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Transcript of Global health
Matthew Rollosson, RN, MPH&TM, BSN
Nurse Epidemiologist
Tacoma-Pierce County Health Department
29 April 2015
Global Health:
Tropical Medicine
Tropical Medicine
Diseases that disproportionately affect the poor
Infectious diseases
Non-infectious diseases
Cancer
Chronic diseases
Malnutrition
Envenomations/intoxications
Mental health
Substance abuse
Trauma
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
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
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Dangerous, outdated equipment sent from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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
U.S. Demographic Transition
Data from U.S. Census Bureau 1999,
U.S. Department of Health and Human Services 2012
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
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
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
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
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
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
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
Timeline By the end of August, the total numbers of EVD
cases and deaths exceeded that of all previous
Ebola epidemics combined
CDC, 2015
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
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
Disinfection Ebolaviruses
Lipid envelope
Derived from host cell
Destroyed by
Alcohol
Chlorine
Heat
Detergents
Soap
UV light
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
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
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
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