Povertà e

patologie riemergenti

Piero ValentiniClinica Pediatrica U.C.S.C. - Roma

19 novembre 2010

Epidemiologic or health transition

• Age of pestilence and famine

• Age of receding pandemics

• Age of degenerative and man-madediseases

Omran A, 1971

“As the control program for a

disease approaches eradication

of that disease,

the control program rather than

the disease may be eradicated”Ingall D, et al. “Syphilis” In Remington and Klein, 4° Ed., 1995

HIV/AIDS (1981)

Cholera (Peru, 1991)

Plague (India, 1994)

Ebola (Zaire, 1995)

Dengue (Cuba, 1983)

SARS (China, 2001-2003)

West Nile Fever (Grecia, 2010)

1997 World Health Day

“Emerging Infectious DiseasesGlobal Alert, Global response”

“…in a global village, no nation is immune”

Fauci A. 1997

“Many infectious diseases have emerged; others have unexpectedly

reappeared. Reasons include urban crowding, environmental changes,

altered sexual relations, intensified food production and increased

mobility and trade.

Foremost, however, is the persistence of poverty and the exacerbation of

regional and global inequality.

Life expectancy has unexpectedly declined in several countries….

In some regions, declining fertility has overshot that needed for optimal

age structure, whereas elsewhere mortality increases have reduced

population growth rates, despite continuing high fertility.”

McMichael AJ, Butler CD. Health Prom Int, 2007

Millennium Development Goals

• Eradicate extreme poverty and hunger

• Reduce child mortality

• Improve maternal health

• Combate HIV/AIDS, malaria and other diseases

• Ensure environmental sustainability

• Develop a global partnership

• Achieve universal primary education

• Promote gender equality

The disease profile of poverty

S. Accorsi, et al. Trans R Soc Trop Med Hyg 2005

Tasso di mortalità delle principali malattie (Uganda settentrionale)

S. Accorsi, et al. Trans R Soc Trop Med Hyg 2005

From the recent lessons of the Malagasy foci towards a global understanding of the factors involved in plague reemergence

Duplantier J-M. Vet Res 2005

The reduction or discontinuance of surveillance and control, as well as poverty and

insalubrity are the main factors in the re-emergence of human cases, allowing increased

contacts with infected rodents and fleas. Environment changes (i.e. climatic changes,

deforestation, urbanization) induce changes in flea and rodent populations by (i)

extension of rodent habitats (for example by replacing forests by steppes or farmlands);

(ii) modifications in population dynamics (possible outbreaks due to an increase of

available food resources); but also, (iii) emergence of new vectors, reservoirs and new Y.

pestis genotypes. Numerous and spontaneous genomic rearrangements occur at high

frequencies in Y. pestis, which may confer selective advantages, enhancing the ability of

Y. pestis to survive, to be transmitted to new hosts, and to colonize new environments.

“Patterns of future urban growth, combined with advances in the treatment of traditional

scourges of communicable diseases, will cause a shift in the burden of disease toward

category 2 (non communicable) and 3 (injury) conditions over the next 30 years.

Communicable diseases, particularly HIV/AIDs, will continue to be the most important

killers among the poor. However, new risks will emerge for several reasons.

First, the marked sprawl of cities in the developing world will make access to care more

difficult. Second, increasing motor vehicles and the likelihood of inadequate infrastructure

will make air pollution and accidents in road traffic more common than in the past.

Third, impoverished urban populations have already shown a propensity toward

undernourishment, and its obverse, obesity, is already emerging as a major risk.”

Campbell T, Campbell A. J Urban Health 2007

‘The DoubleBurden

ofDisease’

Incidenza media annuale di polmoniti batteriche invasive in adulti in base a etnia ed area di residenza

Burton DC. Am J Public Health, 2010

24,2/100.000/year

10,1/100.000/year

RR = 2.40;CI = 2.24, 2.57

Williams DR Pediatrics 2009

Social Determinants: Taking the Social Context of Asthma Seriously

Nonwhite children residing in urban areas and children living in poverty

have a significantly higher risk of asthma and higher disease morbidity

than do white children; for example, asthma prevalence, hospitalization,

and mortality rates are higher for black children than for white children.

Puerto Rican individuals have an elevated risk of asthma, compared with

other Hispanic populations. Indicators of area deprivation also are

positively related to childhood asthma prevalence and hospitalization

rates, which suggests that SES (Socioeconomic status) characteristics at the

individual, household, and community level affect a child’s risk of asthma.

Climate change is increasing the global burden of disease and in the year

2000 was responsible for more than 150,000 deaths worldwide.

Of this disease burden, 88% fell upon children.

Documented health effects include changing ranges of vector-borne diseases

such as malaria and dengue; increased diarrheal and respiratory disease;

increased morbidity and mortality from extreme weather; changed exposures

to toxic chemicals; worsened poverty; food and physical insecurity; and

threats to human habitation. Heat-related health effects for which research is

emerging include diminished school-performance, increased rates of

pregnancy complications, and renal effects.

Global Climate Change and Children’s Health:Threats and Strategies for Prevention

Sheffield PE, Landrigan PJ. ehp, 2010

1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007

Casi di tubercolosi nella fascia 0-17 anni (1990 - 2007)

italiani

stranieri

Studio multicentrico GLNBI (NO, PD, GE, RM-UCSC, RM-OPBG, NA, BA)

0

5

10

15

20

25

30

35

1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

Italians

Not Italians

Total

Italiani Stranieri Stranieri + NN

Notifiche casi di tubercolosi (1999-2008)

Tubercolosi pediatrica a Roma: 1999-2009

Buonsenso D, et al. ISCOMS, 2010

1999: 8,5/100.000nati vivi affetti da Sifilide congenita

Incidenza di sifilide primaria e secondaria nei paesi dell’ex-Unione Sovietica

1991: 0,9/100.000nati vivi affetti da Sifilide congenita

Simms I, Broutet N. JDDG 2008

Notifiche di sifilide in Norvegia ed alcuni paesi dell’Unione Europea

Simms I, Broutet N. JDDG 2008

Notifiche di sifilide per anno (ISTAT: 1955-1999)

Nu

mer

o c

asi

1955 1999

Notifiche di sifilide per anno (ISTAT)

Lombardia

BolzanoPiemonte

Veneto

Valle D’Aosta

• Immigrant women were more likely to be seropositive than Italian women

(relative risk 28.17, 95% confidence interval (CI)14.97 to 53.02, p 0.001).

• Of the seropositive Italian women, 9 of 11 were treated before pregnancy, while the

remaining 2 were treated during the first trimester of pregnancy. Women untreated at

delivery were more likely to be from eastern Europe (9/10) than from other countries

(p,0.05): 4 women were from Romania, 3 from Moldova, 1 from Ukraine and 1 from

Russia.

• The mother’s age ranged from 18 to 42 years. Untreated women with first-time

diagnosis at delivery were younger than the adequately treated women

(median standard deviation (SD) age 25 (4.6) v 29.2 (5.7) years; p 0.05).

• The overall syphilis seroprevalence in pregnant women was 0.44%, but it was 4.3%

in women from eastern Europe and 5.8% in women from Central–South America

Tridapalli E, et al. Sex Transm Infect 2007

• Periodo: 1 luglio 2006 – 30 giugno 2007

• Prevalenza sifilide materna al parto: 0.17%

• 207 nati da 203 madri sieropositive per sifilide

• 25 neonati con sifilide congenita (20/100.000 nati vivi), di cui

11 (44%) prematuri, 6 (24%) di peso < 2000 g, 19 (76%) con

madre straniera

• Fattori di rischio materni: età < 20 anni, nessuna cura

prenatale o trattamento inadeguatoTridapalli E, et al. Arch Dis Child Fetal Neonatal Ed, 2010

TBC del SNC e del polmone

Sifilidecongenita

“About 1 to 2 percent of sera from patients with secondary

syphilis will exhibit a prozone phenomenon….due to an excess

amount of reagin antibody present in the patient’s undiluted

serum…. The prozone effect can be overcome by diluting the

serum before testing, after which the serum will usually

exhibit titers of 1:16 or greater”

Int J Dermatol, 1982 – JAMA, 1964 - N Engl J Med, 1971

Coinfezione HIV/TBC

AIDS

Health promotion must, of course, continueto deal with the many local and immediate

health problems faced by individuals, families and communities.

But to do so without also seeking to guide socio-economic development and

the forms and policies of regional andinternational governance is to risk being

‘penny wise, but pound foolish’.

McMichael AJ, Butler CD. Health Prom Int, 2007