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Presentation outline -Definitions and statistics at a glance

MALARIA AND MOBILE POPULATIONS MALARIA IN THE AMERICAS FORUM 2009 PAHO, WASHINGTON DC NOVEMBER 6, 2009. Presentation outline -Definitions and statistics at a glance -Health implications of mobile populations: refugees, displaced populations and infectious and tropical diseases

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Presentation outline -Definitions and statistics at a glance

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  1. MALARIA AND MOBILE POPULATIONSMALARIA IN THE AMERICAS FORUM 2009PAHO, WASHINGTON DCNOVEMBER 6, 2009 • Presentation outline • -Definitions and statistics at a glance • -Health implications of mobile populations: refugees, displaced • populations and infectious and tropical diseases • -Mobile populations and impact on malaria transmission • -Key elements for discussion CARLOS ESPINAL M.D. Director Public Health sanofi pasteur Latin America

  2. WHY POPULATIONS MOVE ? Internal conflicts Violence Migration related to natural resources: mining, agriculture, oil Natural disasters Government and irregular Military Forces Human rights violations Commerce in frontiers • REMARKS • Medicine and public health focused on pathogens • Today focus should be in globally move populations that move pathogens across international borders and internally • Human mobility has always been associated with the spread of diseases: Influenza H1N1, avian FLU, dengue, malaria, TB, HIV, SARS • Impact of migration patterns is a great challenge for modern epidemiology and public health programs

  3. Refugees Status of Refugees People crossed international border 2008: 15 million Mobile populationsUNHCR definitions and statistics at a glance 2008: 42 million forcibly displaced people worldwide • Asylum-seekers • Claimants for refugee status pending of approval • 2008: 827.000 • Internally displaced persons (IDPs) • People forced to leave habitual residence, who have not crossed international borders • 2008: 26 million • Natural Migrants (borders populations) • Individuals or groups with residence within the international borders, with a wide circulation across the frontiers • Stateless • No belonging to any recognized state or Nation • 2008: 6.6 million Overall about 12 million • Return refugees (returnees) • Refugees who returned voluntarily to their country of origin or habitual residence • 2008: 604.000 • Returned IDPs • IDPs beneficiaries of protection and assistance to return to their habitual residence • 2008: 1.3million 2008 Global trends UNHCR 2009

  4. Populations of concern to UNHCR 2008 Latin America: 3.571.620 UNHCR Internally displaced Persons IDPs 2008

  5. People displaced and evacuated by sudden-onset natural disasters 2008 Natural disasters: Earthquakes, floods, storms

  6. MOBILE POPULATIONS AND SPREAD OF INFECTIOUS AND TROPICAL DISEASES • Denmark: TB incidence in foreign-born persons rose from 18% in 1986 to 60% in 1996 (1) • England: TB, 40% of new cases occur in people from Indian subcontinent (1) • Germany: 14% of HIV/AIDS cases are detected in migrants from Africa, USA, Asia, and Latin America (1) • USA: Polio, in 2005 Minnesota State Health Department detected vaccine-derived poliovirus infection in 4 children, in unvaccinated community, probably originated in a person vaccinated with OPV in another country (2) • Polio: 2003-2006, polio imported to 24 polio-free countries (2) • USA: TB, Rates, 2007 2.1x100.000 in US-born persons vs 20.6x100.000 in foreign-born persons (1)M Caballero A Nerukar Em Inf Dis 2001. 7(3):556-560 (2) E Yanny et al. Em Inf Dis 2009. 15(11):1715-1719

  7. IMPORTED INFECTIOUS DISEASES IN MOBILE POPULATIONS SPAIN REMARKS: 2008: EU 1.9 million immigrants. Spain 700.000. Total Immigrants in Spain by 2008: 5.2 million (1) Malaria: 15 patients (7.1%) were asymptomatic. P falciparum most frecuent in Africans. (2) Chagas: 95% of positive patients from Bolivia. Study in Spain estimated between 37.000-122.000 immigrants potentially infected with T cruzy B Monge-Maillo et al. Emerg Infect Dis 2009. 15(11);1745-1752

  8. MOBILE POPULATIONS IN LATIN AMERICA 2009 Malaria Latin America 2007 WHO/UNICEF Report 2008 México Cuba Guatemala Nicaragua Venezuela Panamá Colombia Ecuador Migrant mine workers Brasil Conflicts, violence, IDPs (UNHCR?) Refugees, Perú Bolivia Gold explotation: Brazil, Venezuela, Surinam , Bolivia, Guyana Paraguay Uruguay Argentina Castaneros Bolivia (nut harvesters): Brazil Chile World Bank. http://web.worldbank.org/WBSITE/EXTERNAL/TOPICS/EXTOGMC/0,,contentMDK:20212491~menuPK:463310~pagePK:148956~piPK:216618~theSitePK:336930,00.html

  9. Consultancy for Human Rights and Displacement (CODHES) National estimates: 4.629.190 persons Average: 925.838 families No Persons www.codhes.org 412.553 380.863 305.966 YEARS

  10. Population profile: Concentration of men, ages 20y-45y, very limited female population, miners in permanent migration, rise of violence, alcohol and drug abuse. Inadequate housing, living in tents, poor sanitation. HEALTH INDICATORS IN GOLD MINING WORKERS LATIN AMERICA • Bolivar State, Venezuela. L Faas, et al. Pan Am J Public Health , 5(1) 1999 • Guyana, Amazon Region. CJ Palmer et al. Emerging Infectious Diseases 8(3), 2002 • Apiacas, Mato Groso, Brazil. FJ Dutra et al. Hepatitis B markers in malaria-exposed gold miners. Mem Inst Oswaldo Cruz, 96, 2001. Garimpo satelite: 16 gold mine campus

  11. Mass population movements could occur in endemic areas., e.g., the Amazon frontiers. Industry – mining, rubber, agriculture, oil fields, attract migrant workers to new areas Incidence and burden of disease will depend upon immunity, intensity of malaria transmission, vectors, and health care services Malaria can be responsible for high rates of morbidity and mortality Displacement exacerbates rapid urbanization in marginal areas, with poor housing condition and sanitation, inadequate vectorborne control, and amplification of malaria to epidemic proportions MALARIA AND HUMAN POPULATION MOVEMENT CHALLENGES FOR PUBLIC HEALTH INTERVENTION Epidemiology of malaria in mobile populations

  12. Health service personnel trained in malaria Demography data, determine high risk groups or vulnerable populations (pregnant women, children) Case definition and case management. Active reporting and high quality data Active vs passive surveillance Rapid diagnostic tests. Blood smears and microscopy routine technique. Asymptomatic case detection by PCR (MS Suarez et al Rev Inst Med Trop S Paulo 49(3) 2007. 20% detection in P vivax) Monitoring of drug efficacy and resistance Hospital-based surveillance for clinical complicated malaria and fatal cases MALARIA AND HUMAN POPULATION MOVEMENT CHALLENGES FOR PUBLIC HEALTH INTERVENTION Surveillance systems Vector surveillance

  13. Selection of antimalarial drug and appropriated regimens. Effective drug combinations. Artesunate combinations. High levels of acceptability in the community and adhesion to treatment Mass drug treatments upon arrival at camps vs selective treatment to febrile patients? Treatment only in confirmed cases? Train local community leaders in techniques for rapid diagnosis and treatment. ( e.g.,Bolivia’s successful case study: reducing malaria in mobile populations in castaneros workers) MALARIA AND HUMAN POPULATION MOVEMENT CHALLENGES FOR PUBLIC HEALTH INTERVENTION Chemotherapy

  14. Overburdening of existing health structure: insufficient personnel, hospitals or clinics, problems with access to medicines including antimalarial drugs, deficiency in lab diagnosis, equipments Malaria control strategies integrated to global health interventions in displaced population, refugees, and mobile workers Very few interventions measure the impact . Effectiveness is not consider it or limited in methods to evaluate their success. MALARIA AND HUMAN POPULATION MOVEMENT CHALLENGES FOR PUBLIC HEALTH INTERVENTION Health services

  15. MALARIA AND HUMAN POPULATION MOVEMENT Large gap in the evidence of what works for change the behavior of public and private health providers. Pay attention to health system constraints that impact effectiveness and sustainability of malaria interventions. LA Smith et al . Improve effective treatment malaria: Do we know what works? Am J Trop Med Hyg. 80(3), 2009:326-35 Resettlement or repatriation: possible introduction or reintroduction of multi-drug resistant malaria. Mass screening strategies?, mass treatment before departure? How to achieve sustained high coverages of control measures: rapid diagnosis and effective treatments with simple schedules, insecticide residual spraying, preventive treatment in vulnerable groups, long-lasting insecticide treated mosquito nets. CHALLENGES FOR PUBLIC HEALTH INTERVENTION Health services

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