7. Noncommunicable Diseases
80% of deaths caused by noncommunicable
diseases are in developing countries
Cardiovascular disease
Heart disease
Stroke
Cancer
Chronic respiratory diseases
Diabetes
Koehlmoos et al., 2011
8. Trauma
90% of deaths due to road traffic accidents
are in developing countries
1.3 million deaths
20 to 30 million people injured or disabled
Occupational injuries
“Export hazard”
Dangerous, outdated equipment sent from
high income to low income countries
Koehlmoos et al., 2011
9.
10. Urbanization
70% of urban residents in developing
countries live in slums
650 million people in Asia
212 million in Africa
Overcrowding
Poor housing
Hazardous locations
Flooding
Unsafe drinking water
Unsanitary conditions
Utzinger & Keiser, 2006
12. United States
Diseases once
endemic in the U.S.:
Hepatitis A
Hookworm
Malaria
Measles
Rubella
Yellow fever
Diseases frequently
imported to the U.S.:
Chikungunya
Dengue
Hepatitis A
Malaria
Measles
13. Mosquito vectors in the U.S.
Aedes aegypti, Ae. albopictus
Chikungunya
Dengue
Eastern equine encephalitis
West Nile virus
Yellow fever
Anopheles spp.
Malaria
CDC, 2014; Zucker, 1996
14. Influenza A
Zoonosis
Birds are the reservoir
Mammals
Antigenic shift
8-segmented genome
Reassorts in coinfected cells
Creates novel viruses
No immunity in the human population
Pandemic
Hayden, 2007; Treanor, 2009
15. Highly Pathogenic Avian Influenza
Risk of reassortment with human influenza A
virus
Novel virus with pandemic potential
Culling exposed/infected flocks
Economic loss
Loss of high quality protein food
Avian influenza A viruses in Washington State
H5N1, H5N2, H5N8
DOH; Tiongco 2008
17. Measles
Eliminated from the WHO Region of the
Americas in 2002
Importation from countries with low measles
vaccine coverage
Outbreaks in U.S. populations with low
measles vaccine coverage
In the U.S., ~20% of people with measles
are hospitalized with complication
145,700 measles deaths worldwide (2013)
Eradicable
18. Measles in the U.S.
Most importations are unvaccinated U.S.
citizens returning from travel to countries with
low immunization coverage
January – August 2013:
Half of measles importations from WHO
European Region
January – May 2014:
49% of importations from the Philippines
CDC 2013, 2014
19. Costs of measles outbreaks in the
U.S.
2011:
107 cases
16 outbreaks
Outbreak investigation:
$4,091 - $10,228 per day
Cost per case:
$11,933 - $29,833
Estimated public health expenditures:
$2.7 million – $5.3 million
Ortega- Sanchez et al., 2014
21. Malaria
Transmitted by mosquitoes
Roughly half of the world’s population lives in
areas where malaria is transmitted
2013:
198 million cases of malaria
584,000 deaths
Majority were children under 5 years of
age in sub-Saharan Africa
Decreases in malaria morbidity and mortality
following control measures
23. Socioeconomic impact of malaria
Loss of household income
Disability
Increased health expenditures
Macroeconomic losses
Foreign investment
Trade
Tourism
GDP for countries with intense malaria
transmission is less than one-fifth that of
countries without malaria
Sachs & Malaney, 2002
24. Demographic Transition
“I have been asked dozens of times
if help for Africa would ultimately
backfire in an even greater
population explosion. Would greater
child survival rates not translate into
more adult hunger and suffering?”
Jeffery Sachs, The End of Poverty
25. Demographic Transition
People have fewer children when
Child mortality decreases
Standards of living improve
Contraception is available
Brauner-Otto et al., 2007;
Conley et al., 2007;
Greenwood & Sesharid,
2001; Newson et al., 2005;
World Bank, 2014
26. Under 5 mortality, fertility
Country
Deaths
per 1,000
live births
Total
births per
woman
Canada 5 1.6
France 4 2
United Kingdom 5 1.9
United States 7 1.9
Democratic Republic of
the Congo
119 5.9
Ethiopia 64 4.5
Guinea 101 4.9
Liberia 71 4.8
Sierra Leone 161 4.7
WHO; World Bank
30. Ebola Virus Disease
Preferred over “Ebola hemorrhagic fever”
Most people with EVD do not have
hemorrhagic symptoms
Disseminated intravascular coagulation
Higher risk for bleeding
Massive fluid loss due to vomiting and
diarrhea
Death is usually due to dehydration and
electrolyte disturbances
Bausch et al., 2007; Blumberg et al., 2014;
Geisbert, 2014; Hartman, 2013
31. Transmission
Direct contact with blood or body fluids of a symptomatic
person
Skin
Cuts, abrasion
Mucous membranes
Parenteral
Reusing unsterilized needles
Accidental needle sticks
Funeral ceremonies
Respiratory droplets?
Not airborne
Not effectively transmitted by inanimate objects
32. Ebola Virus Disease
Easily mistaken for other diseases
Health care personnel at risk for infection
Outbreaks frequently associated with
transmission in health care facilities
- Hepatitis - Shigellosis
- Malaria - Typhoid fever
- Meningococcemia - Typhus
- Plague - Yellow fever
33. Health Workers
Frequently infected
Illness not
recognized as
EVD
Lack of
appropriate PPE
Fewer health care
workers available
Death
Flee out of fear of
infection
35. Timeline
West African Ebola epidemic traced to a 2-year-
old child in Guinea who died from the disease
December 6, 2013
First outbreak of EVD in West Africa
March 10, 2014: World Health Organization
(WHO) notified of an outbreak of an unknown
infectious disease characterized by fever,
vomiting, and diarrhea in Guinea
Zaïre ebolavirus identified in blood from patients
who were hospitalized with the disease
Baize et al., 2014
36. Timeline
…modest further intervention efforts
at that point could have achieved
control.”
WHO Ebola Response Team (2014)
Epidemic spreads to
Liberia in March
Sierra Leone in May
Nigeria in July
37. Timeline
August 8, 2014: WHO declared the Ebola
epidemic in West Africa a Public Health
Emergency of International Concern
Cases Deaths
Guinea 495 367
Liberia 554 294
Nigeria 13 2
Sierra Leone 717 298
Totals 1,779 961
WHO, 2014
38. Timeline
By the end of August, the total numbers of EVD
cases and deaths exceeded that of all previous
Ebola epidemics combined
CDC, 2015
39. Maforki Ebola Treatment Unit
Port Loko, Sierra Leone
100 bed capacity
44 confirmed
56 suspect
54. Long-term consequences
Interruption of health care services
Immunizations
Outbreaks of vaccine-preventable diseases
Could result in additional 2,000 to 16,000 measles deaths
Takahashi et al., 2015
Malaria control
Estimated10,900 malaria deaths
Walker et al., 2015
Prenatal, obstetric, pediatric care
Economic
Unemployment
Trade interrupted
Education
School closures
Teen pregnancy
Dumbaya, 2015
55. Health Worker Migration
Nursing shortage in the U.S.
Nurses aggressively recruited from other countries
Remittences from nurses working abroad contribute
to economies of countries of origin
Create shortages in countries of origin
“Brain drain”
Philippines
Exporting nurses since the 1950s
Medical doctors retrain as nurses to work in the U.S.
NCLEX testing centers:
Australia, Canada, England, Hong Kong, India, Japan,
Mexico, Philippines, Puerto Rico, Taiwan
Aiken, 2007; Bach, 2003; Brush & Sochalski 2007;
Buchan et al., 2003; Kiringia et al., 2006; Marchal & Kegels 2003
57. References
Aiken, L. H. (2007). U.S. nurse labor market dynamics are key to global nurse
sufficiency. Health Service Research, 42(3p2), 1299-1320.
Bach, S. (2003). International migration of health workers: labour and social
issues (Working Paper 209). International Labour Office: Geneva.
Baize, S., Pannetier, D., Oestereich, L., Rieger, T., Koivogui, L., Magassouba, N.,
et al. (Emergence of Zaire Ebola virus disease in Guinea. New England Journal
of Medicine, 371(15),1418-1425. doi:10.1056/NEJMoa1404505.
Bausch, D. G., Towner, J. S., Dowell, S. F., Kaducu, F., Lukwiya, M., Sanchez, A.,
et al. (2007). Assessment of the risk of Ebola virus transmission from bodily fluids
and fomites. Journal of Infectious Diseases, 196(Supple. 2), S142-S147.
Blumberg, L., Enria, D., & Bausch, D. G. (2014). Viral hemorrhagic fevers. In J.
Farrar, P. J. Hotez, T. Junghanss, G. Kang, D. Lalloo, & N. J. White (Eds.)
Manson's tropical diseases, 23rd Ed. [Electronic version]. Elsevier.
Brauner-Otto, S., Axinn, W., & Ghimire, D. (2007). The spread of health services
and fertility transition. Population Studies Center Research Report 07-619.
http://www.psc.isr.umich.edu/pubs/pdf/rr07-619.pdf.
Brush, B. L., & Sochalski, J. (2007). International nurse migration: lessons from
the Philippines. Policy, Politics, & Nursing Practice, 8(1), 37-46.
58. References
Buchan, J., Parkin, T., & Sochalski, J. (2003). International nurse mobility: trends
and policy implications (WHO/EIP/OSD/2003.3). World Health Organization:
Geneva.
Centers for Disease Control and Prevention. (2011). Neglected tropical diseases.
http://www.cdc.gov/globalhealth/ntd/diseases/index.html.
Centers for Disease Control and Prevention. (2013). Measles – United States,
January 1 – August 24, 2013. Morbidity and Mortality Weekly Report, 62(36),
741-743. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a2.htm.
Centers for Disease Control and Prevention. (2014). Dengue homepage.
http://www.cdc.gov/dengue/entomologyEcology/index.html.
Centers for Disease Control and Prevention. (October 3, 2014). Ebola virus
disease outbreak – Nigeria, July-September, 2014. Morbidity and Mortality
Weekly Report, 63(39), 867-872.
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6339a5.htm.
Centers for Disease Control and Prevention. (2014). Measles – United States,
January 1 – May 23, 2014. Morbidity and Mortality Weekly Report, 63(22), 496-
499. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6322a4.htm.
Centers for Disease Control and Prevention. (2015). Outbreaks chronology:
Ebola virus disease.
http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html.
59. References
Centers for Disease Control and Prevention. (2015). 2014 Ebola outbreak in West Africa –
cumulative reported cases in Guinea, Liberia, and Sierra Leone.
http://www.cdc.gov/vhf/ebola/csv/graph1-cumulative-reported-cases-all.csv.
Conley, D., McCord, G. C., & Sachs, J. D. (2007). Africa's lagging demographic transition:
evidence from exogenous impacts of malaria ecology and agricultural technology. National
Bureau of Economic Research Working Paper Series No. 12892.
http://www.nber.org/papers/w12892.
Davtyan, M., Brown, B., & Folayan, M. O. (2014). Addressing Ebola-related stigma: lessons
learned from HIV/AIDS. Global Health Action, 7(26058).
http://dx.doi.org/10.3402/gha.v7.26058.
De Roo, A. D., Ado, B., Rose, B., Guimard, Y., Fonck, K.,& Colebunders, R. (1998). Survey
among survivors of the 1995 Ebola epidemic in Kikwit, Democratic Republic of Congo: their
feelings and experiences. Tropical Medicine and International Health, 3(11), 883-885.
Dumbaya, C. (January 29, 2015). Sierra Leone's First Lady: 'Ebola has increased teenage
pregnancy rates.' http://www.eboladeeply.org/articles/2015/01/7263/sierra-leones-lady-ebola-
increased-teenage-pregnancy-rates.
Geisbert, T. W. (2014). Marburg and Ebola hemorrhagic fevers (Filoviruses). In J. E. Bennett,
R. Dolin, & M. J. Blaser (Eds.). Mandell, Douglas, and Bennett's principles and practice of
infectious diseases, 8th Ed. [Electronic version]. Elsevier.
Greenwood, J. & Sesharid, A. (2001). The U.S. demographic transition. AEA Papers and
Proceedings, 92(2), 153-159. http://www.econ.wisc.edu/~aseshadr/publication_pdf/usdt.pdf.
60. References
Hartman, A. L. (2013). Ebola and Marburg virus infections. In, A. J. Magill, D. R.
Hill, T. Solomon, & E. T. Ryan (Eds.) Hunter's tropical medicine, 9th Ed.
[Electronic version]. Elsevier.
Hewlett, B. L. & Hewlett, B. S. (2005). Providing care and facing death: nursing
during Ebola outbreaks in Central Africa. Journal of Transcultural Nursing, 16(4),
289-297.
Hewlett, B. S. & Amola, R. P. (2003). Cultural contexts of Ebola in northern
Uganda. Emerging Infectious Diseases, 9(10), 1242-1248.
Hayden, F. G. (2007). Influenza. In Goldman, L., & Ausiello, D. (Eds.) Cecil
medicine, (23rd Ed.). [Electronic version]. Elsevier.
Kiringia, J. M., Gbary, A. R., Muthuri, L. K., Nyoni, J., & Seddoh, A. (2006). The
cost of health professionals’ brain drain in Kenya. BMC Health Services
Research, 6(89), doi:10.1186/1472-6963-6-89.
Koehlmoos, T. P., Anwar, D., & Cravioto, A. (2011). Global health: chronic
diseases and other emergent health issues in global health. Infectious Disease
Clinics of North America, 25(3), doi:10.1016.j.idc.2011.05.008.
Marchal, B., & Kegels, G. (2003). Health workforce imbalances in times of
globalization: brain drain or professional mobility. International Journal of Health
Planning and Management, 18(S1), S89-S101.
61. References
Newson, L., Postmes, T., Lea, S. E. G., & Webley, P. (2005). Why are modern families small?
Toward an evolutionary and cultural explanation for the demographic transition. Personality
and Social Psychology Review, 9(4), 360-373.
Ortega-Sanchez, I. R., Vijayaraghavan, M., Barskey, A. E., & Wallace, G. S. (2014). The
economic burden of sixteen measles outbreaks on Unites States public health departments
in 2011. Vaccine, 32(11). doi:10.1016/j.vaccine.2013.10.012.
Sachs, J. D. (2005). The end of poverty: economic possibilities for our time. New York: The
Penguin Press.
Sachs, J., & Malaney, P. (2002). The economic and social burden of malaria. Nature,
415(6872), 680-685.
Takahashi, S., Metcalf, C. J. E., Ferrari, M. J., Moss, W. J., Truelove, S. A., Tatem, A. J.,et al.
(2015). Reduced vaccination and the risk of measles and other childhood diseases. Science,
347(6227), doi:10.1126/science.aaa3438.
Tiongco, M. (2008). Costs and Benefits of HPAI Prevention and Control Measures: A
Methodological Review. Africa/Indonesia Team Working Paper No. 13.
http://r4d.dfid.gov.uk/Output/178612.
Treanor, J. J. (2009). Influenza viruses, including avian influenza and swine influenza. In
Mandell, G. L., Bennett, J. E., & Dolin, R. (Eds.). Mandell, Douglas, and Bennett's principles
and practice of infectious diseases (7th Ed.) [Electronic version].
62. References
United Nations Children's Fund. (2012). Levels and trends in child mortality
report 2012.
http://www.who.int/maternal_child_adolescent/documents/levels_trends_child_m
ortality_2012.pdf.
U.S. Census Bureau. (1999). 20th Century Statistics. Statistical abstract of the
United States: 1999. http://www.census.gov/prod/www/statistical_abstract.html.
U.S. Department of Health and Human Services. (2012). United States Life
Tables, 2008. National Vital Statistics Report, 61(3).
Utzinger, J. & Keiser, J. (2006). Urbanization and tropical health – then and now.
Annals of Tropical Medicine and Parasitology, 100(5 and 6),
doi:10.1179/136485906X97372.
Walker, P. G. T., White, M. T., Griffin, J. T., Reynold, A. Ferguson, N. M., & Ghani,
A. C. (2015). Malaria morbidity and mortality in Ebola-affected countries caused
by decreased health capacity, and the potential effect of mitigation strategies: a
modelling analysis. Lancet Infectious Diseases, doi:10.1016/S1473-
3099(15)70124-6
Washington State Department of Health. (n.d.) Avian influenza.
http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/AvianInfluenza.
World Bank. (2014). Data. http://data.worldbank.org.
63. References
World Bank. (2015). Fertility rate, total (births per woman).
http://data.worldbank.org/indicator/SP.DYN.TFRT.IN.
World Health Organization. (March 30, 2014). Ebola virus disease in
Liberia. http://www.who.int/csr/don/2014_03_30_ebola_lbr/en.
World Health Organization. (May 26, 2014). Ebola virus disease, West
Africa – update. http://www.who.int/csr/don/2014_05_28_ebola/en.
World Health Organization. (August 8, 2014). Ebola virus disease
update – West Africa. http://www.who.int/csr/don/2014_08_08_ebola/en.
World Health Organization (October 31, 2014). Personal protective
equipment (PPE) in the contact of Filovirus disease outbreak response:
technical specification for PPE equipment to be used by health workers
providing clinical care for patients.
http://apps.who.int/iris/bitstream/10665/137411/1/WHO_EVD_Guidance
_SpecPPE_14.1_eng.pdf.
World Health Organization. (2014). Under-five mortality.
http://apps.who.int/gho/data/view.main.180?lang=en.
World Health Organization. (2015). Malaria.
http://www.who.int/mediacentre/factsheets/fs094/en.
64. References
World Health Organization. (2015). Measles.
http://www.who.int/mediacentre/factsheets/fs286/en.
World Health Organization. (2015). Neglected tropical diseases.
http://www.who.int/neglected_diseases/diseases/en.
World Health Organization. (2015). Influenza at the human-
animal interface: summary and assessment as of 31 March
2015.
http://www.who.int/influenza/human_animal_interface/Influenza_
Summary_IRA_HA_interface_31_March_2015.pdf.
World Health Organization Ebola Response Team. (2014). Ebola
virus disease in West Africa – the first 9 months of the epidemic
and forward projections. New England Journal of Medicine,
371(16), doi:10.1056/NEJMoa1411100.
Zucker, J. R. (1996). Changing patterns of autochthonous
malaria transmission in the United States: a review of recent
outbreaks. Emerging Infectious Diseases, 2(1),
doi:10.3201/eid0201.960104.
