This document provides an overview of tropical medicine and global health issues. It discusses diseases that disproportionately impact those living in tropical regions, including neglected tropical diseases. It also covers non-communicable diseases, trauma, urbanization, vector-borne diseases, influenza, avian influenza, measles, malaria, Ebola virus disease, and long-term consequences of the 2014-2015 West Africa Ebola outbreak. Health worker migration is also briefly discussed. The document contains detailed information on the transmission, epidemiology, and impact of various tropical and global health challenges.

1. Matthew Rollosson, RN, MPH&TM, BSN
Nurse Epidemiologist
Tacoma-Pierce County Health Department
29 April 2015
Global Health:
Tropical Medicine

2. Tropical Medicine

3. Tropics
 Tropic of Cancer
 Tropic of Capricorn
CIA, 2013

4. Tropical Medicine
 Diseases that disproportionately affect the poor
 Infectious diseases
 Non-infectious diseases
 Cancer
 Chronic diseases
 Malnutrition
 Envenomations/intoxications
 Mental health
 Substance abuse
 Trauma

5. Neglected Tropical Diseases
 Bacteria
 Buruli ulcer
 Leprosy (Hansen's disease)
 Trachoma
 Yaws
 Protozoa
 Chagas disease
 Human African
trypanosomiasis (sleeping
sickness)
 Leishmaniasis
 Viruses
 Chikungunya
 Dengue
 Rabies
 Helminth (worms)
 Cysticercosis
 Dracunculiasis (Guinea
worm disease)
 Echinococcosis
 Fascioliasis
 Lymphatic filariasis
 Onchocerciasis (river
blindness)
 Schistosomiasis
 Soil-transmitted helminths
CDC, 2011; WHO, 2015

6. Neglected Tropical Diseases
CDC, 2011

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 Dangerous, outdated equipment sent from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

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

11. Urbanization
 Increased risk of infectious diseases
 Acute respiratory diseases
 Diarrheal diseases
 HIV/AIDS
 Tuberculosis
 Vector-borne diseases
 Increased risks of chronic diseases
 Dietary changes
 Sedentary lifestyle
 Tobacco use

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

16. WHO, 2015

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

20. Measles in Pierce County, WA

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

22. Plasmodium falciparum transmission
Malaria Atlas Project

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

27. U.S. Demographic Transition
Data from U.S. Census Bureau 1999,
U.S. Department of Health and Human Services 2012

28. Under 5 mortality
UNICEF 2012

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

34. Ebola epidemics, 1976 - 2013
CDC 2014

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

40. Maforki Ebola Treatment Unit

41. Maforki Ebola Treatment Unit

42. Admission

43. Suspect ward

44. Confirmed ward

45. Immediate concerns
 Infection control
 Doffing
 Chlorine
 Patient care
 Oral rehydration
solution not at bedside
 Staff avoided contact
with patients
 Patient records
 Census
 Laboratory results
 Medication
administration

46. Personal protective equipment
 WHO recommends:
 Face shield or
goggles
 Fluid-resistant
medical/surgical
mask
 Double gloves
 Disposable
gown/coverall
 Head cover
 Waterproof apron
 Waterproof boots
WHO, 2014
Partners in Health

47. Disinfection
 Ebolaviruses
 Lipid envelope
 Derived from host cell
 Destroyed by
 Alcohol
 Chlorine
 Heat
 Detergents
 Soap
 UV light

48. Zero to 60 in four weeks

49. Stigmatization
 Survivors
 Loss of employment, family, home, property
 Harassed
 Victims of violence
 Health workers
 Loss of employment, family, home, property
 Harassed
 Unnecessary quarantine
Davtyan et al., 2014; De Roo et al., 1998;
Hewlett & Hewlett, 2005; Hewlett & Amola, 2003

50. Number of cases of EVD in contacts of
health workers returning to the U.S.: 0

51. Current case count:
CDC, 2015

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

56. Questions?
 http://fullyvaccinated.blogspot.com

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