Download Communicable Diseases and Public Policy

Communicable Diseases and
Human Security
Kelechi Ohiri MD MPH MS
Health, Nutrition, Population
Human Development Network
World Bank
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 Bank’s role and involvement
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.
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
CD- Modes of transmission

Direct





Indirect



Blood-borne or sexual – HIV, Hepatitis B,C
Inhalation – Tuberculosis, influenza, anthrax
Food-borne – E.coli, Salmonella,
Contaminated water- Cholera, rotavirus, Hepatitis A
Vector-borne- malaria, onchocerciasis, trypanosomiasis
Formites
Zoonotic diseases – animal handling and feeding
practices (Mad cow disease, Avian Influenza)
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
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.
Communicable Disease Burden Varies
Widely Among Continents
Communicable disease burden in
Europe
Causes of Death Vary Greatly by Country
Income Level
Age distribution of death in Sierra Leone around 2005
Female
Male
90 - 94
90 - 94
75 - 79
75 - 79
60 - 64
60 - 64
Age group
Age group
Male
Age distribution of death in Denmark around 2005
45 - 49
30 - 34
45 - 49
30 - 34
15 - 19
15 - 19
0-4
0-4
80
60
40
20
0
20
Percent of total of deaths
40
60
80
Female
80
60
40
20
0
20
Percent of total deaths
40
60
80
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
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
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
Human Security concerns

Potential magnitude and rapid spread of
outbreaks/pandemics. e.g. SARS outbreak


Bioterrorism and intentional outbreaks


No country or region can contain a full blown
outbreak of Avian influenza
Anthrax, Small pox
New and re-emerging diseases

Ebola, TB (MDR-TB and XDR-TB), HPAI, Rift valley
fever.
Select Communicable Diseases
Tuberculosis

2 billion people infected with microbes that cause TB.

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




Not everyone develops active disease
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.
Global Prevalence of TB cases (WHO)
Tuberculosis
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
Malaria

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

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

In 2005, 38.6 million people worldwide were
living with HIV, of which 24.7 million (twothirds) 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

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
Global HIV Burden
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)
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.
Avian Influenza

Control depends on the phase of the epidemic

Pre-Pandemic Phase



Emergence of Pandemic virus




Contain and/or delay the spread at source
Pandemic Declared


Reduce opportunity for human infection
Strengthen early warning system
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


Cause over 500,000 deaths and 57 million
DALYs annually.
Include the following

Helminthic infections


Protozoan infections


Hookworm (Ascaris, trichuris), lymphatic filariasis,
onchocerciasis, schistosomiasis, dracunculiasis
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


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

Improved hygiene and sanitation


Information, education and behavior change




Hand washing, proper waste disposal, food
preparation and handling.
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”

Reliance on personal responsibility



Social Isolation and Quarantine measures


Polio, small pox, DPT, Hepatitis, Yellow fever
Mass treatment programs –


Home treatment; Isolation
Mass vaccination programs and campaigns


not always the optimal option given different knowledge levels
and values.
Public good nature of the interventions
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.
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.
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)
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.
Isn’t Donor Collaboration Wonderful?
GTZ
WHO
CIDA
UNAIDS
RNE
INT NGO
3/5
UNICEF
Norad
WB
Sida
USAID
T-MAP
MOF
UNTG
CF
DAC
GFCCP
PRSP
PEPFAR
GFATM
HSSP
MOH
PMO
MOEC
SWAP
CCM
CTU
NCTP
CCAIDS
NACP
LOCALGVT
CIVIL SOCIETY
PRIVATE SECTOR
Source: WHO: Mbewe
A paradigm shift - Enlightened
Self interest

Communicable diseases have no borders.



Interventions are non-rival, non-exclusive and have
positive externalities.




Predominantly affect the poor, and poor countries
Also affect richer households and countries.
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
Burden of disease in disability adjusted life years by income
category
34.4%
9.7%
55.9%
% DALYs in LIC
% DALYs in MIC
% DALYs in HIC
Global Mismatch Between Disease
Burden and Health Spending
Distribution of Total Global Expenditures on Health by
Income Category
2%
10%
88%
Low income
Middle income
High income
Future Population Growth Will be in
LICs and MICs
10,000
T o ta l p o p u la tio n (m illio n s)
9,000
8,000
7,000
6,000
5,000
D eveloping countries
4,000
D eveloped countries
3,000
2,000
1,000
0
1950
1960
1970
1980
1990
2000
Y ear
2010
2020
2030
2040
2050
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
World Bank’s 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
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 $2.5 billion
Sources of Development Assistance
for Health
12,000
US$ (in millions)
10,000
Private Non-profit
8,000
Other Multilateral
6,000
Development Banks
UN System
4,000
Bilateral
2,000
0
Average 1997-99
2003
Year
Source: Michaud 2006
The World Bank’s 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.
Thank You.