BIOE 260: Intro to Global Health Issues

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BIOE 260 Intro to Global Health Issues

• Lecture 4

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Fun with Epidemiology

• Hans Rosling
• GapMinder
• http//tools.google.com/gapminder/

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Outline

• Case Studies from Millions Saved
• Controlling TB in China
• Preventing Diarrheal Deaths in Egypt
• Controlling Trachoma in Morocco
• Reducing Guinea Worm in Asia and Sub-Saharan
  Africa
• Reducing Fertility in Bangladesh
• Preventing Hib Disease in Chile and the Gambia
• Case Study Justa Stove

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Controlling TB in China

• Bacterial infection of the lungs caused by
  mycobacterium tuberculosis
• 2003
• 8.8 million new cases
• Growing 1/year
• 1.6 million deaths
• 98 of deaths occur in developing world
• Leading cause of death among adults from
  infectious disease in China
• TB will kill 35 million people in next 20 years
  if situation does not change
• Drugs which cure TB were discovered in 1940s
• If untreated, results in death in 5 years in half
  of all cases

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Tuberculosis

• 1/3 of worlds population infected with TB
• Not all have active TB
• Most have latent TB - Immune system has walled
  off bacilli with waxy coat
• 5-10 of people with normal immune systems will
  go on to develop active TB
• Higher in people with compromised immune systems
  (10X higher in people with AIDS)
• TB is leading cause of death among people with
  HIV/AIDS

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Tuberculosis

• Symptoms
• Fever
• Night sweats
• Weight loss
• Weakness
• Coughs (productive with bloody sputum)
• Airborne transmission
• Left untreated, one person with active TB can
  infect 10-15 people each year

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Tuberculosis Treatment

• Latent TB
• Treated with isoniazid, prevents development of
  active TB
• Active TB
• Can almost always be cured by taking several
  antibiotics in combination
• Stay home for several weeks while contagious
• Take drugs for 6 months

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Tuberculosis Treatment

• Resistant TB
• Can develop if patients do not take all medicine
• Growing problem
• 425,000 new cases per year
• In Russia and China, 14 of new cases are
  resistant
• Must be treated with special medicines
• Poorly supervised Rx is worse than no Rx

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Intervention in China

• DOTS
• Trained health care workers watch patients
  swallow antibiotics every other day for 6 months
• Developed in 1970s in Tanzania
• Implemented in China in 1991
• Cost
• 6 month supply is 11
• 130 million (inc. 58 million from World Bank)
• 100/person
• One healthy life saved for 15-20

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Intervention in China

• 95 cure rate for new cases within 2 years (up
  from lt50)
• MDR-TB rate three times lower in provinces
  covered by DOTS than non-covered provinces
• Important incentives
• Symptomatic pts referred to dispensaries
• Village doctors received incentives for
• referring pts
• Dxs
• Rx completions
• Free diagnosis
• Treatment was free to smear-positive patients

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Worldwide Intervention

• DOTS
• 17 million patients worldwide have been treated
  with DOTS since 1995
• 25 of worlds population does not have access to
  DOTS
• In China, DOTS is available to 68 of population
• China today
• http//www.npr.org/templates/story/story.php?story
  Id1289157

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Preventing Diarrheal Deaths in Egypt

• 1977
• Diarrhea caused ½ of all infant deaths in Egypt
• All preventable
• Project in Egypt
• Produced ORTs locally
• Dispensed ORT, information about appropriate
  treatment to mothers
• Trained health care workers
• Cost
• 6/treatment
• 100-200/life saved
• 43 million total cost (60 from USAID)

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Diarrheal Disease

• Serious gastrointestinal disease, with frequent,
  watery stools
• Caused by viral or bacterial infection of the GI
  tract
• Bacteria Escherichia coli, Vibrio cholerae
• Viral Rotavirus
• Less common in neonates
• Frequently related to unsafe drinking water

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Diarrheal Disease

• Can rapidly lead to death due to dehydration
• How does this happen?
• Ordinary digestion
• Food mixed with water in stomach
• 98 of water is reabsorbed as mixture passes
  through colon
• Infection interferes with fluid reabsorption
• Loss of 10 of bodily fluids ? death

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Oral Rehydration Therapy

• 1 liter of water, 1 teaspoon of salt, 8 teaspoons
  of sugar
• Reduced mortality to diarrhea from 4.6 million
  deaths per year to 1.8 million deaths per year in
  2000
• Developed in 1960s
• Most significant medical advance of the
  century. The Lancet, 1978

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How Does ORT Work?

• Epithelial cells which line colon are responsible
  for fluid reabsorption
• They reabsorb osmotically active products of
  digestion, sodium
• Water follows
• Toxins produced by bacteria bind to epithelial
  cells in gut and cause cells to secrete chloride
  and interfere with ability to absorb sodium?
  watery diarrhea

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How Does ORT Work?

• What if you give patients more water to drink?
• Just get more diarrhea
• Discovery in 1950s
• New method of sodium transport which depends on
  glucose, not affected by bacteria which produce
  diarrhea
• Theorize
• Provide glucose can increase sodium transport

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Oral Rehydration Therapy

• 1975 WHO and UNICEF
• 90 mM sodium
• 20 mM potassium
• 80 mM chloride
• 30 mM bicarbonate
• 111 mM glucose
• Packet of ORT 10 cents
• US use of ORT

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Key Components of Intervention

• Science in place, intervention available
• 1977 ORTs introduced in Egypt
• 1982 used in only 10-20of cases
• Education
• Public
• Health care workers
• Small scale community trials
• Nurses taught moms to use ORT
• Public physicians educated about use
• Child mortality decreased 38 in test villages
• 1984 program scaled up

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Key Components of Intervention

• Changed size from 1 L to 200 ml
• Small measuring cup sold by pharmacies, so they
  could make a profit
• Inventory control system
• Social marketing
• Logo widely recognized mother feeding small
  child
• Mass media campaign targeted mothers of young
  children
• Coincided with availability of TV
• TV spots featured well-liked, motherly soap opera
  star
• http//www.npr.org/templates/story/story.php?story
  Id916687
• http//www.changemakers.net/library/temp/newyorker
  soapoperas.cfm

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Impact in Egypt

• 1982-1987
• Infant mortality dropped by 36
• Child mortality dropped by 43

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Controlling Trachoma in Morocco

• 1992
• 5 of population in Morocco had Trachoma
• Cases concentrated in rural areas
• 625,000 needed treatment
• Trachoma
• 2nd leading cause of blindness in world
• Leading cause of preventable blindness
• National Blindness Control Program
• Formed in 1991
• Eliminate Trachoma by 2005

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Intervention

• SAFE
• Surgery
• Antibiotics
• Face Washing
• Environmental change
• Largely financed by Moroccan government
• Pfizer donated millions of dollars worth of
  Zithromax
• Impact
• Prevalence has fallen 75 since 1999
• Fallen by 90 in children under the age of 10

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Trachoma

• Bacterial infection Chlamydia trachomitis
• Chronic conjunctivitis
• Highly contagious
• Spread by direct contact with eye and nasal
  secretions, contaminated towels, clothing, fluid
  seeking flies
• Over years, can lead to blindness
• Upper lid becomes chronically inflamed
• Trichiasis in-turning of eyelid
• Eyelash painfully rubs eye and leads to corneal
  scarring ? blindness
• Prevalence among children aged 2-5 years 90
• Closely linked with poverty
• Once common throughout the world
• http//video.on.nytimes.com/ifr_main.jsp?nsida-4e
  06e22f11031bc2a9663f4rfrssfr_story9bc8316667
  e5f3d7898a94fd1efdb11bddb7c011st1169068554453mp
  WMPcpftruefvn8fr011707_041558_w4e06e22fx110
  31bc2a96x63f5rdm139728.24955661633

http//www.trachoma.org/trachoma.php
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Trachoma
http//medicine.plosjournals.org/perlserv?request
get-documentdoi10.1371/journal.pmed.0030041
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SAFE

• Introduced by Edna McConnell Clark Foundation
• Surgery
• Halts corneal damage in late stages of Trichiasis
• Make slit in outer lid and restitch to pull
  lashes away from eye
• Costs 6
• Antibiotics
• Zithromax discovered enabled treatment in single
  dose
• Pfizer partnered with the Clark Foundation to
  make available (60 million donation)
• Face washing
• Model lesson on trachoma developed for primary
  schools
• Environmental change
• Construct pit latrines to reduce prevalence of
  flies that spread trachoma

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Impact
http//www.npr.org/templates/story/story.php?story
Id1045688
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Global Impact

• 400 million in need of antibiotic treatment
• Pfizer will donate 500 million of antibiotic
  over the next 5 years, 135 million doses

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Guinea Worm

• Parasitic disease once common throughout the
  world
• Contracted when person drinks stagnant water
  contaminated with tiny fleas that carry guinea
  work larvae
• Once in human, larvae mature in abdomen, grow to
  average of 2-3 feet in length
• After one year, fully grown worm rises to skin to
  lay larvae
• Painful blister forms, usually in foot
• To ease burning pain, individuals submerge
  blister in cool water
• Blister ruptures and water is contaminated
• Worm gradually emerges from blister over period
  of 8-12 weeks
• Agonizing pain, debilitating bedridden for one
  month
• Worms coaxed out of blister by being wound around
  a narrow stick, a few cm each day
• Must not break worm or get painful inflammation

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Guinea Worm
http//pathmicro.med.sc.edu/parasitology/nematodes
.htm
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History

• 1981
• CDC launched eradication efforts
• Slow momentum, lack of prevalence data
• 1986
• Jimmy Carter convinced Pakistan to launch
  eradication campaign
• Focused efforts on Africa
• Recruited former heads of state in Mali and
  Nigeria

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Eradication Campaign

• Provide safe water
• Deep well digging can be costly
• Larvicide
• Purifying water through nylon cloth filters
  Dupont made 14M donation
• Health Education
• Social marketing campaign
• Worm weeks
• Intensive health education when local and
  international volunteers provide education
  (plays, ceremonies with local officials,
  demonstrate use of filters)
• Surveillance and Case Management

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Impact

• Disease is in line to be eradicated

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Cost

• Over a decade, intervention cost 88M
• Cost per case prevented 5-8
• http//www.cartercenter.org/news/multimedia/media_
  console/console.aspx?sectionIDHdirectoryEXTh08
  linkEXTCC_slideshow.swf

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HW Due Next Time

• Task 3 Literature review background