Download CHALLENGES IN COMMUNICABLE DISEASES

CHALLENGES IN COMMUNICABLE DISEASES
JOHORE HEALTH CONFERENCE 2015
LOKMAN HAKIM
S,
MD, DAP&E, MScPH, PhD, FA
MM, FAMS, FASc
Ministry of Health
Malaysia
2015-2035: Three Domains of Health
Challenges
High rates of avertable
infectious, child, and
maternal deaths
Demographic change
and shift in GBD
towards NCDs and
injuries
Impoverishing
medical
expenses, unproducti
ve cost increases
Cost agenda
Unfinished agenda
Emerging agenda
Infectious diseases continue to post great challenges to
health
• Profound impact on human history
– Influenced course of wars
– Determined fates of nations
– Affected civilisation
• Economic development and technology advancement leading to
demographic transition
• Epidemiologic transition incomplete, unfolding at different rates
• Emerging and re-emerging infections coupled with new challenges
–
–
–
–
Hospital acquired infections and the “Super Bug”
Drug resistance
Pandemics
Health security and bioterrorism
Communicable Diseases
• 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:
– 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.
GLOBAL DISTRIBUTION OF EMERGING & RE-EMERGING DISEASES (1996-2004)
• H1N1
• H7N9
• EBOLA
• MERS-COV
Source: Morens et al. 2004. The challenge of emerging and re-emerging infectious diseases. Emerg Infect Dis. 430: 242-249
Global Burden of Communicable Disease
2005
2015
Burden of Disease
Burden of Disease
CD
26%
CD
30%
Others
70%
Others
74%
6
Leading causes of global deaths from infectious diseases
(Fauci AS et al, N Engl J Med 2012, 366: 454-461)
Respiratory infections
Diarrheal diseases
HIV/AIDS
Tubercolosis
Malaria
Meningitis
Pertussis
Measles
Hepatitis B
Other infectious diseases
0
0.5
1
1.5
2
2.5
3
No. of Deaths (millions)
3.5
4
4.5
5
Economic burden
• The epidemic of BSE, UK : USD 30 billion.
• SARS outbreak Hong Kong/Global: range from USD 8
billion to 24 billion,
• Plague in Surat, India (1994), USD 1.5 billion
• Avian influenza outbreak, Hong Kong (1997), estimated to
cost hundreds of millions of euros in lost poultry
production, commerce and tourism.
• Nipah outbreaks, Malaysia (1998/1999): USD 97 million for
direct compensation for the culled 1.1 million pigs (total
estimate USD500 million)
Malaysia dengue notification 2001-2015
Vector-borne disease transmission dynamics and
targets for control and elimination
Host
MALARIA
Agent
(parasite)
Host
Environment
Vector
(Anopheles)
Agent
(virus)
DENGUE
Vector
(Aedes)
Unique characteristics of infectious diseases
• Extraordinary adaptability
– Replication and mutation capacity
• Closely dependent on the nature and complexity of
human behavior
– Reflect who we are, what we do, how we live and interact
– Acquired as a result of our lifestyle
• Ease of transportation, ease of spread
• Environmental degradation and climate change
• Explosive potential
Epid-Curve of the Pandemic A(H1N1) 2009
No. of Cases
Number of Lab-Confirmed Influenza A(H1N1) Cases,
Malaysia, 2009 - 2010
3500
MALAYSIA
3,136
(as of 31/12/2010)
3000
2500
2000
15 May 2009:
1st confirmed
case
Mid Year
Population, 2010
Total no. of
confirmed cases
Total no. of
death
Mortality Rate
(per 100,000 pop)
28,908,800
15,792
95
0.33
November 2009:
Pandemic vaccination
strategies initiated
1500
1000
21 June 2009:
Community
transmission
confirmed
500
352
0
17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51
10 July 2009:
Mitigation
Phase initiated
2009
2010
Epid Week
Specific challenges
Migration
and Health
Land use
changes, Cl
imate
Change
and Health
Infectious
diseases
and Health
Security
Migration
The Global Picture
Migration
The Regional Picture
But who are these people?
• Challenge: No internationally adopted
definition for most terms
• Why do we care about definition?
– To better understand the great
diversity among migrants.
– Limit contradictory or misleading
information
Legal vs
illegal
Foreigners
Economic
Migrants
Refugees
Migrant
workers
– Achieve comparability of migration
statistics among countries
– Evidence-based , tailor-made policy
synthesis
Formal vs
informal
19
Migration & public health concerns :
Communicable Diseases
– Mobile people interact with and potentially affect and
adopt the health profile of all communities along their
migration route.
•
– The cost to societies:
•
•
•
•
Outbreak of disease (Health)
Trade
Political relationships
Financial position in a global economy
• Travel in affected regions.
Temperatures are rising rapidly, following increases in
CO2 emissions and concentrations
Climate Change and Communicable Diseases
• Climate may affect:
– Spatial distribution of outbreaks: where?
– Timing of disease outbreaks: when?
– Frequency of disease outbreaks: how often?
– Intensity or severity of outbreaks: how bad?
• Via effects on
– Pathogens: if free-living or outside of host
– Hosts: e.g, immunity
– Vectors: e.g. mosquitoes, ticks etc
– Dynamics: e.g. contact rates
– Indirect effects: effects on other disease drivers
Malaysia weekly dengue case notification 2001-2015
Number of dengue reported cases in the Americas
from 2000 to 2007.
Shepard DS et al. (2011). Am. J. Trop. Med. Hyg; 84(2): 200-207.
Annual economic burden of dengue in the Americas from
2000 to 2007 (in 2010 US$).
Shepard DS et al. (2011). Am. J. Trop. Med. Hyg; 84(2): 200-207.
Aggregate values of dengue episodes and economic
burden by year for 12 countries in SEA (2001–2010).
Shepard DS et al. 2013. PloS Negl Trop Dis; 7(2):e2055. doi:10.1371/journal.pntd.0002055
Use of multiple data sources to estimate the
economic cost of dengue illness in Malaysia.
Shepard DS et al (2012). Am. J. Trop. Med. Hyg;
87(5), 796-805
• Adjusted estimate of total dengue cases
• Economic burden of USD56 million per year.
• Overall economic burden would be higher if
costs associated with prevention and
control, dengue surveillance and long-term
sequelae of dengue were included.
Changing human-animal interface: Impact on
zoonotic malaria in Malaysia (2014)
Peninsular 2014
Sabah 2014
Sarawak 2014
P. falciparum
P. vivax
P. malariae
Mixed
P. knowlesi
Penisular 2015
Sabah 2015
Sarawak 2015
P. falciparum
P. vivax
P. malariae
Mixed
P. knowlesi

GLOBAL & NATIONAL HEALTH SECURITY:
Bancroftian filariasis
Leishmaniasis
Exotic zoonoses including avian influenza, H7N9
Polio
Mutlidrug resistance malaria
Mutlidrug resistance TB
Mutlidrug resistance malaria
Cholera
Mutlidrug resistance TB
Mutlidrug resistance TB
Avian influenza H5N1
Mutlidrug resistance TB
Managing infectious diseases threats
• Epidemiological surveillance through indicator (mandatory &
administrative notification) and syndromic surveillance
• Role of health intelligence
• Real time electronic communication on outbreaks need to be
developed
• Networking of laboratories
– National and Regional Public Health Laboratories
– Clinical laboratories – hospitals and private laboratories, IMR
– Others- DVM, Chemistry Labs
• Early warning and response system – CPRC, IHR focal points and WHO
& GOARN response structure
• Better integration and cooperation across various
government ministries and agencies
Health systems and infectious diseases
• Health systems play an important role.
• Failure to response to emerging challenges may
affects communicable disease program delivery
system:– Constraints not due to lack of technical guidance or
expertise but rather the shortcomings of health systems
• Surveillance systems not in place / not monitored / not
evaluated thus not detecting ALERT WARNING trends and
signals
• Multi sources of information not gathered to make a meaningful
and appropriate policy decision
• Current Rabies outbreak a case study
The Threats Continue
• Populations grow and move …

Microbes adapt …

Changing climates …

Increasing global interconnectedness …
WHO Briefing Notes: Pandemic (H1N1) 2009
“…. The 2009 influenza pandemic has spread
internationally with unprecedented speed. In past
pandemics, influenza viruses have needed more than six
months to spread as widely as the new H1N1 virus has
spread in less than six weeks ….”
WHO , Geneva (16 July 2009)
Thank you
[email protected]
33