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Infectious Diseases

A Global View
Why learn about problems that
mostly affect people elsewhere?
• Addressing the most important problems of human health is
part of a university education in medicine
• In a global context, it is Edmonton that is “exotic”, not malaria
• Canada is a nation of immigrants
• Some of you will work or study overseas
• There is much to learn, which may be applicable locally, from
studying these diseases and disease patterns in other settings
• It can be exciting and rewarding
Objectives
• A global perspective on the frequency and impact
of communicable diseases
• Appreciation of the distribution of various
representative communicable diseases
• An understanding of some of the determinants of
disease distribution
• An introduction to the principles and practice of
communicable disease control
• An introduction to the idea that International
Health can be fascinating and rewarding
• NOT: To teach the pathophysiology or life cycle
of various tropical and communicable diseases
Causes of Death 1998 (WHO)
Disability Adjusted Life Years
Lost, WHO 1998
Communicable Disease: Impact
Mortality due to Morbidity
Infectious diseases (DALY’s lost)

World’s poorest 59% 64%


20%
World’s richest 8% 11%
20%
World total 34% 44%
Rank of Infectious Diseases
Cause of Death millions %
Pneumonia (all bugs) 3.745 7.2
Tuberculosis 2.910 5.6
Diarrheal diseases (all bugs) 2.455 4.7
HIV 2.300 4.4
Malaria (falciparum) 1.5-2.7 2.9-5.2
Measles .960 1.8
Hepatitis B .605 1.2
Pertussis .410 0.8
Global Distribution of Disease
What can it Teach Us?
• What to look for when a patient comes from
there
• What to watch out for when a traveller goes
there
• Evidence concerning the causes and
determinants of disease
Malaria Distribution:

• Temperature, (therefore latitude and


altitude)
• Distribution of most efficient vector
species
• Control measures
Distribution of
Chagas’
Disease
Trypanosoma
cruzi
“Reduvid bug”, Vector of Trypanosoma cruzi—Chagas’ Disease
Distribution of Lyme Disease in the US
Distribution
Of Loa Loa
Infections with well-defined
geographic distributions
• Schistosomiasis (200 million people, 4
species)
– Vector snails and their habitat
• Lyme disease
– Ixodes tick and mouse and deer hosts
• Hookworm and Strongyloides
– Warm soil, poor sanitation, bare feet
Universal Human Diseases
• Rotavirus
• Most respiratory viruses
• Herpes simplex I
• Herpes zoster
• Most STD’s
• Epstein Barr virus
• Staphylococcus aureus, Streptococcus pyogenes
Distribution due to
Socioeconomic Development,
Poor Sanitation, etc.
• Hepatitis A
• Typhoid fever
• Helicobacter pylori
• Other bacterial diarrheas
• TB
Basic Water Supply
Other factors
• Measles—requires minimum population
pool
• Hydatid disease (Echinococcus granulosus)
herbivore & canid & human contact
• Hepatitis C may require iatrogenic
transmission
• Brucella: consumption unpasteurized milk
• Paragonimus: ingestion of uncooked crab
H
E
A
L
T
H

Of

R
E
F
U
G
E
E
S
Distribution of Burkitt’s lymphoma
Worldwide distribution of penicillin
resistant pneumococcus
Diseases of Evolving
Distribution
• HIV and other Emerging Infectious
Diseases
• The great historical epidemic
diseases: Plague and Cholera
• TB and Leprosy
Plague (Bubonic plague, Black
Death)
• Yersinia pestis is endemic in rodents in many
parts of Asia, Africa and N. America
• Justinian plague 542-767 AD---toll: 40 m.
• Black Death 1347 X 300 yrs---toll: ¼ Europe’s
population
• Origin: ? Central Asia
• Spread: trade & shipping routes & war
• Risks: rats and poor hygiene (fleas)
• Last plague epidemic, San Francisco: 1908
• Most recent epidemic: Surat, India 1994
Cholera (Vibrio cholerae)
• 6 “Pandemics” since 1817— due to V. cholerae 01
• Can be both endemic and epidemic
• Risks: poor water supply, sanitation & hygiene
• Major problem in Western cities in 19th century e.g.
John Snow & the Broad Street pump
• 7th Pandemic 1961-present—new strain: El Tor
• Cholera returned to Americas (starting in Peru) 1991
after >100 years absence
• Other recent outbreaks:
• 1992: new species V. cholerae 0139
The TB Epidemic in the Western World
Tuberculosis
• Decrease in Western countries from the most
common cause of death in 1900 to <5/100,000 in
Canadian-born, non-aboriginals
• +/- 5X increase in TB incidence in HIV-affected
communities
• Increasing TB in former Soviet Union
• Increasing drug resistance
Leprosy:
• Formerly endemic in Europe, now imported only
HIV vs. Other Causes of Death in the U.S.
Global Warming and Malaria
Selected Communicable Diseases
of Global Importance
• Acute Respiratory Infection (ARI)
• Diarrheal Disease
• Malaria
• Causes of Blindness
ARI (Acute Respiratory
Infection, pneumonia)
• #1 Cause of death in under 5’s in Low Income Countries
• Multiple organisms:
– pneumococcus, Hemophilus, viruses, coliforms and
Pneumocystis in the HIV-infected, pertussis, measles
• Risks
– Malnutrition, HIV, non-vaccination, vitamin A deficiency,
indoor air pollution, residential crowding
ARI: Prevention & Management
Prevention:
• Socioeconomic development, improved nutrition, HIV
prevention programs, breast feeding, reduced indoor
pollution, vaccination (pertussis, measles)
• ? Hemophilus and pneumococcal vaccine
Management:
• Prompt recognition of pneumonia by family and 1e
health care workers (in functioning 1e care system)
• Rapid treatment with (implies availability of) antibiotics
• Rapid recognition and referral of the sickest kids
Diarrheal Disease
• # 2 cause of death in under 5’s in LIC’s (cholera
and others can cause epidemic diarrhea in adults)
• Multiple organisms
– Rotavirus and other viruses, various types of E. coli,
Salmonella, Shigella, Campylobacter, giardia,
cryptosporidia, ? helminths etc.
• Different types/patterns of diarrhea:
– acute watery, dysentery, chronic
• Main mechanism of death, esp. in acute watery dd
– Dehydration
• Risks:
– unsafe drinking water, poor sanitation, unavailable
washing water, malnutrition, not breast feeding, probably
HIV, traditional treatment practices, and misuse of
medication
Diarrhea: Prevention &
Management
• Prevention:
– Better drinking water, better sanitation, more washing
water, food safety, hygiene, breast feeding & food
safety, immunization
– ??rotavirus vaccine
• Management
– Oral rehydration with appropriate fluid (cereal-based
ORS probably better)
– Continued breast (or other feeding if weaned)
– Avoid dangerous traditional practices (withholding oral
intake, purges etc.)
– Train health workers that ORS, not medicines, is the
treatment (except for dysentery).
HIV: How fast can it spread?
• San Francisco gay men 0-50% in +/- 5
years
• Edinburgh IVDU 0-50% in 3 years
• Nairobi prostitutes 0-85% in 6 years
• Chiangmai (Thailand) prostitutes--incidence
10% per month
• Harare (Zimbabwe) young adults--.2%–
20% in 5 years
GLOBAL DI STRI BUTIOF
ONBLI NDNESS, BY MAJ
OR CAUSE AND REGI ON
3
No. of blind (x10
) from:

Region Cataract Trachoma Glaucoma OnchocerciasisOthers Total


Established Market Economies 84 -- 180 -- 2136 2400
Former Socialist Economies of Europe91 -- 74 -- 935 1100
I ndia 5120 865 1141 -- 1774 8900
China 2166 1174 1514 -- 1846 6700
Other Asia and I slands 2314 1362 973 -- 1151 5800
Sub-Saharan Africa 3101 1380 853 358.5 1407.5 7100
Latin America and the Caribbean 1326 158 183 1.5 631.5 2300
Middle-Eastern Crescent 1627 927 205 -- 841 3600
Total 15829 5866 5123 360 10722 37900
(41.8)* (15.5) (13.5) (0.9) (28.3) (100)
* Figures in parentheses are percentages.
Thylefors B, Négrel AD, Pararajasegaram R, Dadzie KY. Global data on letin
blindness.
of the World
Bul Health Organization 1995;73(1):115
-121.
Malaria (mainly P. falciparum)
• Impact:
– > 2 billion people at risk
– +/- 300 million cases/yr
– +/- 2 million deaths/yr., mainly African kids
• Biology:
– Vector-borne (Anopheles mosquito)
– Gradually acquired, incomplete immunity
Malaria: Control
• Bednets, especially when insecticide-treated
• Early diagnosis & treatment requires access to
functioning lab, effective drugs
• Domiciliary spraying
• Control of larval breeding
– Environmental, chemical, biological
• Chemoprophylaxis of selected groups
• Vaccine (don’t hold your breath)
TB: Mycobacterium tuberculosis
• Impact:
• 2nd most common cause of death due to a specific
microbial pathogen species
• 2 billion people infected
• 8 million active cases/year
• 3 million deaths/year
• Exploding epidemic in HIV-affected pop’s
• Increasing drug resistance
TB treatment and control
• Infectious TB is readily diagnosed with
simple microscopic exam
• >95% cure of drug-sensitive disease with 6
months treatment if compliance assured
• In TB, cure of infectious cases is the main
means of disease control
• Well structured programs (DOTS) can cure
patients, prevent transmission and avoid
drug resistance
• TB treatment/control among the most cost-
effective of all health interventions
Travel & Immigration
• Canada, with no local malaria transmission
has > 1,000 reported cases of malaria/year
• Over 60% of Canada’s TB cases each year
are foreign-born
A tropical disease in the comfort
of your own home
• The food we eat is increasingly grown
elsewhere, often in low-income countries
• 2X outbreaks of cyclosporiasis in the U.S.
and Canada, >700 people affected in each—
source: Guatamela raspberries
• Cholera in Maryland from Thai cocoanut
milk
• Botulism in the U.K. from Canadian salmon
Communicable Disease Control,
Global and Local: Methods
• **Immunization (measles and many more)
• Chemotherapy (STD’s, TB)
• Water, sanitation & washing (many)
• Vector control (malaria, yellow fever etc.)
• Education/behaviour change (HIV etc. etc.)
• Regulatory measures (pasteurization, quarantine etc.)
• **Socioeconomic development
Impact of Immunization
A Recent Vaccine Success—H. influenzae in Canada
Thailand “100% Condom Program”
Effect on STD and HIV in Male Army Conscripts

1991 1993
STD incidence/100 person years (95% CI)
17.0 (15.7-18.4) 1.79 (1.3-2.4)

HIV incidence/100 person years (95% CI)


2.48 (2.00-3.07) 0.55 (0.3-0.99)

AIDS 1998;12:F29-36
Disease
Eradication—
A Rash Idea?
First Published
Report of
Vaccination
Disease Eradication
• The best kind of disease control
• Smallpox eradication (last case 1977)
• Huge reduction in morbidity and mortality
(4million Deaths/year in 1950)
• Indefinitely compounded savings
($120m/yr in U.S. alone while whole
eradication program cost $300m.)
Disease Eradication
• Wild polio virus transmission halted in Western Hemisphere
—progress occurring in Asia, Africa
• Dracunculus (guinea worm) Dramatic reductions in the
remaining endemic areas

Possible future considerations:


• Measles, hepatitis B, hepatitis A, rubella, lymphatic filariasis,
Hemophilus influenzae
Sub-national Immunization Day Program in South Sudan
Cost Effectiveness of Interventions
assuming consistent, correct use: Heymann, WHO.

Intervention Cost/case Effectiveness Cost/yr., per


US$ population
TB Rx 20 95% 0.60
Anti-malarials 0.05 99% ?
Condom supply 14 95% 1.70
Oral rehydration 0.33 High 1.60
STD treatment 0.80
ARI treatment 0.27 90% ?
Measles vaccine 0.26 98% 0.50
Lessons Learned from
International Experience
• TB treatment
• Oral rehydration in the management of
diarrhea
• Epidemiology of heterosexual HIV
• Doing more with less
Objectives
• A global perspective on the frequency and impact
of communicable diseases
• Appreciation of the distribution of various
representative communicable diseases
• An understanding of some of the determinants of
disease distribution
• An introduction to the principles and practice of
communicable disease control
• An introduction to the idea that International
Health can be fascinating and rewarding
• NOT: To teach the pathophysiology or life cycle
of various tropical and communicable diseases

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