Contents
Burden of infectious diseases 2 The biggest killer of the young Six diseases cause 90% of infectious disease deaths Infectious diseases are also among the biggest disablers
Affordable to prevent 14 Avoidable at a low cost Controllable in any country The end of the line for some infectious diseases?
Inadequate response 26 Investing in healthy development Many countries do not yet use WHO recommended policies Many factors contribute to the spread of infectious diseases
Uncertain future 38 Diseases continue to catch the world off guard Near misses Medicines are losing their effectiveness The world is becoming a smaller place for microbes
Staying prepared 54 Development of new drugs and vaccines The need for intensified research
A call for healthy development 62
Notes: • Th roughout this report, the term "infectious disease" is used to refer to all communicable diseases, including parasitic and zoonotic diseases, and some forms of respiratory infections and diarrhoeal diseases . • $ refers to us·do llars. • The term "billion" is used to mean a thousand million. II The biggest killer of the young
An infectious disease crisis of global proportions is All this has been made worse by the huge today threatening hard-won gains in health and life increase in mass population movements over the expectancy. Infectious diseases are now the past decade. In 1996, as many as 50 million world's biggest killer of children and young adults. people - 1% of the world's population - had been They account for more than 13 million deaths a uprooted from their homes. Not only are refugees year - one in two deaths in developing countries. and displaced people especially vulnerable to Over the next hour alone, 1 500 people will die infectious disease; their movement can help from an infectious disease - over half of them spread infectious diseases into new areas. children under five. Of the rest, most will be Meanwhile, the growth of densely populated working-age adults - many of cities with unsafe water, poor them breadwinners and sanitation and widespread parents. Both are vital age poverty has created the perfect groups that countries can ill breeding ground for outbreaks of afford to lose. disease. In deprived inner-city Most deaths from infectious areas children are less likely to be diseases occur in developing immunized against killer diseases countries - the countries with and parents are less likely to be the least money to spend on able to pay for health care when health care. In developing they get sick. Under these countries, about one third of the circumstances, diseases that population - 1.3 billion people - were once under control can live on incomes of less than $1 a day. Almost one rapidly gain a foothold and re-establish in three children are malnourished. One in five are themselves. not fully immunized by their first birthday. And over In addition, many diseases once thought one third of the world's population lack access to unrelated to infectious diseases - especially essential drugs. Against this backdrop of poverty cancers - are now known to be the result of and neglect it is little wonder that deadly infectious chronic infections. Cervical cancer, for example - diseases have been allowed to gain ground. Today one of the most common cancers among women some of the poorest countries are paying a heavy in the developing world - is now known to be price for the world's complacency and neglect. associated with human papillomavirus infection. Leading causes of death 53.9 million from all causes, worldwide, 1998
Other 6% Infectious diseases Respiratory and digestive 25% 9%
Maternal 5%
Injuries 11 %
Cancers Cardiovascular diseases 13% 31 %
Note: Cancers, cardiovascular and respiratory/digestive deaths can also be caused by infections and raise the percentage of deaths due to infectious diseases even more.
Source: WHO, 1999 II Meanwhile, chronic infectious hepatitis B and Main causes of death hepatitis C can both cause liver cancer and it is estimated that over 6% of the world's population is in low-income countries at risk. And bladder cancer can result from chronic In South-East Asia and Africa Estimates for 1998 infection with schistosomiasis. But infectious diseases are not just a Maternal2% Nutritional 1% developing country problem. Unless checked, the Perinatal 6% crisis threatens the industrialized countries as well. Old scourges such as tuberculosis and diphtheria have occurred in explosive epidemics in Europe and other industrialized countries. And a 1996 outbreak of polio in Albania, Greece and the Federal Republic of Yugoslavia showed how easily a disease can be reintroduced to countries once free of the disease if immunization coverage is allowed to drop. A rapid increase in air travel has Noncommunicable conditions 35% meant that diseases can now be transported from Source: WHO, 1999 one continent to another in a matter of hours. Even today, no country is safe from the threat of infectious diseases. This is happening at a time when the arsenal resistance of microbes to antimicrobial drugs. of drugs available to treat infectious diseases is Because the scale and complexity of the being progressively depleted due to increasing infectious disease crisis is so great, and the causes linked so closely to poverty, there is a tendency for some to be fatalistic about the situation. But the situation is far from hopeless. IR CONDITIONING has played a major role in the spread of Efforts to prevent and control those diseases are Legionnaire's disease - a form of among the most practical and achievable ways of bacterial pneumon1a. AThe infection is spread by water droplets alleviating poverty and furthering social and through air-conditioning systems. The . Legionella organism caused 29 deaths In economic development. a Philadelphia hotel in 1976 and 16deaths ' . a Los Angeles hospital the following year. This report argues that we have a window of In . I 0 f 172 11 is believed that1n 1995, a Iota uests in Western European hOtels had been opportunity to make dramatic progress against ;xposed 10 Legionella.ln ear~ 1999, 23 ancient diseases, and to establish an early participants in a flower show In the Netherlands died of the disease. warning system to protect us from new and II Main causes of death unexpected diseases. If we fail, increased drug resistance and the emergence of new bacteria among children and viruses threaten to make the control of Ages 0 to 4 years infectious diseases both scientifically and Estimates for 1998, worldwide economically unlikely in the future.
Injuries 6% Noncommunicable conditions 8% The World Health Nutritional 3% Organization The World Health Organization (WHO) can Perinatal 20% help mobilize the partners and develop the policies that will prevent and control infectious diseases. There is still a window of opportunity to make dramatic progress against the diseases that have been with us for thousands of years
Source: WHO, 1999 and to establish an early warning system to pro tect from new and unexpected diseases. WHO Main causes of was created in 1948 and today, with over 190 Member States, it is the lead agency in interna premature death tional health. WHO's goal is to foster the attain Ages 0 to 44 years ment by all peoples - especially the poor and Estimates for 1998, worldwide most vulnerable - of the highest possible
Maternal 3% Nutritional 2% standards of health. The guiding principles of WHO are: • "We can't do it alone, so we work in partnership with others:' • 'We can't do it all at once so we set priorities. Noncommunicable Priority setting helps focus the world's atten conditions 18% tion, resources and actions on innovative and cost-effective public health action with specific goals and measurable results:' WHO is the health conscience of the world. • General WHO information can be accessed Source: WHO, 1999 at www.who.int Six diseases cause 90°/o of infectious disease deaths
Most deaths from infectious diseases - almost young children and adult breadwinners, their impact 90% - are caused by only a handful of diseases. on families can be catastrophic. Children may lose And most of them have plagued mankind one or both parents to an infectious disease. The throughout history, often ravaging populations AIDS epidemic alone has left over eight million more effectively than wars. In an age of vaccines, children orphaned. To make matters worse, families antibiotics and dramatic scientific progress, these risk being driven into debt through lost earnings and diseases should have been brought under control. high health care costs- trapping them in a vicious Yet, in developing countries today they continue to circle of poverty and ill-health. kill at an alarming rate. And at times - as in recent outbreaks Pneumonia of influenza - they also kill at Acute respiratory infections (ARis) an alarming rate in the are responsible for many deaths. industrialized countries. Pneumonia, the deadliest ARI , kills No more than six deadly more children than any other infectious diseases infectious disease. Most of these pneumonia, tuberculosis, deaths (99%) occur in developing diarrhoeal diseases, malaria, countries. Yet in industrialized measles and more recently countries childhood deaths from HIV/AIDS - account for half pneumonia are rare. of all premature deaths, Pneumonia often affects killing mostly children and young adults. children with low birth weight or those whose Every three seconds a young child dies - in immune systems are weakened by malnutrition or most cases from an infectious disease. In some other diseases. Without treatment, pneumonia kills countries, one in five children die before their fifth quickly. birthday. Every day 3 000 people die from malaria The influenza virus is another cause of -three out of four of them children. Every year 1.5 pneumonia. There is very little information million people die from tuberculosis and another available on the number of influenza deaths in eight million are newly infected. developing countries. However, in the United Behind each of these deaths lies a human States alone, the disease kills 10 000-40 000 tragedy. Because these diseases affect mainly people in an average influenza season. a Leading infectious killers Millions of deaths, worldwide, all ages, 1998
3.5
3.0 Over age five •D Under age five 2.5 2.3 2.2 en c .Q .-E 2.0 c en ..c co 1.5 -Q) 0 1.1 1.0 0.9
0.5
0 Acute AIDS* Diarrhoeal TB Malaria Measles respiratory diseases infections (including • HIV-positive people who died with TB have been included among AIDS deaths.
pneumonia and Source: WHO, 1999 influenza) II HIV/AIDS Tuberculosis (TB) Over 33 million people are living with HIV/AIDS Tuberculosis, a disease once thought to be under worldwide. There is still no cure on the horizon. control, has bounced back with a vengeance to kill Worst affected is sub-Saharan Africa. In some 1 .5 million people a year - even more when in countries, up to one in four of the adult population combination with HIV/AIDS. Nearly two billion are now living with HIV/AIDS. In Zimbabwe, 20%- people- one-third of the world's population -have 50% of pregnant women in some areas are latent TB infection. Together they constitute a huge infected with HIV and risk infecting their children. potential reservoir for the disease. TB kills more An increasing number of maternal deaths are now adolescents and adults than any other single due to infections contracted by HIV-positive infection.lt is also a leading cause of death among women during delivery. In many countries, life women. expectancy and child survival rates have To make matters worse, infection with HIV plummeted. In Botswana life expectancy at birth weakens the immune system and can activate has fallen from 70 to around 50 years. latent TB infection. It is also believed to multiply the risk of initial infection with TB. About one-third of all Diarrhoea AIDS deaths today are caused by TB. Diarrhoeal diseases claim nearly two million lives a year among children under five. They are so Malaria widespread in developing countries that parents Malaria kills over one million people a year- most often fail to recognize the danger signs. Children of them young children. Most malaria deaths die simply because their bodies are weakened occur in sub-Saharan Africa, where malaria often through rapid loss of fluids and accounts for one in five of all childhood deaths. undernourished through lack of food . Women are especially vulnerable during Diarrhoeal diseases impose a heavy burden pregnancy. They are more likely to die from the on developing countries - accounting for 1.5 disease, suffer miscarriages or give birth to billion bouts of illness a year in children under five. premature, low-weight babies. The burden is highest in deprived areas where Malaria can rapidly overwhelm a young child there is poor sanitation, inadequate hygiene and causing high fever, convulsions and breathing unsafe drinking water. difficulties. With the onset of cerebral malaria - an In certain developing countries, epidemics acute form of the disease - the child lapses into a of diarrhoeal diseases such as cholera and coma and may die within 24 hours. dysentery strike down adults and children alike. The high incidence of malaria cases - over Other major diarrhoeal diseases include 275 million a year globally - can impose a huge typhoid fever and rotavirus which is the main economic burden on both families and cause of severe dehydrating diarrhoea among governments through lost productivity, missed children. education and high health care costs. II Measles The death of a child Measles is the most contagious disease known to Percentage of women aged 15 to 49, man . It is a major childhood killer in developing married or previously married, countries - accounting for about 900 000 deaths who have had at least one child die a year. The measles virus may ultimately be responsible for more child deaths than any other single microbe - due to complications from pneumonia, diarrhoea and malnutrition. I Burkina Faso 30%
Columbia 1 13% Combating childhood deaths Egypt 32% Children are among the most vulnerable to Indonesia 26% infectious diseases, and child infections demand rapid and effective treatment. WHO's Integrated Management of Childhood Illnesses (IMCI) strategy permits immediate treatment at the very periphery of health care Malawi 52% systems. IMCI is disease control through man agement of the five most common causes of Namibia 26% childhoqd deaths - pneumonia, diarrhoeal dis eases, malaria, measles and malnutrition. 1~ _ ~_k_ista__ n______~l 30% The IMCI treatment guidelines have been developed to assist health workers to recognize ,_1Pe _ ru__ __---', 25% easily signs of illness and take appropriate action, even if there are co-existing health con I Philippines 19% ditions. IMCI also helps prevent illness through promoting improved nutrition and vaccination. Research & Development being conducted 1~-.Se_n_eg_a_l __~~~-----~' 45o/o by the Special Programme for Research and Training in Tropical Diseases (TOR) is develop United Republic of Tanzania 40% I ing new drugs and studying drug combinations to make IMCI even more effective. • Information on IMCI can be accessed at Source: Demographic and Health Surveys, 1994 www. who.int/chdl II Infectious diseases are also among the biggest disablers
The high death toll from infectious diseases is only malaria can also be a huge burden for the poorest part of the story. The scale of individual pain and families. In Nigeria, it has been estimated that suffering inflicted by these diseases is immense. subsistence farmers spend as much as 13% of At any one time, hundreds of millions of people total household expenditure on malaria treatment. mainly in developing countries - are disabled by Measles can lead to severe disability among infectious diseases. children who survive the disease. Measles Some infectious diseases can cause sudden infection can result in blindness, deafness, brain repeated bouts of debilitating illness throughout and lung damage, and stunted growth and the year- keeping children away development. from school and preventing Lymphatic filariasis is adults from working or caring for second only to mental illness their children. as the world's leading cause of Other diseases result in long-term disability. A severe deformities - covering the mosquito-borne disease body with gaping sores, involving infection with parasitic mutilating the facial features, worms, it can cause grotesque causing the loss of fingers and enlargement of the limbs and toes and leading to withering or genitals and damage to internal grotesque swellings of the limbs organs. It affects about 120 and other body parts. Those million people. At least one affected not only suffer from excruciating pain and billion people are at risk - one in six of the world's severe handicap but are also victims of population. Over 40 million people are severely stigmatization, shame and anguish. disfigured and disabled by filariasis. In addition, Meanwhile, the economic impact of repeated the social and psychological impact can be episodes of illness and long-term disability is a enormous- often destroying marriages and family major cause of underdevelopment in many relationships. countries today. The economic burden of malaria Another widespread parasitic worm disease, alone has cost Africa billions of dollars this schistosomiasis, causes chronic urinary tract decade. In addition to the cost of lost working disease and often results in cirrhosis of the liver days, the cost of treatment for repeated bouts of and bladder cancer. Over 200 million people are Burden of disease DALYs (Disability Adjusted Life Years) lost in 1998 due to infectious diseases, millions, all ages
100
80
(/) -c 0 60 E -(/) ~ <( 0 40
20
0
Acute Diarrhoeal HIV/AIDS Malaria Measles TB Sexually Pertussis Tropical respiratory diseases transmitted diseases* infections infections
• Tropical diseases include trypanosomiasis, Chagas disease. schistosomiasis, leishmaniasis, lymphatic filariasis and onchocerciasis. Source: WHO , 1999 Note: One DALY is one lost year of healthy life. Ill infected worldwide and up to three times as many trachoma and an additional 154 million are are at risk. This debilitating disease is spread by infected - mainly in Africa and Asia. The disease water snails and contracted through contact with is transmitted through person-to-person contact stagnant water sources. It can spread to new due to poor hygiene. In addition, over 85 million areas through dam-building and irrigation people in Africa, Latin America, and the Arabian projects. Children and rural workers are most at Peninsula are threatened by onchocerciasis risk and the disease can cause high absenteeism (river blindness). This parasitic disease, at school and work. In some of the worst-affected transmitted by blackflies, causes visual areas over 90% of children can be affected simply impairment, blindness, unbearable itching and as a result of wading through water. skin lesions. The itching can be so intense that More than 12 million people are infected with people scratch themselves with knives or stones leishmaniasis, another insect-borne parasitic to stop it. Some have even been driven to suicide. disease. The disease can cause internal organ In sub-Saharan Africa, sleeping sickness damage, skin lesions and mutilation of the nose threatens 55 million people in 36 countries. A and mouth. People disfigured by the disease often parasitic disease transmitted by the tsetse fly, have to endure rejection by their families as well. sleeping sickness causes long-term debilitating Today there is alarm at the sharp increase in illness and mental suffering. Without treatment, cases of visceral leishmaniasis - a deadly form of the disease is fatal. In the worst-affected countries the disease - due to emerging co-infections with over half the people in some villages become ill. In HIV and an upsurge in epidemics in countries some provinces the disease is reported to have such as India and Sudan. claimed more lives than AIDS. In addition, millions of people are Leprosy- one of the oldest scourges known incapacitated by infectious diseases which cause to humanity - is still a problem in many countries blindness. An estimated 5.6 million people today in South-East Asia, Africa, and Latin America. have been blinded or visually disabled by Over half a million cases occur every year. About
AMS, such as the one GGS infected with the Salmonella bacterium and eaten RYSTAL METH , GHB constructed on the Senegal raw or undercooked cause and ketamine are river in 1986, have led to . severe foOd poisoning increasingly common rapid increases in snatl popu· E particularly affecting the ' club drugs in North Dlations which cause schistosomtast~.oo;. th very young and C e old. About five million cases of America and Europe. Their use can Originally free of the disease, over o salmonellosis in the US alone f ople in the Senegal river area were occur cause loss of judgement, leading to each year. Outbreaks which oc ' unprotected sex and infection from o fpeted with schistosomiasis three years wid ' cur world- tn ec ck f dams tn . e, are usually traced to food . HIV and other STis. It is estimated later. Paradoxically the Ia o . tng raw e s contatn- . gg prOducts. Salmonella epi- that half of all new HIV infections in india and Nepal has led to fioodtng d emtcs are also c d the United States are among peo downstream in Bangladesh, bnngtng dair ause by contaminated ·ty health servtces to a Y. meat and poultry goods. ple under 25. many communt . standstill during the ratnY season.
II two million people are currently disabled by hundred million people are at risk. In Santa Cruz, leprosy, which can cause severe mutilation of the Bolivia, over 50% of the blood in blood banks was face and extremities as well as damage to bones, infected with the parasites. eyes, nerves, and internal organs. Although the In 1995, four Sexually transmitted disease is not highly contagious, even today infections (STis) - gonorrhoea, chlamydia, leprosy sufferers can become social outcasts. syphilis, and trichomonas - accounted for an Guinea-worm disease (dracunculiasis) is a estimated 333 million new cases of curable STis. parasitic disease transmitted by a tiny crustacean. These four infections and their complications are During 1998, there were almost 72 000 cases of among the top ten causes of disease burden. guinea-worm disease in Africa. The countries worst affected today are Ghana, Nigeria and Sudan. This debilitating disease causes joint pain, fever and vomiting. When the mature guinea Rolling back worm slowly emerges through the skin - by then up to a metre long - it causes excruciating pain malaria and frequent infections at the exit point. The Partnerships strengthen advocacy and help disability prevents people from going to work or unify public health action while making more school. resources available for the fight against infec In Latin America, up to 18 million people are tious diseases. Roll Back Malaria is one of infected with Chagas disease, a deadly parasitic WHO's best examples of how global partner disease transmitted by blood-sucking insects. The ships help control infectious diseases. disease can also be transmitted through blood Through a global coalition involving UNDP, transfusions and from mother to baby. The chronic UNICEF, WHO and the World Bank, Roll Back stage of the disease can last for years as Malaria is helping health systems deliver cost parasites invade the internal organs - causing effective interventions including: better health irreversible damage to care, insecticide-treated bednets and improved the heart and environmental management. At the same time intestines. The Roll Back Malaria is harnessing the support of ARMING and food disease is very both the public and private sector in developing production can be slowed difficult to treat with by infectious diseases. new malaria drugs and vaccines. The Roll Back Each year, nearly 30 000 existing drugs. In Fpeople contract Japanese . . Malaria partnership is working in all countries encephalitis while working In nee some parts of Latin where malaria is a health problem, and focusing addies across Asia. The Food and America it is the ~gricutture Organization reports that its greatest efforts in Africa where most malaria AIDS may have reduced the leading cause of working time of local agricultural deaths occur. cardiac death in services in Uganda by 20 to 50%. • Information on Roll Back Malaria can be young adults. One accessed at www. who. int/rbm Avoidable at a low cost
Most of the 13 million deaths a year from antimalarial drugs, and vitamin and mineral infectious diseases can be prevented. Low-cost supplements. Another key focus is prevention health interventions already exist to either prevent through promoting immunization, breastfeeding or cure the infectious diseases which take the and better feeding practices. greatest toll on human lives. And most of these Millions of lives could be saved every year interventions have been widely available for years. through the IMCI approach. Correct management Unfortunately for a number of reasons they of pneumonia and diarrhoeal diseases alone are not being used. Inadequate funding of health could prevent up to three million deaths a year. care in developing countries is one reason. Government failure to prioritize, lack of cross Childhood vaccinations sectoral collaboration and the More widespread use of low-cost inability of weak health service vaccines could prevent 1.6 million delivery systems to reach the - deaths a year among children entire population - particularly under the age of five. Yet today, the most vulnerable and difficult- one in five children are still not to-reach are contributing fully immunized against the six factors. major killer diseases: diphtheria, whooping cough, tetanus, polio, Integrated Management measles and TB. of Childhood Illnesses (IMCI) DOTS Millions of TB deaths could be This radical , low-cost strategy can dramatically averted through the use of DOTS (Directly reduce the 70% of deaths from pneumonia, Observed Treatment, Short-course) an diarrhoea, malaria, measles, malnutrition and inexpensive strategy for the detection and other infectious diseases such as meningitis. treatment of TB. This highly-effective health care Seriously ill children are often suffering from package involves detection of TB cases through more than one condition at the same time - low-cost sputum smear tests, followed by 6-8 making exact diagnosis difficult. For these children months of treatment with a combination of combined therapy can be life-saving. Treatment inexpensive drugs. A key component is regular may include oral rehydration salts to treat ongoing support to the patient. This includes diarrhoea, low-cost antibiotics to treat pneumonia, observation to ensure that patients follow the II Preventable deaths It is estimated that the majority of deaths from infectious diseases can be prevented with existing, cost-effective strategies.
Childhood vaccinations have proven extremely effective in reducing deaths from measles and other preventable diseases.
Bed nets and other prevention and treatment strategies can prevent 50% of all malaria deaths.
Deaths DOTS (Directly Observed Treatment, Short-course) can prevent 60% of al l tuberculosis deaths. avoidable with IMCI (Integrated Management of Childhood existing Illnesses) can prevent most childhood deaths tools from pneumonia, diarrhoea, malaria and measles. An important part of IMCI is oral rehydration therapy, which can prevent up to 90% of deaths from diarrhoeal diseases.
Antibiotics used in timely and correct doses, combined with other strategies such as IMCI , are highly effective in preventing deaths from pneumonia.
HIV prevention strategies such as condom promotion , sex education and treatment of STis have been proven to reduce the spread of HIV/AIDS.
Source : WHO Affordable health services for developing countries
Disease Intervention Prevention or Annual cost treatment costs per capita (1990) AIDS Treatment of STis $0.20 Prevention programmes $14 for a year's $1.70 supply of condoms TB DOTS strategy $20 for $0.60 6 months of medicines Malaria Prevention $1 0 for a bed net Being treated with insecticide determined Measles Immunization $0.26 to administer one $0.50 dose of measles vaccine Diarrhoeal Integrated Management $0.33 for oral $1.60 diseases of Childhood Illness rehydration salts ARI Treatment of pneumonia $0.27 for 5 days Being of antibiotics determined
Source for per capita spending: World Development Report, 1993. Source for prevention or treatment costs: WHO treatment correctly and follow-up sputum tests to Availability of essential drugs determine whether it has been successful. The Millions of people in developing countries are strategy can detect and cure disease in up to 95% dying needlessly from diseases that could be of infectious patients, even in the poorest easily treated with safe, inexpensive drugs. More countries. than one-third of the world's population lack regular access to essential life-saving drugs. Impregnated bednets Drugs may be too expensive for those on the One in four child deaths from malaria could be lowest incomes, or they may not be available. prevented if children at risk slept under bednets at In Africa, where many of the poorest countries night to avoid mosquito bites. Bednets dipped in have no more than $1 per capita each year to an insecticide cost about $10 each and $0.50 to spend on drugs, fewer than half have access to $1 a year for a supply of insecticide to re-treat the the basic drugs they need. net. Dip-it-yourself kits are now available for re User-friendly packaging of drugs is a low-cost treating the nets at home. The cost of a net and way of increasing compliance with antimalarial one year's supply of insecticide is less than one drug therapy. Studies in Ghana show that over hour's parking in New York, Paris or Tokyo. 80% of patients given a course of antimalarial
-• drugs packaged in a numbered blister pack g1v1ng children vitamin A supplements. Malaria finished the course of treatment. Of those deaths among children could be reduced through receiving loose, unpackaged drugs- the way they the use of iron supplements to treat anaemia. Yet are usually dispensed in developing countries - these inexpensive remedies are not always only 65% completed the treatment. available where they are needed most. A simple packet of fast-acting drugs made Effective health education can also save widely available to parents -together with training countless lives - by promoting safe sex, good to recognize malaria symptoms - could save the nutrition and hygiene, immunization and ensuring lives of many children with severe malaria. parents know what to do when a child is sick.
Prevention strategies for HIV/AIDS While expensive antiretroviral drug therapy for StoppingTB HIV/AIDS is still way beyond the means of most The STOP TB Initiative is mounting a political developing countries, well-targeted, low-cost HIV and' social movement against TB throughout the prevention and care strategies can have a major world by promoting the use of cost-effective impact on the spread of HIV. Directly Observed Treatment, Short-course Millions of new infections could be prevented (DOTS). Despite the DOTS policy, there are through low-cost interventions including: obstacles to countries adopting its use. These • access to cheap condoms and, where Include lack of political will and commitment to necessary, safe drug injecting equipment support TB control programmes, inadequate • use of essential drugs to treat other sexually financing and human resources, poor transmitted infections (which amplify the risk of organization of and management capacity for subsequent infection with HIV) programmes, and interrupted supplies of high • HIV testing and counselling (which can lead to quality anti-TB drugs. safer sex) STOP TB, based at WHO, is a partnership • counselling and support for HIV-positive of countries with serious TB problems, UN and mothers along with antiretroviral drugs and other international organizations, bilateral counselling on safe alternatives to breastfeeding donors, scientific and public health institutions • promotion of safe injection practices and NGOs. The partnership is: • sex education at school and beyond. • ending social apathy towards TB • expanding the global coalition of partners Other important strategies involved in TB control Inexpensive vitamin and mineral supplements can • pushing TB issues higher on both also save lives. As many as one in fo ur child international and national health agendas deaths from infectious diseases - mainly from • increasing investment in DOTS. measles and diarrhoea - could be prevented by • check out www.stoptb.org Controllable in any country
Wherever a low-cost strategy is available to populations and reducing health centres to rubble. prevent or treat infectious diseases, individual Within six years a disease had been eliminated countries - even low-income countries - can from the Americas. It could be done. make dramatic progress in getting them under In Viet Nam, a four-year onslaught on malaria control. But few countries have succeeded without between 1992 and 1996 succeeded in reducing strong political commitment at the highest level, a malaria deaths by over 90% and malaria cases by health care system that can deliver services to the 40%. A decade earlier the situation was dire. An entire population, and public demand for action. economic recession had dealt a body blow to During the 1980s the success of mass health services, donations of insecticide had been campaigns against polio in the stopped, resistance to Americas showed what could antimalarial drugs was rising be achieved against all the fast and migrant workers odds with strong political were carrying malaria into commitment. The WHO areas where it had once been Regional Office for the eliminated. In 1991 alone, Americas and its partner there were 144 epidemics of organizations worked with malaria. governments and civil society Through government throughout the Americas to commitment, increased carry out a massive social funding, and the widespread mobilization campaign. use of locally produced low Parents were educated about cost tools, health workers the need for immunization and have today succeeded in millions of health workers and volunteers were turning the situation around. Locally produced mobilized. high-quality drugs are now being used to treat In war-torn countries, negotiators worked with cases of severe and multidrug-resistant malaria. the warring factions to ensure that children's Throughout Viet Nam, about 12 million people are health would not become another casualty of the protected by house spraying and insecticide war. And the ceasefire for immunization worked. It impregnated bednets. In areas where malaria is worked in the poorest countries, in a densely endemic, insecticide impregnation is provided as a populated country like Brazil, and even in public service -free of charge. The success of the countries where armed conflict was terrorizing programme has attracted international funding - II Success stories
ORT reduces diarrhoeal deaths Sex education reduces among children in Mexico HIV prevalence in Uganda 20-24 year olds in Nsambya 300 40
0 8 250 0 35 0 .,.... :.::;~ ·u; Qj 200 0 o._ o._ 30 Q) > HI V ~ 150 I education introduced in .£ 1980s 100 ~0 :::2: 20 50
15L_____ J_ ____ ~ ______L_ ____ J______J 0 78 80 82 84 86 88 90 92 1992 1993 1994 1995 1996
Source: Gutierrez et al, 1996 Source: UNAIDS
Condom promotion reduces STis Free treatment reduces among sex workers in India malaria deaths in Viet Nam
I Always using condoms I
c Q) E ~ 0 30 CfJ 3000 Q) ..c Ol Cil Q) ~ a5 20 0 2000 ~ cf 10 1000
Source: WHO Global Programme on AIDS Source: Turning Malaria Around, WHOfTDR Global annual reported measles cases 1982-1997
100 5 coverage .._..~0 Vl 80 c Q.) .Q 4 en ·- ~ E Q.) .._.. > (f) 60 0 (.) Q.) 3 (f) Q.) ro c (.) T5 -o (.) Q.) 40 ro ..... 2 > -0 Q.) 0.. c Q.) :+::: a: ::I 20 a:0
0 1982 1984 1986 1988 1990 1992 1994 1996
Note: Reported cases only. Estimated actual cases are many times higher Source: WHO/EPI Information System allowing the government to give greater attention primary health care clinics. It has grown from to the control of other diseases such as dengue. small beginnings, steadily increasing its reach In West Africa, a small low-income country - every year. Today every prefecture is covered. Guinea - has shown what can be done to control Guinea has also established a network of TB through government commitment to use the laboratories for diagnosis and research. When the DOTS treatment strategy. Within four years of TB programme was launched in 1990 there were launching its TB control programme, the case only 15 laboratories. Today there are 67. detection rate had doubled and almost 80% of In Mexico the success of efforts to reduce patients were being cured. The number of patients child deaths from diarrhoeal diseases has served who failed to complete the treatment was halved as a model for other national programmes. Strong as home visits were used to motivate patients to political commitment and leadership were key complete the course. factors in achieving a 60% reduction in death rates With three out of four people living in rural within a decade. areas, the TB programme operates through Even more impressive, the dramatic reduction Condom promotion promoting the use of condoms. The results so far have been impressive. As reduces HIV HIV infection rates have risen steadily in other among Thai urban centres, the rate in the capital city, Dakar, has stayed below 2%. Over 60% of men and 40% army conscripts of women aged 15-24 are now reported to be routinely using condoms with casual partners. 4.0 And , as a result of active condom promotion in Senegal, the condom distribution rate has soared Q) u - from 800 000 a year in 1987 to over seven @ 3.5 1 million by 1998. 0.. > 3.0 I 0 ~ 2.5 Condom promotion Towards a -111 becomes official policy Q) ~ 2.0 polio-free world 0... Polio has proven to be controllable in any 1 5 · 1993 1994 1995 1996 country. Ceasefires in war-torn countries and strong partnerships are now overcoming natural Source: Ministry of Public Health. Thailand and man-made obstacles along the road to freeing the world from polio. in death rates was achieved in the face of a Through its Polio Eradication Initiative, nationwide epidemic of cholera during 1990-92. WHO is spearheading a global partnership to The strategy involved efforts to ensure correct eradicate polio by the year 2000. In just ten home case management and the availability and years the number of cases worldwide has fallen use of oral rehydration solutions at home and in by almost 90% to 5 000 today. The Americas health centres. have been declared polio-free and polio has Meanwhile in Senegal, a rapid broad-based disappeared from Europe and China. response to the HIV/AIDS epidemic has Transmission is now restricted to a band of sub succeeded in holding the spread of HIV at much Saharan Africa and the Indian subcontinent. As lower levels than in many other African countries. well as creating a polio-free world, polio The government acted swiftly - putting sex eradication activities are strengthening our education on the timetable in primary and capacity to tackle other preventable diseases. secondary schools, providing treatment for • Information on the Polio Eradication Initiative sexually transmitted infections, and actively can be accessed at www.who.int/gpv fl The end of the I i ne for some infectious diseases?
Throughout history only one infectious disease - corners of the world. Health workers have used smallpox- has ever been eradicated. Today, two camels, horses, dug-out canoes, boats and motor more diseases- polio and guinea-worm disease bikes to get the vaccines through. In many -are on the verge of eradication. Several more are countries polio immunization campaigns have gradually being brought under control or reduced been used to deliver vitamin A supplements as to a level manageable within the existing health well , increasing the impact of immunization on system. child health. These efforts to reach neglected But progress is not always straightforward. groups were made possible with the support of Environmental change, internal conflict, mass partners such as Rotary International and the population movements and the Centers for Disease Control collapse of basic health services and Prevention (CDC). can rapidly overwhelm efforts to But problems remain. Polio control infectious diseases. And, is still widespread in a few in the final stages when a heavily populated countries. disease becomes less visible, Worst affected are Afghanistan, progress is often hampered by Democratic Republic of Congo, complacency. Success can never India, Nigeria and Pakistan. be taken for granted. Many polio cases still go Today efforts are being undetected due to poor stepped up to ensure that polio reporting systems. Conflict is is eradicated by the year 2000. another frequent constraint, Prospects are good. Over the past decade the hampering vital mass immunization campaigns in number of reported cases fell from 35 000 cases war-torn countries and triggering a polio outbreak to about 5 000. The disease has been eradicated in Angola in early 1999. throughout the Americas and transmission now There is concern at the shortfall in funding appears to have been halted in the Western needed to carry out the final mass immunization Pacific Region, including China. campaigns. Once polio has been eradicated, Mass immunization campaigns which reach savings on vaccination costs worldwide will hundreds of millions of children in a few days have amount to $1.5 billion a year. The United States had a dramatic impact on the disease. Children alone will save around $250 million a year - the have been reached in some of the remotest amount it now spends on polio immunization Nearly eradicated or eliminated Polio Guinea worm Annual reported cases 1988-1998, worldwide Reported prevalence, worldwide
40
35 3000
(f) 30 ""0 (f) c ""0 ctl 25 c (f) ctl ::::l g; 2000 0 20 0 £ £ en en
5
0 1988 1990 1992 1994 1996 1998 Source: WHO/EPI
Neonatal tetanus Leprosy Annual reported cases, worldwide Reported prevalence, worldwide
30 6000
25 5000 (f) (f) ""0 ""0 c 20 tii 4000 ctl (f) (f) ::::l ::::l 0 0 15 £3000 £ en en
0 1990 1989 1993 1997
Source: WHO Source: WHO every year to prevent the re-importation of a plans to eliminate the disease. disease it has already eradicated. Almost ten million people have been cured of Guinea-worm disease is also on the way out. leprosy over the past 15 years in an effort to Over the past decade the number of cases has eliminate the disease by the year 2000. Today been reduced by 90%. The strategy used involves virtually every registered patient is receiving multi health education, case containment and provision drug therapy. The number of countries where the of safe drinking water. Guinea-worm disease is disease is a public health problem has been now restricted to 14 countries in Africa. reduced from 122 in 1985 to only 28. But leprosy Principal partners in guinea-worm eradication remains a serious problem in 16 countries which are UNICEF, the Carter Foundation and CDC, all together account for over 90% of all cases. working together to intensify eradication efforts. Today the efforts of WHO and its principal Over 100 countries have been freed of the partners - the International Federation of disease, but stumbling blocks remain. War and Antileprosy Associations and the Nippon social upheaval have frequently hampered efforts Foundation - are being stepped up to reach to eradicate guinea-worm disease. In one country neglected groups in remote areas. About half a the number of cases actually increased between million new cases are reported every year. While 1996 and 1998. global targets may be met by the year 2000, in Today there are fears that lack of resources some countries intensified efforts will have to could lead to a resurgence of both polio and continue for some time. guinea-worm disease in areas that are now almost Global efforts to control measles are being free of these diseases- reversing hard-won gains. hampered by continuing low immunization Success can breed complacency. A disease can coverage rates in some countries. In Africa, fewer rapidly become yesterday's story once it has low than two in three children today are immunized visibility and limited impact. against measles. And in ten countries fewer than Efforts are also under way to control or half of all children are protected. eliminate a range of other diseases. Neonatal Mass vaccination campaigns are now being tetanus has been eliminated in over 100 countries carried out in the highest-risk areas in some but the disease continues to kill almost 300 000 regions - especially densely populated deprived newborn babies every year, and tetanus kills urban areas. In the Americas, where the disease is about 40 000 mothers as well. The disease could targeted for elimination by the year 2000, over 90% be eliminated through immunizing women with of children are now immunized against measles. tetanus toxoid during pregnancy and ensuring Efforts are also under way to eliminate they have access to a safe delivery. But in 1997, lymphatic filariasis as a global public health only 64% of pregnant women were immunized problem. The elimination initiative has been made and, of the almost 50 countries where the disease possible by greatly improved diagnostic is still a public health problem, only 17 had national techniques and dramatic advances in treatment II Lymphatic filariasis in China vector spraying and now providing once-yearly community-based treatment with the drug Number of counties with infections ivermectin - supplied free by the manufacturer 800 Merck. In 1994, with partners including the World 700 (f) Bank, the African Programme for Onchocerciasis 600 ~ Control was established to ensure that the :::1 0 500 (.) disease is eliminated in the remaining 19 African 0 400 countries where it is a serious health problem. (ij ..0 300 E z:::1 200 100 Partnerships O~-L~1~9~81~_L~1~98~5~-L~19~8~9~~~19~9~3~ for long-term goals Source: National Technical Steering Group for Filariasis Control and Research, MOPH , in Chinese Journal of Parasitology and Parasitic Diseases, 1995 Seven infectious diseases - filariasis, leprosy, guinea-worm disease, tetanus, Chagas disease, methods - both for controlling the spread of the measles and polio-have been targeted by WHO for disease and for alleviating the suffering involved. eradication/elimination. WHO's immediate aim is to In addition, partnerships with pharmaceutical lower their prevalence so that they are more easily manufacturers SmithKiine Beecham and Merck managed by health systems. are ensuring that drugs are available wherever Effective public/private sector partnerships they are needed. are exemplified in WHO's Eradication and In Latin America, countries have made a Elimination Programmes against these seven political commitment to eliminate Chagas diseases. Like polio, the eradication of guinea disease. The first initiative was launched in 1991 worm disease is in its final phase with a by Argentina, Brazil, Bolivia, Chile, Paraguay and stubborn, but disappearing incidence in only 14 Uruguay. So far Uruguay has been successful. of the initial 20 countries where the disease was The strategy used involves screening blood rampant at the beginning of the campaign. donations and vector control. Diseases such as leprosy and lymphatic More recently, the Andean and Central filariasis, Chagas and measles are being American group of countries have launched eliminated, with the disease burden decreasing similar elimination efforts. One of the key tools dramatically. Partnerships include public and being used is a low-cost colourless latex-based private organizations and institutions, NGOs and insecticide paint developed within this region. the pharmaceutical industry. Onchocerciasis (river blindness) has been • Information on Eradication and Elimination virtually eliminated in 11 countries in West Africa Programmes is found at www.who.int/ctd and through a 20-year programme initially involving www. who.int/lep and www. filariasis.org/index Investing in healthy development
Effective medicines and control strategies are the amount provided to energy, transportation and available to reduce dramatically the deaths and communications projects. suffering caused by infectious diseases. Yet many Infectious diseases are a neglected concern governments are failing to ensure that these within this neglected sector. In 1990, bilateral, strategies receive enough funding to succeed. In multilateral, foundation and NGO partners some cases, this is because health budgets are provided just over $800 million to help developing unrealistically small. In other cases, it is because countries control infectious diseases. This health spending is poorly prioritized to address the represents less than 2% of total donor funds. This most urgent health threats. sum is considerably stretched since 50% of Some of the poorest countries have no more deaths in low-income countries are caused by than $7 a head to spend on infectious diseases. health care annually- making With these disparities, it is it difficult to ensure that even not surprising that a child born the most basic health needs in a developing country today are met. On average, health runs a 1 000-fold greater expenditures in 1994 in low chance of dying from measles income countries were $16 than a child born in an per capita. Comparatively, industrialized country. Or that average health expenditures children born in Singapore are in high-income countries were likely to live 40 years longer than more than $1 800 per capita. children born in Sierra Leone. Low-income countries However, more money is spend 4% of GOP per capita not the solution when provided on health, half the amount spent by wealthier to governments that fail to make cost-effective use countries. In many poor countries, spending is of resources. In some developing countries, 60% even lower. In Cameroon, Indonesia, Nigeria and or more of government health expenditures are Sri Lanka, for example, it is less than 2% of their devoted to meeting the operating costs of urban GOP. hospitals and expensive equipment. For the cost Donor assistance has helped supplement of a few expensive operations in such institutions, underfunded health initiatives. However, resources thousands of lives could be spared from infectious available for such support are relatively small. diseases. Health, nutrition and population projects receive One of the most important roles of the World less than 5% of donor support, which is a fifth of Health Organization is to assist countries in Limited funding
Health assistance
1.5% Infectious diseases 7.3% Other areas of health, Total donor nutrition and population assistance worldwide
Source: Global Comparative Assessments in the Health Sector
Health expenditures
2.6% Public sector Total GOP ....:::::::.....__ __~ 2.6% Private sector worldwide
Source: WHO, 1999 making optimum use of scarce health resources. Defending our borders With a budget representing only $0.01 out of every $30 spent on health worldwide, WHO Strong national defence must include provides technical and policy guidance that helps protecting the population increase the impact of larger public and private from microbial invaders. health budgets. WHO priorities for the control of infectious diseases in developing countries include $864 billion childhood immunization, integrated management Global military spending 1995 of childhood illnesses, use of the DOTS strategy to control TB, a package of interventions to control malaria, a package of interventions to prevent HIV/AIDS, access to essential drugs, and the overall strengthening of surveillance and health service delivery systems. Funds are urgently needed for implementing these and other cost $15 billion effective interventions to prevent further deaths Estimated global and suffering. spending for prevention It is in the best interest of all countries to and control of AIDS, support global initiatives to control infectious TB and malaria, 1995 diseases. Any segment of society that ignores the spread of infections among its neighbours does so at its own peril. When a country becomes a weak link in the chain of global surveillance and disease control, everyone is affected. And we must effectively use 23 million Military and civilian the tools we deaths have today from war LOBAL WARMING is creating more while there is 1945-1993 ecosystems that are still a window hospitable for deadly G of opportunity. 150 million diseases such as malari a and dengue. The optimum temperature Smallpox Estimated deaths from for mosquitos is between 25 and AIDS, TB and malaria 27'C. Increases in average provides a since 1945 temperature of just a few degrees very striking centigrade can transform a mosquito "no fly zone" into example. If a malaria breeding area. Source: US ACDA World Military Expenditures and Arms Transfers, 1996. smallpox had Ruth L. Sivard, World Military and Social Expenditures not been eradicated in a few remaining countries dollars in health care costs. in 1977, the world might still be paying a heavy These lessons have been overlooked. The price today. Unforeseen was the imminent progress that the world can make today against emergence of HIV/AIDS. infectious diseases may not be possible a decade Immunization with the smallpox vaccine - from now. Increased drug resistance and the made from a live weakened virus- would now be unforeseen emergence of new microbes could fatal for many people whose immune system is close the current window of opportunity for impaired by HIV. Just a few years delay and global controlling infectious diseases. eradication of smallpox may have become impossible without the discovery of a new vaccine. Had smallpox not been eradicated - at a cost then totalling $300 million- it could be among the Value for money top six infectious killers in the world today. Without past concerted efforts to fight the disease, With a budget not much larger than that smallpox would still be causing at least a million needed to construct and operate a large deaths a year and costing governments billions of modern hospital, WHO provides exceptional value for money. WHO contributes to healthy human development by: • setting standards of quality and safety for medicines and health products
IGHWAYS, heavily used • bringing together medical experts from by truck drivers who have around the world to coordinate research unprotected sex with roadside prostitutes, efforts Hhave unwittingly helped the spread of • monitoring and measuring disease trends infectious diseases. The AI DS . . ·n Africa spread first along epidemiC I the • alerting countries to unexpected disease commercial truck routes , such as Kinshasa Highway from Mombasa threats on the indian Ocean to NairObi , • mobilizing the world's response to health Kenya in the 1980s. ETS have helped speed the spread of infectious dis emergencies eases. In 1994, six • advising decision-makers on health people travelling on a MMIGRANTS are Jflight from Chicago to Hawaii were priorities deported in some coun· infected by a passenger who had tries when found to have TB. A flu outbreak occurred in • helping to direct donor resources to effec an infectious disease. 1979 among passengers on a fli ght tive projects IBut these harsh penalties often that had a three-hour ground delay do more harm than good, . with over 70% of passengers • identifying the most cost-effective policies causing immigrants to av01d being infected. seeking medical care and to and strategies for prevention and control. remain infectious. • WHO's web site is at www.who.int Many countries do not yet use WHO recommended policies
Money can be wasted in preventing and - and is effective in preventing the spread of drug controlling infectious diseases if effective public resistant forms of the disease. But it is still a health policies are not in place. Over the years, the strategy waiting to be used. In 1996, only 15% of World Health Organization and its technical all TB patients had access to DOTS. Only half of partners have redeveloped low-cost strategies WHO's Member States have adopted DOTS so based on clinical best practice in Member States, far. And of those that have, one in three have not operational efficiency, scientific breakthroughs, yet made the treatment available countrywide. cost-effectiveness and, above all, on what works In Eastern Europe - where TB rates are best. When deployed effectively, these strategies among the highest in Europe- the health system can save millions of lives. is still struggling to maintain The problem is that many outdated control measures countries are still not using these such as the unnecessary strategies - or not deploying annual screening of all children, them widely enough to make a revaccination and hospital difference. For example, treatment. Although several Integrated Management of pilot projects of DOTS have Childhood Illnesses, a strategy been launched in this region , with the potential to save millions expansion programmes have of children's lives every year, has been neglected due to lack of only been adopted in 57 political commitment, shortage countries so far and, to date, the of funds and an unsustainable strategy has not been implemented throughout supply of drugs. any one country. Expansion of IMCI and other Malaria is a particular risk for women during effective strategies is often slowed due to pregnancy. Pregnant women are more likely to die weaknesses in a country's health system, such as from malaria - either during pregnancy or at a the lack of available medical supplies or difficulties later date - due to chronic anaemia. Many suffer in retaining qualified- but extremely overburdened miscarriages or premature births and give birth to - medical staff. low-weight babies. Babies are occasionally even The DOTS strategy for TB is highly cost born with malaria after being infected in the womb. effective. It can detect the disease and cure up to To prevent this, WHO recommends that all 95% of TB patients -even in the poorest countries pregnant women in high-risk malaria areas should Health policy void
250
D Countries adopting WHO policies D Countries not adopting WHO policies
200 Adopted by all countries
(/) (j) ·;:: -~ 150 "- (j) ""0 -c cu 120 developing (/) (j) ·;:: countries only -c ::::l 0 100 () C\J T""" C\J
50
0 Routine HIV/AIDS DOTS to Integrated Management childhood education control TB of Childhood Illnesses immunization in schools • Number of countries not adopting an intervention where it would be appropriate to do so.
Source: WHO II Economic AIDS $14 billion burden prevention When infectious and health diseases are not care costs, worldwide, controlled , they can Malaria Drug BSE annually place a tremendous $500 resistance burden on economies. Cholera Plague million $3 billion $4 bil lion direct $770 $1.7 billion direct treatment million lost lost tourist costs, and costs, indirect seafood income Sub- US, UK, Economic export, and trade, Saharan annually savings Peru , India, 1994 Africa, 1997 1991 annually The cost of I I I I I I contro lling I I or elim inating infectious diseases Smallpox Polio is often recovered $1 .07 billion $1.56 billion many times over estimated projected in future savings. savings in savings Source: WHO direct costs annually 1997 prices be given antimalarial drugs to prevent infection. parental consent until they are 18. Yet almost one Yet fewer than one in five are protected today. in two teenage girls have had sex by the age of 16 Lack of funds and poorly functioning health and many teenagers are infected with HIV. During delivery systems are often to blame. 1998, as many as half of all new HIV infections HIV prevention efforts are being thwarted in worldwide were in the 15-24 age group. some countries by failure to implement some of Inexpensive vaccines available through WHO the key measures which would make a difference. and UNICEF prevent about three million child In many countries, HIV prevention campaigns are deaths a year and ensure that at least 750 000 not being targeted to young people - one of the fewer children grow up mentally or physically highest-risk age groups. In some countries sex handicapped. Yet in Africa, barely half of all education cannot be taught in schools. In others, children are immunized before their first girls often miss out on school health programmes birthday. Fewer than half of all pregnant women because they are unable to complete secondary are protected against tetanus which kills education. To make matters worse, there is little almost 300 000 newborn babies and about 40 000 provision in many countries for adolescent health mothers in developing countries every year. services that are both accessible and confidential. Hepatitis B vaccine which WHO In Zambia, one of the worst-affected countries, recommends for use in all childhood immunization young people cannot have an HIV test without programmes - has now been introduced in over 100 countries. But countries in sub-Saharan rate. Since the late 1980s, there has been a Africa, the Indian subcontinent, eastern and dramatic resurgence of the disease in Africa and central Europe, and the Newly Independent the Americas. States are still unable to afford this vaccine- even A 1993 cost-effectiveness study based on data at the preferential price for developing countries of from Nigeria showed that routine delivery of yellow $0.50 to $1 per dose. There are an estimated 350 fever vaccine would be seven times as effective in million chronically infected hepatitis B carriers reducing the number of cases and deaths as worldwide, who can transmit the disease for many firefighting epidemics with emergency mass years before going on to develop cirrhosis of the immunization. Yet out of 45 countries at risk for liver or liver cancer. Hepatitis B kills about 92 000 yellow fever, less than one-third use yellow fever people a year- but chronic hepatitis B contributes vaccine in routine immunization programmes. to another 700 000 deaths each year from cirrhosis and liver cancer. In many parts of Africa, Packaging Asia and the Pacific Basin, primary liver cancer is now one of the principal causes of death. Two interventions thirds of the world's population live in areas with high levels of hepatitis B infection. Consistent, cost-effective health services, Similarly, an inexpensive yellow fever vaccine including care, prevention and promotion, are has been on the market since 1937 but is still not required across peripheral health services available today in some of the countries most at where diagnostic capabilities and in-patient risk - among them some of the poorest countries care are at a minimum. They must be available in the world. WHO recommends that the vaccine to all age groups. By identifying and perfecting should be given routinely to all infants in the yellow the best clinical practice pathways, guidelines fever belts of Africa and South America as well as for diseases such as TB and other adult to people travelling to those countries. Yellow fever respiratory illnesses (Adult Lung Health is a viral haemorrhagic disease with a high fatality Initiative) are being developed and evaluated for effectiveness. At the same time WHO guidelines are being promoted for the
ITCHENS are often the Integrated Management of Pregnancy and place where foodborne Childbirth (IMPAC), for IMCI and for the infections, one of the most K common causes of acute syndromic management of STis. These cost illness, begin. Such infections are caused by toxins produced by bacteria effective "packages of care" prevent death and in the food before consumption or disability and ensure value for money at the directly by bacterial, viral and parasitic agents. Prevention and control of these periphery of health systems. diseases depends on educating food handlers in proper practices in cooking • Information on Packages of Care can be and storage of food and in personal hygiene. accessed at www.who.int/rht Many factors contribute to the spread of infectious diseases
In many countries, lack of funds and inadequate In developing countries, about 700 million use of existing cost-effective tools to fight infectious people - mainly women and children in poor rural diseases are compounded by a failure to take areas- inhale harmful smoke from burning wood account of the health impact of other sectors. and other fuels. They are increasingly at risk from All too often, the key determinants of health acute respiratory infections, especially pneumonia. as well as the solutions - lie outside the direct Over a billion people lack access to safe drinking control of the health sector. They are rooted in water - increasing their vulnerability to diarrhoeal areas such as sanitation and water supply, and parasitic diseases. In Africa, Asia and Latin environmental and climate change, education, America, at least 600 million urban dwellers live agriculture, trade, tourism, in unhealthy homes or transport, industrial development neighbourhoods. Almost 800 and housing. Yet many countries million people worldwide lack lack the capacity to measure the access to health services. impact of other sectors on health. Elsewhere, changes in land Unless these issues are and water use can also have a addressed, it can be difficult to major impact on the incidence prevent or even control some and pattern of disease. infectious diseases. Deforestation, agricultural The link between development, dams and environmental quality and irrigation schemes can trigger health, for example, is critical. outbreaks of parasitic or other Over 10% of all preventable ill-health today is due infectious diseases through favouring the spread to poor environmental quality- conditions such as of malarial mosquitos or freshwater snails that bad housing, overcrowding, indoor air pollution, spread schistosomiasis. Most at risk are the over poor sanitation and unsafe water. half a billion poor people who live in ecologically Bad housing and poor environmental fragile regions. Other diseases affected conditions have the greatest impact on acute by environmental change include lymphatic respiratory infections and diarrhoeal diseases. filariasis, dengue fever, leishmaniasis, Chagas And children are worst affected - accounting for disease and bacterial meningitis. as much as two-thirds of all preventable ill-health Meanwhile, an increase in global warming due to environmental conditions. could have a similar impact on the spread of Not only a health problem CJ Minor, indirect or no factor CJ Important factor D Very important factor
~\q, . i,\q, c:, ~,~ '3-~0 r:,O :1-'lJ. S ·~q,'-0 ~e~ :\ ~ Deforestation Climate change Irrigation projects and dams Poor sanitation and hygiene Hunger and malnutrition Illiteracy Low status of women Lack of adequate housing Increased travel and migration Lack of multisector coordination Lack of surveillance system Unavailability of health services Lack of prevention tools or strateQies Failure to use prevention strategies Lack of effective treatment Failure to use treatment strategies Lack of effective vaccine Failure to use vaccine Misuse of Rlllglaul lndllar* War, civil Other factors IJiblnlllton IJiblnlllton antibiotics - ...... disorder Source: WHO estimates, based on available inlormation tropical diseases. A temperature rise of only 1-2°C infrastructure development plans, laws, education, over the next 50 years could extend the range of labour policies and the exercise of human rights, malarial mosquitos further north - increasing the for example, in an effort to create an environment proportion of the world's population at risk of that makes it easier for people to avoid HIV/AIDS. malaria and other mosquito-borne diseases such This can involve providing incentives to enable as dengue and lymphatic filariasis. girls to finish secondary education, boosting job Poverty and malnutrition are other key factors and educational opportunities for women to break that affect health. Malnutrition is particularly lethal the cycle of economic and sexual dependency, in combination with infectious diseases such as and ending the criminalization of marginalized pneumonia, malaria, measles and diarrhoeal groups such as sex workers and injecting drug diseases - the major killer diseases affecting users. It can also involve carrying out impact children. It is an underlying factor in over half of all assessments for development projects to foresee child deaths. In 1997, an estimated 160 million ways in which schemes could fuel the epidemic - children were moderately or severely through accelerating the pace of urbanization, for malnourished. More than one in four of the world's example, or splitting up families through creating population were estimated to be living in poverty the need for a migrant labour force. over a billion of them with incomes of less than $1 In Thailand, where prostitution remains illegal, a day. Even in industrialized countries, 100 million the government's pragmatic approach to slowing people live below the poverty line. down the epidemic has brought a significant The critical need for collaboration between decline in infections - especially among the health and other sectors has been highlighted young. The multisectoral approach included work most recently by efforts to prevent HIV/AIDS. A with brothel owners to urge 100% condom use in few governments have attempted to reduce brothels, the launch of mass media campaigns to individual vulnerability to HIV/AIDS through a encourage respect for women and discourage cross-sectoral approach. The aim is to influence men from visiting sex workers, improved IVESTOCK are at risk of infectious diseases, just like OTHERS' breasffeeding ERVE GAS released in the humans. Increasingly, diseases habits are critical to the Tokyo subway system in that affect animals are entering healthy growth and March 1995 underscores L development of a child. the human population. BSE, also known as M the need fo r countries to be Improved breastfeeding alone can save N "mad cow disease· is a fatal disease of well prepared in counteracting deliber cattle involving degeneration of the central between 1 to 1.5 million lives each ate attempts to undermine human nervous system. It has been shown that year. When mothers breastfeed health with chemical and biological BSE in cattle and the new variant CJD are exclusively during the first four to six weapons. Governments are suspected caused by similar agents. It is believed that months of life, there is a dramatic of having already developed biologi 41 cases of CJD in humans are related to decrease in episodes of diarrhoea and cal weapons that make use of infec respiratory infections. Continued exposure to SSE-contaminated tissue, tious agents such as anthrax, plague breastfeeding helps speed probably brain or nervous tissue. and Rift Valley fever virus. recovery and reduces weight loss. educational and vocational opportunities for a private sector service organization, has raised women to keep them out of the sex industry and $500 million to fund vast quantities of vaccine for improved access to care, as well as economic and mass immunization campaigns and to help equip social support for people living with HIV/AIOS. a refrigerated cold chain for vaccine transport. In addition to the need for increased Rotary has used its global network of over 28 000 collaboration between the different public sectors clubs in 155 countries to enlist volunteers to carry which impact on health, there is a need to build out social mobilization campaigns, provide partnerships with the private sector. The recent organizational skills for immunization campaigns, launch of the New Medicines for Malaria Venture and administer polio vaccine drops to children. - a joint initiative by the public and private sectors to develop new antimalarial drugs - is an example Effective research of efforts to harness greater public and private sector collaboration in developing new products Research can help address the issue of inade for use in developing countries. Another example quate use of existing cost-effective tools. The is the donation of drugs by industry free-of-charge partnership of UNOP, World Bank and WHO in to help eliminate infectious diseases with a high the Special Programme for Research and disease burden in developing countries. These Training in Tropical Diseases (TOR) is testi include donations of drugs by pharmaceutical mony to the effectiveness of proper research. manufacturers SmithKiine Beecham and Merck In a recent TOR study in Ghana, simple for the treatment of lymphatic filariasis and river prepackaging of drugs meant that 82% of blindness, and Pfizer for trachoma. In addition patients complied with a full course of chloro vaccine manufacturers have occasionally donated quine tablets for malaria treatment, rather than vaccines during outbreaks of disease, such as 62% as in the control communities. In Kenya, meningitis, for polio eradication, and for vaccine after 14 shopkeepers serving a community of trials in developing countries. 5 000 were trained to offer information when WHO's efforts to eradicate or eliminate selling antimalarials and fever-reducing drugs, diseases are a collaborative effort by global the number of fever cases receiving treatment partnerships. WHO has forged strategic alliances with chloroquine increased from 2% to 49% and with governments, ministries of health in the number treated with an adequate amount of developing countries, international development chloroquine increased from 4% to 75%. Other banks, foundations, the private sector, civil society, studies on malaria treatment, including devel non-governmental and international organizations opment of artesunate in a form that will save the and other UN agencies. lives of children with malaria, are also a part of Global efforts to eradicate polio, for example, TOR's activities. have demonstrated what can be achieved through • Information on TOR can be accessed at private sector collaboration. Rotary International, www.who.int/tdr Diseases continue to catch the world off guard As the battle to control known infectious diseases 1993, an outbreak in the United States of a new continues, other new threats have emerged. disease, hantavirus pulmonary syndrome was Diseases once thought to be retreating have sparked off by a drought that brought disease made a deadly comeback. Even worse, new killer carrying rodents into closer contact with humans. diseases have emerged - many of them neither There were over 50 cases of the disease in preventable nor treatable. several States. More than two-thirds died. The situation is getting worse, not better. Over Meanwhile, changes in food production, the past two decades over 30 emerging diseases handling and processing have increased the have been identified in humans for incidence of foodborne diseases the first time. During the past ten such as salmonella, which comes years, outbreaks of old foes such from infected eggs, or a as plague, diphtheria, yellow fever, potentially fatal form of E. coli - dengue, meningitis, influenza and triggering outbreaks of disease. cholera have claimed many lives. In the early 1990s, a major The increase in mass epidemic of diphtheria swept population movements, the through eastern Europe. As the massive growth in international number of cases skyrocketed over travel, and the transportation of live the next three years the epidemic animals and animal products have was declared an international helped carry diseases into areas emergency. In 1980, Europe where they have never been seen before. In some accounted for less than 1% of diphtheria cases cases, environmental change - deforestation for worldwide. By 1994, almost 90% of reported cases example- has brought humanity into closer contact were occurring there. The region has also seen a with animals and insects that harbour diseases. dramatic increase in syphilis and other STis over Over the past decade, more than two-thirds of the past decade. In the Russian Federation emerging diseases are known to have originated between 1989-1995 there was a 40-fold increase in from animals - both wild and domestic species. infection rates for syphilis, while rates in the Newly Elsewhere, unusual seasonal weather Independent States increased 15-30 times. patterns can affect animal habitats and cause a In Africa during 1996-1998 there were clustering of new diseases that affect humans. In outbreaks of meningitis involving 300 000 cases Large outbreaks Selected outbreaks of more than 10 000 cases, 1970 - 1990 infected 200 people 344 cases Rift Valley fever ooo Dengue fever ooo and caused 600 deaths in Egypt in 1977. were reported in an outbreak in Havana, Cuba in May 1981 . Visceral leishmaniasis caused 1oo ooo deaths in the western upper Nile of Southern Sudan in 1985-87. Hepatitis C was first identified in North America in 1989. There may now be as many as 170 million infectious Diphtheria Since 1993, d!phtheria cases carriers of the disease worldwide. have skyrocketed in the Russ1an Federation and Newly Independent States. Over 50 000 cases were reported in 1995. Hepatitis A 300 000 cases were reported in an outbreak Cholera An outbreak of in Shanghai in 1989. cholera in Latin America infected over 500 000 people in 1991. Meningitis An outbreak in Sao Paulo in 1974 caused 30 000 cases. There were Typhus 100 ooo Dengue fever One out of five 187 000 cases in an outbreak cases emerged in in Africa in 1996. people in New Delhi, India, became Burundi between 1996 sick with this disease during a 1982 and 1998. outbreak. Anthrax In Zimbabwe over 10 ooo people became sick during the largest outbreak of anthrax ever reported in the 1970s. and 35 000 deaths. East Africa was hit by major human plague reappeared in Malawi, Mozambique cholera epidemics which affected tens of and India- after a 15-30 year absence. There was thousands of people in over ten countries. An an outbreak of epidemic typhus in Burundi from earlier cholera epidemic in the Americas- the first 1996-1998 which affected up to 100 000 people. for over a century - involved over a million cases The disease - which is carried by lice - has in the and about 11 000 deaths. In 1992 a new cholera past emerged during wars or famine. strain was detected in the Bay of Bengal and has Today there are other deadly diseases to already spread to ten other countries. contend with: HIV/AIDS, Ebola haemorrhagic Elsewhere dengue, and the more serious fever, Lassa fever, Marburg virus, a new form of dengue haemorrhagic fever, are also on the animal influenza in humans, Legionnaires' increase as the mosquito which carries the disease and a new variant of Creutzfeldt-Jakob disease extends its reach - establishing new disease (nvCJD). Some are believed to have habitats in the Americas and parts of Africa and emerged from rainforests and crossed the species Asia. Over the past 40 years the number of cases barrier to infect humans. Others are amplified from has increased at least 20-fold. And the number of deadly co-infections with diseases such as TB or cases of dengue haemorrhagic fever- which may occur after a second or third attack of dengue fever- has increased over the same period. The Funding is needed early to disease is now hyperendemic in many countries. prevent epidemics In 1996, seven countries in Africa reported deaths Donor fund ing for HIV/AIDS interventions from yellow fever - another viral haemorrhagic in developing countries disease which is spreading into new areas. Sudden explosions of rodent or human plague have occurred over the past decade. In 1994, RISONS often serve as incubators for infectious RPHANS. At least ten diseases. Malnutrition, over· million children are crowded conditions, squalor estimated to have lost P and lack of drugs all contribute to the one or both parents to 0 transmission of infections among either AIDS or TB in the past ten Inmates which then spread outside the years. Studies show that when a prison walls once infected prisoners are mother dies her children become Donor funding to released into the community. It is esti· Donor funding to support three times more likely to die as well. mated that in Eastern Europe alone, countries in the initial support countries where Orphans can be deprived of food, over 1.1 million prisoners suffer from stages of the AIDS AIDS is widespread shelter, emotional security and TB. Each year, approximately a quarter appropriate education all of which epidemic of prisoners are released, many of help them develop into healthy, whom are infected with TB and HIV. Source: WHO/GPA funding database as analysed in Pyne, National and well-adjusted and productive adults. International Response in the HIV/AIDS Epidemic in Developing Countries. 1997 Rapid increase of leishmaniasis and HIV/AIDS. An outbreak of Ebola haemorrhagic fever in dengue fever the former Zaire in 1995 was a dramatic reminder Average number of cases reported annnually of the need for constant vigilance in the face of emerging diseases. Although only a small 514,139 outbreak of 316 cases, over three-quarters of those who became ill died. About a third of the victims were health care workers who came into contact with blood or body fluids. Two years later, in a smaller outbreak in Gabon, there were 58 cases and 43 deaths. Ebola haemorrhagic fever is one of the most virulent infectious diseases known to medical science. No treatment or vaccine is available and 50%-90% of those affected die. 908 15,497 1955-59 1960-69 1970-79 1980-89 1990-98 Global alert Source: WHO and response Diphtheria in the Russian No country is safe from infectious diseases. In a world of rapid air travel, outbreaks of infectious Federation and Newly disease leave populations and nations Independent States vulnerable. WHO's Outbreak Verification Number of cases reported annnually network is linked to the WHO global 60 surveillance system, a worldwide network of 1995 NIS overa ll Vi laboratories and reporting sites that collects "0 50,319 cases c: 50 ro information on reported and rumoured Cf) ::::l outbreaks nationally and worldwide. Once 0 40 2- confirmed, information is made available Cf) (j) 30 immediately on the World Wide Web, and WHO Cf)ro () forms partnerships to investigate and contain 0 20 (jj those outbreaks which could spread ..0 E internationally and require concerted action. ::::l 10 z • Information on current outbreaks can be 1965 1970 1975 1980 1985 1990 1995 accessed at www.who.int/emc/outbreak_news/ index Source: WHO Ill Near misses Over the past two decades, explosive epidemics provide constant alert and rapid response to of unidentified and re-emerging diseases have outbreaks of endemic diseases, but also ready to given the world a few close calls. Some have respond to a sudden unexpected outbreak of a affected international trade and tourism. Others known or unknown disease. The emergence of the have led to the mass slaughter of poultry and farm HIV/AIDS pandemic in the 1980s is a devastating animals. Some have overwhelmed a country's example of what can happen when the world is health services and diverted resources from looking the other way. elsewhere. Almost all have caused fear and panic. Reporting systems are the intelligence network The appearance of pneumonic plague in that underpins disease control and prevention. Surat in India in 1994 led thousands to flee to Without this framework in place it is impossible to other areas -at the risk of spreading the epidemic track where disease is occurring, measure progress elsewhere. The outbreak in disease control targets, highlighted the need for good monitor antimicrobial drug disease intelligence systems. resistance, or provide an early Early identification of the cause warning system for outbreaks followed by a rapid response can and the emergence of new prevent a small outbreak from diseases. Surveillance data is becoming a major epidemic. also needed to assess where During 1997, the vast resources should go for majority of countries had at least maximum cost-effectiveness. one infectious disease outbreak. Today, efforts are under Several had as many as eight. way to strengthen national Some of the diseases involved - surveillance systems through cholera, plague, typhoid, and epidemiology and laboratory meningitis - were old foes. Others - like the new training, and to help countries establish integrated variant Creutzfeldt-Jakob disease, a bird influenza surveillance systems. The aim is to improve affecting humans for the first time and a virus surveillance capacity through streamlining carried by pigs - were less familiar. activities and establishing good reporting systems If a global disease surveillance system had in which information is shared- and used- at the not been in place the outcome could have been national, regional and global levels. This reinforced disastrous. Ultimately national surveillance approach is being pioneered in Africa. systems need to be strong enough, not only to At a global level, WHO has established an Unexpected outbreaks Examples of emerging and re-emerging infectious diseases 1994-1999 V Anthrax • Brucellosis Cholera 'W Crimean-Congo haemorrhagic fever • Cryptosporidiosis • Dengue haemorrhagic fever ,' ,/ ~ Diphtheria W Ebola haemorrhagic fever ~ Influenza A (H5N 1) W Nipah Ross River virus W E.coli 0157 w -w Influenza A (H9N2) ~ Omsk haemorrhagic fever w Typhoid ~ Echinococcosis w Lassa fever "W O'nyong-nyong fever w Venezuelan equine ~ Enterovirus 71 encephalitis "W Leptospirosis ~ Plague W Epidemic meningitis West Nile fever "W Lyme borrellosis 'W Poliomyelitis w ~ Hendra Yellow fever "W Malaria W Reston virus ~ W Human monkeypox New variant CJD ~ -w Rift Valley fever Source: WHO Reported outbreaks of known infectious diseases, 1998-1999 As of April 15, 1999 Other Plague Yellow fever Anthrax Acute respiratory infections Acute haemorrhagic fevers Enteric infections Meningoccal disease Cholera 0 10 20 30 40 50 Number of outbreaks Source: WHO epidemic intelligence team who monitor and verify authorities responded by establishing an reports of outbreaks anywhere in the world and intensified surveillance network and by destroying provide a response team, where needed. WHO all live poultry stocks. By the end of 1997, only 18 has also developed a global alert system which cases had been confirmed. The virus did not prioritizes surveillance for diseases such as appear to have been transmitted person-to influenza (FiuNet), rabies (RABNET), HIV/AIDS, person and the threat of a pandemic receded. In Creutzfeldt-Jakob disease and related diseases. 1999, the new system detected and reacted to yet In 1997, FluNet picked up reports of a new another new type of animal influenza in humans. form of human influenza transmitted from birds. Every year FluNet gathers surveillance data This virus had killed a three-year-old boy in Hong from around the world on the various strains of Kong SAR. The incident sparked off fears of a new flu virus that affect humans. Twice a year, pandemic which - unless contained - could recommendations are made to manufacturers on spread to other continents and kill millions. In the the content of the next year's influenza vaccine so 1918 influenza pandemic 20-40 million people that effective vaccines are available each year. died in one year - more than the total deaths In 1996, Africa experienced the world's largest during the First World War. It could happen again. recorded epidemic of meningitis involving over Six months later another outbreak caused 17 187 000 cases and 20 000 deaths. At the time, cases and five deaths. Through a rapid outbreak vaccine stocks were exhausted and countries response - which sampled over 1 800 animals were late in recognizing the outbreak. To make and birds- the virus was traced to live poultry. The matters worse, the wealthier countries started Newly identified infectious the purchase and distribution of an emergency stock of high-quality vaccine and injection diseases and pathogens equipment. Countries get rapid access to the emergency stock of vaccine at a preferential price. 1999 Nipah virus Early warning systems and prompt 1997 H5N1 (avian flu) intervention to contain an outbreak can be highly 1996 nvCJD cost-effective as well as saving lives. In Peru , an Australian bat lyssavirus 1995 HHV8 (Kaposi sarcoma virus) epidemic of cholera in 1991 cost an estimated 1994 Sabia virus $770 million in lost trade and tourism - almost Hendra virus one-fifth of normal export earnings. Three years 1993 Hantavirus pulmonary syndrome later the epidemic of plague in India resulted in (Sin Nombre virus) losses totalling $1.7 billion. Hotel bookings fell by 1992 Vibrio cholerae 0139 20%-60% and one airline lost $1 million a week. 1991 Guanarito virus Elsewhere, the mass slaughter and destruction of 1989 Hepatitis C cattle, pigs and poultry in the United Kingdom, 1988 Hepatitis E Malaysia and Hong Kong SAR respectively, have Human herpesvirus 6 caused heavy economic losses. 1983 HIV 1982 Escherichia coli 0 157:H7 Lyme borreliosis HTLV-2 virus First-line defence 1980 Human T-lymphotropic virus 1977 Campylobacter jejuni against flu 1976 Cryptosporidium parvum The WHO Influenza Surveillance Network is Legionnaires' disease the first line of defence against epidemics and Ebola pandemics of influenza. The Network ensures the rapid detection of new strains of influenza buying up vaccine - in excess of real needs. viruses around the world and also helps to Countries with vaccine stocks were using it determine the composition of next season's sometimes in an unplanned way and with unsafe influenza vaccine. Once a new virus has been injection equipment. detected and isolated, it is stored for possible In response WHO established an interagency inclusion in a future flu vaccine. group to monitor the incidence of meningitis and • This global system of surveillance, including coordinate the emergency supply and fair over 11 0 laboratories in 83 countries, provides distribution of meningitis vaccine for countries in a model for other global networks and can be greatest need and ensure that it was used safely. accessed at http://oms.b3e.jussieu.fr/flunet The group estimates vaccine needs, and oversees Medicines are losing their effectiveness The dramatic upsurge in the spread of drug And the cost of treatment for acute respiratory resistant microbes over the past decade is infections - the most frequent cause of child undermining today's efforts to control infectious deaths - increases from $5 to $40 for a course of diseases. As diseases once thought to be under antibiotics. control become increasingly resistant to the In addition, multidrug-resistant forms of arsenal of available drugs, the spectre of incurable diseases can become untreatable in any country infectious diseases looms large. The fight against - at any price - once the options have been five of the six deadliest diseases - TB, malaria, exhausted. Pharmaceutical manufacturers have pneumonia, cholera and HIV- is severely affected. found it difficult to develop new antibiotics and Although antimicrobial other drugs fast enough to resistance affects industrialized replace those that have become and developing countries alike, ineffective. its impact is far greater in Tuberculosis: A 1997 report on developing countries. The anti-tuberculosis drug resistance problem is that the switch from pinpointed "hot zones" around normally less expensive first the world where a significant line drugs to second or third-line percentage of cases are drugs involves a dramatic resistant to the most commonly escalation in the price of prescribed drugs. Unless treatment. In some of the checked, this could propel a poorest countries, the wave of tuberculosis that is prohibitive cost of lengthy difficult - even impossible - to treatment and replacement drugs means some cure using drugs. In some countries in eastern diseases are too expensive to treat. Europe, more than one in five TB patients have In low-income countries - which may spend multidrug-resistant TB. no more than $7 per capita on health - the cost Malaria: Chloroquine - once the first-line of treating a case of multidrug-resistant TB, likely treatment - is no longer effective in over 80 of the to be as high as $1 500- $4 000 a patient, is out of 92 countries where malaria is a major public reach. In some Asian countries, the cost of treating health problem. In some places in Africa people a child for bacterial meningitis increases from $20 use chloroquine more often than aspirin -taking it to $110 whenever second-line drugs are needed. regularly for minor fevers, aches and pains. This Antimicrobial resistance Malaria Quinine and mefloquine in Thailand Tuberculosis 45% Note: There is already Short-course chemotherapy in resistance complete resistance to Portugal 13% chloroquine and single sulfadoxine drug pyrimethamine in ~------1 resistance Thailand Staphylococcus 4% multidrug resistance in Japan Source: Anti· TB Drug Resistance in the World, WHO 1997; Report on Malaria Control Programme and Drug Resistance in Thailand, 60% multidrug resistance Sirichaisintop and Banchongaksorn, 1997, WPRO -' increases the rate of resistance. To make matters Gonorrhoea: In some countries, 98% of worse, mosquitos are now resistant to the three gonorrhoea cases are resistant to penicillin. If left most commonly used insecticides. untreated, gonorrhoea heightens the risk of infection with HIV and can cause infertility, Pneumonia and meningitis: In some countries, miscarriages, stillbirths and blindness. up to half of all cases of the most common forms Hospital infections: Hospital infections of men ingitis and pneumonia are now resistant to acquired by patients after admission to hospital penicillin. Even under optimal treatment, 10-30% - are now a leading cause of death in some of patients with meningitis suffer permanent brain countries and up to 60% of hospital infections are damage depending on age, treatment and caused by drug-resistant microbes. In the United infectious agent. States, 14 000 patients die every year from drug resistant bacteria they picked up in hospital. Dysentery: In some countries, up to 90% of all cases are resistant to the two fi rst-line drugs. In Leishmaniasis: In certain parts of India, over central and southern Africa epidemics of dysentery 60% of visceral leishmaniasis cases no longer over the past decade - including those in refugee respond to the first-line drug. camps - have included drug-resistant forms of the Widespread misuse of antimicrobial drugs lies disease. Up to 15% of those infected died. at the root of this crisis. This happens in developing and industrialized countries alike. Typhoid: Since 1989, 11 countries have been hit Overprescribing is rife. Antibiotics are often by epidemics of multidrug-resistant typhoid fever. prescribed for the wrong kind of infection . The Without effective treatment typhoid kills almost dosage may be wrong and treatment may be 10 % of those affected. prescribed for the wrong length of time. In Canada and the United States studies indicate that approximately half of all outpatient UARANTINE was used for the first time in 137 4AD as result of a decree voted by the city of Venice by which all ships Q TREET CLEANING The entering the port of Venice ODENTS have been budget for street cleaning in would remain in complete isolation for a the main carrier of New York City is larger than period of 40 tquaranta) days. It is said the many diseases. such the entire budget of the bubonic plague entered Italy and the rest of as Lyme d' S Rinfects A . •sease which World Health Organization. One Europe from Asia via the ports of Genoa 17 000 industrial nation alone spends twice and Venice. Quarantine was used then to year and lassa ,mencans every as much on pets than the amount prevent transmission of new epidemics Rodents h ever m Africa. ave also h I needed to prevent half of the deaths across Europe. It is only used today to spread of 8 e Ped the outhAm · currently caused in developing restrict animals who may have been orrhagic fe"er . encan haem- • v~ruses th countries by AIDS, TB, malaria and exposed to infectious diseases and taviruses and th . e han- e plague. basic childhood diseases. continues to carry the same name. prescriptions for antibiotics are unnecessary. In a Pen ici IIi n-resistant study in Viet Nam, over 70% of patients were given inadequate dosages. gonorrhoea in Viet Nam Even where the prescribed treatment is correct it may not be followed. Once the symptoms 100 disappear people often stop taking the antibiotics - increasing the risk of developing drug-resistant 80 forms of disease. In developing countries (/) m 6o antibiotics can be bought without a prescription Cll () and self-medication is commonplace. 0 To make matters worse, some of the drugs on -~-·- The world is becoming a smaller place for microbes In the Middle Ages deadly plagues were shipped people who had refused immunization. from one continent to another - carried by flea In South Africa in 1996, a health worker was infested rats on board ships. Today they travel by infected with Ebola by a patient who had entered plane - carried by airline passengers from one the country to seek medical care during an corner of the earth to another. And all in a matter outbreak in Gabon. The South African government of hours. asked WHO to establish a screening system for As the number of international airline airline passengers travelling from other parts of passengers has soared from Africa. two million a year in 1950 to In the early 1990s, a flight over 1 .4 billion today, the world attendant with active TB is has been slow to recognize the believed to have infected up to implications for public health. 23 fellow crew members over the Deadly airborne diseases course of several flights. In 1994, such as pneumonic plague, a person with active TB is influenza and TB can easily believed to have infected six spread in crowded airport fellow passengers on a flight lounges, on a jumbo jet or by from Chicago to Honolulu. passengers after their return In 1996, travellers returning home. And infectious diseases to the United States and can also be carried across Switzerland developed yellow borders by their animal or insect hosts. Disease fever. They had not been vaccinated against the does not respect national boundaries. disease. In the United States in 1977, over 70% of the There have been reports of a surprising passengers on board an airliner grounded for number of malaria deaths in northern countries several hours were infected with influenza by a following unrecognized infection through a blood fellow passenger. transfusion or a one-off mosquito bite near an In 1978 and again in 1992, poliovirus was international airport. Brussels, Geneva and Oslo imported into Canada by people travelling from have all had recent cases of airport malaria. western Europe. Eleven people were affected by Malaria deaths are not uncommon among polio paralysis in the first outbreak - all of them travellers who develop unexpected fever after Frequent flyers Most popular air routes between continents, 1997 ~ ·~.~· .. / " .. Tokyo Los Angeles .· . . '. -' /. Johannesburg . 32% bt 44°/o 46°/o 32% y Americas Europe Africa Middle East South East Asia Asia& Pacific Percentage increase in international arrivals, 1993 to 1997 Source: World Tourism Organization/International Civil Aviation Organization II returning to their home country. In northern Diseases affecting tourists countries where the disease is rarely seen, Exiting tourists with infectious diseases, Thailand 1995 doctors may fail to diagnose malaria in time. Infectious diseases can cross borders in other Respiratory ways too. In 1985, the aggressive tiger mosquito - infections 8% normally found in Asia - slipped unnoticed into the United States inside a shipment of water-logged Fever (cause unknown) 6% used tyres from Asia. Within two years the mosquitos - capable of transmitting yellow fever, Hepatitis 4% dengue and other diseases - had established Gonorrhoea 4% themselves in 17 States. In Sub-Saharan Africa, HIV was spread Other 10% among migrant workers, who later carried the disease back to their homes, and by lorry drivers, who bought sex at truck stops on their way across the continent. Tourism, international travel and migration are Source: Ministry of Health, Thailand Quoted in WHO/EMC Annual Report, 1995 all helping to spread disease. The number of refugees and displaced people has increased nine-fold over the past two decades. In 1996, as Malaria in the United Kingdom many as 50 million people worldwide had been A total of 8 353 cases of imported malaria uprooted from their homes - 1% of the world's in the United Kingdom between 1987-1992 population. Refugees and displaced persons living in overcrowded, unsanitary conditions are at Immigrants 11 % risk of outbreaks of cholera and other waterborne Visitors to the UK diseases. 19% In 1991 in Peru, YRES, discarded or left on the a ship carrying streets, store enough water to contaminated water provide a habitat for mosquito T larvae. Discarded tyres have from Asia in its ballast served as the breeding grounds for a Tourists 16% large outbreak of dengue fever in Rio de tanks sparked off Janeiro, Brazil. In 1985, dengue was a cholera epidemic that introduced into Texas, U.S from a shipment of used tyres from Asia. spread rapidly The tiger mosquito - a super-mosquito throughout South and strong enough to withstand North Expatriates 5% American winters - entered the United Central America. About States in a load of used tyres. 11 000 people died. Source: Behrens, Travel Morbidity in Ethnic Minority Travellers II The International Health Regulations require Increased international travel governments to report all cases of three diseases - cholera, plague and yellow fever. The aim is to provide a rapid international alert system for 500 diseases of international public health importance. enc The system is designed to steer a course between .Q 400 maximum protection against these diseases and E minimum interference with world traffic and trade. - But many countries fail to report outbreaks - deterred by the threat of potential economic losses. And the rules are difficult to enforce. Today these regulations are being revised and broadened to provide an early warning about outbreaks of any deadly diseases. An outbreak anywhere in the world must now 1950 1960 1970 1980 1990 be treated as a threat to virtually all countries - Source: World Tourism Organization , 1993 especially those that serve as major hubs for international travel. Without an active global disease surveillance system in place to provide an Hi-tech disease early warning of outbreaks, the export of infectious diseases could become a growth industry. mapping The latest computer technologies are used in Spread of meningococcal meningitis by HEALTHMAP, the WHO/UNICEF partnership pilgrims returning from the Haj, 1987 for mapping infectious diseases. Through com puter-generated geographical display systems the prevalence of infectious diseases is mapped in relation to the surrounding topography and health care infrastructure. This powerful technol ogy permits reconciling health problems with the needs in countries or at the regional or glob al level. HEALTHMAP's simplified training pro grammes permit transfer of mapping technology to those countries most in need. • HEALTHMAP information can be accessed at Source: WHO www. who.int/ctd/html/hmap.html Development of new drugs and vaccines Over the past few decades we have learnt to our development today are vaccines against acute cost that diseases are an ever-moving target. respiratory infections, diarrhoeal diseases, Dangerous microbes adapt to survive. And we HIV/AIDS, malaria, tuberculosis and dengue. must always be one step ahead if we too are to Of these, a vaccine against HIV/AIDS is arguably survive. The race is on to find new low-cost tools the most important since no cure exists and which can be used not only to step up the mortality is high. For people living with HIV/AIDS prevention of diseases, but to improve and today the disease is still fatal , although some have accelerate their diagnosis and treatment as well . access to life-prolonging drugs. In drug development, Efforts are also under way to urgent efforts are under way to reach the one in five children who develop new drugs to treat are still not immunized each year diseases like malaria, through national immunization tuberculosis and pneumonia programmes. This includes which are rapidly becoming efforts to lower vaccine delivery resistant to first-line drugs. costs, simplify the administration Without a new generation of of vaccines, and reduce the low-cost drugs, some diseases number of immunization contacts could become untreatable in needed. countries which cannot afford to buy more expensive second HIV/AIDS vaccine line drugs. Also being tested are Until now, efforts to develop a safe new combination therapies to treat diseases such and effective vaccine have been hampered by as lymphatic filariasis, river blindness and malaria failure to evoke or identify a protective immune - using more than one drug to increase response. However, the recent launch of the first effectiveness and lower the risk of developing ever large-scale human trials of HIV vaccines in the drug-resistance. Other priority drugs include a United States and Thailand represents a major new oral drug which could help reduce deaths step forward. If these efficacy trials are successful, from visceral leishmaniasis and a new, non it is hoped they will pave the way for the injectable, quick-acting drug to treat severe cases development of similar vaccines to protect against of malaria. HIV/AIDS in Africa. Even if they are not successful, Top of the global priority wish-list in vaccine -they are expected to provide valuable information In the pipeline Pre-development Preclinical ry Post-regulatory Research to discover Developing potential Testing in humans for Registered and new tools. new tools and safety safety and efficacy. on the market but - testing in animals. being investigated further. Chagas disease Onchocerciasis/ Lymphatic filariasis Leishmaniasis ALA+ IL-12 ALM/alum+BCG ALM+BCG id Recombinant cocktail for Old World ALA+BCG id for New World MLA im for New World Schistosomiasis Paramyosin+Ouii-A GST+alum (Sh28) GST (Sj26) GST (Sj28) Malaria Sleeping sickness CGP 40,215 Eflornithine SIPI-1 029 analogues Note: These are examples of just a few of the many drugs and vaccines under development for infectious diseases. Source: WHO/PAD for future research efforts. The trials involve 5 000 Four manufacturers are now carrying out volunteers in the United States and 2 500 clinical trials on new pneumococcal vaccines. The volunteers in Thailand. Results are due in 2001. most promising are modelled after the Hib Until recently, research has been hampered conjugate vaccine which has been highly by the lack of animal models to test vaccines and successful in reducing bacterial meningitis and by the ability of the virus to mutate with every new pneumonia in the industrialized countries. infection. As most initial vaccine research focused on the type of virus most common in North Malaria vaccine America and Europe, research must now be The need for malaria prevention measures and intensified on virus types from developing the spiralling rate of resistance to antimalarial countries, where over 90% of infections occur. drugs could be reduced by an effective vaccine. But no effective vaccine has yet been developed Pneumococcal vaccine against a parasite - and the challenges are Although low-cost drugs are available to treat formidable. pneumonia, many children die because they fail to A large number of malaria vaccines are under get treatment in time. And the disease is development. Several of the more advanced are becoming too expensive to treat in some countries now being tested in Asia, Africa and the United as the available drugs become less effective due States. The most extensively studied is a vaccine to increasing drug-resistance. Although developed in Colombia (SPf66). Although initial pneumococcal vaccines already exist, they are promising results have so far not been replicated not effective in children under two - the highest in other studies, this vaccine has now been risk age group. modified to increase its potency. And there are A new, improved vaccine would be a major hopes that this second-generation vaccine could breakthrough in preventing pneumococcal provide the much-needed breakthrough in malaria pneumonia - the biggest childhood killer. prevention. Another advanced-stage vaccine, which might be able to prevent the onset of disease in someone already infected, is now EGETARIANS · 2lo' f · ' 0 o read- ers polled by the Bu . being tested in the Gambia and Kenya. The cost RBANIZATION facilitates r; smess the spread of infectious dis thlmes of Singapore claimed of developing a malaria vaccine has been eases. The average child In V ey were becomin ans as a resu lt of mad co . g vegetari- a developing country slum estimated at $50 million over the next 10 years. U flu. Japanese ence .. w disease, bird is 40 limes more likely to die from food Phahlls and recent scares. Many fo db preventable infectious diseases than are caused by . o orne diseases a child living in rural settings in the an mfectio . meat and poultr us agent m New antimalarial drugs same country. Some of the last cases fruit and Y products or in fresh vegetables H . of smallpox in Asia were found within causes severe I. . uman fascioliasis One promising new product is an oral treatment slums of major metropolitan areas. . lver Problem Infectious agent . t s and the Cholera and diarrhoeal diseases are IS ransmitted b . for cases of uncomplicated malaria in Africa. Watercress and othe . Y eat1ng also rife in urban slums where water contaminated b . f r aquatic plants Development of this new drug (a combination of and sanitation are poor. Y m ected snails. chlorproguanil and dapsone) is a collaborative effort involving the UNDP/World Bank/WHO efforts to protect women who are unable to Special Programme for Research and Training in enforce condom use. Tropical Diseases (TOR) , the United Kingdom Women are biologically more vulnerable than Department for International Development men to sexual transmission of HIV and account for (DFID), and the pharmaceutical manufacturer 75% of all new infections today. Unlike the female SmithKiine Beecham. condom, which is visible, vaginal microbicides Another promising new product is a could be used without a male partner's consent. suppository (artesunate) for malaria sufferers who are too sick to take oral medication. It is quick acting, easy to administer and can "buy time" for people with severe malaria living in remote areas who might not survive the journey to hospital. Providing finance for malarial drugs Diagnostic tests for sexually transmitted infections (STis) WHO's new Medicines for Malaria Venture New diagnostic tests for sexually transmitted (MMV) is a joint public-private sector initiative infections (STis) currently under development could which aims to develop antimalarial drugs and help prevent thei r spread, ensure prompt and more drug combinations for distribution in poor countries. Partners include the World Bank effective treatment and provide a valuable weapon ' in the fight against HIV/AIDS. The currently Global Forum for Health Research, The available tests are too expensive for use in Rockefeller Foundation and the Wellcome Trust. developing countries and laboratory analysis is not Industry participants include the International always available. To make matters worse Federation of Pharmaceutical Manufacturers ' syndromic case management - a cost-effective Associations and the Association of British way of treating STis on the basis of the symptoms Pharmaceutical Industries. alone - is often inadequate for women as they may MMV will help develop new drugs for malaria have no symptoms of infection. Simple diagnostic at a rate of one every five years. MMV will tests are also required for other diseases including create a fund and operate by financing and TB and malaria. resourcing projects in a cost-effective manner. A funding commitment of $15 million a year, rising Microbicides to $30 million, is being sought. MMV aims to Efforts are continuing to develop a vaginal accelerate R&D on new drugs and bring them microbicide that could inactivate HIV and other to the market. microbes that cause sexually transmitted • Medicines for Malaria information can be diseases. This would be a major breakthrough in accessed at www.who.int/ctd The need for intensified research Infectious diseases figure low on the global health improve compliance and replace drugs that have research and development agenda. In 1992, been compromised by antimicrobial resistance. global spending on health research was $56 Equally important is the need for research to billion -less than 4% of total global expenditure on find ways of making more widespread and better health. And of that, no more than 10% was use of existing cost-effective tools such as allocated to research relating to the health needs vaccines, multidrug therapy, bednets and an of developing countries - mainly infectious integrated approach to childhood illness. diseases. Meanwhile, research is also needed to establish The combined investment in research and the disease burden in individual countries, so that development into ARI , diarrhoeal diseases and TB health systems can respond effectively to today's - which kill over 7 million people and future health needs in the a year- was $133 million( about most cost-effective way. 0.2% of global spending on A top priority today is the health research and urgent need to develop new development). Yet these three low-cost antimicrobial drugs diseases together account for to replace drugs that have almost one-fifth of the global become ineffective due disease burden. Malaria, which to antimicrobial resistance. accounts for 3% of the disease Without this ongoing research burden globally and almost 10 % and development, diseases in sub-Saharan Africa, fared as such as TB, malaria, poorly- attracting about 0.1% of pneumonia and dysentery research funds. could become untreatable in countries which In contrast to the limited funds available, the cannot afford available second- or third-line drugs. research needs for infectious diseases are vast. To help accelerate the discovery of new drugs Some of the research needed involves cutting to treat malaria, a new joint initiative has been edge science - sequencing the genome of the launched involving both the private and public major disease-causing microbes, for example, or sector. The New Medicines for Malaria Venture discovering ways of slowing the spread of (MMV) aims to develop one new affordable antimicrobial drug resistance. Other critical antimalarial drug every five years. research needs include the discovery of new Elsewhere, research is under way to develop affordable drugs, vaccines and diagnostic tests. In new low-cost drugs that could improve compliance some cases, these are needed to lower costs, with drug therapy by shortening the course or Health research budgets 100% 80% 60% 40% 20% 2o/o t Health research by both public and Global health R&D funding devoted to AIDS, private sectors devoted to health malaria, acute respiratory infections, diarrhoeal problems in developing countries. diseases and TB. Source : Global Forum for Health Research. 1999 Source: Investing in Health Research & Development, 1996 ..~. Vaccines licensed simplifying the treatment. The drop-out rates for DOTS therapy for TB, for example, could be since 1900 greatly improved if the multidrug therapy could be combined in a single tablet and the length of 1900-1950 treatment reduced from the minimum 24 weeks now required. For leprosy, efforts are being made 1951 -1998 to develop new drugs which could both increase Number of vaccines the effectiveness and shorten the duration of multidrug therapy. Source: Mandell. Pri nciples and Practice of Infectious Diseases A new generation of vaccines is under development which could save millions of lives. the tuberculosis-causing microbe in 1998 was a Dramatic advances in genetic engineering have major breakthrough that is expected to shed more produced a raft of vaccine contenders that will light on which genes cause TB and to speed up simplify immunization, boost the performance of the development of a more effective vaccine. existing vaccines and protect children against Meanwhile progress in microbial genetics is also diseases which are not yet vaccine-preventable. In driving the development of new, improved addition, new vaccines against diseases such as vaccines against meningococcal meningitis, TB, malaria and acute respiratory infections could dengue fever and Japanese encephalitis. provide the first line of defence against drug In addition to the need to develop new or resistant microbes. Vaccines under development improved vaccines, research is also under way to to address rotavirus, cholera, typhoid and shigella simplify the administration of existing vaccines, will help reduce the burden of disease caused by reduce delivery costs, and boost immunization diarrhoeal disease. coverage. This includes research into ways of The successful sequencing of the genome of reducing the number of immunization contacts 2K problems {the Year 2000 bug) could potentially affect public health natrona! and global efforts to control ·TRA SMALL condoms AGES of health . rnfectrous diseases. Some countries are seldom available in Y are str /1 not rmplementing corrective measures workers are very low l atin America's in many countries ~oh compensate for Y2K computer malfunctions machismo culture reducing the capacity X rs could mean that infectious disease data . (x·tra large sizes are). Most of the Wof the health services to attract ~tat r st r cs and electronic patients' records couid region's 40 million street . e affected o r lost in cyberspace; patients' drug skilled staff. Many qualified health children are unable to obtain rntake, monrtorin g and follow up, particularly workers migrate from rural to urban condoms of any size, large or Important fo r TB and HIV patients, could areas for better employment. small. Not surprisingly, at least become untraceable. Cross-border trans In times of economic cri sis in their 2% of Brazil's street children are mrssron of electronic information on epidemics own countries they may emigrate believed to be infected with H 1 v. and outbreaks could also be affected. to seek work abroad. that are A number of initiatives have been launched to needed help improve the use of existing tools. They e parks are oos circuses and gam . through include efforts to improve the home management r' the effeCtS of infectiOUS fee lng Tigers cheetahs, lions, combining of malaria and other childhood diseases and diseases. ' nts in Kruger leopards and e_lepha been diag- several provide clear information about the need for South Afnca haVe ZNational Park, . The disease is also prompt referral for severely ill children. nosed with tu berculoS I S~r threat to some 42 vaccines considered to be a m::rica's Hluhluwe/ in a single Studies are being carried out to improve the 000 buffalo 'n South U ·ted States recently, 01 Umtolozi Park. In the h ts became infected dose and follow-up by parents of health care advice from a group of circus elepd anore than half of the combining health workers and studies are under way to with TB. One died an . mthe circus shOwed 22 elephant handlers~~ - In France and the several determine why some parents fail to seek care for signs of exposure to . rous animals in zoos United Kingdom ca~n~:: diseases. booster sick children before it is too late. have died from ma doses in a Similarly, research is also critically needed to sing I e find ways of ensuring that newer, more expensive slow-release dose. Another priority is the vaccines such as Hib and hepatitis B- which have development of new, safer ways of delivering proved so successful in the industrialized countries vaccines- orally or nasally- that minimize the risk --can now be introduced into developing countries. of injection hazards. Research is also needed to develop low-cost rapid diagnostic tests to improve the accuracy of diagnosis and accelerate the start of appropriate Into the treatment. Although rapid diagnostic dipstick tests for malaria are in the final stages of development, new millenium they are currently too expensive for widespread Investment in health research and development use in developing countries. Tests are also needed must be focused on disease priorities. WHO's for TB, gonorrhoea and sleeping sickness for use Global Burden of Disease appraisal for the in developing countries. year 2000 will provide the information for priori However, in the short term a great deal could ty setting. Through detailed epidemiological be achieved through research into ways of estimates and projections, over 1 00 improving the use of existing tools - one of the diseases will be studied and their impacts eval most neglected areas of research. A 1997 study uated. Risk factors for disease will also be by WHO on TB research funding, involving 17 assessed and their importance projected under public and non-profit research funders, found that various scenarios. most of the $92 million they spent in 1995 was to Appraisals such as these will help to ensure extend the knowledge base and develop new the availability of the tools necessary to effective tools. They spent least on research to improve the ly continue the fight against infectious diseases. use of existing tools such as DOTS. • A call for healthy development By Dr Gro Harlem Brundtland uphill struggle in many countries where the Health indicators are a common measure of workforce has been devastated by HIV. In the progress. For decades, governments and donor United Republic of Tanzania, the investments in agencies have used life expectancy and infant education required to yield expected standards mortality to demonstrate the impact of social and have been increased substantially because economic development. The underlying HIV/AIDS is affecting an increasing number of assumption for this is sound. By improving the teachers. Additionally, 20% fewer children attend economic prosperity of countries in a sustainable school because parents are ill or dying as a result and equitable way, improvements in health usually of HIV/AIDS. follow. Good health is at the The opposite is also true. heart of poverty Development and a good social alleviation infrastructure are indicators of a healthy population. Where there How does one break through are significant improvements in the vicious circle of poverty the health of families and the causing illness, and illness workforce, economic and social causing poverty? Frustrations in conditions often improve as well identifying a simple path for as economic output. human development can lead to The interrelationships be ineffective responses. tween health and development One is to compartmentalize are so intertwined, that it is impossible to address and focus health and development activities one without the other. Improvements in community on singular, isolated projects as they can yield health depend on sustainable development. At the rapid and measurable progress. Unfortunately, same time, health is a minimum requirement for accomplishments can soon unravel and prove to be development. unsustainable. Efforts to cure TB in refugee In the past two decades, the AIDS epidemic situations provide one such example. Well has made this interdependence obvious. One meaning health workers often begin with what example is the relationship of AIDS with education. seems to be a straightforward task: treating every Prevention strategies are much more difficult person diagnosed with TB. After a few weeks of where basic literacy skills are absent. At the same treatment, the patient's' health will improve. But time, efforts to increase literacy have become an when refugees are returned to communities Impact of development on infectious disease control Safe drinking-water. The number of people with access to Economic transition has affected safe drinking-water has doubled from 40% in 1980 to nearly 80% health services and contributed to a resurgence in some countries, reducing the risk of diarrhoeal diseases. of TB and diphtheria in the Russian Federation and Eastern Europe . Mining settlements • in the Amazon have contributed to an ms in China, increase in malaria cases. Egypt, Ghana and Senegal have led to an increase in schistosomiasis e Positive impact Adult literacy in developing countries • Negative impact has increased from 34% in 1977 to 49% in 1985. This increases access to health education messages. Relationship between health and economic development Countries with GNP per capita under $4 000 in 1995 + Costa Rica Czech Republic 75 Georgia __ . Jamaica - ...... L • • • • China' -. • • .. • • •• .. • • Viet Nam • • _ • ••• ••• ••• • • ••• 65 • • • • • • • •• • • •• • • • • .- • South Africa • .•. • Papua 55 .... • New Guinea • Namibia Gabon -'---t •• . ·- • • Botswana • ••• • 45 ••• ·~·: ••---= ~- • Rwanda 35 + • Sierra Leone I I J 1 000 2 000 3 000 4 000 GNP per capita ($) Source: World Bank, 1997 lacking health services, it is unlikely that TB countries where there is exceptional political patients can continue their treatment for the entire leadership and the capacity to carry it through. six months required to cure the disease. These Where such political leadership does not exist, patients may ultimately develop virtually incurable development initiatives that attempt to address multidrug-resistant types of TB and spread the everything across sectors often risk achieving few disease throughout their communities. measurable results. Another way is to plan initiatives that are as Poverty and underdevelopment cannot be comprehensive and encompassing as possible. made to disappear by magic. To make progress, But while well-coordinated multisector responses concrete and measurable contributions must be to poverty abound in theory, producing the desired made in a coordinated way to remove the results in practice has proven to be a challenge. obstacles that prevent people from reaching their Widespread reforms, prioritization and full human, economic and social potential. In any collaboration are more likely to succeed in country, careful analysis of the evidence can Impact of infectious disease control on development Economic development Confusion among health Micro Credit loan Vertical approaches to defaults due to illness disease control run the risk of In addition to supporting the well-being officials surrounding the 1994 have been reduced in compartmentalizing and distancing of the public and the labour forces in outbreak of the plague in Bangladesh and other the health sector from other other sectors, the health sector also Sural, India, undercut Indian countries through the development activities. produces goods and services that tourism . More than 45 000 contribute to the national economy. people cancelled their travel strengthening TB control plans to India. and other community health programmes. Worker productivity Weavers in India with chronic symptoms of ------J lymphatic filariasis produced 27% Coml1)4nity less cloth than orgamz1ng by gays, healthy weavers. lesbians and IV drug users in response to AIDS has strengthened the capacity of these communities to • respond to other social issues. Health initiatives are frequently spearheads for developing community par School attendance Children in the ticipation . Solomon Islands missed - on average - one week of school each year due to malaria, prior to the implementation of effective control strategies. Economic growth National hospitals Many developing Ten years of the malaria • Positive impact country governments allocate more than half of elimination programme in Sri Lanka their health budgets to hospitals, leaving little is estimated to have boosted • Negative impact money for basic health services. national income by 13%. Days of work lost from malaria Estimated average time lost by adults due to one episode of malaria Burkina Kenya Malawi Nigeria Rwanda Sudan Sri Lanka Fa so Source: Ettling , 1991 & 1994; Guiguemde, 1997: Leigh1on and Foster, 1993; Kondrasen, 1977 identify priority health needs that can be cost-effective initiatives that provide substantial addressed cost-effectively. This evidence must be benefits to communities. It also recognizes that in advocated to new partners and other sectors, and political decision-making, facts often do not always they must be persuaded to contribute to an speak for themselves. Social conditions must be integrated approach. The vicious cycles of illness created through partnerships with governments, and underdevelopment cannot be broken by NGOs, the private sector, the media and health projects alone. But progress can be grassroots community organizations to encourage achieved by a new generation of people leaders to make responsible choices. concerned about health and development, who can involve new partners through persuasive Reducing the burden of infectious presentation of the evidence. diseases is an achievable objective This is why the World Health Organization Poverty breeds infections; infections breed believes that evidence-based decision-making poverty. The road out of this vicious cycle begins and advocacy are at the core of its leadership role with efforts that contribute to a person's ability to in health. The task of furthering health and meet basic needs. People cannot contribute to the development begins by identifying achievable and economic progress of their family and community Priority steps for overcoming the burden of infectious diseases Political support - particularly money, policies and multisector involvement - is required to overcome the burden of infectious diseases. By mobilizing political support to address the following priorities, much of the death and suffering caused by infectious disease could be prevented. • Support for proven, effective and affordable priority strategies in controlling the most devastating infectious diseases, including: • Bednets and treatment strategies for rolling back malaria. • DOTS (Directly-Observed Treatment, Short-course) for stopping TB. • Childhood vaccinations for reducing deaths from measles and other preventable diseases. • IMCI (Integrated Management of Childhood Illnesses) for addressing diarrhoeal diseases. • HIV prevention strategies such as condom promotion, sex education and STI treatment for reducing the spread of HIV/AIDS. • Antibiotics used timely and appropriately for preventing pneumonia. • Strengthened health services and delivery systems in developing countries. • Intensified efforts to eradicate polio and guinea worm, and eliminate neonatal tetanus, leprosy, lymphatic filariasis, Chagas disease and onchocerciasis. • Expansion of surveillance systems that can alert the world to unexpected outbreaks, the emergence of new diseases and increased drug resistance. • Investment in the development of diagnostic tools, drugs and vaccines that can further improve our ability to affordably address the most serious and widespread infectious diseases. when they are rendered helpless by infectious marketing of condoms and many other diseases. By fighting infectious diseases, major interventions can make a big difference to obstacles to development are removed. As this people's lives. report has shown, infectious diseases are the heaviest health burden faced by the poor and the Healthy development young. Just six infectious diseases cause over Healthy development requires the alleviation of the 90% of deaths due to infections. But in every case most devastating and avoidable health obstacles at least half - and in some cases nearly all - of that slow economic and social development. It these deaths could be avoided simply by using addresses the greatest health crisis of developing affordable interventions. Effective disease control countries - infectious diseases - without strategies such as DOTS, IMC! , ORT, childhood simultaneously exchanging it for chronic and vaccinations, insecticide-treated bednets, social costly health problems that are rampant in richer -• countries. Healthy development implements millennium. Western civilization had emerged from poverty alleviation strategies in ways that the Dark Ages and was beginning to take contribute - and do not damage - the health of advantage of new knowledge afforded by travel communities. and urbanization. Unfortunately, bubonic plague, In the past 25 years, we have witnessed syphilis, cholera and other diseases also significant progress in sustainable development. capitalized on these opportunities. The population The end of the Cold War and the reversal of of Europe was reduced by nearly half. Will the new nuclear proliferation have reduced global military millennium be any safer from infectious diseases? spending and have provided opportunities to Two futures are equally conceivable as we increase spending in other sectors. On average, enter the 21st century. The rapid economic and life expectancy has increased by nine years. scientific advances of the past decade can be Since 1975, child death rates in developing built upon, and the impact of infectious diseases countries have been cut nearly in half. can be cut dramatically. Or, infectious diseases This progress must be tempered with the can continue to burden human development, sobering reality that one out of two people in new diseases can emerge and drug resistance developing countries will still die from an infectious can reverse the scientific progress of the past disease and by the fact that HIV/AIDS is changing century. Unlike our ancestors of a thousand their demography. On average, most of these years ago, we know both the causes and the deaths could have been prevented for $5 per solutions for most of the epidemics that plague person. us. How will history refer to us if we fail to control Infectious diseases inflicted a new magnitude infectious diseases at the beginning of the of suffering after the world entered the last new millennium? The Bottom Line "Illness and death from infectious diseases can be, in most cases, avoided at an affordable cost. It is everyone's interest that these obstacles to development be removed. Because of drug resistance, increased travel and the emergence of new diseases, we may only have a limited time in which to make rapid progress. Those who have received this report have a unique responsibility, as they are leaders in society who can make a substantial contribution to the prevention and control of infectious diseases." Dr Gro Harlem Brundtland, Director-General, World Health Organization Managing editor: Agnes Leotsakos Writer: Sheila Davey Cover design and illustrations: Agnes Leotsakos Editorial support: Lanese Carpenter Documentation of data: Evidence and Information for Policy cluster Editorial Committee: John Clements, Peggy Crease, Andy Crump, Sandra Doyle, Arlette Miller, Francesco Rio, Jim Tulloch, Mary Vallanjon, Cathy Wolfheim, David Heymann Photographs: WHO Photo Library Production: Jay Dowie Printer: Atar, Switzerland The cost of this report is SF12 per copy. In developing countries, SF 8.40. ©World Health Organization 1999 Publication code: WHO/CDS/99.1 This document is not a formal publication of the World Health Organization (WHO) and all rights are reserved by the organization. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but not for sale nor for use in conjunction with commercial purposes. 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