Transcript Malaria - Amazon Malaria Initiative

MALARIA AND MOBILE POPULATIONS
MALARIA IN THE AMERICAS
FORUM 2009
PAHO, WASHINGTON DC
NOVEMBER 6, 2009
Presentation outline
-Definitions and statistics at a glance
-Health implications of mobile populations: refugees, displaced
populations and infectious and tropical diseases
-Mobile populations and impact on malaria transmission
-Key elements for discussion
CARLOS ESPINAL M.D.
Director Public Health
sanofi pasteur
Latin America
WHY POPULATIONS MOVE ?
Internal
conflicts
Violence
Human rights
violations
Natural
disasters
Commerce
in frontiers
Migration related to
natural resources:
mining, agriculture, oil
Government
and irregular
Military Forces
REMARKS
•Medicine and public health focused on pathogens
•Today focus should be in globally move populations that move pathogens across
international borders and internally
•Human mobility has always been associated with the spread of diseases: Influenza H1N1,
avian FLU, dengue, malaria, TB, HIV, SARS
•Impact of migration patterns is a great challenge for modern epidemiology and public
health programs
Mobile populations
UNHCR definitions and statistics at a glance
2008: 42 million forcibly displaced people worldwide
Refugees
Status of Refugees
People crossed
international border
Asylum-seekers
Claimants for
refugee status
pending of approval
2008: 827.000
2008: 15
million
Stateless
No belonging to any
recognized state or
Nation
2008: 6.6 million
Overall about 12
million
Internally displaced
persons (IDPs)
Natural Migrants
(borders
populations)
People forced to
leave habitual
residence, who have
not crossed
international borders
Individuals or
groups with
residence within the
international
borders, with a wide
circulation across
the frontiers
2008: 26 million
Return refugees
(returnees)
Refugees who
returned voluntarily
to their country of
origin or habitual
residence
2008: 604.000
Returned IDPs
IDPs beneficiaries
of protection and
assistance to return
to their habitual
residence
2008: 1.3 million
2008 Global trends
UNHCR 2009
Populations of concern to UNHCR 2008
Latin America:
3.571.620
COUNTRY
26.000.000
SUDAN
4.900.000
COLOMBIA*
2.650.00-4.360.000
IRAQ
2.840.000
PAKISTAN
2.400.000
DEMOC REP CONGO
2.000.000
SOMALIA
1.300.000
ZIMBABWE
1.000.000
AZERBAIJAN
603.251
KENYA
400.000
AFGANISTAN
235.000
ETHIOPIA
200.000-300.000
PERU*
150.000
UNHCR
Internally displaced
Persons IDPs
2008
People displaced and evacuated by sudden-onset
natural disasters 2008
Natural disasters: Earthquakes, floods, storms
Hazard
type
Geophysical
Meteorolog
Hydrolog
Climatol
All disasters
No of
disasters
21
61
128
11
221
Total
displaced
and
evacuated
15,769.430
8.246.523
11.485.418
561.472
36.062.843
Country
Total displaced and
evacuated
Country
Total displaced and
evacuated
China
19.979.423
Myanmar
800.000
India
6.705.085
Indonesia
400.815
Philippines
2.736.389
Brazil
381.035
USA
2.014.473
Mozamb
289.486
Cuba
980.000
Thailand
202.680
MOBILE POPULATIONS AND SPREAD OF INFECTIOUS AND
TROPICAL DISEASES
•Denmark: TB incidence in foreign-born persons rose from 18% in 1986
to 60% in 1996 (1)
•England: TB, 40% of new cases occur in people from Indian
subcontinent (1)
•Germany: 14% of HIV/AIDS cases are detected in migrants from Africa,
USA, Asia, and Latin America (1)
•USA: Polio, in 2005 Minnesota State Health Department detected
vaccine-derived poliovirus infection in 4 children, in unvaccinated
community, probably originated in a person vaccinated with OPV in
another country (2)
•Polio: 2003-2006, polio imported to 24 polio-free countries (2)
•USA: TB, Rates, 2007 2.1x100.000 in US-born persons vs 20.6x100.000
in foreign-born persons
(1) M Caballero A Nerukar Em Inf Dis 2001. 7(3):556-560
(2) E Yanny et al. Em Inf Dis 2009. 15(11):1715-1719
IMPORTED INFECTIOUS DISEASES IN MOBILE POPULATIONS SPAIN
Diagnostic
Population n=2.198 Sub-Sah Africans
Latin America
Malaria (1)
Chagas (2)
212
101
199
0
101 13
101
Filariasis
Cysticercosis
421
31
418
3
3
28
Latent TB
Active TB
716
107
596
52
120
55
HIV
Acute Hepatitis
97
31
82
27
15
4
Chronic hepatitis
267
257
10
REMARKS:
2008: EU 1.9 million immigrants. Spain 700.000.
Total Immigrants in Spain by 2008: 5.2 million
(1) Malaria: 15 patients (7.1%) were asymptomatic. P falciparum most frecuent in Africans.
(2) Chagas: 95% of positive patients from Bolivia. Study in Spain estimated between 37.000-122.000
immigrants potentially infected with T cruzy
B Monge-Maillo et al. Emerg Infect Dis 2009. 15(11);1745-1752
MOBILE POPULATIONS IN LATIN AMERICA 2009
Malaria Latin
America 2007
WHO/UNICEF
Report 2008
México
Cuba
Guatemala
Nicaragua
Panamá
Venezuela
Colombia
Ecuador
Conflicts, violence, IDPs (UNHCR?)
Refugees,
Brasil
Perú
Bolivia
Gold explotation: Brazil, Venezuela,
Surinam , Bolivia, Guyana
Castaneros Bolivia (nut harvesters):
Brazil
Paraguay
Chile
Argentina
Uruguay
World Bank.
http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTOGMC/0,,contentMDK:20212491~menuPK:463310~pageP
K:148956~piPK:216618~theSitePK:336930,00.html
Migrant mine
workers
Consultancy for Human Rights and Displacement (CODHES)
National estimates: 4.629.190 persons
Average: 925.838 families
No Persons
www.codhes.org
450000
412.553
400000
380.863
350000
305.966
300000
250000
200000
150000
100000
50000
0
1985
1987
1989
1991
1993
1995
YEARS
1997
1999
2001
2003
2005
2007
HEALTH INDICATORS IN GOLD MINING WORKERS LATIN AMERICA
Population profile: Concentration of men, ages 20y-45y,
very limited female population, miners in permanent
migration, rise of violence, alcohol and drug abuse.
Inadequate housing, living in tents, poor sanitation.
Bolivar State, Venezuela. L Faas, et al. Pan Am J Public Health , 5(1) 1999
Totals
893
STDs (1 or 2): 178 (19.6%)
Syphilis: 148 (16.6%)
Guyana, Amazon Region. CJ Palmer et al. Emerging Infectious Diseases 8(3), 2002
Totals
216
HIV+: 14 (6.5%)
Impact of co-infection HIV-Malaria
Apiacas, Mato Groso, Brazil. FJ Dutra et al. Hepatitis B markers in malaria-exposed
gold miners. Mem Inst Oswaldo Cruz, 96, 2001. Garimpo satelite: 16 gold mine campus
Totals
569
Age 20-40y
HBV markers 82.9%
HBsAg
7.1%
HCV
2.1%
Malaria
99.4 % with previous
episodes
610 (20%) positive
for malaria
P falciparum
56 (53%)
P vivax
47 (44%)
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
1. Mass population movements could occur in endemic
areas., e.g., the Amazon frontiers.
2. Industry – mining, rubber, agriculture, oil fields,
attract migrant workers to new areas
Epidemiology
of malaria in
mobile
populations
3. Incidence and burden of disease will depend upon
immunity, intensity of malaria transmission, vectors,
and health care services
4. Malaria can be responsible for high rates of
morbidity and mortality
5. Displacement exacerbates rapid urbanization in
marginal areas, with poor housing condition and
sanitation, inadequate vectorborne control, and
amplification of malaria to epidemic proportions
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
1. Health service personnel trained in malaria
2. Demography data, determine high risk groups or
vulnerable populations (pregnant women,
children)
3. Case definition and case management. Active
Surveillance
systems
reporting and high quality data
4. Active vs passive surveillance
5. Rapid diagnostic tests. Blood smears and
Vector
surveillance
microscopy routine technique. Asymptomatic
case detection by PCR (MS Suarez et al Rev Inst Med
Trop S Paulo 49(3) 2007. 20% detection in P vivax)
6. Monitoring of drug efficacy and resistance
7. Hospital-based surveillance for clinical
complicated malaria and fatal cases
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
1. Selection of antimalarial drug and appropriated
regimens. Effective drug combinations.
Artesunate combinations. High levels of
acceptability in the community and adhesion to
treatment
Chemotherapy
2. Mass drug treatments upon arrival at camps vs
selective treatment to febrile patients?
3. Treatment only in confirmed cases?
4. Train local community leaders in techniques for
rapid diagnosis and treatment. ( e.g.,Bolivia’s
successful case study: reducing malaria in
mobile populations in castaneros workers)
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
1. Overburdening of existing health structure:
insufficient personnel, hospitals or clinics, problems
with access to medicines including antimalarial
drugs, deficiency in lab diagnosis, equipments
Health services
2. Malaria control strategies integrated to global health
interventions in displaced population, refugees, and
mobile workers
3. Very few interventions measure the impact .
Effectiveness is not consider it or limited in methods
to evaluate their success.
MALARIA AND HUMAN POPULATION MOVEMENT
CHALLENGES FOR PUBLIC HEALTH INTERVENTION
1. Large gap in the evidence of what works for
change the behavior of public and private health
providers.
Pay attention to health system constraints that
impact effectiveness and sustainability of
malaria interventions. LA Smith et al . Improve effective
treatment malaria: Do we know what works? Am J Trop Med Hyg.
80(3), 2009:326-35
Health services
2. Resettlement or repatriation: possible
introduction or reintroduction of multi-drug
resistant malaria. Mass screening strategies?,
mass treatment before departure?
3. How to achieve sustained high coverages of
control measures: rapid diagnosis and effective
treatments with simple schedules, insecticide
residual spraying, preventive treatment in
vulnerable groups, long-lasting insecticide