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Global Infectious Diseases Objectives

Global Infectious Diseases Objectives. Problem Determinants Diseases Control and eradication Triumphs Tribulations . DEFINITIONS. CONTROL: Reduction of disease incidence, prevalence, morbidity, mortality, and

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Global Infectious Diseases Objectives

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  1. Global Infectious Diseases Objectives • Problem • Determinants • Diseases • Control and eradication • Triumphs • Tribulations

  2. DEFINITIONS CONTROL: Reduction of disease incidence, prevalence, morbidity, mortality, and disability to a locally acceptable level Away All Disease! ELIMINATION: Reduction of infection and disease to zero in a defined area. Continued efforts required. ERADICATION: Permanent reduction of worldwide incidence to zero as a result of deliberate interventions. Continued efforts not required. DESTRUCTION: Destruction of all isolates of microbial agent.

  3. Problems in Defining Burden • Poor case definition • Poor recognition • Poor diagnosis • Poor reporting • Poor statistical use • Poor understanding of problem • Poor control actions • Poor resource allocation

  4. Fogarty InternationalCenter Human Hookworm, 1909 Yellow fever, 1915 Aedes aegypti, 1934-42 Anopheles gambiae, 1939-68 Malaria, 1955-1973 Yaws, 1950 Smallpox, 1958, 1966-80 Poliomyelitis, 1985 Dracunculiasis, 1987 Eradication Programs Animal Bovine contagious pleuropneumonia (cows), 1884 Glanders (horses, mules) Piroplasmosis (cattle, “Texas fever” Dourine (STD of horses) Rinderpest Sheep pox

  5. Eradication Yellow fever (failed) Aedes aegypti (failed) Anopheles gambiae (failed) Yaws (failed) Malaria (failed) Smallpox (success) Guinea worm (dracunculiasis)* Poliomyelitis * Elimination Onchocerciasis (Onchocera volvulus)• Filariasis (Wuchereria bancrafti) • Measles • Chagas disease (Tryanasomia cruzi) • Tuberculosis Eradication and Elimination Programs • * eradication underway • elimination underway

  6. Candidates for Elimination Haemophilus influenzae type B Neonatal tetanus Rabies Yellow fever Japanese B encephalitis Hepatitis A Hepatitis B Rubella

  7. Global Infectious Diseases Objectives • Problem • Determinants • Diseases • Control and eradication • Triumphs • Tribulations

  8. Control vs. Eradication

  9. Fogarty InternationalCenter Edward Jenner’s Clairvoyance “…It now becomes too manifest to admit of controversy, that the annihilation of the Small Pox, the most dreadful scourge of the human species, must be the final result of this practice.” — Edward Jenner, The Origin of the Vaccine Inoculation, 1801

  10. Biologic and Epidemiolgic Basis for Smallpox Eradication • Humans were the only reservoirs and vectors • No intermediate host • All cases symptomatic with typical rash • Lifelong immunity after disease • Laboratory diagnosis effective • Incubation period 7-17 days, conducive to control • Effective heat-stable vaccine • Mode of acquisition and transmission known • Pathogenesis and pathology known • Research important

  11. Social, Political and Economic Factors Favoring Smallpox Eradication • Disfiguring disease • Periodic epidemics • Endemic countries started activities at same time • All non-endemic countries at peril • Prestige to countries, bilateral and international organizations • Economic benefits to all* stop vaccination* stop vaccination card and border controls* stop medical costs due to vaccine complications

  12. Rahima Banu, age 3, Last Case of variola major, Bangladesh, 1975

  13. Poliovirus Importations in 2000 and 2001

  14. Label, 2002

  15. Savings from International Disease Eradication Programs U.S. Eradication Savings Disease Cost/Contribution World Smallpox 1949 – 1977 $30 million/30 1998 $30 million every 26 days in U.S. million $421 million per year $11 billion since 172 when vaccination stopped in U.S. Poliomyelitis 1979 – 2000 Ongoing 2000 $500 million yearly worldwide 2015 $3 billion yearly Measles Americas 2000 Ongoing Huge Europe 2007 Middle East 2010 Fogarty International Center

  16. Vaccination and Savings to Society Savings per Dollar Spent Vaccine Diphtheria – titanus – pertussis $29 (DPT) Measles – mumps – rubella $13 (MMR) Oral polio vaccine $ 6 (OPV) Varicella (chickenpox) $ 5 Hemopulus influenza, type b $ 2 Hepatitis B (infant) $ 2 ____ Savings per $6 dollars invested = $57 Ratio of savings to investment ~ 10: 1

  17. Global Infectious Diseases Objectives • Problem • Determinants • Diseases • Control and eradication • Triumphs • Tribulations

  18. Ebola Virus, Zaire, 1976 Unfixed diagnostic specimen from Vero cell passage: sodium phosphotungstate x90,000 (Fred Murphy)

  19. Number of Cases of Ebola Hemorrhagic Fever in the Equator Region, by Day of Onset and Probable Type of Transmission, 1976 50 45 40 35 30 25 20 15 10 5 Probable Type of Transmission Person to Person Both Syringe Cases 1-3 4-6 7-9 10-12 13-15 16-18 19-21 22-24 25-27 28-30 1-3 4-6 7-9 10-12 13-15 16-18 19-21 22-24 25-27 28-30 September October

  20. Patient with Ebola Hemorrhagic Fever, Bumba Zone, Equateur Province, DR Congo (Zaire), October 1976

  21. Ebola Virus Marburg Virus Both

  22. Syndromes Potentially Resulting from Bioterrorism • Encephalitis • Hemorrhagic mediastinitis • Pneumonia with abnormal liver function tests (LFTs) • Papulopustular rash • Hemorrhagic fever • Descending paralysis • Nausea, vomiting ± diarrhea

  23. Biologic Warfare with Smallpox QUESTION: … at the time of the Pontiac rebellion, 1763: “Could it not be contrived to send smallpox among those disaffected tribes of Indians? We must on this occasion use every strategem in our power to reduce them.” —Sir Jeffrey Amherst, Commander-in-Chief, British Forces, North America Heagerty, 1928, cited in Fenner et al, 1988

  24. Biologic Warfare with Smallpox … at the time of the Pontiac rebellion, 1763: ANSWER: “I will try to inoculate them with some blankets that may fall in their hands, and take care not to get the disease myself.” — Colonel Henry Bousquet Heagerty, 1928, cited in Fenner et al, 1988

  25. Fogarty International Center The TribulationsSmallpox and Biologic Terrorism • Does smallpox virus exist outside of two WHO collaborating centers?* Ken Alibek’s story in Biohazard; other countries, groups* VerificationPreparedness* Diagnosis* Primary care* Antiviral therapy* Vaccination • Prevention of hysteria and disorder

  26. Scientific Needs for Live Variola VirusInstitute of Medicine, 1999 • Development of antiviral agents • Development of improved and new vaccines • Detection and diagnosis • Bioinformatics, genetic variability • Understanding the biology of the variola virus • Research on expressed protein products of variola

  27. Research, Training, and Support Needs According to Understanding of Diseases andEfficacy of Control Methods High High Training Efficacy of Control Methods Research Needs Low Low Some Moderate High Research Support Needs

  28. Research, Training, and Support Needs According to Understanding of Diseases andEfficacy of Control Methods High High Training Efficacy of Control Methods DengueMalaria HIV/AIDSTuberculosisEbola/Marburg InfluenzaCancersAlzheimer’s SmallpoxGuinea wormPoliomyelitisH. influenzae type BMeaslesTetanus Research Needs Low Low Some Moderate High Research Support Needs

  29. Infectious Causes of Common Chronic Diseases • Helicobacter pylori (peptic ulcers) • Hepatitis B and C (cirrhosis and liver cancer) • Human herpesvirus 8 (Kaposi’s sarcoma) • Human papillomavirus (cervical cancer, recurrent respiratory infections, and papillomatosis) • Epstein-Barr virus (posttransplant lymphoproliferative disease, B-cell lymphoma)

  30. Rank Order of Disease Burden for 15 Leading Causes

  31. Rank Order of Disease Burden for 15 Leading Causes (2)

  32. www.nih.gov/fic Fogarty International Center www.nih.gov For More Information E-mail: jbreman@nih.gov

  33. Ebola, Zaire, 1976 Spectrum of Emotion and Activity Highest Anxiety Less high Confidence (false) Uncertainty Anger Emotion Celebration Terror Sorrow Understanding Comfort (false) Fear People fleeing Active case detection Activity Patient management Rapid Surveillance Chaos Plasmapheresis Com-mission formed Isolation and quarantine Field Investigations Investigations/ quick Information Sharing Low High

  34. Fogarty InternationalCenter Lessons Applicable to Other Programs • Clear objectives known to all • Scientifically justifiable* No animal reservoir* Clinically manifest* Two-week incubation period* Virus did not survive in environment

  35. Fogarty InternationalCenter Lessons Applicable to Other Programs (2) • Operationally feasible but difficult* Effective, heat-stable vaccine* Vaccine protection of long duration* Vertical programs supported nationally and internationally* All programs started together* field staff needs are top priority

  36. Fogarty International Center Lessons Applicable to Other Programs (3) • Research and evaluation is crucial* Diagnosis* Active surveillance for cases* Coverage surveys for vaccination* Epidemiology to define groups at risk* Vaccine delivery systems* Adverse events from vaccination* Monkeypox and other orthopoxviruses* Poxviruses as vaccine vectors* Therapeutics

  37. Fogarty International Center Lessons Applicable to Other Programs (4) • Confirmation of eradication* Independent commissions* Certification format* Credibility and confidence

  38. Fogarty International Center Lessons Applicable to Other Programs (5) • Exchange of experiences* Routine disease surveillance* Special communications (research, outbreaks)* Cross-notification of importations* TransparencyPolitical, administrative, and economic* Commitment of high-level leadership* Use political/administrative infrastructure* Sustaining interest is difficult at the end* Show medical and economic improvements* Use staff who have been successful in one program in others* Achieve altruistic goal

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