CHALLENGES IN COMMUNICABLE DISEASES

LOKMAN HAKIM S, MD, DAP&E, MScPH, PhD, FA

MM, FAMS, FASc

JOHORE HEALTH CONFERENCE 2015

Ministry of Health

Malaysia

2015-2035: Three Domains of Health Challenges

High rates of avertable infectious, child, and

maternal deaths

Unfinished agenda

Demographic change and shift in GBD

towards NCDs and injuries

Emerging agenda

Impoverishing medical

expenses, unproductive cost increases

Cost agenda

Infectious diseases continue to post great challenges to health

• Profound impact on human history

– Influenced course of wars

– Determined fates of nations

– Affected civilisation

• Economic development and technology advancement leading to demographic transition

• Epidemiologic transition incomplete, unfolding at different rates

• Emerging and re-emerging infections coupled with new challenges

– Hospital acquired infections and the “Super Bug”

– Drug resistance

– Pandemics

– Health security and bioterrorism

Communicable Diseases

• Defined as

– “any condition which is transmitted directly or indirectly to a person from an infected person or animal through the agency of an intermediate

animal, host, or vector, or through the inanimate environment.”

• Transmission is facilitated by the following:

– More frequent human contact due to

• Increase in the volume and means of transportation (affordable international air travel),

• globalization (increased trade and contact).

– Microbial adaptation and change.

– Breakdown of public health capacity at various levels.

– Change in human demographics and behavior.

– Economic development and land use patterns.

Source: Morens et al. 2004. The challenge of emerging and re-emerging infectious diseases. Emerg Infect Dis. 430: 242-249

GLOBAL DISTRIBUTION OF EMERGING & RE-EMERGING DISEASES (1996-2004)

• MERS-COV

• EBOLA

• H7N9

• H1N1

Global Burden of Communicable Disease

2005

CD30%

Others70%

Burden of Disease

2015

CD26%

Others74%

Burden of Disease

6

Leading causes of global deaths from infectious diseases (Fauci AS et al, N Engl J Med 2012, 366: 454-461)

0 0.5 1 1.5 2 2.5 3 3.5 4 4.5 5

Other infectious diseases

Hepatitis B

Measles

Pertussis

Meningitis

Malaria

Tubercolosis

HIV/AIDS

Diarrheal diseases

Respiratory infections

No. of Deaths (millions)

Economic burden

• The epidemic of BSE, UK : USD 30 billion.

• SARS outbreak Hong Kong/Global: range from USD 8 billion to 24 billion,

• Plague in Surat, India (1994), USD 1.5 billion

• Avian influenza outbreak, Hong Kong (1997), estimated to cost hundreds of millions of euros in lost poultry production, commerce and tourism.

• Nipah outbreaks, Malaysia (1998/1999): USD 97 million for direct compensation for the culled 1.1 million pigs (total estimate USD500 million)

Malaysia dengue notification 2001-2015

Vector-borne disease transmission dynamics and targets for control and elimination

Host Host

Agent (parasite) Agent

(virus)

Vector (Anopheles)

Vector (Aedes)

MALARIA DENGUEEnvironment

Unique characteristics of infectious diseases

• Extraordinary adaptability

– Replication and mutation capacity

• Closely dependent on the nature and complexity of human behavior

– Reflect who we are, what we do, how we live and interact

– Acquired as a result of our lifestyle

• Ease of transportation, ease of spread

• Environmental degradation and climate change

• Explosive potential

0

500

1000

1500

2000

2500

3000

3500

17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51

2009 2010

No. of Cases

Epid Week

Number of Lab-Confirmed Influenza A(H1N1) Cases, Malaysia, 2009 - 2010

352

Epid-Curve of the Pandemic A(H1N1) 2009

15 May 2009: 1st confirmed

case

21 June 2009: Communitytransmission

confirmed

10 July 2009: Mitigation

Phase initiated

November 2009: Pandemic vaccination

strategies initiated

MALAYSIA (as of 31/12/2010)

Mid Year Population, 2010

Total no. of confirmed cases

Total no. of death

Mortality Rate(per 100,000 pop)

28,908,800 15,792 95 0.33

3,136

Specific challenges

Migration and Health

Land use changes, Cl

imate Change

and Health

Infectious diseases

and Health Security

The Global PictureMigration

The Regional PictureMigration

But who are these people?

• Challenge: No internationally adopted definition for most terms

• Why do we care about definition?

– To better understand the great diversity among migrants.

– Limit contradictory or misleading information

– Achieve comparability of migration statistics among countries

– Evidence-based , tailor-made policy synthesis

19

Economic Migrants

Legal vs illegal

RefugeesMigrant workers

Foreigners

Formal vs informal

Migration & public health concerns : Communicable Diseases

– Mobile people interact with and potentially affect and adopt the health profile of all communities along their migration route.

•

– The cost to societies:

• Outbreak of disease (Health)

• Trade

• Political relationships

• Financial position in a global economy

• Travel in affected regions.

Temperatures are rising rapidly, following increases in CO2 emissions and concentrations

Climate Change and Communicable Diseases

• Climate may affect:

– Spatial distribution of outbreaks: where?

– Timing of disease outbreaks: when?

– Frequency of disease outbreaks: how often?

– Intensity or severity of outbreaks: how bad?

• Via effects on

– Pathogens: if free-living or outside of host

– Hosts: e.g, immunity

– Vectors: e.g. mosquitoes, ticks etc

– Dynamics: e.g. contact rates

– Indirect effects: effects on other disease drivers

Malaysia weekly dengue case notification 2001-2015

Number of dengue reported cases in the Americas from 2000 to 2007.

Shepard DS et al. (2011). Am. J. Trop. Med. Hyg; 84(2): 200-207.

Annual economic burden of dengue in the Americas from

2000 to 2007 (in 2010 US$).Shepard DS et al. (2011). Am. J. Trop. Med. Hyg; 84(2): 200-207.

Aggregate values of dengue episodes and economic burden by year for 12 countries in SEA (2001–2010).

Shepard DS et al. 2013. PloS Negl Trop Dis; 7(2):e2055. doi:10.1371/journal.pntd.0002055

Use of multiple data sources to estimate the economic cost of dengue illness in Malaysia.

Shepard DS et al (2012). Am. J. Trop. Med. Hyg; 87(5), 796-805

• Adjusted estimate of total dengue cases

• Economic burden of USD56 million per year.

• Overall economic burden would be higher if costs associated with prevention and control, dengue surveillance and long-term sequelae of dengue were included.

Changing human-animal interface: Impact on zoonotic malaria in Malaysia (2014)

Peninsular 2014 Sabah 2014 Sarawak 2014

P. falciparum

P. vivax

P. malariae

Mixed

P. knowlesi

Sarawak 2015

P. falciparum

P. vivax

P. malariae

Mixed

P. knowlesi

Sabah 2015 Penisular 2015

GLOBAL & NATIONAL HEALTH SECURITY:

Mutlidrug resistance malaria

Mutlidrug resistance malaria

Polio

Mutlidrug resistance TB

Mutlidrug resistance TB

Mutlidrug resistance TB

Mutlidrug resistance TB

Cholera

Leishmaniasis

Bancroftian filariasis

Avian influenza H5N1

Exotic zoonoses including avian influenza, H7N9

Managing infectious diseases threats • Epidemiological surveillance through indicator (mandatory &

administrative notification) and syndromic surveillance

• Role of health intelligence

• Real time electronic communication on outbreaks need to be developed

• Networking of laboratories

– National and Regional Public Health Laboratories

– Clinical laboratories – hospitals and private laboratories, IMR

– Others- DVM, Chemistry Labs

• Early warning and response system – CPRC, IHR focal points and WHO & GOARN response structure

• Better integration and cooperation across various government ministries and agencies

Health systems and infectious diseases

• Health systems play an important role.

• Failure to response to emerging challenges may affects communicable disease program delivery system:-

– Constraints not due to lack of technical guidance or expertise but rather the shortcomings of health systems

• Surveillance systems not in place / not monitored / not evaluated thus not detecting ALERT WARNING trends and signals

• Multi sources of information not gathered to make a meaningful and appropriate policy decision

• Current Rabies outbreak a case study

The Threats Continue• Populations grow and move …

Microbes adapt …

Changing climates …

Increasing global interconnectedness …

WHO Briefing Notes: Pandemic (H1N1) 2009

“…. The 2009 influenza pandemic has spread internationally with unprecedented speed. In past

pandemics, influenza viruses have needed more than six months to spread as widely as the new H1N1 virus has

spread in less than six weeks ….”

WHO , Geneva (16 July 2009)

Thank you

lokman.hakim@moh.gov.my

33