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 Banks 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

Indirect

Blood-borne or sexual HIV, Hepatitis B,C

Inhalation Tuberculosis, influenza, anthrax
Food-borne E.coli, Salmonella,
Contaminated water- Cholera, rotavirus, Hepatitis A
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

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

Bioterrorism and intentional outbreaks

No country or region can contain a full blown

outbreak of Avian influenza
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.

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

Not everyone develops active 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 worlds 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

Emergence of Pandemic virus

Contain and/or delay the spread at source

Pandemic Declared

Reduce opportunity for human infection

Strengthen early warning system

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

Protozoan infections

Hookworm (Ascaris, trichuris), lymphatic filariasis,

onchocerciasis, schistosomiasis, dracunculiasis
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

Information, education and behavior change

Hand washing, proper waste disposal, food

preparation and handling.
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

Social Isolation and Quarantine measures

Polio, small pox, DPT, Hepatitis, Yellow fever

Mass treatment programs

Home treatment; Isolation

Mass vaccination programs and campaigns

not always the optimal option given different knowledge levels

and values.
Public good nature of the interventions

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.

Isnt Donor Collaboration Wonderful?

GTZ
Norad

CIDA

UNAIDS

RNE
Sida

USAID

WB

WHO

UNICEF

T-MAP

MOF

UNTG
CF

DAC

GFCCP
GFCCP

PEPFAR
GFATM

HSSP
HSSP

MOH

INT NGO

3/5

PMO
PRSP
PRSP
MOEC

SWAP
SWAP

CCM

CTU

NCTP
NCTP

CCAIDS
NACP

LOCALGVT

CIVIL SOCIETY

PRIVATE SECTOR
Source: WHO: Mbewe

A paradigm shift Enlightened Self interest

Communicable diseases have no borders.

Interventions are non-rival, non-exclusive and

have positive externalities.

Predominantly affect the poor, and poor countries

Also affect richer households and countries.

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

Global Mismatch Between

Disease Burden and Health
Spending

Future Population Growth Will be

in LICs and MICs

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 Banks 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 ofJune 2007, the World Bank had
approved financing of $377 millionfor 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

Source: Michaud 2006

The World Banks 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.