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PAKISTAN 1963 We can look forward with confidence to a considerable degree of freedom from infectious diseases at a time not too far in the future. Indeed . . . it seems reasonable to anticipate that within some measurable time . . . all the major infections will have disappeared T Adian Cockburn 1968 It might be possible with interventions such as antimicrobials and vaccines to “close the book” on infectious diseases and shift public health resources to chronic diseases US Surgeon General WHO 2004 World Health Report In 2002 infectious diseases accounted for about 26 % of the 57 m deaths worldwide Infectious diseases are the 2nd leading cause of death globally Among young people infections are overwhelmingly the leading cause of death Approximately 75 percent of emerging pathogens are zoonotic EMERGING INFECTIOUS DISEASES Those diseases that have never been recognised before HIV/AIDS SARS Nipah Virus Encephalitis vCJD RE-EMERGING INFECTIOUS DISEASES Those diseases that have been around for decades or centuries, but have come back in a different form or a different location – Returned with a vengeance West Nile Virus Monkey pox Dengue Contributing Factors Economic development Land use Human demographics and behavior International travel Commerce Microbial adaptation and change Breakdown of public health measures Contributing Factors Human vulnerability Climate and weather Changing ecosystems Poverty and social inequality War and famine Lack of political will Intent to harm Pakistan’s Scenario Low income To feed a family of 4 for 10 days or to vaccinate? Population explosion 180 million Shrinking resources GDP – 6.8% (2006) to 2% (2009) Low expenditure on health Health 1.5% of GDP GDP Pakistan’s Scenario Urbanization Crumbling public health Limited access to potable water Rudimentary waste disposal Lack of political will Drug resistant microbes Excessive & unregulated antibiotic abuse The Vicious Circle Low socio economic group Costly Treatment Poor public health facilities Resistant strains Infection Drug Abuse Top Ten Causes of Death, all Ages Pakistan, 2002 Causes Deaths Years of Life Lost (000) (%) (%) All causes 139 100 100 Lower respiratory infections 164 12 14 Ischemic heart disease 154 11 5 Diarrheal diseases 118 9 12 Perinatal conditions 113 8 13 Cerebro-vascular disease 78 6 2 Tuberculosis 66 5 4 Chronic obstructive pulmonary disease 48 4 1 Measles 36 3 4 Whooping cough 24 2 3 Congenital anomalies 21 2 2 Fundamental Characteristics of Microbes Replication Human generations - every two decades Microbes - in minutes rapid replication Microbes also can mutate with each replication cycle Selectively circumvent human interventions Antimicrobials Vaccines public health measures Important Emerging & Re-Emerging Infectious Diseases in Pakistan Community Level Hospitals MDR/XDR-TB MRSA Drug Resistant MRSE Malaria Hepatitis B & C HIV/AIDS MRST Dengue Fever VRE O157:H7 ESBL producing GNRs Tuberculosis Incidence of TB per 100,000 population: 181 National disease burden: 5.1% Pakistan 6th in prevalence worldwide 96% of Medical Professionals are unaware of the existence of XDR-TB MDR/XDR-TB MDR TB Laboratory-confirmed resistance to the two most potent first-line medications, Isoniazid and Rifampacin XDR TB Resistance to both Isoniazid and Rifampacin with additional resistance to at least one Fluoroquinolone and one injectable agent (Amikacin, Kanamycin or Capreomycin) MDR/XDR-TB Gross underreporting Lack of resources Unreliable reporting system Unavailability of quality labs Lack of trained manpower in public health sector Lack of political will Cost Effect of TB Type Duration of Treatment Cost Tuberculosis 6 months $ 60 MDR 18 – 24 months $ 6,000 XDR 18 – 36 months $ 8,000- 12,000 Malaria Malaria is the 2nd most prevalent and devastating disease in the country (HMIS, 2006) Eco-epidemiological Zones Pakistan in Group 3: Countries with moderate/ high malaria burden, weak health system and/or complex emergencies Causal Organism Plasmodium falciparum is most dangerous (25%) Plasmodium vivax is most dominant (75%) High incidence in rural areas (38.65%) than in urban areas (22.39%) Economic cost 6 full working days lost due to illness 12.5 days lost due to partial morbidity Malaria Epidemiology Year 2006 2007 2008 Number of confirmed cases 124,910 128,570 104,454 • Estimated number of annual malaria episodes in Pakistan is 1.5 million. • In 2005, falciparum malaria constituted 33% of reported confirmed malaria cases, this figure decreased to 24% in 2008. • 40% of cases were reported from Baluchistan province. Roll Back Malaria If no Malaria control program incidence will double From 0.69/1000 to 1.39/1000 1million new cases every year (Malaria Economic Survey 2002/03) Total number of malaria cases averted 481,356 (Economic analysis of National Malaria Control Program, 2004) Hepatitis Current Estimated Prevalence Hepatitis B Hepatitis C Hepatitis A - 3-4 % 5-6 % (Intermediate) 100% exposed by adult age Hepatitis E ○ Quality of water and poor sewage disposal leads to pockets of resurgence Hepatitis B & C Needles in healthcare settings Receipt of blood and blood products Only 23% screening for HCV 50% of blood banks regularly utilized paid blood donors Injection drug users (IDUs) 500,000 addicts 75,000 (15%) are regular IDUs 150,000 (30%) are occasional IDUs Hepatitis B & C Occupational risks Higher prevalence in healthcare workers ○ HBV 6% ○ HCV 5.5% Shaving by barbers Awareness in only 13% 46% reuse of razors Household contacts/spousal transmission HIV/AIDS Until September 2004 Full-blown AIDS HIV infection - 300 cases 2300 cases HIV infection - 70,000 to 80,000 persons (0.1 % of the adult population) Pakistan Low-prevalence With many risk factors Underreporting HIV/AIDS Social stigma attached to the infection Limited surveillance and voluntary counseling Testing systems Lack of knowledge general population health practitioners Changing Situation HIV/AIDS Karachi 2004 Injecting Drug Users (IDUs) - 20 % infected Men who have sex with men (MSM) - 4 % Eunuchs - 2 % Significant risk factors Very low use of condoms among vulnerable populations Low use of sterile syringes among IDUs High prevalence of STI among eunuchs ○ 60 % in Karachi ○ 33 % in Lahore The Tip of Iceberg 70 – 80,000 cases Large susceptible population of, MSM, CSW, IDU Large Numbers of Migrants and Refugees Unsafe Medical Injection Practices Inadequate Blood Transfusion Screening and High Level of Professional Donors Low Levels of Literacy and Education Social and Economic Disadvantages RISK FACTORS HIV/AIDS Injecting Drug Users (IDUs) ○ Drug dependents in Pakistan about 500,000, an estimated 60,000 inject drugs Men who have Sex with men (MSM) Lahore estimated 38,000 MSM in 2002 Unsafe Practices among Commercial Sex Workers (CSW) 3 large cities population of 100,000 RISK FACTORS HIV/AIDS Inadequate Blood Transfusion Screening and High Level of Professional Donors 1.5 million annual blood transfusions 40 % not screened for HIV 1998 study in Karachi Infection ○ Hepatitis C ○ Hepatitis B ○ HIV 20 % 10 % 1% 20 % Professional donors RISK FACTORS HIV/AIDS Large Numbers of Migrants and Refugees Around 4 million are employed overseas Unsafe Medical Injection Practices High rate of medical injections - 4.5/capita/year 94 % injection reuse Unsafe injections account for ○ 62 % of Hepatitis B ○ 84 % of Hepatitis C ○ 3 % of new HIV RISK FACTORS HIV/AIDS Low Levels of Literacy and Education Illiteracy rate of women over 15 years 71 % Vulnerability Due to Social and Economic Disadvantages limited access to information and preventive and support services Young people are vulnerable Both men and women from impoverished households may be forced into the sex industry for income Typhoid 1987 1st Salmonella typhi reported to show In Vitro resistance (AFIP) to ○ Chloramphenicol ○ Cotrimaxazole ○ Amoxicillin 1991-2 Flouroquinolone 1997 Flouroquinolone treatment failure Today Multi Resistant Salmonella paratyphi A Impending therapeutic failure Typhoid – Current Situation Defervesence of fever 1990 Now 48 hrs 5th day Drug of Choice 3rd generation Cephalosporins Costly Cost Effect Serious public health problem in Pakistan Incidence - 800/100,000 in urban populations Rapid growth of Antibiotic-resistant typhoid Greater difficulty in treating cases Prolonged treatment Rising treatment costs Heavy economic burden on affected families Implications of growing antibiotic resistance Average Treatment Costs for Typhoid (US$) Child weighing 20 kg using standard treatment guidelines Course of antibiotics for non-resistant cases $3-5 Prolonged Fluoroquinolone treatment for Quinolone or Nalidixic acid resistant cases $24-30 Azithromycin $35-42 Oral Cephalosporins (Cefixime) $37-42 Parenteral Cephalosporins (Ceftriaxone) $44-104 Source: AKU Pharmindex 2004 & WHO guidelines 2003 Dengue Fever Dengue Fever 1st epidemic of DHF in 1953–1954 Manila, Philippines Expanded from Southeast Asian countries to Asian countries Pakistan, India and Sri Lanka Before 1989, DHF common in Southeast Asia but rare in the Indian Sub-continent After 1989 regular epidemics were reported from the Indian subcontinent Dengue Fever Pakistan absent from the WHO listing for South East Asian countries endemic for dengue until 1993 The first confirmed outbreak from Pakistan - 1994 Epidemic outbreaks of DF and DHF in Pakistan since 1994 Dengue Fever Ill defined types In 1994 DEN-1 & DEN-2 was reported in three of the 10 patients tested DEN-3 & DEN-4 in Pakistan 1st reported during DHF outbreak in 2005 2006 outbreak DEN-2 & DEN-3 Dengue Fever The circulation of two Dengue types classifies Pakistan as hyper-endemic region for dengue Dengue Fever AKU (2006) 250 confirmed cases Responsible strains - DEN-2 and DEN-3 The introduction of a new strain (DEN-3) and or a shift of DEN-2 are the probable factors for the recent outbreaks of DHF in this region Abbasi Shaheed Hospital (2007) Suspect cases Confirmed cases Died 1,200 260 22 CCHF Year n Deaths % 1976 17 3 14% 1978 8 8 100% 1987 2 2 100% 1994 3 0 - 1998 45 20 44% 2004 47 18 37% 2005 20 4 25% 2006 18 6 33% Infections in ICU Settings PRSP EHEC MRSA MRSE VRE ESBLs Acinetobacter baumanii Globally # 1 problem for ICUs High mortality and morbidity Drug resistance Gentamycin Tobramycin Amikacin Costly Tigecycline $ 140/day Minocycline $1/day War Against Microbes GNR Sulzone β Lactamases 3rd generation Cephalosporins Penicillin Cephalosporins Monobactem ESBL Carbepenamase Cabapenam ICU 50 cases Pathogen Acinetobectar Pseudomonas E Coli n 32 9 7 Resistant to Carbapenam 84% 78% 71% Misc 2 - Avian Influenza Avian Influenza Low prevalence High mortality 2003 – Feb 2008 Total cases Deaths Mortality 359 226 66% Directly infected from birds Little evidence of human to human spread Swine Flu Epidemic 2009 Flu Pandemic Data Area Confirmed deaths Worldwide (total) 14,286 European Union and EFTA 2,290 Other European countries and Central Asia 457 Mediterranean and Middle East 1,450 Africa 116 North America 3,642 Central America and Caribbean 237 South America 3,190 Northeast Asia and South Asia 2,294 Southeast Asia 393 Australia and Pacific 217 Source: ECDC – January 18, 2010 Virus of the Year: The Novel H1N1 Influenza It was supposed to come from Asia Instead it came from North America It was supposed to be a ne strain like Avian Flu (H5N1) It was simply another form of H1N1 It was supposed to be severe with high lethality It was severe in some populations, such as children and pregnant women, but overall mortality only 0.20.4% It was supposed to cause catastrophe Instead it caused confusion Swine Flu High mortality but limited spread despite greater scare Total cases 63 Deaths 10 No cases in Hajjaj Swine Flu No effective strategy to stop the spread Only 1 Lab in Islamabad Virus transport Medium Expensive treatment 10 x Tablets Tamiflu 75mg $125.00 Vaccine $ 20/dose Factors in our Armamentarium Intellect and a Will Public health measures Biomedical research Technological advances Human species uses its intellect and will to contain, or at least strike a balance with, microbial species that rely on genes, replication and mutation The Way Forward Prevention is best as we cannot afford to fight microbes through treatment Improved disease surveillance Community Hospitals Increase Public Awareness In Schools Through Mass Media Health professionals The Way Forward Improvement in Public Health Improve waste management Supply of potable water Institution of Antibiotic Policy Effective hospital infection control policy Greater Budgetary Allocation for health No room for complacency The future of humanity and microbes likely will unfold as episodes of a suspense thriller that could be titled Our Wits Versus Their Genes Thank You ?