workers who should use it, WHO will be
collaborating with national Ministries of Health and health-focused nongovernmental organizations to organize
‘training of trainers’ workshops and distribution of the pocket guide.
The risk-prediction charts integrate the following risk factors when predicting the risk of a heart attack or stroke
in the 10 year period following the patient assessment: age, sex, tobacco use, blood pressure, diabetes status, blood
cholesterol.
The pocket guide also incorporates management recommendations, based on the risk of developing heart attacks
and strokes, in the following areas: smoking cessation, dietary changes, physical activity, weight control, alcohol
intake, antihypertensive drugs, lipid-lowering drugs, hypoglycaemic drugs, antiplatelet drugs, anticoagulant
treatment, revascularization surgery, drugs that are not recommended.
Background
Cardiovascular disease (CVD) is the number one cause of death globally, causing one third of all deaths. In 2005,
11.8 million people died of heart attacks and other heart diseases, and 5.7 million died of stroke. Around 80% of
these deaths were in low- and middle-income countries. By 2015, an estimated 20 million people will die from
CVD annually, mainly from heart attacks and strokes. Socioeconomic costs of premature deaths and disability, and
escalating costs of medical care make it all the more urgent to take measures to prevent and control this burgeoning
epidemic in low- and middle-income countries where health care resources are limited.
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Urbanization and globalization promote tobacco use, unhealthy diet and physical inactivity. These risk factors result
in increased risk of people developing heart attacks and strokes because the result is raised levels of blood pressure,
blood glucose, blood cholesterol and body weight. These, in addition to increasing age, are major risk factors that
determine an individual’s chances of having a heart attack or stroke. This is known as the cardiovascular risk.
Until now, individuals have often been assessed and treated based on a single cardiovascular risk factor such as high
blood pressure, high blood lipids or diabetes. This approach can result in committing a patient who has only a small
cardiovascular risk to many years of drug therapy or, conversely, neglecting to treat those with an overall higher
cardiovascular risk. Most importantly, the single risk factor approach is not cost effective and is not affordable for
many low-income and middle-income countries.
For successful prevention and control of the CVD epidemic, the combination of population-based and individual-based
strategies are needed to lower the cardiovascular risk of populations and individuals. Population-wide strategies
such as tobacco control and promotion of a healthy diet and physical activity are very cost effective in all countries.
Cost effective interventions are also available to treat those who have survived heart attacks and strokes. However,
treating risk factors such as high blood pressure and blood lipids is cost effective for low-income and middle-income
countries only if interventions are targeted at high risk individuals.
In many low-income and middle-income countries, national and state health care budgets and per capita health
expenditures are suboptimal. It is imperative, therefore, to use the limited resources that are available as effectively
and efficiently as possible. This requires the prioritization of cost-effective approaches and the targeting of those
patients who are most likely to benefit from interventions. In any population, those people who are most likely to
benefit from cost-effective CVD interventions are the people with the highest cardiovascular risk.
The World Health Organization, in collaboration with the International Society of Hypertension (ISH), has
developed cardiovascular risk prediction charts that enable cardiovascular risk assessment and prediction in nonwestern populations.
Many health care systems in low-income countries do not have the basic infrastructure facilities to support
resource intensive risk prediction tools, particularly in primary health care. The WHO/ISH charts use easily
measurable indicators of risk to quantify the 10-year risk of developing heart attacks and strokes. These indicators
of risk include gender, age, systolic blood pressure, smoking status, diabetes and total blood cholesterol. For use in
low-resource settings, where blood cholesterol measurement is not routinely available, alternative charts have been
developed that predict risk without blood cholesterol. Also, in many low-resource settings, urine sugar levels may
be used as a surrogate marker for diabetes.
Although the risk-prediction charts and pocket guides are simple to use, short training sessions will be required to
introduce the charts into regular health care practice. The charts are ready for use now, and will be updated over
time. Like all risk-prediction tools, the accuracy of this tool for specific populations can be improved over the long
term by making minor adaptations as data are collated for individual populations. Technical assistance will be
provided, through the WHO-ISH collaboration, to compare this new tool with other risk prediction methods, to
further improve accuracy, and to adapt the CVD risk-prediction charts to suit very specific country contexts.
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Background Information: Child-specific medicines
A global priority
Reducing child mortality and treating children affected by major diseases are global priorities expressed in
the Millennium Development Goals (Goals Four and Six). A pre-condition to achieve these goals is increased
production and availability of essential medicines for children. At present, many medicines for priority diseases are
not developed for children; and when they are they are not reaching the children who need them most.
Children metabolize medicines differently from adults. They therefore need different dosage forms. Differences also
exist between children of different ages, body weight and physical conditions. Child-specific medicines are those
manufactured to suit the age, physical condition and body weight of the child taking them.
Apart from dosage, child specific medicines need to be in a format that is palatable to children. Small children have
trouble swallowing big tablets but can tolerate oral solution or syrups. For children with chronic conditions such as
HIV/AIDS, where several medicines must be taken daily, the fixed-dose combination approach - several medicines
in one pill - is best. However, the few existing pediatric fixed dose combinations developed for children are generally
three times more expensive than the adult dosage form.
Research and development gaps
There is little knowledge about the effects certain medicines can have on children. This is partly due to the fact that
fewer clinical trials are conducted in children than in adults. The ethical approach to conducting clinical trials is to
obtain signed informed consent from volunteers before they take part in a trial. Obtaining informed consent from
a child - particularly in the younger age bracket - is clearly difficult. Insufficient clinical trials for pediatric medicines
in turn lead to information gaps related to quality and safety. Those gaps deter pharmaceutical companies from
researching and developing child-friendly medicines and generics companies from producing them at lower cost.
In addition, children are generally a silent sector of the population, relying on others to speak for them - they do
not vote, they do not buy and generally do not have a public voice in society. Although they would benefit from
more pharmaceutical research and development, they do not have the means to demand it.
Distribution problems
Child specific medicines already developed and available often do not reach the children who need them most.
For instance, diarrhoea, which can easily be treated with oral rehydration salts plus zinc, still kills 1.9 million
under-fives every year. Oral rehydration salts are easy to use, easy to manufacture and relatively inexpensive. Due
to years of advocacy campaigns, they are widely available in developing countries. Zinc, on the other hand, is not
easily found in areas with a high incidence of diarrhea disease. Oral rehydration solution with zinc is more effective
than without it.
There may be numerous, poverty-related causes for the fact that children are still dying of diarrhoeal diseases, but
one obvious reason is that the full remedy - rehydration salts plus zinc - is not made available to them.
The target diseases
WHO estimates that of all the child killers, five conditions in particular demand immediate action:
Pneumonia and other acute lower respiratory infections
An estimated 20% of all deaths in children under-five are due to acute lower respiratory infections, representing
the single most important cause of infant mortality worldwide. Pneumonia alone causes approximately 2 million
deaths every year which could be prevented with proper access to child-specific medicines.
HIV/AIDS
Although contributing to only about 3% of all annual deaths in children under-five, pediatric HIV is a growing
public health challenge. Every day, an estimated 1150 children become infected.
Malaria
An estimated 1 million children die every year due to malaria infection and 40% of the world>s children live in
malaria-endemic countries. In Africa, a child dies of malaria every 30 seconds. Although malaria is a priority illness
and has been the subject of numerous global conferences and calls to action, the issues of access to and development
of child specific treatment need to be further addressed.
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Diarrhea diseases
An estimated 1.9 million children under five die each year from diarrhoea and related complications. This amounts
to 18% of all under-five deaths and means that more than 5000 children die every day as a result of diarrhea
diseases, which can be treated easily and effectively.
Tuberculosis
About 1.1 million (12%) of the 8.8 million new tuberculosis cases in 2005 occurred in children under 14 years of
age.
Lymphatic filariasis and schistosomiasis
Although not major killers of children, the neglected tropical diseases filariasis and shistiosomiasis are also prioritized
by WHO because of gaps in either the development or accessibility of medicines.
WHO estimates that 330 million children under 15 years of age currently require chemotherapy to prevent
Lymphatic Filariasis in endemic areas (Asia, Pacific, Africa and South America). Another 125 million children in
the same age category require preventive treatment for schistosomiasis. The necessary medicines exist in pediatric
form but are hardly available or accessible to the targeted populations.
WHO action
Recognizing the lack of child specific medicines, the Member States of WHO passed a resolution on «Better
Medicines for Children» during the 2007 World Health Assembly, the Organization’s annual meeting. The
resolution mandates WHO to explore ways to promote more research and development into pediatric medicines
and to improve knowledge on the quality, effectiveness and safety of these medicines.
To address this, WHO created an Expert Sub-Committee to develop an essential medicines list for children.
The list, finalized and published in December 2007, consists of 206 medicines, including anti-AIDS treatment,
vaccines, anaesthetics, hormones, vitamins and minerals.
The list should serve as a reference for countries to develop national lists according to their specific public health
priorities, and is the beginning of a longer process to ensure that child specific medicines are developed and delivered
to the intended patient group.
More needs to be done to identify research gaps in children’s medicines and problems related to supply and
distribution. WHO is beginning to address these issues with UN partners, in particular UNICEF.
The initial objective of WHO’s work in this area is to tackle HIV/AIDS, malaria, tuberculosis, pneumonia and
diarrhea diseases, which account for over 50% of under-five mortality.
More specifically, WHO will work towards the following objectives:
• Increase additional and independent studies on the development of pediatric medicines and their efficacy and
safety;
• Provide better information on child specific medicines to prescribers, pharmacists and health workers;
• Explore ways of fast-tracking the regulation of quality pediatric formulations;
• Establish systems for ensuring that health facilities have adequate stocks of essential medicines and clinical
consumable for children;
• In the absence of clinical trials, identify safety and efficacy indications for which essential medicines may be used
in pediatric formulations;
• Improve infrastructure and equipment to store liquid paediatric formulations which are less stable than solid
dosages;• Monitor the use of unlicensed, off-label and unsafe medicines for children.
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Facts about children and child-specific medicines
* Due to the lack of appropriate monitoring, children are commonly given medicines unlicensed for them. This
practice can be unsafe and lead to potentially harmful side effects.
* Even though syrup or oral liquid forms of medicines are ideal and in some cases available for children, the cost
may be two to three times higher than the pill form for adults.
* As an unsafe alternative to missing pediatric formulations, healthcare workers and parents often use fractions of
adult dosage forms or prepare makeshift prescriptions of medicines by crushing tablets or dissolving portions of
capsules in water.
* According to a 2005 study published by WHO, potentially harmful medication errors may be three times more
common in the pediatric population than in adults.
* An estimated four million children who need antibiotics to support HIV/AIDS treatment are not accessing
them.
* A WHO report states that increased availability of essential pediatric formulations could yearly save the lives of
over one million children under five in the Western Pacific Region.
* According to UNICEF’s latest estimate, approximately 10 million children under five years are expected to die
in 2007. About two thirds of those deaths will be caused by diseases which could be treated with safe essential
child-specific medicines.
* A 2007 WHO survey of 29 countries in Africa, the Eastern Mediterranean and the Western Pacific regions,
shows that:
• 13 countries identified dosing problems with pediatric medicines
• 14 countries identified a lack of available pediatric dosage forms and reported high prices
• 11 countries have a separate list of pediatric medicines for priority infectious diseases (HIV/AIDS, TB and
malaria)
• General pediatric and disease specific standard treatment guidelines were available in 67% of the respondent
countries - Almost 80% of the countries provided all medicines and vaccines free of charge to pediatric
patients
• 21 of the respondent countries provided examples of problems with pediatric medicines for acute and chronic
diseases
• The reported countries presented a limited availability of a number of essential medicines, including vitamin
and mineral preparations, antibiotics in syrup form and anti-epileptic medicines.
* According to UNICEF’s latest estimate, approximately 10 million children under five years are expected to die
in 2007. About two thirds of those deaths will be caused by diseases which could be treated with safe essential
child-specific medicines.
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