The Development Impact of the Neglected Tropical Diseases (Ntds)

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The Development Impact of the Neglected Tropical Diseases (Ntds) United Nations Department of Economic and Social Affairs Population Division Expert Paper No. 2011/1 The development impact of the neglected tropical diseases (NTDs) Peter J. Hotez This page is intentionally left blank Population Division Expert Paper No. 2011/1 The development impact of the neglected tropical diseases (NTDs) Peter J. Hotez George Washington University United Nations New York, 2011 NOTE The views expressed in the paper do not imply the expression of any opinion on the part of the United Nations Secretariat. The designations employed and the presentation of material in this paper do not imply the expression of any opinion whatsoever on the part of the United Nations Secretariat concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. The term “country” as used in this paper also refers, as appropriate, to territories or areas. This publication has been issued without formal editing. ii PREFACE In November 2009, the Population Division of the Department of Economic and Social Affairs of the United Nations Secretariat convened an Expert Group Meeting on Health, Mortality and Development at the United Nations Headquarters in New York. The purpose of the meeting was twofold. First, in preparation for the forty-third session of the Commission on Population and Development, the meeting brought together experts and officials of inter-governmental organizations to discuss the challenges in combating the major causes of death and improving health, including consideration of how to strengthen health systems. Second, building upon earlier United Nations Coordination Meetings on the Estimation of Adult Mortality held in 2006 and 2008, the meeting focused on methodological issues in the estimation of adult mortality and initiated a comparison and review of adult mortality estimates for selected countries as produced by different institutions. The meeting took place from 10 to 12 November 2009. Its agenda and list of participants can be found at http://www.un.org/esa/population/meetings/EGM-healthmortality/agenda- participantslist.pdf. A selection of the papers prepared by experts participating in the first part of the meeting is being issued under the Expert Paper Series published on the website of the Population Division (www.unpopulation.org). Since 2000, the Millennium Development Goals (MDGs) have focused international attention on the reduction of major communicable diseases, especially those covered under MDG 6—HIV/AIDS, malaria and tuberculosis. As a result, great strides have been made toward combating those diseases. Yet the burden of disease associated with other infectious and parasitic diseases remains high. In 2009, an estimated 1.2 billion people were suffering from a range of neglected tropical diseases (NTDs), including parasitic diseases caused by worms (e.g., ascariasis, trichuriasis, hookworm and lymphatic filariasis) which are the most common type of infection. Newly available evidence confirms that NTDs contribute to undernutrition, which in turn delays cognitive development in children and, by compromising the health of adults, has a negative impact on economic development in the heavily affected communities. The Population Division is grateful to Dr. Peter J. Hotez, Distinguished Research Professor in the Department of Microbiology, Immunology and Tropical Medicine of the George Washington University and President of the Sabin Vaccine Institute, for having participated in the meeting and having prepared this paper on the prevalence and development impact of the neglected tropical diseases. The Expert Paper Series aims at providing access to government officials, the research community, non-governmental organizations, international organizations and the general public to overviews by experts on key demographic issues. The papers included in the series will mainly be those presented at Expert Group Meetings organized by the Population Division on the different areas of its competence, including fertility, mortality, migration, urbanization and population distribution, population estimates and projections, population and development, and population policy. The views and opinions expressed in the papers that are part of the series are those of their authors and do not necessarily reflect those of the United Nations. The papers in the series are released without undergoing formal editing. For further information concerning this series, please contact the office of Hania Zlotnik, Director, Population Division, Department of Economic and Social Affairs, United Nations, New York, 10017, USA, telephone (212) 963-3179, fax (212) 963-2147. iii This page is intentionally left blank A. OVERVIEW The concept of the neglected tropical diseases (NTDs) was established partly in response to the Millennium Development Goals (MDGs) for sustainable poverty reduction (Hotez, 2006; Hotez, 2008a; Molyneux, 2008). Launched in 2000, the sixth MDG, to combat HIV/AIDS, malaria and other diseases, stimulated large-scale initiatives for the control of HIV/AIDS and malaria through two massive stimulus packages from the United States Government—the President’s Emergency Plan for AIDS Relief (PEPFAR) and the President’s Malaria Initiative (PMI)—as well as a third stimulus provided by the Group of Eight (G8) countries through the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). Through such initiatives, tens of billions of dollars were committed to provide millions of people living in low- and middle-income countries with antiretroviral therapy for AIDS, directly observed treatment for tuberculosis, and drugs and bed nets for malaria. At the same time, scientists, physicians, public health experts, and global health policymakers concerned about the “other diseases” mentioned in MDG 6 noted a dearth of resources. Of particular concern was a group of tropical infections known as the NTDs, which were prevalent in low-income countries and were increasingly recognized to cause disease burdens comparable to AIDS or malaria. Moreover, there were opportunities to control the NTDs at costs far lower than those required for AIDS, tuberculosis or malaria. Despite the opportunity afforded by targeting the NTDs, none of these conditions was prioritized either by the United States Government or the G8 nations during the first few years of the new millennium. The absence of global commitment to the NTDs prompted the drafting of a series of policy papers. The first two peer-reviewed papers to use the term NTDs were published in 2005 (Molyneux and others, 2005) and 2006 (Hotez and others, 2006a), respectively. These policy papers as well as subsequent ones in 2006 and 2007 (Brady and others, 2006; Lammie and others, 2006; WHO, 2006; Hotez and others, 2007a; 2007b), highlighted the NTDs as the most common infections in low- and middle-income countries. An estimated 1.4 billion people live below the World Bank poverty level of US$1.25 per day (a group sometimes referred to as “the bottom billion,”), almost all of whom are adversely affected by one or more of the NTDs (Hotez and others, 2006a; 2007a; 2009a; Musgrove and Hotez, 2010). The major NTDs afflicting the bottom billion are shown in tables 1 and 2, ranked according to their prevalence. The three soil-transmitted helminth (STH) infections (ascariasis, trichuriasis, and hookworm infection) are the most common NTDs, each affecting approximately 600-800 million people worldwide. In order of prevalence, STH infections are followed by schistosomiasis (200 million infected), lymphatic filariasis (LF; 120 million infected), trachoma (60 million to 80 million infected), onchocerciasis (37 million infected), the food-borne trematode infections (>20 million infected), leishmaniasis (12 million infected), and Chagas disease (8 million to 9 million infected) (Hotez and others, 2007a; 2009a). In spite of their substantial health impact, the NTDs have been ignored relative to the “big three diseases” in part because they cause far fewer deaths, on the order of half a million deaths annually due to the NTDs compared to two million or more deaths each year from AIDS, malaria, or tuberculosis (Hotez and others, 2006a). In 2006, the publication of a revised estimate of the global disability resulting from the NTDs marked a key revelation in global health (Hotez and others, 2006a). Using disability adjusted life years (DALYs) as a metric, it determined that the NTDs result in almost 57 million DALYs lost annually, a burden that is greater than that caused by malaria or tuberculosis and almost as great as the burden of disability resulting from HIV/AIDS (Hotez and others, 2006a; Hotez and others, 2007a). However, such estimates are not universally accepted by the global health community. A new initiative led by the Institute of Health Metrics at 1 the University of Washington, together with the Sabin Vaccine Institute is working to resolve controversies surrounding disability estimates for the NTDs. Many of the NTDs share a number of common features. Most of the highest prevalence NTDs are parasitic helminth infections, with the exception of the bacterial infection, trachoma, and the protozoan infections, leishmaniasis and Chagas disease. There are several common protozoan infections including amebiasis, toxoplasmosis, and giardiasis for which there are no global prevalence estimates. Among their major common features, the NTDs shown in tables 1 and 2 are mostly chronic infections lasting
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