Communicable Diseases and Human Security

Kelechi Ohiri MD MPH MS

Health, Nutrition, PopulationHuman 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 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)

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 Communicable Disease Burden Varies Widely Among ContinentsVaries Widely Among Continents

Communicable disease burden in Europe

Causes of Death Vary Greatly by Causes of Death Vary Greatly by Country Income LevelCountry Income Level

Age distribution of death in Denmark around 2005

Male Female

80 60 40 20 0 20 40 60 80

0 - 4

15 - 19

30 - 34

45 - 49

60 - 64

75 - 79

90 - 94

Age g

roup

Percent of total deaths

Age distribution of death in Sierra Leone around 2005

Male Female

80 60 40 20 0 20 40 60 80

0 - 4

15 - 19

30 - 34

45 - 49

60 - 64

75 - 79

90 - 94

Age g

roup

Percent of total of deaths

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 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.

Select Communicable Diseases

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

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 (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.

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 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

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 Hookworm (Ascaris, trichuris), lymphatic filariasis,

onchocerciasis, schistosomiasis, dracunculiasis Protozoan infections

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 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.

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.

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.

MOH MOEC

MOF

PMO

PRIVATE SECTORCIVIL SOCIETYLOCALGVT

NACP

CTU

CCAIDS

INT NGO

PEPFAR

Norad

CIDA

RNE

GTZ

SidaWB

UNICEF

UNAIDSWHO

CF

GFATM

USAID

NCTP

NCTP

HSSP

HSSP

GFCCPGFCCPDAC

CCM

T-MAP

3/5

SWAPSWAP

UNTG

PRSP PRSP

Isn’t Donor Collaboration Wonderful?Isn’t Donor Collaboration Wonderful?

Source: WHO: Mbewe

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.

Global Mismatch Between Disease Global Mismatch Between Disease Burden and Health SpendingBurden and Health Spending

Burden of disease in disability adjusted life years by income category

9.7%55.9%

34.4%

% DALYs in LIC % DALYs in MIC % DALYs in HIC

Global Mismatch Between Global Mismatch Between Disease Burden and Health Disease Burden and Health SpendingSpending

Distribution of Total Global Expenditures on Health by Income Category

10%

2%

88%

Low income Middle income High income

Future Population Growth Will be Future Population Growth Will be in LICs and MICsin LICs and MICs

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

9,000

10,000

1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Year

Tota

l popula

tion (

millions)

Developing countries

Developed countries

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 Sources of Development Assistance for HealthAssistance for Health

0

2,000

4,000

6,000

8,000

10,000

12,000

Average 1997-99 2003Year

US$ (

in m

illio

ns)

Private Non-profit

Other Multilateral

Development Banks

UN System

Bilateral

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.