Transcript Week 7 Powerpoint - EPI5180

Preventing the Preventable
Infectious Diseases in Developing Countries
Anne E McCarthy, MD, MSc, FRCPC, DTM&H
Director Tropical Medicine and International Health Clinic
The Ottawa Hospital General Campus, Ottawa Canada
Session objectives
Describe the evolution of thinking and approaches to
infectious diseases prevention and control in
developing countries using tuberculosis and HIV as
examples.
Understand limitations of vital statistics and data
gathering in developing countries (and developed
countries)
Understand mortality pattern variations and risk
factors for disease across countries and change in
balance between infection and chronic disease in
some countries
Global Burden on Disease Framework
(1990)
An attempt to determine how
population’s health changing
To help health policy and planning purposes.
Using common language and measurement.
Provides an opportunity to compare own
progress and between areas.
Global Burden on Disease Framework
(1990)
Gets away from simply reporting mortality
Introduced Disability-Adjusted Life
Expectancy
Include non-fatal health outcomes
Almost all sources health data likely
worthwhile
• Methods to assess reliability of data
• Methods to deal with missing data
• Common metric
Global Burden on Disease Study (2001)
Refined framework
Global and Regional Mortality
Leading causes of disability
Neuropsychiatric
Vision
Hearing loss
Alcohol use
Global Burden on Disease Study (2001)
Noted the importance of the
unrecognized burden of injury
More than 85% disease burden due to
non-fatal health outcomes in LMIC
Global Burden on Disease Study (2001)
So those in LMIC cf high income
countries…
Live shorter periods of time
Live those years with increased disability
Note: This is morbidity data – and only infectious diseases
What do you think are the most important causes of death in
travellers/tourists?
Millennium Development Goals (MDG) UN 2000 by 2015
1.
2.
3.
4.
5.
6.
Eradicate extreme poverty and hunger
Achieve universal primary education
Promote gender equality & empower women
Reduce child mortality ***
Improve maternal health***
Combat HIV/AIDS malaria and other
diseases***
7. Ensure sustainable development
8. Create external partnerships
Potential for risk reduction
World Health Report 2002 states that some
of risks to healthy life can be reversed
quickly, even with modest changes in risks
To determine best strategies for a country
we first need to Measure – need a
systematic approach to estimate burden of
disease and injury due to different risks
WHY BOTHER??
WHR 2002
Emphasizes global gap
The gap between the “haves” and the
“have nots”
Yet the “haves” are not necessarily
lavishing in a health advantage
WHR 2002
LMIC VS high income countries
Poor countries > 170 million underweight
children and 3 million deaths
• Poverty strong underlying determinant
• Loss of 130 million years healthy life
Rich countries (NA EU) > 1 billion overweight
and 300 million obese adults
• Leading to 500,000 deaths NAm and EU
WHR 2002
Unsafe Sex (2.9 million deaths, most Africa)
HIV/AIDS
4th leading cause of death
70% of the 40 million cases in Africa
Growing epidemics elsewhere
• Highest increases in cases Eastern Europe and central Asia
Life expectancy Africa now 47 years
Without HIV/AIDS estimated would be 62 years
Africa 99% HIV related to unsafe sex
WHR 2002
Unsafe water, sanitation, hygiene
Lead to 1.7 million deaths, many infectious
• Most (90%) children
• Most in LMIC
WHR 2002
Iron deficiency
2 billion affected -> almost million deaths.
Most in young children and their mothers
Indoor air pollution
36% LRTI; 22% COPD
WHR 2002
Most risk factors strongly related to
patterns of living
Too little
• Examples?
Too much
• Can you give examples in LMIC?
• Easier to give examples in High income countries
WHR 2002 REVERSE TRANSITION
Of real concern… increasing LMIC
blood pressure, cholesterol, alcohol, tobacco,
obesity
traditionally high income countries
WHR 2002 REVERSE TRANSITION
These risk factors part of REVERSE
TRANSITION
Marked changes in patterns of living in world
with adverse health outcomes
World Health Report 2002
Reducing Risks, Promoting Healthy Life
Ultimate goal – increase healthy life expectancy
Describes amount disease, disability , death in
world attributed to select number of most
important risks to human health
Calculates how much of burden could be avoided
with risk reduction
Shows how some of risks can be reduced in
cost-efficient ways
World Health Report 2002
Reducing Risks, Promoting Healthy Life
Suggests improvement of at least one
decade of healthy life expectancy can be
within grasp of many of world’s poorest
countries (LMIC)
Even high income countries could gain 5
years…
World Health Report 2002
Reducing Risks, Promoting Healthy Life
What are the top 10 risks globally
with respect to burden of disease?
World Health Report 2002
Reducing Risks, Promoting Healthy Life
What are the top 10 risks globally
with respect to burden of disease?
Underweight
Unsafe sex
High Blood Pressure
Tobacco
Alcohol
Unsafe water, sanitation, hygiene
Iron deficiency
Indoor smoke
High cholesterol
Obesity
Which ones are problems in LMIC/HIC?
Global TB control 2012
8.8 million incident cases (2010)
1.1 million deaths in those HIV –ve
0.35 million deaths with HIV co-infection
2009- 10 million children orphaned by TB
GOOD News
On target to meet MDGs
Absolute numbers TB cases decreasing
TB incidence falling
Est numbers of deaths decreasing
China is making a lot of progress
WHR 2007 : Global TB Control
(2005 data)
8.8 million new cases (7.4 million India & SSA)
1.6 million deaths (195,000 HIV co-infected)
Part of MDG – halt and begin to reverse
Global TB control 2012
Strengthening diagnostics and
laboratories
Why is this important??
Addressing co-epidemics TB and HIV
All TB patients should be tested for HIV
• Why?
All those with HIV infection should be
tested for TB.
• Why?
TB world report
Still important global problem
Even though effective therapy has been
available for many decades
Goal - TB free world
Need to expand availability of diagnosis
and treatment
Need to expand treatment under DOTS
• What is DOTS and why is it important??
WHR 2007 : Global TB Control
(2005 data)
Intersection of HIV and TB
great potential to lose gains made by TB
control programs
Recently described highly resistant TB
(XDRTB) further risk to WHO TB control
programs
C Dye , WHO 2002 rates
Estimated HIV prevalence in TB cases, 2003
HIV prevalence in TB
cases, 15-49 years (%)
0-4
5 - 19
20 - 49
50 or more
No estimate
The designations employed and the presentation of material on this map do not imply the expression of any opinion
whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or
area or of its authorities, or concerning the delimitation of its frontiers or boundaries. White lines on maps represent
approximate border lines for which there may not yet be full agreement.
© WHO 2004
So why are TB control programs failing?
To understand this need to consider differences
in TB control between LMIC and HIC countries.
How is the diagnosis made?
Who is targeted to get diagnosis and treatment?
How is failing therapy identified?
How is failing therapy managed?
How do you identify MDRTB or XDRTB?
Tuberculosis in Canada
contribution by Foreign born and Aboriginal 1980-02
Other Canadians
Foreign Born
Aboriginal
100%
80%
60%
40%
20%
0%
80
82
84
86
88
90
92
94
96
98
00
0
2
02
0
2
Even within Canada we are not
always winning…
Ongoing cases in northern communities
Failure of therapy
Ongoing transmission.
BCG was withdrawn from TB control in
many communities
Any comments about the role of BCG or lack
of BCG?
So what do we need to win vs TB
Great programs
Case detection
Culture all
(is this all my bias of working in a resource
rich setting?)
Directly observed therapy (DOT) for all
Monitor and document response and cure
Goals Global AIDS Day Report 2011
Zero new HIV infections
How?
Zero discrimination
How?
Zero HIV-related deaths
How?
Goals Global AIDS Day Report 2011
Decreased numbers of new infections
Yet, there are more people living with
HIV
• Why?
Goals Global AIDS Day Report 2011
Why are more people living with HIV
Increased efforts to prevent transmission
Increased coverage of treatment
Up 20% in SSA
Better health, less deaths
Less transmission
• including mother to child
Goals Global AIDS Day Report 2011
Majority of cases (60%) SSA
Overall, less new cases
2.7million new cases, almost 400K children
Increasing cases in some areas – eg Eastern
Europe and Central Asia
Less HIV deaths
Proportion women remains at 50%; 59% in
SSA, 53% Caribbean
Goals Global AIDS Day Report 2011
UNAIDS has mapped new framework
Want longer term, more organized
response
Behavior change
Focus on people at higher risk infection
Identify and invest in young leaders
Rapid increase in ART coverage
Decrease risk of TB disease – treat
latent TB infection
Goals Global AIDS Day Report 2011
UNAIDS has mapped new framework
Maximize benefits of HIV response
Use country specific epidemiology to
ensure rational resource allocation
Have effective programmes based on
local context
Increasing efficiency in HIV prevention,
treatment, care and support
Global Estimates of Adults and Children 2004
People living with HIV……39.4 million
New HIV Infections in 2004….4.9 million
Deaths due to AIDS in 2004…..3.1 million
Adults and Children Living with HIV/AIDS 2004
N. America
1.0 million
Caribbean
440,000
Latin America
1.9 million
Data from
UNAIDS
Western Europe
610,000
North Africa
540,000
Eastern Europe
& Central Asia
1.4 million
S & SE Asia
7.1 million
Sub-Saharan
Africa 25.4 million
Oceania
35,000
Total: 39.4 (35.9 – 44.3) Million
Global View of HIV infection
1300
%
20%
20%
100
%
160%
60%
40%
Adult prevalence rate
15%-36%
5%-15%
1%-5%
0.5%-1%
0.1%-0.5%
0%-0.1%
Not available
30%
20%
Increases in HIV infection 1996–
2003
About 14 000 new HIV infections a day in 2004!
More than 95% in LMIC countries
Almost 2000/day are children < 15 years
The rest (12 000)
• 50% are women
• 50% are 15-24 year olds
1 New infection every 5 seconds!
Why Antiretroviral Therapy?
Editorial by David Heymann
Emphasizes the need to avoid
complacency
Public health needs to still pay attention
to potential for re-introduction and reestablishment of infectious diseases in
areas controlled/eradicated
Editorial by David Heymann
We are a global village…
and can get all the way around that village
within 24-48 hours
Influenza pandemic in 1918 covered the
world in months
at a time when there was no rapid transit
sobering proposition when you consider the
potential for human transport in 2009!
So, what have we achieved?
Session summary
Describe the evolution of thinking and approaches to
infectious diseases prevention and control in developing
countries using tuberculosis and HIV as examples.
Understand limitations of vital statistics and data
gathering in developing countries (and developed countries)
Understand mortality pattern variations and risk factors
for disease across countries and change in balance between
infection and chronic disease in some countries
QUESTIONS??????