This document provides an overview of communicable diseases and their impact on human security. It defines communicable diseases as conditions transmitted directly or indirectly from infected people or animals. Selected diseases discussed include tuberculosis, malaria, HIV/AIDS, and avian influenza. These diseases place a significant burden on low and middle income countries and can have social, economic, and security impacts. Approaches to control discussed include personal responsibility, public health interventions, regulations and laws, and partnerships. Effective response requires a global approach as communicable diseases respect no borders in an increasingly interconnected world.
2. Overview of Communicable
diseases
Introduction and Definition
Importance of CDs
Selected CDs of Public Health Concern
Mounting a Global Response
Approaches to intervention
Key elements of a global response
3. 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.
4. 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
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
5. 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)
6. 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
7. 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.
8. Communicable Disease Burden VariesCommunicable Disease Burden Varies
Widely Among ContinentsWidely Among Continents
10. Causes of Death Vary Greatly by CountryCauses of Death Vary Greatly by Country
Income LevelIncome 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
Agegroup
Pe rc ent of total deaths
Age dis tribution of death in Sie rra 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
Agegroup
Pe rcent of total of deaths
11. 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
12. 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
13. 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
14. 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.
16. 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
17. 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.
21. 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
22. 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
25. 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
26. 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.
27. 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
29. 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)
30. 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.
31. 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
34. 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
35. 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.
36. 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.
37. 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.
38. 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)
39. 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.
40. Global Mismatch Between DiseaseGlobal Mismatch Between Disease
Burden and Health SpendingBurden and Health Spending
41. Global Mismatch Between DiseaseGlobal Mismatch Between Disease
Burden and Health SpendingBurden and Health Spending
Introduction and Definition
Definition:
Modes of transmission
Examples of CDs
Common Infectious diseases
Neglected diseases
History of Communicable Diseases
Burden of Disease
Global burden of disease and communicable diseases, by region, gender and income levels
Importance of CDs
Sheer Burden
Economic impact
Rate of spread
Recurrence of diseases
Security and CDs
Interventions
Why intervene? Why should policy makers care about CDs?
History of interventions and policy issues
What is needed for effective control of CDs
Global Approaches
Global responsibility
International law
Partnerships and collaboration
Financial support
World Bank’s role and involvement
Total lending in health
Special programs the Bank is involved in.
Conclusions and Way forward
These have become more important given the modern means of transportation and increased interaction across countries that makes it easy for an infectious pathogen to spread from one part of the world to another
Even with the projected rise in the burden of NCDs, CDs are expected to account for 26% of the BoD in 2015 globally, and 56% in Africa. (Global Burden of Disease
In Sierra Leone most deaths occur in the U5 age group, whereas in Denmark it is among those over 65.
Global importance of Communicable Diseases
Enormous burden and impact globally
Economic impact
Constrain health and development of infants and children and affect their schooling
Stigma and discrimination against people with certain communicable diseases such as HIV/AIDS, TB. Leprosy
Disruption of social networks and family structure e.g. with Orphans and other vulnerable children who have lost their parents or other care gives due to HIV/AIDS
TB-
Malaria
HIV/AIDS etc
Reduction in revenue for the country
India example during the bubonic plague outbreak
Substantial loss in productivity and income
In Tanzania, men with AIDS lost an average of 197 days of work over an 18 month period.
Catastrophic costs of treating illness
In history, attempts at stopping communicable diseases from entering a country often proved ineffective
Two billion people – one third of the world’s total population–are infected with the microbes that cause TB.
Of these, 10% will become sick with active TB in their lifetime. Risks are higher in those with HIV infection.
A total of 1.6 million people died from TB in 2005, equal to about 4400 deaths a day. TB is a disease of poverty, affecting mostly young adults in their most productive years. The vast majority of TB deaths are in the developing world, with more than half occurring in Asia
TB/HIV- About 200 000 people with HIV die from TB every year, most of them in Africa.
TB is a worldwide pandemic. Although the highest rates per capita are in Africa (28% of all TB cases), half of all new cases are in six Asian countries (Bangladesh, China, India, Indonesia, Pakistan and the Philippines).
Multidrug-resistant TB (MDR-TB) is a form of TB that does not respond to the standard treatments using first-line drugs. MDR-TB is present in virtually all countries recently surveyed by WHO and its partners.
About 450 000 new MDR-TB cases are estimated to occur every year. The highest occurrence rates of MDR-TB are in China and the countries of the former Soviet Union. Extensively drug-resistant TB (XDR-TB) occurs when resistance to second-line drugs develops. It is extremely difficult to treat and cases have been confirmed in South Africa and worldwide.
WHO’s Stop TB Strategy aims to reach all patients and achieve the target under the Millennium Development Goals (MDG): to reduce by 2015 the prevalence of and deaths due to TB by 50% relative to 1990 and reverse the trend in incidence.
The Global Plan to Stop TB 2006-2015, launched January 2006, aims to achieve the MDG target with an investment of US$ 56 billion. This represents a three-fold increase in investment from 2005. The estimated funding gap is US$ 31 billion.
Most cases of XDR-TB were in HIV infected individuals.
More than one million people die of malaria every year, mostly infants, young children and pregnant women and most of them in Africa
Approximately, 40% of the world’s population, mostly those living in the world’s poorest countries, are at risk of malaria. Every year, more than 500 million people become severely ill with malaria. Most cases and deaths are in sub-Saharan Africa.
With full LLITN coverage, child mortality from all causes is reduced by 18%
One of the most devastating conditions of the 21st century
An estimated 38.6 million [33.4 million–46.0 million] people worldwide were
living with HIV in 2005. An estimated 4.1 million [3.4 million–6.2 million]
became newly infected with HIV and an estimated 2.8 million [2.4
million–3.3 million] lost their lives to AIDS.
Growing body of evidence on the interactions between both conditions
Both are diseases of poverty
Limited evidence suggests that some antiviral drugs, notably oseltamivir (commercially known as Tamiflu), can reduce the duration of viral replication and improve prospects of survival, provided they are administered within 48 hours following symptom onset.
Improved hygiene and sanitation
Hand washing, proper waste disposal, sewage system, cooking methods and boiling water
Information, education and behavior change including household practices
Livestock handling, knowledge about contagion,
Cultural norms
Poultry and farming methods, …..
Self reporting of illnesses and compliance with interventions and treatment
Unexplained fevers, ARI symptoms, etc
Compliance with medications to reduce potential for drug resistance. – hasn’t always worked - DOTS
Utilitarian Approaches – “Greatest good for the greatest number” – Sort of cost benefit analyses, where the benefits of the intervention such as the lives saved or years of live gained, etc, exceed the costs which could range from just the prick of a needle to a minority developing side effects of the vaccine.
Social Isolation and Quarantine measures
Home treatment
Isolation
Mass Vaccination programs
Polio in Nigeira
Regulations and Laws-
Challenge of enforceability, as it often relies on international cooperation and pressure
Notification - The IHR (2005) require States to notify WHO of all events that may constitute a public health emergency of international concern and to respond to requests for verification of information regarding such events.
Under the WHO Constitution, all WHO Member States are automatically bound by the new IHR (2005) unless they affirmatively opt out within a limited time period, namely by 15 December 2006. No WHO Member State has completely opted out, and only a very small number made reservations.
The need to move beyond charity-model.
Non-rival –The benefits from the Interventions can be enjoyed simultaneously by all in the community.
Lack of access to TB drugs may fuel resistance and the development of MDR-TB
The World Bank has committed more than $430 million to Booster projects. A nine-fold increase in IDA funding for malaria control in Africa.