Download Global Eradication of Infectious Diseases

Children and Infectious
Diseases:
Vaccine Preventable Diseases
and Maternal Health
Yvonne Maldonado, MD
Departments of Pediatrics and Health
Research and Policy
Stanford University School of Medicine
Ten Great Public Health Achievements
United States, 1900 - 1999
Vaccination
Motor-vehicle safety
Safer workplaces
Control of infectious diseases
Decline in deaths from coronary heart disease
Safer and healthier foods
Healthier mothers and babies
Family planning
Fluoridation of drinking water
Recognition of tobacco use as a health hazard
– Source: Center for Disease Control and Prevention, 1999
Decreased Mortality in the US from
Infectious Diseases in the 1900s
Sharp drop in infant and child mortality
In 1900
30.4% of all deaths among children <5; by
1997 only 1.4%
Leading causes of death pneumonia,
tuberculosis, diarrhea, and diphtheria
29.2 year increase in life expectancy
Comparison of Maximum and Current Reported Morbidity
Vaccine-Preventable Diseases and Vaccine Adverse Events
United States
Disease
Diphtheria
Measles
Mumps
Pertussis
Polio (wild)
Rubella
Cong. Rubella Synd.
Tetanus
Invasive Hib Disease
Vaccine Adverse Events
Maximum
Cases
206,939
894,134
152,209
265,269
21,269
57,686
20,000+
1,560 +
20,000 +
0
* Provisional
+ Estimated because no national reporting existed in the
prevaccine era
Year
1996*
Percentage
Change
(1921)
(1941)
(1968)
(1934)
(1952)
(1969)
(1964-5)
(1948)
(1984)
1
488
658
6,467
0
210
2
27
276
-99.99
-99.95
-99.57
-97.56
-100.00
-99.64
-99.99
-98.27
-98.62
11,690
+++
Vaccine Successes and Failures
Pediatric vaccinations have had the most
profound impact of any intervention on
increasing global child survival, accounting for
3 million children’s lives saved annually.
Even in the 21st century, however, vaccinepreventable infectious diseases, including
tetanus, measles and pertussis, cause disease
and death in many parts of the world.
Global Burden of Disease – Where do
vaccine preventable diseases fit in?
World Health Organization assessment
of global scope and cause of death
Many sources of information to assess
mortality throughout the world
Categories: infectious, non-infectious,
trauma
Leading Global Causes of Death - 1990
The Ten Leading Causes of Death, 1990
Developed
1 Ischemic heart disease
2 Cerebrovascular disease
3 Lung cancer
4 Lower respiratory infections
5 COPD
6 Colon cancer
7 Stomach cancer
8 Road traffic accidents
9 Self-inflicted injuries
10 Diabetes mellitus
Developing
Lower Respiratory Infections
Ischemic heart disease
Cerebrovascular disease
Diarrheal disease
Perinatal conditions
Tuberculosis
COPD
Measles
Malaria
Road traffic accidents
Global Burden of Infections
One death in three of the ~54 million deaths
worldwide is from an infectious cause
Virtually all of these deaths are in developing areas of
the world – mainly India and sub-Saharan Africa
Disproportionately affect children
Many of the developing world deaths are due to
preventable causes
Pneumonia and Diarrhea – account for 40% of these deaths
Tuberculosis
Measles
Malaria
Limitations of GBD Index
In most developing areas, this is just an estimate of
death
Does not account for incapacitating illness
Acute and chronic illness may have long term effects
on family and social structure
Individuals in marginal circumstances, even in
developed settings, are at higher risk
The Global Infectious Disease Threat
Infectious diseases are a leading cause of death
worldwide
Spread due to two major causes
• Changes in human behavior--including lifestyles
and land use patterns, increased trade and
travel, inappropriate use of antibiotics
• Microbial factors – mutations, antibiotic
resistance
The Global Infectious Disease Threat
and Its Implications for the United States
Of the seven biggest killers worldwide, TB, malaria, hepatitis,
and, in particular, HIV/AIDS continue to surge
HIV/AIDS and TB likely to account for the overwhelming
majority of deaths from infectious diseases in developing
countries by 2020
Acute lower respiratory infections, diarrheal diseases and
measles appear to have peaked at high incidence levels
The Global Infectious Disease Threat
and Its Implications for the United States
Global Burden of Vaccine Preventable Deaths
~2.5M deaths/year
What is the global status of
immunization?
Each year 130 million children are born, 91 million of
them (70%) in developing countries.
Almost 30 million children have no access to
immunization.
Due to immunization, and in particular to the global
Expanded Programme on Immunization (EPI),
launched by the World Health Assembly in 1974,
almost 3 million lives have been saved each year,
and 750 000 children are saved from disability.
Global Impact of Immunization
on Vaccine-Preventable Diseases
Disease
# of Preventable Cases
Hepatitis B
900,000
Measles
888,000
Haemophilus influenzae type b (Hib)
400,000
Pertussis (Whooping cough)
346,000
Neonatal Tetanus
215,000
Tetanus
195,000
Yellow Fever
Diphtheria
Poliomyelitis
TOTAL
30,000
5,000
720
2,979,720
What is the global status of
immunization?
In 1990, worldwide average vaccination
coverage of children under five was 80% but
by 1999 fell to 74%.
One in four children in the world remains
without immunization against the six diseases
initially covered by EPI (measles, polio,
pertussis, diphtheria, tetanus and
tuberculosis).
Access to immunization varies
greatly across the world
A child in a developing country is ten times more likely
to die of a vaccine-preventable disease than a child
from an industrialized one.
In some countries, up to 70% of children do not
receive the full set of vaccines; the lowest coverage is
found in sub-Saharan Africa.
In Africa as a whole, over 40% of children are not
immunized against measles, a major cause of infant
mortality that kills one child every minute.
Access to immunization varies
greatly across the world
WHO has been recommending vaccination
against Hepatitis B since 1993, yet it kills
approximately one million people each year.
Recommendations have also been made for
yellow fever, yet 30 000 deaths occur each
year.
What is the global status of
immunization?
There is no equality of access to vaccines for
children in industrialized and developing
countries, and there is a lack of equality
between rural and urban areas within
countries.
It is estimated that a child in an industrialized
country receives eleven vaccines on average,
while a child from a developing country is lucky
to receive half that number.
What is the global status of
immunization?
There is a lack of investment in research and
development for new vaccines or to disseminate
existing vaccines to combat the diseases that are
prevalent in developing countries:
Diarrhoeal diseases (Rotavirus, E. coli, Salmonella, Shigella,
Cholera)
Malaria
Tuberculosis
Pneumonia (Pneumococcus, H. influenzae type B, RSV)
HIV/AIDS.
Progress in Eradication of
Global Infections
Eradication of Smallpox in 1977
Elimination of Poliomyelitis from the Western
Hemisphere in 1994
Potential elimination of global poliomyelitis in
the next 5 to 10 years
Potential elimination of measles in the next
10 to 20 years
Vaccines in development for prevention of
diarrheal diseases, cervical cancer (HPV)
New Modes of Vaccination
Administration of vaccines is a major area of research
Many antigens given in the first year of life so combination
vaccines available and in development
“Needle-less” injections a global priority for compliance and
safety reasons (decrease spread of HIV and HBV through
reuse of needles)
• Development of edible vaccines (bananas, potatoes)
• Nasal or other mucosal routes
Impact of Infectious Diseases in
the Next 20 years
Three variables will affect the immediate future
Relationship between increasing microbial resistance and
scientific efforts to develop new antibiotics and vaccines
Trajectory of developing and transitional economies,
especially concerning the basic quality of life of the poorest
groups in these countries
Degree of success of global and national efforts to create
effective systems of surveillance and response
The interplay of these drivers will determine the overall outlook
Why Global Eradication of
Infectious Diseases?
Immunization is one of the most cost effective health
interventions in existence.
If polio is eradicated by 2005, $ 1.5 billion per annum
will be saved on immunization costs alone.
Similarly, eradication of smallpox in 1979 led to direct
savings of $ 275 million per annum.
Immunization reduces the social and financial costs of
treating diseases, offering opportunities for poverty
reduction and greater social and economic
development.
Why Global Eradication of
Infectious Diseases?
Improved survival
generally result in
improved standard of
living for all
Benefits to society
when most members
are healthy and
productive
Overall global stability
Maternal and Neonatal Health
Maternal-Perinatal
Morbidity & Mortality
Infections
Inadequate Perinatal Care
Premature Births
Obstructed Labor
Fistulas
Genital Mutilation
Cancer
Maternal and Neonatal Health
Women and their babies
suffer at the hands of
•
•
•
•
Poverty
Poor nutrition
Infection
Lack of effectively trained health workers
and medical staff
• Natural disasters
Maternal and Neonatal Health
529,000 pregnant women die per annum, 1 per
minute, and 5.7 million newborns die, almost all
in the developing countries of the world
In addition, for every woman who dies in
childbirth, 20 more suffer injury, infection and
disease– 10 million women a year.
A woman living in sub-Saharan Africa has a 1 in
16 chance of dying on pregnancy or childbirth,
compared with a 1 in 2,800 risk for a woman in
a developed country.
Maternal and Neonatal Health
70% of maternal deaths are due to hemorrhage,
obstructed labor, eclampsia, sepsis, and unsafe
abortion.
Of the 529,000 maternal deaths, 527,000 are
from the developing world.
2.7 million newborns are born dead each year
and 3 million will not survive the first week of
life– the astonishing total of 5.7 million!
Maternal and Neonatal Health
The WHO Department of
Making Pregnancy Safer (MPS)
“every birth should be attended by a skilled health
worker if the terrible toll of maternal deaths is to
be reduced… many of the deaths could be
avoided if all women had the assistance of a
skilled health care worker before, during and
after pregnancy, including access to emergency
medical care if complications should arise.”
Maternal and Neonatal Health
Goals
• UN Goal is to reduce by three-quarters the
rate that women die by childbirth by 2015
• WHO Goal is to dramatically increase the
number, training and availability of trained
health care workers in areas where there
is unmet need.
Pediatric Preventable Infections –
Immigrant Populations
Immunizations are key
Lack of a sustained medical home
Poor tracking by immunizations registries
Tuberculosis rates are high among immigrant
populations in the US
Exposure to infected adults
Disease most severe in infants and young children
Maternal prenatal care important for good
perianatal outcomes
Lack of consistent prenatal care in immigrant women