Communicable Diseases and Human Security

1. Communicable Diseases and Human Security Kelechi Ohiri MD MPH MS Health, Nutrition, Population Human Development Network World Bank

2. 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

3. 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.

4. 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

5. CD- Modes of transmission • Direct • Blood-borne or sexual – HIV, Hepatitis B,C • Inhalation – Tuberculosis, influenza, anthrax • Food-borne – E.coli, Salmonella, • Contaminated water- Cholera, rotavirus, Hepatitis A • Indirect • Vector-borne- malaria, onchocerciasis, trypanosomiasis • Formites • Zoonotic diseases – animal handling and feeding practices (Mad cow disease, Avian Influenza)

6. 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

7. 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.

8. Communicable Disease Burden Varies Widely Among Continents

9. Communicable disease burden in Europe

10. Causes of Death Vary Greatly by Country Income Level

11. 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

12. 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

13. 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

14. Human Security concerns • Potential magnitude and rapid spread of outbreaks/pandemics. e.g. SARS outbreak • No country or region can contain a full blown outbreak of Avian influenza • Bioterrorism and intentional outbreaks • Anthrax, Small pox • New and re-emerging diseases • Ebola, TB (MDR-TB and XDR-TB), HPAI, Rift valley fever.

15. Select Communicable Diseases

16. Tuberculosis • 2 billion people infected with microbes that cause TB. • Not everyone develops active disease • 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

17. 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.

18. Global Prevalence of TB cases (WHO)

19. Tuberculosis

21. 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

22. 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

23. Annual Reported Malaria Cases by Country (WHO 2003)

24. Global malaria prevalence

25. 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

26. HIV/AIDS • In 2005, 38.6 million people worldwide were living with HIV, of which 24.7 million (two-thirds) 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.

27. 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

28. Global HIV Burden

29. 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)

30. 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.

31. Avian Influenza • Control depends on the phase of the epidemic • Pre-Pandemic Phase • Reduce opportunity for human infection • Strengthen early warning system • Emergence of Pandemic virus • Contain and/or delay the spread at source • Pandemic Declared • 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

32. Confirmed human cases of HPAI

33. Migratory pathway for birds and Avian influenza

34. Neglected diseases • Cause over 500,000 deaths and 57 million DALYs annually. • Include the following • Helminthic infections • Hookworm (Ascaris, trichuris), lymphatic filariasis, onchocerciasis, schistosomiasis, dracunculiasis • Protozoan infections • Leishmaniasis, African trypanosomiasis, Chagas disease • Bacterial infections • Leprosy, trachoma, buruli ulcer

35. Communicable Disease and Human Security Part 2 - Mounting an Effective Global Response

36. 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

37. Personal Responsibility and action • Improved hygiene and sanitation • Hand washing, proper waste disposal, food preparation and handling. • Information, education and behavior change • Changing harmful household practices • Livestock handling, knowledge about contagion • Cultural and social norms • Self reporting of illnesses and compliance with interventions and treatment.

38. Utilitarian Approaches – “Greatest good for the greatest number” • Reliance on personal responsibility • not always the optimal option given different knowledge levels and values. • Public good nature of the interventions • Social Isolation and Quarantine measures • Home treatment; Isolation • Mass vaccination programs and campaigns • Polio, small pox, DPT, Hepatitis, Yellow fever • Mass treatment programs – • 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.

39. 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.

40. 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)

41. 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.

42. Isn’t Donor Collaboration Wonderful? WHO INT NGO CIDA 3/5 UNAIDS GTZ RNE UNICEF Norad WB Sida USAID T-MAP MOF UNTG PMO CF DAC GFCCP PRSP PEPFAR HSSP GFATM MOEC MOH SWAP CCM NCTP CTU CCAIDS NACP LOCALGVT CIVIL SOCIETY PRIVATE SECTOR Source: WHO: Mbewe

43. A paradigm shift - Enlightened Self interest • Communicable diseases have no borders. • Predominantly affect the poor, and poor countries • Also affect richer households and countries. • Interventions are non-rival, non-exclusive and have positive externalities. • 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.

44. Global Mismatch Between Disease Burden and Health Spending

45. Global Mismatch Between Disease Burden and Health Spending

46. Future Population Growth Will be in LICs and MICs

47. 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

48. 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

49. 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

50. Sources of Development Assistance for Health Source: Michaud 2006