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Avian influenza

Fact sheet
Updated March 2014

Key facts

Avian influenza (AI), commonly called bird flu, is an infectious viral disease of
birds.
Most avian influenza viruses do not infect humans; however some, such as
A(H5N1) and A(H7N9), have caused serious infections in people.
Outbreaks of AI in poultry may raise global public health concerns due to their
effect on poultry populations, their potential to cause serious disease in
people, and their pandemic potential.
Reports of highly pathogenic AI epidemics in poultry, such as A(H5N1), can
seriously impact local and global economies and international trade.
The majority of human cases of A(H5N1) and A(H7N9) infection have been
associated with direct or indirect contact with infected live or dead poultry.
There is no evidence that the disease can be spread to people through
properly cooked food.
Controlling the disease in animals is the first step in decreasing risks to
humans.

Avian influenza (AI) is an infectious viral disease of birds (especially wild water
fowl such as ducks and geese), often causing no apparent signs of illness. AI
viruses can sometimes spread to domestic poultry and cause large-scale
outbreaks of serious disease. Some of these AI viruses have also been reported
to cross the species barrier and cause disease or subclinical infections in humans
and other mammals.
AI viruses are divided into 2 groups based on their ability to cause disease in
poultry: high pathogenicity or low pathogenicity. Highly pathogenic viruses result
in high death rates (up to 100% mortality within 48 hours) in some poultry
species. Low pathogenicity viruses also cause outbreaks in poultry but are not
generally associated with severe disease.
Avian influenza A(H5N1) and A(H7N9) background
The A(H5N1) virus subtype, a highly pathogenic AI virus, first infected humans in
1997 during a poultry outbreak in Hong Kong SAR, China. Since its widespread reemergence in 2003 and 2004, this avian virus has spread from Asia to Europe
and Africa and has become entrenched in poultry in some countries, resulting in
millions of poultry infections, several hundred human cases, and many human
deaths. Outbreaks in poultry have seriously impacted livelihoods, the economy
and international trade in affected countries.
The A(H7N9) virus subtype, a low pathogenic AI virus, first infected 3 humans 2
residents of the city of Shanghai and 1 resident of Anhui province - in March
2013. No cases of A(H7N9) outside of China have been reported. Containment

measures, including the closure of live bird markets for several months, have
impacted the agriculture sectors of affected countries and international trade.
Continued surveillance for A(H7N9) will be necessary to detect and control the
spread of the virus.
Ongoing circulation of A(H5N1) and A(H7N9) viruses in poultry, especially where
endemic, continues to pose threats to public health, as these viruses have both
the potential to cause serious disease in people and may have the potential to
change into a form that is more transmissible among humans. Other influenza
virus subtypes also circulate in poultry and other animals, and may also pose
potential threats to public health.
Avian influenza A(H5N1) and A(H7N9) infections and clinical features in
humans
The case fatality rate for A(H5N1) and A(H7N9) virus infections in people is much
higher compared to that of seasonal influenza infections. The A(H7N9) virus
particularly affects people with underlying medical conditions.
Clinical features
In many patients, the disease caused by the A(H5N1) virus follows an unusually
aggressive clinical course, with rapid deterioration and high fatality. Like most
emerging disease, A(H5N1) influenza in humans is not well understood.
The incubation period for A(H5N1) avian influenza may be longer than that for
normal seasonal influenza, which is around 2 to 3 days. Current data for A(H5N1)
infection indicate an incubation period ranging from 2 to 8 days and possibly as
long as 17 days. Current data for A(H7N9) infection indicate an incubation period
ranging from 2 to 8 days, with an average of five days. 1 WHO currently
recommends that an incubation period of 7 days be used for field investigations
and the monitoring of patient contacts.
Initial symptoms include high fever, usually with a temperature higher than 38C,
and other influenza-like symptoms (cough or sore throat). Diarrhea, vomiting,
abdominal pain, chest pain, and bleeding from the nose and gums have also
been reported as early symptoms in some patients.
One feature seen in many patients is the development of lower respiratory tract
early in the illness. Respiratory distress, a hoarse voice, and a crackling sound
when inhaling are commonly seen. Sputum production is variable and sometimes
bloody.2Complications of A(H5N1) and A(H7N9) infection include hypoxemia,
multiple organ dysfunction, and secondary bacterial and fungal infections. 3
Antiviral treatment
Evidence suggests that some antiviral drugs, notably oseltamivir, can reduce the
duration of viral replication and improve prospects of survival.
In suspected cases, oseltamivir should be prescribed as soon as possible (ideally,
within 48 hours following symptom onset) to maximize its therapeutic benefits.
However, given the significant mortality currently associated with A(H5N1) and
A(H7N9) infection and evidence of prolonged viral replication in this disease,
administration of the drug should also be considered in patients presenting later
in the course of illness. The use of corticosteroids is not recommended.

In cases of severe infection with the A(H5N1) or A(H7N9) virus, clinicians may
need to consider increasing the recommended daily dose or/and the duration of
treatment.
In severely ill A(H5N1) or A(H7N9) patients or in patients with severe
gastrointestinal symptoms, drug absorption may be impaired. This possibility
should be considered when managing these patients. 4 Moreover, most A(H5N1)
and A(H7N9) viruses are predicated to be resistant to adamantine antiviral drugs,
which are therefore not recommended for use.
Risk factors for human infection
The primary risk factor for human infection appears to be direct or indirect
exposure to infected live or dead poultry or contaminated environments, such as
live bird markets. Controlling circulation of the A(H5N1) and A(H7N9) viruses in
poultry is essential to reducing the risk of human infection. Given the persistence
of the A(H5N1) and A(H7N9) viruses in some poultry populations, control will
require long-term commitments from countries and strong coordination between
animal and public health authorities.
There is no evidence to suggest that the A(H5N1)and A(H7N9) viruses can be
transmitted to humans through properly prepared poultry or eggs. A few A(H5N1)
human cases have been linked to consumption of dishes made of raw,
contaminated poultry blood. However, slaughter, defeathering, handling
carcasses of infected poultry, and preparing poultry for consumption, especially
in household settings, are likely to be risk factors.
Human pandemic potential
Influenza pandemics (outbreaks that affect a large proportion of the world due to
a novel virus) are unpredictable but recurring events that can have health,
economic and social consequences worldwide. An influenza pandemic occurs
when key factors converge: an influenza virus emerges with the ability to cause
sustained human-to-human transmission, and the human population has little to
no immunity against the virus. With the growth of global trade and travel, a
localized epidemic can transform into a pandemic rapidly, with little time to
prepare a public health response.
The A(H5N1) and A(H7N9) AI viruses remain two of the influenza viruses with
pandemic potential, because they continue to circulate widely in some poultry
populations, most humans likely have no immunity to them, and they can cause
severe disease and death in humans.
However, whether the influenza A(H7N9) virus could actually cause a pandemic is
unknown. Experience has shown that some animal influenza viruses that have
been found to occasionally infect people have not gone on to cause a pandemic
while others have done so. Surveillance and the investigations now underway will
provide some of the information needed to make this determination.
In addition to A(H5N1) and A(H7N9), other animal influenza virus subtypes
reported to have infected people include avian H9, and swine H1 and H3 viruses.
H2 viruses may also pose a pandemic threat. Therefore, pandemic planning
should consider risks of emergence of a variety of influenza subtypes from a
variety of sources.

WHO response
WHO, in its capacity for providing leadership on global health matters, is
monitoring avian influenza very closely, developing and adjusting appropriate
interventions in collaboration with its partners. Such partners include animal
health agencies and national veterinary authorities responsible for the control
and prevention of animal diseases, including influenza.
Specifically, WHO, the World Organisation for Animal Health (OIE), and the Food
and Agriculture Organization (FAO) collaborate through a variety of mechanisms
to track and assess the risk from animal influenza viruses of public health
concern, and to address these risks at the human animal interface wherever in
the world they might occur. In short, WHO is monitoring the situation as it
evolves, and as more information becomes available, will revise its guidance and
actions accordingly.

Cholera
Fact sheet N107
Updated July 2015

Key facts

Cholera is an acute diarrhoeal disease that can kill within hours if left
untreated.
Researchers have estimated that there are 1.4 to 4.3 million cases, and 28
000 to 142 000 deaths worldwide1 due to cholera every year.
Up to 80% of cases can be successfully treated with oral rehydration salts.
Provision of safe water and sanitation is critical to control cholera and other
waterborne diseases.
Oral cholera vaccines are an additional way to control cholera, but should not
replace conventional control measures.

Cholera is an acute diarrhoeal infection caused by ingestion of food or water


contaminated with the bacterium Vibrio cholerae. Researchers have estimated
that every year, there are roughly 1.4 to 4.3 million cases, and 28 000 to 142 000

deaths per year worldwide1 due to cholera. The short incubation period of 2 hours
to 5 days, is 1 factor that triggers the potentially explosive pattern of outbreaks.
Symptoms
Cholera is an extremely virulent disease. It affects both children and adults and
can kill within hours.
About 80% of people infected with V. cholerae do not develop any symptoms,
although the bacteria are present in their faeces for 1-10 days after infection and
are shed back into the environment, potentially infecting other people.
Among people who develop symptoms, 80% have mild or moderate symptoms,
while around 20% develop acute watery diarrhoea with severe dehydration. This
can lead to death if left untreated.
History
During the 19th century, cholera spread across the world from its original
reservoir in the Ganges delta in India. Six subsequent pandemics killed millions of
people across all continents. The current (seventh) pandemic started in South
Asia in 1961, and reached Africa in 1971 and the Americas in 1991. Cholera is
now endemic in many countries.
Vibrio cholerae strains
Two serogroups of V. cholerae O1 and O139 cause outbreaks. V. cholerae O1
causes the majority of outbreaks, while O139 first identified in Bangladesh in
1992 is confined to South-East Asia.
Non-O1 and non-O139 V. cholerae can cause mild diarrhoea but do not generate
epidemics.
Recently, new variant strains have been detected in several parts of Asia and
Africa. Observations suggest that these strains cause more severe cholera with
higher case fatality rates. Careful epidemiological monitoring of circulating
strains is recommended.
The main reservoirs of V. cholerae are people and aquatic sources such as
brackish water and estuaries, often associated with algal blooms. Recent studies
indicate that global warming creates a favourable environment for the bacteria.
Risk factors and disease burden
Cholera transmission is closely linked to inadequate environmental management.
Typical at-risk areas include peri-urban slums, where basic infrastructure is not
available, as well as camps for internally displaced persons or refugees, where
minimum requirements of clean water and sanitation are not met.
The consequences of a humanitarian crisis such as disruption of water and
sanitation systems, or the displacement of populations to inadequate and
overcrowded camps can increase the risk of cholera transmission should the
bacteria be present or introduced. Dead bodies have never been reported as the
source of epidemics.
Cholera remains a global threat to public health and a key indicator of lack of
social development.

The number of cholera cases reported to WHO continues to be high. During 2013,
a total of 129 064 cases were notified from 47 countries, including 2102 deaths.
The discrepancy between those figures and the estimated burden of the disease
is due to the fact that many cases are not recorded for due to limitations in
surveillance systems and fear of trade and travel sanctions.
Prevention and control
A multidisciplinary approach is key for reducing cholera outbreaks, controlling
cholera in endemic areas and reducing deaths.
Water and sanitation interventions

The long-term solution for cholera control (which benefits all diseases spread by
the fecal-oral route) lies in economic development and universal access to safe
drinking water and adequate sanitation, which is key in preventing both epidemic
and endemic cholera.
Actions targeting environmental conditions include:
the development of piped water systems with water treatment facilities
(chlorination);
interventions at the household level (water filtration, water chemical or
solar disinfection, safe water storage containers); and
as well as the construction of systems for sewage disposal and latrines.
Most of those interventions require substantial long term investments and high
maintenance costs which are difficult to fund and sustain by the least developed
countries, where they are also most needed.
Treatment
Cholera is an easily treatable disease. Up to 80% of people can be treated
successfully through prompt administration of oral rehydration salts
(WHO/UNICEF ORS standard sachet). Very severely dehydrated patients require
the administration of intravenous fluids. These patients also need appropriate
antibiotics to diminish the duration of diarrhoea, reduce the volume of
rehydration fluids needed, and shorten the duration of V. cholerae excretion.
Mass administration of antibiotics is not recommended, as it has no effect on the
spread of cholera and contributes to increasing antimicrobial resistance.
In order to ensure timely access to treatment, cholera treatment centres (CTCs)
should be set up within the affected communities. With proper treatment, the
case fatality rate should remain below 1%.
Surveillance
Under the International Health Regulations, notification of all cases of cholera is
no longer mandatory. However, public health events involving cholera must
always be assessed against the criteria provided in the Regulations to determine
whether there is a need for official notification.
Local capacities for improving diagnosis, and for collecting, compiling and
analysing data, need to be strengthened so that vulnerable populations living in
high-risk areas can be identified in order to benefit from comprehensive control

activities. Cholera surveillance should be part of an integrated disease


surveillance system that includes feedback at the local level and informationsharing at the global level.
Social mobilisation
Health education campaigns, adapted to local culture and beliefs, should
promote the adoption of appropriate hygiene practices such as hand-washing
with soap, safe preparation and storage of food and breastfeeding.
Awareness campaigns during outbreaks also encourage people with symptoms to
seek immediate health care. The campaigns should use modern communication
channels (mobile phones, smartphones, social media, etc.) and adapted to local
cultures. The use of qualitative methods of analysis, to help adapt messages to
local culture and beliefs, is also encouraged.
Oral cholera vaccines
Currently there are 2 WHO pre-qualified oral cholera vaccines (OCVs) (Dukoral
and Shanchol). Both vaccines have been used in mass vaccination campaigns
with WHO support. Their use has enabled evidence to be collected on the
effectiveness and feasibility on implementation of oral cholera vaccination
campaigns as a public health tool in protecting populations at high risk of
cholera.
Dukoral is administered to adults and children aged >6 years in 2 doses; and to
children aged >2 years and <6 years in 3 doses. Protection can be expected 1
week after the last dose. Field trials in Bangladesh and Peru have shown that this
vaccine is safe and confers 85% protection for 46 months in all age groups. This
vaccine is not licensed for use in children aged <2 years.
Shanchols immunization schedule is 2 doses given at an interval of 2 weeks for
those aged >1 year. Shanchol has provided longer term protection than
Dukoral in children aged <5 years, and therefore does not require a booster
dose after 6 months in this age group, unlike Dukoral. Shanchol provided 67%
protection against clinically significant V. cholerae O1 cholera in an endemic area
for at least 2 years after vaccination. A field trial in Kolkata, India obtained
protective efficacy (65%) of the vaccine up to 5 years.
An OCV stockpile of 2 million doses was formally established mid-2013 for
outbreak control and emergencies. The OCV stockpile was created on the
principle that vaccines have a role in the prevention and control of cholera when
used in conjunction with accessible healthcare and improvements in water and
sanitation.
In November 2013, the GAVI board approved a contribution to the global cholera
vaccine stockpile for epidemic and endemic settings, for 2014-2018. The
objectives of the GAVI investment are to:
1. break the current cycle of low demandlow supply, significantly increasing
global OCV production and availability;
2. reduce the impact of cholera outbreaks; and
3. strengthen the evidence base for periodic pre-emptive campaigns.

4. As of June 2015, about 2 million doses of OCV have been shipped from the
stockpile in various settings, either in the form of reactive campaigns in
areas experiencing an outbreak or pre-emptive vaccination campaigns
among populations at elevated risk for cholera (hotspots), or at
heightened vulnerability during an humanitarian crisis.
Impact on cholera burden or transmission was significant in all endemic, outbreak
and emergency settings. Furthermore, contrary to earlier concerns, the
communities readily accepted the vaccines and high vaccine coverage were
reported. No serious adverse effects have been reported so far.
Travel and trade
Today, no country requires proof of cholera vaccination as a condition for entry.
Past experience shows that quarantine measures and embargoes on the
movement of people and goods are unnecessary. Import restrictions on food
produced using good manufacturing practices, based on the sole fact that
cholera is epidemic or endemic in a country, are not justified.
Countries neighbouring cholera-affected areas are encouraged to strengthen
disease surveillance and national preparedness to rapidly detect and respond to
outbreaks should cholera spread across borders. Further, information should be
provided to travellers and the community on the potential risks and symptoms of
cholera, together with precautions to avoid cholera, and when and where to
report cases.
WHO response

Through the WHO Global Task Force on Cholera Control, WHO works to:
support the design and implementation of global strategies to contribute
to capacity development for cholera prevention and control globally;
provide a forum for technical exchange, coordination, and cooperation on
cholera-related activities to strengthen countries capacity to prevent and
control cholera;
support countries for the implementation of effective cholera control
strategies and monitoring of progress;
disseminate technical guidelines and operational manuals;
support the development of a research agenda with emphasis on
evaluating innovative approaches to cholera prevention and control in
affected countries;
increase the visibility of cholera as an important global public health
problem through the dissemination of information about cholera
prevention and control, and conducting advocacy and resource
mobilization activities to support cholera prevention and control at
national, regional, and global levels.

Dengue and severe dengue


Fact sheet N117
Updated May 2015

Key facts

Dengue is a mosquito-borne viral infection.


The infection causes flu-like illness, and occasionally develops into a
potentially lethal complication called severe dengue.
The global incidence of dengue has grown dramatically in recent decades.
About half of the world's population is now at risk.
Dengue is found in tropical and sub-tropical climates worldwide, mostly in
urban and semi-urban areas.
Severe dengue is a leading cause of serious illness and death among children
in some Asian and Latin American countries.
There is no specific treatment for dengue/ severe dengue, but early detection
and access to proper medical care lowers fatality rates below 1%.
Dengue prevention and control solely depends on effective vector control
measures.

Dengue is a mosquito-borne viral disease that has rapidly spread in all regions of
WHO in recent years. Dengue virus is transmitted by female mosquitoes mainly
of the species Aedes aegypti and, to a lesser extent, A. albopictus. The disease is
widespread throughout the tropics, with local variations in risk influenced by
rainfall, temperature and unplanned rapid urbanization.
Severe dengue (also known as Dengue Haemorrhagic Fever) was first recognized
in the 1950s during dengue epidemics in the Philippines and Thailand. Today,
severe dengue affects most Asian and Latin American countries and has become
a leading cause of hospitalization and death among children in these regions.
There are 4 distinct, but closely related, serotypes of the virus that cause dengue
(DEN-1, DEN-2, DEN-3 and DEN-4). Recovery from infection by one provides
lifelong immunity against that particular serotype. However, cross-immunity to
the other serotypes after recovery is only partial and temporary. Subsequent
infections by other serotypes increase the risk of developing severe dengue.

Global burden of dengue


The incidence of dengue has grown dramatically around the world in recent
decades. The actual numbers of dengue cases are underreported and many
cases are misclassified. One recent estimate indicates 390 million dengue
infections per year (95% credible interval 284528 million), of which 96 million
(67136 million) manifest clinically (with any severity of disease). 1 Another study,
of the prevalence of dengue, estimates that 3900 million people, in 128
countries, are at risk of infection with dengue viruses. 2
Member States in 3 WHO regions regularly report the annual number of cases. In
2010, nearly 2.4 million cases were reported. Although the full global burden of
the disease is uncertain, the initiation of activities to record all dengue cases
partly explains the sharp increase in the number of cases reported in recent
years.
Other features of the disease include its epidemiological patterns, including
hyper-endemicity of multiple dengue virus serotypes in many countries and the
alarming impact on both human health and the global and national economies.
Before 1970, only 9 countries had experienced severe dengue epidemics. The
disease is now endemic in more than 100 countries in the WHO regions of Africa,
the Americas, the Eastern Mediterranean, South-East Asia and the Western
Pacific. The America, South-East Asia and Western Pacific regions are the most
seriously affected.
Cases across the Americas, South-East Asia and Western Pacific exceeded 1.2
million in 2008 and over 3 million in 2013 (based on official data submitted by
Member States). Recently the number of reported cases has continued to
increase. In 2013, 2.35 million cases of dengue were reported in the Americas
alone, of which 37 687 cases were of severe dengue.
Not only is the number of cases increasing as the disease spreads to new areas,
but explosive outbreaks are occurring. The threat of a possible outbreak of
dengue fever now exists in Europe and local transmission of dengue was reported
for the first time in France and Croatia in 2010 and imported cases were detected
in 3 other European countries. In 2012, an outbreak of dengue on the Madeira
islands of Portugal resulted in over 2000 cases and imported cases were detected
in mainland Portugal and 10 other countries in Europe.
In 2013, cases have occurred in Florida (United States of America) and Yunnan
province of China. Dengue also continues to affect several South American
countries, notably Costa Rica, Honduras and Mexico. In Asia, Singapore has
reported an increase in cases after a lapse of several years and outbreaks have
also been reported in Laos. In 2014, trends indicate increases in the number of
cases in the People's Republic of China, the Cook Islands, Fiji, Malaysia and
Vanuatu, with Dengue Type 3 (DEN 3) affecting the Pacific Island countries after a
lapse of over 10 years. Dengue was also reported in Japan after a lapse of over
70 years. In 2015 an increase in the number of cases was reported in Brazil and
several neighbouring countries. The Pacific island countries of Fiji, Tonga and
French Polynesia have continued to record cases.
An estimated 500 000 people with severe dengue require hospitalization each
year, a large proportion of whom are children. About 2.5% of those affected die.

Transmission
WHO/TDR/Stammers
The Aedes aegypti mosquito is the primary vector of dengue. The virus is
transmitted to humans through the bites of infected female mosquitoes. After
virus incubation for 410 days, an infected mosquito is capable of transmitting
the virus for the rest of its life.
Infected humans are the main carriers and multipliers of the virus, serving as a
source of the virus for uninfected mosquitoes. Patients who are already infected
with the dengue virus can transmit the infection (for 45 days; maximum 12)
via Aedesmosquitoes after their first symptoms appear.
The Aedes aegypti mosquito lives in urban habitats and breeds mostly in manmade containers. Unlike other mosquitoes Ae. aegypti is a day-time feeder; its
peak biting periods are early in the morning and in the evening before dusk.
Female Ae. aegyptibites multiple people during each feeding period.
Aedes albopictus, a secondary dengue vector in Asia, has spread to North
America and Europe largely due to the international trade in used tyres (a
breeding habitat) and other goods (e.g. lucky bamboo). Ae. albopictus is highly
adaptive and, therefore, can survive in cooler temperate regions of Europe. Its
spread is due to its tolerance to temperatures below freezing, hibernation, and
ability to shelter in microhabitats.

Characteristics
Dengue fever is a severe, flu-like illness that affects infants, young children and
adults, but seldom causes death.
Dengue should be suspected when a high fever (40C/104F) is accompanied by
2 of the following symptoms: severe headache, pain behind the eyes, muscle and
joint pains, nausea, vomiting, swollen glands or rash. Symptoms usually last for
27 days, after an incubation period of 410 days after the bite from an infected
mosquito.
Severe dengue is a potentially deadly complication due to plasma leaking, fluid
accumulation, respiratory distress, severe bleeding, or organ impairment.
Warning signs occur 37 days after the first symptoms in conjunction with a
decrease in temperature (below 38C/100F) and include: severe abdominal pain,
persistent vomiting, rapid breathing, bleeding gums, fatigue, restlessness and
blood in vomit. The next 2448 hours of the critical stage can be lethal; proper
medical care is needed to avoid complications and risk of death.
Treatment
There is no specific treatment for dengue fever.
For severe dengue, medical care by physicians and nurses experienced with the
effects and progression of the disease can save lives decreasing mortality rates
from more than 20% to less than 1%. Maintenance of the patient's body fluid
volume is critical to severe dengue care.
Immunization

There is no vaccine to protect against dengue. However, major progress has been
made in developing a vaccine against dengue/severe dengue. Three tetravalent
live-attenuated vaccines are under development in phase II and phase III clinical
trials, and 3 other vaccine candidates (based on subunit, DNA and purified
inactivated virus platforms) are at earlier stages of clinical development. WHO
provides technical advice and guidance to countries and private partners to
support vaccine research and evaluation.
Prevention and control
WHO/TDR/Crump
At present, the only method to control or prevent the transmission of dengue
virus is to combat vector mosquitoes through:
preventing mosquitoes from accessing egg-laying habitats by
environmental management and modification;
disposing of solid waste properly and removing artificial man-made
habitats;
covering, emptying and cleaning of domestic water storage containers on
a weekly basis;
applying appropriate insecticides to water storage outdoor containers;
using of personal household protection such as window screens, longsleeved clothes, insecticide treated materials, coils and vaporizers;
improving community participation and mobilization for sustained vector
control;
applying insecticides as space spraying during outbreaks as one of the
emergency vector-control measures;
active monitoring and surveillance of vectors should be carried out to
determine effectiveness of control interventions.
WHO response
WHO responds to dengue in the following ways:
supports countries in the confirmation of outbreaks through its
collaborating network of laboratories;
provides technical support and guidance to countries for the effective
management of dengue outbreaks;
supports countries to improve their reporting systems and capture the true
burden of the disease;
provides training on clinical management, diagnosis and vector control at
the regional level with some of its collaborating centres;
formulates evidence-based strategies and policies;
develops new tools, including insecticide products and application
technologies;
gathers official records of dengue and severe dengue from over 100
Member States; and
publishes guidelines and handbooks for case management, dengue
prevention and control for Member States.

Ebola virus disease


Fact sheet N103
Updated August 2015

Key facts

Ebola virus disease (EVD), formerly known as Ebola haemorrhagic fever, is


a severe, often fatal illness in humans.
The virus is transmitted to people from wild animals and spreads in the
human population through human-to-human transmission.
The average EVD case fatality rate is around 50%. Case fatality rates have
varied from 25% to 90% in past outbreaks.
The first EVD outbreaks occurred in remote villages in Central Africa, near
tropical rainforests, but the most recent outbreak in West Africa has
involved major urban as well as rural areas.

Community engagement is key to successfully controlling outbreaks. Good


outbreak control relies on applying a package of interventions, namely
case management, surveillance and contact tracing, a good laboratory
service, safe burials and social mobilisation.
Early supportive care with rehydration, symptomatic treatment improves
survival. There is as yet no licensed treatment proven to neutralise the
virus but a range of blood, immunological and drug therapies are under
development.
There are currently no licensed Ebola vaccines but 2 potential candidates
are undergoing evaluation.

Background
The Ebola virus causes an acute, serious illness which is often fatal if untreated.
Ebola virus disease (EVD) first appeared in 1976 in 2 simultaneous outbreaks,
one in Nzara, Sudan, and the other in Yambuku, Democratic Republic of Congo.
The latter occurred in a village near the Ebola River, from which the disease takes
its name.
The current outbreak in West Africa, (first cases notified in March 2014), is the
largest and most complex Ebola outbreak since the Ebola virus was first
discovered in 1976. There have been more cases and deaths in this outbreak
than all others combined. It has also spread between countries starting in Guinea
then spreading across land borders to Sierra Leone and Liberia, by air (1
traveller) to Nigeria and USA (1 traveller), and by land to Senegal (1 traveller)
and Mali (2 travellers).
The most severely affected countries, Guinea, Liberia and Sierra Leone, have
very weak health systems, lack human and infrastructural resources, and have
only recently emerged from long periods of conflict and instability. On August 8,
the WHO Director-General declared the West Africa outbreak a Public Health
Emergency of International Concern under the International Health Regulations
(2005).
The virus family Filoviridae includes three genera: Cuevavirus, Marburgvirus, and
Ebolavirus. There are five species that have been identified: Zaire, Bundibugyo,
Sudan, Reston and Ta Forest. The first three, Bundibugyo ebolavirus, Zaire
ebolavirus, and Sudan ebolavirus have been associated with large outbreaks in
Africa. The virus causing the 2014 West African outbreak belongs to the Zaire
species.

Transmission
It is thought that fruit bats of the Pteropodidae family are natural Ebola virus
hosts. Ebola is introduced into the human population through close contact with
the blood, secretions, organs or other bodily fluids of infected animals such as
chimpanzees, gorillas, fruit bats, monkeys, forest antelope and porcupines found
ill or dead or in the rainforest.
Ebola then spreads through human-to-human transmission via direct contact
(through broken skin or mucous membranes) with the blood, secretions, organs

or other bodily fluids of infected people, and with surfaces and materials (e.g.
bedding, clothing) contaminated with these fluids.
Health-care workers have frequently been infected while treating patients with
suspected or confirmed EVD. This has occurred through close contact with
patients when infection control precautions are not strictly practiced.
Burial ceremonies in which mourners have direct contact with the body of the
deceased person can also play a role in the transmission of Ebola.
People remain infectious as long as their blood contains the virus.
Sexual transmission
More surveillance data and research are needed on the risks of sexual
transmission, and particularly on the prevalence of viable and transmissible virus
in semen over time. In the interim, and based on present evidence, WHO
recommends that:
All Ebola survivors and their sexual partners should receive counselling to
ensure safe sexual practices until their semen has twice tested negative.
Survivors should be provided with condoms.
Male Ebola survivors should be offered semen testing at 3 months after
onset of disease, and then, for those who test positive, every month
thereafter until their semen tests negative for virus twice by RT-PCR, with
an interval of one week between tests.
Ebola survivors and their sexual partners should either:
o abstain from all types of sex, or
o observe safe sex through correct and consistent condom use until
their semen has twice tested negative.
Having tested negative, survivors can safely resume normal sexual
practices without fear of Ebola virus transmission.
If an Ebola survivors semen has not been tested, he should continue to
practise safe sex for at least 6 months after the onset of symptoms; this
interval may be adjusted as additional information becomes available on
the prevalence of Ebola virus in the semen of survivors over time.
Until such time as their semen has twice tested negative for Ebola,
survivors should practise good hand and personal hygiene by immediately
and thoroughly washing with soap and water after any physical contact
with semen, including after masturbation. During this period used
condoms should be handled safely, and safely disposed of, so as to
prevent contact with seminal fluids.
All survivors, their partners and families should be shown respect, dignity
and compassion.
Read the interim advice on the sexual transmission of the Ebola virus
disease

Symptoms of Ebola virus disease


The incubation period, that is, the time interval from infection with the virus to
onset of symptoms is 2 to 21 days. Humans are not infectious until they develop
symptoms. First symptoms are the sudden onset of fever fatigue, muscle pain,
headache and sore throat. This is followed by vomiting, diarrhoea, rash,
symptoms of impaired kidney and liver function, and in some cases, both internal

and external bleeding (e.g. oozing from the gums, blood in the stools).
Laboratory findings include low white blood cell and platelet counts and elevated
liver enzymes.
Diagnosis
It can be difficult to distinguish EVD from other infectious diseases such as
malaria, typhoid fever and meningitis. Confirmation that symptoms are caused
by Ebola virus infection are made using the following investigations:
antibody-capture enzyme-linked immunosorbent assay (ELISA)
antigen-capture detection tests
serum neutralization test
reverse transcriptase polymerase chain reaction (RT-PCR) assay
electron microscopy
virus isolation by cell culture.
Samples from patients are an extreme biohazard risk; laboratory testing on
non-inactivated samples should be conducted under maximum biological
containment conditions.
Treatment and vaccines
Supportive care-rehydration with oral or intravenous fluids- and treatment of
specific symptoms, improves survival. There is as yet no proven treatment
available for EVD. However, a range of potential treatments including blood
products, immune therapies and drug therapies are currently being evaluated. No
licensed vaccines are available yet, but 2 potential vaccines are undergoing
human safety testing.
Prevention and control
Good outbreak control relies on applying a package of interventions, namely case
management, surveillance and contact tracing, a good laboratory service, safe
burials and social mobilisation. Community engagement is key to successfully
controlling outbreaks. Raising awareness of risk factors for Ebola infection and
protective measures that individuals can take is an effective way to reduce
human transmission. Risk reduction messaging should focus on several factors:
Reducing the risk of wildlife-to-human transmission from contact
with infected fruit bats or monkeys/apes and the consumption of their raw
meat. Animals should be handled with gloves and other appropriate
protective clothing. Animal products (blood and meat) should be
thoroughly cooked before consumption.
Reducing the risk of human-to-human transmission from direct or
close contact with people with Ebola symptoms, particularly with their
bodily fluids. Gloves and appropriate personal protective equipment should
be worn when taking care of ill patients at home. Regular hand washing is
required after visiting patients in hospital, as well as after taking care of
patients at home.
Reducing the risk of possible sexual transmission, because the risk
of sexual transmission cannot be ruled out, men and women who have
recovered from Ebola should abstain from all types of sex (including analand oral sex) for at least three months after onset of symptoms. If sexual

abstinence is not possible, male or female condom use is recommended.


Contact with body fluids should be avoided and washing with soap and
water is recommended. WHO does not recommend isolation of male or
female convalescent patients whose blood has been tested negative for
Ebola virus.
Outbreak containment measures, including prompt and safe burial of
the dead, identifying people who may have been in contact with someone
infected with Ebola and monitoring their health for 21 days, the
importance of separating the healthy from the sick to prevent further
spread, and the importance of good hygiene and maintaining a clean
environment.

Controlling infection in health-care settings:


Health-care workers should always take standard precautions when caring for
patients, regardless of their presumed diagnosis. These include basic hand
hygiene, respiratory hygiene, use of personal protective equipment (to block
splashes or other contact with infected materials), safe injection practices and
safe burial practices.
Health-care workers caring for patients with suspected or confirmed Ebola virus
should apply extra infection control measures to prevent contact with the
patients blood and body fluids and contaminated surfaces or materials such as
clothing and bedding. When in close contact (within 1 metre) of patients with
EBV, health-care workers should wear face protection (a face shield or a medical
mask and goggles), a clean, non-sterile long-sleeved gown, and gloves (sterile
gloves for some procedures).
Laboratory workers are also at risk. Samples taken from humans and animals for
investigation of Ebola infection should be handled by trained staff and processed
in suitably equipped laboratories.
WHO response
WHO aims to prevent Ebola outbreaks by maintaining surveillance for Ebola virus
disease and supporting at-risk countries to developed preparedness plans. The
document provides overall guidance for control of Ebola and Marburg virus
outbreaks:
Ebola and Marburg virus disease epidemics: preparedness, alert, control,
and evaluation
When an outbreak is detected WHO responds by supporting surveillance,
community engagement, case management, laboratory services, contact
tracing, infection control, logistical support and training and assistance
with safe burial practices.
WHO has developed detailed advice on Ebola infection prevention and
control:
Infection prevention and control guidance for care of patients with
suspected or confirmed Filovirus haemorrhagic fever in health-care
settings, with focus on Ebola

Hepatitis A
Fact sheet N328
Updated July 2015

Key facts

Hepatitis A is a viral liver disease that can cause mild to severe illness.
The hepatitis A virus is transmitted through ingestion of contaminated food
and water or through direct contact with an infectious person.
Almost everyone recovers fully from hepatitis A, but very small proportions
die from fulminant hepatitis.
Hepatitis A infection risk is associated with a lack of safe water and poor
sanitation.
Epidemics can be explosive and cause significant economic loss.
Improved sanitation and the hepatitis A vaccine are the most effective
ways to combat the disease.

Hepatitis A is a liver disease caused by the hepatitis A virus. The virus is primarily
spread when an uninfected (and unvaccinated) person ingests food or water that
is contaminated with the faeces of an infected person. The disease is closely
associated with unsafe water, inadequate sanitation and poor personal hygiene.
Unlike hepatitis B and C, hepatitis A infection does not cause chronic liver disease
and is rarely fatal, but it can cause debilitating symptoms and fulminant hepatitis
(acute liver failure), which is associated with high mortality.
Hepatitis A occurs sporadically and in epidemics worldwide, with a tendency for
cyclic recurrences. The hepatitis A virus is one of the most frequent causes of
foodborne infection. Epidemics related to contaminated food or water can erupt
explosively, such as the epidemic in Shanghai in 1988 that affected about 300
000 people1. Hepatitis A viruses persist in the environment and can withstand
food-production processes routinely used to inactivate and/or control bacterial
pathogens.

The disease can lead to significant economic and social consequences in


communities. It can take weeks or months for people recovering from the illness
to return to work, school or daily life. The impact on food establishments
identified with the virus, and local productivity in general, can be substantial.
Geographical distribution
Geographical distribution areas can be characterized as having high,
intermediate or low levels of hepatitis A infection.
Areas with high levels of infection
In developing countries with very poor sanitary conditions and hygienic practices,
most children (90%) have been infected with the hepatitis A virus before the age
of 10 years2. Those infected in childhood do not experience any noticeable
symptoms. Epidemics are uncommon because older children and adults are
generally immune. Symptomatic disease rates in these areas are low and
outbreaks are rare.

Areas with intermediate levels of infection


In developing countries, countries with transitional economies and regions where
sanitary conditions are variable, children often escape infection in early
childhood. Ironically, these improved economic and sanitary conditions may lead
to a higher susceptibility in older age groups and higher disease rates, as
infections occur in adolescents and adults, and large outbreaks can occur.
Areas with low levels of infection
In developed countries with good sanitary and hygienic conditions, infection rates
are low. Disease may occur among adolescents and adults in high-risk groups,
such as injecting-drug users, men who have sex with men, people travelling to
areas of high endemicity, and in isolated populations, such as closed religious
communities.
Transmission
The hepatitis A virus is transmitted primarily by the faecal-oral route; that is
when an uninfected person ingests food or water that has been contaminated
with the faeces of an infected person. Waterborne outbreaks, though infrequent,
are usually associated with sewage-contaminated or inadequately treated water.
The virus can also be transmitted through close physical contact with an
infectious person, although casual contact among people does not spread the
virus.
Symptoms
The incubation period of hepatitis A is usually 1428 days.
Symptoms of hepatitis A range from mild to severe, and can include fever,
malaise, loss of appetite, diarrhoea, nausea, abdominal discomfort, dark-coloured

urine and jaundice (a yellowing of the skin and whites of the eyes). Not everyone
who is infected will have all of the symptoms.
Adults have signs and symptoms of illness more often than children, and the
severity of disease and mortality increases in older age groups. Infected children
under 6 years of age do not usually experience noticeable symptoms, and only
10% develop jaundice. Among older children and adults, infection usually causes
more severe symptoms, with jaundice occurring in more than 70% of cases.
Who is at risk?
Anyone who has not been vaccinated or previously infected can contract
hepatitis A. In areas where the virus is widespread (high endemicity), most
hepatitis A infections occur during early childhood. Risk factors include:
poor sanitation;
lack of safe water;
injecting drugs;
living in a household with an infected person;
being a sexual partner of someone with acute hepatitis A infection; and
travelling to areas of high endemicity without being immunized.

Diagnosis
Cases of hepatitis A are not clinically distinguishable from other types of acute
viral hepatitis. Specific diagnosis is made by the detection of HAV-specific IgM
and IgG antibodies in the blood. Additional tests include reverse transcriptase
polymerase chain reaction (RT-PCR) to detect the hepatitis A virus RNA, but may
require specialised laboratory facilities.
Treatment
There is no specific treatment for hepatitis A. Recovery from symptoms following
infection may be slow and may take several weeks or months. Therapy is aimed
at maintaining comfort and adequate nutritional balance, including replacement
of fluids that are lost from vomiting and diarrhoea.
Prevention
Improved sanitation, food safety and immunization are the most effective ways
to combat hepatitis A.
The spread of hepatitis A can be reduced by:
adequate supplies of safe drinking water;
proper disposal of sewage within communities; and
personal hygiene practices such as regular hand-washing with safe water.
Several hepatitis A vaccines are available internationally. All are similar in
terms of how well they protect people from the virus and their side-effects.
No vaccine is licensed for children younger than 1 year of age.
Nearly 100% of people develop protective levels of antibodies to the virus
within 1 month after a single dose of the vaccine. Even after exposure to
the virus, a single dose of the vaccine within 2 weeks of contact with the
virus has protective effects. Still, manufacturers recommend two vaccine
doses to ensure a longer-term protection of about 5 to 8 years after
vaccination.

Millions of people have been immunized worldwide with no serious adverse


events. The vaccine can be given as part of regular childhood
immunizations programmes and also with other vaccines for travellers.

Immunization efforts
Vaccination against hepatitis A should be part of a comprehensive plan for the
prevention and control of viral hepatitis. Planning for large-scale immunization
programmes should involve careful economic evaluations and consider
alternative or additional prevention methods, such as improved sanitation, and
health education for improved hygiene practices.
Whether or not to include the vaccine in routine childhood immunizations
depends on the local context. The proportion of susceptible people in the
population and the level of exposure to the virus should be considered. Several
countries, including Argentina, China, Israel, Turkey, and the United States of
America have introduced the vaccine in routine childhood immunizations.
While the 2 dose regimen of inactivated hepatitis A vaccine is used in many
countries, other countries may consider inclusion of a single-dose inactivated
hepatitis A vaccine in their immunization schedules. Some countries also
recommend the vaccine for people at increased risk of hepatitis A, including:
travellers to countries where the virus is endemic;
men who have sex with men; and
people with chronic liver disease (because of their increased risk of serious
complications if they acquire hepatitis A infection).
Regarding immunization for outbreak response, recommendations for
hepatitis A vaccination should also be site-specific. The feasibility of
rapidly implementing a widespread immunization campaign needs to be
included.
Vaccination to control community-wide outbreaks is most successful in
small communities, when the campaign is started early and when high
coverage of multiple age groups is achieved. Vaccination efforts should be
supplemented by health education to improve sanitation, hygiene
practices and food safety.

WHO response

WHO is working in the following areas to prevent and control viral


hepatitis:
raising awareness, promoting partnerships and mobilizing resources;
formulating evidence-based policy and data for action;
preventing transmission; and
executing screening, care and treatment.
WHO also organizes World Hepatitis Day on July 28 every year to increase
awareness and understanding of viral hepatitis.

Hepatitis B
Fact sheet N204
Updated July 2015

Key facts

Hepatitis B is a viral infection that attacks the liver and can cause both
acute and chronic disease.
The virus is transmitted through contact with the blood or other body fluids
of an infected person.
An estimated 240 million people are chronically infected with hepatitis B
(defined as hepatitis B surface antigen positive for at least 6 months).
More than 780 000 people die every year due to complications of hepatitis
B, including cirrhosis and liver cancer1.

Hepatitis B is an important occupational hazard for health workers.


However, it can be prevented by currently available safe and effective
vaccine.

Hepatitis B is a potentially life-threatening liver infection caused by the hepatitis


B virus. It is a major global health problem. It can cause chronic infection and
puts people at high risk of death from cirrhosis and liver cancer.
A vaccine against hepatitis B has been available since 1982. The vaccine is 95%
effective in preventing infection and the development of chronic disease and liver
cancer due to hepatitis B.
Geographical distribution
Hepatitis B prevalence is highest in sub-Saharan Africa and East Asia, where
between 510% of the adult population is chronically infected. High rates of
chronic infections are also found in the Amazon and the southern parts of eastern
and central Europe. In the Middle East and the Indian subcontinent, an estimated
25% of the general population is chronically infected. Less than 1% of the
population in Western Europe and North America is chronically infected.
Transmission
The hepatitis B virus can survive outside the body for at least 7 days. During this
time, the virus can still cause infection if it enters the body of a person who is not
protected by the vaccine. The incubation period of the hepatitis B virus is 75 days
on average, but can vary from 30 to 180 days. The virus may be detected within
30 to 60 days after infection and can persist and develop into chronic hepatitis B.
In highly endemic areas, hepatitis B is most commonly spread from mother to
child at birth (perinatal transmission), or through horizontal transmission
(exposure to infected blood), especially from an infected child to an uninfected
child during the first 5 years of life. The development of chronic infection is very
common in infants infected from their mothers or before the age of 5 years.
Hepatitis B is also spread by percutaneous or mucosal exposure to infected blood
and various body fluids, as well as through saliva, menstrual, vaginal, and
seminal fluids. Sexual transmission of hepatitis B may occur, particularly in
unvaccinated men who have sex with men and heterosexual persons with
multiple sex partners or contact with sex workers. Infection in adulthood leads to
chronic hepatitis in less than 5% of cases. Transmission of the virus may also
occur through the reuse of needles and syringes either in health-care settings or
among persons who inject drugs. In addition, infection can occur during medical,
surgical and dental procedures, tattooing, or through the use of razors and
similar objects that are contaminated with infected blood.
Symptoms
Most people do not experience any symptoms during the acute infection phase.
However, some people have acute illness with symptoms that last several weeks,
including yellowing of the skin and eyes (jaundice), dark urine, extreme fatigue,

nausea, vomiting and abdominal pain. A small subset of persons with acute
hepatitis can develop acute liver failure which can lead to death.
In some people, the hepatitis B virus can also cause a chronic liver infection that
can later develop into cirrhosis of the liver or liver cancer.
More than 90% of healthy adults who are infected with the hepatitis B virus will
recover naturally from the virus within the first year.
Who is at risk for chronic disease?
The likelihood that infection with the virus becomes chronic depends upon the
age at which a person becomes infected. Children less than 6 years of age who
become infected with the hepatitis B virus are the most likely to develop chronic
infections.
In infants and children:
8090% of infants infected during the first year of life develop chronic
infections;
3050% of children infected before the age of 6 years develop chronic
infections.
In adults:
<5% of otherwise healthy persons who are infected as adults will develop
chronic infection;
2030% of adults who are chronically infected will develop cirrhosis and/or
liver cancer.

Diagnosis
It is not possible, on clinical grounds, to differentiate hepatitis B from hepatitis
caused by other viral agents and, hence, laboratory confirmation of the diagnosis
is essential. A number of blood tests are available to diagnose and monitor
people with hepatitis B. They can be used to distinguish acute and chronic
infections.
Laboratory diagnosis of hepatitis B infection focuses on the detection of the
hepatitis B surface antigen HBsAg. WHO recommends that all blood donations
are tested for hepatitis B to ensure blood safety and avoid accidental
transmission to people who receive blood products.
Acute HBV infection is characterized by the presence of HBsAg and
immunoglobulin M (IgM) antibody to the core antigen, HBcAg. During the
initial phase of infection, patients are also seropositive for hepatitis B e
antigen (HBeAg). HBeAg is usually a marker of high levels of replication of
the virus. The presence of HBeAg indicates that the blood and body fluids
of the infected individual are highly contagious.
Chronic infection is characterized by the persistence of HBsAg for at least
6 months (with or without concurrent HBeAg). Persistence of HBsAg is the
principal marker of risk for developing chronic liver disease and liver
cancer (hepatocellular carcinoma) later in life.
Treatment
There is no specific treatment for acute hepatitis B. Therefore, care is aimed at
maintaining comfort and adequate nutritional balance, including replacement of

fluids lost from vomiting and diarrhoea. Chronic hepatitis B infection can be
treated with drugs, including oral antiviral agents. Treatment can slow the
progression of cirrhosis, reduce incidence of liver cancer and improve long term
survival.
WHO recommends the use of oral treatments - tenofovir or entecavir, because
these are the most potent drugs to suppress hepatitis B virus. They rarely lead to
drug resistance as compared with other drugs, are simple to take (1 pill a day),
and have few side effects so require only limited monitoring.
However, in most people, the treatment does not cure hepatitis B infection, but
only suppresses the replication of the virus. Therefore, most people who start
hepatitis B treatment must continue it for life.
Treatment using interferon injections may be considered in some people in
certain high-income settings, but its use is less feasible in low-resource settings
due to high cost and significant adverse effects requiring careful monitoring.
There is still limited access to diagnosis and treatment of hepatitis B in many
resource-constrained settings, and many people are diagnosed only when they
already have advanced liver disease. Liver cancer progresses rapidly, and since
treatment options are limited, the outcome is in general poor. In low-income
settings, most people with liver cancer die within months of diagnosis. In highincome countries, surgery and chemotherapy can prolong life for up to a few
years. In high-income countries, liver transplantation is sometimes used in
people with cirrhosis, with varying success.
Prevention
The hepatitis B vaccine is the mainstay of hepatitis B prevention. WHO
recommends that all infants receive the hepatitis B vaccine as soon as possible
after birth, preferably within 24 hours. The birth dose should be followed by 2 or
3 doses to complete the primary series. In most cases, one of the following two
options is considered appropriate:
a 3-dose schedule of hepatitis B vaccine, with the first dose (monovalent)
being given at birth and the second and third (monovalent or combined
vaccine) given at the same time as the first and third doses of diphtheria,
pertussis (whooping cough), and tetanus (DTP) vaccine; or
4 doses, where a monovalent birth dose is followed by three monovalent or
combined vaccine doses, usually given with other routine infant vaccines.
The complete vaccine series induces protective antibody levels in more
than 95% of infants, children and young adults. Protection lasts at least 20
years and is probably lifelong. Thus, WHO does not recommend booster
vaccination for persons who have completed the 3 dose vaccination
schedule.
All children and adolescents younger than 18 years-old and not previously
vaccinated should receive the vaccine if they live in countries where there
is low or intermediate endemicity. In those settings it is possible that more
people in high-risk groups may acquire the infection and they should also
be vaccinated. They include:
people who frequently require blood or blood products, dialysis patients,
recipients of solid organ transplantations;

people interned in prisons;


persons who inject drugs;
household and sexual contacts of people with chronic HBV infection;
people with multiple sexual partners;
health-care workers and others who may be exposed to blood and blood
products through their work; and
travellers who have not completed their hepatitis B vaccination series, who
should be offered the vaccine before leaving for endemic areas.
The vaccine has an excellent record of safety and effectiveness. Since
1982, over 1 billion doses of hepatitis B vaccine have been used
worldwide. In many countries where 815% of children used to become
chronically infected with the hepatitis B virus, vaccination has reduced the
rate of chronic infection to less than 1% among immunized children.

As of 2013, 183 Member States vaccinate infants against hepatitis B as part of


their vaccination schedules and 81% of children received the hepatitis B vaccine.
This is a major increase compared with 31 countries in 1992, the year that the
World Health Assembly passed a resolution to recommend global vaccination
against hepatitis B. Furthermore, as of 2013, 93 Member States have introduced
the hepatitis B birth dose vaccine.
In addition, implementing of blood safety strategies, including quality-assured
screening of all donated blood and blood components used for transfusion, can
prevent transmission of HBV. Safe injection practices, eliminating unnecessary
and unsafe injections, can be effective strategies to protect against HBV
transmission. Furthermore, safer sex practices, including minimizing the number
of partners and using barrier protective measures (condoms), also protect
against transmission.
WHO response
In March 2015, WHO launched its first "Guidelines for the prevention, care and
treatment of persons living with chronic hepatitis B infection". The
recommendations:
promote the use of simple, non-invasive diagnostic tests to assess the
stage of liver disease and eligibility for treatment;
prioritize treatment for those with most advanced liver disease and at
greatest risk of mortality; and
recommend the preferred use of the nucleos(t)ide analogues with a high
barrier to drug resistance (tenofovir and entecavir, and entecavir in
children aged 211 years) for first- and second-line treatment.
These guidelines also recommend lifelong treatment in those with
cirrhosis; and regular monitoring for disease progression, toxicity of drugs
and early detection of liver cancer.
WHO is working in the following areas to prevent and control viral
hepatitis:
raising awareness, promoting partnerships;
formulating evidence-based policy and data for action;
promoting prevention of transmission through vaccination, safe injection
practices and blood safety; and

promoting wider access to monitoring and screening, care and treatment


services for hepatitis B.
WHO also organizes World Hepatitis Day on July 28 every year to increase
awareness and understanding of viral hepatitis.

HIV/AIDS
Fact sheet N360
Updated July 2015

Key facts

HIV continues to be a major global public health issue, having claimed


more than 34 million lives so far. In 2014, 1.2 [1.01.5] million people died
from HIV-related causes globally.
There were approximately 36.9 [34.341.4] million people living with HIV
at the end of 2014 with 2.0 [1.92.2] million people becoming newly
infected with HIV in 2014 globally.
Sub-Saharan Africa is the most affected region, with 25.8 [24.028.7]
million people living with HIV in 2014. Also sub-Saharan Africa accounts for
almost 70% of the global total of new HIV infections.
HIV infection is often diagnosed through rapid diagnostic tests (RDTs),
which detect the presence or absence of HIV antibodies. Most often these
tests provide same day test results; essential for same day diagnosis and
early treatment and care.
There is no cure for HIV infection. However, effective treatment with
antiretroviral (ARV) drugs can control the virus so that people with HIV can
enjoy healthy and productive lives.
It is estimated that currently only 51% of people with HIV know their
status. In 2014, approximately 150 million children and adults in 129 lowand middle-income countries received HIV testing services.
In 2014, 14.9 million people living with HIV were receiving antiretroviral
therapy (ART) globally, of which 13.5 million were receiving ART in low- and
middle-income countries. The 14.9 million people on ART represent 40%
[3745%] of people living with HIV globally

The Human Immunodeficiency Virus (HIV) targets the immune system and
weakens people's defence systems against infections and some types of cancer.

As the virus destroys and impairs the function of immune cells, infected
individuals gradually become immunodeficient. Immune function is typically
measured by CD4 cell count. Immunodeficiency results in increased susceptibility
to a wide range of infections and diseases that people with healthy immune
systems can fight off.
The most advanced stage of HIV infection is Acquired Immunodeficiency
Syndrome (AIDS), which can take from 2 to 15 years to develop depending on the
individual. AIDS is defined by the development of certain cancers, infections, or
other severe clinical manifestations.
Signs and symptoms
The symptoms of HIV vary depending on the stage of infection. Though people
living with HIV tend to be most infectious in the first few months, many are
unaware of their status until later stages. The first few weeks after initial
infection, individuals may experience no symptoms or an influenza-like illness
including fever, headache, rash or sore throat.
As the infection progressively weakens the immune system, an individual can
develop other signs and symptoms, such as swollen lymph nodes, weight loss,
fever, diarrhoea and cough. Without treatment, they could also develop severe
illnesses such as tuberculosis, cryptococcal meningitis, and cancers such as
lymphomas and Kaposi's sarcoma, among others.
Transmission
HIV can be transmitted via the exchange of a variety of body fluids from infected
individuals, such as blood, breast milk, semen and vaginal secretions. Individuals
cannot become infected through ordinary day-to-day contact such as kissing,
hugging, shaking hands, or sharing personal objects, food or water.
Risk factors
Behaviours and conditions that put individuals at greater risk of contracting HIV
include:
having unprotected anal or vaginal sex;
having another sexually transmitted infection such as syphilis, herpes,
chlamydia, gonorrhoea, and bacterial vaginosis;
sharing contaminated needles, syringes and other injecting equipment and
drug solutions when injecting drugs;
receiving unsafe injections, blood transfusions, medical procedures that
involve unsterile cutting or piercing; and
experiencing accidental needle stick injuries, including among health
workers.
Diagnosis
Serological tests, such as RDTs or enzyme immunoassays (EIAs), detect the
presence or absence of antibodies to HIV-1/2 and/or HIV p24 antigen. When such
tests are used within a testing strategy according to a validated testing
algorithm, HIV infection can be detected with great accuracy. It is important to

note that serological tests detect antibodies produced by an individual as part of


their immune system to fight off foreign pathogens, rather than direct detection
of HIV itself.
Most individuals develop antibodies to HIV-1/2 within 28 days and therefore
antibodies may not be detectable early after infection, the so-called window
period. This early period of infection represents the time of greatest infectivity;
however HIV transmission can occur during all stages of the infection.
It is best practice to also retest all people initially diagnosed as HIV-positive
before they enroll in care and/or treatment to rule out any potential testing or
reporting error.
HIV testing services
HIV testing should be voluntary and the right to decline testing should be
recognized. Mandatory or coerced testing by a health-care provider, authority or
by a partner or family member is not acceptable as it undermines good public
health practice and infringes on human rights.
Some countries have introduced, or are considering, self-testing as an additional
option. HIV self-testing is a process whereby a person who wants to know his or
her HIV status collects a specimen, performs a test and interprets the test results
in private. HIV self-testing does not provide a definitive diagnosis; instead, it is an
initial test which requires further testing by a health worker using a national
validated testing algorithm.
All HIV testing services must include the 5 Cs recommended by WHO: informed
Consent, Confidentiality, Counselling, Correct test results and Connection (linkage
to care, treatment and other services).

Prevention
Individuals can reduce the risk of HIV infection by limiting exposure to risk
factors. Key approaches for HIV prevention, which are often used in combination,
include:
1. Male and female condom use
Correct and consistent use of male and female condoms during vaginal or anal
penetration can protect against the spread of sexually transmitted infections,
including HIV. Evidence shows that male latex condoms have an 85% or greater
protective effect against HIV and other sexually transmitted infections (STIs).
2. Testing and counselling for HIV and STIs
Testing for HIV and other STIs is strongly advised for all people exposed to any of
the risk factors. This way people learn of their own infection status and access

necessary prevention and treatment services without delay. WHO also


recommends offering testing for partners or couples.
Tuberculosis (TB) is the most common presenting illness among people with HIV.
It is fatal if undetected or untreated and is the leading cause of death among
people with HIV- responsible for roughly 1 of every 4 HIV-associated deaths. Early
detection of TB and prompt linkage to TB treatment and ART can prevent these
deaths. It is strongly advised that HIV testing services integrate screening for TB
and that all individuals diagnosed with HIV and active TB urgently use ART.
3. Voluntary medical male circumcision
Medical male circumcision, when safely provided by well-trained health
professionals, reduces the risk of heterosexually acquired HIV infection in men by
approximately 60%. This is a key intervention in generalized epidemic settings
with high HIV prevalence and low male circumcision rates.
4. Antiretroviral (ART) use for prevention
4.1 ART as prevention
A 2011 trial has confirmed if an HIV-positive person adheres to an effective ART
regimen, the risk of transmitting the virus to their uninfected sexual partner can
be reduced by 96%. For couples in which one partner is HIV-positive and the
other HIV-negative, WHO recommend offering ART for the HIV-positive partner
regardless of her/his CD4 count.
4.2 Pre-exposure prophylaxis (PrEP) for HIV-negative partner
Oral PrEP of HIV is the daily use of ARV drugs by HIV-uninfected people to block
the acquisition of HIV. More than 10 randomized controlled studies have
demonstrated the effectiveness of PrEP in reducing HIV transmission among a
range of populations including serodiscordant heterosexual couples (where one
partner is infected and the other is not), men who have sex with men,
transgender women, high-risk heterosexual couples, and people who inject drugs.
In July 2014, WHO released "Consolidated guidelines on HIV prevention,
diagnosis, treatment and care for key populations" which recommended PrEP as
an additional HIV prevention choice within a comprehensive HIV prevention
package for men who have sex with men.
4.3 Post-exposure prophylaxis for HIV (PEP)
Post-exposure prophylaxis (PEP) is the use of ARV drugs within 72 hours of
exposure to HIV in order to prevent infection. PEP includes counselling, first aid
care, HIV testing, and administering of a 28-day course of ARV drugs with followup care.
Updated WHO guidelines issued in December 2014 recommend PEP use for both
occupational and non-occupational exposures and for adults and children. The
new recommendations provide simpler regimens using ARVs already being used
in treatment. The implementation of the new guidelines will enable easier
prescribing, better adherence and increased completion rates of PEP to prevent
HIV in people who have been accidentally exposed to HIV such as health workers
or through unprotected sexual exposures or sexual assault.

5. Harm reduction for injecting drug users


People who inject drugs can take precautions against becoming infected with HIV
by using sterile injecting equipment, including needles and syringes, for each
injection. A comprehensive package of interventions for HIV prevention and
treatment includes:
needle and syringe programmes;
opioid substitution therapy for people dependent on opioids and other
evidence based drug dependence treatment;
HIV testing and counselling;
HIV treatment and care;
access to condoms; and
management of STIs, tuberculosis and viral hepatitis.
6. Elimination of mother-to-child transmission of HIV (eMTCT)
The transmission of HIV from an HIV-positive mother to her child during
pregnancy, labour, delivery or breastfeeding is called vertical or mother-to-child
transmission (MTCT). In the absence of any interventions during these stages,
rates of HIV transmission from mother-to-child can be between 15-45%. MTCT
can be nearly fully prevented if both the mother and the child are provided with
ARV drugs throughout the stages when infection could occur.
WHO recommends options for prevention of MTCT (PMTCT), which includes
providing ARVs to mothers and infants during pregnancy, labour and the postnatal period, and offering life-long treatment to HIV-positive pregnant women
regardless of their CD4 count.
In 2014, 73% [6879%] of the estimated 1.5 [1.3-1.6] million pregnant women
living with HIV globally received effective antiretroviral drugs to avoid
transmission to their children.
Treatment
HIV can be suppressed by combination ART consisting of 3 or more ARV drugs.
ART does not cure HIV infection but controls viral replication within a person's
body and allows an individual's immune system to strengthen and regain the
capacity to fight off infections.
Approximately 14.9 million people living with HIV were receiving ART at the end
of 2014 globally. About 823 000 of those were children.
In 2014, there was a large increase in number of people on ART 1.9 million-- in a
single year.
WHO recommends initiating ART when their CD4 cell counts falls to 500
cells/mm or less. ART regardless of CD4 count is recommended for all people
living with HIV in serodiscordant couples, pregnant and breastfeeding women
living with HIV, people with TB and HIV, and people co-infected with HIV and
hepatitis B infection with severe chronic liver disease. Likewise, ART is
recommended for all children living with HIV who are younger than 5 years-old.

WHO response
WHO is working with countries to implement the Global Health Sector Strategy on
HIV/AIDS for 2011-2015. WHO has identified six operational objectives for 2014
2015 to support countries most efficiently in moving towards the global HIV
targets. These are to support:
strategic use of ARVs for HIV treatment and prevention;
eliminating HIV in children and expanding access to paediatric treatment;
an improved health sector response to HIV among key populations;
further innovation in HIV prevention, diagnosis, treatment and care;
strategic information for effective scale up;
stronger links between HIV and related health outcomes.
WHO is a cosponsor of the Joint United Nations Programme on AIDS (UNAIDS).
Within UNAIDS, WHO leads activities on HIV treatment and care, HIV and
tuberculosis co-infection, and jointly coordinates with UNICEF the work on the
elimination of mother-to-child transmission of HIV.
Currently, WHO is working on a follow-up strategy for the global health sector
response to HIV for 2016-2021.

Influenza (Seasonal)
Fact sheet N211
March 2014

Key facts

Seasonal influenza is an acute viral infection that spreads easily from


person to person.
Seasonal influenza viruses circulate worldwide and can affect anybody in
any age group.
Seasonal influenza viruses cause annual epidemics that peak during winter
in temperate regions.
Seasonal influenza is a serious public health problem that causes severe
illness and death in high risk populations.
An influenza epidemic can take an economic toll through lost workforce
productivity and strain health services.
Influenza vaccination is the most effective way to prevent infection.
Antiviral drugs are available for treatment, however influenza viruses can
develop resistance to the drugs.

Overview
Seasonal influenza is an acute viral infection caused by an influenza virus.
There are 3 types of seasonal influenza viruses A, B and C. Type A influenza
viruses are further classified into subtypes according to the combinations of
various virus surface proteins. Among many subtypes of influenza A viruses,
influenza A(H1N1) and A(H3N2) subtypes are currently circulating among
humans.
Influenza viruses circulate in all parts of the world. Type C influenza cases occur
much less frequently than A and B. That is why only influenza A and B viruses are
included in seasonal influenza vaccines.
Signs and symptoms
Seasonal influenza is characterized by a sudden onset of high fever, cough
(usually dry), headache, muscle and joint pain, severe malaise (feeling unwell),
sore throat and runny nose. Cough can be severe and can last 2 or more weeks.
Most people recover from fever and other symptoms within a week without
requiring medical attention. But influenza can cause severe illness or death
especially in people at high risk (see below). The time from infection to illness,
known as the incubation period, is about 2 days.
Who is at risk?
Yearly influenza epidemics can seriously affect all populations, but the highest
risk of complications occur among children younger than age 2 years, adults
aged 65 years or older, pregnant women, and people of any age with certain

medical conditions, such as chronic heart, lung, kidney, liver, blood or metabolic
diseases (such as diabetes), or weakened immune systems.
Transmission
Seasonal influenza spreads easily and can sweep through schools, nursing
homes, businesses or towns. When an infected person coughs, infected droplets
get into the air and another person can breathe them in and be exposed. The
virus can also be spread by hands contaminated with influenza viruses. To
prevent transmission, people should cover their mouth and nose with a tissue
when coughing, and wash their hands regularly.
Seasonal epidemics and disease burden
In temperate climates, seasonal epidemics occur mainly during winter while in
tropical regions, influenza may occur throughout the year, causing outbreaks
more irregularly.
Influenza occurs globally with an annual attack rate estimated at 5%10% in
adults and 20%30% in children. Illnesses can result in hospitalization and death
mainly among high-risk groups (the very young, elderly or chronically ill).
Worldwide, these annual epidemics are estimated to result in about 3 to 5 million
cases of severe illness, and about 250 000 to 500 000 deaths.
In industrialized countries most deaths associated with influenza occur among
people age 65 or older. Epidemics can result in high levels of worker/school
absenteeism and productivity losses. Clinics and hospitals can be overwhelmed
during peak illness periods.
The precise effects of seasonal influenza epidemics in developing countries are
not known, but research estimates indicate that a large percent of child deaths
associated with influenza occur in developing countries every year.
Prevention
The most effective way to prevent the disease and/or severe outcomes from the
illness is vaccination. Safe and effective vaccines are available and have been
used for more than 60 years. Among healthy adults, influenza vaccine can
provide reasonable protection. However among the elderly, influenza vaccine
may be less effective in preventing illness but may reduce severity of disease
and incidence of complications and deaths.
Vaccination is especially important for people at higher risk of serious influenza
complications, and for people who live with or care for high risk individuals.
WHO recommends annual vaccination for:
pregnant women at any stage of pregnancy
children aged 6 months to 5 years
elderly individuals (65 years of age)
individuals with chronic medical conditions
health-care workers.
Influenza vaccination is most effective when circulating viruses are well-matched
with vaccine viruses. Influenza viruses are constantly changing, and the WHO
Global Influenza Surveillance and Response System (GISRS) a partnership of

National Influenza Centres around the world monitors the influenza viruses
circulating in humans.
For many years WHO has updated its recommendation on vaccine composition
biannually that targets the 3 (trivalent) most representative virus types in
circulation (two subtypes of influenza A viruses and one B virus). Starting with
the 2013-2014 northern hemisphere influenza season, quadrivalent vaccine
composition has been recommended with a second influenza B virus in addition
to the viruses in the conventional trivalent vaccines. Quadrivalent influenza
vaccines are expected to provide wider protection against influenza B virus
infections.

Treatment
Antiviral drugs for influenza are available in some countries and may reduce
severe complications and deaths. Ideally they need to be administered early
(within 48 hours of onset of symptoms) in the disease. There are 2 classes of
such medicines:
1. adamantanes1(amantadine and rimantadine); and
2. inhibitors of influenza neuraminidase (oseltamivir and zanamivir; as well as
peramivir and laninamivir licensed in several countries).
Some influenza viruses develop resistance to the antiviral medicines, limiting the
effectiveness of treatment. WHO monitors antiviral susceptibility among
circulating influenza viruses to provide timely guidance for antiviral use in clinical
management and potential chemoprophylaxis.
WHO response
WHO, with its partners, monitors influenza globally, recommends seasonal
influenza vaccine compositions twice a year for the Northern and Southern
hemispheres, and supports Member States efforts to develop prevention and
control strategies.
WHO works to strengthen national and regional influenza diagnostic capacities
including antiviral susceptibility monitoring, disease surveillance, outbreak
responses, and increase vaccine coverage among high-risk groups.

Currently, WHO recommends neuraminidase inhibitors as the first-line treatment


for people requiring antiviral therapy, as the currently circulating influenza
viruses are resistant to the adamantanes.

Leprosy
Fact sheet N101
Updated May 2015

Key facts

Leprosy is a chronic disease caused by a slow multiplying


bacillus,Mycobacterium leprae.
M. leprae multiplies slowly and the incubation period of the disease is
about 5 years. Symptoms can take as long as 20 years to appear.
The disease mainly affects the skin, the peripheral nerves, mucosa of the
upper respiratory tract and also the eyes.
Leprosy is curable.
Although not highly infectious, it is transmitted via droplets, from the nose
and mouth, during close and frequent contacts with untreated cases.
Early diagnosis and treatment with multidrug therapy (MDT) remain key in
eliminating the disease as a public health concern
Untreated, leprosy can cause progressive and permanent damage to the
skin, nerves, limbs and eyes.
Official figures from 103 countries from 5 WHO regions show the global
registered prevalence of leprosy to be at 180 618 at the end of 2013;
during the same year, 215 656 new cases were reported.

Leprosy is a chronic infectious disease caused by Mycobacterium leprae, an acidfast, rod-shaped bacillus. The disease mainly affects the skin, the peripheral
nerves, mucosa of the upper respiratory tract and also the eyes.
Leprosy is curable and treatment provided in the early stages averts disability.

Multidrug therapy (MDT) treatment has been made available by WHO free of
charge to all patients worldwide since 1995, and provides a simple yet highly
effective cure for all types of leprosy.
Elimination of leprosy globally was achieved in the year 2000 (i.e. a prevalence
rate of leprosy less than 1 case per 10 000 persons at the global level). Nearly 16
million leprosy patients have been cured with MDT over the past 20 years.
Leprosy today
Leprosy control has improved significantly due to national and subnational
campaigns in most endemic countries. Integration of primary leprosy services
into existing general health services has made diagnosis and treatment of the
disease easy.
Detection of all cases in a community and completion of prescribed treatment
using MDT are the basic tenets of the Enhanced Global Strategy for Further
Reducing Disease Burden Due to Leprosy (plan period: 20112015).
The Strategy emphasizes the need to sustain expertise and increase the number
of skilled leprosy staff, improve the participation of affected persons in leprosy
services and reduce visible deformities otherwise called Grade 2 disabilities
(G2D cases) as well as stigma associated with the disease.
National leprosy programmes for 20112015 now focus more on underserved
populations and inaccessible areas to improve access and coverage. Since
control strategies are limited, national programmes actively improve caseholding, contact tracing, monitoring, referrals and record management.
According to official reports received from 103 countries from 5 WHO regions, the
global registered prevalence of leprosy at the end of 2013 was 180 618 cases.
The number of new cases reported globally in 2013 was 215 656 compared with
232 857 in 2012 and 226 626 in 2011.
The number of new cases indicates the degree of continued transmission of
infection in the community. A total of 13 countries reported zero cases in 2013.
Global statistics show that 206 107 (96%) of new leprosy cases were reported
from 14 countries and only 4% of new cases from the rest of the world. Only
these 14 countries reported >1000 new cases in 2013.
Pockets of high endemicity still remain in some areas of many countries but a few
are mentioned as reference: Angola, Bangladesh, Brazil, Peoples Republic of
China, Democratic Republic of Congo, Ethiopia, India, Indonesia, Madagascar,
Mozambique, Myanmar, Nepal, Nigeria, Philippines, South Sudan, Sri Lanka,
Sudan and the United Republic of Tanzania.
Brief history of the disease and treatment
Leprosy was recognized in the ancient civilizations of China, Egypt and India. The
first-known written mention of leprosy is dated 600 BC. Throughout history,
people afflicted have often been ostracized by their communities and families.
Although leprosy was treated differently in the past, the first breakthrough
occurred in the 1940s with the development of the drug dapsone, which arrested
the disease. But the duration of the treatment was many years and even a
lifetime, making it difficult for patients to follow it. In the 1960s, M. leprae started
to develop resistance to dapsone, the worlds only known anti-leprosy drug at

that time. In the early 1960s, rifampicin and clofazimine, the other two
components of recommended multidrug therapy (MDT), were discovered.
In 1981, a WHO Study Group recommended MDT. MDT consists of 3 drugs:
dapsone, rifampicin and clofazimine, and this drug combination kills the
pathogen and cures the patient.
Since 1995, WHO provides free MDT for all patients in the world, initially through
the drug fund provided by the Nippon Foundation, and since 2000 through the
MDT donation provided by Novartis and the Novartis Foundation for Sustainable
Development.
Elimination of leprosy as a public health problem
In 1991 the World Health Assembly passed a resolution to eliminate leprosy by
the year 2000. Elimination of leprosy is defined as a prevalence rate of less than
1 case per 10 000 persons. The target was achieved on time and the widespread
use of MDT reduced the disease burden dramatically.
Over the past 20 years, more than 14 million leprosy patients have been
cured, about 4 million of them since 2000.
The prevalence rate of the disease has dropped by 90%: from 21.1 per 10
000 persons to less than 1 per 10 000 persons in 2000.
A dramatic decrease has been achieved in the global disease burden: from
5.2 million in 1985 to 805 000 in 1995, 753 000 at the end of 1999 and
180 618 cases at the end of 2013.
Leprosy has been eliminated from 119 out of the 122 countries where the
disease was considered a public health problem in 1985.
So far, there has been no resistance to antileprosy treatment when used as
MDT.
Efforts currently focus on eliminating leprosy at a national level in the
remaining endemic countries and at a sub-national level from the others.
Actions and resources required
In order to reach all patients, leprosy treatment needs to be fully integrated into
general health services. Moreover, political commitment needs to be sustained in
countries where leprosy remains a public health problem. Partners in leprosy
elimination also need to ensure that human and financial resources continue to
be available.
The age-old stigma associated with the disease remains an obstacle to selfreporting and early treatment. The image of leprosy has to be changed at the
global, national and local levels. A new environment, in which patients will not
hesitate to come forward for diagnosis and treatment at any health facility, must
be created.
WHO response
The WHO strategy for leprosy elimination contains the following:
ensuring accessible and uninterrupted MDT services available to all
patients through flexible and patient-friendly drug delivery systems;

ensuring the sustainability of MDT services by integrating leprosy services


into the general health services and building the ability of general health
workers to treat leprosy;
encouraging self-reporting and early treatment by promoting community
awareness and changing the image of leprosy;
monitoring the performance of MDT services and quality of patients care,
and the progress being made towards elimination through national disease
surveillance systems.
Sustained and committed efforts by the national programmes along with
continued support from national and international partners have led to a
decline in the global burden of leprosy. Increased empowerment of people
affected by the disease, together with their greater involvement in
services and the community, will bring us closer to a world without leprosy.

Lymphatic filariasis
Fact sheet N102
Updated May 2015

Key facts

Lymphatic filariasis is a parasitic infection that can result in an altered


lymphatic system and the abnormal enlargement of body parts, causing
pain, severe disability and social stigma.

About 1.23 billion people in 58 countries worldwide are threatened by


lymphatic filariasis and require preventive largescale treatment, also
known as preventive chemotheraphy, to stop its spread.
Over 120 million people are infected, with about 40 million disfigured and
incapacitated by the disease.
Lymphatic filariasis can be eliminated by stopping the spread of infection
through preventive chemotherapy with single doses of 2 medicines for
persons living in areas where the infection is present.
A basic, recommended package of care can alleviate suffering and prevent
further disability among patients.

The disease
Lymphatic filariasis, commonly known as elephantiasis, is a neglected tropical
disease. Infection occurs when filarial parasites are transmitted to humans
through mosquitoes. Infection is usually acquired in childhood causing hidden
damage to the lymphatic system.
The painful and profoundly disfiguring visible manifestations of the disease,
lymphoedema, elephantiasis and scrotal swelling occur later in life and lead to
permanent disability. These patients are not only physically disabled, but suffer
mental, social and financial losses contributing to stigma and poverty.
Currently, 1.23 billion people in 58 countries are living in areas where lymphatic
filariasis is transmitted and are at risk of being infected. Approximately 80% of
these people are living in the following 10 countries: Bangladesh, Cte dIvoire,
Democratic Republic of Congo, India, Indonesia, Myanmar, Nigeria, Nepal,
Philippines and the United Republic of Tanzania.
Globally, an estimated 25 million men suffer with genital disease and over 15
million people are afflicted with lymphoedema. Eliminating lymphatic filariasis
can prevent unnecessary suffering and contribute to the reduction of poverty.
Cause and transmission
Lymphatic filariasis is caused by infection with parasites classified as nematodes
(roundworms) of the family Filariodidea. There are 3 types of these thread-like
filarial worms:
Wuchereria bancrofti, which is responsible for 90% of the cases
Brugia malayi, which causes most of the remainder of the cases
B. timori, which also causes the disease.
Adult worms lodge in the lymphatic system and disrupt the immune system. The
worms can live for an average of 6-8 years and, during their life time, produce
millions of microfilariae (immature larvae) that circulate in the blood.
Mosquitoes are infected with microfilariae by ingesting blood when biting an
infected host. Microfilariae mature into infective larvae within the mosquito.
When infected mosquitoes bite people, mature parasite larvae are deposited on
the skin from where they can enter the body. The larvae then migrate to the
lymphatic vessels where they develop into adult worms, thus continuing a cycle
of transmission.

Lymphatic filariasis is transmitted by different types of mosquitoes, for example


theCulex mosquito that is widespread across urban and semi-urban areas; the
Anopheles mainly in rural areas, and Aedes, mainly in endemic islands in the
Pacific.
Symptoms
Lymphatic filariasis infection involves asymptomatic, acute, and chronic
conditions. The majority of infections are asymptomatic, showing no external
signs of infection. These asymptomatic infections still cause damage to the
lymphatic system and the kidneys as well as alter the bodys immune system.
Acute episodes of local inflammation involving skin, lymph nodes and lymphatic
vessels often accompany the chronic lymphoedema or elephantiasis. Some of
these episodes are caused by the body's immune response to the parasite.
However most are the result of bacterial skin infection where normal defences
have been partially lost due to underlying lymphatic damage.
When lymphatic filariasis develops into chronic conditions, it leads to
lymphoedema (tissue swelling) or elephantiasis (skin/tissue thickening) of limbs
and hydrocele (scrotal swelling). Involvement of breasts and genital organs is
common. Such body deformities lead to social stigma, as well as financial
hardship from loss of income and increased medical expenses. The
socioeconomic burdens of isolation and poverty are immense.
WHO's response
World Health Assembly Resolution 50.29 encourages Member States to eliminate
lymphatic filariasis as a public health problem. In response, WHO launched its
Global Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000 with the aim
of eliminating the disease as a public health problem. In 2012, the WHO NTD
Roadmap reconfirmed the target date for achieving elimination as 2020.
WHOs strategy is based on 2 key components:
stopping transmission through large-scale annual treatment of all eligible
people in an area or region where infection is present; and
alleviating the suffering caused by lymphatic filariasis through increased
morbidity management and disability prevention activities.
Large-scale treatment (preventive chemotherapy)
Elimination of lymphatic filariasis is possible by stopping the spread of the
infection. Large-scale treatment involves a single dose of 2 medicines given
annually to an entire at-risk population in the following way: albendazole (400
mg) together with ivermectin (150200 mcg/kg) or with diethylcarbamazine
citrate (DEC) (6 mg/kg).
These medicines have a limited effect on adult parasites but effectively clear
microfilariae from the bloodstream and prevent the spread of parasites to
mosquitoes. This recommended large-scale treatment strategy, called preventive
chemotherapy, when conducted annually for 46 years can interrupt the
transmission cycle.

At the start of GPELF, 81 countries were considered endemic for lymphatic


filariasis. Further epidemiological data indicated that preventive chemotherapy
was not required in 9 countries. From 2000 to 2013, over 5 billion treatments
were delivered to a targeted population of about 984 million individuals in 56
countries, considerably reducing transmission in many places. Recent research
data show that the transmission of lymphatic filariasis in at-risk populations has
dropped by 43% since the start of GPELF. The overall economic benefit of the
programme during 20002007 is conservatively estimated at US$ 24 billion.
Currently 73 countries are considered endemic and 17 of these have successfully
implemented recommended strategies and are under surveillance to
demonstrate that elimination has been achieved.
However, preventive chemotherapy has not been delivered to all endemic areas
and 28 countries are not on track to achieve elimination targets and stop
treatment by 2020.
Morbidity management
Morbidity management and disability prevention are vital for improving public
health and should be fully integrated into the health system to ensure
sustainability. Surgery can alleviate most cases of hydrocele. Clinical severity of
lymphoedema and acute inflammatory episodes can be improved using simple
measures of hygiene, skin care, exercise, and elevation of affected limbs. People
with lymphoedema must have access to continuing care throughout their lives,
both to manage the disease and to prevent progression to more advanced
stages.
The GPELF aims to provide access to a minimum package of care for every
person with associated chronic manifestations of lymphatic filariasis in all areas
where the disease is present, thus alleviating suffering and improving their
quality of life. Success in 2020 will be achieved if patients have access to the
following minimum package of care:
treatment for episodes of adenolymphangitis (ADL),
guidance in applying simple measures to manage lymphoedema and
hydrocele to prevent progression of lymphoedema and debilitating,
inflammatory episodes of ADL,
hydrocele surgery,
treatment with antifilarial medicines to destroy any remaining worms and
microfilariae by preventive chemotherapy or individual treatment.
Vector control
Mosquito control is another supplemental strategy supported by WHO. It is used
to reduce transmission of lymphatic filariasis and other mosquito-borne
infections. Measures such as insecticide-treated nets or indoor residual spraying
may help protect people from infection. In some settings, vector control in the
absence of preventive chemotherapy has eliminated lymphatic filariasis.

Malaria
Fact sheet N94
Reviewed April 2015

Key facts

Malaria is a life-threatening disease caused by parasites that are


transmitted to people through the bites of infected mosquitoes.
In 2013, malaria caused an estimated 584 000 deaths (with an uncertainty
range of 367 000 to 755 000), mostly among African children.
Malaria is preventable and curable.
Increased malaria prevention and control measures are dramatically
reducing the malaria burden in many places.
Non-immune travellers from malaria-free areas are very vulnerable to the
disease when they get infected.

According to the latest estimates, released in December 2014, there were about
198 million cases of malaria in 2013 (with an uncertainty range of 124 million to
283 million) and an estimated 584 000 deaths (with an uncertainty range of 367
000 to 755 000). Malaria mortality rates have fallen by 47% globally since 2000,
and by 54% in the WHO African Region.
Most deaths occur among children living in Africa where a child dies every minute
from malaria. Malaria mortality rates among children in Africa have been reduced
by an estimated 58% since 2000.
Malaria is caused by Plasmodium parasites. The parasites are spread to people
through the bites of infected Anopheles mosquitoes, called "malaria vectors",
which bite mainly between dusk and dawn.
There are four parasite species that cause malaria in humans:
Plasmodium falciparum
Plasmodium vivax
Plasmodium malariae
Plasmodium ovale.
Plasmodium falciparum and Plasmodium vivax are the most
common. Plasmodium falciparum is the most deadly.
In recent years, some human cases of malaria have also occurred
with Plasmodium knowlesi a species that causes malaria among monkeys and
occurs in certain forested areas of South-East Asia.

Transmission
Malaria is transmitted exclusively through the bites of Anopheles mosquitoes.
The intensity of transmission depends on factors related to the parasite, the
vector, the human host, and the environment.
About 20 different Anopheles species are locally important around the world. All
of the important vector species bite at night. Anopheles mosquitoes breed in
water and each species has its own breeding preference; for example some
prefer shallow collections of fresh water, such as puddles, rice fields, and hoof
prints. Transmission is more intense in places where the mosquito lifespan is
longer (so that the parasite has time to complete its development inside the
mosquito) and where it prefers to bite humans rather than other animals. For
example, the long lifespan and strong human-biting habit of the African vector
species is the main reason why about 90% of the world's malaria deaths are in
Africa.
Transmission also depends on climatic conditions that may affect the number and
survival of mosquitoes, such as rainfall patterns, temperature and humidity. In
many places, transmission is seasonal, with the peak during and just after the
rainy season. Malaria epidemics can occur when climate and other conditions
suddenly favour transmission in areas where people have little or no immunity to
malaria. They can also occur when people with low immunity move into areas
with intense malaria transmission, for instance to find work, or as refugees.
Human immunity is another important factor, especially among adults in areas of
moderate or intense transmission conditions. Partial immunity is developed over
years of exposure, and while it never provides complete protection, it does
reduce the risk that malaria infection will cause severe disease. For this reason,
most malaria deaths in Africa occur in young children, whereas in areas with less
transmission and low immunity, all age groups are at risk.
Symptoms
Malaria is an acute febrile illness. In a non-immune individual, symptoms appear
seven days or more (usually 1015 days) after the infective mosquito bite. The
first symptoms fever, headache, chills and vomiting may be mild and difficult
to recognize as malaria. If not treated within 24 hours, P. falciparum malaria can
progress to severe illness often leading to death. Children with severe malaria
frequently develop one or more of the following symptoms: severe anaemia,
respiratory distress in relation to metabolic acidosis, or cerebral malaria. In
adults, multi-organ involvement is also frequent. In malaria endemic areas,
persons may develop partial immunity, allowing asymptomatic infections to
occur.
For both P. vivax and P. ovale, clinical relapses may occur weeks to months after
the first infection, even if the patient has left the malarious area. These new
episodes arise from dormant liver forms known as hypnozoites (absent in P.
falciparum and P. malariae); special treatment targeted at these liver stages is
required for a complete cure.
Who is at risk?

Approximately half of the world's population is at risk of malaria. Most malaria


cases and deaths occur in sub-Saharan Africa. However, Asia, Latin America, and
to a lesser extent the Middle East and parts of Europe are also affected. In 2014,
97 countries and territories had ongoing malaria transmission.
Specific population risk groups include:
young children in stable transmission areas who have not yet developed
protective immunity against the most severe forms of the disease;
non-immune pregnant women as malaria causes high rates of miscarriage
and can lead to maternal death;
semi-immune pregnant women in areas of high transmission. Malaria can
result in miscarriage and low birth weight, especially during first and
second pregnancies;
semi-immune HIV-infected pregnant women in stable transmission areas,
during all pregnancies. Women with malaria infection of the placenta also
have a higher risk of passing HIV infection to their newborns;
people with HIV/AIDS;
international travellers from non-endemic areas because they lack
immunity;
immigrants from endemic areas and their children living in non-endemic
areas and returning to their home countries to visit friends and relatives
are similarly at risk because of waning or absent immunity.

Diagnosis and treatment


Early diagnosis and treatment of malaria reduces disease and prevents deaths. It
also contributes to reducing malaria transmission.
The best available treatment, particularly for P. falciparum malaria, is artemisininbased combination therapy (ACT).
WHO recommends that all cases of suspected malaria be confirmed using
parasite-based diagnostic testing (either microscopy or rapid diagnostic test)
before administering treatment. Results of parasitological confirmation can be
available in 15 minutes or less. Treatment solely on the basis of symptoms should
only be considered when a parasitological diagnosis is not possible. More detailed
recommendations are available in the "Guidelines for the treatment of malaria"
(second edition). An updated edition will be published in 2015.
Antimalarial drug resistance
Resistance to antimalarial medicines is a recurring problem. Resistance of P.
falciparum to previous generations of medicines, such as chloroquine and
sulfadoxine-pyrimethamine (SP), became widespread in the 1970s and 1980s,
undermining malaria control efforts and reversing gains in child survival.
In recent years, parasite resistance to artemisinins has been detected in 5
countries of the Greater Mekong subregion: Cambodia, Laos, Myanmar, Thailand
and Viet Nam. While there are likely many factors that contribute to the
emergence and spread of resistance, the use of oral artemisinins alone, as
monotherapy, is thought to be an important driver. When treated with an oral
artemisinin-based monotherapy, patients may discontinue treatment prematurely
following the rapid disappearance of malaria symptoms. This results in

incomplete treatment, and such patients still have persistent parasites in their
blood. Without a second drug given as part of a combination (as is provided with
an ACT), these resistant parasites survive and can be passed on to a mosquito
and then another person.
If resistance to artemisinins develops and spreads to other large geographical
areas, the public health consequences could be dire.
WHO recommends the routine monitoring of antimalarial drug resistance, and
supports countries to strengthen their efforts in this important area of work.
More comprehensive recommendations are available in the "WHO Global Plan for
Artemisinin Resistance Containment (GPARC)", which was released in 2011. For
countries in the Greater Mekong subregion, WHO has issued a regional
framework for action titled "Emergency response to artemisinin resistance in the
Greater Mekong subregion" in 2013.
Prevention
Vector control is the main way to reduce malaria transmission at the community
level. It is the only intervention that can reduce malaria transmission from very
high levels to close to zero.
For individuals, personal protection against mosquito bites represents the first
line of defence for malaria prevention.
Two forms of vector control are effective in a wide range of circumstances.

Insecticide-treated mosquito nets (ITNs)


Long-lasting insecticidal nets (LLINs) are the preferred form of ITNs for public
health distribution programmes. WHO recommends coverage for all at-risk
persons; and in most settings. The most cost effective way to achieve this is
through provision of free LLINs, so that everyone sleeps under a LLIN every night.
Indoor spraying with residual insecticides
Indoor residual spraying (IRS) with insecticides is a powerful way to rapidly
reduce malaria transmission. Its full potential is realized when at least 80% of
houses in targeted areas are sprayed. Indoor spraying is effective for 36 months,
depending on the insecticide used and the type of surface on which it is sprayed.
DDT can be effective for 912 months in some cases. Longer-lasting forms of
existing IRS insecticides, as well as new classes of insecticides for use in IRS
programmes, are under development.
Antimalarial medicines can also be used to prevent malaria. For travellers,
malaria can be prevented through chemoprophylaxis, which suppresses the blood
stage of malaria infections, thereby preventing malaria disease. In addition, WHO
recommends intermittent preventive treatment with sulfadoxine-pyrimethamine
for pregnant women living in high transmission areas, at each scheduled
antenatal visit after the first trimester. Similarly, for infants living in hightransmission areas of Africa, 3 doses of intermittent preventive treatment with
sulfadoxine-pyrimethamine is recommended delivered alongside routine
vaccinations. In 2012, WHO recommended Seasonal Malaria Chemoprevention as
an additional malaria prevention strategy for areas of the Sahel sub-Region of

Africa. The strategy involves the administration of monthly courses of


amodiaquine plus sulfadoxine-pyrimethamine to all children under 5 years of age
during the high transmission season.
Insecticide resistance
Much of the success to date in controlling malaria is due to vector control. Vector
control is highly dependent on the use of pyrethroids, which are the only class of
insecticides currently recommended for ITNs or LLINs. In recent years, mosquito
resistance to pyrethroids has emerged in many countries. In some areas,
resistance to all 4 classes of insecticides used for public health has been
detected. Fortunately, this resistance has only rarely been associated with
decreased efficacy, and LLINs and IRS remain highly effective tools in almost all
settings.
However, countries in sub-Saharan Africa and India are of significant concern.
These countries are characterized by high levels of malaria transmission and
widespread reports of insecticide resistance. The development of new, alternative
insecticides is a high priority and several promising products are in the pipeline.
Development of new insecticides for use on bed nets is a particular priority.
Detection of insecticide resistance should be an essential component of all
national malaria control efforts to ensure that the most effective vector control
methods are being used. The choice of insecticide for IRS should always be
informed by recent, local data on the susceptibility target vectors.
In order to ensure a timely and coordinated global response to the threat of
insecticide resistance, WHO has worked with a wide range of stakeholders to
develop the "Global Plan for Insecticide Resistance Management in malaria
vectors" (GPIRM), which was released in May 2012. The GPIRM puts forward a
five-pillar strategy calling on the global malaria community to:
plan and implement insecticide resistance management strategies in
malaria-endemic countries;
ensure proper and timely entomological and resistance monitoring, and
effective data management;
develop new and innovative vector control tools;
fill gaps in knowledge on mechanisms of insecticide resistance and the
impact of current insecticide resistance management approaches; and
ensure that enabling mechanisms (advocacy as well as human and
financial resources) are in place.
Surveillance
Tracking progress is a major challenge in malaria control. In 2012, malaria
surveillance systems detected only around 14% of the estimated global number
of cases. Stronger malaria surveillance systems are urgently needed to enable a
timely and effective malaria response in endemic regions, to prevent outbreaks
and resurgences, to track progress, and to hold governments and the global
malaria community accountable.
Elimination

Malaria elimination is defined as interrupting local mosquito-borne malaria


transmission in a defined geographical area, i.e. zero incidence of locally
contracted cases. Malaria eradication is defined as the permanent reduction to
zero of the worldwide incidence of malaria infection caused by a specific agent;
i.e. applies to a particular malaria parasite species.
On the basis of reported cases for 2013, 55 countries are on track to reduce their
malaria case incidence rates by 75%, in line with World Health Assembly targets
for 2015. Large-scale use of WHO-recommended strategies, currently available
tools, strong national commitments, and coordinated efforts with partners, will
enable more countries particularly those where malaria transmission is low and
unstable to reduce their disease burden and progress towards elimination.
In recent years, 4 countries have been certified by the WHO Director-General as
having eliminated malaria: United Arab Emirates (2007), Morocco (2010),
Turkmenistan (2010), and Armenia (2011).
Vaccines against malaria
There are currently no licensed vaccines against malaria or any other human
parasite. One research vaccine against P. falciparum, known as RTS, S/AS01, is
most advanced. This vaccine has been evaluated in a large clinical trial in 7
countries in Africa and has been submitted to the European Medicines Agency
under art. 58 for regulatory review. A WHO recommendation for use will depend
on the final results from the large clinical trial and a positive regulatory review.
The recommendation as to whether or not this vaccine should be added to
existing malaria control tools is expected in late 2015.
WHO response
The WHO Global Malaria Programme (GMP) is responsible for charting the course
for malaria control and elimination through:
setting, communicating and promoting the adoption of evidence-based
norms, standards, policies, technical strategies, and guidelines;
keeping independent score of global progress;
developing approaches for capacity building, systems strengthening, and
surveillance;
identifying threats to malaria control and elimination as well as new areas
for action.
GMP serves as the secretariat for the Malaria Policy Advisory Committee
(MPAC), a group of 15 global malaria experts appointed following an open
nomination process. The MPAC, which meets twice yearly, provides
independent advice to WHO to develop policy recommendations for the
control and elimination of malaria. The mandate of MPAC is to provide
strategic advice and technical input, and extends to all aspects of malaria
control and elimination, as part of a transparent, responsive and credible
policy setting process.
WHO is also a co-founder and host of the Roll Back Malaria partnership, which is
the global framework to implement coordinated action against malaria. The
partnership mobilizes for action and resources and forges consensus among

partners. It is comprised of over 500 partners, including malaria endemic


countries, development partners, the private sector, nongovernmental and
community-based organizations, foundations, and research and academic
institutions.

Measles
Fact sheet N286
Reviewed February 2015

Key facts

Measles is one of the leading causes of death among young children even
though a safe and cost-effective vaccine is available.
In 2013, there were 145 700 measles deaths globally about 400 deaths
every day or 16 deaths every hour.
Measles vaccination resulted in a 75% drop in measles deaths between
2000 and 2013 worldwide.
In 2013, about 84% of the world's children received one dose of measles
vaccine by their first birthday through routine health services up from
73% in 2000.
During 2000-2013, measles vaccination prevented an estimated 15.6
million deaths making measles vaccine one of the best buys in public
health.

Measles is a highly contagious, serious disease caused by a virus. In 1980, before


widespread vaccination, measles caused an estimated 2.6 million deaths each
year.
The disease remains one of the leading causes of death among young children
globally, despite the availability of a safe and effective vaccine. Approximately
145 700 people died from measles in 2013 mostly children under the age of 5.
Measles is caused by a virus in the paramyxovirus family and it is normally
passed through direct contact and through the air. The virus infects the mucous
membranes, then spreads throughout the body. Measles is a human disease and
is not known to occur in animals.
Accelerated immunization activities have had a major impact on reducing
measles deaths. During 2000-2013, measles vaccination prevented an estimated
15.6 million deaths. Global measles deaths have decreased by 75% from an
estimated 544 200 in 2000 to 145 700 in 2013.
Signs and symptoms
The first sign of measles is usually a high fever, which begins about 10 to 12 days
after exposure to the virus, and lasts 4 to 7 days. A runny nose, a cough, red and
watery eyes, and small white spots inside the cheeks can develop in the initial
stage. After several days, a rash erupts, usually on the face and upper neck. Over
about 3 days, the rash spreads, eventually reaching the hands and feet. The rash
lasts for 5 to 6 days, and then fades. On average, the rash occurs 14 days after
exposure to the virus (within a range of 7 to 18 days).
Most measles-related deaths are caused by complications associated with the
disease. Complications are more common in children under the age of 5, or
adults over the age of 20. The most serious complications include blindness,
encephalitis (an infection that causes brain swelling), severe diarrhoea and
related dehydration, ear infections, or severe respiratory infections such as
pneumonia. Severe measles is more likely among poorly nourished young

children, especially those with insufficient vitamin A, or whose immune systems


have been weakened by HIV/AIDS or other diseases.
In populations with high levels of malnutrition and a lack of adequate health care,
up to 10% of measles cases result in death. Women infected while pregnant are
also at risk of severe complications and the pregnancy may end in miscarriage or
preterm delivery. People who recover from measles are immune for the rest of
their lives.
Who is at risk?
Unvaccinated young children are at highest risk of measles and its complications,
including death. Unvaccinated pregnant women are also at risk. Any non-immune
person (who has not been vaccinated or was vaccinated but did not develop
immunity) can become infected.
Measles is still common in many developing countries particularly in parts of
Africa and Asia. The overwhelming majority (more than 95%) of measles deaths
occur in countries with low per capita incomes and weak health infrastructures.
Measles outbreaks can be particularly deadly in countries experiencing or
recovering from a natural disaster or conflict. Damage to health infrastructure
and health services interrupts routine immunization, and overcrowding in
residential camps greatly increases the risk of infection.
Transmission
The highly contagious virus is spread by coughing and sneezing, close personal
contact or direct contact with infected nasal or throat secretions.
The virus remains active and contagious in the air or on infected surfaces for up
to 2 hours. It can be transmitted by an infected person from 4 days prior to the
onset of the rash to 4 days after the rash erupts.
Measles outbreaks can result in epidemics that cause many deaths, especially
among young, malnourished children. In countries where measles has been
largely eliminated, cases imported from other countries remain an important
source of infection.
Treatment
No specific antiviral treatment exists for measles virus.
Severe complications from measles can be avoided through supportive care that
ensures good nutrition, adequate fluid intake and treatment of dehydration with
WHO-recommended oral rehydration solution. This solution replaces fluids and
other essential elements that are lost through diarrhoea or vomiting. Antibiotics
should be prescribed to treat eye and ear infections, and pneumonia.
All children in developing countries diagnosed with measles should receive two
doses of vitamin A supplements, given 24 hours apart. This treatment restores
low vitamin A levels during measles that occur even in well-nourished children
and can help prevent eye damage and blindness. Vitamin A supplements have
been shown to reduce the number of deaths from measles by 50%.
Prevention

Routine measles vaccination for children, combined with mass immunization


campaigns in countries with high case and death rates, are key public health
strategies to reduce global measles deaths. The measles vaccine has been in use
for 50 years. It is safe, effective and inexpensive. It costs approximately one US
dollar to immunize a child against measles.
The measles vaccine is often incorporated with rubella and/or mumps vaccines in
countries where these illnesses are problems. It is equally effective in the single
or combined form. Adding rubella to measles vaccine increases the cost only
slightly, and allows for shared delivery and administration costs.
In 2013, about 84% of the world's children received 1 dose of measles vaccine by
their first birthday through routine health services up from 73% in 2000. Two
doses of the vaccine are recommended to ensure immunity and prevent
outbreaks, as about 15% of vaccinated children fail to develop immunity from the
first dose.
WHO response
The fourth Millennium Development Goal (MDG 4) aims to reduce the under-five
mortality rate by two-thirds between 1990 and 2015. Recognizing the potential of
measles vaccination to reduce child mortality, and given that measles
vaccination coverage can be considered a marker of access to child health
services, routine measles vaccination coverage has been selected as an indicator
of progress towards achieving MDG 4.Overwhelming evidence demonstrates the
benefit of providing universal access to measles and rubella-containing vaccines.
By 2013, the global push to improve vaccine coverage resulted in a 75%
reduction in deaths. During 2000-2013, with support from the Measles & Rubella
Initiative (M&R Initiative), measles vaccination prevented an estimated 15.6
million. During 2013, about 205 million children were vaccinated against measles
during mass vaccination campaigns in 34 countries. All WHO Regions have now
established goals to eliminate this preventable killer disease by 2020.
The M&R Initiative is a collaborative effort of WHO, UNICEF, the American Red
Cross, the United States Centers for Disease Control and Prevention, and the
United Nations Foundation to support countries to achieve measles and rubella
control goals.

M&R Initiative
In 2012, the MR Initiative launched a new Global Measles and Rubella
Strategic Plan which covers the period 2012-2020. The Plan includes new
global goals for 2015 and 2020:
By the end of 2015

To reduce global measles deaths by at least 95% compared with 2000


levels.
To achieve regional measles and rubella/congenital rubella syndrome (CRS)
elimination goals.
By the end of 2020

To achieve measles and rubella elimination in at least 5 WHO regions.


The strategy focuses on the implementation of 5 core components:

achieve and maintain high vaccination coverage with 2 doses of measlesand rubella-containing vaccines;
monitor the disease using effective surveillance, and evaluate
programmatic efforts to ensure progress and the positive impact of
vaccination activities;
develop and maintain outbreak preparedness, rapid response to outbreaks
and the effective treatment of cases;
communicate and engage to build public confidence and demand for
immunization;
perform the research and development needed to support cost-effective
action and improve vaccination and diagnostic tools.
Implementation of the Strategic Plan can protect and improve the lives of
children and their mothers throughout the world, rapidly and sustainably.
The Plan provides clear strategies for country immunization managers,
working with domestic and international partners, to achieve the 2015 and
2020 measles and rubella control and elimination goals. It builds on years
of experience in implementing immunization programmes and
incorporates lessons from accelerated measles control and polio
eradication initiatives.
Based on current trends and performance, global immunization experts
concluded that the 2015 measles milestones and elimination goals will not be
achieved on time. Resuming progress will require countries and immunization
partners to raise the visibility of measles elimination, address barriers to measles
vaccination, and make substantial and sustained additional investments to
strengthen health systems and achieve equitable access to immunization
services.

Middle East respiratory syndrome coronavirus (MERS-CoV)


Fact sheet N401
June 2015

Key facts
Middle East respiratory syndrome (MERS) is a viral respiratory disease caused
by a novel coronavirus (MERSCoV) that was first identified in Saudi Arabia in
2012.
Coronaviruses are a large family of viruses that can cause diseases ranging
from the common cold to Severe Acute Respiratory Syndrome (SARS).
Typical MERS symptoms include fever, cough and shortness of breath.
Pneumonia is common, but not always present. Gastrointestinal symptoms,
including diarrhoea, have also been reported.
Approximately 36% of reported patients with MERS have died.
Although the majority of human cases of MERS have been attributed to
human-to-human infections, camels are likely to be a major reservoir host for
MERS-CoV and an animal source of MERS infection in humans. However, the
exact role of camels in transmission of the virus and the exact route(s) of
transmission are unknown.
The virus does not seem to pass easily from person to person unless there is
close contact, such as occurs when providing unprotected care to a patient.

Symptoms

The clinical spectrum of MERS-CoV infection ranges from no symptoms


(asymptomatic) or mild respiratory symptoms to severe acute respiratory disease
and death. A typical presentation of MERS-CoV disease is fever, cough and
shortness of breath. Pneumonia is a common finding, but not always present.
Gastrointestinal symptoms, including diarrhoea, have also been reported. Severe
illness can cause respiratory failure that requires mechanical ventilation and
support in an intensive care unit. Approximately 36% of reported patients with
MERS-CoV have died. The virus appears to cause more severe disease in older
people, people with weakened immune systems, and those with chronic diseases
such as cancer, chronic lung disease and diabetes.
Source of the virus
MERS-CoV is a zoonotic virus that is transmitted from animals to humans. The
origins of the virus are not fully understood but, according to the analysis of
different virus genomes, it is believed that it originated in bats and was
transmitted to camels sometime in the distant past.
Transmission
Non-human to human transmission: The route of transmission from animals to
humans is not fully understood, but camels are likely to be a major reservoir host
for MERS-CoV and an animal source of infection in humans. Strains of MERS-CoV
that are identical to human strains have been isolated from camels in several
countries, including Egypt, Oman, Qatar, and Saudi Arabia.
Human-to-human transmission: The virus does not appear to pass easily from
person to person unless there is close contact, such as providing unprotected
care to an infected patient. There have been clusters of cases in healthcare
facilities, where human-to-human transmission appears to be more probable,
especially when infection prevention and control practices are inadequate. Thus
far, no sustained community transmission has been documented.
The virus appears to be circulating throughout the Arabian Peninsula, primarily in
Saudi Arabia, where the majority of cases (>85%) have been reported since
2012. Several cases have been reported outside the Middle East. Most of these
infections are believed to have been acquired in the Middle East, and then
exported outside the region. The ongoing outbreak in the Republic of Korea is the
largest outbreak outside of the Middle East, and while concerning, there is no
evidence of sustained human to human transmission in the Republic of Korea. For
all other exported cases, no secondary or limited secondary transmission has
been reported in countries with exported cases.
Prevention and treatment
No vaccine or specific treatment is currently available. Treatment is supportive
and based on the patients clinical condition.
As a general precaution, anyone visiting farms, markets, barns, or other places
where camels and other animals are present should practice general hygiene
measures, including regular hand washing before and after touching animals, and
should avoid contact with sick animals.

The consumption of raw or undercooked animal products, including milk and


meat, carries a high risk of infection from a variety of organisms that might cause
disease in humans. Animal products that are processed appropriately through
cooking or pasteurization are safe for consumption, but should also be handled
with care to avoid cross contamination with uncooked foods. Camel meat and
camel milk are nutritious products that can continue to be consumed after
pasteurization, cooking, or other heat treatments.
Until more is understood about MERS-CoV, people with diabetes, renal failure,
chronic lung disease, and immunocompromised persons are considered to be at
high risk of severe disease from MERS-CoV infection. These people should avoid
contact with camels, drinking raw camel milk or camel urine, or eating meat that
has not been properly cooked.
Health-care facilities
Transmission of the virus has occurred in healthcare facilities in several
countries, including from patients to healthcare providers and between patients
in a health care setting before MERS-CoV was diagnosed. It is not always possible
to identify patients with MERSCoV early or without testing because symptoms
and other clinical features may be nonspecific.
Infection prevention and control measures are critical to prevent the possible
spread of MERSCoV in healthcare facilities. Facilities that provide care for
patients suspected or confirmed to be infected with MERSCoV should take
appropriate measures to decrease the risk of transmission of the virus from an
infected patient to other patients, healthcare workers, or visitors. Healthcare
workers should be educated and trained in infection prevention and control and
should refresh these skills regularly.
Travel
WHO does not recommend the application of any travel or trade restrictions or
entry screening related to MERS-CoV.
WHO response
WHO is working with clinicians and scientists in affected countries and
internationally to gather and share scientific evidence to better understand the
virus and the disease it causes, and to determine outbreak response priorities,
treatment strategies, and clinical management approaches. The Organization is
also working with countries to develop public health prevention strategies to
combat the virus.
Together with affected countries and international technical partners and
networks, WHO is coordinating the global health response to MERS, including: the
provision of updated information on the situation; conducting risk assessments
and joint investigations with national authorities; convening scientific meetings;
and developing guidance and training for health authorities and technical health
agencies on interim surveillance recommendations, laboratory testing of cases,
infection prevention and control, and clinical management.

The DirectorGeneral has convened an Emergency Committee under the


International Health Regulations (2005) to advise her as to whether this event
constitutes a Public Health Emergency of International Concern (PHEIC) and on
the public health measures that should be taken. The Committee has met a
number of times since the disease was first identified. WHO encourages all
Member States to enhance their surveillance for severe acute respiratory
infections (SARI) and to carefully review any unusual patterns of SARI or
pneumonia cases.
Countries, whether or not MERS cases have been reported in them, should
maintain a high level of vigilance, especially those with large numbers of
travellers or migrant workers returning from the Middle East. Surveillance should
continue to be enhanced in these countries according to WHO guidelines, along
with infection prevention and control procedures in health-care facilities. WHO
continues to request that Member States report to WHO all confirmed and
probable cases of infection with MERS-CoV together with information about their
exposure, testing, and clinical course to inform the most effective international
preparedness and response.

Pneumonia
Fact sheet N331
Updated November 2014

Key facts

Pneumonia is the leading infectious cause of death in children worldwide,


accounting for 15% of all deaths of children under 5 years old.
Pneumonia killed an estimated 935 000 children under the age of five in
2013.
Pneumonia can be caused by viruses, bacteria or fungi.
Pneumonia can be prevented by immunization, adequate nutrition and by
addressing environmental factors.
Pneumonia caused by bacteria can be treated with antibiotics, but only
one third of children with pneumonia receive the antibiotics they need.

Pneumonia is a form of acute respiratory infection that affects the lungs. The
lungs are made up of small sacs called alveoli, which fill with air when a healthy
person breathes. When an individual has pneumonia, the alveoli are filled with
pus and fluid, which makes breathing painful and limits oxygen intake.
Pneumonia is the single largest infectious cause of death in children worldwide.
Pneumonia killed an estimated 935 000 children under the age of five in 2013,
accounting for 15% of all deaths of children under five years old. Pneumonia
affects children and families everywhere, but is most prevalent in South Asia and
sub-Saharan Africa. Children can be protected from pneumonia, it can be
prevented with simple interventions, and treated with low-cost, low-tech
medication and care.
Causes
Pneumonia is caused by a number of infectious agents, including viruses,
bacteria and fungi. The most common are:
Streptococcus pneumoniae the most common cause of bacterial pneumonia
in children;
Haemophilus influenzae type b (Hib) the second most common cause of
bacterial pneumonia;
respiratory syncytial virus is the most common viral cause of pneumonia;
in infants infected with HIV, Pneumocystis jiroveci is one of the commonest
causes of pneumonia, responsible for at least one quarter of all pneumonia
deaths in HIV-infected infants.
Transmission
Pneumonia can be spread in a number of ways. The viruses and bacteria that are
commonly found in a child's nose or throat, can infect the lungs if they are
inhaled. They may also spread via air-borne droplets from a cough or sneeze. In
addition, pneumonia may spread through blood, especially during and shortly
after birth. More research needs to be done on the different pathogens causing
pneumonia and the ways they are transmitted, as this is of critical importance for
treatment and prevention.
Presenting features

The presenting features of viral and bacterial pneumonia are similar. However,
the symptoms of viral pneumonia may be more numerous than the symptoms of
bacterial pneumonia. In children under 5 years of age, who have cough and/or
difficult breathing, with or without fever, pneumonia is diagnosed by the
presence of either fast breathing or lower chest wall indrawing where their chest
moves in or retracts during inhalation (in a healthy person, the chest expands
during inhalation). Wheezing is more common in viral infections.
Very severely ill infants may be unable to feed or drink and may also experience
unconsciousness, hypothermia and convulsions.
Risk factors
While most healthy children can fight the infection with their natural defences,
children whose immune systems are compromised are at higher risk of
developing pneumonia. A child's immune system may be weakened by
malnutrition or undernourishment, especially in infants who are not exclusively
breastfed.
Pre-existing illnesses, such as symptomatic HIV infections and measles, also
increase a child's risk of contracting pneumonia.
The following environmental factors also increase a child's susceptibility to
pneumonia:
indoor air pollution caused by cooking and heating with biomass fuels
(such as wood or dung)
living in crowded homes
parental smoking.

Treatment
Pneumonia should be treated with antibiotics. The antibiotic of choice is
amoxicillin dispersable tablets. Most cases of pneumonia require oral antibiotics,
which are often prescribed at a health centre. These cases can also be diagnosed
and treated with inexpensive oral antibiotics at the community level by trained
community health workers. Hospitalization is recommended only for severe cases
of pneumonia, and for all cases of pneumonia in infants younger than 2 months
of age.
Prevention
Preventing pneumonia in children is an essential component of a strategy to
reduce child mortality. Immunization against Hib, pneumococcus, measles and
whooping cough (pertussis) is the most effective way to prevent pneumonia.
Adequate nutrition is key to improving children's natural defences, starting with
exclusive breastfeeding for the first 6 months of life. In addition to being effective
in preventing pneumonia, it also helps to reduce the length of the illness if a child
does become ill.
Addressing environmental factors such as indoor air pollution (by providing
affordable clean indoor stoves, for example) and encouraging good hygiene in
crowded homes also reduces the number of children who fall ill with pneumonia.

In children infected with HIV, the antibiotic cotrimoxazole is given daily to


decrease the risk of contracting pneumonia.
Economic costs
The cost of antibiotic treatment for all children with pneumonia in 66 of the
countdown to 2015 countries for maternal, newborn and child survival is
estimated at around US$ 109 million per year. The price includes the antibiotics
and diagnostics for pneumonia management.

WHO response
The WHO and UNICEF integrated Global action plan for pneumonia and diarrhoea
(GAPPD) aims to accelerate pneumonia control with a combination of
interventions to protect, prevent, and treat pneumonia in children with actions to:
protect children from pneumonia including promoting exclusive
breastfeeding and adequate complementary feeding;
prevent pneumonia with vaccinations, hand washing with soap, reducing
household air pollution, HIV prevention and cotrimoxazole prophylaxis for
HIV-infected and exposed children;
treat pneumonia focusing on making sure that every sick child has access
to the right kind of care -- either from a community-based health worker,
or in a health facility if the disease is severe -- and can get the antibiotics
and oxygen they need to get well;
A number of countries including Bangladesh, India, Uganda and Zambia
have developed district, state and national plans to intensify actions for
the control of pneumonia and diarrhoea.

Rabies
Fact Sheet N99
Updated September 2015

Key facts

Rabies is a vaccine-preventable viral disease which occurs in more than


150 countries and territories.
Dogs are the source of the vast majority of human rabies deaths.
Rabies elimination is feasible by vaccinating dogs.
Infection causes tens of thousands of deaths every year, mostly in Asia
and Africa.
40% of people who are bitten by suspect rabid animals are children under
15 years of age.
Immediate wound cleansing with soap and water after contact with a
suspect rabid animal can be life-saving.
Every year, more than 15 million people worldwide receive a post-bite
vaccination to prevent the disease; this is estimated to prevent hundreds
of thousands of rabies deaths annually.

Rabies is an infectious viral disease that is almost always fatal following the onset
of clinical signs. In more than 99% of human cases, the rabies virus is
transmitted by domestic dogs. Rabies affects domestic and wild animals, and is
spread to people through bites or scratches, usually via saliva.
Rabies is present on all continents with the exception of Antarctica, but more
than 95% of human deaths occur in Asia and Africa.
Rabies is a neglected disease of poor and vulnerable populations whose deaths
are rarely reported and where human vaccines and immunoglobulin are not
readily available or accessible. It occurs mainly in remote rural communities
where children between the age of 514 years are the most frequent victims.
The average cost of rabies post-exposure prophylaxis (PEP) can be the cost of
catastrophic expenses for poor populations, since a course of PEP can cost US$

40 in Africa and US$ 49 in Asia, where the average daily income is about US$ 12
per person.
Prevention
Eliminating rabies in dogs
Rabies is a vaccine-preventable disease. Vaccinating dogs is the most costeffective strategy for preventing rabies in people. Dog vaccination will drive down
not only the deaths attributable to rabies but also the need for PEP as a part of
dogbite patient care.
Preventive immunization in people
The same safe and effective vaccines can be used for pre-exposure
immunization. This is recommended for travellers spending a lot of time
outdoors, especially in rural areas, involved in activities such as bicycling,
camping, or hiking as well as for long-term travellers and expatriates living in
areas with a significant risk of exposure.
Pre-exposure immunization is also recommended for people in certain high-risk
occupations such as laboratory workers dealing with live rabies virus and other
rabies-related viruses (lyssaviruses), and people involved in any activities that
might bring them professionally or otherwise into direct contact with bats,
carnivores, and other mammals in rabies-affected areas. As children are
considered at higher risk because they tend to play with animals, may receive
more severe bites, or may not report bites, their immunization could be
considered if living in or visiting high-risk areas.
Symptoms
The incubation period for rabies is typically 13 months, but may vary from <1
week to >1 year. The initial symptoms of rabies are fever and often pain or an
unusual or unexplained tingling, pricking or burning sensation (paraesthesia) at
the wound site. As the virus spreads through the central nervous system,
progressive, fatal inflammation of the brain and spinal cord develops.
Two forms of the disease can follow. People with furious rabies exhibit signs of
hyperactivity, excited behaviour, hydrophobia and sometimes aerophobia. After a
few days, death occurs by cardiorespiratory arrest.
Paralytic rabies accounts for about 30% of the total number of human cases. This
form of rabies runs a less dramatic and usually longer course than the furious
form. The muscles gradually become paralyzed, starting at the site of the bite or
scratch. A coma slowly develops, and eventually death occurs. The paralytic form
of rabies is often misdiagnosed, contributing to the under-reporting of the
disease.
Diagnosis
No tests are available to diagnose rabies infection in humans before the onset of
clinical disease, and unless the rabies-specific signs of hydrophobia or aerophobia
are present, the clinical diagnosis may be difficult. Human rabies can be
confirmedintra-vitam and post mortem by various diagnostic techniques aimed at

detecting whole virus, viral antigens or nucleic acids in infected tissues (brain,
skin, urine or saliva).
Transmission
People are usually infected following a deep bite or scratch by an infected animal.
Dogs are the main host and transmitter of rabies. They are the cause of human
rabies deaths in Asia and Africa.
Bats are the source of most human rabies deaths in the Americas. Bat rabies has
also recently emerged as a public health threat in Australia and western Europe.
Human deaths following exposure to foxes, raccoons, skunks, jackals, mongooses
and other wild carnivore host species are very rare.
Transmission can also occur when infectious material usually saliva comes
into direct contact with human mucosa or fresh skin wounds. Human-to-human
transmission by bite is theoretically possible but has never been confirmed.
Rarely, rabies may be contracted by inhalation of virus-containing aerosol or via
transplantation of an infected organ. Ingestion of raw meat or other tissues from
animals infected with rabies is not a source of human infection.
Post-exposure prophylaxis (PEP)
Post-exposure prophylaxis (PEP) means the treatment of a bite victim that is
started immediately after exposure to rabies in order to prevent rabies infection.
This consists of:
local treatment of the wound, initiated as soon as possible after exposure;
a course of potent and effective rabies vaccine that meets WHO standards;
and
the administration of rabies immunoglobulin, if indicated.
Effective treatment soon after exposure to rabies can prevent the onset of
symptoms and death.

Local treatment of the wound


This involves first-aid of the wound that includes immediate and thorough
flushing and washing of the wound for a minimum of 15 minutes with soap and
water, detergent, povidone iodine or other substances that kill the rabies virus.
Recommended PEP
Depending on the severity of the contact administering with the suspected rabid
animal, administration of PEP is recommended as follows (see table):
Table: Categories of contact and recommended postexposure prophylaxis (PEP)

Categories of contact with


suspect rabid animal

Post-exposure
prophylaxis measures

Table: Categories of contact and recommended postexposure prophylaxis (PEP)


Category I touching or feeding
animals, licks on intact skin

None

Category II nibbling of
uncovered skin, minor scratches
or abrasions without bleeding

Immediate vaccination
and local treatment of the
wound

Category III single or multiple


transdermal bites or scratches,
licks on broken skin;
contamination of mucous
membrane with saliva from licks,
contacts with bats.

Immediate vaccination
and administration of
rabies immunoglobulin;
local treatment of the
wound

All category II and III exposures assessed as carrying a risk of developing rabies
require PEP. This risk is increased if:
the biting mammal is a known rabies reservoir or vector species;
the animal looks sick or displays an abnormal behaviour;
a wound or mucous membrane was contaminated by the animals saliva;
the bite was unprovoked; and
the animal has not been vaccinated.
In developing countries, the vaccination status of the suspected animal
alone should not be considered when deciding whether to initiate
prophylaxis or not.

The Organization continues to promote human rabies prevention through the


elimination of rabies in dogs as well as a wider use of the intradermal route for
PEP which reduces volume and thereby the cost of cell-cultured vaccine by 60%
to 80%.
WHO response
WHO, in close collaboration with the Food and Agriculture Organization of the
United Nations (FAO), the World Organisation for Animal Health (OIE) and the
Global Alliance for Rabies Control, is raising awareness of and commitment to
overcoming this persistent zoonosis in endemic countries.
Great strides have been made in the Philippines, South Africa and Tanzania where
a project is underway as part of a Bill & Melinda Gates Foundation project led by
WHO. The key towards sustaining and expanding the rabies programmes to new
territories and countries has been to start small, demonstrate success and costeffectiveness, and ensure community engagement.
Stockpiles of dog and human rabies vaccine have had a catalytic effect on rabies
elimination efforts in countries.
Rabies transmitted by dogs has been eliminated in many Latin American
countries, including Chile, Costa Rica, Panama, Uruguay, most of Argentina, the
states of So Paulo and Rio de Janeiro in Brazil, and large parts of Mexico and
Peru.

Many countries in the WHO South-East Asia Region have embarked on


elimination campaigns in line with the target of regional elimination by 2020.
Bangladesh launched an elimination programme in 2010 and, through the
management of dog bites, mass dog vaccination and increased availability of
vaccines free of charge, human rabies deaths decreased by 50% during 2010
2014.

Schistosomiasis
Fact sheet N115
Updated May 2015

Key facts

Schistosomiasis is an acute and chronic disease caused by parasitic


worms.
People are infected during routine agricultural, domestic, occupational and
recreational activities which expose them to infested water.
Lack of hygiene and certain play habits of school-aged children such as
swimming or fishing in infested water make them especially vulnerable to
infection.
Schistosomiasis control focuses on reducing disease through periodic,
large-scale population treatment with praziquantel; a more comprehensive
approach including potable water, adequate sanitation and snail control
would also reduce transmission.
At least 261 million people required preventive treatment for
schistosomiasis in 2013.
More than 40 million people were treated for schistosomiasis in 2013.

Schistosomiasis is an acute and chronic parasitic disease caused by blood flukes


(trematode worms) of the genus Schistosoma. At least 261 million people
required preventive treatment in 2013. Preventive treatment, which should be
repeated over a number of years, will reduce and prevent morbidity.
Schistosomiasis transmission has been reported from 78 countries. However,
preventive chemotherapy for schistosomiasis, where people and communities are
targeted for large scale treatment, is only required in 52 endemic countries with
moderate to high transmission.
Transmission
Transmission occurs when people suffering from schistosomiasis contaminate
freshwater sources with their excreta containing parasite eggs which hatch in
water.
People become infected when larval forms of the parasite released by
freshwater snails penetrate the skin during contact with infested water.
In the body, the larvae develop into adult schistosomes. Adult worms live in the
blood vessels where the females release eggs. Some of the eggs are passed out
of the body in the faeces or urine to continue the parasites life-cycle. Others
become trapped in body tissues, causing immune reactions and progressive
damage to organs.
Epidemiology
Schistosomiais is prevalent in tropical and sub-tropical areas, especially in poor
communities without access to safe drinking water and adequate sanitation. It is
estimated that at least 90% of those requiring treatment for schistosomiasis live
in Africa.
There are two major forms of schistosomiasis intestinal and urogenital caused
by five main species of blood fluke (see table).

Table: Parasite species and geographical distribution of schistosomiasis

Species

Geographical
distribution

Africa, the Middle East, the


Intestinal
Caribbean, Brazil,
schistosomiasis Schistosoma mansoni Venezuela and Suriname
Schistosoma
japonicum

China, Indonesia, the


Philippines

Schistosoma
mekongi

Several districts of
Cambodia and the Lao
Peoples Democratic
Republic

Schistosoma
guineensisand
related S.
intercalatum

Rain forest areas of central


Africa

Urogenital
Schistosoma
schistosomiasis haematobium

Africa, the Middle East,


Corsica (France)

Table: Parasite species and geographical distribution of schistosomiasis


Schistosomiasis mostly affects poor and rural communities, particularly
agricultural and fishing populations. Women doing domestic chores in infested
water, such as washing clothes, are also at risk. Inadequate hygiene and contact
with infected water make children especially vulnerable to infection.
Migration to urban areas and population movements are introducing the disease
to new areas. Increasing population size and the corresponding needs for power
and water often result in development schemes, and environmental modifications
facilitate transmission.
With the rise in eco-tourism and travel off the beaten track, increasing numbers
of tourists are contracting schistosomiasis. At times, tourists present with severe
acute infection and unusual problems including paralysis.
Urogenital schistosomiasis is also considered to be a risk factor for HIV infection,
especially in women.
Symptoms
Symptoms of schistosomiasis are caused by the bodys reaction to the worms
eggs.
Intestinal schistosomiasis can result in abdominal pain, diarrhoea and blood in
the stool. Liver enlargement is common in advanced cases, and is frequently
associated with an accumulation of fluid in the peritoneal cavity and

hypertension of the abdominal blood vessels. In such cases there may also be
enlargement of the spleen.
The classic sign of urogenital schistosomiasis is haematuria (blood in urine).
Fibrosis of the bladder and ureter, and kidney damage are sometimes diagnosed
in advanced cases. Bladder cancer is another possible complication in the later
stages. In women, urogenital schistosomiasis may present with genital lesions,
vaginal bleeding, pain during sexual intercourse and nodules in the vulva. In
men, urogenital schistosomiasis can induce pathology of the seminal vesicles,
prostate and other organs. This disease may also have other long-term
irreversible consequences, including infertility.
The economic and health effects of schistosomiasis are considerable and the
disease disables more than it kills. In children, schistosomiasis can cause
anaemia, stunting and a reduced ability to learn, although the effects are usually
reversible with treatment. Chronic schistosomiasis may affect peoples ability to
work and in some cases can result in death. 1 The number deaths due to
schistosomiasis is difficult to estimate because of hidden pathologies such as
liver and kidney failure and bladder cancer. Estimates therefore vary widely
between 20 000 and 200 0002deaths per year.
Diagnosis
Schistosomiasis is diagnosed through the detection of parasite eggs in stool or
urine specimens. Antibodies and/or antigens detected in blood or urine samples
are also indications of infection.
For urogenital schistosomiasis, a filtration technique using nylon, paper or
polycarbonate filters is the standard diagnostic technique. Children with S.
haematobium almost always have microscopic blood in their urine and this can
be detected by chemical reagent strips.
The eggs of intestinal schistosomiasis can be detected in faecal specimens
through a technique using methylene blue-stained cellophane soaked in
glycerine or glass slides, known as the Kato-Katz technique.
For people living in non-endemic or low-transmission areas, serological and
immunological tests may be useful in showing exposure to infection and the need
for thorough examination, treatment and follow-up.
Prevention and control
The control of schistosomiasis is based on large-scale treatment of at-risk
population groups, access to safe water, improved sanitation, hygiene education
and snail control.
The WHO strategy for schistosomiasis control focuses on reducing disease
through periodic, targeted treatment with praziquantel. This involves regular
treatment of all people of at-risk groups. In a few countries, where there is low
transmission, the elimination of the disease should be aimed for.
Groups targeted for treatment are:
school-aged children in endemic areas,
adults considered to be at risk in endemic areas, and people with
occupations involving contact with infested water, such as fishermen,

farmers, irrigation workers, and women whose domestic tasks bring them
in contact with infested water,
entire communities living in highly endemic areas.

The frequency of treatment is determined by the prevalence of infection in


school-age children. In high-transmission areas, treatment may have to be
repeated every year for a number of years. Monitoring is essential to determine
the impact of control interventions.
The aim is to reduce disease: periodic treatment of at-risk populations will cure
mild symptoms and prevent infected people from developing severe, late-stage
chronic disease. However, a major limitation to schistosomiasis control has been
the limited availability of praziquantel. Data for 2013 show that 13.1% of people
requiring treatment were reached.
Praziquantel is the recommended treatment against all forms of schistosomiasis.
It is effective, safe and low-cost. Even though re-infection may occur after
treatment, the risk of developing severe disease is diminished and even reversed
when treatment is initiated and repeated in childhood.
Schistosomiasis control has been successfully implemented over the past 40
years in several countries, including Brazil, Cambodia, China, Egypt, Mauritius
and Saudi Arabia. There is evidence that schistosomiasis transmission was
interrupted in Morocco. In Burkina Faso, Niger, Sierra Leone and Yemen, it has
been possible to scale up schistosomiasis treatment to the national level and
have an impact on the disease in a few years. An assessment of the status of
transmission is being made in several countries.
Over the past 10 years, there has been scale-up of treatment campaigns in a
number of sub-Saharan countries, where most of those at risk live.
WHO response
WHOs work on schistosomiasis is part of an integrated approach to the control of
neglected tropical diseases. Although medically diverse, neglected tropical
diseases share features that allow them to persist in conditions of poverty, where
they cluster and frequently overlap.
WHO coordinates the strategy of preventive chemotherapy in consultation with
collaborating centres and partners from academic and research institutions, the
private sector, nongovernmental organizations, international development
agencies and other United Nations organizations. WHO develops technical
guidelines and tools for use by national control programmes.
Working with partners and the private sector, WHO has advocated for increased
access to praziquantel and resources for implementation. A significant amount of
praziquantel, to treat more than 100 million children of the school age per year,
has been pledged by the private sector and development partners.

Sexually transmitted infections (STIs)


Fact sheet N110
Updated November 2013

Key facts

More than 1 million people acquire a sexually transmitted infection (STI)


every day.
Each year, an estimated 500 million people become ill with one of 4 STIs:
chlamydia, gonorrhoea, syphilis and trichomoniasis.
More than 530 million people have the virus that causes genital herpes
(HSV2).
More than 290 million women have a human papillomavirus (HPV)
infection.
The majority of STIs are present without symptoms.
Some STIs can increase the risk of HIV acquisition three-fold or more.

STIs can have serious consequences beyond the immediate impact of the
infection itself, through mother-to-child transmission of infections and
chronic diseases.
Drug resistance, especially for gonorrhoea, is a major threat to reducing
the impact of STIs worldwide.

What are sexually transmitted infections and how are they transmitted?
STIs are caused by more than 30 different bacteria, viruses and parasites and are
spread predominantly by sexual contact, including vaginal, anal and oral sex.
Some STIs may be spread via skin-to-skin sexual contact. The organisms causing
STIs can also be spread through non-sexual means such as blood products and
tissue transfer. Many STIsincluding chlamydia, gonorrhoea, hepatitis B, HIV,
HPV, HSV2 and syphiliscan also be transmitted from mother to child during
pregnancy and childbirth.
A person can have an STI without having obvious symptoms of disease.
Therefore, the term sexually transmitted infection is a broader term than
sexually transmitted disease (STD). Common symptoms of STDs include
vaginal discharge, urethral discharge in men, genital ulcers, and abdominal pain.
Eight of the more than 30 pathogens known to be transmitted through sexual
contact have been linked to the greatest incidence of illness. Of these 8
infections, 4 are currently curable: syphilis, gonorrhoea, chlamydia and
trichomoniasis. The other four are viral infections and are incurable, but can be
mitigated or modulated through treatment: hepatitis B, herpes, HIV, and HPV.
Scope of the problem
STIs have a profound impact on sexual and reproductive health worldwide, and
rank among the top 5 disease categories for which adults seek health care.
More than 1 million people acquire a sexually transmitted infection every day.
Each year, an estimated 500 million people acquire one of four sexually
transmitted infections: chlamydia, gonorrhoea, syphilis and trichomoniasis. More
than 530 million people are living with HSV2. More than 290 million women have
an HPV infection, one of the most common STIs.

Estimated new cases of curable sexually transmitted infections


(gonorrhoea, chlamydia, syphilis and trichomoniasis) by WHO region,
2008

STIs can have serious consequences beyond the immediate impact of the
infection itself.
Some STIs can increase the risk of HIV acquisition three-fold or more.
Mother-to-child transmission of STIs can result in stillbirth, neonatal death,
low-birth-weight and prematurity, sepsis, pneumonia, neonatal
conjunctivitis, and congenital deformities. Syphilis in pregnancy leads to
approximately 305 000 fetal and neonatal deaths every year and leaves
215 000 infants at increased risk of dying from prematurity, low-birthweight or congenital disease.
HPV infection causes 530 000 cases of cervical cancer and 275 000
cervical cancer deaths each year.
STIs such as gonorrhoea and chlamydia are major causes of pelvic
inflammatory disease, adverse pregnancy outcomes and infertility.
Prevention of STIs
Counselling and behavioural approaches
Counselling and behavioural interventions offer primary prevention against STIs
(including HIV), as well as against unintended pregnancies. These include:
comprehensive sexuality education, STI and HIV pre- and post-test
counselling;
safer sex/risk-reduction counselling, condom promotion; and
interventions targeted at key and vulnerable populations, such as
adolescents, sex workers, men who have sex with men and people who
inject drugs.

In addition, counselling can improve peoples ability to recognize the symptoms


of STIs and increase the likelihood they will seek care or encourage a sexual
partner to do so. Unfortunately, lack of public awareness, lack of training of
health workers, and long-standing, widespread stigma around STIs remain
barriers to greater and more effective use of these interventions.

Barrier methods
When used correctly and consistently, condoms offer one of the most effective
methods of protection against STIs, including HIV. Female condoms are effective
and safe, but are not used as widely by national programmes as male condoms.
Diagnosis of STIs
Accurate diagnostic tests for STIs are widely used in high-income countries.
These are especially useful for the diagnosis of asymptomatic infections.
However, in low- and middle-income countries, diagnostic tests are largely
unavailable. Where testing is available, it is often expensive and geographically
inaccessible; and patients often need to wait a long time (or need to return) to
receive results. As a result, follow up can be impeded and care or treatment can
be incomplete.
The only inexpensive, rapid blood test currently available for an STI is for syphilis.
This test is already in use in some resource-limited settings. The test is accurate,
can provide results in 15 to 20 minutes, and is easy to use with minimal training.
Rapid syphilis tests have been shown to increase the number of pregnant women
tested for syphilis. However, increased efforts are still needed in most low- and
middle-income countries to ensure that all pregnant women receive a syphilis
test.
Several rapid tests for other STIs are under development and have the potential
to improve STI diagnosis and treatment, especially in resource-limited settings.
Treatment of STIs
Effective treatment is currently available for several STIs.
Three bacterial STIs (chlamydia, gonorrhoea and syphilis) and one parasitic
STI (trichomoniasis) are generally curable with existing, effective singledose regimens of antibiotics.
For herpes and HIV, the most effective medications available are antivirals
that can modulate the course of the disease, though they cannot cure the
disease.
For hepatitis B, immune system modulators (interferon) and antiviral
medications can help to fight the virus and slow damage to the liver.

Resistance of STIsin particular gonorrhoeato antibiotics has increased rapidly


in recent years and has reduced treatment options. The emergence of decreased
susceptibility of gonorrhoea to the last line treatment option (oral and
injectable cephalosporins) together with antimicrobial resistance already shown
to penicillins, sulphonamides, tetracyclines, quinolones and macrolides make
gonorrhoea a multidrug-resistant organism. Antimicrobial resistance for other
STIs, though less common, also exists, making prevention and prompt treatment
critical.
STI case management
Low- and middle-income countries rely on syndromic management, which is
based on the identification of consistent groups of symptoms and easily

recognized signs (syndromes) to guide treatment, without the use of laboratory


tests. This approach, which often relies on clinical algorithms, allows health
workers to diagnose a specific infection on the basis of observed syndromes.
Syndromic management is simple, assures rapid, same-day treatment, and
avoids expensive or unavailable diagnostic tests. However, this approach misses
infections that do not demonstrate any syndromes - the majority of STIs globally.

Vaccines and other biomedical interventions


Safe and highly effective vaccines are available for 2 STIs: hepatitis B and human
papillomavirus (HPV). These vaccines have represented major advances in STI
prevention. The vaccine against hepatitis B is included in infant immunization
programmes in 93% of countries and has already prevented an estimated 1.3
million deaths from chronic liver disease and cancer.
HPV vaccine is available as part of routine immunization programmes in 45
countries, most of them high- and middle-income. HPV vaccination could prevent
the deaths of more than 4 million women over the next decade in low- and
middle-income countries, where most cases of cervical cancer occur, if 70%
vaccination coverage can be achieved.
Research to develop vaccines against herpes and HIV is advanced, though no
viable vaccine candidates for either infection have yet emerged. Research into
vaccines for chlamydia, gonorrhoea, syphilis and trichomoniasis is in earlier
stages of development.
Other biomedical interventions to prevent some STIs include adult male
circumcision and microbicides.
Male circumcision reduces the risk of heterosexually acquired HIV infection
in men by approximately 60% and provides some protection against other
STIs, such as herpes and HPV.
Tenofovir gel, a microbicide with the potential to allow women to actively
avert HIV acquisition, reached proof of concept stage in clinical trials in
2010. Further clinical research to support regulatory approval of its safety
and effectiveness is underway.

Current efforts to contain the spread of STIs are not sufficient


Behaviour change is complex
Despite considerable efforts to identify simple interventions that can reduce risky
sexual behaviour, behaviour change remains a complex challenge. Research has
demonstrated the need to focus on carefully defined populations, consult
extensively with the identified target populations, and involve them in design,
implementation and evaluation.
Health services for screening and treatment of STIs remain weak
People seeking screening and treatment for STIs face numerous problems. These
include limited resources, stigmatization, poor quality of services, and little or no
follow-up of sexual partners.

In many countries, STI services are provided separately and not available
in primary health care, family planning and other routine health services.
In many settings, services are often unable to provide screening for
asymptomatic infections, lacking trained personnel, laboratory capacity
and adequate supplies of appropriate medicines.
Marginalized populations with the highest rates of STIssuch as sex
workers, men who have sex with men, people who inject drugs, prison
inmates, mobile populations and adolescentsoften do not have access to
adequate health services.

WHO response
WHO develops global norms and standards for STI treatment and prevention,
strengthens systems for surveillance and monitoring, including those for drugresistant gonorrhoea, and leads the setting of the global research agenda on
STIs.
Our work is guided by Millennium Development Goals 4, 5 and 6, the global
strategy for the prevention and control of STIs adopted by the World Health
Assembly in 2006 and the 2010 United Nations Secretary-Generals Global
Strategy for Women's and Children's Health, which highlights the need for a
comprehensive, integrated package of essential interventions, including
information and services for the prevention of HIV and other sexually transmitted
infections.
WHO works with countries to:

Scale-up effective STI services including:


o STI case management and counseling
o syphilis testing and treatment, in particular for pregnant women
o hepatitis B and HPV vaccination.
Promote strategies to enhance STI-prevention impact including:
o integrate STI services into existing health systems
o promote sexual health
o measure the burden of STIs
o monitor and respond to STI antimicrobial resistance.
Support the development of new technologies for STI prevention such as:
o point-of care diagnostic tests for STIs
o additional drugs for gonorrhoea
o STI vaccines and other biomedical interventions.

Soil-transmitted helminth infections


Fact sheet N366
Updated May 2015

Key facts

Soil-transmitted helminth infections are caused by different species of


parasitic worms.
They are transmitted by eggs present in human faeces, which contaminate
the soil in areas where sanitation is poor.
Approximately 2 billion people are infected with soil-transmitted helminths
worldwide.
Infected children are physically, nutritionally and cognitively impaired.
Control is based on:
I.
periodical deworming to eliminate infecting worms
II.
health education to prevent re-infection
III.
improved sanitation to reduce soil contamination with infective
eggs.
Safe and effective medicines are available to control infection.

Soil-transmitted helminth infections are among the most common infections


worldwide and affect the poorest and most deprived communities. They are
transmitted by eggs present in human faeces which in turn contaminate soil in
areas where sanitation is poor. The main species that infect people are the

roundworm (Ascaris lumbricoides), the whipworm (Trichuris trichiura) and


hookworms (Necator americanus and Ancylostoma duodenale).
Global distribution and prevalence
More than 1.5 billion people, or 24% of the worlds population, are infected with
soil-transmitted helminth infections worldwide. Infections are widely distributed
in tropical and subtropical areas, with the greatest numbers occurring in subSaharan Africa, the Americas, China and East Asia.
Over 270 million preschool-age children and over 600 million school-age children
live in areas where these parasites are intensively transmitted, and are in need of
treatment and preventive interventions.
Transmission
Soil-transmitted helminths are transmitted by eggs that are passed in the faeces
of infected people. Adult worms live in the intestine where they produce
thousands of eggs each day. In areas that lack adequate sanitation, these eggs
contaminate the soil. This can happen in several ways:
eggs that are attached to vegetables are ingested when the vegetables are
not carefully cooked, washed or peeled;
eggs are ingested from contaminated water sources;
eggs are ingested by children who play in the contaminated soil and then put
their hands in their mouths without washing them.
In addition, hookworm eggs hatch in the soil, releasing larvae that mature into
a form that can actively penetrate the skin. People become infected with
hookworm primarily by walking barefoot on the contaminated soil.
There is no direct person-to-person transmission, or infection from fresh faeces,
because eggs passed in faeces need about 3 weeks to mature in the soil before
they become infective. Since these worms do not multiply in the human host, reinfection occurs only as a result of contact with infective stages in the
environment.
Morbidity and symptoms
Morbidity is related to the number of worms harboured. People with light
infections usually have no symptoms. Heavier infections can cause a range of
symptoms including intestinal manifestations (diarrhoea and abdominal pain),
general malaise and weakness, and impaired cognitive and physical
development. Hookworms cause chronic intestinal blood loss that can result in
anaemia.
Nutritional effects
Soil-transmitted helminths impair the nutritional status of the people they infect
in multiple ways.
The worms feed on host tissues, including blood, which leads to a loss of iron
and protein.
The worms increase malabsorption of nutrients. In addition, roundworm may
possibly compete for vitamin A in the intestine.

Some soil-transmitted helminths also cause loss of appetite and, therefore, a


reduction of nutritional intake and physical fitness. In particular, T.
trichiura can cause diarrhoea and dysentery.
The nutritional impairment caused by soil-transmitted helminths is recognized to
have a significant impact on growth and physical development.
WHO strategy for control
In 2001, delegates at the World Health Assembly unanimously endorsed a
resolution (WHA54.19) urging endemic countries to start seriously tackling
worms, specifically schistosomiasis and soil-transmitted helminths.
The strategy for control of soil-transmitted helminth infections is to control
morbidity through the periodic treatment of at-risk people living in endemic
areas. People at risk are:
preschool children,
school-age children,
women of childbearing age (including pregnant women in the second
and third trimesters and breastfeeding women),
adults in certain high-risk occupations such as tea-pickers or miners.
WHO recommends periodic medicinal treatment (deworming) without
previous individual diagnosis to all at-risk people living in endemic
areas. Treatment should be given once a year when the prevalence of
soil-transmitted helminth infections in the community is over 20%, and
twice a year when the prevalence of soil-transmitted helminth
infections in the community is over 50%. This intervention reduces
morbidity by reducing the worm burden. In addition:
health and hygiene education reduces transmission and reinfection by
encouraging healthy behaviours; and
provision of adequate sanitation is also important but not always
possible in resource-poor settings.
Morbidity control aims to reduce intensity of infection and protect
infected individuals from morbidity through periodic treatment of at-risk
populations.
Periodic deworming can be easily integrated with child health days or
supplementation programmes for preschool children, or integrated with
school health programmes. In 2013, over 368 million schoolchildren
were treated with anthelminthic medicines in endemic countries,
corresponding to 42% of all children at risk.
Schools provide a particularly good entry point for deworming activities, as they
allow the easy provision of the health and hygiene education component, such as
promotion of handwashing and improved sanitation.
WHO recommended medicines
The WHO recommended medicines albendazole (400 mg) and mebendazole
(500 mg) are effective, inexpensive and easy to administer by non-medical

personnel (e.g. teachers). They have been through extensive safety testing and
have been used in millions of people with few and minor side-effects.
Both albendazole and mebendazole are donated to national ministries of health
through WHO in all endemic countries for the treatment of all children of school
age.
Global target
The global target is to eliminate morbidity due to soil-transmitted helminthiases
in children by 2020. This will be obtained by regularly treating at least 75% of the
children in endemic areas (an estimated 873 million).

Tuberculosis
Fact sheet N104
Reviewed March 2015

Key facts

Tuberculosis (TB) is second only to HIV/AIDS as the greatest killer worldwide


due to a single infectious agent.
In 2013, 9 million people fell ill with TB and 1.5 million died from the disease.
Over 95% of TB deaths occur in low- and middle-income countries, and it is
among the top 5 causes of death for women aged 15 to 44.
In 2013, an estimated 550 000 children became ill with TB and
An estimated 37 million lives were saved through TB diagnosis and treatment
80 000 HIV-negative children died of TB.
TB is a leading killer of HIV-positive people causing one fourth of all HIVrelated deaths.
Globally in 2013, an estimated 480 000 people developed multidrug resistant
TB (MDR-TB).
The estimated number of people falling ill with TB each year is declining,
although very slowly, which means that the world is on track to achieve the
Millennium Development Goal to reverse the spread of TB by 2015.
The TB death rate dropped 45% between 1990 and 2013.
between 2000 and 2013.

Tuberculosis (TB) is caused by bacteria (Mycobacterium tuberculosis) that most


often affect the lungs. Tuberculosis is curable and preventable.
TB is spread from person to person through the air. When people with lung TB
cough, sneeze or spit, they propel the TB germs into the air. A person needs to
inhale only a few of these germs to become infected.
About one-third of the world's population has latent TB, which means people
have been infected by TB bacteria but are not (yet) ill with the disease and
cannot transmit the disease.
People infected with TB bacteria have a lifetime risk of falling ill with TB of 10%.
However persons with compromised immune systems, such as people living with
HIV, malnutrition or diabetes, or people who use tobacco, have a much higher
risk of falling ill.
When a person develops active TB (disease), the symptoms (cough, fever, night
sweats, weight loss etc.) may be mild for many months. This can lead to delays in
seeking care, and results in transmission of the bacteria to others. People ill with
TB can infect up to 10-15 other people through close contact over the course of a
year. Without proper treatment up to two thirds of people ill with TB will die.
Who is most at risk?
Tuberculosis mostly affects young adults, in their most productive years.
However, all age groups are at risk. Over 95% of cases and deaths are in
developing countries.
People who are infected with HIV are 26 to 31 times more likely to become sick
with TB (see TB and HIV section). Risk of active TB is also greater in persons
suffering from other conditions that impair the immune system.
Over half a million children (0-14 years) fell ill with TB, and 80 000 HIV-negative
children died from the disease in 2013.

Tobacco use greatly increases the risk of TB disease and death. More than 20% of
TB cases worldwide are attributable to smoking.
Global impact of TB
TB occurs in every part of the world. In 2013, the largest number of new TB cases
occurred in the South-East Asia and Western Pacific Regions, accounting for 56%
of new cases globally. However, Africa carried the greatest proportion of new
cases per population with 280 cases per 100 000 population in 2013.
In 2013, about 80% of reported TB cases occurred in 22 countries. Some
countries are experiencing a major decline in cases, while in others the numbers
are dropping very slowly. Brazil and China for example, are among the 22
countries that showed a sustained decline in TB cases over the past 20 years. In
the last decade, the TB prevalence in Cambodia fell by almost 50%.
Symptoms and diagnosis
Common symptoms of active lung TB are cough with sputum and blood at times,
chest pains, weakness, weight loss, fever and night sweats.
Many countries still rely on a long-used method called sputum smear microscopy
to diagnose TB. Trained laboratory technicians look at sputum samples under a
microscope to see if TB bacteria are present. With three such tests, diagnosis can
be made within a day, but this test does not detect numerous cases of less
infectious forms of TB.
Diagnosing MDR-TB (see Multidrug-resistant TB section below) and HIV-associated
TB can be more complex. A new two-hour test that has proven highly effective in
diagnosing TB and the presence of drug resistance is now being rolled-out in
many countries.
Tuberculosis is particularly difficult to diagnose in children.
Treatment
TB is a treatable and curable disease. Active, drug-sensitive TB disease is treated
with a standard six-month course of four antimicrobial drugs that are provided
with information, supervision and support to the patient by a health worker or
trained volunteer. Without such supervision and support, treatment adherence
can be difficult and the disease can spread. The vast majority of TB cases can be
cured when medicines are provided and taken properly.
Between 2000 and 2013, an estimated 37 million lives were saved through TB
diagnosis and treatment.
TB and HIV
At least one-third of people living with HIV worldwide in 2013 were infected with
TB bacteria, although they did not become ill with active TB. People living with
HIV are 26 to 31 times more likely to develop active TB disease than people
without HIV.
HIV and TB form a lethal combination, each speeding the other's progress. In
2013 about 360 000 people died of HIV-associated TB. Approximately 25% of
deaths among HIV-positive people are due to TB. In 2013 there were an

estimated 1.1 million new cases of TB amongst people who were HIV-positive,
78% of whom were living in Africa.
WHO recommends a 12-component approach of collaborative TB-HIV activities,
including actions for prevention and treatment of infection and disease, to reduce
deaths.
Multidrug-resistant TB
Standard anti-TB drugs have been used for decades, and resistance to the
medicines is widespread. Disease strains that are resistant to a single anti-TB
drug have been documented in every country surveyed.
Multidrug-resistant tuberculosis (MDR-TB) is a form of TB caused by bacteria that
do not respond to, at least, isoniazid and rifampicin, the two most powerful, firstline (or standard) anti-TB drugs.
The primary cause of MDR-TB is inappropriate treatment. Inappropriate or
incorrect use of anti-TB drugs, or use of poor quality medicines, can all cause
drug resistance.
Disease caused by resistant bacteria fails to respond to conventional, first-line
treatment. MDR-TB is treatable and curable by using second-line drugs. However
second-line treatment options are limited and recommended medicines are not
always available. The extensive chemotherapy required (up to two years of
treatment) is more costly and can produce severe adverse drug reactions in
patients.
In some cases more severe drug resistance can develop. Extensively drugresistant TB, XDR-TB, is a form of multi-drug resistant tuberculosis that responds
to even fewer available medicines, including the most effective second-line antiTB drugs.
About 480 000 people developed MDR-TB in the world in 2013. More than half of
these cases were in India, China and the Russian Federation. It is estimated that
about 9.0% of MDR-TB cases had XDR-TB.
WHO response
WHO pursues six core functions in addressing TB.
1. Provide global leadership on matters critical to TB.
2. Develop evidence-based policies, strategies and standards for TB
prevention, care and control, and monitor their implementation.
3. Provide technical support to Member States, catalyze change, and build
sustainable capacity.
4. Monitor the global TB situation, and measure progress in TB care, control,
and financing.
5. Shape the TB research agenda and stimulate the production, translation
and dissemination of valuable knowledge.
6. Facilitate and engage in partnerships for TB action.
The WHOs Stop TB Strategy, which is recommended for implementation by all
countries and partners, aims to dramatically reduce TB by public and private
actions at national and local levels such as :
1.
pursue high-quality DOTS expansion and enhancement. DOTS is a fivepoint package to:
a.
secure political commitment, with adequate and sustained financing

b.

ensure early case detection, and diagnosis through quality-assured


bacteriology

c.
d.
e.
2.
3.
4.
5.
6.

provide standardized treatment with supervision and patient support


ensure effective drug supply and management and
monitor and evaluate performance and impact;
address TB-HIV, MDR-TB, and the needs of poor and vulnerable
populations;
contribute to health system strengthening based on primary health care;
engage all care providers;
empower people with TB, and communities through partnership;
enable and promote research.

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