Freeing the Americas from NIDs: Addressing the Unfinished Agenda

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  • Neglected diseases, forgotten diseases, and Forgotten populations. ... What are these diseases, and where are they? Urban, rural, indigenous communities Who gets infected? [ Urban, rural, indigenous: photos of a girl living in a Honduran shantytown , a mother and children in rural Honduras, and an indigenous women and children in Peru. Do health workers really recognize the NIDs ?... [photos of Buruli ulcer in Peruvian person, and health worker in Bolivia] Let’s look at an example …[next slide - Trachoma in Colombia] Photo sources (thanks to these sources): http://www.nationalturk.com/en/two-thirds-of-children-in-honduras-live-in-poverty11986 http://blog.compassion.com/el-salvador-facts-what-is-life-like-in-rural-el-salvador/ http://enperublog.com/2007/02/26/half-the-peruvian-amazon-covered-with-oil-leases/ http://www.who.int/buruli/photos/small_ulcers/en/index.html http://www.anesvad.org/actualidad/acercando-la-salud [promotora en salud El Salvador]
  • In an isolated community in a Latin American country two indigenous women died in 1998 due to snake bite (snakes bites are common in the Orinoco River Basin and elsewhere). An entomologist surveying for vector-borne diseases there asked: “ Why did these women die?” The neighbors answered: “ Because they didn’t see the snakes .” The entomologist then asked: “ Why they didn't see the snakes ?” The people replied: “ Because they were blind .” Surprised, the entomologist again asked for the reason, and the people answered: “ Because they, like other people in our community, were blind ”. “ Why were they blind ?”, was his next question… but his answer came only eight years later after field research: they had Blinding Trachoma! The health team serving that remote and forgotten place then asked him: “ What is Trachoma ?” Director’s information only: This is a true story about the Amerindian Nukak Maku communities of San Joaquin and Santa Catalina in the southern parts of the Department of Vaupes, Colombia: 1998-2006 (Source: PAHO’s report of the first regional meeting on trachoma elimination, 2011). The report of the presence of trachoma in Colombia was published by H. Miller et al., in Biomedicina (Colombia), July-September 2010, vol 30(3): 432-439. Thanks to these Photo sources: http://www.niels.com/nukak/ (photos of the people) http://www.mallamaseps.com.co/paginas/ofidico.htm and http://www.mallamaseps.com.co/imagenes/ofidico_clip_image004.gif (photo of the snake Bothrops asper in Vaupes) http://www.colarte.com/recuentos/Colecciones/ETNIAS/NukakMaku.htm (two women and child in front of hut) http://www.who.int/blindness/causes/priority/en/index2.html (person with trachoma, TT)
  • Neglected ('forgotten') diseases are a set of infectious diseases, many of them parasitic, that primarily affect the most vulnerable populations: the poorest of the poor, the most marginalized, and those with the least access to health services—especially impoverished people living in remote rural areas and urban shantytowns. Neglected infectious diseases affect population groups living in poor socio-economic conditions, with low income and education levels, poor housing, lack of access to basic services such as clean water and sanitation, and in areas where armed conflict is present, environmental conditions are deteriorated and there are access barriers to health services. As they share similar social and environmental factors, neglected infectious diseases frequently coexist in the same geographical areas be they tropical or subtropical.
  • Information for the Director: Resolution CD R49.19 of the PAHO’s Directing Council, signed by Member States in October 2009, on "Elimination of neglected diseases and other infections related to poverty”, included 12 neglected infectious diseases with the aim of eliminating them as public health problems or significantly reducing their impact in LAC by the year 2015. The Regional Program for neglected infectious diseases of PAHO, has under its direct responsibility, those diseases whose elimination or control can be achieved through the implementation of preventive chemotherapy (i.e., schistosomiasis, lymphatic filariasis, soil-transmitted helminthiasis, onchocerciasis and blinding trachoma) plus others such as Chagas disease, leishmaniasis and leprosy; while also interacting with other technical CD programs such as malaria and dengue control. Other NIDs which need further study and mapping to clarify their epidemiological situation and opportunities for control: Leishmaniasis, various parasitic zoonoses, Buruli ulcer Parasitic zoonoses in LAC include fascioliasis, cysticercosis and hydatidosis. Other NIDs noted in the Region include Buruli ulcer, scabies, fungal infections, Loxoceles spider bites which are also being addressed by the technical progam though to a lesser extent, and some of these NIDs could the subject of future PAHO Resolutions if Ministers so determine.
  • Key message: We have a great opportunity to reach elimination [as a public health problem], reduce suffering and physical and mental impairment. Information for the Director: List taken from the report for the 144 th Executive Committee, 2009 on Elimination of Neglected Diseases and other Infections related to Poverty. This Resolution targets these diseases for end of 2015. Each disease has a VERY SPECIFIC epidemiological indicator to meet. Informal current assessment by HSD: Realistically, short-term elimination 3-5 years: Oncho (except Yanomami area), LF, Chagas, Trachoma, and Leprosy(?) Longer term elimination 10-15 years: Malaria, Congenital syphilis, human Rabies transmitted by dogs (human deaths), Plague (human deaths), Neonatal tetanus Chagas disease: Eliminate transmission by principle domestic vectors and blood transfusion (blood bank screening). See slide 18, below. Malaria, in general: Elimination targeted in Hispaniola as a theme of the Carter Center, however this will be challenging to meet as thousands of cases were still reported in 2010. What may be more feasible in the short term would be elimination of malaria in ELS and PAR, which have prepared elimination plans for malaria and where reported cases are under 100/year. The same may obtain for COR. In MesoAmerica, there is a new initiative by the Gates Foundation, Carlos Slim’s foundation and Spain to eliminate malaria there. Goals for Malaria Elimination stated in the 2009 PAHO Resolution are: To eliminate malaria in areas where interruption of local transmission is feasible (Argentina, the Dominican Republic, Haiti, Mexico, Paraguay, and Central America). Elimination (zero local cases for 3 consecutive years); pre-elimination (slide positivity rate = < 5 % and <1 case / 1,000 population at risk).
  • GOAL, Generally stated: Reduce prevalence to less than 20% for STH, and less than 10% for schistosomiasis SPECIFIC GOAL (per the 2009 Resolution): STH – To reduce prevalence among school-age children in high risk areas (prevalence >50%) to less than <20% prevalence as measured by quantitative egg count. Schisto – To reduce prevalence and parasite load in high transmission areas to less than 10% prevalence as measured by quantitative egg counts. Text in right-hand column taken from the report for the 144 th Executive Committee, 2009 on Elimination of Neglected Diseases and other Infections related to Poverty. Question for the audience after concluding this slide: “ Now… Can you name at least 5 NIDs? How many have you forgotten?”
  • Background Information for the Director (not to be read to the audience): In 2009, in LAC 66 states were identified with the presence of one of five selected NIDs (schistosomiasis, lymphatic filariasis, onchocerciasis, trachoma and human rabies transmitted by dogs), 33 states with the presence of two of the diseases, two states presented three of the five diseases and only one state has evidence of the presence of four of the five selected NIDs, classifying these overlapping areas as the ‘‘major hotspots’’. The combination of diseases that overlap varies according to the country: for Brazil the greatest overlap is between trachoma and schistosomiasis; in Haiti it is lymphatic filariasis with human rabies transmitted by dogs; and in Venezuela it is schistosomiasis with onchocerciasis. While it is believed that soil-transmitted helminths are present, to a varying extent, in most of the first subnational administrative levels, STH were not included in the overlapping analysis given that this information is only available for some geopolitical units in selected countries. Identifying hot-spots at the first sub-national level is useful at the national and state political levels for advocacy purposes and for decision-makers to know the states where integrated approaches to tackle the NIDs might be required and identify existing gaps and needs for information. However, elimination programs need maps refined to a lower level of disaggregation, down to the community level, for proper planning of integrated public health and intersectoral interventions. Therefore, further studies could be performed to identify ‘‘hot-spots’’ to define more accurate baselines, possibly including additional diseases, socio-economic and environmental variables, and applying other clustering and correlation spatial analysis techniques. In areas where overlapping of STH infections occurs either with lymphatic filariasis, onchocerciasis and schistosomiasis, there is an opportunity to integrate deworming for the two diseases. In fact, a deworming drug (albendazole) is included in the recommended combination for MDA used in the regional program to eliminate lymphatic filariasis. Besides deworming, another opportunity to integrate interventions to reduce the burden of several neglected tropical diseases is improving access to both safe water supply and adequate basic sanitation. This is critical to achieve a long-term reduction in both the burden (intensity of infection) and prevalence of STH in pre-school and school-age children, and also plays an important role in reducing the burden of schistosomiasis and lymphatic filariasis. Source: Schneider M, Aguilera X, Barbosa da Silva Junior J, Ault S, Najera P, et al. (2011) Elimination of Neglected Diseases in Latin America and the Caribbean: A Mapping of Selected Diseases. PLoS Negl Trop Dis 5.
  • Background information for the Director: More than one billion people worldwide suffer from at least one NID, and the total burden of disease by a group of NIDs is 56.6 million of Disability Adjusted Life Years (DALYs), only surpassed, among infectious diseases, lower respiratory infections, HIV-AIDS and diarrheal diseases, and in turn greater than the burden of illness due to malaria, tuberculosis and measles. The NID disease burden in Latin America and the Caribbean is 8.8% of the global burden, about 5 million DALYs (4), higher than the burden of HIV disease in the Region. This important figure is explained considering that, in 2008, 40% of the approximately 556 million people in Latin America and the Caribbean live in poverty, including 47 million people with a daily per capita income less than $ 1 United States and 74 million on less than $ 2 a day. Sources: Savioli L. Neglected Tropical Disease Department, World Health Organization. [Consulted: November 11, 2011] Available at: http://www.who.int/neglected_diseases/director/en/index.html Hotez PJ, Molyneux DH, Fenwick A, Kumaresan J, Sachs SE, Sachs JD, Savioli L. Control of neglected tropical diseases. N Engl J Med. 2007; 357:1018-27. Hotez PJ, Bottazzi ME, Franco-Paredes C, Ault SK, Roses-Periago M. The Neglected Tropical Diseases of Latin America and the Caribbean: A Review of Disease Burden and Distribution and a Roadmap for Control and Elimination. PLOS Neglected Tropical Diseases 2008; 2: e300. [Consulted: November 11, 2011]. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2553488/pdf/pntd.0000300.pdf
  • NIDs NOT Exempt! Certain NIDs such as the microbes of leprosy/Hansens ( Mycobacterium leprae ) and trachoma ( Chlamydia trachomatis ) , the pathogenic protozoans (e.g., Leishmania spp.), macroparasites (e.g., geohelminths) and certain mycoses (e.g., Candidiasis, Histoplasmosis) are susceptible to selection for drug resistance Special Risks of Resistance Immunocompromised individuals may have higher risks, especially if infected with multiple NTDs. Scientists are still evaluating whether Mass Drug Administration (MDA) of common drugs used in NID elimination/control campaigns increases risks - ( NOTE: The development of treatment failures, reduced drug sensitivity or even resistance is of major concern because alternative drugs for MDA are not available to respond to drug resistance should it occur. However, evidence that altered drug sensitivity plays a role in the observed suboptimal effect of MDA is weak but, with the extension of programs and increased drug pressure, it could become an important issue, particularly in the cases of onchocerciasis owing to the use of a single drug in combination with the very long lifespan of the adult female worms and in the cases of STH and LF owing to the simple mechanism by which resistance to ALB is developed . With the progression of the different programs, the implementation of effective monitoring systems for MDA efficacy will be crucial and a shift to targeted case detection and treatment may be needed in order to eliminate foci of transmission and to identify emerging drug-resistance at an early stage. Unfortunately, viable alternatives to current MDA programs are not readily available. However, drug-discovery programs for some of the NTDs have yielded promising compounds that may be developed into effective drugs.Vaccine developments are, at best, still at the stage of basic research.) Prevention and Mitigation - critical need for rational use of medicines . Combating over-the-counter sales Rigid infection control in hospitals and all health care facilities Health professional-directed treatment schemes: hospital patients and infected persons in the community should have a specific medical prescription take the complete treatment therapy take it on schedule and not “save a bit” of the medicine for other family members or “for future use” All the more important in countries with weak disease surveillance and therapeutic medicine monitoring systems!
  • By Elimination we mean, generally, elimination as a public health problem . The 2009 Resolution of PAHO on NIDs discusses the specific goals for each disease. This document can be found on the PAHO website www.paho.org, under the theme of the Directing Council.
  • PoA = Plan of Action (preferably integrated) PoA should be developed building on the primary care system, with higher levels of care involved as needed, and complemented by monitoring and surveillance Some key PAHO Resolutions and documents on NIDs: Onchocerciasis Resolution CD48.R10 (2008) Neglected Infectious Diseases of Poverty Resolution: CD49.R19 (2009) Congenital Syphilis Resolution CD50.R15 (2010) Chagas Resolution CD50.R17 (2010) PAHO Control and Elimination of Five NTDs: prioritization strategy for LAC 2010-2015, (2010) PAHO Guidelines for the preparation of integrated Plans of Action for Control and Elimination of NTDs (2011)
  • i.e., reach a balance by offering social support, empowerment and solidarity with the poor…. Background information for the Director: PAHO has focused efforts to begin implementation of integrated actions within the health sector, as a first step to integrate intersectoral interventions for affected populations in LAC. There is an important cautionary point to recognize about the opportunity costs of operating within a SDH framework without substantial additional dedication of resources to health inequities. The Commission on Social Determinants of Health has placed critically needed emphasis on the structural determinants of health inequities, such as income inequality and social exclusion based on race, ethnicity, gender, or physical impairment. Interventions to address those structural causes of health disparities by government, NGDOs, international organizations, and CBOs, in the absence of additional resources , could have the effect of diverting resources from vertical, disease-specific interventions, that are in place, effective, and in some cases, on the verge of eliminating grave neglected infections of poverty. Those resources can be monetary (financing for specific disease programs); human (clinical and community workers dedicated to those projects); and emotional (the enthusiasm of both governmental and community actors).
  • … . including those medicines used for NIDs
  • Elimination goal set by the 2009 PAHO Resolution: – To eliminate ocular morbidity and to interrupt transmission of human onchocerciasis [to by done by end of 2012, per PAHO Resolution CD48.R10 (2008)] ] Note: This goal is unlikely to be fully met because of the discovery in 2010-2011 of new, unknown Yanomami groups/communities migrating in southern Venezuela, most of whom have not yet begun drug treatment with Mectizan (ivermectin).
  • Elimination Goals set in the 2009 PAHO Resolution: – To interrupt domestic vector-borne transmission of T. cruzi (domestic triatomine infestation index of less than 1% and negative seroprevalence in children up to five years of age, with the exception of the minimum represented by cases in children of seropositive mothers). – To interrupt transfusional transmission of T. cruzi (100% blood screening coverage). – To integrate diagnosis of Chagas’ disease in the primary health care system, in order to provide treatment and medical care to all patients for both the acute and chronic phases and to reinforce the supply chain of the existing treatments within countries to scale up access. – To prevent the development of cardiomyopathies and intestinal problems related to Chagas’ disease, offering adequate health care to those affected by the various stages of the disease.   1) "Transmission by the primary vector has been interupted in  14 countries". Se trata de:   Uruguay Chile Brasil Paraguay (Región Orinetal donde vive el 99,5% de los paraguayos) Guatemala Perú (2 Dptos.) El Salvador (eliminación de R.prolixus) Honduras Costa Rica (ausencia de R.prolixus) México (ausencia de R.prolixus en Oaxaca y Chiapas - toda su área de distribución-) Nicaragua Belice Bolivia (1 Dpto.) Argentina (5 provincias a las que pueden agregarse otras 5 nuevas) Total: 14 países   2) “ 20 countries doing blood-bank screening". Se trata de: ARG, BRA, BOL, CHI, PAR, URU, ECU, PER, COL, VEN, PAN, COR, HON, ELS, GUT, BLZ, GUY, GUY Fr., SUR y NIC.
  • LF Elimination Goal set in the 2009 PAHO Resolution: – To eliminate the disease as a public health problem (less than 1% prevalence of microfilaria in adults in sentinel sites and spot-check sites in the area). – Interrupt its transmission (no children between ages 2 and 4 are antigen positive). – To prevent and control disability. Notes: SUR, TRT and COR were removed from the WHO list of “LF-endemic” countries in 2011 based on a set of evidence. HAI, DOR and GUY integrate LF treatment with STH treatment (BRA does not yet do this). Haiti population data source: http://www.who.int/countries/hti/en/ - 10 million people currently
  • Elimination Goal set by the 2009 PAHO Resolution: To eliminate leprosy as a public health problem (less than 1 case per 10,000 people) from the first sub-national political/administrative levels. See footnotes 6, 7, and 8 below for details, taken from the Resolution. 6. Based on: WHO. Adoption of Multidrug Therapy for Elimination of Leprosy as a Public Health Problem . Forty-fourth World Health Assembly. WHA44.9. Geneva: WHO, 1991. 7. Based on: WHO. Guide to Eliminate Leprosy as a Public Health Problem. Geneva: WHO, 2000. 8 Instead of the goal of elimination, Brazil will adopt the targets recommended for epidemiological surveillance of the disease contained in WHO document “ Enhanced Global Strategy for Further Reducing the Disease Burden Due to Leprosy- 2011-2015” (SEA-GLP-2009.4) − Number of new cases detected per year and rate per 100,000 population − Number of new cases with grade 2 disability per year and rate per 100,000 population − Proportion of patients who complete their treatment in a timely manner as a proxy for cure First subnational level = state, province or department
  • So, in summary: Together we can see the END of the NIDs! Together we can win the battle! It’s an ethical and moral imperative!
  • Freeing the Americas from NIDs: Addressing the Unfinished Agenda

    1. 1. Philadelphia, 6 December 2011 Mirta Roses, M.D., M.P.H. Director Pan American Health Organization American Society for Tropical Medicine and Hygiene Freeing the Americas from NIDs: Addressing the Unfinished Agenda
    2. 2. Neglected diseases, forgotten diseases. Forgotten populations. What are these diseases, and where are they? Who gets infected? Do health workers really recognize the NIDs ?...
    3. 3. A Case of Forgotten People, Forgotten Diseases
    4. 5. Key neglected infectious diseases in LAC <ul><li>12 diseases are targeted under PAHO’s 2009 Resolution on NIDs: </li></ul><ul><ul><li>10 targeted for elimination… </li></ul></ul><ul><ul><li>2 targeted for reducing disease burden… </li></ul></ul>
    5. 6. Ten diseases targeted for elimination as a public health problem <ul><li>Lymphatic Filariasis </li></ul><ul><li>Onchocerciasis </li></ul><ul><li>Blinding Trachoma </li></ul><ul><li>Chagas disease (domestic vectors, blood transfusion) </li></ul><ul><li>Human Rabies transmitted by Dogs </li></ul><ul><li>Plague </li></ul><ul><li>Leprosy/Hansen’s disease </li></ul><ul><li>Malaria (where possible) </li></ul><ul><li>Neonatal Tetanus </li></ul><ul><li>Congenital Syphilis </li></ul>
    6. 7. Two diseases targeted to reduce the burden of disease, using available tools <ul><li>Schistosomiasis ( S. mansoni ) </li></ul><ul><li>Soil-transmitted helminthiasis </li></ul><ul><ul><li>Ascaris, Trichuris, human hookworms </li></ul></ul><ul><li>Persistence in areas or sites with a very high prevalence </li></ul><ul><li>Limited knowledge of the epidemiological situation </li></ul>
    7. 8. Many of these diseases are overlapping: affecting the same people within the same geographical areas <ul><li>6 NIDs mapped at the first administrative level: </li></ul><ul><li>Schistosomiasis </li></ul><ul><li>Lymphatic filariasis </li></ul><ul><li>Onchocerciasis </li></ul><ul><li>Trachoma </li></ul><ul><li>Human Rabies transmitted by Dogs </li></ul><ul><li>Soil-transmitted Helminthiasis </li></ul>
    8. 9. What is the Burden of Disease in Latin America and the Caribbean for NIDs? <ul><li>Although disease burden in LAC is 8.8% of the global burden: </li></ul><ul><li>Soil-transmitted helminthiasis is widely disseminated: 43 million children at risk </li></ul><ul><li>Pockets of transmission of schistosomiasis in Brazil, Saint Lucia, Suriname and Venezuela </li></ul><ul><li>Lymphatic filariasis in Brazil, Guyana, Haiti and the Dominican Republic </li></ul><ul><li>Onchocerciasis in Brazil, Ecuador, Guatemala, Mexico, and Venezuela </li></ul><ul><li>Trachoma in Brazil, Colombia, Guatemala and Mexico </li></ul>5 million DALYs , higher than the burden of HIV disease in the Region
    9. 10. Other challenge: Antimicrobial Resistance… NIDs NOT Exempt! <ul><li>Some examples </li></ul><ul><ul><li>Leprosy </li></ul></ul><ul><ul><li>Leishmaniasis </li></ul></ul><ul><ul><li>Mycosis </li></ul></ul><ul><ul><li>Trachoma </li></ul></ul><ul><li>Special Risks of Resistance </li></ul><ul><ul><li>Chronically immunocompromised individuals </li></ul></ul>
    10. 11. How do we reach Elimination? Think of vulnerable peoples. Keep these diseases on the radar. Diagnosis and treatment are necessary but not enough.
    11. 12. We can eliminate NIDs in LAC working first within the health sector …by achieving universal coverage through primary care
    12. 13. Inter-programmatic and inter-sectoral Integration: the approach needed
    13. 14. Protect the Medicines we have… Prevention and Mitigation of Antimicrobial Resistance – via Rational Use of Medicines
    14. 15. Although still “neglected”, we have success stories to share… We need more stories, to reach millions more
    15. 20. Key actions, innovation, collaboration
    16. 21. Thank you Together we can see the END of the NIDs! Together we can win the battle! It’s an ethical and moral imperative!

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