Professional Documents
Culture Documents
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)
Of
R
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F
U
G
E
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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:
1991 1993
STD incidence/100 person years (95% CI)
17.0 (15.7-18.4) 1.79 (1.3-2.4)
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