Matthew Rollosson, RN, MPH&TM, BSN

Nurse Epidemiologist

Tacoma-Pierce County Health Department

29 April 2015

Global Health:

Tropical Medicine

Tropical Medicine

Tropics

Tropic of Cancer

Tropic of Capricorn

CIA, 2013

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

Neglected Tropical Diseases

CDC, 2011

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Dangerous, outdated equipment sent from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

WHO, 2015

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

Measles in Pierce County, WA

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

Plasmodium falciparum transmission

Malaria Atlas Project

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

Under 5 mortality

UNICEF 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

Ebola epidemics, 1976 - 2013

CDC 2014

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

Maforki Ebola Treatment Unit

Port Loko, Sierra Leone

100 bed capacity

44 confirmed

56 suspect

Maforki Ebola Treatment Unit

Maforki Ebola Treatment Unit

Admission

Suspect ward

Confirmed ward

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

Zero to 60 in four weeks

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

Number of cases of EVD in contacts of

health workers returning to the U.S.: 0

Current case count:

CDC, 2015

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

Questions?

http://fullyvaccinated.blogspot.com

References Aiken, L. H. (2007). U.S. nurse labor market dynamics are key to global nurse

sufficiency. Health Service Research, 42(3p2), 1299-1320.

Bach, S. (2003). International migration of health workers: labour and social issues (Working Paper 209). International Labour Office: Geneva.

Baize, S., Pannetier, D., Oestereich, L., Rieger, T., Koivogui, L., Magassouba, N., et al. (Emergence of Zaire Ebola virus disease in Guinea. New England Journal of Medicine, 371(15),1418-1425. doi:10.1056/NEJMoa1404505.

Bausch, D. G., Towner, J. S., Dowell, S. F., Kaducu, F., Lukwiya, M., Sanchez, A., et al. (2007). Assessment of the risk of Ebola virus transmission from bodily fluids and fomites. Journal of Infectious Diseases, 196(Supple. 2), S142-S147.

Blumberg, L., Enria, D., & Bausch, D. G. (2014). Viral hemorrhagic fevers. In J. Farrar, P. J. Hotez, T. Junghanss, G. Kang, D. Lalloo, & N. J. White (Eds.) Manson's tropical diseases, 23rd Ed. [Electronic version]. Elsevier.

Brauner-Otto, S., Axinn, W., & Ghimire, D. (2007). The spread of health services and fertility transition. Population Studies Center Research Report 07-619. http://www.psc.isr.umich.edu/pubs/pdf/rr07-619.pdf.

Brush, B. L., & Sochalski, J. (2007). International nurse migration: lessons from the Philippines. Policy, Politics, & Nursing Practice, 8(1), 37-46.

References Buchan, J., Parkin, T., & Sochalski, J. (2003). International nurse mobility: trends

and policy implications (WHO/EIP/OSD/2003.3). World Health Organization: Geneva.

Centers for Disease Control and Prevention. (2011). Neglected tropical diseases. http://www.cdc.gov/globalhealth/ntd/diseases/index.html.

Centers for Disease Control and Prevention. (2013). Measles – United States, January 1 – August 24, 2013. Morbidity and Mortality Weekly Report, 62(36), 741-743. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6236a2.htm.

Centers for Disease Control and Prevention. (2014). Dengue homepage. http://www.cdc.gov/dengue/entomologyEcology/index.html.

Centers for Disease Control and Prevention. (October 3, 2014). Ebola virus disease outbreak – Nigeria, July-September, 2014. Morbidity and Mortality Weekly Report, 63(39), 867-872. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6339a5.htm.

Centers for Disease Control and Prevention. (2014). Measles – United States, January 1 – May 23, 2014. Morbidity and Mortality Weekly Report, 63(22), 496-499. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6322a4.htm.

Centers for Disease Control and Prevention. (2015). Outbreaks chronology: Ebola virus disease. http://www.cdc.gov/vhf/ebola/outbreaks/history/chronology.html.

References Centers for Disease Control and Prevention. (2015). 2014 Ebola outbreak in West Africa –

cumulative reported cases in Guinea, Liberia, and Sierra Leone. http://www.cdc.gov/vhf/ebola/csv/graph1-cumulative-reported-cases-all.csv.

Conley, D., McCord, G. C., & Sachs, J. D. (2007). Africa's lagging demographic transition: evidence from exogenous impacts of malaria ecology and agricultural technology. National Bureau of Economic Research Working Paper Series No. 12892. http://www.nber.org/papers/w12892.

Davtyan, M., Brown, B., & Folayan, M. O. (2014). Addressing Ebola-related stigma: lessons learned from HIV/AIDS. Global Health Action, 7(26058). http://dx.doi.org/10.3402/gha.v7.26058.

De Roo, A. D., Ado, B., Rose, B., Guimard, Y., Fonck, K.,& Colebunders, R. (1998). Survey among survivors of the 1995 Ebola epidemic in Kikwit, Democratic Republic of Congo: their feelings and experiences. Tropical Medicine and International Health, 3(11), 883-885.

Dumbaya, C. (January 29, 2015). Sierra Leone's First Lady: 'Ebola has increased teenage pregnancy rates.' http://www.eboladeeply.org/articles/2015/01/7263/sierra-leones-lady-ebola-increased-teenage-pregnancy-rates.

Geisbert, T. W. (2014). Marburg and Ebola hemorrhagic fevers (Filoviruses). In J. E. Bennett, R. Dolin, & M. J. Blaser (Eds.). Mandell, Douglas, and Bennett's principles and practice of infectious diseases, 8th Ed. [Electronic version]. Elsevier.

Greenwood, J. & Sesharid, A. (2001). The U.S. demographic transition. AEA Papers and Proceedings, 92(2), 153-159. http://www.econ.wisc.edu/~aseshadr/publication_pdf/usdt.pdf.

References Hartman, A. L. (2013). Ebola and Marburg virus infections. In, A. J. Magill, D. R.

Hill, T. Solomon, & E. T. Ryan (Eds.) Hunter's tropical medicine, 9th Ed. [Electronic version]. Elsevier.

Hewlett, B. L. & Hewlett, B. S. (2005). Providing care and facing death: nursing during Ebola outbreaks in Central Africa. Journal of Transcultural Nursing, 16(4), 289-297.

Hewlett, B. S. & Amola, R. P. (2003). Cultural contexts of Ebola in northern Uganda. Emerging Infectious Diseases, 9(10), 1242-1248.

Hayden, F. G. (2007). Influenza. In Goldman, L., & Ausiello, D. (Eds.) Cecil medicine, (23rd Ed.). [Electronic version]. Elsevier.

Kiringia, J. M., Gbary, A. R., Muthuri, L. K., Nyoni, J., & Seddoh, A. (2006). The cost of health professionals’ brain drain in Kenya. BMC Health Services Research, 6(89), doi:10.1186/1472-6963-6-89.

Koehlmoos, T. P., Anwar, D., & Cravioto, A. (2011). Global health: chronic diseases and other emergent health issues in global health. Infectious Disease Clinics of North America, 25(3), doi:10.1016.j.idc.2011.05.008.

Marchal, B., & Kegels, G. (2003). Health workforce imbalances in times of globalization: brain drain or professional mobility. International Journal of Health Planning and Management, 18(S1), S89-S101.

References Newson, L., Postmes, T., Lea, S. E. G., & Webley, P. (2005). Why are modern families small?

Toward an evolutionary and cultural explanation for the demographic transition. Personality and Social Psychology Review, 9(4), 360-373.

Ortega-Sanchez, I. R., Vijayaraghavan, M., Barskey, A. E., & Wallace, G. S. (2014). The economic burden of sixteen measles outbreaks on Unites States public health departments in 2011. Vaccine, 32(11). doi:10.1016/j.vaccine.2013.10.012.

Sachs, J. D. (2005). The end of poverty: economic possibilities for our time. New York: The Penguin Press.

Sachs, J., & Malaney, P. (2002). The economic and social burden of malaria. Nature, 415(6872), 680-685.

Takahashi, S., Metcalf, C. J. E., Ferrari, M. J., Moss, W. J., Truelove, S. A., Tatem, A. J.,et al. (2015). Reduced vaccination and the risk of measles and other childhood diseases. Science, 347(6227), doi:10.1126/science.aaa3438.

Tiongco, M. (2008). Costs and Benefits of HPAI Prevention and Control Measures: A Methodological Review. Africa/Indonesia Team Working Paper No. 13. http://r4d.dfid.gov.uk/Output/178612.

Treanor, J. J. (2009). Influenza viruses, including avian influenza and swine influenza. In Mandell, G. L., Bennett, J. E., & Dolin, R. (Eds.). Mandell, Douglas, and Bennett's principles and practice of infectious diseases (7th Ed.) [Electronic version].

References United Nations Children's Fund. (2012). Levels and trends in child mortality

report 2012. http://www.who.int/maternal_child_adolescent/documents/levels_trends_child_mortality_2012.pdf.

U.S. Census Bureau. (1999). 20th Century Statistics. Statistical abstract of the United States: 1999. http://www.census.gov/prod/www/statistical_abstract.html.

U.S. Department of Health and Human Services. (2012). United States Life Tables, 2008. National Vital Statistics Report, 61(3).

Utzinger, J. & Keiser, J. (2006). Urbanization and tropical health – then and now. Annals of Tropical Medicine and Parasitology, 100(5 and 6), doi:10.1179/136485906X97372.

Walker, P. G. T., White, M. T., Griffin, J. T., Reynold, A. Ferguson, N. M., & Ghani, A. C. (2015). Malaria morbidity and mortality in Ebola-affected countries caused by decreased health capacity, and the potential effect of mitigation strategies: a modelling analysis. Lancet Infectious Diseases, doi:10.1016/S1473-3099(15)70124-6

Washington State Department of Health. (n.d.) Avian influenza. http://www.doh.wa.gov/YouandYourFamily/IllnessandDisease/AvianInfluenza.

World Bank. (2014). Data. http://data.worldbank.org.

References World Bank. (2015). Fertility rate, total (births per woman).

http://data.worldbank.org/indicator/SP.DYN.TFRT.IN.

World Health Organization. (March 30, 2014). Ebola virus disease in Liberia. http://www.who.int/csr/don/2014_03_30_ebola_lbr/en.

World Health Organization. (May 26, 2014). Ebola virus disease, West Africa – update. http://www.who.int/csr/don/2014_05_28_ebola/en.

World Health Organization. (August 8, 2014). Ebola virus disease update – West Africa. http://www.who.int/csr/don/2014_08_08_ebola/en.

World Health Organization (October 31, 2014). Personal protective equipment (PPE) in the contact of Filovirus disease outbreak response: technical specification for PPE equipment to be used by health workers providing clinical care for patients. http://apps.who.int/iris/bitstream/10665/137411/1/WHO_EVD_Guidance_SpecPPE_14.1_eng.pdf.

World Health Organization. (2014). Under-five mortality. http://apps.who.int/gho/data/view.main.180?lang=en.

World Health Organization. (2015). Malaria. http://www.who.int/mediacentre/factsheets/fs094/en.

References World Health Organization. (2015). Measles.

http://www.who.int/mediacentre/factsheets/fs286/en.

World Health Organization. (2015). Neglected tropical diseases. http://www.who.int/neglected_diseases/diseases/en.

World Health Organization. (2015). Influenza at the human-animal interface: summary and assessment as of 31 March 2015. http://www.who.int/influenza/human_animal_interface/Influenza_Summary_IRA_HA_interface_31_March_2015.pdf.

World Health Organization Ebola Response Team. (2014). Ebola virus disease in West Africa – the first 9 months of the epidemic and forward projections. New England Journal of Medicine, 371(16), doi:10.1056/NEJMoa1411100.

Zucker, J. R. (1996). Changing patterns of autochthonous malaria transmission in the United States: a review of recent outbreaks. Emerging Infectious Diseases, 2(1), doi:10.3201/eid0201.960104.