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Communicable Diseases and

Human Security

Kelechi Ohiri MD MPH MS

Health, Nutrition, Population


Human 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 Varies
Widely Among Continents
Communicable disease burden in
Europe
Causes of Death Vary Greatly by Country
Income Level
Age distribution of death in Sierra Leone around 2005
Age distribution of death in Denmark around 2005
Male Female
Male Female

90 - 94 90 - 94

75 - 79 75 - 79

60 - 64 60 - 64

Age group
Age group

45 - 49 45 - 49

30 - 34 30 - 34

15 - 19 15 - 19

0-4 0-4
80 60 40 20 0 20 40 60 80 80 60 40 20 0 20 40 60 80
Percent of total of deaths Percent of total 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.
Isn’t Donor Collaboration Wonderful?
WHO INT NGO
CIDA UNAIDS 3/5
GTZ

RNE UNICEF
Norad WB
Sida
USAID T-MAP MOF
UNTG PMO
CF DAC GFCCP PRSP
PEPFAR
GFATM MOEC
HSSP MOH SWAP

CCM
CTU
NCTP
CCAIDS
NACP

LOCALGVT CIVIL SOCIETY PRIVATE SECTOR


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 Burden
and Health Spending

Burden of disease in disability adjusted life years by income


category 34.4%

55.9% 9.7%

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


Global Mismatch Between Disease
Burden and Health Spending
Distribution of Total Global Expenditures on Health by
Income Category
2%

10%

88%

Low income Middle income High income


Future Population Growth Will be in
LICs and MICs
10,000

9,000
T o ta l p o p u la tio n (m illio n s)

8,000

7,000

6,000

5,000

4,000
D eveloping countries

3,000
D eveloped countries

2,000

1,000

0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050

Y ear
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 Assistance
for Health

12,000

10,000
US$ (in millions)

Private Non-profit
8,000
Other Multilateral

6,000 Development Banks


UN System
4,000
Bilateral
2,000

0
Average 1997-99 2003
Year
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.